BOARD OF DIRECTORS

Wednesday 29 April 2015 at 09:00 – 12:00 Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust

AGENDA - PART 1

Presenter Timings Enclosure 1 WELCOME AND APOLOGIES FOR ABSENCE PW 09:00 Verbal 2 DECLARATIONS OF INTEREST RELATING TO ITEMS ON

THE AGENDA All Verbal

3 TO APPROVE THE MINUTES OF 25 MARCH 2015

AND TO DISCUSS ANY MATTERS ARISING PW 09:05 Appendix 1

4 ACTION SHEET PW Appendix 2 5 PATIENT STORY – Symphony Hub HR / TF 09:10 Presentation

Executive Director Reports for Discussion 6 CHIEF EXECUTIVE REPORT PM 09:30 Appendix 3 7 VANGUARD AND DEVELOPMENT OF

NEW MODELS OF CARE PM Tabled

8 DIRECTOR OF NURSING, SAFER STAFFING REPORT

AND NURSING RECRUITMENT HR MG

09:50 Appendix 4 Presentation

9 MEDICAL DIRECTOR REPORT TS 10:10 Appendix 5 10 CHIEF FINANCE AND COMMERCIAL OFFICER REPORT TN 10:20 Appendix 6

Break – 10:35 11 FINANCIAL RESILIENCE COMMITTEE

To Receive a Verbal Update from the Meeting Held on 27 April 2015

JG/TN 10:45 Verbal

12 SMARTCARE HIGHLIGHT REPORT JHOW 10:50 Appendix 7 13 OPERATIONAL AND FINANCIAL PERFORMANCE

OVERVIEW PM

JHIG / LA 11:00 Appendix 8

14 ASSURANCE COMMITTEES

To Receive Verbal Updates from NCRAC, GGAC and the Audit Committee Meetings Held on 17 April 2015

JH / JG PvdH

11:30 Verbal

15 Q4 CORPORATE RISK REGISTER AND BOARD

ASSURANCE FRAMEWORK HR 11:40 Appendix 9

16 TO CONSIDER REVISIONS TO THE BOARD

GOVERNANCE STRUCTURE PW 11:50 Appendix 10

17 ANY OTHER BUSINESS PW 11:55 Verbal 18 EXCLUSION OF THE PUBLIC

12:00

19 To resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting due to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

20 DATE AND TIME OF NEXT MEETING 20 May 2015, 9:00am, Boardroom, Level 1,

Yeovil District Hospital

APPENDIX 1 BOARD OF DIRECTORS

29 APRIL 2015 BOARD OF DIRECTORS

Minutes of the meeting of the Board of Directors held on

Wednesday 25 March 2015 at Yeovil District Hospital

Present: Peter Wyman Chairman Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director Paul von der Heyde Non-Executive Director Jonathan Howes Deputy Chief Executive Mark Saxton Non-Executive Director Paul Mears Chief Executive Tim Newman Chief Finance & Commercial Officer

Helen Ryan Director of Nursing & Clinical Governance In Attendance: Leah Allen Director of Elective Care John Hawkins Public Governor (Observer)

Jonathan Higman Director of Urgent Care/Long Term Conditions Jo Howarth Associate Director of Patient Safety and

Governance [item 1-43/15] Jade Renville Company Secretary

Apologies: Simon Blackburn Head of Communications Tim Scull Medical Director Action 1-39/15 APOLOGIES AND WELCOME

Peter Wyman welcomed everyone present to the meeting, extending a particular welcome to John Hawkins, Governor Observer, Charlie Houghton, Graduate Finance Trainee observing in the audience, and to Jo Howarth presenting for item 1-43/15]. Apologies were noted as listed above.

1-40/15 DECLARATIONS OF INTEREST Peter Wyman declared that he is Treasurer and a member of the Council of the University of Bath.

1-41/15 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 25 February 2015 were approved as a true and accurate record, subject to noting Chris Moore was in attendance, rewording a sentence at 1-28/15 and working with Leah Allen to refine the notes relating to the RTT discussion [item 1-28/15]. There were no matters arising not on the agenda.

1-42/15 ACTION SHEET The Board noted that all actions were complete, on the agenda or in progress. The Board discussed action 1-19/15 relating to fire safety and management and Tim Newman confirmed that a thorough review will be undertaken by the Strategic Estates Partner. Following the review, a paper will be presented to the Board of Directors, which should be by June 2015.

TN

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1-43/15 QUALITY AND PATIENT SAFETY IMPROVEMENT PROGRAMME OVERVIEW Jo Howarth tabled a presentation on the quality and patient safety improvement programme, including the deliverables and achievements in 2014/15, the sign up to safety campaign and the CQUIN framework and next steps. In terms of progress against the quality and patient safety priorities set for 2014/15, Jo Howarth highlighted that: • YDH is on target for a 20% reduction in hospital acquired

pressure ulcers.

• In terms of maintaining low rates of hospital acquired infection, rates of C.difficile have increased (in part due to previous strong performance and challenging target levels) and 2 incidents of MRSA have been recorded (the first since March 2013).

• YDH is likely to achieve a 6% reduction in the number of

patients falling in hospital, against a target of 10%. • Electronic discharge summaries have been implemented. • There has been ongoing improvement of patient experience

programmes within the organisation.

• There has been ongoing improvement of patient safety culture, including increased engagement in the junior doctor QI programme and enhanced rates of incident reporting (with low level harm).

• YDH is a consultation site for the development of the patient

safety incident management system. • Staffing levels are presented to the Board on a monthly basis. • A quality strategy is in development.

Jo Howarth reminded the Board that YDH has signed-up to the national “sign-up to safety” campaign pledges to make reductions against four main areas: pressure ulcers, medication errors, falls and sepsis. She added that YDH is in the process of setting its CQUINS for 2015/16. The nationally mandated areas include improving care for dementia, acute kidney injury, sepsis, urgent and emergency care across local health economies and the physical care of patients with mental health conditions. The safety thermometer and the friends and family test will be covered in 2015/16 by requirements within the NHS Standard Contract. Locally, YDH is considering indicators in connection with transition from child to adult services and FOPAS. To ensure delivery, YDH is continuing with the operation of various groups and training and the delivery of quality improvement programmes and the safety thermometer.

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The next steps will involve finalising the quality improvement strategy (which replaces the patient safety strategy), a review of learning from 2014/15 for implementation in 2015/16, setting the CQUINS for 2015/16, refinement of workplans and continuing to instill a “blame-free”, candid patient safety culture. The Board asked various questions, following which Jo Howarth confirmed the following: • The risks of pressure ulcers are multi-factorial. Where trusts

identify areas of best practice, these are shared and implemented at YDH.

• YDH is part of the regional patient safety collaborative now run by the AHSN in which learning and areas of best practice are shared.

• The priorities highlighted above (which have been reviewed by

the Patient Safety Committee) above do not comprise all the Trust’s work in relation to patient safety and quality; each strategic business unit has detailed, annual work-plans which they are implementing. Ward action plans need to be monitored to ensure they are effective.

• Through the Patient Safety Committee, YDH is considering

innovative ways in which it can collect friends and family survey data.

There was discussion about the importance to YDH of implementing learning/best practice and of leadership in enhancing quality and patient safety culture. Mark Saxton asked whether, as part of their walk-rounds, there is anything additional the non-executives could do to further improve patient safety culture. Jo Howarth said she would give this further thought, that she valued the contribution and challenge brought by the non-executives as part of the walk-rounds and that she would produce a report explaining their impact. The Board thanked Jo Howarth and the clinical governance team for their work in this area.

JHOW

1-44/15 DIRECTOR OF NURSING AND CLINICAL GOVERNANCE REPORT, INCLUDING SAFER STAFFING • While the Trust has strong infection prevention performance, 2

MRSA bacteraemia have been confirmed. The first investigation is being undertaken and an update will be presented to CGAC on 17 April 2015. In terms of the second case, YDH will request external scrutiny as part of the investigation. These cases are the first since March 2013 and Helen Ryan said the Trust is taking their incidence very seriously and will ensure any lessons learned are actioned. While there remains a high level of norovirus in the community and previously there were cases at YDH, currently there is no incidence at the Trust.

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Wendy Grey, Infection Control Lead, has met with the estates team to consider the practical preventative measures that could be put in place at YDH. C.difficile infections have continued to rise and although the target threshold has been breached, this is reflective of traditionally strong performance resulting in challenging target rates. YDH is below the target of those infections that are deemed to be avoidable.

• YDH continues to progress its focused nursing recruitment

campaign which is a key priority to reduce ongoing dependency on agency/bank nurses due to ongoing escalation. Recruitment in Italy has been a positive experience and a number of appointments have been made. A dedicated support package will be put in place for them and they are committed to remain at YDH for at least one year. Other local recruitment activities are also in progress; 12 nurses have been appointed as part of the return to the acute care environment scheme and 5 nurses have been appointed following the submission of their CVs.

• Helen Williams, Associate Director and Head of Midwifery, has been in post for three months and is continuing to develop plans to further improve maternity services at YDH. Jane Henderson suggested this requires further scrutiny and Helen Williams will present an overview of maternity services at CAGC on 17 April 2015.

• Helen Ryan has agreed a scope of work with PwC who are

supporting YDH with CQC readiness preparation. Their baseline assessment will be presented to the Board in June 2015. YDH is also reviewing learning from the CQC outstanding rating recently ascribed to Frimley Heath NHS Foundation Trust following inspection.

• Chris Routley, Matron for Child Health, retired on the 30 March

2015 after 35 years service, for which she was thanked by the Board. Anna Cannon, who is currently a Sister in ED with a wealth of paediatrics experience, has been appointed in her place. There have also been changes to ward sister posts on 6a and 9b.

• There has been a never event at YDH involving a minor

procedure. While no harm was suffered by the patient, the Trust is taking the incident very seriously and an investigation is in progress, an overview of which will be presented at a future meeting of the Board or CGAC.

The Board noted the enclosed safer staffing report.

HR

1-45/15 MEDICAL DIRECTOR REPORT In the absence of Tim Scull, Jon Howes presented highlights from the Medical Director’s written report, from which it was noted that:

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• Recruitment to junior doctor expansion roles, which have been made available to ease pressures on junior physicians, has been somewhat successful, although since appointment some have moved-on. There remain consultant vacancies in certain specialties where recruitment efforts have not been successful due to national workforce shortages. Locum and agency medics remain in place where these vacancies cannot be covered by internal arrangements. There has been positive reception to the Trust’s recent recruitment exercise to appoint GPs to the Symphony Hub, which presents an opportunity to deliver care as part of a new, integrated model. Connected to this, YDH is continuing to work and meet with NHS Health Education South West to consider future training for clinical staff aligned to the integrated care agenda.

• YDH recently and successfully hosted the Practical Assessments of Clinical Examination Skills (PACES) for doctors aspiring to become a medical consultant.

• Representatives (including clinicians) from the Trust have reviewed the AMSURG facilities in the USA, including two day surgery centres, learning from which will be beneficial to YDH in the development of its primary and acute care system (PACS) model of care.

1-46/15 CHIEF EXECUTIVE REPORT

Paul Mears presented highlights from his written report, from which the Board noted that: • The bid, led by YDH, with the Somerset CCG, South Somerset

GPs, and Somerset County Council, to become one of the Government’s vanguard sites, has been successful, for which the executive team and Paul Mears and Jeremy Martin, Symphony Director, in particular were congratulated by the Board. Building on the Symphony project, this is a positive step in the Trust’s long-term aims to develop in South Somerset an integrated model of care aligned to the PACS set out in the NHS Five Year Forward View, which has cross-party political support. Local GPs will be integral partners to the ongoing development and implementation of proposals. As YDH progresses its strategic plans, operational delivery, quality, safety and performance must remain of parallel focus and the impetus for transformational change. By being a vanguard, YDH is eligible to access transformation resource, along with revenue support, for the implementation of its long-term plans, a business case for which has been submitted. Clarity is still required about the way this resource will be processed. As part of the vanguard process, NHS England is undertaking a site visit in April to meet with the key stakeholders. Regular vanguard updates will be scheduled at future Board meetings.

• Monitor has provided feedback on the Trust’s Q3 financial and operational position, which is enclosed.

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It confirms a continuity of services risk rating of 2 and that the governance risk rating remains under review as the investigation into the Trust’s short-term financial challenges is ongoing. Monitor has submitted clarification questions on the new models of care business case, to which YDH is responding.

• The independent report into serious incidents in the maternity

department at Furness General Hospital (FGH) (“the Morecambe Bay Report”) has been published. Helen Williams, Associate Director and Head of Midwifery, is currently reviewing the recommendations and undertaking an assessment of any areas of learning for YDH, which will be presented to CGAC on 17 April 2015.

• An independent lessons learned report into the activities of Jimmy Savile within NHS hospitals has been published, the recommendations of which will be reviewed by YDH so feedback can be provided to Monitor by 15 June 2015, the key elements of which will be presented to CGAC on 17 July 2015.

• Following the provider veto to the proposed NHS tariff, interim

arrangements have been put in place. The annual planning timetable has been revised as set out in the enclosed report.

Paul Mears verbally advised that YDH is about to enter purdah period and will adhere to the rules and conduct required of public bodies. Prior to purdah, YDH representatives equitably met with a number of local candidates.

HR

1-47/15 CHIEF FINANCE AND COMMERCIAL OFFICER REPORT AND FINANCIAL RESILIENCE COMMITTEE UPDATE Tim Newman presented highlights from his written report, from which the Board noted: Financial Position (February 2015) and Annual Planning 15/16 • Year to date, the financial deficit is £7.0m, which is £4.6m

adverse variance to budget. The in-month financial performance demonstrates a deficit of £1.1m, which is £0.2m adverse to budget but £50k better than the latest forecast. The exceptional and unprecedented operational pressures and associated medical and nursing agency, locum and bank expenditure continue to contribute the greatest adverse cost pressure. Further financial detail is included within the operational and financial report.

• The month end cash position was £2.9m largely as a result of

some capital projects being delayed (capital expenditure year to date is £4.3m which is £1.4m less than planned), the continued application by the finance team of a cash mitigation plan and advance invoicing from the Dorset CCG. The Somerset CCG has agreed in principle to “double invoice” from April 2015 and so cash support would not be required until August 2015.

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Julian Grazebrook said that as the Trust starts work in line with the vanguard new models of care, initial expenditure may be incurred before transformation resource is secured through the business case which could impact the Trust’s cash position. A full six month programme schedule with costs should be developed and presented at a future meeting of the Financial Resilience Committee.

• Year to date, YDH has achieved £2.4m of CIP savings against

a plan of £3.0m, of which £1.7m is recurrent.

Following discussion at the Financial Resilience Committee, Tim Newman tabled a presentation on CIP for 2015/16, about which the non-executives had requested clarity on the detailed plans and deliverability. Tim Newman acknowledged that plans, which are under development, are required to ensure achievement of the Trust’s intended 2015/16 CIP, particularly as the savings target of £2.9m is relatively conservative. He added that a contingency of £1.0m, which predominately relates to the 1% items, has been set against the £2.9m resulting in a net CIP of £1.9m. The schemes identified to date total £1.8m. Tim Newman said additional resource has been secured to provide focus to the CIP programme. A further update on the detailed CIP plans and progress would be presented to the Board at its meeting on 20 May 2015. Tim Newman verbally advised that the contract negotiations for 2015/16 with the Dorset CCG have been settled and that they have agreed an additional £250k for 2014/15 for operational pressures and a 3.8% increase in funding for 2015/16. Negotiations with the Somerset CCG are ongoing and the Trust’s plans for 2015/16 are not yet aligned with that of its primary commissioners. While YDH is predicating growth with population and service developments applied to forecast outturn, the Somerset CCG has offered flat cash and applied a layer of QIPP savings to fund admission avoidance schemes, detailed plans for which have been requested by YDH in order to understand how they will reduce admissions in practice and to mitigate the risk of efficiency schemes being counted by both organisations. The non-executives said that YDH should pursue the contract negotiations with the Somerset CCG to ensure it is based on realistic activity assumptions. Financial Resilience Committee • Julian Grazebrook confirmed that at its meeting on 25 March

2015, the Committee received an update on the Monitor investigation, the new models of care business case, the February financial position, contract negotiations, and the Trust’s 2015/16 going concern status.

Estates and Workforce The enclosed estates and workforce updates were noted.

TN

TN

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Tim Newman highlighted changes to the HR back office function to enable focus on nursing and medical recruitment, with a dedicated team to manage responses to other queries. Commenting on work with Bath University to develop a new and practical management and leadership training programme for senior staff and other managers, Mark Saxton asked when Andy Sant and Meredith Kane would provide feedback at a Board seminar session on their experiences of the NHS leadership fast track scheme, learning from which could be built into the new programme. Jade Renville advised that it is scheduled for 29 April 2015.

1-48/15 OPERATIONAL AND FINANCIAL PERFORMANCE REPORT AND UPDATE ON FAST FORWARD PROGRAMME The Board reviewed the previously circulated report and the Chairman asked executive directors to verbally provide further details by exception. In doing so, he acknowledged that the Trust remains under significant operational pressure and thanked the clinical teams and strategic business units for continuing to provide care to patients in challenging circumstances. In February 2015, YDH did not meet by a margin (94.55%) the 95% target of patients seen and discharged within 4 hours from A&E. Jonathan Higman added that demand and A&E attendances increased during this period. Jonathan Higman said any breaches in meeting the two week exhibited breast cancer screening target were as a result of patient choice. In any case, the draft data (to be validated) for February 2015 indicates the 93% target was met. In terms of achieving the 31 and 62 day cancer treatment targets, draft data (to be validated) for February 2015 indicates there have been challenges in meeting the targets which Jonathan Higman said Teresa Coombes, Cancer Services Business Manager, is keeping under review. Discussion about patient safety and infection control [item 1 -44/15] occurred during the course of the meeting and was not repeated. Jonathan Higman and Leah Allen tabled a presentation on the Trust’s fast forward initiative, which YDH operated from Monday 16 March 2015 - Sunday 22 March 2015. The initiative aimed to proactively address the relentless and unsustainable operational demands which pose risks to patient experience and quality of care, the levels of delayed discharges, the number of cancelled operations and the Trust’s black/red escalation status. During fast forward, YDH used the gold, silver and bronze command procedures to respond to issues, engaged with partner organisations and empowered and supported frontline staff to make pro-active operational changes to improve efficiency. Not all the aims of fast forward were met for while internal improvements were made, reliance on escalation areas reduced, discharges increased and clinical incidents reduced, there were significant increases in demand and A&E attendances which impacted the overall success.

