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$: BOARD OF DIRECTORS - fhft.nhs.uk · BOARD OF DIRECTORS Meeting in Public Friday, 2nd February 2018, 11:40 to 14:15 Board Room, Admin Block, Frimley Park Hospital, GU16 7UJ ... \board$
BOARD OF DIRECTORS Meeting in Public

Friday, 2nd February 2018, 11:40 to 14:15

Board Room, Admin Block, Frimley Park Hospital, GU16 7UJ

A G E N D A

Time Agenda Item Paper Action Lead

11:40 1. Welcome and Apologies for Absence

- Chairman

2.

Declarations of Interest Oral - Chairman

3. Minutes of the Previous Public Board Meeting held on 5th January 2018

Attached For Approval

Chairman

4. Action Log from Previous Meeting

Attached To Action Chairman

QUALITY

11:50 5. Ward to Board - Cardiology Dr Peter Clarkson, Consultant Cardiologist Mena Vallance, Head of Nursing, Emergency & Cardiovascular Medicine Deidre Carter, Matron Cardiovascular Medicine Michelle Youens, Head of Nursing Medicine

Part To Follow

For Information

12:15 6. Chief Executive’s Report and Quality & Performance Report

Attached To Note Chief Executive & Executive Directors

12:40 7. Quality Improvement Plan

Attached For Approval

Medical Director

FINANCE & PERFORMANCE

12:50 8. Finance Report - Month 9 8.1 FHFT Proposed Revised Board Report vs HfMA Suggested Area for Board Scrutiny

Attached Attached

To Note To Note

Director of Finance & IM&T

13:00 9. CIP Update 2017-18

Attached To Note Directors of Operations

13:10 10. Frimley Health Complaints & Patient Advice and Liaison Service Half Year Report 2017/2018

Attached To Note Director of Nursing & Quality

GOVERNANCE AND COMPLIANCE

13:20 11. Corporate Risk Assurance Framework Attached For Assurance

Chief Executive

13:30 12. Senior Information Risk Owner (SIRO) Attached For Assurance

Director of Finance & IM&T

13:40 13. Annual Review of Board Effectiveness

Attached For Completion

Company Secretary

AGENDA

1 of 184PUBLIC Board of Directors - 2nd February 2018-02/02/18

13:50 14. 14.1 14.2 14.3

Board Sub-Committee Summaries & Recommendations Performance & Remuneration Committee, 12th January Commercial Development & Investment Committee, 23rd January Finance Assurance Committee Meeting, 26th January

Attached Attached To follow

To Note To Note To Note

Committee Chair Committee Chair Committee Chair

OTHER BUSINESS

14:00 15. Any Other Business Oral - All

14:05 16. Meeting Review

Oral - All

14:10 17. Questions from Members of the Public

-

14:15 18. Date of Next Meeting; Friday, 2nd March 2018 Board Room, Frimley Park Hospital

-

NB: An ‘Acronym Buster’ has been included at the end of the Public Board papers pack.

AGENDA

2 of 184 PUBLIC Board of Directors - 2nd February 2018-02/02/18

k:\board of directors\board minutes\2018\1. 05 january 2018\public\public board minutes 050118 draft final mom.docx Page 1 of 17

BOARD OF DIRECTORS MEETING IN PUBLIC Friday 5th January 2018, 11:40 to 14:15

Lecture Theatre, PGEC, Wexham Park Hospital

MINUTES OF MEETING

Present: Pradip Patel (PP) Chairman Andrew Morris (AVM) Chief Executive Janet King (JK) Director of HR & Corporate Services Nigel Foster (NF) Director of Finance & IM&T Duncan Burton (DB) Director of Nursing & Quality Helen Coe (HC) Director of Operations FPH Lisa Glynn (LG) Director of Operations WPH Tim Ho (TH) Medical Director Mark Escolme (ME) Non-Executive Director Dawn Kenson (DK) Non-Executive Director Ray Long (RL) Non-Executive Director Mike O’Donovan (MOD) Non-Executive Director Rob Pike (RP) Non-Executive Director Thoreya Swage (TS) Non-Executive Director John Weaver (JW) Non-Executive Director In Attendance: Jen Lomas (JL) Senior Matron Paediatrics and Neonates, FPH Ros Rushworth (RR) Senior Matron Paediatrics and Neonates, WPH Amy Olley (AO) Associate Director Women and Children Joanne Philpot (JP) Chief of Service Paediatrics Susanne Nelson-Wehrmeyer (SNW) Company Secretary Kevin Jacob (KJ) Assistant Company Secretary (minutes) 1. Welcome, Introduction and Apologies for Absence a. b. c.

PP welcomed everyone to the first board meeting in public of 2018 and thanked the members of the public and governors for attending. PP asked AVM to share the Prime Minister’s (PM) visit to Frimley Park Hospital, (FPH) on the 4th January. The PM wanted to see for herself what the Trust did to manage over the Xmas and New Year period and thank all the staff who worked through this period. She met about 25 staff and she thanked each one individually. The PM also wanted to see what the Trust had put in place to handle the winter pressures. She was taken around the ambulatory care unit at FPH and she talked to patients and staff and then met a number of staff in the ED. The PM was told that Frimley Health had not cancelled out-patients or elective work as we felt it was important to carry on treating people in spite of the difficult circumstances. The Trust was able to share with the PM, that the challenge was to scale up services in community to prevent attendances at ED, as the pressure faced was

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Tab 3 Minutes of the Previous Public Board Meeting held on 5th January 2018



d. e. f. g.

both a function of the volume of patients and also how sick they were. Frimley Health had not had any 12 hour trolley waits and no one was kept waiting in ambulances to come into the ED. Notwithstanding this, performance had not been good and the Trust had unfortunately experienced the worst few days on the 4 hour target since it was first introduced. There was a need to get back control of the situation which was not all about beds but also about the flow of patients within the ED. AVM commented that he felt that the PM had walked away with the impression that everyone worked well as a team and people worked extra hours and shifts when required. She had also got the message that the solution was not around building more hospitals, but about building more services in the community and getting other things in place. The big challenge and focus over the spring and summer would be get things in a good place before the next winter. In the meantime, the Trust remained under enormous pressure and this was likely to continue for a few weeks yet. The PM had taken questions from staff and others in the ED. From the Trust’s perspective the visit had worked well and staff were thanked for all their efforts. PP said it was important to hear this and JK indicated that the Trust should be proud that the PM came along and left with a good view on Frimley Health. PP commented that he had received excellent feedback on the visit from a member of the PM’s team and this was a credit to AVM and everyone involved in planning the visit. Overall it had been very useful for the PM to see and talk to staff about what the pressures are like in the ED. There were no apologies for absence.

2. Declarations of Interest a.

There were no declarations of interest.

3. Minutes of the Previous Meeting a.

The minutes of the previous Board meeting held in public on 1st December 2017 were approved as a correct record.

4. Action Log from the Previous Meeting a. b.

1st September 2017 - 18.e Meeting Review PP to undertake a review of board papers and work with the EDs to make the papers fit for board. Update: PP commented that work was on-going, but the Cost Improvement Plan, (CIP) report was a good example of what a good board paper should be. He encouraged all the Execs to use this model for their papers. 6th October 2017 – 11.b Corporate Risk Assurance Framework-now closed Finance Assurance Committee to undertake a deep drive on the Medium Term Financial risk and the Quality Assurance Committee to undertake a deep dive of four hour A&E performance risk. Both Committees to report back to the Board. Update: FAC review of Medium Term Financial risk undertaken at the 25 October

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c.

meeting and reported back to November board meeting. QAC considered ED performance on 8th December and reported back to January meeting. Update: action closed. 6th October 2017 – 14.b – Infection Control Report also closed off Hand hygiene scores to be included in the KPI’s within the next infection control report: Update: KPI’s included. Action closed.

5. Ward to Board – Pediatrics’ Wards a. b. c.

PP introduced the Paediatrics team to the board: • Joanne Philpot - Chief of Service Paediatrics • Amy Olley - Associate Director Women and Children • Jen Lomas - Senior Matron Paediatrics and Neonates, FPH • Ros Rushworth - Senior Matron Paediatrics and Neonates, WPH A comprehensive presentation was delivered by the senior staff of the Paediatric departments of Frimley Park and Wexham Park Hospitals. They highlighted the following successes and challenges: Neonatal Wards – Jen Lomas (Frimley Park) • It had been a very busy year for both sites, but Frimley Park had experienced

about 1,200 more deliveries than Wexham Park. • There had been an increased number of sicker babies with hypoxic injuries

and grade 3 babies. Work had been undertaken with maternity to look into the reasons for this, but no common themes had been found. Learning was shared between the sites.

• Frimley Park had achieved BLISS Baby Charter accreditation in September 2017, the first neonatal unit in the country to do so. The accreditation process looked for really good family centred care and training to support nurses. BLISS was due to return to the unit during January to shoot a video that would be hosted on the BLISS website, which was a significant honour for Frimley Health.

• Wexham Neonates unit was working towards BLISS accreditation and planned to submit in July 2018. They were receiving help from staff at Frimley Park to prepare for this.

• Members of the team had presented at national neonatal network events • Frimley Park had achieved Stage 3 Unicef Baby Friendly Initiative

accreditation with Wexham achieving Stage 1. • Patient experience was excellent as measured by the Friends and Family

Test and good feedback had been received from volunteers and the outreach service.

• A challenge was to increase the response rate to the F&F Test. One of the challenges was that parents may have been asked for feedback on several occasions before arriving in the neonatal unit and as such didn’t respond when asked again.

• No complaints had been received in respect of Frimley Park. Two complaints had been received in respect of Wexham Park which had related to communications.

• The NHS was reducing term admissions to less than 4%. Both sites were

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d.

working together on this. There was an action plan which was monitored on a quarterly basis.

• Innovative measures put in place included hats for cold babies and babies with low blood sugar and work to try and reduce instances of babies being separated from their mothers.

• National audited data submitted and year on year data collection showed how well the Trust performed on maternity supporting activities, i.e. excellent performance on parent consultations as seen within 24 hours and retinal screening.

• A national neo-natal peer review had been undertaken at Frimley Park in November 2017 which had showed no serious concerns and it was commented that the unit was well-run. The Wexham neo-natal unit was due to be reviewed during January and the two units were working together on polices etc.

• Staffing – there had been some issues on the Frimley Park site in recruiting an Advance Nurse Practitioner (ANP). The unit had looked at trainee posts and the availability of central funding.

• Vacancies – there was one band 5 vacancy at Frimley Park and more at Wexham; action was being taken to address these. The units worked closely with paediatrics and at short notice used each other’s staff if necessary for help. A band 8 vacancy for matron would be advertised shortly.

• Training was a rolling programme and there were also some nurse instructors on both sites.

Paediatric Wards – Ros Rushworth (Wexham Park) • There had not been any Serious Incidents on either site but one unexplained

death. Following review, there was national learning from the case which had been unusual.

• Medicines admin policies were being reviewed as the dosage on lots of medicines was based on patient weights, leading to a wide range for paediatric patients.

• Compliance with hand hygiene and anti-microbial prescribing was at 100%. • Patient experience scores from the FFT survey at Wexham were in the 92-

100% range for patients who would recommend the Trust to family and friends. A challenge was to increase response rates and at Wexham one person had been identified to hand out and collect the surveys. As a result of this the level of responses had increased significantly.

• Children and Young People Inpatient and Day Surgery Survey for Frimley Health results showed no elements were in the top 20% nationally and one element relating to discharge information was in the bottom 20% out of a total of 65 indicators. The Senior Matron was going to visit Stoke Mandeville Hospital to learn from them as they were in the upper quartile.

• Staff that had gone the extra mile were having their achievements recognised at Clinical Governance meetings.

• A sepsis screening tool based on the new NICE guidance red-flag triggers and re-attendance to paediatrics ED had been introduced. Mini audits showed an increase in performance.

• A cross site National Paediatric Early Warning System, (PEWS) had been introduced which meant that every paediatric patient had their own risk score which could be tracked and escalations triggered which was similar to

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e. f. g. h. i. j.

the adult NEWS system. • Examples of shared learning included the ’12 key messages for Christmas’

campaign and a major incident exercise based on a school coach crash. The exercise had identified that in this situation, walking wounded patients would not have their parents around and therefore there was a need to have nonclinical staff around to help.

• Challenges faced included the national nursing shortage. The units were trying to address this by promoting and training staff from within as much as possible. Band 5 staff were being supported to do more, but there remained a significant issue around band 6 training posts. A number of band 6 staff were currently on maternity leave and there was a need for doctors’ assistants to help free up doctors time.

• The number of paediatric patients with mental health needs requiring CAMHS support was increasing, together with the complexity and severity of the needs. Two specialist band 7 mental health nurses had been appointed for the ED and the ward.

• With regard to Facing the Future – a major refurbishment had been undertaken at Wexham Park to create a spacious and bright area with more space for children transitioning into adult services. Feedback from this had been very positive.

AO commented that the units were currently underspent on their payroll budgets. She commented that there was great team of doctors and nurses in post which meant the use of agency staff was decreasing. In summary, JP highlighted that a key message when reflecting on the Trust’s neo-natal and paediatric provision was that it was not just confined to one area, there was activity throughout the system. In terms of scale of activity, the Wexham Park Paediatric Assessment Unit, (PAU) had seen over 1,000 children during the month of November without having a band 7 member of nursing staff. At Frimley Park there was sufficient bed provision, but there were issues around staffing. Roles were demanding and staff burn-out at band 5 and 6 was a particular issue. During the week commencing 24th December more patients had been discharged by paediatrics than the whole of the Medical Directorate with 6 middle grade doctors and 12 consultants. Admission avoidance had been regular practice within paediatrics and neonates for a decade and the average length of stay was only one day. This was all in the context of high activity levels. Tribute was paid by JP to the staff for their achievements, particularly in respect to the BLISS awards which were national achievements. The directorate was small in size, but had achieved a great deal. PP thanked the team for an excellent presentation and opened up the session for questions and comments. RP thanked JP, JL, AO and RR for their presentation which he felt had been very positive and backed up his own observations from undertaking a ward walkabout. He commented that he had been shocked by how many young people were experiencing mental health issue and was concerned about what the solution might be.

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k. l. m. n. o. p.

RL echoed RP’s remarks in paying tribute to the team and the quality of the presentation. He referred to the statistic that some 25% of pregnant women experienced a mental health issue and asked if there was more the Trust needed to do generally to support staff in treating patients with mental health needs. RR responded that the paediatrics and neonatal units had good links with the Berkshire Healthcare NHS Foundation Trust including around training. Part of the training was around staff resilience and putting in space for staff to talk about how they were feeling. JP added that traditionally mental health had not been addressed sufficiently which was reflected in the number and type of issues staff had to deal with now. Roles could be stressful and subject to high rates of turnover. However, there was real team effort including support from security staff and the midwives had also received some mental health training. MOD asked about the trend in sicker babies. JL commented responded that levels of acuity were increasing as were the number of deliveries. The reasons for this were being looked into. Physical capacity was becoming a problem as the increase in acuity meant that more equipment was required to support each patient, reducing the available floor space. JW commented that he felt the update had been very comprehensive and he had been particularly pleased to note the good performance of the wards in respect to hand hygiene. He asked why more children had attended the Frimley Park ED than at Wexham Park. JP commented that at Wexham Park many paediatric patients presented to the paediatric ward directly, thus by passing the ED. The Frimley Park and Wexham Park units had developed differently overtime. If children presented directly to the Wexham Park ED they would be seen, but referrals from GPs tended to be direct to the PAU. There was a different structure at Frimley Park. Overall, the service treated similar number of patients on both sites. To relieve pressure on the Frimley Park ED the possibility of increasing bed provision was being explored. DK referred to the level of readmissions and asked whether the rate was higher than the team would like. JP responded that this was being investigated on the Wexham Park site, but it was important to take into consideration that at Wexham more complex children had open access to wards and could return if they were concerned about anything. A key focus was around ambulatory care and a significant proportion of the readmissions were attributed to children with bad asthma, who could come back any time they needed to. On the plus side, they tended to have a short length of stay and were not admitted to a ward. In summary PP commented that a key point for him from the presentation was both the high number of children being treated and that these patients were also sicker, hence needing a higher level of care. To be the first District General Hospital to achieve BLISS Baby Charter Status and Unicef accreditation represented significant achievements that the team should be very proud of. External evaluation, peer review and patient feedback was also very good. It emphasised the importance of leadership and getting the right people in the team. PP commended the team for their ‘Committed to Excellence Recognition

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Scheme’ which was a great idea and others could learn from. It was also good to note that even though the units were performing strongly the team remained open to learning from others and they were going to Stoke Mandeville to do so. He paid tribute to RR, JP, AO and JL for their leadership and asked them to take back the thanks from the entire Board to their teams for what they were doing for their patients.

6. Chief Executive’s Report and Quality & Performance Report a. b. c. d. e. f.

AVM stated that in light of the extremely difficult and challenging situation the whole of the NHS and the Trust had faced over the previous ten days, it would be good to hear from LG and HC on our four hour ED performance and the measures taken to keep services running. There had been deterioration in the weather and a sicker cohort of people presenting at the Trust’s EDs, particularly patients with respiratory problems. Frimley Park HC commented that performance for Q3 was in a good place and therefore it was expected that the Trust would achieve Sustainability and Transformation Funding, (STF) for Q3. Unfortunately, the Trust and Frimley Park had struggled with performance in December and January. Despite lots of new schemes to reduce demand, more consultant cover than ever before, a new Chief of Service and deputies, the Trust had struggled to achieve the four hour target. The Board was informed that the Acute Medical Unit, (AMU) at Frimley had significantly helped mitigate the pressure, as had the availability of a physician at the front door of ED to filter out less serious cases. At Frimley Park there had been a big cohort of orthopaedic patients and high levels of acuity in general. In response to the pressures the Trust’s incident room had been activated both pre and post-Christmas in order to closely monitor the situation. At least two Executive Directors had been present in the hospital all the time over the holiday period. Notwithstanding the significant challenges to staff, patient safety had remained good and many staff across the hospitals had helped to meet the challenge by doing additional shifts. Wexham Park LG commented that it had been anticipated that the winter would be a difficult and challenging time at Wexham Park with the development of the new ED and the rise in attendance from patients from Buckinghamshire. Orthopaedics, medicine and sepsis had been particularly tricky areas and patient length of stay had crept up. Despite all the planning, there had been some congestion at Wexham Park from Boxing Day onwards. Actions taken included the opening of a ward at Heatherwood Hospital for 16 medical patients and many staff came back early from their annual leave to help the Trust staff those areas. Although feedback on the measures put in place had been good it was necessary to continue to work through the current situation and it was recognised it was a big stretch for medical teams who currently had 120 more patients than normal,

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g. h. i. j. k. l.

who they needed to look after and which also impacted negatively on length of stay. AVM stressed that although people were pulling out all the stops to maintain services it was not a situation that was sustainable over an extended period of time. HC stated the Trust would be opening up Hale ward at Farnham Hospital for a month to take off some pressure off the Frimley Park site and it was also noted that DB had authorised the use of his central nursing team as additional help for the service front line. These staff had been undertaking shifts on wards rather than their regular duties and as a consequence could not progress their primary role. HC concluded that these temporary measures would become unsustainable after a month or so and there was a need to return to normal pattern of service delivery asap. Performance AVM stated that data For October to December indicated that 90% or 9/10 of patients in ED were seen within 4 hours. Performance had not been great for the first few days of 2018, but the Trust did hope to improve on this. It would be necessary to deliver 95% performance from March 2018 which would be a big ask and there was a need to ensure that the current poor performance did not become normalised. A positive for the Trust was that it enjoyed good relationships with social care and the local authorities concerned had been supportive. It would remain a challenge to get through January and the current situation demonstrated the need to develop more health infrastructure in the community. Winter pressure funding As part of the Chancellor’s announcement to boost NHS funding by £350 million for this winter, the Trust had received £1.8 million to help fund the additional costs associated with pressures in quarters 3 and 4. This was therefore a welcomed boost however, it had been disappointing that this allocation has been made on condition that the Trust’s financial control total also increased by £1.8 million. The Trust had gone back to the DoH to clarify this and hoped that a more common sense approach might prevail. Accountable care system There was good news in respect of the development of the Accountable Care System, (ACS). The Frimley System had been successful in its capital bids of £28 million to establish integrated community hubs mainly in the north of the area, it was hoped that such hubs could be provided in Slough, one at Kind Edward VII Hospital in Ascot , one in Maidenhead, potentially three in Bracknell, and two in Ascot and one in Fleet. A further £3 million had been earmarked as part of joint venture with Bracknell Forest Council to improve the Heathlands care home into a discharge to assess facility. The ACS had been strongly supported in developing community infrastructure with good buy in from local GPs and community services

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m. n. o. p. q. u.

professionals to changing models of care. It was expected that from February the ACS would be called an AC Partnership and both NHSE and NHSI were working to develop a new framework so that performance for health and care systems would be managed via a single operating plan and financial control total for 2018/2019. It was hoped that there would be a smooth transition. CQC – Local system review AVM stated that in March 2018 the Care Quality Commission would be undertaking a system review of the social care services offered by Hampshire County Council. The review will be similar to one carried out in Bracknell Forest which had gone well, but it was likely that the Hampshire one would be tougher. Questions and discussion followed: TS referred to the ED target of 95% in March as being very challenging to achieve and asked whether performance from other parts of the system would count towards the target. AVM indicated that his impression had been that the target related to the performance of the system as a whole, but he had now been told it was only the Trust’s performance. He felt that this was odd and was seeking clarification. DK referred to the benchmarking data which showed that the Trust was the best for the timely treatment of cancer amongst all its neighbours and felt that this should be highlighted in the context of the significant pressures the Trust faced. AVM responded that it was really important that the Trust did not lose sight of the importance of the cancer treatment target as 95% of what the Trust did related to the 18 week, cancer performance and A&E targets. The Trust had not cancelled appointments and it was important to remember there were real people involved. In his view, if someone has to wait for another hour for non-life threatening care in the ED, this was a more preferable outcome than someone in pain waiting another week for a hip replacement. The Trust admitted about 1,000 people every week and if activity was postponed it would be really difficult to catch up and the Trust would also lose a lot of income in the process. He felt that most of the public would rather accept some delays in ED to keep elective and cancer work going, RP commented that the Government’s announcement that elective work could be postponed would impact on efficiency as theatres would be underutilised. The NHS was currently failing the 18 weeks and cancer targets, which was a bad position. He felt that it was important that as a Trust we kept up the good work on all the national standards. AVM responded that the Trust had worked hard to maintain its position, but would fail the whole year on the 18 week indicator if it postponed activity. HC added that delays of only one month would be enough for the target to be missed. PP commented that he had indicated to the Prime Minister on her visit that the Trust was holding its own really well through the leadership of the Chief Executive and Executive Directors. The national news was full of negative stories around the NHS daily and yet Frimley Health was managing to do so well despite

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r. s.

the pressures and he paid tribute to all the Trust’s staff. PP commented that both he and the Chief Executive had been unhappy regarding the Government announcement to cancel out patient activity and elective operations. This had caused confusion amongst patients and led to lots of phone calls, which the staff could also have done without. It had been a brave call by AVM to keep going as normal and it was the correct call for the Trust. The Board noted the report.