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However, a number of lessons were learned and key themes identified which will help YDH manage operational pressures more efficiently in future. In response to questions from the Board about maintaining momentum, Jonathan Higman said fast forward could be undertaken at key strategic points during the year. The key outcomes will be linked with the Trust’s quality improvement work. Jane Henderson spoke of the impact of the operational pressures on patient outcomes, the quality of patient care and the number of cancelled operations and asked how the Trust is mitigating these risks. Helen Ryan referred to the quality assessment which she had explained at previous meetings [items 1-12/15 and 1-28/15 refer] and the actions arising from it. She added that identified risks are incorporated on departmental risk registers and those scored at 12 and above are placed on the corporate risk register for scrutiny by the assurance committees and the Board. Paul Mears added that in terms of cancelled operations, while this is below the standard YDH aims to deliver, all urgent operations and those relating to cancer were undertaken as scheduled. Commenting on RTT performance, Leah Allen said that the Somerset CCG has agreed for YDH to book patients chronologically (i.e., booked and treated according to length of wait and urgency) which will enable the Trust to clear the backlog of patients but will impact the Trust’s RTT performance. She added that no patients have been waiting for more than one year. Julian Grazebrook asked about the number of delayed discharges and why the “completion of assessment” historically accounted for so many. Paul Mears explained that within this category is the reliance on social care, for instance, to undertake external assessment. The decreasing trend demonstrates the improvements that have been made in this area. Workforce Performance The Board noted the workforce performance report. Financial Performance Discussion about financial performance [item 1-47/15] occurred during the course of the meeting and was not repeated here, although the additional detail was noted by the Board.

1-49/15 FEEDBACK FROM THE COUNCIL OF GOVERNORS HELD ON 18 MARCH 2015 Peter Wyman confirmed the Council of Governors had a positive and constructive meeting on 18 March 2015. There were no specific issues to report. John Hawkins concurred.

1-50/15 ANY OTHER BUSINESS There was no further business to discuss.

1-51/15 DATE OF NEXT MEETING The next meeting will be held on Wednesday 29 April 2015.

1

APPENDIX 2 BOARD OF DIRECTORS

29 APRIL 2015

BOARD OF DIRECTORS – ACTION SHEET 29 APRIL 2015

Minute Action Outcome Due By

ACTIONS FROM 16 APRIL 2014 1-56/14 Arrange a seminar session on the

NHS Leadership Fast Track Programme with Dr Meredith Kane and Dr Andy Sant.

On seminar agenda

ACTIONS FROM 15 OCTOBER 2014 1-137/14 Lessons learned report to be

considered by the Board following the implementation of VitalPAC.

Deferred -April 2015

HR

1-137/14 E-rostering demonstration to be provided to the Board.

On Board agenda

ACTIONS FROM 19 NOVEMBER 2014 1-151/14 Update on NoF developments

and next steps to be presented to the Board.

Not yet due Deferred –June 2015

LA/MH

ACTIONS FROM 28 JANUARY 2015 1-19/15 Arrange update or seminar

session on fire management. Update included

within CFO Report

1-15/15 Undertake a review of staff turnover.

In progress TN/MA

ACTIONS FROM 25 MARCH 2015 1-42/15 SEP is undertaking a thorough

review of fire, health and safety, an update on which will be presented to the Board.

Not yet due June 2015 TN

1-43/15 Report on the learning from non-executive walk-rounds to be developed.

In progress May 2015 JHOW

1-44/15 Overview of never event and MRSA investigations to be presented to the Board

In progress By June 2015

HR

1-46/15 Overview of Morecambe Bay Report to be presented at CGAC

Complete

1-47/15 New models of care - six month programme schedule, with costs, to be developed and presented at the Financial Resilience Committee.

In progress May 2015 TN

1-47/15 Update on the detailed CIP plans and progress to be presented to the Board.

Not yet due May 2015 TN

APPENDIX 3 BOARD OF DIRECTORS

29 APRIL 2015

Report to: Board of Directors Report from: Paul Mears Subject: Chief Executive Report Date: 29 April 2015 Somerset CCG Clinical Risk Assessment

The Board has discussed recently the challenging situation that the Trust has experienced over several months in maintaining operational flow through the hospital. The Board has recognised the continuous escalation that the hospital has been under has had a negative impact for patients and staff and we have continued to raise this with the Somerset CCG.

The Somerset CCG has recently undertaken a clinical risk assessment for YDH of opening escalation beds in the day surgery unit as well as reviewing the risks associated with opening beds in South Petherton Community Hospital.

They recognised the risks and the impact it would have on patients at YDH but also acknowledged that Somerset Partnership NHS Foundation Trust were having considerable difficulty recruiting registered nurses to staff the beds in South Petherton. The Somerset CCG has therefore asked that we work with Somerset Partnership to support recruitment and develop a plan as to how we propose to work more closely with their organisation moving forward. A copy of the letter from the Somerset CCG is appended to this report.

The Chairman and I are currently planning to arrange a meeting with our counterparts at Somerset Partnership to discuss the points raised by the Somerset CCG and will report back to the Board following this meeting.

New Commissioning Proposals for Somerset

Somerset CCG, NHS England and Somerset County Council are currently reviewing the way in which services are commissioned in the county. The three commissioners have expressed their intention to develop a new model of contract from April 2016 where the focus would be on outcomes based commissioning for a population of patients.

This new commissioning model would be a significant change from the existing approach but would very much support the work we are doing with primary care to develop an integrated model of provision for the local population. The Somerset CCG has commissioned COBIC and PwC to support them in developing their proposals with an expectation that they will be seeking approval from the CCG Governing Body in July to move to a new commissioning model.

A letter from David Slack, Accountable Officer at the Somerset CCG, is appended to this report and representatives from YDH will be attending a workshop run by the commissioners on 22 April to discuss these proposals in more detail.

Care Quality Commission (CQC) Safeguarding Children Review

Health and social care has recently been subject to an unannounced review by the CQC into safeguarding children arrangements in Somerset. The review was run over five days and involved all the NHS providers in Somerset with the CQC spending time at YDH in the emergency department, paediatric ward and maternity.

A verbal update following the inspection will be provided by the Director of Nursing and Clinical Governance at the Board meeting.

Director Responsibilities

The Board will know that there are a number of key strategic projects underway within the organisation that are important to the delivery of the Trust’s strategy. To ensure that there is sufficient executive capacity to lead these projects I have agreed with Jonathan Higman that he will take on a new role of Director of Strategic Development from the middle of June. Jonathan will continue to report to me and will remain a non-voting member of the Trust Board.

To fill the role of Director of Urgent Care and Long Term Conditions on an interim basis a new Director, Simon Sethi, will be joining the Trust in June. A graduate from the NHS Management Training Programme, he is currently Programme Director for Urgent Care at Gloucestershire CCG and has also worked previously in operational management roles in acute hospitals.

Meeting with Taunton and Somerset NHS Foundation Trust

The Chairman and I met recently with Sam Barrell and Colin Drummond the Chief Executive and Chairman of Musgrove Park. We discussed opportunities for collaboration between our two organisations, the challenges facing both acute providers and the developing commissioning plans of Somerset CCG.

~ Somerset

Our Ref: DS/lw Clinical Commissioning Group

25 March 2015

Wynford HouseSent bye-mail Lutton Way Lutton

Edward Colgan, Chief Executive Yeovil SomersetSomerset Partnership NHS Foundation Trust BA228HR

Paul Mears, Chief Executive Tel: 01935384000 Fax : 01935 384079 Yeovil District Hospital NHS Foundation Trust

enquiries@somersetccg.nhs.uk

Dear Edward and Paul

Health System Quality Impact Assessment

I am writing following our telephone call on Friday 6 March 2015 to discuss the quality impact assessments of caring for patients in the day surgery area at Yeovil District Hospital, and similarly for reopening beds at South Petherton Hospital. Lucy Watson Director of Quality, Safety and Governance coordinated the quality impact assessment to consider the risks to patient care being managed across the health system, with Helen Ryan, Director of Nursing and Governance, at Yeovil District Hospital NHS Foundation Trust and Sue Balcombe, Director of Nursing and Patient Safety, at Somerset Partnership NHS Foundation Trust. The impact assessment process was initiated by the CCG following a request from Yeovil District Hospital to reopen the eight beds temporarily closed at South Petherton Hospital , when the Trust was experiencing particularly high levels of demand and escalation at the end of last month . The level of demand had resulted in the Trust having to continue to keep open beds for patients in day surgery which does not meet the standards for inpatient care.

The quality impact assessment for caring for patients in the day surgery area at Yeovil District Hospital NHS Foundation Trust demonstrated the risks to quality of care for patients are that there are no washing facilities , limited toilet facilities, care is provided by a mix of permanent staff from other clinical areas, and there are delays in treatment and care for patients due to the nature of the case mix and medical staff having to care for patients in the day surgery area as well as in inpatient wards. There is also an increased risk of patient falls due to the nature of the environment and an increased risk of medication errors due to the use of agency staffing and lack of continuity of care. The Trust also considered the impact on patients waiting for elective surgery whose operations are postponed as a result of the day surgery area being unavailable. The Trust requested opening of the South Petherton beds with a view to being able to stand down the use of escalation beds in day surgery and so that patients are cared for in environments designed for inpatient care.

Chair: Dr Matthew Dolman I Managing Director: David Slack /MINDFUL

VEMPLOYER Clinical Leadership to Improve Health

www.somersetccg.nhs.uk

Somerset Partnership NHS Foundation Trust temporarily closed eight beds at South Petherton Hospital in March 2014 as a result of a high number of nursing vacancies and a lack of response to recruitment to vacant nursing posts . The Trust has continued to attempt to recruit to the vacant posts since this time with little success. The Trust has been able to reopen temporarily closed community hospital beds in other parts of the county during November and December 2014 and in January 2015, but have informed the GGG that recruitment of registered nursing staff at South Petherton Hospital remains a challenge.

The quality impact assessment undertaken by Somerset Partnership NHS Foundation Trust indicated that staffing the 16 beds in use on the inpatient ward remains a challenge. On nearly half of the shifts there is only one permanent member of registered nursing staff with an agency registered nurse usually also on duty but in some cases the shift has to manage with only one registered nurse. The ward sister post is currently vacant and clinical leadership is compromised. The staffing in a community hospital setting is considered in the absence of other wards where clinical nursing staff may be called on to assist or to flex staffing for managing sickness. The Trust has been seeking agency staffing to cover all shifts at the hospital on a daily basis and has struggled to cover the current shifts. The quality impact assessment for opening further beds at the hospital identified the increased shortfall in nursing staff if additional beds were opened and considered the patient group who are stroke patients with associated high level of dependency and acuity. The Trust considered that it would not be possible to secure agency staffing for these beds and therefore additional beds would increase the risk of falls and pressure ulcer incidence in the current patients, and increase challenges to provision of basic care and nutritional support.

The GGG reviewed the quality impact assessments with the Directors of Nursing from both Foundation Trusts through a telephone conference and afterwards with the Director of Nursing and Quality for NHS England South West sub region. As a result of these reviews the GGG reached a conclusion that both Trusts were managing a set of individual risks in providing quality of care in each clinical setting. The nature of the risks were different due to the different clinical environments and the differing needs of the patient case mix. The impact assessments did not indicate that there was a clear reduction in risk to patient care to be achieved through opening additional beds at South Petherton and that it would not be possible at the present time to secure staffing on a sustainable basis to open these additional beds.

The GGG has been clear that it does expect Somerset Partnership NHS Foundation Trust to reopen the eight temporarily closed beds at South Petherton Hospital during 2015. The process of quality impact assessment across the health system has indicated a number of key actions to be taken to resolve this situation . Firstly that Somerset Partnership should continue to take every action to recruit to the vacant nursing posts and the GGG will monitor this position actively with the Trust. Secondly that it is essential that Somerset Partnership successfully recruit to the vacant ward sister post to secure a stable staffing establishment and quality of care at the hospital.

The GGG has requested that Yeovil District Hospital provide support to Somerset Partnership in securing an experienced registered nurse for the post of ward sister who can provide strong clinical leadership in stroke care to the nursing team for this stroke rehabilitation unit. We would encourage Yeovil District Hospital to assist with this where possible and continue to support the patient journey in stroke care across the pathway.

The CCG will monitor this position actively with Somerset Partnership and requests that the Trust provides an action plan for recruitment to the ward sister post and to vacant posts so that the Trust can reopen the eight beds.

Carrying out a joint quality impact assessment on this issue has raised concerns about the degree of communication and co-operation between the two Foundation Trusts at a senior level. The eCG is therefore requesting that you arrange for the contents of this letter to be shared with both your Boards and to agree between the two organisations on the steps that will be taken to ensure that both organisations discharge your legal and contractual duty to co-operate effectively in providing high quality care to local communities. We are asking that a shared plan is produced setting out how Yeovil District Hospital and Somerset Partnership will work together at a senior level to deliver both the required staffing at South Petherton and the Vanguard proposals. This plan should be available by 31 May 2015 to allow the CCG to have assurance that every opportunity is being taken to work co-operatively to deliver the highest quality care in South Somerset.

Yours sincerely

David Slack Managing Director

Copy:

Lucy Watson, Director of Quality, Safety and Governance, Somerset CCG Sue Balcombe, Director of Nursing and Patient Safety , Somerset Partnership NHS Foundation Trust Helen Ryan, Director of Nursing and Governance, Yeovil District Hospital NHS Foundation Trust

~ Somerset

Our Ref: DS/sf Clinical Commissioning Group

20 April 2015

Wynford HouseDr Sam Barrell, Chief Executive Lufton WayTaunton and Somerset NHS Foundation Trust Lufton

Yeovil SomersetEdward Colgan, Chief Executive BA228HR

Somerset Partnership NHS Foundation Trust Tel: 01935384000 Fax: 01935 384079 Paul Mears, Chief Executive

Yeovil District Hospital NHS Foundation Trust enquiries@somersetccg.nhs.uk

Dear Colleague

Commissioning of Joined-Up Person-Centred Care

I am writing to update you on the Somerset commissioners' intentions to consider a move to an outcomes-based contracting model for Joined-up Person-Centred Care. With the County Council and NHS England we have continued to build on the plans first set out in my letter to you dated 2 October 2014.

There have been a number of developments over the past few months as a consequence of our commissioning intentions:

• The four Local Implementation Groups (L1Gs) are operational • Three of the four L1G areas have 'Test and Learn' pilots to develop person-centred

services for people with three or more Long Term Conditions • The most mature 'Test and Learn' pilot is the Symphony project in South

Somerset, and this was selected to be part of the NHS England 'Accelerator' programme, and more recently to be one of 29 'Vanguard' or 'Forerunner' sites across the UK developing 'New Models of Care'

• The CCG, in supporting South Somerset in the Vanguard application also made the case for resources to enable commissioner reform and the development of the other 'Test and Learn' pilots.

In parallel to these initiatives, the CCG commissioned a 'stocktake' report from Cobic Solutions Ltd which explored the appetite to move to an outcomes-based contract using capitated budgets, and the health and care system's ability to respond to such a move in terms or capability and capacity. The stocktake report was broadly positive (its summary findings are attached as Annex 1).

As a consequence, the CCG and its partner commissioners (SCC, and the Local Area Team) have agreed to prepare an options appraisal and business case to be presented to the respective governance bodies in July 2015 . These documents will become the key decision documents on whether to proceed to an outcomes-based contract and what the scope of such a move might be.

Chair: Dr Matthew Dolman I Managing Director: David Slack / MINDFUL

V EMPLDYER Clinical Leadership to Improve Health

www.somersetccg.nhs.uk

To support the preparation of the business case, the commissioners ran a competitive procurement process to hire external advisors . Following completion of the competition, I can report that we have appointed a joint team from PWC and Cobic Solutions Ltd.

Our intention is that over the next few months the commissioners will work closely with the provider community and other stakeholders (to include patients, carers and the voluntary sector) to agree the key components of a future commissioning offer. These could include: the vision for patient experience; scope including consideration of geography and population; the balance of prevention and treatment; the identification of capitated budgets; operational challenges; and risk and reward structures.

Any formal process to recommission services would not begin before July 2015 and we will be exploring the use of a most capable provider approach. Between now and then, however, we would seek to involve you in the system design discussions both formally and informally.

A joint provider and commissioner workshop has been arranged for 22 April, to which you and your colleagues have been invited. There will be other events arranged to encourage provider input into the options appraisal and business case and, of course, there are the regular forums through which information will be shared (Leadership Group, STG and COG for example).

The move to a new contract structure would be challenging but offers the opportunity to reassess and improve how the people of Somerset receive health and care services in a more focused, joined up and sustainable way.

Yours sincerely

David Slack Managing Director

Copy:

Anthony Farnsworth, Director of Commissioning Operations, NHS England South Region, South West Patrick Flaherty, Chief Executive, Somerset County Council Dr Sue Roberts, Chair, Somerset Local Medical Committee Alison Foulkes, Chief Executive, Somerset Primary Healthcare Ltd

Federation Chairs Dr Stephen Gardiner (COG Delegate), Bridgwater Bay Health Federation Dr Geoff Sharp, Central Mendip Federation Dr Emeline Dean, Chard, Crewkerne and IIminster Federation Dr Helen Kingston, East Mendip Federation Dr Carol Reynolds, North Sedgemoor Federation Dr David Cripps , South Somerset Healthcare Federation Dr William Chandler, Taunton Deane General Practice Federation Dr Mike Pearce, (COG Delegate), West Mendip Federation Dr David Davies, West Somerset Federation

Local Implementation Group Chairs (L1G) Dr Stephen Gardiner, Somerset Coast Dr Mike Gorman, Taunton Dr Geoff Sharp , Mendip Dr lain Phillips , South Somerset

Annex 1

Key Findings from Cobie 'Stakeholder' Report January 2015

1. Three key themes emerged from the interviews with stakeholders in Somerset:

a. A great energy and appetite for change within stakeholders in Somerset. b. A [perceived] lack of clarity around the CCG's vision for person-centred,

integrated care and how it will be delivered . c. Providers' desire for commissioners to be strong leaders and exert authority

over the next 12 months.

2. Somerset GGG's readiness for a move to an outcomes-based commissioning contract was assessed:

a. In general , there is strong evidence around the potential scope and population for an outcomes-based, incentivised commissioning contract for people with Long-Term Conditions in Somerset, and some robust outcomes work that has been completed around the initial Symphony population of those with 3 or more comorbidities. There is also considerable financial data and modelling available for these populations.

b. Areas requiring further development include consistency around the chosen service model, the contractual form and procurement route, and the need to initiate open engagement with providers in Somerset around what will be required from them and when, particularly around the role of primary care.

3. Areas for further consideration and analysis:

a. Scope and target population - selection of population based on the number of long-term conditions, or 'all adults' or another defined cohort.

b. Geography - taking into account the rurality of Somerset, transport links to services and patient choice.

c. Funding - the CGG is considering a capitated budget approach. d. Procurement mechanisms - whether to move to open competition or selection

based on 'most capable provider' .

APPENDIX 4 BOARD OF DIRECTORS

29 APRIL 2015 Report to: Board of Directors

Report from: Director of Nursing and Clinical Governance Subject: Directors of Nursing’s Report

Date: 29 April 2015

Safe Staffing and Recruitment Maddie Groves, Associate Director of Nursing (workforce), will be presenting on this topic at the Board meeting. CQC Readiness The CQC readiness work with PwC has now commenced and a mock inspection is planned for 19 May 2015. The first stage of evidence gathering and meeting with key staff has been going well and I expect an update on the data gathering exercise w/c 4 May 2015. This exercise has already paid dividends in heightening awareness around the CQC domains and the whole inspection process. YDH has now been sent its draft CQC intelligent monitoring report for May which I will table in part 2 of the Board meeting as it wasn’t available in time to be considered by the CGAC on 17 April 2015. I have met with our new CQC Inspector, Carl Crouch, and we had a useful update on current issues at the Trust and establishing working relationships. Infection Control An overview of rates of c.difficile is provided in the Medical Director‘s Report. I will be in position to verbally share learning following investigation of the two recent cases of MRSA bacteraemia. A CCG assurance visit took place on 22 April on wards 9A and 6A. The team met staff and patients and we have had favourable feedback on the day of the visit. I will be able to share the report with CGAC when it has been published. Patient Experience I have commissioned a review of the Patient Experience Team to establish that this newly formed service has sufficient resources and skills to deliver against challenging standards. I am very pleased with the team’s progress to date but am aware of the consistent pressure they are under and would like to undertake a piece of work to ensure we have the key responsibilities correctly established. I am delighted that Hala Hall (Public Governor) has agreed to undertake this work along with a review of our volunteers service in response to the Lampard Report. I am delighted to report that we will go live with the new patient meal service from Steamplicity on 12 May 2015 (NURSES DAY…) Nursing/Midwifery As well as good progress with the current recruitment campaign, I am pleased to confirm the changeover to new uniforms for some job roles which will take effect from 12 May 2015 (NURSES DAY!) The main change will be a new royal blue uniform for staff nurses and navy blue for all sisters.

Helen Williams, Associate Director and Head of Midwifery, gave an excellent presentation to CGAC on the findings and areas of learning from Morecambe Bay and a comparison with our own unit. This was also an opportunity for Helen Williams to give a wider overview of her first impressions in the five months since joining the Trust; this was refreshing and reassuring and gave insight into the key actions for the next year.

Board of Directors Meeting

April 2015

Director of Nursing Report

Monthly Report of Nurse/Midwifery Staffing Levels

1 March 2015 - 31 March 2015 EXECUTIVE SUMMARY The NHS National Quality Board published a new guidance in November 2013 to support providers and commissioners to make the right decisions about nursing, midwifery and care staffing capacity and capability “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 Staff Capacity and Capability. There are nine key expectations that apply to the Trust: 1. Boards take full responsibility for the quality of care provided. 2. Processes are to be in place to enable staffing establishments to be met on a shift by

shift basis. 3. Evidence based tools to be used. 4. Clinical and managerial leaders foster a culture of professionalism and responsiveness

where staff feel able to raise concerns. 5. Multi-professional approach is taken when setting staffing establishments. 6. Sufficient time to undertake care and duties in practice. 7. Boards receive monthly updates on workforce information and staffing capacity and

capability and is discussed at public Board meetings every six months. 8. Clearly display information about the nursing and care staff present on each ward,

clinical setting or service on each shift. 9. Provider to take an active role in securing staff in line with their workforce requirements. PURPOSE The purpose of this report is to provide the Board of Directors with monthly information regarding the nursing and midwifery registered and unregistered staffing levels on a shift by shift basis of the planned and actual nurse staffing levels across the organisation and across inpatient areas of the Trust as per the guidance received from NHS England and the Care Quality Commission. METHODOLOGY AND SCOPE FOR REVIEW This report focusses on all adult inpatient areas including Critical Care, inpatient maternity wards and inpatient paediatric wards. With the Trust working towards the 1:8 ratio as recommended in the National Safe Staffing Alliance for relevant adult wards. For the purpose of this report non inpatient areas such as the operating theatres, day theatre, endoscopy and emergency department are currently excluded.

KEY POINTS National Unify return Safer Staffing: A Guide to Care Contact Time published November 2014 acknowledges

that safe staffing is more than just looking at the number of staff on the ward. Safe Staffing for Nursing and Adult Inpatient Wards in Acute Hospitals - Red Flags NICE Guidance:

- Safe staffing nursing in A&E Departments, draft currently out to consultation. - Safe midwifery staffing for maternity setting.

Recruitment: The current recruitment drive is ongoing. e-Rostering and implementation of bank booking system. Temporary Staffing and unfilled shifts: Activity continues to be challenging with

escalation areas remaining open. Unify return

Day Night Day Night

Ward name

Registered midwives/nurses Care Staff Registered

midwives/nurses Care Staff Average fill rate -

registered nurses/

midwives (%)

Average fill rate - care staff

(%)

Average fill rate -

registered nurses/

midwives (%)

Average fill rate - care staff

(%)

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

JW 987.5 1121 1229.5 1494.5 775 775 600 657.5 113.5% 121.6% 100.0% 109.6% Kingston Wing 713 713 713 730 713 713 356.5 356.5

100.0% 102.4% 100.0% 100.0%

6A 1030 1014.5 1535.5 1709 713 724.5 589 623.5 98.5% 111.3% 101.6% 105.9%

6B 1309.5 1194 1558 1674.5 1023.5 1035 713 760 91.2% 107.5% 101.1% 106.6%

7A 1208.5 1173.5 1022.5 1053.5 713 713 713 701.5 97.1% 103.0% 100.0% 98.4%

EAU 1314 1219.5 1698.5 1717 1069.5 1069.5 713 747.5 92.8% 101.1% 100.0% 104.8%

8A 1047 1040.5 1324.5 1434.5 713 724.5 701.5 701.5 99.4% 108.3% 101.6% 100.0%

8B 1125 1024.5 1479 1467.5 713 724.5 713 747.5 91.1% 99.2% 101.6% 104.8%

9A 1250 1187.5 1075 1206.5 713 736 713 770.5 95.0% 112.2% 103.2% 108.1%

9B 1040.5 1040.5 1216 1223 713 701.5 713 724.5 100.0% 100.6% 98.4% 101.6%

10 1047 1012 379 505 1069.5 1069.5 0 11.5 96.7% 133.2% 100.0%

ICU 2358.5 2382.5 155 155 2495.5 2530 0 0 101.0% 100.0% 101.4%

CCU 1384 1378.5 0 5.5 872 872 0 11.5 99.6% 100.0%

Freya 2857.5 2542.5 997.5 862.5 1953 1701 651 609 89.0% 86.5% 87.1% 93.5%

SCBU 930 930 465 412.5 294.5 275.5 294.5 237.5 100.0% 88.7% 93.5% 80.6%

Safer Staffing: A Guide to Care Contact Time A Guide to Care Contact Time in November 2014 acknowledged that safe staffing is more than just looking at the numbers of staff on a ward. We have now engaged the support of both Plymouth and Bournemouth Universities to allow us to utilise student nurses in assisting in our data collection. The data gathering tool for the iPAD has been devised and tested and we are now ready for implementation. The first audit is planned to take place during April and May 2015. The Guidance recommends that a registered and unregistered nurse are audited on a week day and a weekend day, however if the resources allow we

would like to audit over the seven day period for both a registered and unregistered nurse to give us more detailed baseline data. We are required to carry this out on a six monthly basis however as an organisation if we have the resources we would like to do this more frequently. The care contact time should be considered alongside other indicators which could include planned v’s required v’s actual staff numbers and quality matrix such as NICE Red Flags and Friends and Family test. The presentation of this data to the Board in a meaningful way is currently being explored. Safe Staffing for Nursing and Adult Inpatient Wards in Acute Hospitals - Red Flags The NICE Guidance issued in July 2014 recommends that wards nursing staff establishment is monitored to ensure that it adequately meets the patients nursing needs using the safe nursing indicators. An aspect of this is giving the staff the opportunity to raise a Red Flag incident. These incidents are: Unable to meet the specified regular checks on individual patients A 30 minute delay in providing adequate pain relief A medication administration error occurs Vital signs are not recorded at the specified time Less than two registered nurses are present on a ward The shortfall of registered nurses is greater than 8 hours or 25% A Red Flag that has been developed and tested and is now available on Trust iPADS and computers. This gives staff the opportunity to raise a Red Flag anonymously in line with the Trust’s open and transparent Raising Concern Policy. The Director of Nursing, Associate Director of Nursing and Matron for the clinical area receive notification of the Red Flag and the Matron is responsible for ensuring that the Red Flag Event is actioned and recorded on the APP. Further education of staff is required for using the tool with the Red Flag Events being included in future Board Reports. Safe Staffing for Nursing in Emergency Departments The draft guidance for Safe Staffing for Nursing in Emergency Departments has been reviewed and the position paper is currently with the Business Unit for comment and to consider the recommendations. Safe Midwifery Staffing for Maternity Settings The Head of Midwifery has reviewed the guidance and has presented to HMT her recommendations for staffing levels within the Unit. Recruitment

The recruitment campaign continues and the following activity took place in March 2015: Three rolling fortnightly interviews with 17 candidates scheduled for interview and five

being offered posts with four currently actively progressing.

RACE Course: 12 registered nurses commenced in post on 16 March with just one candidate withdrawing after their start date. This has been followed up and there were genuine reasons for her withdrawal. This has been publicised in the Western Gazette on line and in addition the Nursing Standard. Following this the Nursing Standard now wish to write a feature piece on one of the RACE nurses, which will help to raise our profile as an ‘employer of choice’.

Italian Recruitment: An extended recruitment drive took place in Italy with 47 nurses being offered positions and 41 currently in active progress.

Spanish Recruitment: An additional recruitment drive took place in Spain on 7 - 9 April 2015 with 14 nurses being offered positions and 13 currently in progress.

With recruitment overseas an attrition rate of 10% should be expected. Currently we are expecting a cohort of 17 nurses commencing in post on the 11 May 2015 with a four week teaching and supported introduction package with the plan that they will be in practice from 8 June 2015. There is a second cohort planned for 6 July with a date in practice of 3 August 2015. Non EU Recruitment

India: With NHS organisations throughout the country recruiting from the EU we also need to consider longer term plans of recruitment from outside the EU. We are currently exploring the possibility of recruiting directly from establishments in India. This has been recommended to us by two Indian members of staff who still have strong links with their training organisation. They have reassured us that there is a surplus of registered nurses and therefore the Trust recruiting would not have an impact on their health communities. This option will require significant planning which has already commenced as we are not proposing to use an agency, which will be more cost effective for the organisation. There are clear benefits from recruiting in this area in that our current staff are recommending us, the nurses are taught in English and are required to have two years post registration experience before they can leave their current employment; this would therefore give us a cohort of experienced nurses to complement our newly qualified.

Ad hoc Recruitment: There have been a total eight CVs received via the website, both registered and unregistered as well as direct e-mail enquiries to the Associate Director of Nursing and telephone calls to the Recruitment Line. These have all been followed up in a timely manner and interview dates offered as appropriate. All non EU candidates have been signposted for additional guidance from the Nursing and Midwifery Council (NMC).

e-Rostering The implementation of e-rostering continues with Maternity being the next phase planned. There is currently a risk with adequate staffing resources to maintain the implementation which is currently being addressed. Temporary Staffing Due to the continuing high vacancy rate and opening of escalation areas, ensuring safe staffing levels continues to be a challenge. The skill mix of every ward is reviewed daily by the Matrons and flexing of staff across all wards continues to ensure the provision of safe care including mitigating the risk of the unavailability of a registered nurse by using a health care assistant. Vacant shifts are escalated to the agencies as soon as the Staffing Solutions Office receives them. In addition, the Associate Director of Nursing reviews all shifts and escalates to Thornbury a week in advance in order to maintain safe staffing levels. There is a continued replacement of bank and less expensive agencies into shifts already filled by the more expensive agencies in order to reduce the financial risk to the organisation. An enhanced rate of pay has been offered to both registered and unregistered nurses to maintain our staffing levels and to try and meet the safe staffing level recommendations.

Positive feedback has been received from the wards with regards to the new staffing levels and that they feel they are able to provide a safer high quality care as a result. The following table indicates the number of bank / agency shifts used during March 2015. Bank and Agency Usage

10

9A

9B

8A

8B

AC

CU

7A

EAU

6A

6B

ICU

KW

JW

FREY

A

Labo

ur

SCB

U

TOTA

L

Registered

Bank

32 23 15 15 55 0 12 12 11 52 41 25 20 14 7 7 341

Unregistered

Bank

44 22 47 21 44 0 26 15 51 81 3 10 17 0 7 2 390

Total Bank 76 45 62 36 99 38 27 62 133 44 35 37 14 14 9 731

Registered

Agency

19 51 33 28 34 0 32 26 56 84 40 22 17 0 6 0 448

Unregistered

Agency

27 31 52 28 44 0 48 20 82 72 3 10 28 0 0 0 445

Total Agency 46 82 85 56 78 0 80 46 138 156 43 32 45 0 6 0 893

TOTAL Bank/Agency

122

127

147

92

177

0

118

73

200

289

87

67

82

14

20

9

1624

Unfilled Shifts The following table indicates the number of unfilled shifts across the ward areas for March 2015. During this time a total of 144 registered nurse shifts and 5 unregistered nurse shifts were unfilled using professional judgement. A total of 110 registered nurse shifts were not filled due to the unavailability of staff and a total of 51 unregistered shifts. The wards would have been working with less than the recommended number and the staff will have been required to prioritise the care they give in order to ensure a safe provision of service. In April these figures may rise as we will be working with the new safer staffing numbers. The number of time shifts fell below the agreed staffing levels continues to be collected manually and therefore there may be inaccuracies in the data. With the implementation of the safe care module in the future it is expected that there will be an automated accurate way of collecting data. When registered nurse shifts were unfilled by using professional judgement the shift will have been filled with an unregistered nurse where possible so that the number of staff on duty was sufficient, although the skill mix did not meet the 1:8 ratio. The vacancy rate continues to impact on the ward sisters achieving their supervisory status however we are planning with the new cohorts of nursing that this will be achieved and that the sisters will be able to supervise their new nurses in practice and ensure that they achieve their competencies in a timely manner. In Maternity and SCBU, 68 registered midwife shifts were uncovered and 33 registered shifts uncovered due to the unavailability of staff.

10

9A

9B

8A

8B

AC

CU

7A

EAU

6A

6B

ICU

KW

JW

FREY

A

SCB

U

TOTA

L

Using

Professional

Judgement

Registered

3 39 5 3 24 2 13 17 6 19 12 0 1 0 0 144

Unregistered

1 0 1 0 0 0 0 0 1 0 2 0 0 0 0 5

Nurse Not

Available Registered

3 3 1 1 2 1 5 14 3 8 1 0 0 64 4 110

Unregistered

0 0 5 2 2 0 2 1 1 5 0 0 0 22 11 51

TOTAL

7 42 12 6 28 3 20 22 11 32 15 0 1 86 15

Recommendations The Board of Directors is asked to note the information contained in this summary report and the actions currently in place.

APPENDIX 5 BOARD OF DIRECTORS

29 APRIL 2015

Report to: Board of Directors Report from: Tim Scull Subject: Medical Director Report Date: 29 April 2015 Medical Staffing The overseas recruitment project to appoint both senior and junior doctors continues. We have engaged the services of three agencies and CVs are being reviewed by the appropriate departments, a series of Skype interviews are planned as is an overseas interview event. We have a number of suitable applicants for our middle grade positions and, whilst not as numerous, some suitable applicants for some of the consultant vacancies. Associate Medical Director I am delighted to report the appointment of Dr Meredith Kane to the position of Associate Medical Director for Urgent Care and Long Term Conditions. Dr Kane is a Consultant Paediatrician who has recently returned to the Trust following completion of the NHS Leadership Fast Track Programme. In addition to her new role, she will continue to work closely with the ED team on their exciting projects. Junior Doctors The Group tasked with looking into ways of increasing the job satisfaction amongst junior doctors continues to meet regularly. Recruitment to increase numbers and hence both ward and 'take' cover is well underway with appointment to five of the seven positions, business cases and costing of augmented outreach and phlebotomy services are being prepared. The annual GMC survey of junior doctors is currently underway. Our DME, Mr Paul Foster, is being sent any comments being made on safety issues in real time, the number of these is significantly less than in previous years. Antimicrobial Stewardship As previously reported by the Director of Nursing and Clinical Governance, the Trust has breached its c. difficile threshold for 2014/15 as17 cases have been counted, 4 of which have been deemed avoidable. This overall number is similar to that experienced at Musgrove Park Hospital, with less avoidable cases attributed to our neighbours. The two trusts share the same lead for anti-microbial stewardship and we are currently working with this microbiologist to strengthen our adherence to local antibiotic guidelines and to understand the reasons behind differences in local and national guidance.

APPENDIX 6 BOARD OF DIRECTORS

29 APRIL2015

Report to: Board of Directors Report from: Tim Newman Subject: Chief Financial and Commercial Officer Report Date: 29 April 2015 Estates Update YDH has now received the results of the “6 facet” survey and this is being reviewed. An initial review shows that the risk adjusted backlog has fallen which is indicative of the work that has been done over the past five years as well as reducing the foot print of the estate. This will assist in prioritisation of future back log works. A fuller update will be presented once we have a chance to review the report in more detail. The Yeovil Estates Partnership is reviewing the Trust’s strategic developments, including the multi-storey car park, and will support work looking at more efficient models of surgery. A project report on SCBU is appended to this report. The costs will be higher than budgeted but we believe that we can manage the phasing of planned capital expenditure in 2015/16 to accommodate the extra cost. Adrian Pickles, currently Trust Risk Manager, will be assuming health and safety and fire management from 1 June 2015 and will transfer to the estates team on that date. This should provide greater focus going forward. We have also commissioned a survey to evaluate the fire risk where most of the plant is located which is a high risk area. Financial Position In March 2015 an operating deficit of £0.5m was delivered. This was £0.5m adverse to budget but in line with forecast. The unprecedented operational escalation has resulted in continued cost pressures, notably in respect of clinical staffing costs. In addition there has been a substantial reduction in private patient activity due to bed pressures, although this is partially mitigated by savings in consumables due to the cancellation of elective procedures. The full year operating deficit is £7.4m which is adverse to budget by £5.0m. A detailed financial overview is included within the operational and financial report. As we are at year end we have also completed a review of fixed assets and there will be a net impairment of £5.4m, i.e., a reduction in the carrying value of the assets in the balance sheet. £2.2m is reported as a reduction of the revaluation reserve, the balance is reported through the income and expenditure account. The full year deficit reported in the financial accounts will therefore be £10.6m.There is no cash impact, other than to reduce PDC recurrently by circa £0.1m pa. Month end cash was £2.1m vs £2.9m last month, the reduction primarily reflecting payment of PDC of £0.7m.The latest cash flow forecast indicates that YDH will not require temporary PDC from the Department of Health until September 2015.