7. Quality Improvement Plan (QIP) a. b. c. d. e.

TH presented the Quality Improvement Plan as set out in the Agenda. A Quality Committee had not taken place in December so plan remained mostly the same as the previous month. Highlights were as follows:

• Sepsis – two new band 7 nurses had been recruited to focus on deteriorating patient.

• Frailty Unit – GPs and senior nurses to be employed within the unit were being recruited.

• Resus training was coming in on target and the number of people who survived cardiac arrest was improving.

• Emergency Pressure – measures put in place to prevent ambulance stacking.

RP noted that the ‘Real Time’ patient system had gone down a few times recently and asked if this had impacted on the plan to use the Real Time to produce a list of medically fit patients. TH responded that there had been a series of issues over Christmas weekend which had necessitated server reboots. The main issue was related to the Symphony system which was now resolved. MOD referred to the maturity of clinical handover as part of the ‘Hospital at Night’ arrangements, which were more embedded at Wexham Park than at Frimley Park. TH responded that physicians in the ED at Frimley Park had good rates of compliance about hand over, but clinical engagement was needed first and then the other two departments could be aligned. Work was in progress to seek to complete this. PP thanked TH, JK and their teams for the improvement on recruitment and retention of staff, both of which were going in the right direction and it had been good to see the results of all the hard work that has been put into this area. The Board noted the report.

8. In-patient Survey and action plan a.

DB presented the report as set out in the Agenda and highlighted the following points: • The Trust would receive the next set of result for 2016 later in January and

these would be released in due course • A lot of work had been put in place to improve arrangements around the

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b. c. d.

discharge of patients and it was important that the Trust focus on improving the patient experience of discharge. The Deputy Directors of Nursing were leading groups to improve this.

• DB had also begun work looking at the Patient Experience Forum. RL commented that he had found the results from the survey to be not that helpful in that they showed the Trust to be about the same as everyone else. What would have been more helpful was more granular information to show where the Trust was just about meeting a category or on the cusp of getting better. DB responded that the survey and format of the results was set by the CQC. RL noted that the survey showed that the Trust appeared to be an outlier on patients not feeling able to talk about their fears. He asked if the Trust was aware of the reasons for this and whether staff could be reminded to ask patients the question? DB commented that staff could be reminded to ask questions of patients about their worries and fears, but that it was also about reminding patients about the sources of information and advice available to them. This could be highlighted more. He indicated that he would take that back to the Team. The Board noted the report.

9. Finance Report - month 8 a. b.

NF presented the Month 8 report as set out in the Agenda. • The Trust had a surplus of £800,000 pre STF which was £500,000 adverse to

plan. Some of this was attributable to non-recurrent item and the forecast for the year end position was still to be on plan.

• Income from Clinical Commissioning Groups and private patient income had improved.

• Agency and bank staff costs were stable. • As a result of the significant winter pressures that the Trust had had to

respond to in December and January, there had been additional expenditure • As referred to by the Chief Executive, the Trust had received additional

winter pressure funding, but this was offset by an increase in the Trust’s control total.

• Notwithstanding these pressures it was still forecast that the Trust would hit the control total required for Sustainability and Transformation Fund, (STF) payment at the end of March 2018.

• As the financial year progressed some risks were less likely to occur and provisions for these could be released if required to offset the final figures.

The Board noted the report.

10. CIP Update 2017/18 – month 8 a.

HC presented the month 8 Continuous Improvement Plan, (CIP) as set out in the Agenda.

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b. c. d. e. f. g. h.

• Performance for month 8 has been £2.5 million against a target of £2.7 million with an improvement in the monthly position to 93.5% and year to date we have delivered £18.3 million against plan of £20.5 million

• Forecast out-turn had improved by £2.2 million, (55% of the original gap) compared to month 4 and a 94% out turn was predicted. The forecast variance against target was £1.8 million

• It was hoped that the Trust would receive some winter pressures funding to cover the additional costs it had experienced

• Overall the 2017/2018 CIP was in a strong position DK referred to problem in previous months with a backlog of coding and asked whether there was still any impact of this on the accuracy of the Trusts income figures. NF responded that majority of the backlog of coding had been cleared and so numbers were coming down. Whilst it would take time to remove the back log completely, any issues would not have a material impact on the forecast. JW referred to the year to date forecast out-turn by directorate as set out in the Agenda on page 157 and asked if each of the directorate lines was owned by individual? LG confirmed that this was picked up at the monthly review between appropriate budget holders and finance. NF confirmed that details were provided to the budget holders and an hour or two allocated to discuss the figures with them. ME commented that the Trust was £25 million behind on its capital expenditure spending against plan and he was nervous of the risk that the Government could seek to recoup the funding. He asked if the risk of this had been heightened. NF responded that he did not anticipate a raid on capital from the DoH. However, slippage against the Trust’s capital programme was a regular item of discussion with NHS Improvement. It was clarified that the total of £25 million included funds allocated for IT and equipment. PP commented that he had been very pleased to note that the CIP report had been reduced to three pages which was an example of an informative and yet concise report. All members of the Execs were encouraged to make further improvements to their reports whilst keeping the number of pages down to the minimum possible. The Board were asked to email LG and HC with PP copied in, on any further suggestion anyone had to improve this report. PP indicated that he wished to develop a model ward to board paper template taking into account learning from the reports that was produced by the paediatrics team. He asked DB to lead on this. HC commented that credit for the CIP report was due to Hugh Cronshey, Associate Director Business Support and other members of NF’s team. The Board noted the report.

11. Corporate Risk Assurance Framework – December 2017 a.

The Board noted the Corporate Risk Assurance Framework report as set out in

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the Agenda.

12. Quarter 3 Board Objectives a. b. c. d. e.

AVM set out the report as included in the Agenda which gave details of the Trust’s performance in meeting each of the Board objectives. DK referred to the Board objective of achieving a Segment 1 rating for Keeping Control of Resources and Delivering Key Standards measure and asked whether the rules had been relaxed by NHS Improvement in this area as result of the winter pressures. AVM responded that NHS Improvement had not changed anything. RP commented regarding the announcement by NHS Improvements about relaxation of fines, but it was clarified that this just related to mixed sex breaches only. AVM commented that there was hope that the chairs of NHS England and NHS Improvement would work together on avoiding duplication. If it was possible to move to assessing Accountable Care Systems through a different framework as a whole system rather than component parts this would be good. The Board noted the report.

13. EPRR - Annual Report a. b. c. d. e.

LG presented the annual Emergency Preparedness Resilience and Response, (EPRR) report as set out in the Agenda which detailed EPRR progress and the outcome of the 2017 annual assurance process. It was highlighted that: • Overall the Trust had declared a Green, (substantial compliance) position for

the EPRR which represented a significant improvement over the previous year’s position and the team had work really well to achieve this.

• Acute Trusts were required to self-assess against 60 of 66 core standards and the Trust had achieved compliance against 56 of the 60. An action plan had been developed for the standards which had not achieved compliance

• It was highlighted that the Trust has been asked to appoint a NED to the EPRR governance team. The Board was asked to confirm if it was comfortable not to appoint a NED to this team.

A short discussion took place and it was felt that the appointment of a specific representative was not required as the board as a whole already received sufficient assurance and was fully sighted. EPRR was reflected in the Board’s Risk Assurance Framework and the board received the annual report. If this was further challenged by NHS England the Board would be informed. TS asked about preparation for emergency events and whether drills were run to test parts of the EPRR plan. LG responded that that each area had a range of questions it had to answer and that some parts of the plan were put to the test. MOD sought clarification that the appointment of a NED was not nationally

3




f. g.

mandated. LG commented that she had worked with SNW to undertake a survey of practice in other trusts. This had showed a range of practice and views and it was not considered that the appointment was a formal requirement. LG also confirmed that the six standards examined in the deep dive were not part of the 60 core standards and therefore the red flag had not affected the Trust’s overall level of compliance. The Board: 1) Noted the EPRR Annual Report 2) Approved the assurance position for 2017 and to support the future planned

activity as identified. 3) Decided that that the appointment of a Non-Executive Director to hold the

EPRR portfolio was not required.

14. Quarterly Infection Control Report a. b. c.

TH presented the quarterly Infection Control report as set out in the Agenda. The report provided the Board with an update on Trust healthcare-associated infection performance for 2017/18 to date, and the feedback on agenda items presented at the Frimley Park and Heatherwood and Wexham Park infection control committees in the current quarter. It was highlighted that: • There had been 32 Trust apportioned clostridium difficile, (C-diff) infection

cases to date against an annual target of 31. Eight cases to date had been due to lapses in care.

• Draconian action had been taken in relation to prescribing antibiotics, but some antibiotics had been wrongly picked and there had also been some late reporting.

• Reporting of Escherichia coli, (E.coli) infections was to start in April. The Infection Prevention and Control Team continued to work closely with colleagues in the local CCGs in identifying and addressing actions which could assist the CCGs in the 2017/18 objective to reduce the number of E.coli bacteraemia cases by 10%. An action plan included measures to reduce catheter and antibiotic use.

• Compliance with Trust antimicrobial prescribing guidelines had improved to 90%, but this needed to be improved further to 100%.

• Hand hygiene compliance rates had improved to 95% at Frimley Park and 93% at Heatherwood and Wexham Park but the target of 100% remained.

RL referred to the reported drop in attendance at infection prevention and control training events as a result of some internal changes to MAST and asked why this had occurred. TH responded that doctors had moved to fixed training days, but there was a big drive for them to undertake their mandatory training as they could not be relicensed without it. There remained a focus to improve rates for all staff, but there had not been any big changes since the previous report. JK asked for further clarification on the changes made to the mandatory training requirements, and perhaps this did not work well for infection training? TH commented it was about the number of sessions provided for infection

3




d. e.

prevention and control. RP referred to page 181 of the Agenda which related to staffing issues and which indicated that the demands placed on the infection prevention and control team were too great and that they wanted more staff despite derogation. TH indicated that whilst the Infection Prevention & Control Nurse Consultant wished they could be at the table for every meeting, there were not enough staff to do so. The Board noted the report.

15. Board Sub-Committee Summaries & Recommendations a. b. c. d.

15.1 Charitable Fund Committee, 5th December 2017 MOD indicated the Charitable Funds balance had reduced by £100,000 and that the Charitable Funds Committee had noted the establishment of a new charitable fund for the Frimley Park Post Graduate Centre. The Committee had been updated on work to rebrand the charity logos. The current design worked well overall at Trust level but not at hospital level. Revised designs were to be put forward to the Charitable Trustee in the coming week for approval by E-Governance. A report on a proposal to establish a community health lottery would be brought to the Trustee to discuss at the February meeting. 15.2 Quality Assurance Committee, 8th December 2017 MOD reported that the Quality Assurance Committee had undertaken it’s twice a year deep dive into serious incidents which had included consideration of a number of categories, agreed action plans and changes in practice. The Committee had obtained a good level of assurance on the Trust’s actions in respect to serious incidents. The Committee had looked at the Trust’s response to the 4 hour ED target following the Board’s earlier consideration and also considered an item on the clinical audit programme. The Committee had been pleased to note that lots of good work was being undertaken in both areas, but noted that the clinical audit team was under pressure with its workload.

16. Quality Assurance Committee Terms of Reference a. b.

MOD recommended the approval of amended Terms of Reference for the Quality Assurance Committee following committee discussion. The Board agreed the Terms of Reference and it was noted that they would updated and published.

SNW

17. Any Other Business a.

There was no other business to discuss.

3




18. Meeting Review a. b. c. d. e. f.

JW commented that the Ward to Board had been fabulous with very impressive leadership shining through. HC felt that future ward to board reports could be based on the current paediatric and neonatal unit model. RP commented that whilst there was a drive to reduce the length of reports in general the Ward to Board had been longer this month. TH felt that the current Ward to Board report had been the best united and integrated report he had seen. PP asked for DB to reflect on the comments made in order to find the optimum format for consistency of Ward to Board reporting although this did not necessarily need to be implemented for the February meeting. DK also felt that the paediatric Ward to Board report had been good and also noted the reduction in the length of the public board agenda to 200 pages.

DB

19. Questions from Members of the Public a. b. c. d. e.

Rod Broad referred to ED attendances and emergency attendances at Wexham Park as set out on Agenda page 106. He commented that there appeared to be a 25-30% drop in minor attendances between August and September and asked if this was evidence of improving relationships with GPs etc.? AVM commented that his understanding was that attendances were increasing not going down. He clarified that the reason for the apparent decrease in the report was a classification issue. Overall numbers were about on plan. What had happened is that some of the attendances had been reassigned to paediatrics and majors. LG added that in August Wexham Park had introduced the ESI classification model as used at Frimley Park and this was the reason for the change. Jan Burnett congratulated the Trust on the granting of planning permission for the Heatherwood Hospital redevelopment. She referred to the number of conditions attached to the approval and asked if any of the conditions were problematic for the Trust. JK confirmed that final approval had been received just before Christmas and the Section 106 legal agreement concluded. The Trust had been very careful in giving its agreement and there was nothing that was a cause for concern or was not manageable including the remodelling of Gate 3 earlier than had been expected. A member of the public referred to the issue of rota gaps and the use of agency staff and asked if the Trust had explored digital solutions for this? JK responded that the Trust’s system were digitised including for recruitment and rostering, but that she could be contacted by email if he wished to contact her with his idea.

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20. Date of the Next Meeting a.

Friday 2nd February 2018 Board Room, Admin Block, Frimley Park Hospital

These minutes of the meeting were duly approved by the Board:

Name: Pradip Patel

Signature:

Date:

3



k:\board of directors\board meetings\2018\2. 2nd feb 2018\public\word, excel & other versions\4. public action log from previous meeting 5th january.docx

BOARD OF DIRECTORS MEETING – PUBLIC Friday 2nd February 2018

ACTION LOG

AGREED ACTION LEAD END DATE

6th October 2017 – 11.b Corporate Risk Assurance Framework Finance Assurance Committee to undertake a deep drive of the Medium Term Financial Strategy risk and the Quality Assurance Committee to undertake a deep dive of four hour A&E performance risk. Both Committees to report back to the Board. Update: Update: FAC review of Medium Terms Financial Plan risk undertaken at the 25 October meeting and reported back on November board agenda. QAC considered A&E performance on 8th December – report back to January meeting.

Rob Pike/ Mike O’Donovan 5th January 2018

6th October 2017 – 14.b – Infection Control Report Hand hygiene scores to be included in the KPI’s within the next infection control report Tim Ho 5th January 2018

ACTIONS IN PROGRESS 1st September 2017 - 18.e Meeting Review PP to undertake a review of board papers and work with the EDs to make the papers fit for board Pradip Patel On-going into 2018

5th January 2018 – 16.b QAC Terms of Reference QAC Terms of Reference to be updated and published

Susanne Nelson-Wehrmeyer 2nd February 2018

5th January 2018 – 18.e Meeting Review DB to reflect on the comments made in order to find the optimum format for consistency of Ward to Board reporting although this did not necessarily need to be implemented for the February meeting.

Duncan Burton TBC

ACTIONS OVERDUE

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Tab 4 A

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ebruary 2018-02/02/18

Report Title

Ward to Board Report Frimley Health Cardiology Wards (FPH wards G9 and CCU, and WPH Ward 4 and CCU)

Meeting

Board of Directors – Public

Meeting Date

Friday, February 2nd 2018

Agenda No.

5.

Report Type

Presentation

Prepared By

IPCT Team, Ward Team and Finance

Presented By

Clinical Matron: D Carter (FPH) and S Roots (WPH) Head of Nursing: P Vallance (FPH) and M Youens (WPH) Chief of Service: Dr J Seymour

Background

The Health and Social Care Act 2008 (Code of Practice on the Prevention and Control of infections and related guidance July 2015) states that NHS provider organisations must demonstrate that infection prevention and cleanliness are an integral part of quality assurance. Please find the report to the Board by Chiefs of Service and Clinical Matrons for FHFT Cardiology Wards: FPH G9 Cardiac Step down and CCU (Coronary Care Unit) WPH WX4 and CCU (Coronary Care Unit) NB this report is presented in conjunction with the performance data provided by the Patient Safety Team.

Issues / Actions

Areas of the Infection Control Section are RAG rated for information

Recommendation

Board members are asked to discuss and note this report

Appendices

NA

5

Tab 5 Ward to Board - Cardiology


Wards FPH G9 FPH CCU WX4 WX CCU MRSA bacteraemia for quarter

0 0 0 0

Clostridium difficile Infection cases (Trust apportioned)

1 (May 2017) 0 1 (June 2017) 0

Clostridium difficile Infection cases with Lapse in care

0 0 1 0

Wards FPH G9 FPH CCU WX4 WX CCU Hand Hygiene Audit 100% (Ward staff

Dec) 97% (IPCNs Nov)

100% (Ward staff Dec) 92% (IPCNs Sep)

80% (IPCN Dec) 90% (IPCN Dec)

Spot check audit of alcohol hand sanitizer availability (Oct 2017)

100% 100% 92% 79%

Infection Control link rep attendance at quarterly forum (2017)

100%

25%

Clinical Lead attendance at monthly HICC (2015/16)

40% 0%

Ward environmental audit

95% 97% 80% 90%

Consultants attendance at annual infection control training

31%

41%

Cleanliness monitoring data obtained from Facilities Dept

Wards FPH G9 FPH CCU WX4 WX CCU National Standards for Cleanliness score

HK 91.4% Nursing 63.2%



Jan-Dec 2017 Average = 97.4%

Antibiotic Audits obtained from Pharmacy Dept (Sept 2017):

Wards FPH G9 FPH CCU WX4 WX CCU Documentation of valid stop/review date on drug chart Was the indication stated on chart Compliance with treatment guidelines

100% 100% 100%

92% 77% 92%

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1

Ward to Board Presentation April 2017- December 2017

Wexham park cardiology highlight: Implementation of an IV diuretic lounge to help improve patient experience and reduce length of stay Primary PCI service and consultant 7 day cover Winter pressures has resulted in Angiography recovery and the IV diuretic lounge being escalated Strong engagement in clinical governance with multidisciplinary team attendance, with an emphasis on learning and development to improve care and practice. There is also a wider cardiology clinical review is underway. Workforce – 4 new substantive consultant appointments and nursing is nearly fully recruited.

“It does not get much better than this staff were attentive and positive attitude” NHS Choices

“Heart failure clinic ward 4 – what a fantastic team and fabulous service” NHS Choices

“Even in their temporary location staff were courteous and efficient” NHS Choices

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2

Ward 4 cardiology stepdown Themes and trends from Patient Experience Success’s Friends and Family Test: response rates have been consistently above target with an average of 73%

- An average of 92% would recommend the ward Patient Experience Tracker (PET) - consistently positive results:

- Within the first couple of days of admission did members of staff ask you about your home situation?

- Did nurses talk in front of you as though you weren’t there? Challenges 4 formal complaints from April 2017 Friends and Family Test:

- Only 2 responses in total were unlikely to recommend the area. Patient Experience Tracker (PET) - consistent concerns:

- Did you have confidence and trust in doctors treating you? - Did you find a member of staff to talk about your worries and fears?

Improvements have been made on noise at night by staff but remain a concern from other patients. Meal time assistance shows at time patients do not feel they get enough support but this only includes those who require assistance and on the 2 instances this was 1 patient who felt they did not get enough at the time. Themes and trends from negative feedback are around communication over treatment, expectations and treatment plans. Solutions We have a volunteer who has just commenced who is able to assist with patients who require assistance with feeding. Survey questionnaires responses inconsistent as reliant on volunteers but ward staff will be undertaking questionnaires to gain greater response. Work with the Patient experience lead to use Cardiology on the Wexham as a pilot for introduction of the new “Always Events” strategy to co-design to improve patient experience. Revised welcome information pack highlighting to discuss with the nurse in charge any concerns about the care and any worries and fears, along with a ward business card. Eye masks and ear plugs are now available and routinely offered.

5



3

Themes and trends from Safety Success’s Dementia Assessments at 100% on arrival to the ward consistently VTE assessment 100% but last 3 months showing 77%-93% but data has been reviewed and above 96% but data waiting to be changed. Housekeeping cleanliness score - Nursing 97.1% There have been 40 falls since April 2017, falls are a significant risk with syncope and arrhythmias – there has been only 1 fall that resulted in a fracture. Medication errors are 9 and relate mostly to prescribing errors and there have been no harm relating to these. Pressure ulcer – no Trust acquired pressure ulcers. Challenges Hand hygiene – ward hand hygiene audits are consistently above 90%, IPCN quarterly audit done in October which showed a slight dip of 80% There have been no MRSA bacteraemia and 1 Clostridium difficile (Trust apportioned) - June 2017 where there were delays in reviewing the stool results and prescribing treatments and the antibiotics should have been flagged and reviewed earlier. Education given to the relevant doctors and nurses. Housekeeping cleanliness score - Housekeeping 89.9% Ward 4 – provides access to ward 18, CCU and Angiography labs and recovery area and is a busy area due to this access. Serious untoward incidents – there have been 2, 1 relating to the delays in recognition of a change of cardiac rhythm and delays in the unsuccessful resuscitation attempt. The 2nd is part of the wider cardiology review. Solutions Allocation of a band 6 infection control link nurse to supports in the ward audit and a resource but also to attendance to the quarterly infection control forums. Staff huddles commenced and team meetings to ensure that information is disseminated Infection control performance is a standing item on the cardiology clinical governance meeting where there is good representation from all staff groups. Wexham is part of the Antibiotic Review Kit (ARK), reviewing appropriateness and duration of antibiotic therapy and also has dedicated cardiology pharmacists. Patients at risk of falls are nursed in bays with higher visibility and use of falls equipment. Also all cardiology patients on admission will have a lying and standing blood pressure to support the identification of syncope/postural drop.

5



4

Themes and trends from Quality Success’s Introduction of telemetry allowing stepdown from CCU and transfer of cardiac patients needing monitoring. Intravenous diuretic lounge located on ward 4 to support the early discharge of heart failure patients and also mission avoidance and support and advice of service users. Vacancy rate has steadily dropped with recruitment of nurses especially students that have a positive experience within cardiology. With current nurses going through the recruitment process this should make ward 4 fully recruited. Challenges Late discharges remain higher due to consultants ward rounds happen later in the day, confirmed easier discharges are also often transferred to angiography recovery escalation. Recruitment and retention of cardiology experienced nurses due to cardiac specialist centres within easy commuting distance. Solutions New consultant appointment will allow a review of consultant patterns to support in early ward rounds and more continuity for the ward using non interventional cardiologists. An introduction and development cardiology pack and pathway with rotational opportunities to CCU allowing growing our own nurses, there is a need for a cardiac specialist practice development nurse.