Both Somerset and Dorset CCGs have agreed to “double invoice” which means that YDH will be able maintain positive cash levels to the late summer before requiring deficit support. 2015/16 Contracts Contract negotiations are continuing with commissioners. We have reached agreement with Dorset CCG from whom we will receive a real increase in funding. The outstanding issues with the Somerset CCG continue to be, firstly, agreement of actual activity for the current year involving interpretation of national tariff guidance; and, secondly, the potential impact of schemes sponsored by the Somerset CCG designed to reduce hospital attendances and admissions (QIPP). There have been regular meetings with the Somerset CCG and some progress has been made with in respect to the first issue and I will update further at the board meeting. Engagement is ongoing with specialist commissioners but we hope to make further progress during the next few days. There is a clear timetable to move to arbitration if agreement cannot be reached. HR and workforce An update on band 5 nursing recruitment will be provided by the Director of Nursing and Clinical Governance. This remains a critical priority given ongoing dependency on agency nurses. While good short-term progress has been made we will redouble efforts as regular staff turnover still means substantive staff are required. We are also working with other South West trusts to review the supply of agency services to investigate whether there would be benefit in joining together to procure temporary staff as we are doing for medical locums. Following the completion of a tender process, a new occupational health provider has been appointed. A third party, Optima, has been awarded the contract, initially for one year. Optima already provide a similar service to Musgrove Park Hospital. The new service should provide a more professional and commercially focused service, providing managers with better support. The new service also has an employee assistance programme which provides staff with access to a 24/7/365 telephone helpline, offering support on work and non-work related matters. A new staff handbook has been published which is available on the HR section of Y cloud. We have moved away from the traditional handbook style, and produced a slimmer, more professional and attractive looking document. Building on this we have started a project to consolidate all HR policies into a single document, again with the view to ensuring staff can easily access and understand our policies.

Yeovil General Hospital NHS Foundation Trust Strategic Partnership Project Report SCBU April 2015

Report Date 15/4/15

General • New statutory regulations 2015 issued by the Health and Safety Executive have been enacted this

month and the SCBU project has been registered under these (no impact on project). • Chris Hull was PM for Phase 1 and 2. Interserve is supporting PM role for Phase 3 and 4. • Interserve has reviewed the architect’s design output but additional work has been necessary to

establish scope of work and standards, which also gives the opportunity to identify areas for potential cost saving.

Phase 1 (individual rooms within maternity) • Demolition and strip out 50% complete

o Walk in shower/toilet, counselling room, outstanding • Building works 50% complete, M&E 15%

o M&E delays incurred delaying completion to family room and new sluice o Mela (the subcontractor) resources distracted due to year end workload o Date for completion 8 June 2015 (delayed from April) o Additional resources and management input from Interserve to try for 1 June completion

Phase 2 (decant space for SCBU to move into) • Demolition and strip out 90%

o Services isolated, deadlegs and redundant services removal outstanding • Building works 0% complete, M&E 0%

o Prices received from Mela and Bowshires being reviewed o Mech Contractor being sourced o Works to recommence 27 April 2015 o Completion due 26 June 2015 (delayed from May) o Additional resources and management input from Interserve to try for 15 June completion.

Phase 3 (new SCBU) • Decant planned 29 June to allow construction to commence 1 July (delayed from June) • Anticipated completion 21 November for reoccupation and operational start 24 November

Phase 4 (refurbishment of remaining floor space plus new toilets/bathrooms) • Construction to commence 24 November with completion due 18 December

Commercial • Detailed cost plan completed for building element, but the mechanical and electrical cost plan is

higher than the original budget. • Currently circa £0.5m over budget, partly due to M&E, due to the high level of services required for a

special care unit, including air cooling and medical gases; and also the scope is greater reflecting works to the maternity ward (phase 4 above)not included in the original budget.

• Mitigation measures are being implemented but will not bridge the gap to budget. These include continual value engineering of the specification as the project progresses. These should save £0.1m.

• The total cost is expected to be between £1.4m vs. a budget of £1.0m. • To recoup the £0.4m we will review other budgeted capex for the year, and if necessary defer

elements of phase 4 into 16/17.

APPENDIX 7 BOARD OF DIRECTORS

29 APRIL2015

Report to: Board of Directors Report from: Jonathan Howes Subject: TrakCare Electronic Health Record Status Report Date: 29 April 2015 EXECUTIVE SUMMARY The project status is currently AMBER. Whilst progress is being against the initial plan, e.g. data migration, some experiences within the current operational assessment phase mean the status has been set as amber, specifically; supplier engagement, ability to quickly understand and learn from the system and the ability to translate this into future Trust operational designs, which has not been as the Trust has expected. The impact of this is more of a quality based risk rather than programme slippage and delay. It is essential the Trust and programme clearly and fully understand the system and any associated operational and clinical change needed to have a safe and effective solution on final delivery. Actions have been initiated to address this and as the detailed planning work continues, any impact on the plan and delivery dates are being assessed to ensure the depth and quality of solution is not adversely impacted. The following sections will provide an update on each programme phase and by exception will provide more detail on outstanding items or areas of risk.

SUMMARY STATUS REPORT

DETAILED UPDATE PREPARATION AIM: Establish the project team, recruit and secure Trust resource. Create the programme plan and project initiation document to define how the work will be run and managed. COMPLETED:

• Team established and moved to Convamore to facilitate space needs. • Trust operational model, agreed, funded and discussions ongoing to approve and

backfill. • Established joint SharePoint site with InterSystems for project control documents. • Clinical Design Assurance Group established – first meeting date set to review work

and clinical impact todate. OUTSTANDING

• Recruit four key roles into programme teams (1 x project manager, 3 x business analysts)

• Meet business managers to agree Trust resource, roles and responsibilities, release and define the backfill plan.

• Complete project initiation document and plan.

RISKS & ISSUES

• RESOURCE – Key roles and staff are needed to ensure the team is fully established • PLAN – Detailed work is ongoing to confirm the supplier proposed OCT golive

KEY ACTIONS

• Business Managers meetings in April and May planned to agree resource and roles and responsibilities. Owner J Smith. Due 15th May

• Recruitment proposal received and being approved for an IT supplier to supply the remaining vacant roles. Owner C Shuff. Due 30th April

• Planning. Detailed planning sessions are underway with the supplier and Programme team. Proposal is by the end of April to confirm the Oct golive date and or by the end of May to replan in detail any alternative options for Board assessment.

OPERATIONAL ASSESSMENT AIM: Define the current ASIS Trust operational processes, attend supplier lead workshops to assess the new system capability, fit and to identify any gaps. This will start the design and specification work for any system build, integration and data migration and for the Trust and any operational processes, roles and responsibility changes needed to create an overall effective solution. COMPLETED:

• 21 workshops (out of 26 planned) covering ED, pharmacy, theatres, out / inpatient RTT and more technical system covering overview, integration, infrastructure and data migration.

• System introduction, overview and demos have been run to show all staff. Several demo sessions have been run by supplier to support the programme.

• Programme has ASIS process maps which are being refreshed post the workshops • “scratch” system – a copy of the system for the programme to use and learn on

provided. • Data Migration – Is a success story so far. The team has been established to clean

our legacy data, map and define what legacy data needs to be migrated and a strategy for clinical approval is being drafted.

OUTSTANDING

• Workshops for maternity, statutory reporting, coding, user security, outputs (print labels).

• Technical work to document and specify reports, integration and many data items needed in the system (e.g. tables values for drop down menu’s).

RISKS & ISSUES In general the main programme risk has been around the quality of the workshops in terms of the Trust’s ability to develop a deep understanding of the system and what it will mean to our operations. The workshops and follow on activity in the operational assessments is designed to drive this but there has been variability in the experiences and outputs from this work. Specifically

• SUPPLIER RESOURCE – Not all workshops have been run. The supplier is balancing resource across 3 south west trusts and 1 northern trust.

• SUPPLIER PEFORMANCE – Some workshops have had delayed agendas, materials and documentation to allow preparation, full in-depth participation.

• TRUST RESOURCE – Due to lack some of the above noted challenges, the most appropriate Trust resource has not always been able to attend and planning becomes more complex.

• UNDERSTANDING – The pace of learning and take-on of knowledge needs to be

rapid as the timeline and resource is limited to re-run or hold follow on sessions • UNDERSTANDING – The system capability needs to be established so the

associated operational and clinical changes can be assess, designed and planned carefully.

KEY ACTIONS

• ESCALATION. Jonathan Smith, Programme Director, has escalated to the InterSystems Programme Director. A factual review of the workshop dates, input quality and resource has been discussed. Agreed actions are to:

o Project Manager – Review and ensure ISC manager is onsite more often o Workshops – Re-runs and follow ups with appropriate resources requested o Workshops – improved agendas, materials and documents in advance

agreed. o Senior Meeting – InterSystems CEO and overall Services Director invited to

meet Sponsor and SRO at YDH to build relationships. • TRUST RESOURCE, PLANNING & CONFIDENCE. The Programme management

has a plan to improve engagement on the YDH side covering: o Business Managers – Jonathan Smith to meet, discuss any issues remaining

from workshops and agree resource and plans to move solutions forward. o Solutions Teams – Programme will fill final vacancies and launch more

formally with the Trust the solution teams whom will work more closely with them going forward.

• PLANNING. Programme Manager is driving team to review and create detailed

delivery plans. This contains YDH view on work to deliver and will also include a joint impact assessment with the supplier. Any risks to the Oct golive and or any recommendations for an alternate plan will then be presented for discussions to the Steering Board.

Operating & Finance

Performance Overview

March 15

2

Section Title

CONTENTS

1 Operational Performance

2 Workforce

3 Financial Performance Summary

4 Appendix - Financial Detail

Operating

Performance Overview

Mortality

4

Latest HSMR 12months to December 14 was 92.55. Actual number of deaths in March 15 was 58.

0

20

40

60

80

100

120

140

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Hospital Standardised Mortality Ratio (HSMR)

Monthly data 6 month moving average

0

20

40

60

80

100

Jan

-11

Ma

r-11

Ma

y-1

1

Jul-

11

Sep

-11

No

v-1

1

Jan

-12

Ma

r-12

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Actual number of deaths

Monthly data 6 month moving average

RTT [1/3]

5

In March 15, the Trust did not achieved the target for admitted patients with 79.4% (target 90%). The Trust did achieve the target for non-admitted patients with 95.1% (target 95%).

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Nov

-11

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

RTT completed pathways - 18 week - admitted

6 month moving average RTT target

85%

88%

91%

94%

97%

100%

Nov

-11

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

RTT completed pathways - 18 week - non admitted

6 month moving average RTT target

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Nov

-11

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

RTT incompleted pathways - 18 week - admitted

6 month moving average RTT target

75%

80%

85%

90%

95%

100%

Nov

-11

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

RTT incompleted pathways - 18 week - non admitted

6 month moving average RTT target

RTT [2/3]

6

Total RTT fines in March 15 totalled £64,800: £29,000 relating to Admitted, £2,600 Non-Admitted and £33,200 Incompletes.

Incomplete Non-Admitted Admitted

£400

£6,400

£3,200

£22,400

£800

£200

£200

£500

£900

£400

£400

£2,600

£1,100

£1,000

£8,300

£16,000

£- £5,000 £10,000 £15,000 £20,000 £25,000

Urology

General Surgery

Ophthalmology

T&O

Gynaecology

Oral

Rheumatology

Paediatrics

Neurology

Thoracic…

General Surgery

Urology

Neurology

Oral

T&O

General Surgery

RTT Fines - March 15

RTT [3/3]

7 Patients that delay treatment through choice are counted as an incomplete pathways until they receive their treatment, or it is decided that they don’t need treatment. Patient choice only adjusts the wait time once they have received an admitted treatment (non-admitted stops aren’t adjusted for patient choice)

At the end of March, 487 admitted patients and 227 non-admitted patients were waiting longer than 18 weeks. 190 of these patients were waiting over 26 weeks - none were waiting longer than 52 weeks. This represents a significant increase resulting from the high level of elective cancellations during December - March.

050

100150200250300350400

>18

wee

ks

>19

wee

ks

>20

wee

ks

>21

wee

ks

>22

wee

ks

>23

wee

ks

>24

wee

ks

>25

We

eks

>26

wee

ks

RTT Incomplete pathways - Aging

Non Admitted Admitted

02004006008001,0001,2001,4001,6001,8002,000

01,0002,0003,0004,0005,0006,0007,0008,0009,000

Jun

-12

Sep

-12

De

c-12

Ma

r-13

Jun

-13

Sep

-13

De

c-13

Ma

r-14

Jun

-14

Sep

-14

De

c-14

Ma

r-15

RTT incomplete pathways

RTT incomplete pathways RTT incomplete pathways > 18 weeks

Waiting lists

8

At the end of March 15, the Inpatient and Day case Waiting List was 2208, an increase of 773 patients from last year (+35%). The Outpatient GP/DP referred Waiting List was 3,166 at the end of March, an increase of 613 patients from last year (+24%). A large proportion of this increase is due to a full Ophthalmology service this year compared to last year.

The above numbers do not include planned or suspended patients i.e. medically unfit patients or planned follow-ups Rag Rating - Remain constant month on month at or below the level as at 31 March 2012.

0

500

1000

1500

2000

2500

3000

3500

Jul-

10

Sep

-10

No

v-1

0Ja

n-1

1M

ar-

11M

ay-

11

Jul-

11

Sep

-11

No

v-1

1Ja

n-1

2M

ar-

12M

ay-

12

Jul-

12

Sep

-12

No

v-1

2Ja

n-1

3M

ar-

13M

ay-

13

Jul-

13

Sep

-13

No

v-1

3Ja

n-1

4M

ar-

14M

ay-

14

Jul-

14

Sep

-14

No

v-1

4Ja

n-1

5M

ar-

15

Waiting Lists

OP Waiting List Size - GP/DP Referred IP/DC Waiting List Size

A&E [1/2]

9

In March 15, 93.62% (target 95%) of patients were seen and discharged within 4 hours from A&E. Average A&E attendances in March were 125 per day. Ambulance arrivals in March averaged 41.4 per day.

89.0%90.0%91.0%92.0%93.0%94.0%95.0%96.0%97.0%98.0%99.0%

Jan

-11

Ma

r-11

Ma

y-1

1

Jul-

11

Sep

-11

No

v-1

1

Jan

-12

Ma

r-12

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

A&E 4 hour performance - All Attendances

6 month moving average

100

110

120

130

140

150

Ma

y-…

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-…

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-…

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Avg A&E attendance per day

20

25

30

35

40

45

50

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Avg A&E ambulance arrivals per day

Day Mar-14 Dec-14 Jan-15 Feb-15 Mar-15 YTD

Monday 145 135 129 127 135 137

Tuesday 125 123 120 119 125 122

Wednesday 130 124 107 118 123 122

Thursday 123 118 106 120 123 122

Friday 127 130 121 118 124 121

Saturday 125 135 112 121 117 126

Sunday 142 130 118 128 128 134

Average 132 128 116 121 125 126.5

0

20

40

60

80

100

120

140

160

180

0

5

10

15

20

25

30

Sun

1

Mo

n 2

Tu

e 3

Wed

4

Th

u 5

Fri 6

Sat

7

Sun

8

Mo

n 9

Tu

e 1

0

Wed

11

Th

u 1

2

Fri 1

3

Sat

14

Sun

15

Mo

n 1

6

Tu

e 1

7

Wed

18

Th

u 1

9

Fri 2

0

Sat

21

Sun

22

Mo

n 2

3

Tu

e 2

4

Wed

25

Th

u 2

6

Fri 2

7

Sat

28

Sun

29

Mo

n 3

0

Tu

e 3

1

March 15 Activity & Breaches

Breaches Atts

A&E [2/2]

10

A&E activity over the two month period February and March was down by -2.4% vs last year (-178 attendances). FY 14/15 A&E attendances (46,776) were up 2.7% vs last FY (46,776).

3000

3200

3400

3600

3800

4000

4200

4400

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

Feb

-14

Ma

r-14

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

A&E Activity

A&E Activity 6 month moving average

-10.0%-8.0%-6.0%-4.0%-2.0%0.0%2.0%4.0%6.0%8.0%

10.0%

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

Feb

-14

Ma

r-14

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

% increase/decrease vs LY

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%A&E Breaches

Majors Minors Resus

Ambulance targets

11

We have achieved the 30 minute handover target (98%) for the last 23 months running. FY 14/15 fines total £13,200. FY 13/14 fines totalled £32,200.

NOTES: Ambulance fines for over 30mins only began in April 2011 Imposed Fines have changed each year but have always been based on breaching 30 mins or more.

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

£0£2,000£4,000£6,000£8,000

£10,000£12,000£14,000£16,000£18,000

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ambulance handovers - Fines Ambulance Handover <30mins

Cancer 2 Week Wait (Draft data)

12

The draft March 2015 data indicates that the Trust has not achieved the 2 Week Wait target for Suspected Cancer with 91.3% (target 93%). This was due to 47 patients choosing to wait longer than 14 days for their first appointment. The trust also did not achieve the 2 Week Wait for exhibited breast symptom referrals (92% against a 93% target). This was again due to patient choice. The position will be finalised in mid-May (in line with National reporting requirements) and the final March position will be presented in next months report alongside draft April data.

0

20

40

60

80

100

0

100

200

300

400

500

600

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15 n

o. r

efer

rals

-b

rea

st s

ymp

ton

s

No

. re

ferr

als

-su

spec

ted

ca

nce

r

Number of referrals seen

2 week wait suspected cancer 2 week wait exhibited breast symptoms

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

2 week cancer targets

2 wk wait suspected cancer 2 wk wait Breast

Cancer 31 day and 62 day targets (Draft data)

13

Draft data for March indicates that the Trust achieved the 96% target of delivering treatment within 31 days of the decision to treat for both First Treat and Subsequent Drugs. However, it indicates that we are below the target for Subsequent Surgery (93.3% against a 94% target).

Draft data indicates that the trust achieved the 62 day treatment standard (85.6% against a 85% target) and the 62 day upgrade target (100% against a 90% target).

Ap

r-1

0Ju

n-1

0A

ug-

10

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4Ju

n-1

4A

ug-

14

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

101.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

31 day treatment first

Achievement % Target % 6 month rolling %

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

101.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

31 day treatment first subsequent drugs

Monthly data Target % 6 month rolling %

75.0%77.0%79.0%81.0%83.0%85.0%87.0%89.0%91.0%93.0%95.0%97.0%99.0%

101.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

31 day treatment subsequent surgery

Monthly data Target % 6 month rolling %

0

1

2

3

4

5

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

62 day treatment screening

Achievement % Target % Number of referrals seen

0

10

20

30

40

50

60

70

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

62 day treatment standard

Achievement % Target % Number of referrals seen

0

5

10

15

20

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

62 day treatment upgrades

Achievement % Target % Number of referrals seen

DNA - Outpatients

14

In March the overall DNA rate was 8.1%, the 1st appointment DNA rate increased slightly to 5.5% (from 5.3%). Follow up DNA rates remained the same at 9.2%.