5



5

War

d 4

WX

WARD QUALITY REQUIREMENTS Outurn 16/17

Apr-17

May-17 Jun-17 Jul-17 Aug-

17 Sep-17

Oct-17

Nov-17 Dec-17 Jan-

18 Feb-18

Mar-18

Target 2017/18

Dementia Assessment 96% 100% 80% 100% 100% 100% 100% 100% 100% 100% 90%

Home between 4pm & 7.59pm (number) 401 32 27 40 47 45 50 46 27 46 N/A

Percentage 44% 48% 40% 59% 51% 67% 70% 60% 55% 53% N/A

Home 8pm & Later (number) 75 7 8 7 15 5 9 7 4 18 N/A

Percentage 8% 10% 12% 10% 16% 7% 13% 9% 8% 21% N/A

PATIENT EXPERIENCE Outurn 16/17

Apr-17


17 Sep-17

Oct-17

Nov-17 Dec-17 Jan-

18 Feb-18

Mar-18

Target 2017/18

Survey questions: (No. of questionnaires completed) 85 13 1

No

surv

eys c

ompl

eted

this

mon

th

13 11 4 23 2 10 5

Overall, did you feel you were treated with respect and dignity while you were in the hospital? 98% 100% 100% 92% 100% 100% 100% 100% 90% 95%

Did you have confidence and trust in the doctors treating you? 88% 77% 100% 86% 100% 75% 87% 50% 80% 95%

Were you involved as much as you wanted to be in decisions about your care and treatment? N/A 85% 0% 79% 64% 75% 74% 100% 90% 90%

Did nurses talk in front of you as if you weren't there? N/A 85% 100% 79% 100% 100% 78% 100% 100% 95%

Were you bothered by noise at night from other patients? 64% N/A 100% 57% 55% 50% 61% 100% 60% 80%

Were you ever bothered by noise at night from hospital staff? 92% 92% 100% 79% 100% 50% 96% 100% 80% 90%

Did you find a member of staff to talk to about your worries and fears? 65% 90% N/A 82% 100% 100% 56% 0% 80% 95%

Did you get enough help from staff to eat your meals? 91% N/A N/A 0% 100% N/A 89% N/A 0% 90%

Within the first couple of days of admission did a member of staff ask you about your home situation? 78% 83% 100% 83% 80% 100% 80% 50% 100% 80%

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Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A N/A N/A N/A N/A N/A N/A N/A N/A 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A N/A N/A N/A N/A N/A N/A N/A N/A 95%

Before the operation or procedure, did the anaesthetist or another member of staff explain how he or she put you to sleep or control your pain in a way you could understand?

N/A N/A N/A N/A N/A N/A N/A N/A N/A 95%

Have you and your family or carers been involved in discussing your discharge from hospital? 83% 86% 0% N/A 75% N/A 70% 0% 0% 80%

Did you feel threatened during your stay in hospital by other patients or visitors? N/A 100% 100% 93% 91% 100% 96% 100% 100% 99%

FFT response rate 73% 71% 38% 29% 56% 37% 58% 59% 63% 91% 40%

FFT % Would recommend 92% 100% 100% 100% 94% 95% 97% 100% 100% 92% 90%

FFT no. extremely unlikely and unlikely responses 4 0 0 0 0 1 1 0 0 0 0

War

d 4

WX

INFECTION CONTROL Outurn 16/17

Apr-17


17 Sep-17

Oct-17

Nov-17 Dec-17 Jan-

18 Feb-18

Mar-18

Target 2017/18

MRSA 0 0 0 0 0 0 0 0 0 0 0

C-Diff N/A 0 0 1 0 0 0 0 0 0 N/A

Was the indication for antibiotics specified on the drug chart? (% Yes) N/A N/A N/A N/A N/A

Was a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/A N/A N/A N/A

Does this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A N/A N/A N/A

Overall Cleaning % 97% NDA NDA NDA 97% 92% 98% 91% 95% 94% 95%

Hand hygiene 91% 90% NDA 80% 90% 90% 95% 95% 95% 90% 90%

Staff hand hygiene (IPCN Audits) N/A NDA 80% 80% NDA NDA NDA 80% NDA NDA

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Overall saving lives compliance N/A 0% 100% 95% 100% 100% 95% 100% 90% 100%

PATIENT SAFETY PERFORMANCE Outurn 16/17

Apr-17


17 Sep-17

Oct-17

Nov-17 Dec-17 Jan-

18 Feb-18

Mar-18

Target 2017/18

Hospital acquired pressure ulcer - Grade 2 4 0 1 0 0 0 0 0 0 N/A



VTE Risk Assessment 96% 100% 100% 100% 100% 100% 100% 93% 90% 77% 95%

Complaints (by number) 3 0 1 0 2 0 1 0 N/A

Compliments (by number) 104 15 15 20 25 N/A

Total number of falls 40 5 3 5 3 2 1 1 5 2 N/A

Total number of falls (with significant injury) 1 0 0 0 0 0 0 0 0 0 N/A

Medication errors 9 0 3 0 3 2 0 1 1 0 N/A

Medication errors with harm 0 0 0 0 0 0 0 0 0 N/A

SIRI's 2 0 0 1 0 0 0 0 0 1 N/A

Staffing incidents 1 0 1 0 2 1 1 0 0 0 N/A

Number of Cardiac Arrest 6 0 0 2 2 1 0 1 2 0 N/A

Emergency Crash trolley compliance 99% 100% 100% 97% 100% 100% 100% 97% 97% 100% 100%

Suction (quarterly) N/A 50% 100% N/A

War

d 4

WX WORKFORCE Outurn

16/17 Apr-17


17 Sep-17

Oct-17

Nov-17 Dec-17 Jan-

18 Feb-18

Mar-18

Target 2017/18

Standard 1 - minimum x2 trained per shift 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Standard 2 - Total compliance against planned staffing 93% 97% 111% 106% 95% 100% 98% 99% 100% 102%

Standard 3 - Trained compliance against planned staffing 85% 78% 90% 95% 80% 89% 90% 94% 87% 92%

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Trained Vacancies WTE N/A 4.8 4.8 4.8 6.9 6.9

Untrained Vacancies WTE N/A 0 0 0 0 0.61

Statutory Mandatory Rates - Annual N/A 65%

Statutory Mandatory Rates - 3 Yearly N/A 55%

Appraisal Rates N/A 85% 87 89

Sickness N/A 3 2 1

Leavers from the organisation N/A 1.00 0.31 0.31 1.00

Leavers from the ward N/A 1.00 0.00 0.00 1

COMMENTS

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CCU Themes and trends from Patient Experience Success’s Friends and Family Test: response rates have been consistently above with an average of 48%

- 99% would recommend the ward - 100% of patients would recommend the area

Patient Experience Tracker (PET) - consistently positive results:

- Overall did you feel you were treated with respect and dignity while you were in hospital

- Did nurses talk in front of you as though you weren’t there? Challenges 4 formal complaints from April 2017 Patient Experience Tracker (PET) - consistent concerns:

- Were you involved as much as you wanted to be in decisions about your care and treatment?

- Within the first couple of days of admission did a member of staff ask you about your home situation?

Noise at night from other patients is a continued issue. Solutions Eye masks and ear plugs are now available and routinely offered. Survey questionnaires responses inconsistent as reliant on volunteers but ward staff will be undertaking questionnaires to gain greater response. Work with the Patient experience lead to use Cardiology on the Wexham as a pilot for introduction of the new “Always Events” strategy to co-design to improve patient experience.

5



10

Themes and trends from Safety Success’s Dementia Assessments at 100% on arrival to the ward consistently VTE assessment has an average of 87%, but has been at 93% or above over the last 7 months. Housekeeping cleanliness score 97.4% There have been 12 falls since April 2017; there has been 2 fall that resulted in a fractures due to cardiac cause for the fall. Medication errors are 11 and relate mostly to prescribing errors and there have been 1 harm related to these requiring a period of further monitoring and delay in discharging. Pressure ulcer – 2 Trust acquired grade 2 pressure ulcers. There have been no MRSA bacteraemia or Clostridium difficile cases Challenges Hand hygiene – ward hand hygiene audits and IPCN quarterly audit remain above 90%,. Serious untoward incidents – there have been 3, 1 relating to the fall and fracture, 2 relate to post angiography procedural complications. Solutions Allocation of a band 6 infection control link nurse to supports in the ward audit and a resource but also to attendance to the quarterly infection control forums. Staff huddles commenced and team meetings to ensure that information is disseminated Infection control performance is a standing item on the cardiology clinical governance meeting where there is good representation from all staff groups. The cardiology pharmacist attends the ward round to identify prescribing errors at the earliest opportunity.

5



11

Themes and trends from Quality Success’s CCU will be fully recruited once nurses have gone through the recruitment along with working closely with ward 4 to support the development of cardiology trained nurses. Early discharges of a majority of patients with only 6% average after 8pm mostly due to recovery from procedures being the cause. Challenges Recruitment and retention of cardiology experienced nurses due to cardiac specialist centres within easy commuting distance. Solutions An introduction and development cardiology pack and pathway with rotational opportunities to CCU allowing growing our own nurses, there is a need for a cardiac specialist practice development nurse.

5



12

Cardiology’s commitment to action for the next 6 months

Keep infection control as a key focus across of cardiology. Be a pilot in adopting the ‘Always Event’ co-designing services to support patient’s experience Nurse led discharges – starting with patients that are post procedures

5



Cardiac Intervention Suite

HON dashboard

CATH LAB

WARD CQUIN REQUIREMENTS Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTDTarget

2017/18

PATIENT EXPERIENCE Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTDTarget

2017/18

Official FFT results

Would you recommend FPH to family and friends?88% 100% NA NA NA NA NA NA NA 100% 100% 90%

FFT Response RateNew 6% 0% 0% 0% 0% 0% 0% 0% 3% 40%

FFT Response - Number of extremely unlikely and unlikely responses0

INFECTION CONTROL Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD 75%

C-Diff 0 0 0 0 0 0 0 0 0 0 0 NA

Hand hygiene 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

PATIENT SAFETY PERFORMANCE Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTDTarget

2017/18

Hospital acquired pressure ulcer - Grade 2 0 0 0 0 0 0 0 0 0 0 NA



Safety Thermometer 100% 100% 100% 100% 100% 100% 100% 100% NA 100% 100% 95%

VTE Risk Assessment 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95%

Complaints (by number) 1 0 0 0 0 0 0 1 1 0 2 NA

Compliments (by number) 0 0 NA

Total number of falls 4 0 2 0 0 0 0 0 0 0 2 NA

Total number of falls (with significant injury) 0 0 0 0 0 0 0 0 0 0 0 NA

Medication errors 7 0 2 0 0 0 0 0 0 0 2 NA

Medication errors with harm 0 0 0 0 0 0 0 0 0In

arrears0 NA

SIRI's 0 0 0 0 0 0 0 0 0 0 0 NA

Staffing incidents 1 0 0 0 0 0 1 0 0 0 1 NA

Emergency trolley compliance 97% 92% 96% 90% 97% 93% 100% 84% 100% 100% 95%

Suction (quarterly) 93% 100% 100%

New

In

arrears

COMMENTS

5



Cardiac cath lab

Ward to board Feb 2018

Themes from patient experience Our patient experience feedback is mostly sought through the Picker institute Friends and family, daily communication with patients and their family and also feedback through social media. Friends and family The CCL have worked hard to improve their response rate for FFT. This is evident as they have increased their response rate from 15 in Nov to 125 in Dec. We have identified a nurse on day ward to be responsible and ensuring these handed to all patients and the response is input by the night team. Comments from our Friends and Family.

"Very high level of care great team."

"Because everything is explained in detail"

Complaints The CCL have had 2 complaints. The theme around these complaints is patients being moved to the CCl escalation prior to discharge and the lack of communication around complicated discharges. Compliments Awaiting info from PALs. The CCL receive numerous thank you cards and gifts from patients and family.

Themes around patient safety Infection The CCL day ward have never had 0 of C-diff. We have on occasion had patients admitted with diarrhoea sent to the side room on the day ward. With the support of the site team we have had to transfer the patient out to another side room as otherwise it could have impacted on the day case list. The CCL scored 100% consistently in hand hygiene.

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Incidents The CCL have not had a SIRI and have reported 19 incidents on Datix. The tables below explain the severity of the incidents.

No Harm / Near Miss

LOW MOD SEVERE DEATH

Cardiac Cath Laboratory

0 0 0

2016 12 2 0 0 0 0

2017 01 1 1 0 0 0

2017 02 2 0 0 0 0

2017 03 2 0 0 0 0

2017 04 1 1 0 0 0

2017 05 1 1 0 0 0

2017 06 0 0 0 0 0

2017 07 0 1 0 0 0

2017 08 1 0 0 0 0

2017 09 4 1 0 0 0

2017 10 0 0 0 0 0

2017 11 0 0 0 0 0

0

1

2

3

4

5

6

201612

201701

201702

201703

201704

201705

201706

201707

201708

201709

201710

201711

Cardiac Cath Lab

No Harm / Near Miss LOW MOD SEVERE DEATH

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Incidents by category in the CCL

2016

12 2017

01 2017

02 2017

03 2017

04 2017

05 2017

06 2017

07 2017

08 2017

09 2017

10 2017

11 Total

Cardiac Cath Laboratory 2 2 2 2 2 2 0 1 1 5 0 0 19

Admission/Discharge/Transfer/Appointment 0 0 0 0 0 0 0 0 0 1 0 0 1

Bed Availability/Capacity 0 0 0 0 0 0 0 0 0 1 0 0 1

Behaviour/Security 1 0 0 0 0 0 0 0 0 2 0 0 3

Clinical Triggers 0 1 0 0 1 0 0 1 0 0 0 0 3

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

Equipment/Medical Device 0 0 0 0 1 0 0 0 0 0 0 0 1

Falls 1 1 1 0 0 0 0 0 0 0 0 0 3

Records Management - Patient 0 0 0 0 0 0 0 0 1 0 0 0 1

Staffing Issues 0 0 0 0 0 0 0 0 0 1 0 0 1

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Challenges

Documentation of complications.

WHO safety checklist

Redeployment of staff.

Use of “Super escalation”

Solutions

Complication books

Any complications from a procedure are documented with the consultant’s knowledge in a

complications book. We aim to present this at our bimonthly m and m.

Any pacemaker complications, including infection are documented by cardiac physiologists

and again will be presented at the cardiology m and m.

WHO safety checklist The process around completing the safety checklist has been revisited as a concern was raised by a visiting ODP. The MDT has worked together and benched marked against other trusts to ensure we completing it in the same way in keeping with BCIS guidelines. Re-deployment of staff. The CCL day ward is used as an escalation area in the evenings. In the last year we have employed our own team to cover the day ward 27/7. The team have taken this on with good grace. Over the summer when bed stock was more available the decision was made to close the day ward occasionally and move staff to other areas, mainly within cardiovascular medicine, but they could be moved to any ward. One member of the team was moved 21 times in a month. I don’t think there is an obvious solution to this but I feel credit needs to be given to the team for their tolerance and willingness to move. Use of super escalation When bed pressures have been extreme the CCL recovery area has been used as a “super escalation”. This has a great impact on the activity through the labs which has resulted in cases being cancelled. The trust have written an escalation policy and have identified some trigger that may require us using super escalation but also recognised the impact it will have on the activity the next day.

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Themes around quality In Sept the trust did a quality walk around cardiology and no concerns were raised. It was observed that the ward is a long way from main reception and that we a re looking into a motorised vehicle to assist. Folding chairs have been placed along the route to facilitate rest. Activity The CCL activity for 2017 is 3500 case in both labs. This figure does not include the cardioversions which are performed weekly in the recovery area, approx. 260 and TOE’s, 150 and Loop recorder devices. As you can see the unit is extremely busy but also they have also performed 190 Primary PPCI which are unplanned and sometimes out of hours. NSTEMI data All STEMI and NSTEMI data are placed on the MINAP dashboard. Any time breaches are flagged and discussed and any learning is shared at in the bimonthly M and M. Staffing overview. The cardiac CCL have at the moment no RN vacancies. We have some members of the team on Modules in Brighton and more attending inhouse study days. Many of the team attend external seminars eg BCIS in London. This allows the team great opportunity to network and find out what other areas are doing.

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CCU

Ward to board report Feb 2018 Themes and trends from Patient Experience Our patient experience feedback is mostly sought through the Picker institute Friends and family, daily communication with patients and their family and also feedback through social media. Success Friends and family test.

100% of our patients felt they were treated with dignity and respect.

100% of our patients had confidence and trust in the Dr’s who were treating them.

100% of our patients got enough help while eating.

100% of our patients would recommend Frimley park to friends and family. Comments from Friends and family Dec 2017

"Excellent care from staff in every role. All impressively skilled."

“Amazing staff, great care."

Formal complaints CCU: 0 The 3 identified on the dashboard have since been attributed to other wards. Compliments. CCU receive numerous letters of thanks.

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Challenges

Increase CCU friends and family response rate.

Noise at night

Ensuring correct placement of patients on CCU Solutions Friends and family. Previously the ward receptionist handed out and inputted the friends and family data. Since the amalgamation of CCU and G9 this role is shared. Going forward other members of the team have been identified to hand out forms. The information is then inputted over the weekend. Noise at night. Noise at night on CCU is unavoidable. To help reduce the noise, monitors are placed on sleep mode, where possible. Patients are also offered ear plugs and eye masks to help alleviate the noise. We are also looking at a Sound ear which acts as a visual indicator when the noise levels reach a set level. Bed flow. To assist with bed flow and ensuring there is always a space for patients who would benefit CCU level care; an admission policy has been devised and is going through the process for comment and evaluation. Once all CCU stakeholders are in agreement we will then present at Clinical goverence for ratification. We will then implement it once we have agreement.

Themes from patient Patient Safety Success

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We now have an established bimonthly M and M and clinical goverence. Infection control CCU had

0 cases of C‐diff and MRSA this year.

Scored 100% on dementia screening

Scored 100% on the safety thermometer,

Scored 100% on VTE,

Scored 100% on Hand hygiene,

Scored 100% on emergency trolley audit and the suction audit.

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Incidents CCU has had 39 incidents on Datix. Please see pg for a break down. The incidents severity have been categorised on the below table.

2016 12 2 1 0 0 0

2017 01 3 1 0 0 0

2017 02 2 1 0 0 0

2017 03 3 2 0 0 0

2017 04 1 0 0 0 0

2017 05 1 1 0 0 0

2017 06 0 2 0 0 0

2017 07 7 0 0 0 0

2017 08 1 0 0 0 0

2017 09 2 2 0 0 0

2017 10 4 3 0 0 0

2017 11 0 0 0 0 0

0

1

2

3

4

5

6

7

8

201612

201701

201702

201703

201704

201705

201706

201707

201708

201709

201710

201711

Coronary Care Unit


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Types of incidents on CCU 2017 Coronary Care Unit 3 4 3 5 1 2 2 7 1 4 7 0 39

Accident/Injury 0 1 1 1 0 0 0 0 0 0 0 0 3

Admission/Discharge/Transfer/ 0 0 0 0 1 1 1 2 0 0 1 0 6



Drug 0 0 0 2 0 0 0 3 0 1 1 0 7


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

Pressure Sore 1 0 0 1 0 1 0 0 1 1 2 0 7

Specimens 0 0 0 0 0 0 0 0 0 0 1 0 1

Staffing Issues 0 0 0 0 0 0 0 0 0 1 0 0 1

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Challenges

Ensuring audits are completed and submitted on time.

Reducing the length of time it takes self‐presenting patients in ED to get to the lab for intervention.

Maintaining high standards. Solutions Ensuring all audits have a person identified who’s responsibility it is to ensure audits are completed in a timely manner. Continue to work with ED and reviewing all door to balloon time breeches (DBT) at clin governanace. Encourage a questioning culture which will challenge the “status quo” and bring fresh

thinking to the service.

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Themes and trends from Quality In Sept, Cardiology had a quality walkabout. Success The ward is clean and had a mark of 83% awarded against the national standards of cleanliness score. We have recently had the ward repainted. Challenges Air flow/ heating From the quality walkabout the heating and airflow system was been investigated as to whether it could be repaired or replaced. Windows. Many of the windows in CCU cannot be closed properly. The estates department are looking to get these replaced or repaired. Solutions CCU will continue to work with estates to improve the working environment. Staffing overview CCU’s daily establishment is 4 trained nurses and1 CA on every shift. Vacancies CCU have promoted 1 WTE band 6 from our band 5 nurses. We are presently advertising for 1 WTE band 6 and are offering a 1 year secondment opportunity for a band 6 (to cover maternity)

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Commitment to action for the next 6 months

Continue to provide a consistent high quality care

Recruitment of Band 6

Development of Band 5

Streamlining PPCI service with particular emphasis on reducing the A&E self presenters

Admission guidance – due to clinical governance 21st Feb

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1

Frimley G9

Ward to board report Feb 2018

Themes from patient experience. Our patient experience feedback is mostly sought through the Picker institute Friends and family, daily communication with patients and their family and also feedback through social media. Friends and family. Our response rate for friends and family is one of the highest within medicine. Our rsponses vary from 73-130 (76%). Key points

98% of our patients felt they were treated with respect and dignity whilst in hospital.

91% of our patients had confidence and trust with the medical team who were treating them.

93% were asked in the first couple of days of admission about their home situation.

93% would recommend FPH to their friends and family. Comments from friends and family (Dec17)

"A very excellent service and exemplary hospital well done."

“Everyone is so lovely and helpful."

G9 has refurbished a store room to use as a family room after a generous family donation. It opened in Dec.

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2

Complaints G9 have had 0 formal complaints. The complaints identified on the dashboard have since been appointed to other areas. Compliments Awaiting response from PALS Examples of outstanding care.

Husband and wife admitted to FPH. G9 accommodated their wish to be cared for together by allocated the 2 bedded bay on the female side which was screened off for their privacy.

EOL patients request to have the family pet visit. This was accommodated in the time and garden.

Themes from patient Safety Infection control G9 have had 1 C-diff case in May 17. This was attributed to antibiotics in the community prior to admission. G9 have scored:

100% in hand hygiene

100% VTE risk assessment

Have had 0 cases of MRSA

Have had 0 grade 3 and 4 pressure ulcers Incidents

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3

G9 have reported 180 incidents on Datix. Please see below a table illustrating the level of harm attributed to each incident.

G9 Cardiology StepDown

1 0 0

2016 12 9 4 0 0 0

2017 01 11 7 0 0 0

2017 02 16 11 0 0 0

2017 03 17 4 0 0 0

2017 04 18 9 0 0 0

2017 05 11 3 0 0 0

2017 06 3 2 0 0 0

2017 07 5 1 1 0 0

2017 08 3 3 0 0 0

2017 09 16 4 0 0 0

2017 10 10 6 0 0 0

2017 11 2 4 0 0 0


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Incidents on G9 210

G9 Cardiology StepDown 13 18 27 21 27 14 5 7 6 20 16 6 180

Accident/Injury 0 0 2 0 0 1 0 1 1 0 1 0 6

Admission/Discharge/Transfer/Appointment 1 0 1 0 3 1 1 1 0 2 0 0 10



Drug 3 0 3 4 2 3 1 0 2 2 2 0 22


Falls 7 10 10 6 12 3 3 3 2 9 8 5 78

Infection Risk 0 0 0 0 1 1 0 0 0 0 0 0 2

Pressure Sore 1 5 6 4 3 0 0 1 0 1 2 1 24

Records Management - Patient 0 0 0 0 0 1 0 0 0 0 0 0 1

Specimens 0 0 0 0 1 0 0 0 0 0 0 0 1

Staffing Issues 0 3 3 4 2 4 0 0 0 5 3 0 24

Totals: 18 24 32 28 30 18 7 15 8 29 23 6 238

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Success

We have appointed a discharge facilitator .