£0

£20

£40

£60

£80

£100

£120

£140

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

No

v-12

Jan-

13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-13

Jan-

14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-14

Jan-

15

Mar

-15

Tho

usa

nd

s

DNA rate

Overall DNA rate First DNA rate

Follow up DNA rate DNA Cost

First to follow up Ratio

15

1st to follow up ratio in March 15 was 1:2.3. The NHS Better Care Q2 Ratio is 1:2. The 6 month rolling average 1st to follow-up ratio is 1:2.3

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

0

2000

4000

6000

8000

10000

12000

14000

16000

Ort

ho

pae

dics

Op

htha

lmol

ogy

Gen

eral

Sur

gery

ENT

Uro

logy

Ort

ho

dont

ics

Gas

tro

ente

rolo

gy

Gen

eral

Med

icin

e

Car

diol

ogy

rate

att

end

an

ces

April 2014 - March 2015 1st to Follow Up Ratio by Speciality

1st Follow Up Rate

1.5

1.7

1.9

2.1

2.3

2.5

2.7

2.9

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4Ju

n-1

4A

ug-

14

Oct

-14

De

c-14

Feb

-15

New:Follow ratio

6 month moving average

Stroke

16

In March 67% of stroke patients spent over 90% of their inpatient stay on the stroke ward, against an 80% target. 48% of patients were admitted directly to the stroke ward within 4 hours, against a target of 90%. This deterioration in performance is a direct result of problems with patient flow resulting from the enhanced Winter pressures.

In March, 67% of high risk Transient Ischaemic Attack (TIA) patients were treated within 24 hours against the 80% target. In March, 41% of patients that were subsequently diagnosed with a stroke had a CT scan within 1 hour of arrival against a target of 50%.

0%

20%

40%

60%

80%

100%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Stroke Unit Stay >90%

Stroke Unit Stay >90% Target

0%

20%

40%

60%

80%

100%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

4Hr Direct Admission

4Hr Direct Admission Target

0%

20%

40%

60%

80%

100%

120%

May

-12

Aug

-12

Nov

-12

Feb-

13

May

-13

Aug

-13

Nov

-13

Feb-

14

May

-14

Aug

-14

Nov

-14

Feb-

15

High Risk TIA <24Hrs

0%

10%

20%

30%

40%

50%

60%

Apr

-12

Jun-

12

Aug

-12

Oct

-12

Dec

-12

Feb-

13

Apr

-13

Jun-

13

Aug

-13

Oct

-13

Dec

-13

Feb-

14

Apr

-14

Jun-

14

Aug

-14

Oct

-14

Dec

-14

Feb-

15

Achievement 1HrCTScan

Cancelled operations

17

In March, 40 operations were cancelled on the day by the trust for non-clinical reasons. 31 of these patients have since been rebooked or no longer require surgery, 4 of which have been booked outside of their 28 day target. Overall, in the month of March, 79 elective operations were cancelled due to lack of beds (this includes cancellations with more than 1 day notice given)

Note: For any elective operation cancelled by the trust on the day of the operation/admission, an offer of a new date must be made within 5 calendar days, and the newly offered date must be within 28 days of the cancelled operation date.

0 50 100 150 200 250 300 350

CONSULTANT / CLINICIAN UNAVAILABLE

EMERGENCY INTERVENED

EQUIPMENT FAILURE / UNAVAILABLE

INSUFFICIENT SESSION TIME / SESSION…

MORE URGENT CASE TOOK PRIORITY -…

NO ANAESTHETIST AVAILABLE

NO BEDS AVAILABLE

NO ITU / HDU BEDS AVAILABLE

PATIENT NOT READY FOR THEATRE

PATIENT NOT SENT FOR BY…

PATIENT TRANSFERRED TO ANOTHER…

SECRETARIAL / ADMINISTRATIVE ERROR

SESSION CANCELLED

TCI / APPOINTMENT RESCHEDULED

THEATRE / OUTPATIENT STAFF SHORTAGE

Hospital Non-clinical Cancellations of Elective Operations

April 14 - February 15

0 2 4 6 8 10 12

CONSULTANT / CLINICIAN UNAVAILABLE

EMERGENCY INTERVENED

INSUFFICIENT SESSION TIME / SESSIONOVERRUN

NO BEDS AVAILABLE

PATIENT NOT SENT FOR BYADMINISTRATIVE STAFF

TCI / APPOINTMENT RESCHEDULED -REQUIRES ALTERNATIVE SESSION / CLINIC

THEATRE / OUTPATIENT STAFF SHORTAGE

Hospital Non-clinical Cancellations of Elective OperationsFebruary 2015

Fractured Neck of Femur

18

In March, Best Practice Tariff achievement was 5% against a contractual target of 39% and an internal target of 60%. This was due to our Orthopaedic Geriatrician leaving part way through March resulting in a low number of patients being assessed within 72 hours and not meeting MDT requirements. FY 14/15 is 37.5% achievement. The FY 14/15 length of stay for patients not directly admitted to 6A is on average 2.8 days longer than those directly admitted to 6A and the overall best practice achievement is 10.4% higher than those that are not directly admitted to 6A.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Operated onwithin 36

hours

GeriatricAssessment

within 72hours

Pre-op AMT Post-op AMT FracturePreventionAssesments

Post-op MDT

Year to Date Best Practice Achievement - #NOF

Overall BPT % Achieving each measure 6A direct Admissions BPT

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-14

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Average Length of Stay - #NOF patients

6A Admission Other Admission

Safety

19

There have been 934 patient falls FY 14/15 compared to 915 FY 13/14. There was a 8% drop in falls in March compared to February. In March 15 there were no C.Diff cases reported (FY 14/15 all C.Diff cases = 13). There have been 3 confirmed avoidable Post-72hr cases for FY 14/15. There was 1 reported case of MRSA in March. (FY 14/15 all MRSA cases = 2).

0

1

2

Mar

-11

Jun-

11

Sep-

11

Dec-

11

Mar

-12

Jun-

12

Sep-

12

Dec-

12

Mar

-13

Jun-

13

Sep-

13

Dec-

13

Mar

-14

Jun-

14

Sep-

14

Dec-

14

Mar

-15

MRSA

Monthly data 6 month moving average

0

20

40

60

80

100

120

140

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

Patient falls

Monthly data 6 month moving average

0

1

2

3

4

5

6M

ar-1

1

Jun-

11

Sep-

11

Dec-

11

Mar

-12

Jun-

12

Sep-

12

Dec-

12

Mar

-13

Jun-

13

Sep-

13

Dec-

13

Mar

-14

Jun-

14

Sep-

14

Dec-

14

Mar

-15

C difficile cases

Monthly data 6 month moving average

0

5

10

15

20

25

May

-12

Jul-1

2

Sep-

12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

Pressure ulcers +2

Monthly data 6 month moving average

Friends and Family Test

20

Response rate for all three areas: Inpatients, A&E and Maternity increased in March to 18.8% with a 6 month average of 18.9%.

FY 14/15 is 21.2% compared to 19.5% for FY 13/14.

Month A&E IP Maternity TOTAL

Apr/14 6.8% 47.8% 31.7% 22.2%

May/14 10.9% 50.2% 35.0% 25.1%

Jun/14 13.3% 41.4% 24.6% 22.2%

Jul/14 16.1% 44.3% 24.2% 24.7%

Aug/14 12.0% 40.1% 40.9% 23.4%

Sep/14 15.3% 36.5% 24.9% 22.3%

Oct/14 16.8% 35.4% 26.3% 23.4%

Nov/14 14.6% 32.5% 31.5% 22.7%

Dec/14 11.4% 23.0% 26.8% 17.0%

Jan/15 9.5% 20.7% 22.9% 14.8%

Feb/15 8.4% 23.3% 30.4% 16.1%

Mar/15 6.9% 39.4% 25.5% 18.8%

YTD 12.0% 36.6% 28.5% 21.2%

% of Responses

68.5% 68.1% 69.9% 68.0% 68.9%64.9%

72.7% 72.1% 72.6%69.3%

73.8%68.1%

26.0% 25.2% 24.6% 23.9% 24.6% 26.3%20.0% 20.1% 21.4% 23.8%

20.4% 21.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

Friends and Family Test Inpatient / ED / Maternity Response to 'extremely

likely' and 'likely' to recommend YDH

% Extremely Likely % Likely

726 878 773 887 806 813 814 735 576 462 451 601

32773493 3482

35883449 3641 3480

3239 33803119

2808

3202

0%

5%

10%

15%

20%

25%

30%

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

Friends and Family Test % of Responses

Number of Respondants No of eligible Patients % of responses

Admissions

21

Total elective admissions in March were 1,626 compared to non-elective admissions of 1,740. The average length of stay during March was 3.1 days for Elective patients and 5.1 days for Emergency patients. This is 0.6 days higher for Elective admissions, but 0.3 days lower for Emergency admissions than in March 14. This increased length of stay for elective admissions is a result of a combination of the reduced volume and urgent nature of the elective activity that the Trust undertook during March.

6mth avg

Elective

Non Elective

LOS

Elective

Non Elective

Average LOS

Elective

Non Elective

0500

1,0001,5002,0002,5003,0003,5004,000

Ma

r-11

Ma

y-1

1

Jul-

11

Sep

-11

No

v-1

1

Jan

-12

Ma

r-12

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Admissions

Total Elective admissions Non Elective admissions

Total admissions (6 mths avg)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Ma

r-11

Ma

y-1

1

Jul-

11

Sep

-11

No

v-1

1

Jan

-12

Ma

r-12

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Average Length of Stay (days)

LOS Elective LOS Non Elective

Average LOS Mar-13 Mar-14 Mar-15

Elective 3.2 2.8 3.1

Non Elective 5.3 4.8 5.1

Delayed Discharges

22

The number of delayed discharges appears to be reducing since the peak in December but levels are still significantly higher than last year. Significant work has been undertaken since January to ensure that the Trusts data collection is in line with National delayed transfers of care definitions.

0

10

20

30

40

50

60

70

Number of Inpatients Medically Fit for Discharge

£0

£50,000

£100,000

£150,000

£200,000

£250,000

Cost of Excess Bed Days (Assuming average price of £236 per bed-day)

0

50

100

150

200

250

300

350

400

450

Completion ofAssessment

Public Funding Further nonacute NHS care

ResidentialHome

Nursing Home Care packagein own Home

CommunityEquipment

Patient orFamily Choice

Monthly Split of Delayed Discharge Reasons (Bed Days)

01/2015 02/2015 03/2015

Monitor

23

Q1 Q2 Q3

Q4 to

Mar

(Draft)

RTT 18 week RTT admitted wait - All specialties 90% M 92.1% 87.8% 88.4% 85.4%

RTT 18 week RTT non-admitted wait - All specialties 95% M 96.8% 95.4% 94.97% 94.8%

RTT 18 week RTT Incomplete pathways - All Specialties 92% M 95.4% 95.4% 93.5% 91.9%

A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 96.0% 95.8% 94.2% 94.4%

Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 93.2% 93.2% 91.6% 92.4%

Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 93.1% 92.0% 93.5% 93.0%

Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 97.0% 98.4% 98.7% 97.8%

Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 100.0% 100.0% 100.0% 100.0%

Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 97.6% 97.1% 94.3% 94.3%

Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 89.6% 91.2% 84.1% 87.6%

Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 66.7% 100.0% 100.0% 100.0%

SafetyC.Diff year on year reduction (avoidable only)

(DH target - Post 72hrs only)10 pa Q 1 0 2 0

Monitor TARGET Period

Results

24

Workforce Performance

FTE

25

Total Workforce in Month 12 is 7% higher compared to same month last year (+127 FTE).

Temporary Workforce accounted for 11.2% of the Total Workforce compared to 8.7% in Mar 14.

Contracted

FTE

Temporary

FTETotal FTE

Temporary

%

42 4 46 8%

47 2 49 3%

362 24 386 6%

90 0 90 0%

156 40 196 21%

21 - 21 0%

212 16 228 7%

493 72 564 13%

75 0 76 0%

213 58 271 21%

1,711 216 1,927 11%

Mar-15

Contracted

FTE

Temporary

FTETotal FTE

Temporary

%

39 2 41 6%

46 2 47 4%

337 15 353 4%

83 2 85 2%

142 41 183 23%

20 - 20 0%

209 16 225 7%

511 46 557 8%

61 - 61 0%

195 30 225 13%

1,643 155 1,798 9%

Mar-14

Skills Groups

Additional Clinical Services

Additional Prof Scientific & Technical

Admin & Clerical

Allied Health Professionals

Ancillary

Estates

Medical & Dental

Nursing & Midwifery Reg

Senior Managers

HCA's

Total

Contracted FTE includes substantive and fixed term employees

Contracted FTE

26

0

100

200

300

400

500

600

Medical &Dental FTE

Nursing &Midwifery Reg

HCA's Allied HealthProfessionals

Additional ProfScientific &Technical

AdditionalClinicalServices

Admin &Clerical

SeniorManagers

Ancillary Estates

Contracted FTE - 3 Year Trend

Mar-13 Mar-14 Mar-15

Temporary FTE

27

0

10

20

30

40

50

60

70

80

Medical &Dental

Nursing &Midwifery Reg

HCA's Allied HealthProfessionals

Additional ProfScientific &Technical

AdditionalClinicalServices

Admin &Clerical

SeniorManagers

Ancillary Estates

Temporary FTE - 3 Year Trend

Mar-13 Mar-14 Mar-15

Staff Turnover

28

Staff Turnover remained the same at 14% (against a target upper limit of 15%).

Leavers

29

The number of staff leaving the Trust for unknown reasons is being reviewed so that we understand better the reasons why staff are leaving.

Sickness Absence

30

The Sickness Absence Rate for February 15 (M11) was 3.4%, representing an adverse variance against target and an decrease in month of 0.3%.

Mandatory Training

31

The percentage of staff up to date with their Mandatory Training has increased to 85% in March, against a target of 90%.

Appraisal

32

The percentage of staff remaining in date for their Annual Appraisal reduced to 78% in March 15, against a target of 90%.

33

Workforce Assurance

Workforce

FTE 1762 42 47 362 90 156 21 212 493 75 213 1711 1643

Vacancy Rate < 11% 3% 1% 2% 2% 6% -3% -2% 9% 6% 9% 5% 6%

Turnover

Turnover * 10% to 15% TBC TBC TBC TBC TBC TBC TBC TBC TBC TBC 14% 12%

Sickness Absence

Sickness Absence (Feb-15) 3.0% 2.5% 2.0% 4.3% 2.4% 3.1% 0.8% 0.6% 4.1% 0.0% 5.6% 3.4% 3.2%

Sickness Absence (YTD) 3.0% 2.6% 1.1% 3.3% 1.8% 6.3% 1.8% 0.6% 4.2% 0.4% 6.3% 3.5% 3.5%

Performance Compliance

Appraisal 90% 82% 85% 83% 93% 73% 82% 83% 74% 75% 69% 78% 81%

Mandatory Training 90% 84% 90% 90% 82% 83% 81% 81% 87% 90% 81% 85% 79%

* excludes Training Doctors

Trustwide

Senior

ManagersHCA's Mar-15 Mar-14

Additional

Clinical

Services

Add'l Prof

Scientific &

Technical

Admin &

Clerical

Allied Health

Professional

Medical

& DentalAncillary EstatesMar-15 Target

Nursing &

Midwifery

34

Workforce Assurance

Ward 6A - Trauma & Ortho 10 9 10% 26 25 7% 105% 9% 10% 1.4% 43% 79% 86% 3 0 0

Ward 7A - Surgery & Gynae 13 11 12% 27 26 5% 100% 5% 23% 7.5% 63% 80% 83% 0 0 0

Kingston Wing 10 9 16% 29 26 8% 101% 3% 7% 2.3% 67% 79% 88% 1 0 0

ICU 42 39 7% 43 41 4% 101% 4% 9% 5.1% 70% 94% 50% 2 0 0

Maternity 57 53 7% 75 70 6% 88% 1% 12% 5.4% 82% 86% 93% 0 1 0

Jasmine - Elective Ward 12 10 11% 25 23 10% 113% 4% 20% 1.9% 100% 85% 96% 0 0 0

Ward 7B - EAU 17 20 -14% 36 38 -6% 99% 3% 14% 7.6% 83% 79% 93% 2 0 0

Ward 8A - Medicine 13 12 3% 29 27 8% 103% 4% 11% 3.0% 36% 89% 77% 2 0 0

Ward 8B - Medicine 11 8 23% 25 19 26% 98% 8% 21% 7.5% 74% 97% 95% 2 1 0

Ward 9A - Medicine 14 12 15% 31 31 -1% 104% 6% 24% 6.8% 71% 80% 97% 2 0 0

Ward 9B - Gastro 11 13 -12% 30 31 -4% 100% 7% 26% 6.1% 74% 80% 91% 2 0 0

Ward 10 17 15 10% 23 21 10% 104% 5% 19% 9.4% 88% 88% 100% 6 0 0

CCU 16 14 16% 18 15 16% 101% 1% 27% 0.6% 81% 82% 100% 0 1 0

SCBU 12 10 12% 16 14 13% 94% 0% 11% 11.7% 89% 94% 0 0 0

Registered Nursing All Staff

Budgeted

FTE

Contracted

FTE

Vacancy

Rate %

Budgeted

FTE

Contracted

FTE

Vacancy

Rate %

Average

Fill Rate

%

Pals Complaints Grievances

Temporary

Staff Usage

%

Mandatory

Training %

Turnover

%

Sickness

Absence %FFT *

Ele

cti

ve

Ca

reU

rge

nt

Ca

re

Mar-15Appraisal

%

Financial Performance Summary

Finance

36

• The in month deficit for March 2015 prior to impairments is £0.5m, this is £0.5m adverse to budget.

• This makes the year to date (YTD) deficit £7.4m , which is £5.0m adverse against budget.