This role has enabled cardiology to have consistent approach to discharge. Sue ensures discussions around discharge are commenced early in admission and works with family and other agencies to ensure whatever help is in place. Many og G9 patients are discharged from the escalation area in the cardiac intervention suite which has resulted in G9 “premium” discharges not been captured correctly.

Cardiac bed flow role. One of our senior nurses holds a bleep to ensure the trust has a clear and current cardiology bed status. This allows for smooth movement when stepping patients from CCU to G9 and the CCL. Challenges

Falls ( 78 this year so far)

Solutions We have had an increase in the number of falls on G9. The majority of the falls are occurring overnight.G9 have a falls link nurse who is attending the falls meeting. Unfortunately they have not received the dates for this year so far. All staff are encouraged to be extra vigilant with patient who are deemed to have more of a falls risk by placing them in beds nearer nurse stations. G9 have also set reducing falls as one of the ward objectives for this year. Themes around Quality Quality walk about. In Sept, G9 had a quality walk about facilitated by the trust. The feedback was that: “The ward is clean and tidy and well looked after by the staff. Staff morale was high on the ward. A staff celebration was witnessed on the walkabout, with members from different teams within the same ward appreciating an employee’s long service, working at Frimley for 20 years. Challenges

From the quality walk about a concern for both staff and patients on the ward is the air flow. There is no air conditioning/heat control and therefore the winters are very cold and the summers are very hot, with limited assistance from opening the windows as the building has been built around. This is an on-going issue that has been raised previously.

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6

Bed flow improvement would be beneficial to the department, as G9 can struggle to move patients on once they are medically able to leave the cardiology ward, which in turn means they are unable to take on the patients that need the specialised cardiology services.

Reduced drug errors Last year, 2016, G9 had an increase in drug errors. Since then the team have worked at reducing this to 15. This is mostly accredited to chart checking at handover. Any drug omissions can be addressed at this point. Solutions. Air flow. We continue to work with estates to find a solution. Bed flow The cardiac bed flow manager works closely with the site team to help facilitate identified patients move off the ward.

Staffing overview Since CCU and G9 amalgamated last May, any vacancies in G9 have been absorbed into the establishment and we have retained our nursing staff since. The team have had many opportunities to develop their knowledge by both attending external and internal study days. We have also allocated nurses to work within different areas of cardiology e.g CCU and the CCL and cardiac bed flow . This has helped gain the team a better understanding of all areas. Every 3 months the team meet with the ward manager on an individual basis and the feedback from this has been that it was felt extremely useful. The team have also worked on developing a team identity with shared goals. Staff morale is high in this ward.

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Ward Performance ReportG9

G9

WARD CQUIN REQUIREMENTS Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTDTarget 2017/18


PATIENT EXPERIENCE Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTDTarget 2017/18

Survey questions: (No. of questionnaires completed) 388 109 85 73 88 113 83 76 130 93 9

Overall did you feel you were treated with respect and dignity whilst in hospital?

97% 93% 94% 96% 98% 97% 100% 99% 98% 98% 97% 95%

Did you have confidence and trust in the doctors treating you? 95% 90% 94% 97% 87% 91% 95% 89% 94% 91% 92% 95%

Were you involved as much as you wanted to be in decisions about your care and treatment?

New 77% 82% 82% 77% 73% 75% 78% 68% 75% 76% 90%

Did nurses talk in front of you as if you weren’t there? New 85% 85% 92% 84% 88% 91% 93% 90% 85% 88% 95%

Were you ever bothered by noise at night from other patients? (no response is counted as positive)

55% 67% 57% 64% 55% 54% 54% 58% 68% 62% 60% 80%

Were you ever bothered by noise at night from hospital staff? (no response is counted as positive)

88% 79% 80% 85% 79% 81% 84% 95% 87% 80% 83% 90%

If you needed it, did you get enough help from staff with eating and drinking?

88% 85% 79% 93% 95% 91% 100% 83% 90% 82% 89% 90%

Within the first couple of days of admission did a member of staff ask you about your home situation? (For example do you have help with 86% 83% 92% 86% 92% 83% 91% 87% 89% 93% 88% 80% Beforehand, did a member of staff explain the risk and benefits of the operation or procedure in a way you could understand? New NA NA NA NA NA NA NA NA NA NA 95%

Have you and your family or carers been involved enough in discussing your discharge from hospital?

83% 76% 71% 87% 83% 79% 74% 84% 78% 90% 80% 80%

Official FFT resultsWould you recommend FPH to family and friends?

95% 100% 100% 100% 93% 96% 90% 100% 90% 93% 96% 90%

FFT Response Rate New 47% 12% 76% 45% 47% 83% 63% 62% 49% 40%

FFT Response ‐ Number of extremely unlikely and unlikely responses 0

INFECTION CONTROL Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTDTarget 2017/18

C‐Diff 0 0 1 0 0 0 0 0 0 0 1 0

MRSA 0 0 0 0 0 0 0 0 0 0 0 NA

Hand hygiene 98% 100% 100%, BBE 96%

100% 100% 100% 100% 100% 100% 100% 100% NA

G9

New

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PATIENT SAFETY PERFORMANCE Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTDTarget 2017/18

Hospital acquired pressure ulcer ‐ Grade 2 4 1 0 0 1 0 1 1 1 5 NA



Safety Thermometer 95% 94% 94% 93% 95% 89% 100% 82% 95% 90% 92% 95%


Complaints (by number) 3 1 0 1 1 0 0 0 1 TBC 4 NA






arrears0 NA

SIRI's 1 0 0 0 0 0 0 0 0 0 0 NA




G9

In arrears

COMMENTS

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CATH LAB

Cat hWARD CQUIN REQUIREMENTS Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTD

Target 2017/18



88% 100% NA NA NA NA NA NA NA 100% 100% 90%



INFECTION CONTROL Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTD 75%

C‐Diff 0 0 0 0 0 0 0 0 0 0 0 NA

Hand hygiene 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

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PATIENT SAFETY PERFORMANCE Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTDTarget 2017/18




Safety Thermometer 100% 100% 100% 100% 100% 100% 100% 100% NA 100% 100% 95%








arrears0 NA

SIRI's 0 0 0 0 0 0 0 0 0 0 0 NA




Cath Lab

In arrears

COMMENTS

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CCU

CCU WARD CQUIN REQUIREMENTS Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTD

Target 2017/18

Dementia Assessment 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90%


Survey questions: (No. of questionnaires completed) 154 16 20 9 9 13 21 39 43 27 197

Overall did you feel you were treated with respect and dignity whilst in hospital?

100% 100% 100% 100% 100% 100% 100% 100% 98% 100% 100% 95%

Did you have confidence and trust in the doctors treating you? 98% 88% 100% 100% 100% 100% 95% 97% 98% 100% 98% 95%

Were you involved as much as you wanted to be in decisions about your care and treatment?

New 88% 80% 100% 67% 85% 90% 79% 84% 89% 85% 90%

Did nurses talk in front of you as if you weren’t there? New 88% 85% 100% 89% 85% 90% 97% 95% 96% 92% 95%

Were you ever bothered by noise at night from other patients? (no response is counted as positive)

55% 100% 55% 78% 44% 69% 45% 79% 63% 55% 65% 80%

Were you ever bothered by noise at night from hospital staff? (no response is counted as positive)

74% 63% 80% 78% 89% 77% 80% 72% 79% 92% 79% 90%

If you needed it, did you get enough help from staff with eating and drinking?

98% 100% 83% 100% 100% 80% 100% 100% 89% 100% 95% 90%

Within the first couple of days of admission did a member of staff ask you about your home situation? (For example do you have help with

85% 90% 87% 100% 80% 100% 85% 83% 86% 80% 88% 80% Beforehand, did a member of staff explain the risk and benefits of the operation or procedure in a way you could understand? NA NA NA NA NA NA NA NA NA NA NA 95%

Have you and your family or carers been involved enough in discussing your discharge from hospital?

84% 85% 69% 100% 56% 90% 62% 83% 92% 78% 79% 80%


99% 100% 96% 94% 100% 100% 100% 100% 97% 100% 99% 90%



INFECTION CONTROL Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTD Target 2017/18

C‐Diff 0 0 0 0 0 0 0 0 0 0 0 0

MRSA 0 0 0 0 0 0 0 0 0 0 0 NA

Hand hygiene 100% 100% 100% Nil Sub. 100% Nil sub. 92% 92% 100% 100% 98%

New

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PATIENT SAFETY PERFORMANCE Outurn Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 YTD Target 2017/18




Safety Thermometer 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95%








arrears0 NA

SIRI's 0 0 0 0 0 0 0 0 0 0 0 NA




CCU

In arrears

COMMENTS

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Ward Performance ReportCCU

WARD QUALITY REQUIREMENTSOuturn 16/17

Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18Target 2017/18


Home before 4pm & 7.59pm (number) 389 32 22 42 45 46 24 36 30 49 N/A

Home before 4pm & 7.59pm (Percentage) 33% 38% 27% 43% 49% 39% 27% 39% 33% 44% N/A

Home 8pm & Later (number) 68 3 5 5 8 12 10 8 2 7 N/A

Home 8pm & Later (Percentage) 6% 4% 6% 5% 9% 10% 11% 9% 2% 6% N/A

PATIENT EXPERIENCEOuturn 16/17


Survey questions: (No. of questionnaires completed) 72 6 4 4 12 12 5 2 3 14 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 99% 100% 100% 100% 92% 92% 100% 100% 100% 100% 95%

Did you have confidence and trust in the doctors treating you? 90% 100% 100% 100% 92% 100% 60% 100% 100% 86% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? N/A 100% 100% 75% 67% 75% 40% 100% 100% 71% 90%

Did nurses talk in front of you as if you weren't there? N/A 83% 100% 75% 67% 100% 100% 100% 100% 93% 95%

Were you bothered by noise at night from other patients? 68% N/A 75% 50% 75% 25% 40% 50% 0% 64% 80%

Were you ever bothered by noise at night from hospital staff? 92% 100% 67% 100% 75% 100% 80% 100% 67% 77% 90%Did you find a member of staff to talk to about your worries and fears? 87% 100% N/A 100% 75% 82% 67% 100% 100% 78% 95%

Did you get enough help from staff to eat your meals? 90% 100% N/A 100% 83% 100% N/A N/A N/A N/A 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 62% 50% N/A 67% 71% 75% 80% 100% 67% 78% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A N/A N/A N/A N/A 67% N/A N/A N/A N/A 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 95%

Before the operation or procedure, did the anaesthetist or another member of staff explain how he or she put you to sleep or control your pain in a way you could understand?

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 95%

CCU

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Have you and your family or carers been involved in discussing your discharge from hospital? 90% 100% 0% 75% 57% 67% 100% 50% 100% 57% 80%Did you feel threatened during your stay in hospital by other patients or visitors? N/A 100% 100% 100% 100% 100% 100% 100% 100% 93% 99%

FFT response rate 48% 35% 39% 51% 54% 62% 41% 30% 54% 64% 40%

FFT % Would recommend 99% 100% 97% 100% 98% 100% 100% 100% 100% 100% 90%

FFT no. extremely unlikely and unlikely responses 1 0 0 0 0 0 0 0 0 0 0

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INFECTION CONTROLOuturn 16/17


MRSA 0 0 0 0 0 0 0 0 0 0 0

C‐Diff 0 0 0 0 0 0 0 0 0 0 N/AWas the indication for antibiotics specified on the drug chart? (% Yes) NDA N/AWas a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/ADoes this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A

Overall Cleaning % 97% 99% NDA 99% 94% 98% 97% 97% 99% 99% 95%

Hand hygiene 90% 100% 90% 95% NDA NDA 100% 95% 94% NDA 90%

Staff hand hygiene (IPCN Audits) N/A N/A 75% 75% NDA NDA NDA 90% NDA NDA

Overall saving lives compliance N/A 100% 100% 100% NDA NDA 100% 100% 100% NDA

PATIENT SAFETY PERFORMANCEOuturn 16/17


Hospital acquired pressure ulcer ‐ Grade 2 2 0 0 1 1 0 0 0 0 N/AHospital acquired pressure ulcer ‐ Grade 3 0 0 0 0 0 0 0 0 0 N/AHospital acquired pressure ulcer ‐ Grade 4 0 0 0 0 0 0 0 0 0 N/AVTE Risk Assessment 87% 85% 92% 95% 99% 99% 94% 97% 93% 97% 95%Complaints (by number) 4 0 0 0 1 0 0 0 N/ACompliments (by number) 0 2 N/ATotal number of falls 12 0 0 2 1 1 2 2 1 3 N/ATotal number of falls (with significant injury) 0 0 0 2 0 0 0 0 0 0 N/AMedication errors 11 2 0 1 0 0 0 1 0 1 N/AMedication errors with harm 1 0 1 0 0 0 0 0 0 N/ASIRI's 1 1 0 1 0 1 0 0 0 0 N/AStaffing incidents 16 0 1 4 0 0 0 0 0 0 N/ANumber of Cardiac Arrest 17 1 4 2 1 0 0 0 0 1 N/AEmergency Crash Trolley Compliance 99% 97% 98% 98% 100% 100% 98% 100% 98% 95% 100%Suction (quarterly) N/A N/A

CCU

94% 100%

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WORKFORCEOuturn 16/17


Standard 1 ‐ minimum x2 trained per shift 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Standard 2 ‐ Total compliance against planned staffing 95% 91% 95% 92% 98% 95% 96% 101% 103% 104%Standard 3 ‐ Trained compliance against planned staffing 93% 91% 94% 84% 84% 85% 86% 87% 90% 95%Trained Vacancies WTE N/A 10.3 9.66Untrained Vacancies WTE N/A 0.00 0.00Statutory Mandatory Rates ‐ Annual N/A 68%Statutory Mandatory Rates ‐ 3 yearly N/A 78%Appraisal Rates N/A 78% 87%Sickness N/A 2 1Leavers from the organisation N/A 0 0Leavers from the ward N/A 1 1

CCU

COMMENTS

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Site Cost Centre YTD Budget YTD Actual YTD Variance

2555 Cardiac Cath Lab 67,814£ 43,615£ 24,198-£ 2800 Medical-Cardiology 1,220,823£ 1,352,268£ 131,445£ 2828 G9 Cardiac Step Down 1,230,388£ 1,247,491£ 17,104£ 2833 Cardiac Cath Med 2,594,403£ 2,972,125£ 377,722£ 2835 Ccu 987,213£ 945,519£ 41,694-£ 3025 Cardiac - Re-Hab 235,103£ 185,160£ 49,943-£ 4341 Cardiology W/List 66,806£ 16,844£ 49,962-£

7161 Cardiology - Ecg 915,700£ 1,199,711£ 284,011£ 7162 Cardiology - Rebate Income 56-£ 7,770£ 7,825£ 7163 Cardiology Administration 213,728£ 157,367£ 56,361-£ 7164 Coronary Care Unit 968,940£ 837,986£ 130,954-£ 7165 Cardiac Angiography Suite 2,566,240£ 2,595,383£ 29,142£ 7167 Cardiac Specialist Nurse 246,995£ 204,010£ 42,985-£ 7173 Medicine Ward 4 Wph 948,104£ 1,203,848£ 255,744£ 7178 Medical Staff - Cardiology 1,379,117£ 1,466,495£ 87,378£

YTD M9

FPH

WPH

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Report Title

Chief Executive’s Report

Meeting

Board of Directors - Public

Meeting Date

Friday 2nd February 2018

Agenda No.

6.

Report Type

To Note

Prepared By

Andrew Morris, Chief Executive Officer

Executive Lead

Andrew Morris, Chief Executive Officer

Performance Overview

Performance April 17 – December 18 December was a particularly challenging month. While there was strong compliance with the cancer and 6 week diagnostic targets the Trust failed 18 weeks for the first time in this financial year with a monthly out turn of 91.3% against a standard of 92%. The Frimley Park site has struggled to meet this standard for several months and Wexham’s better performance has been compensating however Wexham just met the standard in December and did not sufficiently offset Frimley Park’s underachievement. Nevertheless putting the under achievement in December into context the Trust has delivered 92.4% against this standard year to date even though it failed achieve the standard in one month. The NHS is not achieving 18 weeks in aggregate this year and so FHFT performance is stronger than most Trusts. The Trust will need to meet 92% for January otherwise NHSI will relegate Frimley’s segmental rating from 2 to a 3 which would be an all time low since becoming a Foundation Trust 2005. 4 hr performance in the Emergency Dept dipped for December to a low point so far this financial year at 84.3% which was just at the national average. The main reason for the dip in performance was a cohort of sicker patients being admitted with respiratory and flu related conditions which has extended length of stay and so the discharges and emergency admissions have remained out of balance for much of the month and patients have had to wait for longer periods to get into a bed. Additional bed capacity was opened over the Christmas period at Heatherwood and Farnham Hospitals to help to maintain the flow of patients through the two Emergency Depts and thanks to an enormous effort from the ED and bed management teams there have been no 12hr trolley waits and ambulances have always been able to offload patients. It is expected that the Trust will achieve around 85% compliance for January which is disappointing as there was the aspiration to maintain performance above

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Tab 6 Chief Executive's Report and Quality & Performance Report


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90%. Given the pressures on beds there have been 5 mixed sex breaches and performance on stroke at Frimley suffered with only 47% of stroke patients getting into a bed in 4 hrs. Overall activity is close to plan and performance on 18 weeks and 4 hrs would have been much worse if activity was increasing. Social care colleagues have been particularly supportive over the Christmas period in ensuring that the number of delayed transfer patients did not worsen. Even though there have been significant operational difficulties the Trust has kept the elective surgery as near to normal as possible. There have been 37 cases of C diff for the period April to December against a target of 31 and the control of infection team is working closely with the ward teams to maintain hand hygiene and antibiotic compliance. One of the three MRSA cases has been reassigned to a third party and so the total number of MRSAs has reduced to 2. Mortality remains at an overall lower rate than average and the incidence of nosocomial pneumonias, cardiac arrests and shock, rising ureas or creatinine and surgical complications remains better than average. There have been 7 Never Events to date which is of continued concern. 6 have resulted in minor harm and one has resulted in moderate harm. The safety team have put together a presentation on the key learnings from these events to be shared with all directorates. All the patients involved have been briefed on what happened and have received copies of the incident reports that have been shared with the Board. The Never Event in spinal surgery has no longer been classified as Never Event due to a change in definition. Compliance with the sepsis bundle is improving which is positive and reflects the efforts made by the safety team to ensure that this standard is better embedded. The take up of the flu jab for staff is at 67% and the occupational health team is making the final push to achieve at least 70%. All staff are encouraged to have the inoculation as it protects them and their patients from contracting flu. Sickness amongst doctors is high and special efforts have been made to make sure that the juniors doctors are aware of the risks of not protecting themselves. Annual appraisal rates for non medical staff is at 61% and needs to improve. Every member of staff is entitled to a once a year structured conversation about there performance and development and the Trust has a responsibility to ensure that appraisals take place. While it is recognised that not all appraisals are entered on the HR IT system improvements are required on data capture and compliance.

Finance

Financial performance – April to December The Trust is still on course to deliver it’s financial plan for the financial year end even though there is very little extra income generated through over performance on activity. The continuous improvement programme of £30m will be close to target thanks to the efforts of the whole management team and agency spend was at its lowest point for a long time. Agency expenditure are now well within the pay cap set by NHSI for the year. Overall pay budgets are still under pressure which is a concern. The STF should be earned in full for Q3 but delivery for 4 hrs is a risk in Q4 as the Trust is expected to deliver 95% or better result. Failure to do so will incur a loss of £1.5m

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Page | 3

which is a concern and may need to be factored in achieving the control total for the health system. Next years CIP of £30m is in development and this will be really challenging to achieve. The whole leadership team is working hard to develop a robust schedule of efficiency measures. The Board will need be clear that the costs of opening the new major capital developments in 2018/19 and 19/20 are affordable.

Issues/ Points to Note

Digital strategy The key projects for the next three years are listed below as part of the move to digital working. In addition to developing the the IT infrastructure and using the best of the existing departmental systems the Trust will be building on the Electronic Data Management System to move towards a electronic medical record over the next three years. This will necessitate the purchase of a new patient administration system and using a limited number of vendors to replace and rationalise the number of systems in use. The Trust did secure over £25m as part of the merger to implement its digital strategy.

Vascular services - Ashford and St Peters Trust St George’s Hospital and Frimley Health have submitted a joint proposal to provide a vascular service to the Ashford and St Peters Trust. Ashford and St Peters are in discussion with a number of Providers and will reach a conclusion on a preferred Provider by early March. Pharmacy services The CEOs making up the Berkshire and Surrey Pathology Service have agreed in principle to explore the feasibility of creating a similar joint venture for Pharmacy services with the focus on making best use of facilities such as the manufacturing unit at Frimley and optimising the aseptic capacity at the Royal Berks and the Royal Surrey. In addition there’s is an opportunity for the Accountable Care System to better align GP/Consultant prescribing. East Nottingham has saved over £8m in moving to a joint formulary for its System.

6



Page | 4

NHSE and NHSI closer working relationships The Boards of NHSE and NHSI have agreed to have cross representation on each other’s Board in attempt to better align how the two elements of the NHS can work more effectively. David Roberts the Deputy Chair of NHSE will join the NHSI Board as a non voting member and Richard Douglas an NED from NHSI will join the NHSE Board. Accountable Care System All the Boards in the Frimley Health and Care System recently met and agreed in principle to sign off the Memorandum of Understanding which endorses the principle of System working, the development of an annual operating plan and working to a financial control total. The Frimley System and the other 7 trail blazing Systems will be required to go through an accreditation process in the next two months and if supported will go live as an ACS from April. A key requirement will be to demonstrate that the System can keep within the financial control total. The changes to keep more patients supported at home by the integrated care teams is working as for the first time in years the emergency activity is on plan and has not increased. Also GPs are managing referrals to hospital for planned care in a more robust way as activity is down against plan. The New Heatherwood Hospital The project team is hoping that work will start in the next few weeks on the clearance of the woodland at the rear of the site to prepare for enabling works and construction of the new hospital which is scheduled start on site later this year. The financial projections on income and expenditure are almost complete and indicate that the scheme is viable but relies on an increase in private patient activity to break even. The hospital will have 8 private beds and outpatient facilities and while the Trust can’t compel surgeons to bring their private work to Heatherwood there is an assumption that the private beds will operate at least a 75% bed occupancy. Without the private income it will be impossible to balance income and expenditure. The Board will need to consider this as a key risk as part of any final go or no go decision later this year.

Recommendation

The Board is asked to note the Report.

6



Quality and performance report December 2017

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Quality and performance report – December 2017 Frimley Health NHS Foundation Trust – Board of Directors Page 2

Contents

Safe Effective Caring Responsive Efficiency / Finance

This report covers the period from December 2016 to allow comparison with historic performance.

However, the key messages and targets relate to December 2017 for the financial year 2017/18

Page Page

Contents 2 Appendix A 36

Chief executive’s overview 3 Methodologies for calculating the measures 37

CQC rating and single oversight framework 7 Glossary 39

Key messages by exception 8

Domains 14

Safe 14

Effective 19

Caring 22

Responsive 24

Well-led (workforce) 27

Well-led (efficiency) 29

Well-led (finance) 30

Benchmarking RAG key

Benchmarking 31 Achieving target

Activity Between target and threshold (where applicable)

Activity 33 Worse than target or threshold (where applicable)

Well-led Activity

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Chief executive’s overview (1)


Performance overview

December was a particularly challenging month. While there was strong compliance with the cancer and 6 week diagnostic targets the

Trust failed 18 weeks for the first time in this financial year with a monthly out turn of 91.3% against a standard of 92%. The Frimley

Park site has struggled to meet this standard for several months and Wexham‟s better performance has been compensating however

Wexham just met the standard in December and did not sufficiently offset Frimley Park‟s underachievement. Nevertheless putting the

under achievement in December into context the Trust has delivered 92.4% against this standard year to date even though it failed

achieve the standard in one month. The NHS is not achieving 18 weeks in aggregate this year and so Frimley Health NHS Foundation

Trust (FHFT) performance is stronger than most Trusts. The Trust will need to meet 92% for January otherwise NHS Improvement

(NHSI) will relegate Frimley‟s segmental rating from 2 to a 3 which would be an all time low since becoming a Foundation Trust 2005.

4 hour performance in the Emergency Department (ED) dipped for December to a low point so far this financial year at 84.3% which

was just at the national average. The main reason for the dip in performance was a cohort of sicker patients being admitted with

respiratory and flu related conditions which has extended length of stay and so the discharges and emergency admissions have

remained out of balance for much of the month and patients have had to wait for longer periods to get into a bed. Additional bed

capacity was opened over the Christmas period at Heatherwood and Farnham Hospitals to help to maintain the flow of patients through

the two Emergency Departments and thanks to an enormous effort from the ED and bed management teams there have been no 12

hour trolley waits and ambulances have always been able to offload patients. It is expected that the Trust will achieve around 85%

compliance for January which is disappointing as there was the aspiration to maintain performance above 90%. Given the pressures on

beds there have been 5 mixed sex breaches and performance on stroke at Frimley suffered with only 47% of stroke patients getting

into a bed in 4 hours.

Overall activity is close to plan and performance on 18 weeks and 4 hours would have been much worse if activity was increasing.

Social care colleagues have been particularly supportive over the Christmas period in ensuring that the number of delayed transfer

patients did not worsen. Even though there have been significant operational difficulties the Trust has kept the elective surgery as near

to normal as possible.

There have been 37 cases of Clostridium difficile for the period April to December against a target of 31 and the control of infection

team is working closely with the ward teams to maintain hand hygiene and antibiotic compliance. One of the three Methicillin-resistant

Staphylococcus aureus (MRSA) bacteraemia cases has been reassigned to a third party and so the total number of MRSAs has

reduced to 2.

Mortality remains at an overall lower rate than average and the incidence of nosocomial pneumonias, cardiac arrests and shock, rising

ureas or creatinine and surgical complications remains better than average.

Well-led Activity

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Performance overview (continued)

There have been 7 Never Events to date which is of continued concern. 6 have resulted in minor harm and one has resulted in

moderate harm. The safety team have put together a presentation on the key learnings from these events to be shared with all

directorates. All the patients involved have been briefed on what happened and have received copies of the incident reports that have

been shared with the Board. The Never Event in spinal surgery has no longer been classified as Never Event due to a change in

definition.

Compliance with the sepsis bundle is improving which is positive and reflects the efforts made by the safety team to ensure that this

standard is better embedded.

The take up of the flu jab for staff is at 67% and the occupational health team is making the final push to achieve at least 70%. All staff

are encouraged to have the inoculation as it protects them and their patients from contracting flu. Sickness amongst doctors is high and

special efforts have been made to make sure that the junior doctors are aware of the risks of not protecting themselves.

Annual appraisal rates for non medical staff is at 61% and needs to improve. Every member of staff is entitled to a once a year

structured conversation about there performance and development and the Trust has a responsibility to ensure that appraisals take

place. While it is recognised that not all appraisals are entered on the HR IT system improvements are required on data capture and

compliance.

Financial performance

The Trust is still on course to deliver it‟s financial plan for the financial year end even though there is very little extra income generated

through over performance on activity. The continuous improvement programme of £30m will be close to target thanks to the efforts of

the whole management team and agency spend was at its lowest point for a long time. Agency expenditure are now well within the pay

cap set by NHSI for the year. Overall pay budgets are still under pressure which is a concern.

The Sustainability and Transformation Fund (STF) should be earned in full for Quarter-3 but delivery for 4 hours is a risk in Quarter-4

as the Trust is expected to deliver 95% or better result. Failure to do so will incur a loss of £1.5m which is a concern and may need to

be factored in achieving the control total for the health system.

Next year‟s Cost Improvement Plan (CIP) of £30m is in development and this will be really challenging to achieve. The whole

leadership team is working hard to develop a robust schedule of efficiency measures. The Board will need to be clear that the costs of

opening the new major capital developments in 2018/19 and 19/20 are affordable.

Well-led Activity

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Issues / points to note

Digital strategy

The key projects for the next three years are listed below as part of the move to digital working. In addition to developing the IT

infrastructure and using the best of the existing departmental systems the Trust will be building on the Electronic Data Management

System to move towards a electronic medical record over the next three years. This will necessitate the purchase of a new patient

administration system and using a limited number of vendors to replace and rationalise the number of systems in use. The Trust did

secure over £25m as part of the merger to implement its digital strategy.

Vascular services - Ashford and St Peters Trust

St George‟s Hospital and Frimley Health have submitted a joint proposal to provide a vascular service to the Ashford and St Peters

Trust. Ashford and St Peters are in discussion with a number of Providers and will reach a conclusion on a preferred Provider by early

March

Pharmacy services

The CEOs making up the Berkshire and Surrey Pathology Service have agreed in principle to explore the feasibility of creating a similar

joint venture for Pharmacy services with the focus on making best use of facilities such as the manufacturing unit at Frimley and

optimising the aseptic capacity at the Royal Berks and the Royal Surrey. In addition there‟s is an opportunity for the Accountable Care

System (ACS) to better align GP/Consultant prescribing. East Nottingham has saved over £8m in moving to a joint formulary for its

System.

Well-led Activity

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Issues / points to note (continued)

NHSE and NHSI closer working relationships

The Boards of NHS England (NHSE) and NHSI have agreed to have cross representation on each other‟s Board in attempt to better

align how the two elements of the NHS can work more effectively. David Roberts the Deputy Chair of NHSE will join the NHSI Board

as a non voting member and Richard Douglas a Non-Executive Director (NED) from NHSI will join the NHSE Board.

Accountable Care System

All the Boards in the Frimley Health and Care System recently met and agreed in principle to sign off the Memorandum of

Understanding which endorses the principle of System working, the development of an annual operating plan and working to a

financial control total. The Frimley System and the other 7 trail blazing Systems will be required to go through an accreditation

process in the next two months and if supported will go live as an ACS from April. A key requirement will be to demonstrate that the

System can keep within the financial control total. The changes to keep more patients supported at home by the integrated care

teams is working as for the first time in years the emergency activity is on plan and has not increased. Also GPs are managing

referrals to hospital for planned care in a more robust way as activity is down against plan.

The New Heatherwood Hospital

The project team is hoping that work will start in the next few weeks on the clearance of the woodland at the rear of the site to prepare

for enabling works and construction of the new hospital which is scheduled start on site later this year.

The financial projections on income and expenditure are almost complete and indicate that the scheme is viable but relies on an

increase in private patient activity to break even. The hospital will have 8 private beds and outpatient facilities and while the Trust

can‟t compel surgeons to bring their private work to Heatherwood there is an assumption that the private beds will operate at least a

75% bed occupancy. Without the private income it will be impossible to balance income and expenditure. The Board will need to

consider this as a key risk as part of any final go or no go decision later this year.

Recommendation

The Board is asked to note the Report

Well-led Activity

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CQC overall rating & NHSI single oversight framework

Year to Date (Month 09) Forecast Outturn

Plan Actual Target Threshold Plan Actual Target Threshold

NHS Improvement’s score for financial performance

Use of resources score (1 - 4) 1 1 1 2 1 1 1 2


Care Quality Commission (CQC) overall rating

Frimley Park Hospital September 2014 Outstanding

Wexham Park Hospital February 2016 Good

Heatherwood Hospital May 2014 Good

Well-led Activity

15/16 16/17 Dec-16 Q3 Jan-17 Feb Mar Q4 Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec-17 Q3 YTD Target Threshold

NHS Improvement (NHSI) – overall segment score

Segment score New 2 1 2 2 2 in arrears 1 2

Operational performance

A&E maximum waiting

time of 4 hours 94.7% 91.6% 88.7% 91.7% 84.7% 91.2% 91.4% 89.1% 92.3% 90.2% 91.3% 91.2% 91.5% 90.4% 90.7% 90.9% 94.2% 91.4% 84.3% 89.9% 90.7% 95% None

Maximum time of 18

weeks from point of

referral to treatment

(RTT) − patients on an

incomplete pathway

93.3% 92.6% 92.2% 92.8% 92.5% 92.2% 92.5% 92.4% 92.2% 93.2% 92.8% 92.8% 92.9% 92.3% 92.0% 92.4% 92.2% 92.5% 91.3% 92.0% 92.4% >=92% None

Maximum 62-day wait

for first treatment from

urgent GP referral for

all suspected cancers

88.7% 89.9% 92.6% 89.7% 87.9% 89.0% 91.0% 89.3% 90.2% 92.6% 92.8% 91.9% 95.7% 94.5% 93.2% 94.2% 94.0% 94.1% in

arrears

in

arrears >=85% None

Maximum 6-week wait

for diagnostic

procedures

0.8% 0.4% 0.3% 0.3% 2.3% 0.8% 0.4% 1.2% 0.7% 0.4% 0.4% 0.5% 0.4% 0.4% 0.3% 0.4% 0.3% 0.2% 0.4% 0.3% 0.4% <=1.0% None

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Key messages – by exception (1)

Safe Effective Caring Responsive Efficiency / Finance Well-led Activity

Domain Key points Action taken

Safe

Never events

There was one never event on the WPH site in

orthopaedics which is currently under review and maybe

downgraded

Never events

There is a full review of the Never Event including a review of themes

throughout the reported never events across Frimley Health

Serious incidents requiring investigation (SIRI)

There were eleven serious incidents requiring

investigations reported, two at FPH and nine at WPH

which included two grade 3 pressure ulcers, one

deteriorating patient, a fall with significant injury and one

intra-uterine death

Serious incidents requiring investigation (SIRI)

All SIRIs are currently under review, with specific action plans in place to

address the theme and trends

C difficile rate

There were six trust apportioned C difficile cases for

FHFT in December. At FPH there were two cases on

one ward and one on a different ward. The three cases

at WPH occurred on different wards/units

C difficile rate

The 2 cases on the same FPH ward have been confirmed as the same

ribotype and in view of this cross infection there was agreed to have

been a lapse in care. Hand hygiene audits have been of a high standard

and so any potential for an environmental source is being investigated

Pressure ulcer incidence

In November, there was an increase in the number of

pressure ulcers reported, including two grade 3‟s, one

on each site and a grade 4 developed in community care


Tissue Viability are closely working with the clinical teams to ensure

preventative measures are implemented timely. The grade 3 and 4 are

currently under review as serious incidents requiring investigation

Sepsis and antimicrobial resistance (AMR)

Improving picture for inpatient screening and time to

antibiotics

Sepsis and antimicrobial resistance (AMR)

New screening tool launched

Safety thermometer on FPH site will be used to audit from February, this

will enable Matrons and Sisters to review performance real time. Matron

audits have been in place for some time on the WPH site and have

supported improvement

All senior clinical staff asked to continue to emphasise the importance of

screening, escalation where necessary and time critical antibiotics

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Effective

Stroke - admitted in 4 hours; swallow screen within 4

hours

There has been an increase in stroke admissions and

referrals, alongside issues with discharges which have

meant delays in freeing up beds or stepping down patients

This has been a mixture of internal and social issues,

community bed availability and transport

The team are still experiencing on-going gaps in the

coordinator rota due to sickness and a vacancy. An offer of

help from the Night Nurse Practitioner team has been

accepted. The vacant post has been filled; however, the

start date may not be until March. The current team of

should be back to normal working from mid-January

Stroke - admitted in 4 hours; swallow screen within 4 hours

The team will work closely with pathway coordinator to ensure all

discharge issues are identified at the earliest opportunity and

addressed. Activity has now settled and we are now only utilising

the agreed bed stock with only one outlier and improved flow

There will need to be a drive for all nurses to have swallow screen

training and be assessed as competent. This will help achieve the

4hrs swallow screening when there are coordinator gaps

All admission and swallow screen breaches will be reviewed at the

January Stroke Clinical Governance meeting to identify any other

trends or required actions

T&O – fractured neck of femur patients going to theatre

within 36 hours

There has been an improvement of nine percentage points

on October‟s performance

T&O – fractured neck of femur patients going to theatre within

36 hours

Discussions are ongoing about surgeon availability and the

consultant mix. Each neck of femur (NOF) breach is reviewed as

part of the Clinical Governance process to ensure any learning is

disseminated

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Caring

Local surveys – bothered by noise at night from patients

There continues to be work across the sites to increase the

volume of local surveys

Local surveys – bothered by noise at night from patients

Individual work is ongoing with clinical teams to review their

patient experience feedback and themes

Local surveys – risks and benefits of operations explained

There continues to be work across the sites to increase the

volume of local surveys

Local surveys – risks and benefits of operations explained

There is a review being undertaken of the literature available

to patients prior to operations

Complaints – % answered within 25 working days

The response rate fell however further resource was secured

and in place from November therefore this will improve. For

assurance no backlog is being accrued on either site. The

remainder of complaints are responded to generally within 40

working days.

Complaints – % answered within 25 working days

Further resource now in place to also cover the additional

responsibility (since May 17) of managing the Wexham

Park GP Clinical Concerns workload in addition to

complaints.

Mixed sex accommodation breaches

There were five mixed sex accommodation breaches in

December. These occurred in daylight hours only and

patients were in agreement to go into a mixed sexed ward

The rationale for this was to ensure patient clinical safety was

maintained, to prevent increased mortality rates and prevent

delays on offloading patients from the ambulance line


We continue to strive for effective flow within the Emergency

Department to prevent mix sex accommodation from

happening

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Responsive

Emergency Department - % admitted or discharged

within 4 hours

Performance at FPH dropped below 90%. It was a

challenging month with an increased volume of high acuity

patients. There were bed capacity issues which had a

direct impact on flow

Performance deteriorated in month at WX; increase in

high acuity and aged patients coupled with bed capacity

issues and reduced staffing levels due to sickness and

agency fill rate issues over the Christmas/New Year

period for both Doctors and Nursing

Emergency Department - % admitted or discharged within 4 hours

Staffing recruitment remains the top priority to prevent waits in the

emergency department. We have successfully recruited a new

paediatric consultant and five middle grade doctors will be starting in

the first months of 2018.

FPH have introduced a ED manger role daily to support safety,

quality and flow within the department

To support flow additional escalation beds opened on the

Heatherwood and Wexham sites, increased engagement with

external agencies to optimise complex discharges and increased

senior decision making ward rounds at weekends

Twilight consultant shift introduced at WX; fill rate determined by staff

availability

Recruitment to substantive vacancies remains a high priority at WX

Referral to treatment (RTT)

Consultants off sick from a number of Specialties was

the major cause of us breaching.

Reduction in referrals

Reduced activity between bank holidays


Extra clinics/theatres added on this month to get ourselves into a

better position going forward.

Delayed transfer of care

We are now working with the Intensive Support Team

from Surrey and Borders to help place patients with

challenging behaviours, this should reduce the time in

sourcing placements and offer on-going support in the

community from the IST (Surrey Heath patients only)

Medically stable list remains high, internal delays under

therapy assessments

Delayed transfer of care

On-going issues with capacity for Domiciliary care, ERS@H

continue to support facilitating these discharges

South Buckinghamshire health and social care remains

challenging. Impact team to commence week commencing 22nd

January 2018

D2A beds utilised however Domiciliary care capacity remains

challenging.

Placements challenging to source due to behavioural needs - both

CHC and social care outsourcing

Well-led Activity

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Well-led

(Workforce)

Turnover Rate

The turnover rate has increased to 15.2% in December

2017, including increases in nursing turnover rates.

Turnover Rate

Action plans continue to be developed and implemented

across hard-to-fill and hot-spot areas.

Time to Recruit

Time to recruit remains above target and has increased

since last month. Particular delays have been in the

authorisation process, shortlisting, and Occupational

Health processing. Induction capacity has also caused

issues with arranging start dates for staff.

Time to Recruit

Work is ongoing to identify areas of improvement and

streamlining in the recruitment process. Standardised

assessment centres for nursing posts will remove some

of delays between the interview and offer stages.

Appraisal (Non-Medical)

The appraisal rate has risen slightly to 61.9% in

December 2017, although remains below the 80% target.

Learning & Organisational Development will be

relaunching and refreshing the appraisal policy and

documentation in March/April.

Appraisal (Non-Medical)

Learning & Organisational Development, and the HR

Business Partners continue to use monthly appraisal

compliance reports to chase the areas of biggest concern.

NHS Staff Survey

Local departmental results will be available over the next

few weeks. National benchmarking data will be available

but under embargo until March.

NHS Staff Survey

Action plans will be developed based upon the top areas

of concern within each department/locality which has a

report available.

Well-led

(Efficiency) No exceptions to report

Well-led Activity

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Domain Key points Risks

Well-led

(Finance)

The Trusts‟ operational surplus was £0.3m in month which was £0.3m better than plan. The year to date is £3.9m deficit which is

£6.0m adverse to plan. CIP mitigations are still lagging. The year end forecast assumes delivery of control totals based on a better

income month and because of the expectation on a positive income deal with commissioners. The underlying position remains behind

plan due to reliance on non-recurrent exceptional gains.

Income

Clinical income in month was close to expectations the Trust was able to

reverse some provisions for challenges and queries to allow a position

£1m better than plan. Uncoded episodes were (£16m). Private patients

income remains below plan.

Year end income deals with commissioners are

nearing conclusion and need to achieve both a

Trust and system balance

Expenditure

Agency and substantive pay costs reduced from last month but still

generated an overspend of £0.24m, non-pay costs generated an

overspend of £0.54

Underlying costs significantly higher than plan

CIP mitigations need constant emphasis and

attention

Net surplus/ deficit

The Trust is £6m adverse YTD against its set budget

one-off exceptional items mean the Trust is showing a positive variance

on the bottom line

STF achieved £1.9m for M09 because of the one-off benefits booked in

Month 03

CIP mitigations still lagging and must be recovered

to ensure no further non-recurrent fixes needed

CIPs

In month £2.5m delivery against a plan of £2.7m or 92% (YTD £20.7m

89%)

CIP is critical to the delivery of the financial plan –

CIP plan is back-ended introducing a further risk


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Safe - Key measures (1)


15/16 16/17 Dec-16 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec-17 YTD Target Threshold

Infection control

Clostridium difficile – total numbers 41 33 2 4 2 2 3 1 5 4 6 3 6 3 6 37 None None

Clostridium difficile due to lapses in care 13 4 0 0 0 0 0 0 1 0 4 2 0 0 1 8 <=31 None

Clostridium difficile - infection rate per 100,000 bed days 5.45 10.91 6.04 5.45 8.45 2.73 14.09 10.91 16.36 8.45 16.36 8.45 16.36 <=7.60 >10.40

Methicillin-resistant Staphylococcus aureus (MRSA)

bacteraemia 2 2 0 0 0 1 0 0 1 0 1 0 0 0 0 2 0 None

Methicillin-susceptible Staphylococcus aureus (MSSA)

bacteraemias New New Data to follow TBC TBC

Escherichia coli (E coli) bacteraemia bloodstream infection (BSI) New New Data to follow TBC TBC

Hand hygiene compliance 85% 86% 86% 90% 91% in arrears >=90% <75%

Medication errors resulting in harm

Low 56 22 1 1 4 1 2 0 2 2 1 0 1 2 in arrears 10 None

Moderate 4 8 0 1 0 1 1 1 0 0 0 1 0 0 in arrears 3 <=42 None

Severe 0 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 0 None


Hospital acquired - grade 2 143 169 18 21 16 21 20 18 21 17 14 14 10 22 in arrears 136 <=216 None

Hospital acquired - grade 3 6 5 0 2 1 1 0 2 0 1 0 1 0 3 in arrears 7 <=12 None

Hospital acquired - grade 4 0 0 0 0 0 0 0 0 0 0 0 0 0 1 in arrears 1 0 None

Community Services- lapses in care 1 0 0 0 0 1 1 0 in arrears 3 TBC TBC

Incident reporting

Never events 6 4 0 1 0 0 1 0 1 1 1 1 0 2 1 8 0 None

Serious incidents requiring investigation (SIRI) (total trust

including Fleet) * 73 70 8 11 3 7 4 11 12 7 14 14 10 10 11 93 <=90 >96

Fleet community services SIRIs 1 0 0 1 0 1 1 0 0 4 TBC TBC

Potential under-reporting of patient safety incidents 30.7 33.96 TBC TBC

NHS England/NHS Improvement Patient Safety Alerts

outstanding 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 None

Incidents triggering a duty of candour response New 96 12 12 6 9 10 13 8 13 13 13 15 12 in arrears 97 TBC TBC

Failure to notify of a suspected or actual reportable patient

safety incident New 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 0 None

Falls resulting in significant injury

Number of falls 28 20 1 4 1 2 1 3 3 2 1 3 1 3 0 17 <=37 None

Number of falls per 1000 bed days 0.06 0.04 0.02 0.09 0.03 0.05 0.03 0.07 0.08 0.05 0.03 0.07 0.02 0.08 0.00 0.05 TBC

Safe staffing - hours filled as planned

Registered nurse day 92% 93% 92% 90% 89% 88% 91% 90% 90% 88% 89% 91% 94% 91% 90% >=90% None

Unregistered care staff day 96% 94% 98% 95% 95% 95% 98% 98% 98% 95% 96% 95% 95% 93% 96% >=90% None

Registered nurse night 96% 97% 98% 96% 94% 94% 96% 96% 96% 94% 95% 95% 96% 96% 95% >=90% None