• In month there was a £3.1m impairment to fixed assets, this makes the actual deficit in month £3.6m and the year to date (YTD) deficit £10.6m ,

Variance: Favourable/(Adverse)

(1,500)

(1,000)

(500)

0

500

1,000

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Trend of Surplus / (Deficit) – Prior to impairment

Surplus / (Deficit) Budget Surplus / (Deficit) Actuals 2013/14 Actuals

Forecast Actuals 2014/15 Revised Forecast 2014/15

Financial Summary

£000's Actual

Variance

to Budget % var Actual

Variance

to Budget % var

Income

Clinical Income 9,486 881 9% 103,572 3,650 4%

Non NHS Clinical Income 426 (93) (22%) 2,699 (858) (32%)

Other Income 1,796 709 39% 13,792 1,127 8%

Total Income 11,709 1,497 13% 120,064 3,918 3%

Pay

Nursing (2,583) (323) 13% (29,253) (2,474) 8%

Medical Staff (2,249) (198) 9% (25,870) (1,671) 6%

Estates, Admin & Clerical (1,211) (71) 6% (13,883) (101) 1%

Pay - Scientific, Therapeutic & Technical (608) (11) 2% (7,230) (85) 1%

Pay - Ancillary (346) (31) 9% (4,062) (224) 6%

Pay - CIP 0 (4) (0%) 0 (48) (0%)

Total Pay Expenditure (6,997) (638) 9% (80,298) (4,602) 6%

Non Pay

Drugs (1,273) (340) 27% (12,545) (1,743) 14%

Consumable M&SE (731) (69) 9% (7,943) (255) 3%

High Cost M&SE (180) 83 (46%) (2,647) 431 (16%)

Other (2,522) (949) 38% (18,625) (2,738) 15%

Total Non Pay Expenditure (4,706) (1,275) 27% (41,761) (4,306) 10%

EBITDA 6 (416) (1,995) (4,989)

Other Technical (3,606) (3,159) 88% (8,561) (3,166) 37%

Surplus / (Deficit) (3,601) (3,574) (10,557) (8,155)

EBITDA Margin % 0.0% (3.4%) (1.9%) (4.0%)

Surplus % (4.2%) (3.9%) (6.2%) (4.1%)

In Month - Mar 15 Year to Date

37

Summary of Key Issues

Income: RTT, winter resilience, drugs and Dorset CCG

over performance.

£41k adverse private patient income.

Adverse on Injury cost recovery scheme and

overseas income

£156k Education income, £215k NHS

Accelerate fund, £222k Smartcare £118k

contract income, all offset by additional costs.

Pay: Costs of escalation and premium for agency

staff.

Additional medical staffing for sickness and

vacancy cover by agency at premium rates.

Non Pay: Drugs costs partially offset by additional

income.

Underspend on consumables cancellation of

theatres.

Other are mostly offset by income, including

Smartcare licences, redundancy, consultancy,

contracts, education cost and year end

adjustments including provisions.

Summary of Month 12 Impairment

38

3.1

2.2

47.8

42.5

35

37

39

41

43

45

47

49

Assets prior to revaluation

£47.8m

Assets after revaluation

£42.5m

Impairment to operating expenditure

£3.1m

Net adjustment to revaluation reserve

£2.2m

Previously paid PDC

dividend on this

value

Now pay PDC

dividend on this

lower value – a

recurrent saving.

Notes

• Independent valuators appointed to review fixed assets.

• Identified changes to asset values.

• Reduction in value will reduce PDC dividend payable each year.

• PDC dividend is paid on average value of net relevant assets over financial year.

Value of Land, Buildings and Dwellings

39

• Cash balance as at 31st March 2015 is £2.1m

• Cash mitigation plans in place, with weekly management and review of cash transactions.

- Appropriate stretch of creditors within government payment guidelines.

- Prompt invoicing of debtors.

(2,000)

0

2,000

4,000

6,000

8,000

10,000

12,000

Ap

r -

13

Jul -

13

Oct

- 1

3

Jan

- 1

4

Ap

r -

14

Jul -

14

Oct

- 1

4

Jan

- 1

5

Ap

r -

15

Jul -

15

Oct

- 1

5

Jan

- 1

6

£ 0

00

's

Cash

Plan Actual Forecast

40

-

500

1,000

1,500

2,000

2,500

Apr

- 13

Ma

y -

13

Ju

n -

13

Ju

l -

13

Au

g -

13

Se

p -

13

Oct -

13

No

v -

13

De

c -

13

Ja

n -

14

Feb

- 1

4

Ma

r -

14

Ap

r -

14

Ma

y -

14

Ju

n -

14

Ju

l -

14

Au

g -

14

Se

p -

14

Oct -

14

No

v -

14

De

c -

14

Ja

n -

15

Feb

- 1

5

Ma

r -

15

£ 0

00

’s

Capital Capital Programme Plan

Capital Programme Actual

Capital Programme Forecast

• Capital expenditure for the financial year 2014/15 is £5.5m this is £0.5m less than planned.

Variance to forecast and projected future impact: Prior to impairments the trust is £144k favourable to the year end forecast

of a £7,587k deficit.

Forecast

Annual

£000's Notes

Forecast annual deficit 2014/15 (7,587) Prior to impairments

Dorset CCG over performance 250

Winter funding tranche 2 fully received 225

Year end one off adjustments 22

Premature retirements (51) Increase in nationally mandated discount rate

Bad debt change in provision (64)

Maternity pathway (36) Payments to other providers

Med staff (95)

Drugs (155)

Other 48

Actual Deficit (7,443)

Variance to Forecast 144

42

APPENDIX

Financial Detail

Monitor Risk Ratings

43

The Trust is achieving a continuity of service risk rating of 1

In Month YTD In Month YTD

56 1,496 142 1,638

(906) (2,214) 7 (2,207)

(16.0) (1.5) 0.1 (1.3)

1 1 1 1

(5,363) (5,363) (6,205) (6,205)

(10,416) (110,353) (11,703) (122,056)

(14.4) (16.3) (16.4) (18.7)

1 1 1 1

1 1 1 1

* Calculation is based on Cash for Continuity of Service divided by Operating Expenses x 30 days per month

Liquidty Metric *

Liquidty Rating

Continuity of Service Risk Rating

Revenue available for Capital

Service

Capital Servicing Capacity Metric

Capital Servicing Capacity Rating

Liquidity

Cash for Continuity of Service

Operating Expenses

Capital Service

Monitor Continuity of Service Risk

Rating

Month 11 Month 12

Debt Service Cover

Income (£’000)

44

Income in month £11,709k (£1,497k favourable to budget)

Clinical Income – £881k favourable to budget in month, £250k of Dorset CCG over performance, £556k of additional Winter and RTT income. Non NHS Clinical Income – £93k adverse to budget in month, £41k private

patient income , lower activity but an improvement on previous months,

£32k due to lower Injury Cost Recovery Scheme income, £20k overseas

visitors.

Other Income – £709k favourable to budget in month, £144k of

additional education income for training and apprentices, £215k NHS

accelerate funding to assist strategic development, £222k funding to cover

Smartcare software licence, £118k of other income for contracts offset by

costs.

N.B. Main components of Other Income include Research & Development, Education & Training funding and Donated Asset Income. Other significant income streams include services provided to external organisations for pharmacy & facilities contracts.

5,000

6,000

7,000

8,000

9,000

10,000

11,000

12,000

13,000

NHS Clinical Income Total Income - Actual PbR Income - Actual

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Non NHS Clinical Income Other Income

Summary of Clinical Activity Performance

45

• General medicine is the biggest over-performer in Non Elective Admissions. (23% over plan) • We continue to improve our data capture for procedures carried out in outpatient settings,

particularly in Trauma and Orthopaedics. • The ‘Other’ category includes the Pathology activity, which includes a high volume of low-cost items. • Maternity data collection has improved significantly since this same period in last year, hence the large

year-on-year movement. • The year-on-year drop in emergency admissions can be partly attributed to the reclassification of

FOPAS and AEC activity as ‘Outpatients’, which have offset the growth in this area.

(-) is a reduction in

activity compared to

previous year.

Patient Type Annual Plan

Year to date

plan

Year to date

actuals Variance

%

variance Variance

%

variance

Elective inpatients 3,139 3,139 2,979 (160) -5% (183) -6%

Elective day case patients 15,023 15,023 14,152 (871) -6% 377 3%

Emergency inpatients 15,468 15,468 16,182 714 5% (299) -2%

Outpatient Attendances 145,590 145,590 146,212 622 0% 2,320 2%

Outpatient Procedures 18,298 18,298 23,364 5,066 28% 5,847 33%

A and E Attendances 46,218 46,218 46,649 431 1% 1,109 2%

Maternity 4,437 4,437 4,709 272 6% (918) -16%

Direct Access 29,461 29,461 28,824 (637) -2% (588) -2%

Subtotal 277,634 277,634 283,071 5,436 1.96% 7,665 3%

Other 822,855 822,855 863,437 40,581 5% (4,000) 0%

TOTAL 1,100,490 1,100,490 1,146,507 46,018 4.18% 3,665 0.26%

Contract Performance Year on Year

46

Clinical Activity Performance against Plan by Activity Type and Commissioner

*The biggest activity % variances are on the Specialist Commissioning and ‘Other’ baselines: however, these are relatively small in ‘real’ terms and

have a negligible financial value compared to the activity on the Somerset CCG baselines.

*These graphs exclude ‘non PbR’ and ‘Other’ elements such as High Cost Drugs, Critical Care and SCBU.

*‘Other’ commissioners include Local Authority, Out-of-Area work and Public Health and Military work (the latter are both commissioned by NHS

England). The relatively low baselines for this activity means that the variance % can be misleadingly high compared to the actual financial value of

the other variances.

Substantive &Total Pay (£’000)

47

Pay in month £6,997k; (£638k) adverse variance to budget)

Nursing – £323k adverse variance to budget in month, expenditure in month was similar to last month. Agency staffing costs continue to be the main

cause of the overspend, these have increase compared to 11. The escalation ward was overspent by £86k, ED overspent by £64k, Medicine wards £125k

The average bed occupancy was 43 higher than the budgeted value.

Medical Staffing – £198k adverse variance to budget in month, primary cause is usage of agency staff to cover vacancies and absence across departments,

and high level of additional session payments made to trust staff.

Vacancies - £119k Medicine consultants (Stroke & Respiratory), £38k FOPAS.

Sickness - £15k Paediatrics consultant sickness cover, £43k Acute Physicians (EAU) middle grade and junior vacancy and sickness absence.

Add’n Sess - £23k Neurology & Dermatology (Capacity for RTT and fast track cancer pts)

Other -£12k Maternity pay, £16k Paediatrics partially offset by income, £37k underspends elsewhere.

4000

4500

5000

5500

6000

6500

7000

7500

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

Ap

r-1

4

Jul-

14

Oct

-14

Jan

-15

Total Pay Expenditure Budget Substantive Actual Forecast

48

Nursing Staff Analysis

• Nursing expenditure has increased slightly compared to February 2015.

• However this month experienced the highest bed occupancy of the year.

• Agency shifts increased to the highest experienced all year.

190

200

210

220

230

240

250

260

270

280

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Ave

rage

Bed

Occ

up

ancy

2014/15 Budget 2014/15 Actual 2014/15 Forecast 2013/14 Actual

600

650

700

750

800

850

900

950

1,000

1,050

1,100

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Exp

en

dit

ure

£'0

00

2014/15 Budget 2014/15 Actual 2014/15 Forecast 2013/14 Actual

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12

WT

E

Agency WTE by Month

Pay Non Substantive (£’000)

49

Non substantive Pay in month £1,172k; (£3,592k YTD greater than M12 13/14)

£'000 Locum Bank Agency Total Locum Bank Agency Total

Medical & Dental 64 0 267 331 787 0 2,285 3,071

Nursing & Midwifery 0 198 338 536 0 1,555 2,523 4,077

Other 0 31 274 305 0 541 2,223 2,765

Total 64 229 879 1,172 787 2,096 7,030 9,913

WTE's Locum Bank Agency Total Locum Bank Agency Total

Medical & Dental 8 0 12 20 154 0 146 300

Nursing & Midwifery 0 28 78 106 0 251 547 799

Other 0 37 57 94 0 465 523 988

Total 8 65 147 220 154 716 1,217 2,087

In Month YTD

0

100

200

300

400

500

600

700

800

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

Dec

-13

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Agency Actual Locum Actual Bank Actual

50

Temporary and Agency Staffing

• Temporary Staffing includes all staff paid through our payroll such as bank, and NHS locums.

• Agency includes all staff paid for through an external agency.

0

100

200

300

400

500

600

700

£0

00

's

Nursing Nursing TemporaryStaffing (Inc Bank)

0

50

100

150

200

250

300

350

400

450

500

£0

00

's

Medical Staff

Medical Temporary Staffing

Medical Agency

Drugs (£’000)

51

Drugs spend in month £1,273k; (£340k adverse variance to budget)

400

600

800

1000

1200

1400

May

-13

Au

g-1

3

No

v-13

Feb

-14

May

-14

Au

g-1

4

No

v-14

Feb

-15

Drugs Budget Drugs Expenditure

• Drugs are overspent in month by £340k, this is offset by £92k of additional clinical income

- £86k from the cancer drugs fund.

- £31k from high cost pass through paid for by NHS England specialised commissioning.

• In month the trust has incurred £65k of additional high cost drugs spend for which we receive no additional income,

this is due to our block contract with Somerset & Dorset CCG’s.

• Year to date drugs are overspent by £1.74m, this is offset by £1.16m of additional income (£0.81m Cancer Drugs

Fund, £0.35m high cost pass through).

• Year to date the trust has incurred £0.36m of additional high cost drugs spend for which we have received no

additional income, due to our block contract with Somerset & Dorset.

Non Pay (£’000)

52

Non Pay (excl drugs) spend in month £3,433k; (£935k adverse variance to budget)

In Month:

– High Cost M&SE: £83k favourable variance to budget in month, £19k due to underspend in Orthopaedics following lower activity in month following cancelations due to escalation pressures, £28k lower spend on pacemakers and £39k lower spend on pathology items.

– Consumable and M&SE: £69k adverse variance to budget in month, £28k additional radiology costs for usage of nighthawk service to review out of hours scan results, £22k pathology test items, £25k day theatres items due to stock adjustment.

– Other Non Pay: £949k adverse variance to budget in month, £222k licence fee costs for Smartcare offset by income, £183k of redundancy payments, £161k of training costs offset by additional income, £51k premature retirements year end provision adjustment, £64k bad debt provision, £77k removals, £42k estates survey, contract expenditure offset by income £56k.

100

150

200

250

300

350

Apr-14 Jul-14 Oct-14 Jan-15

High Cost M&SE

Budget 2014/15 Exp 2013/14 Exp 2014/15

200

300

400

500

600

700

800

900

Apr-14 Jul-14 Oct-14 Jan-15

Consumable M&SE

Budget 2014/15 Exp 2013/14 Exp 2014/15

200

700

1,200

1,700

2,200

2,700

Apr-14 Jul-14 Oct-14 Jan-15

Other Non-Pay

Budget 2014/15 Exp 2013/14 Exp 2014/15

Use of Capital (£’000)

53

Total Capital spend in month is £1,178k, planned spend was £334k. Total spend in year £5,493k.

Variance: Favourable/(Adverse)

Operational Capital General Site Capex The in month adverse variance is due to catch up of work planned earlier in year. Medical & Radiological Equipment Underspent by £272k at year to date due to ultrasound scanner being purchased via lease not capital. IT - Development IT overspend of relates to new projects in year- Allocate e-rostering £103k, Switchboard £30k, Radiology order comms £21k and the completion of the Business Intelligence system £67k & Digital Dictation £75k. Major Developments IT – Smartcare Year end underspend is due to scheduling change, and lower costs for staff trust involvement than planned. Car Park (Including Demolition) Works are now complete, the overspend is due to re-phasing of works from 2013/14 into 2014/15. Car Park (MSCP) Includes legal and consultancy preliminary consultancy costs incurred. Women's Hospital - SCBU Works have started, a significant proportion of the work will occur in 2015/16.

Capital Expenditure

Actual Variance Actual Variance

Operational Capital Spend

Total General Site Capex 565 (437) 1,844 (80)

Medical Equipment 231 (201) 425 272

Radiology 124 (124) 851 (11)

IT Upgrade/ Developments 82 (72) 371 (326)

Contingency / Developments 0 17 (0) 400

Major Developments

IT - Smartcare 62 32 424 297

Car Park Phase 1 - Inc Demolition 26 (26) 806 (141)

Car Park (MSCP) 0 0 35 (35)

Masterplan 87 (82) 205 (80)

Energy Project (1) 1 282 (25)

Donated schemes in Year 0 50 251 249

Total 1,178 (844) 5,493 522

In Month Year to Date

-

500

1,000

1,500

2,000

2,500

Ap

r -

13

May

- 1

3

Jun

- 1

3

Jul -

13

Au

g -

13

Sep

- 1

3

Oct

- 1

3

No

v -

13

Dec

- 1

3

Jan

- 1

4

Feb

- 1

4

Mar

- 1

4

Ap

r -

14

May

- 1

4

Jun

- 1

4

Jul -

14

Au

g -

14

Sep

- 1

4

Oct

- 1

4

No

v -

14

Dec

- 1

4

Jan

- 1

5

Feb

- 1

5

Mar

- 1

5

Capital Capital Programme Plan

Capital Programme Actual

Capital Programme Forecast

54

Cash (£’000)

Cash outflow in month is £878k.

Key Cash Movements and Variances Cash balance at 31st March 2015 is £2.1m, this remains inline with forecast. A significant cash outflow in M12 was the payment of PDC dividend to the Department of Health. Payables are being maintained within government payment guidelines, with appropriate creditor management being followed. For year end 31 March 2015 the Trust paid 92% of all invoices by value within 30 days. Weekly monitoring of cash continues with detailed weekly cash forecasting. Double invoicing arrangements have been agreed with Somerset & Dorset CCG to support the cash position from 1st April 2015.

(2,000)

0

2,000

4,000

6,000

8,000

10,000

12,000

Ap

r -

13

Jul -

13

Oct

- 1

3

Jan

- 1

4

Ap

r -

14

Jul -

14

Oct

- 1

4

Jan

- 1

5

Ap

r -

15

Jul -

15

Oct

- 1

5

Jan

- 1

6

£ 0

00

's

Cash Plan Actual Forecast

Cash Flow

£ 000's Actual Variance to Plan

EBITDA 6 (268)

Trade Receivables (151) (465)

Trade Payables (97) 53

Provisions 168 131

Capital (343) (59)

PDC (600) 157

Stock (109) (133)

Other 249 249

Total (878) (335)

In Month

55

Statement of Financial Position (£’000)

Key Movements Current Assets Debtors have decreased following payment being received during year end agreements between NHS organisations. Prepaid contracts have increased as many maintenance agreements are paid in advance throughout February – April. Current Liabilities Capital creditors have increased following work to catch up programme in March 2015. PDC Dividend creditor has reduced following payment being made in March 2015.

Feb 15 Mar 15 Mvt In Mth

Non Current Assets 56,461 51,970 (4,491)

Current Assets

Stock 2,027 2,136 109

NHS Trade Debtors 1,738 1,428 (310)

Non NHS Trade Debtors 926 802 (124)

Accrued Income 946 1,795 849

Prepaid Contracts 1,024 760 (264)

Non Current Assets Held for Sale 0 0 0

Cash in Hand and at Bank 2,931 2,053 (878)

Total Current assets 9,592 8,974 (618)

Current Liabilities

Trade Creditors (1,547) (3,067) (1,520)

Other Creditors (3,946) (2,742) 1,204

PDC Dividend Creditor (594) 0 594

Capital Creditor (614) (1,404) (790)

Accruals (6,113) (5,700) 413

Borrowings <1yr (114) (130) (16)

Deferred Income 0 0 0

Current Liabilities (12,928) (13,043) (115)

Net Current Assets (3,336) (4,069) (733)

Total Assets less Current Liabilities 53,125 47,901 (5,224)

Trade and other Payables >1yr (12) (11) 1

Borrowings> 1yr (1,394) (1,660) (266)

Provisions >1yr (879) (1,047) (168)

Net Assets employed 50,840 45,183 (5,657)

Financed by:

I&E Reserve Current year (6,956) (10,557) (3,601)

Public Dividend Capital 41,678 41,823 145

I&E Reserve Previous year 5,898 5,918 20

Revaluation Reserve 10,220 7,998 (2,222)

Donation Reserve 0 0 0

Total Financed 50,840 45,182 (5,658)

Trust Level Key Ratios

56

EBITDA margin % in month

Return on pay has decreased compared to the previous month.