Unregistered care staff night 100% 98% 100% 97% 96% 96% 99% 99% 99% 98% 99% 97% 99% 98% 99% >=90% None

* Fleet community services were transferred under FHFT from January 2017

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Safe - Key measures (2)


15/16 16/17 Dec-16 Jan-17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec-17 YTD Target Threshold

VTE (venous thromboembolism) risk assessment

Admitted adult patients who have been

risk assessed for VTE 98% 97% 97% 98% 98% 98% 98% 98% 97% 98% 97% 97% 97% 98% in arrears 98% >=95% None

Delivering a 7-day service

Emergency admissions reviewed by a

consultant within 14 hours of

admission

New 95% 87% Bi-annual audit TBC

Access to diagnostics * New 100% Bi-annual audit TBC

Access to consultant-directed

interventions * New 100% Bi-annual audit TBC

Twice daily consultant reviews for high

acuity areas * New 100% Bi-annual audit TBC

Sepsis CQUIN - Timely identification of Sepsis in emergency department (ED) and acute inpatient settings

The percentage of patients screened

for sepsis in ED 66% 94% 88% 96% 96% 94% 96% 88% 100% 100% 100% 96% 100% 100% in arrears 98% >=90% <50%

The percentage of acute inpatients

screened for sepsis New 61% 70% 66% 66% 66% 42% 42% 34% 28% 30% 44% 66% 64% in arrears 44% >=90% <50%

Sepsis CQUIN – Timely treatment of Sepsis in emergency department (ED) and acute inpatient settings

The percentage of patients who met

criteria were administered intravenous

antibiotics within 1 hour of arrival in ED

New 83% 87% 90% 70% 80% 38% 85% 75% 85% 71% 73% 79% 83% in arrears 75% >=90% <50%

The percentage of patients who met

criteria were administered intravenous

antibiotics within 1 hour of arrival on

the ward

New 68% 70% 67% 87% 87% 63% 43% 57% 63% 50% 63% 56% 89% in arrears 59% >=90% <50%

Sepsis CQUIN – Antibiotic Review

% of antibiotic prescriptions for patients

diagnosed with sepsis that were

documented and reviewed by a

clinician within 72 hours

82% 88%

Q1 >=25%

Q2 >=50%

Q3 >=75%

Q4 >=90%

Reduction in antibiotic consumption

per 1,000 admissions 4828

baseline in arrears TBC

Reduction in total consumption of

carbapenem per 1,000 admissions TBC

Reduction in total consumption of

piperacillin-tazobactam per 1,000

admissions TBC

* Audit data to be treated with caution due to loose national definitions and the use of questions that were open to interpretation

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Safe – Other CQUINS 2017/18 (1)

15/16 16/17 Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan-18 Feb Mar-18 Q4 YTD Target Threshold

Improving Staff Health and Wellbeing

Staff Survey Question : Does

your organisation take positive

action on Health and Wellbeing

33% Improvement plans to be in place

Staff

survey

for 2017

to go live

Improvement plans to be in place

Staff

survey

due to be

reported

Review for

2018

requirement

>35% None

Staff Survey Question : In the

last 12months have you

experienced musculoskeletal

problems (negative response

measured)

76% Improvement plans to be in place Improvement plans to be in place >78% None

Staff Survey Question : During

the last 12 months have you

felt unwell as a result of work

related stress (negative

response measured)

69% Improvement plans to be in place Improvement plans to be in place >71% None

Healthy Food – changes to food and drink provision

Percentage of drink lines

stocked that are sugar-free New Due Due Due Due >=70% None

Percentage of confectionary

and sweets stocked that do

not exceed 250 calories

New Due Due Due Due >=60% None

Percentage of pre-packed

sandwiches and other savoury

pre-packed meals that contain

less than 400 calories

New Due Due Due Due >=60% None

Improving the uptake of ‘flu vaccinations for Frontline Clinical Staff

Cumulative uptake of „flu

vaccination by frontline staff 38.5% Launch of „flu campaign Launch of „flu campaign 60% 66% 67% Due Due Due >70% None

NHS e-Referral System (e-RS)

% of referrals to first outpatient

services able to be received

through e-RS

New Due Due Due Due Q2 >=80%

Q3 >=90%

Q4 =100%

None

Appointment slot issue (ASI)

reduction New 30% 30% 25% 25% 28% 28% 18% 25% 21% 17% 14% 17%

<=4% by

Q4 None


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Safe - Other CQUINS 2017/18 (2)

15/16 16/17 Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan-18 Feb Mar-18 Q4 YTD Target Threshold

Advice and Guidance

Advice and Guidance

Services to be in place for

services agreed with CCG

and be operational to cover

at least 35% of total GP

referrals

New

Agree specialities,

trajectories, timetable and

implementation plan

Advice and guidance services

to be operational from Jan-18

>=35% by

Jan-18 None

Provide asynchronous

responses within 2 working

days

New

Agree local quality

standard for provision of

responses

>=80% None

Supporting Safe Proactive Discharge

Increase the number of

patients discharged to usual

place of residence

(applicable to patients aged

65yrs and above)

New

Map and streamline existing discharge pathways

across acute, community and NHS care home

settings – roll out protocols in partnership across

local whole systems. Deliver and agree with

commissioners a plan, baseline and trajectories to

reflect impact of local initiatives agreed

Q3, Q4 2.5%

point increase

None

Implement Emergency Care

Data Set (ECDS) New

Demonstrate credible

planning to evidence that

the ECDS can be

collected and returned

from 01/10/2017

Return data

weekly and ensure

95% of patients

have valid chief

complaint and

diagnosis

Q3 >=95%

None

Improving services for people with mental health needs

Reduce by 20% the number

of attendances to emergency

department (ED) for those

within a selected cohort of

frequent attenders

New

Identify and agree cohort. Review and develop care

plan for each person with the patient and other

relevant care organisations

20% reduction

in ED

attendances

within selected

cohort

None

Improve Mental Health need

coding data New

Conduct internal audit of

ED mental Health Coding.

Agree data quality

improvement plan

Review progress against

data quality improvement

plan and confirm systems

are in place to ensure ED

HES data submissions are

correct

None None


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Safe – CQUINS – key messages


Area Key points Action taken

Sepsis and

antimicrobial

resistance (AMR)

Improving picture for inpatient screening and time to antibiotics

• New screening tool launched

• Safety thermometer on FPH site will be used to audit from February,

this will enable Matrons and Sisters to review performance real time.

Matron audits have been in place for some time on the WPH site and

have supported improvement

• All senior clinical staff asked to continue to emphasise the importance

of screening, escalation where necessary and time critical antibiotics

Health and

Wellbeing

• Flu vaccination – Bank staff are not currently included in figures.

Performance may drop when included in March return. As of 16/01/18

we were at 69%

• HWB food and Drink – on track

• HWB – staff survey – await results (February 2018)

• Letter sent to bank staff from Director of Nursing

• ESR notification about flu vaccine established

• Increased communications from Director of Nursing and Medical

Director

• Peer vaccinators ask to provide daily support

• Additional walkabouts provided by OH Team

• All senior clinical staff asked to continue to emphasise the importance

of staff having vaccine to protect themselves, their families and our

patients

NHS

e-Referrals • On track to deliver against this CQUIN

Advice and

Guidance • On track to deliver against CQUIN. Local agreement made with CCGs

Supporting

Proactive and

Safe Discharge

• Delay in data collection from ECDS –however CCG are aware of the

delays in implementing and have been supportive as Trust have

provided clear time frames to remedy this .

• No Q3 report required for other elements, however LOS increase in

some specialties and DTOC will impact on achievement of CQUIN

target

• IT issues with real time on FPH may have impacted confidence and

caused disruption to engagement and use

• Discharge groups in place on both sites

• Orthopaedics to review actions to reduce LOS e.g. physio resource etc

Improving

Mental Health

• On track to reduce ED visits by frequent attenders in cohort ED

• Challenges with patient engagement

• Awaiting ECDS report re: mental health coding

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Effective - Mortality and morbidity – key measures & messages


In-hospital mortality and summary hospital-level mortality indicator (SHMI)

KEY: Higher than expected Within expected range : 90 - 110 (overall and non-elective)

70 - 130 (elective) Lower than expected

Well-led Activity

Key messages


Mortality

SHMI trust wide remains within expected limits

Elective SHMI remains high at Wexham Park

Informatics are investigating badging of these

cases as many are not truly elective.

All elective deaths are reviewed using the SI or

M&M process

Potentially

avoidable deaths

All these deaths have been reviewed through the SI process.

Themes from Q2 are presented in the safety report

We have recent access to the RCP on-line

database which will allow better interrogation of

the learning from all our reviews

15/16 16/17 Dec-16 Jan-17 Feb Mar Apr May Jun Jul-17 Aug Sep Oct Nov Dec-17 YTD Threshold

Potentially avoidable deaths

Total deaths reviewed New 252 309 292 259 243 242 280 264 304

Deeper review New 65 69 70 49 41 52 32 13 2

Number of deaths of patients

with Learning Disability 1 1 3 1 1 2 3 3 2

Total number of deaths judged

more than 50% likely to be

related to problems with care

New 4 2 2 5 2 1 in arrears

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Effective – CRAB morbidity – key measures & messages


Key messages


CRAB data

All medical triggers are improving and are close to or within national

norms. This is a sustained improvement since March. It may be a

seasonal affect and there will be continued monitoring. It may also be

due to the effect of the NEWS call system

Surgical, morbidity and mortality remain below expected trust wide.

There are some peaks and troughs due to low numbers

Continued work streams and surveillance

Continued monitoring. If the rise in mortality

continues next month, we will investigate further

*The final data point may be subject to change due to late reported data

Medical

practice

trigger

trends *

Surgical

complications *

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Effective - Clinical performance measures



Stroke *

% of patients admitted directly to

the stroke unit in 4 hours 66% 72% 68% 55% 83% 80% 83% 76% 78% 81% 77% 70% 84% 70% 47% 75% >=80% <72%

% of patients scanned within 1

hour of arrival 58% 64% 63% 69% 71% 71% 67% 76% 65% 55% 58% 66% 62% 57% 56% 63% >=50% <45%

% of patients receiving a swallow

screen within 4 hours of arrival 75% 81% 63% 84% 87% 86% 81% 80% 81% 77% 84% 80% 79% 74% 56% 78% >=90% <80%

Cardiology

% of eligible patients receive

treatment; call to balloon within

150 minutes

93% 92% 86% 90% 90% 66% 96% 95% 100% 94% 84% 96% 96% 81% in arrears 93% >=85% <80%

Trauma and orthopaedics

% fractured neck of femur

patients meeting best practice

criteria

87% 83% 74% 77% 82% 74% 52% 75% 69% 75% 66% 66% 62% 58% in arrears 65% >=65% <55%

% fractured neck of femur

patients going to theatre within

36 hours

87% 85% 90% 90% 86% 71% 77% 90% 77% 83% 93% 69% 78% in arrears 80% >=90% <80%

Critical care

Critical care non-clinical transfers

out of the trust New 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 None

Theatres

Compliance with the WHO

surgical safety checklist New 99% 99% 98% 98% 98% 98% 98% 99% 99% 99% 100% 99% 99% 100% 99% >=95% <90%

Obstetrics

Caesarean section rate (planned

& unscheduled) 26% 26.9% 32% 28% 27% 29% 27% 29% 30% 27% 26% 27% 29% 29% 27% 28% <=25% >27%

Emergency C-section rate New 14% 17.1% 13.9% 13.1% 15.9% 13.4% 14.7% 15.2% 14.2% 13.5% 13.8% 13.5% 14.3% 14.3% 14.1% <=14.0% >15.0%

Still births over 24 weeks New 41 4 4 4 6 4 1 3 2 3 1 4 3 4 25 None None

Emergency readmissions

Emergency re-admissions within

30 days following an elective or

emergency spell

7.0% 6.9% 7.1% 6.5% 7.2% 6.5% 7.1% 7.2% 6.9% 6.9% 7.0% 7.2% 6.2% 6.2% in arrears 6.8% <=6.8% None

* Stroke data is for FPH only as the unit at Wexham Park was decommissioned during 2016/17

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Caring - Key measures (1)



Local Surveys *

1. Overall did you feel you were treated with

respect and dignity while you were in this ward? 96% 96% 96% 97% 96% 97% 97% 97% 98% 96% 97% 97% 96% 96% 97% 97% >=95% <90%

2. Do you have confidence and trust in the

doctors treating you? 92% 93% 91% 92% 93% 93% 93% 93% 95% 92% 94% 91% 92% 94% 93% 93% >=95% <90%

3. Were you bothered by noise at night from

hospital staff? (percentage of patients saying

no) 87% 87% 88% 90% 86% 87% 85% 88% 87% 89% 88% 88% 86% 87% 87% 87% >=90% <80%

4. Were you ever bothered by noise at night

from other patients? (percentage of patients

saying no) 69% 66% 59% 65% 63% 69% 77% 70% 73% 72% 67% 69% 69% 68% 68% 69% >=80% <70%

5. If you needed it, did you get enough help

from staff with eating and drinking? 88% 90% 92% 90% 88% 92% 92% 90% 95% 90% 95% 91% 85% 88% 91% 91% >=90% <80%

6. Have you and your family or carers been

involved enough in discussing your discharge

from hospital? 70% 82% 85% 77% 83% 86% 84% 85% 88% 84% 84% 82% 83% 86% 86% 85% >=80% <70%

7. Were you involved as much as you wanted to

be in decisions about your care and treatment?

**** New 92% 92% 91% 92% 92% 86% 87% 90% 84% 88% 83% 83% 85% 87% 86% >=90% <80%

8. Within the first couple of days of admission

did a member of staff ask you about your home

situation? New 83% 86% 83% 86% 86% 84% 87% 86% 88% 88% 89% 86% 89% 91% 88% >=80% <70%

9. Did nurses talk in front of you as if you

weren‟t there? (percentage of patients saying

no) New New 89% 92% 94% 92% 95% 93% 92% 93% 94% 93% >=95% <85%

10. Beforehand, did a member of staff explain

the risks and benefits of the operation or

procedure in a way you could understand? New New 86% 94% 93% 98% 95% 88% 90% 90% 88% 92% >=95% <90%

Complaints

Number of complaints received ** *** 765 920 64 75 71 49 63 70 80 75 93 88 78 80 53 680 <=77 >88

Number of complaints per 100 patient contacts 0.00 0.07 0.07 0.08 0.07 0.04 0.06 0.06 0.07 0.07 0.09 0.08 0.07 0.07 0.06 0.07 <=0.07 >0.09

% of complaints answered within 25 working

days 60% 37% 46% 33% 29% 8% 47% 64% 55% 48% 42% 47% 40% 30%

in

arrears 46% >85% <70%

Number of complaints re-opened 71 97 10 5 11 9 2 12 11 11 13 12 9 11 7 88 <=8 >9

* Note all targets and thresholds have been reviewed and made more challenging for 2017/18, but have been applied retrospectively to 2016/17 as well

** provisional data for the reporting month

*** Annual targets are as follows: Number of complaints (923)

**** Note – this question last year was “Did the doctors clearly explain the treatment plan?”

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Caring - Key measures (2)



Patient Friends and Family Scores - What % would recommend this trust to friends and family if they needed similar care or treatment?

Emergency department - %

positive 91.1% 89.2% 91.5% 92.4% 93.1% 94.2% 94.5% 94.0% 91.3% 92.3% 92.9% 94.2% 93.5% 93.9% 93.5% >=94.4% <89.1%

Outpatients - % positive 95.9% 96.5% 95.5% 95.6% 96.4% 95.6% 96.2% 97.1% 96.5% 96.1% 97.0% 96.9% 97.0% 97.0% 96.6% >=96.8% <94.6%

Inpatients - % positive 97.4% 97.2% 97.1% 97.4% 97.6% 98.0% 97.7% 97.5% 97.3% 97.9% 97.3% 97.6% 98.0% 97.3% 97.6% >=97.7% <96.4%

Maternity - % positive (of those

giving birth here) 96.7% 95.3% 95.1% 95.3% 95.6% 97.5% 95.4% 98.4% 97.5% 94.3% 95.4% 96.3% 93.6% 98.7% 96.6% >=99.0% <97.9%

Community - % positive 98.8% 98.6% 100% 100% 90.9% 100% 93.9% 100% 100% 96.7% >=98.3% <97.0%

CQC inpatient survey

Overall satisfaction out of 10 (Q72) 8.30 Annual survey >=8.40 <7.99


Mixed sex accommodation

breaches 6 0 6 0 0 0 0 0 0 6 7 5 0 5 23 0 None

Dementia care - % of all admitted patients (75+) who :

Have been screened for Dementia

(within 72 hours) 95% 96% 97% 99% 99% 99% 99% 100% 99% 100% 99% 99% 99%

in

arrears 99% >=90% None

Scored positively on the dementia

screening tool that then received a

dementia diagnostic assessment

(within 72 hours)

97% 97% 96% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% in


Received a dementia diagnostic

assessment with a “positive‟ or

“inconclusive‟ outcome that were

then referred for further diagnostic

advice/follow up (within 72 hours)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% in


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Responsive - Key measures



Diagnostics Diagnostics waiting 6 weeks

and over 87 49 27 224 87 49 76 40 40 44 48 29 32 26 36 None

% waiting 6 weeks and over

for a diagnostic procedure 0.8% 0.4% 0.3% 2.3% 0.8% 0.4% 0.7% 0.4% 0.4% 0.4% 0.4% 0.3% 0.3% 0.2% 0.4% 0.4% <=1.0% None


% waiting within 18 weeks 93.3% 92.6% 92.2% 92.5% 92.2% 92.5% 92.2% 93.2% 92.8% 92.9% 92.3% 92.0% 92.2% 92.5% 91.3% 92.4% >=92.0% None

Incomplete

waiting list

Total 35470 36093 34787 34430 35470 36093 36097 36694 36772 36587 37031 37315 36780 34912 34585

Admitted 8145 7727 8485 8294 8145 7727 7976 7904 8099 8407 8364 8633 8715 8762 9044

Non-admitted 27325 28366 26302 26136 27325 28366 28121 28790 28673 28180 28667 28682 28065 26150 25541

Waiting 18 weeks and over

(backlog) 2775 2715 2697 2582 2775 2715 2812 2489 2729 2692 2833 2985 2855 2608 2998

Waiting 35 weeks and over 160 149 164 153 160 149 136 136 156 141 124 126 148 121 140

Waiting 52 weeks and over 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 None

Cancelled operations

Last minute cancelled

operations for non-clinical

reasons (% of elective

admissions)

0.9% 0.9% 1.3% 1.1% 0.9% 0.7% 0.8% 0.8% 0.9% 1.2% 0.8% 1.0% 1.0% 1.2% in arrears 1.0% <=0.8% >1.2%

% of cancelled patients

admitted within 28 days 93.3% 91.5% 94.9% 92.5% 96.8% 79.2% 100% 95.0% 88.9% 91.0% 96.2% 98.4% 98.5% 92.3% in arrears 94.7% 100% <90%

Delayed transfers of care

% of bed days lost due to

delays 3.5% 4.4% 4.8% 3.9% 4.7% 5.5% 6.5% 5.7% 6.3% 5.6% 5.2% 5.3% <=3.5% >4.0%

Number of patients delayed

at the end of each month 305 395 53 72 60 65 55 53 66 64 74 89 84 62 75 622

Emergency department

A&E Delivery Board

performance (includes

Type-3 activity) 91.2% 94.2% 92.6%

Q1=90%,

Q2=92.55%,

Q3=92.07%,

Mar 2018 = 95%

None

% of all ambulance

handovers taking longer

than 60 mins?

0.8% 1.2% 1.3% 2.1% 0.5% 0.3% 0.1% 0.5% 0.2% 0.5% 0.4% 0.4% 0.1% 0.3% in arrears 0.3% <=1.0% >2.0%

Number of patients

spending >12 hours from

decision to admit to

admission

12 4 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 None

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Responsive – Cancer – Key measures


Dec-16 Q3 Jan-17 Feb Mar Q4 Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec-17 Target

Cancer

2 week waits – urgent

GP referrals 96.3% 95.9% 95.6% 97.9% 96.8% 96.8% 95.6% 96.4% 96.4% 96.2% 96.8% 95.6% 95.5% 96.0% 96.5% 97.1% in arrears >=93%

2 week waits - Breast

symptomatic referrals 96.8% 96.8% 97.2% 97.1% 97.0% 97.1% 95.8% 96.2% 95.7% 95.9% 97.5% 95.1% 96.9% 96.5% 94.7% 95.0% in arrears >=93%

31 day wait for first

treatment 99.5% 99.7% 98.5% 100% 100% 99.5% 98.9% 99.2% 97.8% 98.6% 99.6% 100% 100% 99.9% 99.3% 98.9% in arrears >=96%

31 day wait

for second or

subsequent

treatment

Surgery 100% 100% 100% 100% 100% 100% 100% 100% 96.9% 98.8% 100% 100% 100% 100% 96.6% 100% in arrears >=94%

Anti-

cancer

drugs 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98.2% 99.3% 100% 100% in arrears >=98%

62 day wait for first

treatment 92.6% 89.7% 87.9% 89.0% 91.0% 89.3% 90.2% 92.6% 92.8% 91.9% 95.7% 94.5% 93.2% 93.3% 94.0% 94.1% in arrears >=85%

62 day wait for

screening patients 100% 100% 95.9% 100% 100% 98.2% 100% 97.0% 97.1% 97.8% 94.2% 100% 98.1% 97.5% 100% 100% in arrears >=90%

Well-led Activity

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Responsive – Cancer 62-day waits standard by tumour group


Dec-16 Q3 Jan-17 Feb Mar Q4 Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec-17 Target

Brain/CNS NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

in

arrears >=85%

Breast 100% 100%

(77.5/77.5) 100% 100% 100%

100%

(65/65) 94.1% 100% 89.4%

94.7%

(62.5/66) 100% 100% 100%

100%

(78/78) 100% 100%

Childrens NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Gynaecological 50.0% 78.3%

(9/11.5) 75.0% 100% 88.9%

91.3%

(10.5/11.5) 77.8% 88.9% 100%

86.4%

(9.5/11) 75.0% 100% 100%

89.3%

(12.5/14) 87.5% 84.6%

Haematological 100% 83.6%

(23/27.5) 75.0% 76.5% 100%

81.8%

(13.5/16.5) 90.9% 100% 100%

96.6%

(28.5/29.5) 100% 75.0% 100%

92.3%

(12/13) 85.7% 100%

Head & Neck 66.7% 76.9%

(5/6.5) 100% 100% 81.8%

88.2%

(7.5/8.5) 100% 75.0% 100%

93.3%

(7/7.5) 100% 60.0% 77.8%

81.0%

(8.5/10.5) 80.0% 36.4%

Lower GI 79.2% 93.0%

(33/35.5) 100% 100% 89.2%

95.1%

(39/41) 90.9% 84.6% 100%

92.1%

(35/38) 93.3% 93.3% 90.0%

92.0%

(34.5/37.5) 90% 100%

Lung 90.0% 74.2%

(11.5/15.5) 75.0% 100% 72.7%

82.6%

(19/23) 75.0% 86.7% 86.7%

84.2%

(16/19) 88.9% 100% 76.5%

86.5%

(16/18.5) 100% 93.3%

Sarcomas NA 25.0%

(0.5/2) 66.7% 100% 100%

83.3%

(2.5/3) 100% NA 100%

100%

(1.5/1.5) 100% 100% NA

100%

(1/1) 100% 0.0%

Skin 91.9% 97.1%

(68/70) 96.4% 100% 96.9%

97.6%

(82/84) 100% 92.3% 100%

96.9%

(63.5/65.5) 100% 97.6% 100%

99.0%

(97.5/98.5) 95.7% 96.8%

Upper GI 87.5% 81.8%

(13.5/16.5) 66.7% 100% 100%

81.6%

(15.5/19) 66.7% 81.8% 90.9%

80.7%

(23/28.5) 85.7% 80.0% 100%

86.0%

(18.5/21.5) 92.3% 100%

Urological 95.2% 83.3%

(80/96) 84.0% 75.9% 82.6%

80.5%

(93/115.5) 88.0% 94.7% 87.5%

90.5%

(86/95) 96.6% 94.7% 87.1%

92.4%

(73/79) 92.5% 96.2%

Other 100% 100%

(5/5) 0.0% 100% 0.0%

20.0%

(0.5/2.5) 100% NA 0.0%

66.7%

(1/1.5) 100% 0.0% NA

25.0%

(0.5/2) 50% 100%

Total 92.6% 89.7%

(325.5/361.5) 87.9% 89.0% 91.0%

89.3%

(345.5/386.5) 90.2% 92.6% 92.8%

91.9%

(332/361.5) 95.7% 94.5% 93.2%

94.2%

(351/372.5) 94% 94.1%

Cancer – 62-day referral to treatment standard – over 104 day waiters

Number of

patients waiting

over 104 days 10 7 5 3 3 3 2 2 3 2 4 2 3

% of patients

waiting over

104 days 0.7% 0.5% 0.3% 0.2% 0.2% 0.2% 0.1% 0.1% 0.2% 0.1% 0.3% 0.1% 0.2% 0%

Half numbers are where a patient has been referred here for treatment from another provider or vice versa; the patient is shared between providers

The additional figures provided for the quarters are the number of patients treated within the 62-day standard out of the total number of patients treated for that tumour group

Well-led Activity

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Well-led – Workforce Key measures (1)

Safe Effective Caring Responsive Well-led Efficiency / Finance Activity


Staff numbers

Staff in post FTE 90182 93395 7831 7921 8003 8011 8062 8081 8066 8038 8079 8121 8113 8138 8160 N/A None

Vacancy FTE 11539 10096 797 801 609 649 706 779 867 819 922 983 934 904 981 N/A None

Starters FTE 1189 1564 81 225 192 94 118 87 71 115 85 129 111 101 46 863 None

Leavers FTE 1135 1197 103 95 87 132 102 80 101 111 102 102 116 75 108 897 None

Turnover

Turnover rate % 14.8% 14.6% 14.7% 14.4% 14.6% 15.0% 15.1% 15.7% 15.1% 14.9% 14.8% 15.0% 15.0% 15.1% 15.2% N/A <=14.5% >15.0%

Nursing turnover rate % 16.9% 14.6% 14.4% 14.0% 14.3% 14.3% 14.6% 15.1% 15.0% 14.9% 14.8% 15.0% 14.1% 13.9% 14.5% N/A <=15.0% >16.0%

Executive team turnover

(definition TBC) New 0 1 0 0 1 0 0 0 0 0 2 None

Time to recruit

Time to recruit from date

vacancy created to date of

unconditional offer (days) New 53.9 50 52.6 64.1 48.7 50.5 53.4 55.5 52.7 48.7 52.2 58.4 51.3 54.4 <=40 >50

Vacancy

Vacancy rate - total % 11.9% 10.2% 9.7% 9.8% 7.4% 8.8% 8.5% 9.3% 10.2% 9.7% 10.8% 11.4% 10.9% 10.5% 11.3% <=11.5% >13.0%

Vacancy rate – doctors % * New New <=5.0% by Q3 >5.5%

Vacancy rate – nurses % New 15.4% 13.9% 15.8% 15.3% 14.3% 14.0% 15.7% 17.1% 18.0% 17.7% 17.7% 15.5% 15.0% 15.3% <=14.5% by

Q3 >15.5%

Agency spend

Agency spend as % of pay bill 9.9% 7.7% 8.0% 8.4% 7.3% 6.3% 5.6% 5.7% 5.9% 6.0% 5.3% 6.0% 5.2% 4.8% 4.3% <=8.0% >10.0%

Agency spend – total (£000s) ** 40705 30473 2626 2830 2483 2137 1886 1917 2036 2012 1789 2042 1764 1658 1461 16565 <=1917 >2013

Agency - doctors (£000s) *** 17375 12656 1113 1333 1052 557 911 794 1018 958 792 1068 836 778 617 7772 <=898 >988

Agency - nurses (£000s) 13534 8490 556 724 582 619 604 465 406 485 492 550 524 452 446 4424 None

Agency - other (£000s) 9796 9327 957 773 849 961 371 658 612 569 505 424 404 428 398 4369 None

Sickness

Sickness absence rate % 3.0% 2.9% 3.2% 3.3% 3.0% 2.8% 2.9% 3.0% 2.9% 2.8% 2.9% 3.1% 3.1% 3.1% 3.1% <=2.9% >3.2%

* On-going reviews with finance are being undertaken to ensure the establishments reflect the actual position trust-wide; data will be available as soon as possible

** The agency spend total is a control target based on an annual total target of £23m or £1.917m per month

*** Agency spend for doctors – the target is based on an overall reduction in spend of £1.88m for 2017/18

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Well-led – Workforce Key measures (2)


Appraisal rates

Appraisal (non-medical) % * N/A N/A 79.0% 48.4% 48.8% 55.3% 54.8% 56.2% 56.9% 58.2% 61.8% 60.7% 61.6% 60.6% 61.9% N/A >=80.0% <70.0%

Appraisal (medical) % N/A N/A 97.4% 96.9% 97.2% 98.3% 98.6% 98.1% 97.2% 97.2% 98.1% 98.4% 96.9% 95.6% 94.6% N/A >=95.0% <85.0%

Training

Statutory and mandatory

training % ** N/A N/A 52.9% 55.0% 62.3% 64.2% 66.7% 68.2% 68.9% 73.7% 72.8% 73.3% 76.5% 77.7% 78.4% N/A >=85.0% <60.0%

Friends & family test for staff

% recommending here as a

place to work N/A N/A 67% *** 71% 73% 69% in arrears

Q1, 2, 4 >=70%

Q3 >= 66%

Q1, 2, 4 <62%

Q3 <62%

% recommending here as a

place for care N/A N/A 77% *** 88% 89% 88% in arrears

Q1, 2, 4 >=86%

Q3 >=76%

Q1, 2, 4 <79%

Q3 <70%

NHS staff survey

NHS staff survey -

engagement score

(definition TBC)

New 3.91 3.91 >=3.87 <3.79

* The data up to December 2016 has been taken from the staff friends and family test, where a question has been added to assess appraisals undertaken in the previous 12 months;

data after this is sourced from the electronic staff record (ESR)

** Work continues to standardise the electronic staff record (ESR) trust-wide from which this data is taken

*** Friends and family test (FFT) replaced by National Staff Survey in Q3; the question is worded slightly differently “If a friend or relative needed treatment, I would be happy with the

standard of care provided by this organisation”. Note the target and threshold for Q3 is based on the National Staff Survey results; Q1, 2 and 4 are based on FFT results


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Well-led – Efficiency Key measures



Outpatients

Did not attend (DNA)

rates 6.5% 6.8% 7.8% 7.3% 6.5% 6.3% 6.5% 6.7% 7.2% 7.3% 7.3% 7.3% 6.9% 6.9% 7.1% 7.0% <=7.6% >10.2%

Outpatient new to

follow-up ratios 2.16 2.03 2.05 2.00 1.98 2.04 2.00 2.04 2.04 1.93 1.98 2.02 1.93 1.94 1.94 1.98 <=2.41 >3.59

Average length of stay

Elective length of stay 2.53 2.53 2.53 2.47 2.58 2.50 2.69 2.96 2.55 2.67 3.11 2.85 2.61 2.42 2.46 2.70 <=2.77 >3.59

Non-elective length of

stay 4.10 4.05 4.01 4.20 4.28 4.19 4.25 4.10 4.13 3.97 3.96 4.01 4.03 3.81 3.93 4.02 <=3.91 >5.05

Day case rate

% day cases of all

electives 81% 81% 81% 83% 82% 81% 81% 82% 82% 82% 82% 82% 83% 83% 81% 82% >=80% <70%

Theatre utilisation

Intra-session theatre

utilisation rate 73% 73% 73% 73% 74% 73% 74% 73% 74% 73% 71% 74% 74% 74% 73% 73% >=85% <70%

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Well-led - Finance Key measures


Year to Date (Month 09) Forecast Outturn

Plan £m Actual £m Variance £m Target Threshold Plan £m Actual £m Variance £m Target Threshold

Income 490.5 490.8 0.3 See EBITDA 658.3 659.4 1.1 See EBITDA

Expenditure (453.0) (453.6) (0.6) See EBITDA (604.1) (604.6) (0.5) See EBITDA

EBITDA (income

less expenditure) 37.5 37.2 (0.3) 0.0 (0.2) 54.2 54.8 0.6 0.0 (0.25)

Financing costs (23.3) (23.1) 0.2 0.0 (0.2) (31.4) (31.8) (0.4) 0.0 (0.25)

Net / surplus

deficit 14.2 14.1 (0.1) 0.0 (0.2) 22.8 23.0 0.2 0.0 (0.25)

CIPs 23.2 20.8 (2.4) 0.0 (1.0) 30.5 28.9 (1.6) 0.0 (1.0)

Cash balance 76.7 81.0 4.3 0.0 (4.5) * 67.1 102.7 35.6 0.0 (6.0) *

Capital

expenditure 67.6 36.8 (30.8) 0.0 (1.0) ** 96.9 60.5 (36.5) 0.0 (0.5)

Figures in brackets indicate an adverse position

* Cash balance - threshold is cumulative at £0.5m per month , given material variances are correlated to STF payments

** Capital expenditure – timing differences / slippage in-month can mean the month threshold is lower than for the forecast

Well-led Activity

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Benchmarking – selected measures (1)

Safe Effective Caring Responsive Efficiency / Finance Activity

Safe Effective

Caring

NOTE – for each graph, the position furthest to the left is the best performing trust

Data quality issues mean that Inpatient FFT data should be treated with caution for November 2017

Data periods: VTE = Q2 2017/18; SHMI = Oct 2016 – Sept 2017; ED FFT, Inpatient FFT (friends & family

test) = Nov 2017; Maternity FFT (friends & family test) = Oct 2017; Dementia = Q2 2017/18

Well-led

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Benchmarking – selected measures (2)

Responsive

Workforce

NOTE – for each graph, the position furthest to the left is the best performing trust

Data periods: A&E (4 hour target) = Dec 2017; RTT (incomplete pathways) = Nov 2017; Diagnostic test waits = Nov 2017; Cancer = Q2 2017/18; Staff FFT

(friends & family test) = Q2 2017/18; Staff turnover = Oct 2017


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Activity


15/16 16/17 Dec-16 Jan-17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec-17 YTD YTD %

change

GP and general dental practitioner (GDP) referrals to all outpatients by CCG

NHS North East Hants and Farnham 40777 42413 2954 3413 3175 4023 2970 3591 3790 3525 3449 3328 3557 3523 2797 30530 -4%

NHS Slough 37444 41487 3250 3577 3233 3872 3246 3767 3691 3714 3637 3572 3637 3314 2644 31222 1%

NHS Windsor, Ascot and

Maidenhead 31293 33290 2584 2900 2701 3067 2424 2872 2929 2850 2782 2799 2784 2760 2199 24399 -1%

NHS Bracknell and Ascot 19019 19568 1336 1663 1686 1765 1454 1639 1602 1749 1737 1726 1791 1728 1338 14764 2%

NHS Surrey Heath 17106 17538 1172 1266 1208 1513 1201 1435 1426 1408 1412 1334 1355 1290 964 11825 -13%

NHS Chiltern 13931 14539 1096 1204 1161 1427 1116 1265 1200 1235 1234 1251 1251 1268 1003 10823 1%

Other CCG's 15846 16432 1076 1374 1304 1431 1239 1412 1467 1309 1276 1262 1387 1352 1093 11797 -4%

Total GP/GDP referrals 175416 185267 13468 15397 14468 17098 13650 15981 16105 15790 15527 15272 15762 15235 12038 135360 -2%

% change on previous year -1% 6% -6% 7% -14% 4% -1% 7% 1% -4% 2% -4% -11%

Outpatient attendances

New attendances 276653 294850 21790 25020 23194 26711 22145 25809 25870 25166 24507 24108 26356 27093 20871 221925 1%

Follow-up attendances 598902 598153 44625 50009 45813 54612 44376 52589 52896 48604 48403 48815 50894 52637 40437 439651 -2%

Total OP attendances 875555 893003 66415 75029 69007 81323 66521 78398 78766 73770 72910 72923 77250 79730 61308 661576 -1%

% change on previous year -3% 5% -5% 14% -8% 7% 3% 4% -3% -7% 3% -1% -8%

Emergency department (ED) attendances

ED attendances (total) 230609 237509 19713 19458 17357 20403 19209 21147 20339 20686 19251 19468 20149 19811 20198 180258 0%

% change on previous year 4% -1% -7% -2% 2% 2% 2% -4% -1% -3% -1% 0% 2%

Non-elective admissions

Non-elective admissions (total) 104023 109237 9425 9073 8014 9322 8522 9312 8883 9230 8734 9104 9261 9529 9546 82121 -1%

% change on previous year 4% 0% -7% -1% -2% 1% -4% -3% 1% -2% -2% 1% 1%

Elective admissions

Daycase 64340 67810 5030 5855 5407 6024 4863 5920 5589 5476 5340 5347 5840 6217 4928 49520 -2%

Overnight 15567 15417 1156 1209 1206 1405 1143 1289 1233 1193 1161 1147 1200 1268 1161 10795 -7%

Regular day attenders 15820 15897 1176 1377 1250 1537 1321 1525 1514 1422 1434 1312 1375 1422 1226 12551 7%

Total elective admissions 95727 99124 7362 8441 7863 8966 7327 8734 8336 8091 7935 7806 8415 8907 7315 72866 -1%

% change on previous year -2% 6% -3% 13% -10% 10% 1% 0% -2% -10% 1% -1% -1%

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Activity - ED attendances and emergency admissions (FPH)


16/17 Dec-16 Jan-17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec-17 YTD YTD %

change


NHS North East Hampshire &

Farnham 51725 4110 4253 3678 4469 4244 4650 4518 4695 4190 4306 4361 4359 4432 39755 1%

NHS Surrey Heath 25195 2100 2035 1860 2087 2044 2243 2203 2185 2124 2108 2077 2094 2198 19276 0%

NHS Bracknell & Ascot 19325 1569 1650 1362 1727 1523 1701 1728 1689 1536 1674 1778 1733 1607 14969 3%

Other 18406 1561 1442 1357 1558 1513 1619 1657 1811 1600 1627 1675 1579 1627 14708 5%

Total 114651 9340 9380 8257 9841 9324 10213 10106 10380 9450 9715 9891 9765 9864 88708 2%

% change on previous year 2% 0% -8% -3% 3% 4% 5% -1% -1% -1% 0% 1% 6%

Emergency department (ED) attendances - by priority

Majors 52496 4428 4547 3860 4389 4177 4486 4399 4712 4433 4336 4354 4244 4395 39536 0%

Resuscitation 8211 729 720 592 583 643 624 629 686 721 672 705 767 1018 6465 2%

Paeds 28424 2175 2139 2003 2415 2555 2744 2785 2671 2632 2548 2376 2246 2243 22800 4%

Minors 24989 1975 1898 1768 2416 1878 2306 2236 2255 1604 2120 2388 2464 2128 19379 2%

Not recorded 531 33 76 34 38 71 53 57 56 60 39 68 44 92 540 43%

Emergency admissions

NHS North East Hampshire &

Farnham 18191 1578 1560 1329 1520 1328 1475 1537 1619 1498 1500 1567 1580 1659 13763 0%

NHS Surrey Heath 8696 764 760 603 721 693 731 715 737 690 750 688 734 753 6491 -2%

NHS Bracknell & Ascot 7541 600 672 479 661 580 629 639 672 609 672 730 755 685 5971 4%

Other 7078 640 570 553 644 549 611 574 674 589 561 591 579 613 5341 0%

Total 41506 3582 3562 2964 3546 3150 3446 3465 3702 3386 3483 3576 3648 3710 31566 0%

% change on previous year 1% 1% -13% -8% -8% -2% -1% 2% 4% -1% 0% 7% 4%

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Activity - ED attendances and emergency admissions (HWP)


16/17 Dec-16 Jan-17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec-17 YTD YTD %

change


NHS Slough 51,401 4,272 4,275 3,770 4,508 4,063 4,525 4,207 4,270 3,920 4,016 4,378 4,208 4,273 37,860 -2%

NHS Windsor, Ascot &

Maidenhead 27,077 2,256 2,243 2,080 2,284 2,089 2,378 2,240 2,121 2,057 2,114 2,227 2,193 2,161 19,580 -4%

NHS Chiltern 28,348 2,422 2,417 2,186 2,545 2,306 2,494 2,343 2,408 2,348 2,429 2,374 2,470 2,577 21,749 3%

NHS Bracknell & Ascot 1,730 139 154 103 119 154 142 138 135 109 157 154 137 108 1,234 -8%

Other 14,302 1,284 989 960 1,106 1,273 1,395 1,303 1,372 1,367 1,037 1,125 1,038 1,215 11,125 -3%

Total 122,858 10,373 10,078 9,099 10562 9,885 10,934 10,231 10,306 9,801 9,753 10,258 10,046 10,334 91,548 -1%

% change on previous year 5% -1% -6% -2% 1% 0% -1% -7% -2% -4% -2% 1% 0%

Emergency department (ED) attendances - by priority

Majors 63624 5443 5616 5242 5795 5366 5987 5644 5698 5734 5677 5843 5649 6134 51732 9%

Resuscitation Included in Majors

Minors 30616 2424 2227 1832 2051 2225 2296 2255 2274 2313 1819 1896 1850 1829 18757 -28%

Paeds 28618 2506 2235 2025 2716 2294 2651 2332 2334 1754 2257 2519 2547 2371 21059 -3%

Emergency admissions

NHS Slough 16,845 1,489 1,409 1,232 1,462 1,363 1,509 1,352 1,396 1,267 1,406 1,420 1,520 1,539 12,772 1%

NHS Windsor, Ascot &

Maidenhead 12,570 1,097 1,022 1,001 1,067 931 1,096 984 942 984 989 1,046 1,090 1,075 9,137 -2%

NHS Chiltern 11,594 1,082 1,020 920 1,069 945 1,019 929 946 983 1,025 937 1,105 1,171 9,060 6%

NHS Bracknell & Ascot 909 69 81 65 76 68 96 64 68 46 76 85 66 52 621 -9%

Other 3,125 288 236 205 246 263 287 287 278 292 255 262 263 262 2,449 -12%

Total 45,043 4,025 3,768 3,423 3,920 3,570 4,007 3,616 3,630 3,572 3,751 3,750 4,044 4,099 34,039 0%

% change on previous year 9% 3% 1% 6% 5% 11% -1% -5% 2% -1% -5% -4% 2%

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Appendix A – Methodologies & glossary

Appendix A


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Appendix A – Methodologies for calculating the measures

Measure name Numerator Denominator

Length of stay Total number of bed days occupied

Excludes private patients

Excludes daycases

Based on admission method, split

between elective (from a waiting

list) and non-elective admissions

(includes emergencies and

obstetrics)

Total number of discharges in the

period

Expressed as a proportion

Measure is consistent with

that reported on HED

(benchmarking service)

Readmissions Emergency readmissions to any

specialty following an elective or

non-elective spell

Readmission length of stay must be

at least 1 day ie an overnight stay

Readmission occurs within 30 days

of previous discharge

Total number of discharges

(completed spells) in the period prior

to the last 30 days


that used by CQC

Daycase % Total number of admitted spells

where the intended management

was daycase, they were admitted

electively (off a waiting list) and

their spell length of stay was 0 days

Total number of elective spells

(admitted off a waiting list) Expressed as a percentage


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Appendix A – Methodologies for calculating the measures

Measure name Numerator Denominator

Outpatient new

to follow-up

ratio

Number of follow-up outpatient

attendances for all referrals and all

appointment types (consultant and

non-consultant led). Includes ward

attenders and private patients

Number of new outpatient

attendances

Expressed as a ratio where

one new attendance results

in “n” follow-up attendances




Outpatient

DNA rates

Number of outpatient appointments

where the patient did not attend.

Includes all referrals and all

appointment types (consultant and

non-consultant led). Includes

private patients

Number of outpatient attendances

plus the number of appointments

where the patient did not attend

Expressed as a percentage




Falls resulting

in significant

injury (rate per

1000 beddays)

Falls recorded on Datix resulting in

moderate or severe harm or death

Total number of occupied beddays

(including daycases)

Divided by 1000

Expressed as a rate


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Appendix A - Glossary

Term Meaning

CCG Clinical Commissioning Group

CIP Cost Improvement Plan or Programme

CoSRR

Continuity of Services Risk Rating As from 1st October 2013 Monitor‟s new Risk Assessment Framework replaced the old Compliance Framework. Part of

the change saw the Financial Risk Rating (FRR) being replace by the Continuity of Services Risk Rating. This measure is

designed to describe the risk of a provider failing to carry on as a going concern. The scale is rated from 1 to 4 with 4

being „No evident concerns‟ and 1 being „Significant Risk‟

CQUIN Commissioning for quality and innovation

CRAB CRAB (Copeland‟s Risk Adjusted Barometer) is based on the POSSUM scoring system

EBITDA Earnings before interest, tax, depreciation and amortization

FHFT Frimley Health NHS Foundation Trust

FPH Frimley Park Hospital

HW Heatherwood Hospital

HWP Heatherwood and Wexham Park Hospitals

POSSUM Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity

WX Wexham Park Hospital

YTD Year-to-date


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Frimley Health NHS FT Board of Directors Page 40

[Copyright information needs to go here]

Xxxxxxxxxxxxxxxxxxxxx

150315-230733-KN-UK

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Page | 1

Report Title

Frimley Health NHS Foundation Trust Quality Improvement Plan as at January 2018

Meeting

Public Board

Meeting Date

Friday, 2nd February 2018

Agenda No.

7.