Return on non pay has increased compared to the previous month. Notes: Ratios are calculated under the current contract income value and not PbR

1.0

1.2

1.4

1.6

1.8

2.0

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Rev

enu

e/P

ay C

ost

s (£

)

Return on Pay Trend

2012/2013 2013/2014 2014/2015

1.0

2.0

3.0

4.0

5.0

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Rev

enu

e/N

on

Pay

Co

sts

(£)

Return on Non Pay Trend

2012/2013 2013/2014 2014/2015

-15%

-10%

-5%

0%

5%

10%

15%

20%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

EBIT

DA

/Rev

enu

e

EBITDA Margin Trend

2012/2013 2013/2014 2014/2015

Service Line Reporting Summary (£’000)

57

The Corporate income figure of £1,975k includes other income streams such as car parking and Injury Cost Recovery Scheme income. The £26,121k of central costs are overheads and include departments such as Facilities, Management Services, HR, Finance, and also depreciation costs.

Elective Care Urgent Care Corporate Total

Revenue 49,718 53,993 1,975 105,687

Direct Costs (23,866) (38,123) 0 (61,988)

Indirect Costs (18,502) (9,632) 0 (28,134)

Gross Contribution 7,350 6,238 1,975 15,564

Central Costs 0 0 (26,121) (26,121)

Net Contribution 7,350 6,238 (24,145) (10,557)

Year to Date (as of Month 12)

Service line reporting – Elective Care contribution

• Average full year budget margin for Elective Care is 21% • Apportionments between the specialities is being reviewed as

part of the ongoing Reference costs exercise • Big drops were seen in ‘elective admissions’ and ‘daycase’

activity, which led to a substantial loss of income, partly responsible for the negative in month contribution

58

£000's % £000's %

Month 12 -307 -8% 1,716 33%

Full Year 7,350 15% 10,995 21%

Elective Care Strategic Business Unit Contribution

Actual Budget

Service line reporting – Urgent Care contribution

• Average full year budget margin for Urgent Care is 16% • Apportionments between the specialities is being reviewed as part of

the ongoing reference costs exercise. • Additional activity was captured in SCBU, hence the big jump in month

59

£000's % £000's %

Month 12 304 6% -14 0%

Full Year 6,238 12% 7,816 16%

Actual

Urgent Care Strategic Business Unit Contribution

Budget

CIP Reporting

60

CIP Update:

As at the end of March 2015 the Trust has achieved £2,669k of

savings versus a plan of £3,440k.

Of these savings £1,908k have been made on a recurrent basis.

In month £223k of savings were made versus a plan of £367k.

0

50

100

150

200

250

300

350

400

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

£'0

00

Month

CIP Plan and Actual by month

Actual by month

Phased plan bymonth

CIP Reporting

61

In Month adjustment for Aseptic

manufacturing income £100k

reduction to CIP

CIP Reporting

62

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

£'0

00

Month

YTD CIP Plan, Actual and Forecast to January 2015

Actual YTD

Phased plan YTD

Forecast

REPORT TO: Board of Directors REPORT FROM: Trust Risk Manager TITLE: Corporate Risk Register and BAF Report Qtr 4 – 2014/15 DATE: 29 April 2015 ____________________________________________________________________

PAPER Yes PRESENTATION No PAPER & PRESENTATION No What is this item about? This aims to provide the Board of Directors (BoD) with an update on the BAF and key operational risks and activity from Qtr 4 relevant to risks scoring Significant or Higher (12+) on the risk matrix. Why is this item necessary? The report provides the necessary information for the Assurance Committees and the Board of Directors that is a fundamental part of the Governance arrangements required by Monitor and the Care Quality Commission. What is BoD asked to do? The Board of Directors is asked to NOTE the report, the BAF and the corporate risk register.

1. How does this paper improve patient care? This report and attachments highlight the key operational risks facing the Trust to achieve its Strategic Objectives of Patient Safety and Quality. Prompt 2 under KLOE Well led = Does the Governance framework ensure that responsibilities are clear and that quality, performance and risks are understood and managed? 2. How does this paper advance the Annual Plan? The report is an essential part of the work towards the Annual Report and the Annual Governance Statement. 3. How does this advance our strategic objectives? The report identifies key areas of operational risks that are fundamentally part of the Trust’s governance arrangements. 4. Is further information available? Risk registers are on YCloud with the Risk Management Strategy approved in December 2014. The Board Assurance Framework (BAF) has links to operational risks where relevant.

Are there implications for the Trust? • Legally? No

• Financially? Yes. Some of the issues discussed reflect the current position against Trust

performance • Regarding Workforce? No Is this paper clear for release under Freedom of Information? YES

1. EXECUTIVE SUMMARY

1.1 This report presents the Corporate Risk Register as at the 22 April 2015. Since last updates to the Board of Directors in January 2015, the following is noted:

• There are 22 Significant or High risks (12+) recorded at the time of this report on the Corporate Risk Register;

• Six new risk has been added, and; • Four risks have been removed since the last review at the end of Qtr 3

1.2 The following sections summarises risks and progress for consideration. The full risk register can be found on YCloud identifying detailed actions and mitigation – Click on this link.

2. RECOMMENDATION

2.1 The Board of Directors is asked to NOTE the BAF and the risks included in the corporate

risk register.

Elective Care Business Unit Risks

Risk No

Risk Description Risk Score Action / Progress Moving towards risk reduction

Where Reviewed

Residual Risk

Static

Has deteriorated

ST010

RTT - Insufficient capacity to

prevent breach of RTT targets from December 2014 resulting in

specialty and aggregate breach and significant numbers of patients

waiting over 18 weeks

20 = High

During Quarter 4 - RTT team has been developed and now has an operational support

manager owning RTT in order for the RTT performance manager to concentrate on

assurance. Currently bed pressures inhibit full booking of lists. Waiting list funding in negation

in order to address the backlog

*Increased Risk – January 2015

Elective Care

Business Unit / HMT

12 -

Significant

OTH009

Orthopaedics - Inadequate levels of Consultant medical

cover on the Orthopaedic ward to support the long term conditions

of frail elderly patients with reduced medical leadership. This risk has increased in Likelihood impacting on length of Stay and

Patient Outcomes. Risk Increased to 12 (Significant)

12 =

Significant

Increase of awareness of both medical and nursing vacancies. Speciality doctor for

Ortho/Geriatrics leaves her post on 25th Feb 2015. This post has been advertised, and the

advert extended due to lack of suitable candidates. Plans being worked on to cover this vacancy with an additional Trust Fellow based

on 6A. Multiple actions on risk register to address risk. Fracture NOF pathway is part of Orthopaedic CIP/Redesign work streams with

task and finish groups reporting into Orthopaedic Steering Group during 2015/16

*Increased Risk – February 2015

Elective Care Business Unit

6 =

Moderate

OTH001

Orthopaedics - Lack of capacity to meet the LDP contract, local 17 week and National 18 week RTT Targets in our admitted pathway.

12 =

Significant

Raised risk possible to likely due to sustained reduction in elective orthopaedic bed capacity early December 2014 and continuing late Feb

15, with no real indication of any sustained improvement in bed flow. 6A / 6B ward moves in

April will assist flow

*Increased Risk – February 2015

Elective Care Business Unit

6 =

Moderate

OG020 Gynaecology - Unable to recruit nursing staff to EPAC/GAU

Gynaecology ward, or retain staff with skills and knowledge. Financial risk of covering

Gynaecology ward with bank nursing staff

12 =

Significant

A ward staffing risk assessment has taken place. Admission protocol developed for Jasmine ward. Review of skill mix within

Gynaecology dept. to determine ability to run a Gynae ward/EPAC/GAU as cross cover for

existing staff

OBS & Gynae Business Unit

4 =

Moderate

Urgent Care and Long Term Conditions Business Unit Risks

Risk No

Risk Description Risk Score

Action / Progress Moving towards risk reduction

Where Reviewed Residual Risk

Static

Has deteriorated

UC006

Urgent Care - Risk to the continued provision of quality services as a

result of increased agency spend to maintain escalation capacity;

financial risk above budget of circa £100k per month.

20 = High

Out to recruit 40 + Nurses in April 15-

‘Fastforward’ project to assist discharges and identify flow issues took place before Easter 15

with action plan as a result to address flow issues. Bed mapping work commencing. 6A /

6B swop taking place to assist flow and capacity. Jasmine ward to move across to

main building in 2015

Urgent Care

Business Unit

12 -

Significant

UC005

Urgent Care - Filling gaps in new services and in support of service developments, including covering

sickness in some areas and having to meet increased costs

20 = High

Appointed long term NHS Locums to cover FOPAS and Respiratory Medicine and reviewing alternative staffing models

Recruited to vacant posts in ED and EAU, SBU manager for Emergency Medicine

Reviewing additional costs in Urology and Dermatology

Urgent Care

Business Unit

9 -

Significant

RA008

Radiology - Loss of Consultant Breast Radiologists due to them

being called back to MPH and MPH advertising for Consultant Breast

radiologists. Without a breast radiologist we would not be able to

support the symptomatic breast service. Loss of income.

12 =

Significant

Locum in place until June 2013.

Recruitment taking place

Radiology

6 =

Moderate

Corporate and Clinical Trustwide Risks

Risk No

Risk Description Risk Score

Action / Progress Moving towards risk reduction

Where Reviewed

Residual Risk

Static

Has deteriorated

TW019

Clinical Trustwide - Failure of

Nursing and Medical staff to accurately record and respond to poor

control of diabetes

16 = High

Action plan in place to address to address actions.Serious incident investigations being

reviewed, implemented e-learning programs for registered nurses. Look to increase the

specialist nurse hours for in-patient care. Workplan in place to include focused and

targeted training, trustwide governance session, Thematic review of investigations

Diabetes Steering

Group

6 =

Moderate

TW023

Clinical Trustwide - Increased demand during winter 14/15 resulting

in escalation areas open, elective activity and quality of care; Major risks

include Falls, Pressure Ulcers, Medication errors, Staffing risks and inability to maintaining high levels of

care

16 = High

Maintain Safe Staffing- 40 Job offers out to overseas recruitment starts 11 May + 12 New

registered Nurses Return to Acute Care Environment (RACE). Additional enhanced

payments for staff working weekends and bank holidays. Associate Director of Nursing full time

on recruitment and safer staffing

HMT

9 =

Significant

TW025

Clinical Trustwide - Inability to recruit experienced registered nurses and

newly qualified due to reduced numbers of registered nurses

available in the UK.

12 =

Significant

Nursing recruitment events overseas in March and April and Return to the Acute Care

Environment (RACE) course commenced for HCA’s. Further overseas trips planned May

*Increased Risk – January

2015

HMT

6 =

Moderate

TW003

Clinical Trustwide - Failure to implement actions for patients at risk of developing pressures ulcers whilst

in hospital resulting in skin deterioration, extended length of stay and expose to infection control risk

12 =

Significant

Regular reviewed at Pressure Ulcer Steering Group. Mattress and Equipment changes being identified as part of risk reduction work. Auditing

use or pressure ulcer relieving equipment Adhering to Tissue Viability Risk assessment is

part of the Fundamentals of Care Audit Monitoring prevalence and continuing reduction in line with CQUIN Target another reduction of 20% end of year Target 2015/16 = 75. Current

PU Action Plan being updated with some slippage due to pressures and a short term

reduction in staffing resources.

Pressure Ulcer Steering Group reporting to the Patient Safety

Steering Group

6 =

Moderate

Risk No

Risk Description Risk Score

Action / Progress Moving towards risk reduction

Where Reviewed

Residual Risk

Static

Has deteriorated

TW002

Clinical Trustwide - Serious injury to patients at high risk of falls resulting in

major harm

12 =

Significant

Review RCA's and monitor falls for trends through the Falls Prevention Group with Corporate action plan developed through the falls prevention lead.

Falls Prevention Working Group /

PSSG

6 =

Moderate

OP006

Emergency Planning - Inability of trust

to manage capacity requirements where pandemic flu affecting up to 50%

of the population across the country.

12 =

Significant

Following assurance meeting with CCG / NHS England - risk amended to reflect trust resilience issues if up to 50% of staff unable to attend site

due to sickness or family sickness / school closures. Also expected increase in patient

activity, critical care capacity constraints with plans to be updated.

Risk will remain high nationally and within YDH. Staffing plan being updated.

*NEW – March

2015

Emergency

Planning Committee

12 =

Significant

OP010

Emergency Planning - Risk of patient presenting with Ebola at YDH exposing staff and others to the virus leading to

exposure and cross contamination

12 =

Significant

Action work plan in place, all currently Amber / Green. Current risk relates to releasing staff

across ICU / ED for training in PPE use. Protocol has been developed for patients

presenting with symptoms with trained staff

Emergency Planning

Committee

12 = Significant

OP005

Emergency Planning - Failure to comply with NHS Core Standards for

Emergency Preparedness, Resilience & Response (EPRR) in line with

contractual obligations

12 =

Significant

Good progress - Assurance process through CCG / NHS England, Quality Committee has supported

review of risk. CBRN plan ratified / Severe Weather plan and Fuel plan awaiting ratification.

Lockdown plan to be developed

Emergency

Planning Committee

6 =

Moderate

PH009

Pharmacy Clinical Trustwide - Delays to patient treatment due to Homecare service failures resulting in medication

not being received on time.

12 =

Significant

Business model being developed through Chief Pharmacist, Commercial Director and Assistant Director of Finance for an Outpatient Pharmacy

solution, wholly owned subsidiary, 3rd party provider. This in effect would reduce the risk as this could be brought under control of the Trust

Pharmacy Lead

6 =

Moderate

EHR001

EHR Project - Failure to realise and agree the risks associated with

implementation of the EHR project (Smartcare) to allow management

decisions to be made on high risk areas

12 =

Significant

Agree a risk reporting process to Board level committee to communicate risk and agree level of acceptable risk as implementation goes forward

for Assurance

Risk added from NCRAC

review April 15

EHR Project

Group

6 =

Moderate

Risk No

Risk Description Risk Score

Action / Progress Moving towards risk reduction

Where Reviewed

Residual Risk

Static

Has deteriorated

F001

Finance - Staff not being paid correctly

and / or on time

15 = High

2 permanent staff now recruited and Payroll Manager recruitment underway after which

closer working with HR will be embedded and the risk will reduce significantly

Finance team

6 =

Moderate

TW017

Finance - Failure to deliver the CQUIN programme for 2014/15 results in loss

of payments

12 =

Significant

Continued performance reporting monitoring through HMT and Board. Plans in place for

2015/16 in negotiation with CCG

CQUIN Steering

Group

6 =

Moderate

EFM046

Estates and Facilities - Ageing Fire

Alarm Systems and building engineering systems do not prevent the

spread of fire and smoke in an emergency which leads to evacuation

delay and potential for evacuation areas to be compromised.

15 = High

Working with Strategic Partner to survey L2 Fire Stopping. Fire doors replaced on L2 £182,000 allocated 15/16 for Fire Alarm upgrades - No significant movement in this risk at this time

Health and Safety

Committee

5 =

Moderate

EFM031

Security - NHS Protect Standards self-

review tool completed and has identified overall Trust risk as Amber.

12 =

Significant

New outsourced Security contract due to be mobilised with effect from 1 June 15. Additional hours to be provided: 1 officer 24 hours per day,

plus a second officer 18:00 - 06:00 daily Increased awareness of incidents and

preventative actions taken through LSMS. Security Camera review taking place.

Conflict Resolution Training levels to be agreed

Security

Committee

3 = Low

HR009

Human Resources - Insufficient

assurance around Medical Devices training which demonstrates staff

competency to deliver safe patient care

12 =

Significant

Improvement in availability with training with records being recorded on completion. OLM training records updated and devices being linked to staff training record – Policy and

procedures remain to be updated but progress is good with a dedicated trainer

Medical Devices

Committee

4 =

Moderate

Risks Reduced from Risk Register

Risk No

Risk Description Risk Score

Progress Moving towards risk reduction

Where Reviewed

Residual Risk

Static Has deteriorated

F005

Finance - Reduced income and increased costs resulting in less cash in bank. The impact of running out of cash is that the Trust will not be able to meet

its payment obligations.

10 =

Significant

The Trust is working with Monitor to identify loans required to support the 2015/16 Trust

plans which has reduced likelihood from 12 to 10

Finance team with

monitor

8 =

Significant

PH011

Pharmacy - The Amicare Isolator in CIVAS which is beyond repair which if

fails will prevent Chemotherapy preparation at YDH

9 =

Significant

.Removed from Corporate Risk Register but remains to be managed through the Business Unit as a Significant risk. Funding has been

allocated funding for 2015/16

Chief Pharmacist

3 = Low

TW014

Clinical Trustwide - Due to resignation and implementation of e-rostering there

are risks around not being able to continue with e-rostering, or providing

bank and agency staff. The Nurse Coordinator is the key post that will be

reduced to manage safe staffing

1 = Low

Resolved, recruitment undertaken

Associate Director

of Nursing for Staffing

1 = Low

TW011

Clinical Trustwide - Lack or arrangements in place across the Trust

for Point of Care Testing (POCT) Equipment to ensure External Quality Assurance is carried out for reliable results to manage patient care and

treatment

6 =

Moderate

Risk reviewed through the POCT Committee, 18 March 2015. The actions completed have significantly improved the compliance with Quality Assurances tests being completed

through Safety Thermometer day. Actions to take on raising awareness with and action plan in place which has reduced from 12 Significant

to 6 = Moderate risk at this time

Point of Care

Testing Committee

4 =

Moderate

Principal Objective Principal Risk Key Strategic Controls Sources and Level of Assurance Gaps in Controls and Assurance Link to Risk

RegisterAction Plan Lead Director

Securing continual

reduction in avoidable

patient harm

Failure to reduce: HSMR/SHMI and

incidents (including pressure ulcers and

inpatient falls) resulting in harm to

patients, extended length of stay,

exposure to infection control risk, not

meeting CQUIN target and cost pressure.

YDH has consistently reduced HSMR rates and

continues to undertake mortality reviews of all

hospital deaths to identify opportunities for

learning.

Investment in additional pressure relieving

equipment, training of staff and use of

intentional rounding to reduce risk of pressure

ulcers.

Ongoing training and awareness with staff.

Renewed focus has supported early

identification of patients at risk of falling and the

implementation of plans to prevent falls.

Working Groups established working to

corporate action plans.

Policy and procedures for risk assessment and

management of patients at risk.

YDH participates in the regional patient

safety collaborative.

Sample strategy is utilised to monitor rates

of harm using Global Trigger Tool.

Corporate action plans monitored via

working groups, the Clinical Governance

Team and the risk management process.

Monitoring of indicators by the Board and

the Clinical Governance Assurance

Committee and Patient Safety Steering

Group.

Serious incidents requiring investigation

and incident reporting policy in place.

Monthly audit of fundamental standards of

care.

Minutes from Patient Safety Steering

Group and Clinical Standards Committees

and Clinical Quality Dashboard.

N/A TW002 & TW003 -

trustwide falls and

pressure ulcer risk for

patients

TW017 - failure to

deliver CQUIN

programme

TW019 - Failure of

Nursing and medical

staff to respond to poor

control of diabetes

TW023 - demand

increase winter

2014/15 affecting

operational

performance including

pressures/escalation/st

affing risks

TW025 - inability to

recruit experienced

registered nurses

Helen Ryan

Developing seven day

working across YDH

Inability to deliver a seven day service

which has a detrimental impact on

weekend admissions and outcomes for

patients.

Development of a patient safety and quality

strategy that incorporates the relevant

recommendations from the Francis Public

Inquiry into Mid Staffordshire NHS Foundation

Trust, the Berwick and Keogh reviews on

patient safety and the Clwyd Report into

complaints and patient experience. It will

include details about safe staffing levels and

plans to develop and implement models to

provide seven day services.

Detailed plans and proposals to be

overseen by the SBUs and HMT.

CQUIN 1415 - 7 day services (Radiology /

Patient Experience)

The two and five year operational and

strategic plans submitted to Monitor

contain outline proposals for seven day

working. These plans were approved and

will be monitored by the Board.

Director of Nursing Report to the Board

contain any relevant updates.

Detailed implementation plans. UC005 & RA008 -

Consultant Vacancies

across areas

TW025 - inability to

recruit experienced

registered nurses

OTH009 - Inadequate

levels of Consultant

Medical cover on the

Orthopaedic ward

Detailed implementation plans are

nearing final completion (radiography and

patient experience). CQUIN for 2015/15

in place but scope is to be determined. 7

day stocktake underway to identify service

priorities to strengthen urgent care

services over the 7 day period.

Helen Ryan, Tim

Scull, Jonathan

Higman

Safer management of

medicines

Increase in prescribing errors resulting in

patient harm and failure to learn from

mistakes.

A Safer Medicines Group has been established

to further promote the reporting of medication

incidents, and to improve learning from these

incidents. Other controls include production of

a clear plan, monthly reporting, bulletin, access

to SCR, medicines reconciliation.

Participate in the regional patient safety

collaborative. Monitoring by the Safer

Medicines Group, Patient Safety Steering

Group and Clinical Governance

Assurance Committee.

Audit and medicine reconciliation data.

Minutes / agenda of safer medicines

group / patient safety group.

Monthly medicines report.

N/A PH009 - homecare

service failures

YDH is procuring an integrated Smartcare

electronic health record (EHR). Clinical

functionality such as e-prescribing and

medicines administration support will be

available.

Tim Scull

Board Assurance Framework - April 2015

Strategic Objective 1 -Patient Safety, Quality and Clinical Effectiveness

Principal Objective Principal Risk Key Strategic Controls Sources and Level of Assurance Gaps in Controls and Assurance Link to Risk

RegisterAction Plan Lead Director

Strategic Objective 1 -Patient Safety, Quality and Clinical Effectiveness

Listening to patients and

families and learning from

their experiences

Failure to learn from mistakes and

improve services and patient experience

Improvements made to front of house

arrangements.

Patient Experience Manager has met with the

SBUs to develop plans to improve learning. All

learning relating to wards now captured within

ward work plans and monitored by relevant

matrons.

Action plans completed for all complex

complaints and shared with complainants.

Complainants invited back to check that action

plans have been completed.

Patient Experience Committee established. First

meeting, October 2014. Reporting to be

streamlined by further training from Ulysses in

November 2014. Patient Experience Committee

will request specific reporting as and when

required.

Duty of Candour protocol now in place. Joint

working with Clinical Governance department

and Patient Experience Manager

Feedback from patient surveys, NHS

Choices, patient opinion websites, patient

voice group, commissioners, patient story

at the Board, complaints and PALs

enquiries.

Monitoring by Patient Experience

Committee and CGAC. Quarterly

reporting to the Board.

Quarterly clinical quality review meetings

with commissioners.

Streamlining reporting and monitoring

processes. Set routine reporting processes

for Patient Experience Committee

No link Half day peer reviews of complaints now

planned for end of January 2015 for all

senior staff in both SBU's in order to

provide robust training in the role of lead

investigator in line with patient association

standards.

Patient Experience Committee to develop

routine reporting cycle and best format.

Internal Audit Report risks and actions

identified

Helen Ryan

Putting patient experience

on a level with clinical

outcomes

Failure to implement a culture that

enhances patient experience and meets

their needs

As above As above As above No link

Helen Ryan

Promoting positive patient

experiences

Poor reputation for good patient

experience

As above.

Strong relationship with local media teams to

promote good news stories and use of Twitter

and social media.

As above N/A TW002 & TW003 -

trustwide falls and

pressure ulcer risk for

patients

TW025 - inability to

recruit experienced

registered nurses

OTH001 - Lack of

capacity to meet LDP

contract for RTT

OTH009 - Inadequate

levels of Consultant

Medical cover on the

Orthopaedic ward

Undertaking further review of

communications plan, channels and

CONECT briefings

Helen Ryan /

Simon Blackburn

Strategic Objective 2 - Patient Experience

Principal Objective Principal Risk Key Strategic Controls Sources and Level of Assurance Gaps in Controls and Assurance Link to Risk

RegisterAction Plan Lead Director

Strategic Objective 1 -Patient Safety, Quality and Clinical Effectiveness

Delivering on financial

obligations

Reduced income and increased costs

results in less cash meaning YDH cannot

meet payment obligations or ensure

future sustainability.

Failure to deliver CIP and create

innovative ways of working that support

operational efficiency.

Five year plan has been submitted to Monitor

which sets out plans to ensure future

sustainability.

Financial Resilience Committee has been

established.

Weekly cash flow monitoring.

CIP being owned within SBUs and projects

embedded within budgets.

Working with directors and managers to

manage cash impacting activities such as CIP

achievement, capital expenditure, overspending

budgets, commercial activities etc.

Monitoring by the Directors, HMT, the

Audit Committee, Financial Resilience

Committee and the Board.

Quarterly contract meetings with

commissioners.

Oversight from Monitor as sector

regulator.

An internal audit of CIP has been

undertaken.

Detailed implementation plans. UC005 & UC006 -

increased agency

spend impacting on

budgets and providing

cover

TW017 - delivering the

CQUIN programme

TW023 - demand

increase winter

2014/15 affecting

operational

performance

ST010 - insufficient

capacity to prevent

breach of RTT targets

in elective

Development of implementation plans for

the five year strategy.

Tim Newman

Supporting operational

efficiency

As above As above As above As above As above As above

Tim Newman

Developing our Commercial

Strategy

Reduction in income Commercial Strategy has been developed and

Commercial Director and Team in post.

Commercial Plan has been developed.

Establishment of Advisory Group.

Commercial Committee and the Board. N/A No link Ongoing implementation of Commercial

Plan.

Tim Newman

Strategic Objective 3 - Delivering Best Value

Principal Objective Principal Risk Key Strategic Controls Sources and Level of Assurance Gaps in Controls and Assurance Link to Risk

RegisterAction Plan Lead Director

Strategic Objective 1 -Patient Safety, Quality and Clinical Effectiveness

Listening to staff and

developing new models of

engagement

Disengaged workforce who do not

support the overall direction of the

organisation.

Poor health and wellbeing of staff leading

to poor staff effectiveness and poor

patient experience.

Inability to recruit and retain staff,

alongside significant operational

pressures.

Staff friends and family test, NHS staff survey,

leadership and development programmes,

CONECT briefings, use of social media, JCNC,

1:1s with managers, staff forum, Head of HR

Strategy and Development in post, suggestion

box, raising concerns policy and organisational

development 'roadmap'.

Regular HR and workforce reports and

monthly performance reports to the Board.

Internal HR / workforce audit work.

Staff surveys and staff friends and family

test.

Recruitment and retention of staff.

Putting actions in place arising from the

'roadmap'

Capacity of managers and staff to attend

workshops/events.

TW025 - inability to

recruit experienced

registered nurses

OTH009 - Inadequate

levels of Consultant

Medical cover on the

Orthopaedic ward

OG020 - unable to

recruit nursing staff to

EPAC/GAU

UC005 - filling gaps in

services for staffing

and covering sickness

EFM031 - Failure to

implement NHS

Protect standards to

protect and support

staff

Implementation of a suite of listening

interventions and strengthen existing

people forums (JCNC, CONECT,

briefings, etc.)

Undertaking further review of

communications plan, channels and

CONECT briefings.

Recruitment plan being implemented.

Implementation of 'roadmap'

Staff Survey Improvement areas

Paul Mears

Tim Newman

Involving staff in the

decision-making processes

As above Internal audit into governance structures and

Board effectiveness has taken place. New

trust governance structure in place. CDs now

invited to HMT. CONECT managers used as a

forum for engaging staff in key strategic

decision making.

As above N/A No link As above

Paul Mears

Communicating through

new and innovative

channels

As above As above

Review of CONECT communications, meetings

and YCloud and development of social media

strategy.

As above N/A No link As above

Paul Mears

Simon Blackburn

Strategic Objective 4 - Our People and Culture

Principal Objective Principal Risk Key Strategic Controls Sources and Level of Assurance Gaps in Controls and Assurance Link to Risk

RegisterAction Plan Lead Director

Strategic Objective 1 -Patient Safety, Quality and Clinical Effectiveness

Developing integrated care

models/Symphony and

continuing with the

procurement and

implementation of

Smartcare

Failure to implement integrated ways of

working and inability to develop systems

to meet the changing healthcare needs of

the population.

Smartcare business case and implementation

plans approved and in place.

See also, section 6 on partnerships and

external relationships.

Governance arrangements in place for

project management of SmartCare (ToR,

agenda and minutes of meetings). There

are updates at the assurance committees,

HMT and the Board.

See also, section 6 on partnerships and

external relationships.

See also, section 6 on partnerships and

external relationships.

Awaiting decisions from NHS

England/Department of Health on funding for

transformation linked to vanguard. Ongoing

discussions with NHS England / Monitor

through new models of care team.

No link See also, section 6 on partnerships and

external relationships.

Paul Mears

Redesigning urgent care

with partners

Managing increased demand becomes

unsustainable within current

configuration.

YDH is part of Urgent and Emergency Care

Working Group led by the Somerset CCG.

Countywide Urgent Care Strategy in place.

Quarterly contracting and quality meetings

with CCG commissioners and regular

discussions at Director meetings.

Involvement in Somerset Health and

Wellbeing Leadership Group and the

System Transformation Group and

Implementation Groups.

Urgent and Emergency Care Working

Group

Focus on urgent care through SBU with an

identified director in place

Indicators of performance of Urgent Care

included within monthly Board information

pack.

Work with AHSN to quantify bed capacity

requirements for the next 3 years forms

the basis of development of annual plan

CCGs are fairly new organisations, unfamiliar

with setting and implementing key strategic

change. There is a need to consider system-

wide change rather than single elements,

such as urgent care, in isolation.

Increased constraints in the external

environment, particularly the closure of beds

at community hospitals and access to adult

social care services, leading to increased

bed utilisation at YDH.

UC006 - Risks to the

provision of services

with increased agency

spend

TW023 - demand

increase winter

2014/15 affecting

operational

performance

Implementation and action plans are

being developed as part of the wider

strategic agenda to more closely integrate

services (building on Symphony).

Operational resilience plan for 2015/16 to

be developed.

Jonathan Higman

Improving productivity in

elective care

Improving productivity in elective care

Inability to reach and maintain 90%

admitted performance resulting in poor

patient experience and financial penalty.

Performance is reviewed weekly by directors

and HMTand monthly by the Board. weekly RTT

management meetings are in place and

monthly strategic RTT review to identify and

advise of future issues

Contact Centre Strategy is in place to help

improve DNA rates. Plans to improve theatre

utilisation and admin efficiency are underway.

Continual review of workforce planning.

Performance is reviewed and managed

weekly. This is reviewed weekly by

directors and HMT, monthly by the Board

and strategic RTT meetings.

Quarterly contracting and quality meetings

with commissioners.

OSM and medical support structure now in

place and RTTMS training underway for

OSMs initially. Trackcare presents a

sustainable solution to managing RTT

performance efficiently but not yet available.

ST010 -Insufficient

capacity to prevent

Breaches of RTT in

Elective Care

OTH001 - Lack of

capacity to meet LDP

contract for RTT

OTH009 - Inadequate

levels of Consultant

Medical cover on the

Orthopaedic ward

RTT Recovery Plan developed with range

of options. Significant involvement from

CCG relating to modelling of future

performance trajectories to determine

RTT performance is key objective for all

SBU Business Managers. Regular

reporting and management of RTT to

improve position clear. Review of

processes at start of RTT pathway for

orthopaedics to streamline and maximise

time available for completion. Linked with

Oasis interface management work led by

the CCG.

Development of plans for ambulatory

surgery unit on site to maximise activity

and efficiency.

Leah Allen

Strategic Objective 5 - Innovation and New Models of Care

Principal Objective Principal Risk Key Strategic Controls Sources and Level of Assurance Gaps in Controls and Assurance Link to Risk

RegisterAction Plan Lead Director

Strategic Objective 1 -Patient Safety, Quality and Clinical Effectiveness

Building positive

relationships with NHS/local

authority partners

Inability to deliver system-wide

transformation. Failure to develop

systems to meet the changing healthcare

needs of the population.

Collaboration, involvement and engagement Proposals being developed to put in place

new commissioning arrangements that

align with the aims set out in the NHS

Forward View

Quarterly contracting and quality meetings

with commissioners.

Involvement in Somerset Health and

Wellbeing Leadership Group, the System

Transformation Group and local

Implementation Groups.

Regular meetings with CCG and Local

Authority chief executives

Primary Care stakeholder engagement

plan in place

Primary Care Liaison Manager appointed

See below No link See below

Paul Mears

Developing a plan with

regulators (Monitor/CQC)

which demonstrates long

term sustainability

Regulatory action and inability to

demonstrate long term sustainability.

Challenging financial position.

Two and five year operational and strategic

plans have been submitted to Monitor.

Assigned relationship managers with the CQC

and with Monitor.

Economic modelling undertaken by Oliver

Wyman regarding viability of long term plans

and deficit diagnostic produced regarding short

term challenges

Regular meetings with Monitor and the

CQC.

Monthly formal reporting to Monitor and

regular meetings with them and the CQC.

Two and five year operational and

strategic plans have been approved by the

Board.

Output from Oliver Wyman work.

Outcomes from Symphony Care Hub

Alignment of plans and strategies across the

health community.

CCGs are fairly new organisations, unfamiliar

with setting and implementing key strategic

change.

Detailed implementation plans for long term

strategic proposals

Capacity to deliver.

Short term financing to enable focus on

delivering long term plans

No link As above

Detailed implementation and business

case being developed, as well as ongoing

work with Oliver Wyman and support from

Bevan Brittan

Project resource being identified

Ongoing discussions with commissioners.

Implementation of Symphony Care Hub

Paul Mears

Building ongoing

relationships with national

bodies

Inability to create understanding and

support for long-term strategic plans (e.g.

integrated care, symphony 0.5)

Ongoing campaign to increase profile of YDH,

which includes: meetings with national health

leaders, new cavendish group, attendance and

presentation at national events, strong

relationships with local media, use of social

media by senior executives, regular meetings

with local and national MPs . Meetings with the

Department of Health, Monitor, CQC

Monthly updates to the Board via the Chief

Executive Report.

Weekly updates at directors meetings and

HMT.

Additional capacity secured to deliver.

No link

Peter Wyman

Paul Mears

Strategic Objective 6 - Partnerships and External Relationships

REPORT TO: Board of Directors PRESENTED BY: Chairman TITLE: Revisions to the Board Governance Structure DATE: 29 April 2015 ____________________________________________________________________

PAPER Yes PRESENTATION No PAPER & PRESENTATION No What is this item about? It is proposed to merge the non-clinical and clinical governance committees into an integrated “governance committee”. In doing so, it is suggested the quality committee formally reports to the governance committee. It is also proposed to fully constitute a finance committee (to replace the time-limited financial resilience committee) which will combine the commercial committee. The focus of the finance committee will be to monitor financial performance, commercial opportunities and strategic developments. The Board should also note intentions to amalgamate the fire, health and safety and the security sub-committees. Why is this item necessary? To support the efficient and effective governance of the organisation, particularly as YDH moves to implement a primary and acute integrated system of care following confirmation of vanguard status. What is Board asked to do? The Board is asked to review and approve the proposed changes to the Board governance structure, following which the changes will be put into effect and the terms of reference for the committees updated accordingly.

1. How does this paper improve patient care? By setting the governance framework in which patient care and safety is overseen and monitored. 2. How does this paper advance the Annual Plan? By setting the governance framework in which the annual plan is progressed and evaluated. 3. How does this advance our strategic objectives? By setting the governance framework in which the strategic objectives are overseen and monitored. 4. Is further information available? Refer to the Trust’s suite of constitutional documents.

Are there implications for the Trust? • Legally? No. The proposals adhere to the Trust’s constitutional documents.

• Financially? No. • Regarding Workforce? No Is this paper clear for release under Freedom of Information? Yes

DRAFT (Revised April 2015) Board Governance Structure

Governance Committee

Equality &

Diversity

Patient Safety

Patient Experience

Audit Committee

Hospital Management Team (HMT)*

Quality Committee

Board of Directors

Information Governance & Caldicott

Emergency Planning

& Bus Continuity

Clinical Standards

Data Quality Nutrition and Food, Patient Voice

Remuneration Committee

Elective Care Strategic Business Unit (SBU)

Finance Committee

Executive Directors*

Board of Trustees

Urgent Care Strategic Business Unit (SBU)

Point of Care Testing, Infection, Prevention & Control, Safeguarding Adults, Safeguarding Children, Medical Devices, Maternity Risk Mgt, Safer Medicines Mgt

Fire, Health & Safety & Security

Board Assurance Committees Board and Committees of the Board Operational Groups and Strategic Business Units

Quality Oversight Sub-Committees Working Groups

See SBU meetings matrix Resuscitation, Blood Mgt

Note*: Terms of Reference set out what should be reported to HMT / Executive Directors and the relationship between them

Operational updates provided to the Board via CEO Report and Operational Report