Report Type

To advise the Board of Directors on the progress against the Frimley Health NHS Foundation Quality Improvement Plan

Prepared By

Debbie Barrow Governance Manager

Executive Lead

Dr Timothy Ho Medical Director

Executive Summary

Attached is the Frimley Health Quality Improvement Plan which was reviewed and agreed at the meeting of the Trustwide Quality Committee in January 2018 The Quality Improvement Plan describes the key quality and patient safety risks identified for Frimley Health and the actions that are being taken to mitigate those risks, current work streams in progress and further work required. Progress against the Improvement Plan is monitored on a monthly basis by the Frimley Health Quality Committee.

Background

The Trust Quality Committee coordinates and monitors the implementation of the responsive actions being taken by the organisation in relation to quality and provides assurance to the Board that the quality agenda is being embedded in line with the quality strategy, and that performance is measured and monitored.

Issues / Actions

• The Trust has recently held a CQC Workshop where the Chiefs of Service, Associate Directors and members of the nursing teams were asked to consider the the key strengths and risks/weaknesses for the organisation against the 5 CQC domains (safe, effective, caring, responsive & well-led).

• The risks/weaknesses identified are to be reviewed against the Trust Quality Improvement Plan to ensure that these have been recognised and appropriate actions being taken

Recommendation

The Board of Directors is asked to review the progress against the action plan, to agree the priority areas of concern and trajectories for achieving compliance

Appendices

Quality Improvement Plan January 2018

7

Tab 7 Quality Improvement Plan


Page 1

FRIMLEY HEALTH NHS FOUNDATION TRUST

Quality Improvement Plan as at January 2018

Ragging Key:

Achieved/on target/progress made

In progress but some challenges

Significant difficulty, poor

progress

Action achieved, closed

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SiteRecommendation & Current Risk Rating Actions

Target Completion

DateDirector Lead(s) Manager

Monitoring Committee Actions / Current Status

Frimley Health

Recruitment & RetentionContinue to improve staffing recruitment and retention

The Trust has put in place a robust recruitment plan and this is monitored regularly by Directors and reported monthly to the Board. The Trust will continue to actively recruit and retain staff using all tools and resources possible. National undersupply of qualified clinical staff is resulting in high vacancy rates and over reliance on agency staff. Specific risks in the following occupations:*Band 5 Staff Nurses (General)*Theatre nurses & ODP's*Paediatric Nurses*Sonographers*RadiographersMedical Roles:1. Paediatrics – middle grade 2. Anaesthetics – middle grade 3. Trauma and orthopaedics – junior and middle grade 4. Acute medicine – junior, middle grade and consultant 5. Care of the Elderly – junior, middle grade and consultant 6. Respiratory Consultant 7. Urology Consultant 8. Dermatology Consultant 8. ED - junior and middle grade

Q4 17/18 Director of HR &

Corporate Services /

Director of Nursing

Deputy Director of

Nursing (WPH) /Assistant

Director of Resourcing

Workforce Committee

Janaury update (Nursing):• Strong performance in regards to nurse recruitment activity (154 nurses recruited in three months (Aug-Oct 17)) with the overall Trust vacancy rate decreasing to 11.4%• Evidence turnover has decreased with an average of 31 nurse leavers per month so far in 2017 compared to 34 in 2016.• Steady flow of Philippine candidates starting with the Trust. 68 remain in the pipeline and on average we expect to an average of 10 to start each month• Skype Interviews for Australian candidates to fill positions in Theatres taking place in January. • Between Jan - Oct 2017 we recruited 43 consultants (25 at FP and 18 at WP) • Also between Jan – Oct 2017 we recruited 49 trust/middle grade doctors (31 at FP and 18 at HWP)• This recruitment represents a 15% increase compared to the same time last year• Focus in recent months to appoint to positions currently being filled by high cost locums in specialties such as Gastroenterology and Dermatology to reduce agency spend• Working with two new recruitment agencies to recruit ED/middle consultants from Qatar and India. So far 2 Speciality Doctors from Qatar starting in ED FPH in January 2018 and 2 Specialty docs in ED WPH in February 2018. There are 6 doctors whose IELTs is under review, aiming for them to start later in the new year but no dates as yet.• We have also established close links with the Royal Colleges to employ MTI doctors in a number of Specialties: O&G, General Medicine, Trauma & Orthopaedics. These are ST3 – ST5 level doctors.

Quality Committee Quality Improvement Planas at January 2018

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Target Completion



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E D M SConsider the size and organisation of paper health records This will remain an ongoing piece of work until such time as all of the records become electronic as part of the EDMS project. Until that time we are continuing to split records each month to meet the size requirement.

EDMS programme over the next 2 years within pilot specialities due to go live in June 2016

Q4 17/18 Director of Ops (WPH)

Head of Nursing and

General Manager

Outpatients

OPD HCG 24/07/2017 - All clusters now live and project is in closedown. The revised scanning strategy means that the Trust will be operating with a mix of paper (legacy) and digital (day forward) records for the forseable future. Outstanding issues to be addressed re: consent and speicality specific proformas September update: The Trust is not planning on digitising all legacy records beyond those required for space saving benefits. Legacy notes will remain available on demand or at the request of the clinician. All current and future activity documentation is now being digitised October update: This space saving should be achieved my mid 2018 at the latest where we will revert to scanning current episode information only. The Programme Board has approved the preparation of an internal scanning hub to provide a service tailored exclusively to the needs of the Trust, which may influence the comments referenced above. Trust has an ambition to implement the use of electronic forms with the Evolve application to reduce spend on externally printed stationary and scanning costs. Current focus on OPD forms. December update: We continue to shelf clear at Frimley and Heatherwood to free the space. eForm work is also progressing with the first forms now live. Availability of forms will increase and therefore the amount of original paper notes will decrease. The programme Board is exploring all options to ensure the digitisation of records happens as quickly and safely as possible. January update – Shelf clearing continues and integration work with other key systems as well as eForm development continues which will continue to reduce the need for paper records. Drawing tools are being trialled to enable handdrawn diagrams to be captured electronically.

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Medical Staffing Out of Hours / Use of AgencyTo ensure early identification of potential gaps in medical staffing cover out of hours and minimise the use of agency staff

Each speciality to review medical staffing model and make recommendations to mitigate forthcoming expected gaps in junior doctor rota

Q4 17/18 Medical Director

Deputy Medical

Directors FPH & WPH

Workforce Committee sub-group will brief all Directorates in early April regardng the need for a Workforce Plan template to be completed, including likely need for changes in the future. Directorates to present their Workforce Plan at the meeting in SeptemberSpend being moniored by SpecialitySpeciality meetings considering vision for workforceRotas changedHCAs and non clinical support staff being used in surgeryNew Temporary Workforce approval process for all medical bank & agency staff developed by HR/Deputy Medical Directors/Directors of Operations. Introduced at beginning of October, email from CEO to all AD's & CoS to launch new process

Frimley Health

Deteriorating Patient:To ensure all clinical staff have the right skills & tools to recognise & deliver timely treatment to the deteriorating patient

Learning from SIs and M&M Reviews to be incoporated into training programmes

Ongoing Medical Director

Lead Nurse for

Deteriorating Patient

Resuscitation Committee

Continues to be a theme arising from Morbidity & Mortaility reviews and serious incidents - November update: ONGOING March update: Learning from SIs is shared and disseminated via Directorates and incorporated into ongoing training programs including November update: ALERT AND ESCALATE In depth review of recent cluster of SIs relating to deteriorating patient to be undertaken. Learning from avoidable deaths - led by Trust lead for Mortality & Morbidity, report to Board in October 17Marked improvement in Cardiac Arrest Audit, FHFT now at 30.60% against national average of 20% patients that survive a cardiac arrest in hospital and go homeNovember update: Introduction of Adult Deteriorating patient study day with assessment called ESCALATE (october 2017) DONE. New plan for improving compliance with mandatory training for resuscitation being developed. December update: Resus team now part of Patient Safety team. Focus over next 6 weeks targetting compliance with Paediatric Electronic observations to be a priority as part of IT Strategy Janaury update:Appointed to Deteriorating Specilaist nurse posts for both sites WPH site to start in early Jan and FPH site beginning of Feb NEWS audit completed, to present at Matrons, senior sisters on both sites Patient safety committee, CQRM in January Adult level 1 Resuscitation compliance at 72.72% against target of 85%.

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Target Completion



Observational review of compliance with Hospital at Night arrangements to be undertaken regarding implementation and effectiveness of night-time handover

Q4 17/18 March update: Deputy Medical Director and Chief of Serivce for Medicine currently to undertake an Observational auditMedical & Deputy Medical Directors to attend clinical handover to observe compliance and agree further actions. November update: No change

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SepsisTo implement the new NICE guidelines for recognition and Management of Sepsis (NG51)

Monitor compliance of the Sepsis Screening Tool through quarterly audits

Ongoing Medical Director

Head of Patient Safety

Sepsis Committee

On HWPH site compliance remains a challenge, weekly ward audits undertaken by the matrons which has improved compliance plus 2 sepsis study days with a 3rd planned 29/6. Both sites have well embedded and attended monthly sepsis meetings and all wards have nominated sepsis champions. June update: Quarterly audits continue, training and education in place. July update: Sepsis bundle distributed cross-site July 17. To be attached to obs equipment to promote screeningAudit findings shared at Quality Committee & nursing forums September update: To review Sepsis bundle and update in line with new Sepsis Guidelines launched September 17. October update: NICE guidelines have been released. Advanced Nurse Practitioner for Critical Care to attend national meeting w/c 2/10 to see a national tool is released. If not then agreement of a revised tool will occur. In the meantime, strong message to clinical matrons regarding screening and 2 sessions for the FY1 is being provided by the Consultant Lead. Aim to ratify new bundle by the end of October and implement in November. Business case for 2 x Band 7 Deteroiorating Patient lead for each site to cover AKI & Sepsis approvedSepsis bundle being agreed, launch date 27/11/17 December update: The bundle was agreed at the Quality Committee in November and launched across Frimley Health on 27th November. Audit of compliance will continue. The 2 band 7 posts will be advertised once signed off by finance. January update: 2 band 7’s appointed to commence beginning of Jan one for each site. Q3 audit in progress, initial data looks much improved. Peer review for January 2018 to focus on sepsis bundle and compliance. Patient information leaflet to be developed to help patients understand sepsis. Sepsis clinician lead from WPH leaving the trust, consider one clinical lead for FHFT to aid alignment.

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Do Not Attempt ResuscitationTo ensure there is evidence that DNAR decisions have been appropriately discussed & and are displayed in the medical records (at the front)

To review new national guidance (ReSPECT)


Lead Nurse for

Deteriorating Patient

Resuscitation Committee

Dr Kelvin Wright now Consultant lead for DNAR.▪ National Guidance (Respect) currently under review, to be rolled out as part of the End of Life care planningJune Update: First ReSPECT workshop held in May. Cross-site DNACPR policy at June HEB.Frimley Health DNACPR policy ratified at HEB. CRoss ite DNACPR form currently under consultation November update: Ongoing new form out for consultation. To be audited in Q4. December update: Resus team now part of Patient Safety team 8. Improvement in compliance in Resus training stats, January update: Proposed new Escalation and DNACPR form for FHFT for consultation in January. DNACPR audit Q4.Adult Level 1 72.72% against target of 85%

Frimley Park Emergency PressureTo ensure quality of patient care through patient flow

Ongoing Director of Operations

AD for Medicine

Unscheduled Care

November update: ambulatory care now open 7 days a week and activity levels being monitored. Business case completed with NEHF for GP(s) to work on frailty unit. Successful recruitment to middle grade rota in ED and new starters will be joining the team between now and Feb 18. December 2017: additional ambulance line handover nurses to be rostered, ESI streaming continues, paediatric emergency flow being reviewed in light of high attendances and higher acuity currently presenting . January update: bid submitted for national funding to support ED flow and discharge to assess beds in the community. Outcome awaited. Flow into Paeds beds now managed by the bed team and working well.

To reduce avoidable admissions through Ambulatory Care pathways and review the threshold for admission by implementing a dynamic response from primary care, social care and community services to support pts at home.

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WPH Emergency PressureTo ensure quality of patient care through patient flow

Ambulatory Care majors streaming commenced in ED January 2017.▪ ESI started 20/04/17.▪ New medical model launched in ED March 2017.▪ The Urgent Care Steering Group has been re-launched August 2017 - GP works on G6 acute frailty unit every Friday to encourage discharge and liaison with primary careAugust 2017 - Joined acute frailty network & has been successful in securing short term national funding December 2017: GPs to be employed in Frailty Unit are being recruited, frailty identification tool in place for emergency attendances and admissions, ERS@H now working weekends in ED to facilitate discharges January update: Frailty Unit GPs progressing well in addition to a wider recruitment into the team

Frimley Health

Discharge planning is a Transformation Workstream supported by the Project Management Office (PMO), currently developing prioritised action plan with ‘quick’ wins and long term actions to be taken

Q4 17/18 Director of Nursing /

Director of Operations

Transformation Group

Heads of Nursing

June update: IRIS 'huddle' twice a week in place for NEH&F ICTs to share information on 'known' patients to facilitate early discharge planning. Work underway to engage with Berks & Surrey SPA.Training on electronic systems completed for NEH teams. An IG solution is required for Berks/Surrey teams2 Deputy Directors of Nursing will be leading discharge groups on both sites with focus on delayed discharges and transfers to community teamsDischarge Groups established on both sites. November update: Safer Discharge Bundle being implemented as first priority In regards to the discharge planning workstream – SAFER Workshop is being held on 3rd November. December update: Further workshop focusing on review & management of stranded patients held in November, changes made in delay reasons list, with a plan to be able to pull a medically fit list from Real time.

Discharge PlanningTo ensure there is a robust discharge planning process in place to reduce patients’ length of stay, pressure on hospital beds and patient readmission

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To review the management of private funding for nursing home care and support families who are privately funded

Q4 17/18 Director of Operations

Matron - Patient Access

Urgent Care Board

Funding has been agreed by CCG and lead in postbut being used by CCG for other purposes. Director of Ops resolvedSocial worker to manage and work with private funders to reduce delays & expedite decision making, evoking CHOICE protocol where appropriateNursing homes to participate have yet to be identifiedJune update:Funding has ceased for this post . Work underway to identify a way forward. Job Description written for new position of Private funding discharge co-ordinator. KPI’s and metrics being collated with options being explored for new positionTrusted assessors scheme in place to reduce emergency admissions and discharge back to care homes November update: Trusted assessors scheme is on-going with additional homes being added. Private funders JD has been written.December update: JD Currently being banded Trusted assessor meeting to held 30/11 to review current process and feedback from all involved.

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Observational review of compliance with Hospital at Night arrangements to be undertaken regarding implementation and effectiveness of night-time handover

Q4 17/18 Medical / Nursing

Directors

WPH Deputy MD

Quality Committee

Different levels of maturity on each site, more embedded at Wexham Park HospitalDiscussed at Critical Care Delivery Group and all Chiefs of Service asked to support attendance at night-time handover to ensure patient safety and priorities are aligned throughout the nightMedical Director & Deputy Medical Director on FPH site to liaise with Chief Registrar to format a plan moving forwardJune update: FPH Chief Registrar had several meetings with ICU, currently H@N at FPH meeting involves medical team and NNP. Site and bed managers attend briefly to give update. Surgery do not attend, ICU attend workload permitting. October update: Obs & gynae WPH day to night + night to day handover trialling Safety SBAR modelMeetings arranged with key stakeholders to discuss handover process between day to night in order to identify how handover can add value for all participants. November update: WPH obs and gynae new safety sbar handovers to be re-auditted in jan, interim feedback positive. January update: No change

Review weekend handover plans/documents to identify consistent approach

Q4 17/18 Su2S Matron Quality Committee

July-17 multiple audits and QI projects being run by junior doctors from different specialities to create clearer weekend handovers plans from specialities. Learning from each project to be brought together to create a single consistent approach.December update: John Seymour contacted re:review and standardisation of current documents used across medical directorate. January update: John Seymour contacted, awaiting response. VM to chase in Jan.

Frimley Health

Clinical HandoverTo ensure consistency in both medical and nursing handover arrangements & ownership

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Consent / Local Safety Standards for Interventional ProceduresTo ensure appropriate checking processes are in place for patients undergoing invasive procedures undertaken outside of Theatres

Recommendations to be considered from national guidance NHS England Patient Safety Alert re: Supporting the introduction of the National Safety Standards for Invasive Procedures published, actions to be taken by September 2016 (progress with implementation)

Sep-16 (The Trust will be expected to demonstrate progress made with

implementation by 14th

Sept. The deadline for developmen

t of all LocSSIPs is still to be confirmed

by NHS England)

Medical Director / Director of

Nursing

Deputy Medical

Director (FPH)

Quality Committee

July - theatres and maternity LocSSIPs are completed and being actioned with new WHO forms being implemeted.Vascular access LocSSIP is in second draft stages and being sent out for comment. Intentionally retained product pathway is currently being reviewed as to how to encorporate the documentation within the patient notes. Paediatric pregnancy testing is being developed by the pre-op matrons in conjunction with the paediatric wards. Cross site development of the emergency department LocSSIPs is underway and the resus team are working on a flashcard for use in emergency invasive procedures.October update: To undertake audit of compliance with WHO surgical safety checklist for interventional procedures undertaken outside of the Theatre environment

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Review consent documentation and procedures & implement new process

Q4 17/18 Consent Policy & Implementation Group

Nov update: Electronic consent ; further discussion with Med Dir regarding e-Consent, on-going investigations regarding options. Consent Policy; Exiting policy is currently being reviewed and revised. Plan to create a Trust Wide policy. Obs & Gynae; 6 consent forms, first proofs approved, advised OK to print waiting for delivery! Next step is to roll out at WPH with support from COS and Head of Midwifery. Orthopaedics; first draft of procedure specific consent forms for TKR, THR & Knee scopes with Cons for review. Fantastic engagement from Obs & Gynae and some Orthopods.Struggling with engagement for Urology at WPH Dec update: Electronic Consent: e-consent discussions and investigations cont. Consent audit Dec 17. Obs & Gynae; Consent forms in use. Excellent engagement with WPH, minor adjustments to be made to the forms, but first drafts available shortly. Orthopaedics; Second draft of procedure spec consent forms for TKR, THR and Knee scopes with Cons for review. Challenges around engaging with Urology at WPH escalated. New, procedure spec consent form for Orthodontics at WPH rolled out. New, procedure spec consent form for Endoscopy ready for ratification by Consent Comm. January 2018 Update: Meeting with WPH Urology planned, procedures identified, first drafts of forms in progress. Consent audit proforma has been revised and request for patient numbers from both sites have been placed. 2nd draft of Orthopaedic forms now ready for ratification.

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Review current patient information with particular focus on risks and benefits to support the consent process for high priority

Q4 17/18 Consent & Implementation Group

The guidance for developing and managing information leaflets is currently being reviewed and will be ratified via the Trust Consent Committee.April update: Obs & Gynae leaflets for top 5 procedures currently being updated in line with current guidance, as part of phase one.June update: Gynae have set up at tracking system for monitoring, reviewing and updating patient information. All Gynae PIL will be looked at in due course. Both Chairs of Consent Groups via Deputy Medical Directors to explain actions being takenSeptember update: Obs & Gynae consent forms on order. Orthopedic procedures identified and work has commenced on formatting prepolulated consent forms. PIL has been gathered for review. Meeting with Urology at Wexham to discuss procedures for review. October update: PIL for; Hallux valgus, total hip replacement, tennis elbow and total knee replacement under review.November update: Gyane Patient Information Group continues to review and update PIL. Review of Orthopaedic PIL on-going. Funding for Knee and Hip information packs previously in circulation has now ceased due to cost. Alternatives options to be explored. December update: Review of Orthopaedic PIL on-going January 2018 Update: Urology PIL to be discussed at Wexham next week.

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Cancer PathwaysTo improve the number of patients treated within the 62 day cancer target and to reduce the number of patients whose diagnosis and treatment takes longer than 104 days To improve cancer patient experience and rationalise referral pathways

Ensure appropriate videoconferencing facilities are in place

Q4 17/18 Directors of Operations

CIO Cancer BoardExecutive BoardTrust Board

Request made again to Informatics. August update: business case in development by IT. Top Team have not agreed funding, issues continue to arise March update: Top Team approved the outfit of 4 rooms in Dec 16. Currently out to procurement at this timePlan in place, currently out to tender.October update: Implementation of the 4 rooms approved in phase 1 to start Oct and will take about 6-8 weeks to complete the work. (dependent on furniture orders, room set up, that are outside IT control). November update: Installation schedule underway.December update: Delays occurred in finalising the contract which is due to be signed off imminently. An initial kick off meeting will take place with the Video Conferencing (VC) supplier within 10 days of the contract being signed and the activity of work will be planned out to deliver VC starting in January 2018. January 18 Update:The contract has now been signed but awaiting confirmation of one room at HWPH from key stakeholders. 3 rooms confirmed at HWPH (1) and FPH (2). Kick off meeting provisionally booked with Video South Tues 9/01/18 to complete the plan, determine the pre-requisite tasks and owners, and to finalise installation dates; anticipating to start the first room in January 18.

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Management of Patients with Mental Health Issues & Learning DisabilitiesTo review with mental health colleagues the increase in number and complexity of patients with with mental health needs

The Trust should ensure that staffhave clarity around accountabilityand Duty of Care when managingpatients sectioned under the MHAincluding the use of restraint

Q4 17/18 Director of Nursing

Deputy Director of

Nursing FPH

Specialist Simulation training to be provided for key stakeholders including security team AwarenessMeeting held with MAYBO to discuss how to provide security staff with next level restraint training. Maybo proposal for simulation training to be sustained through train-the-trainer. Rapid Tranquilisation Policy in draftConsultant Psychiatrist now delivering Rapid Tranqulisation training and Broadmoor trainingMaybo Level II training undertaken by all Security staff on both sites. 'Managing Challenging Behaviour' incidents roles & responsibilities in-house awareness video being developed. On-line roll out anticipated end June 17, dependent on SIM suite availabilityJune update: In-house training video filming has commenced. Paediatric scenario roll out expected by end of July. Delay caused by availability of SIM suite & clinicians. Paediatric senario filming completed. January Update Paediatric scenario filming completed, and with the right commentary an adult scenario may not be required. Currently with Director of Nursing to record the voice over links. Requirement for additional restraint training for clinical staff still being scoped.

The Trust should ensure that any patient detained under section 2 of the MHA with a high risk of absconding, self-harm and previous suicidal attempts must be escalated and addressed by the senior nursing staff if a RMN or a 1:1 specialist cannot be provided. All patients requiring 1:1 supervision should receive a daily assessment of their requirement and priority for 1:1care

Q4 17/18 Director of Nursing

Assoc Director for Site

Management

All patients sectioned under the Mental Health Act are now highlighted & discussed at the Bed Management MeetingsPolicy approved at Nursing & Midwifery Board, now at implementation stagePolicy to be reviewed in August 17Discussions with Commissioners & Mental Health providers around Paediatric Mental Health pathwayAdults ongoing CAMHS commissioning issues being addressed with Berkshire HealthcareEducation video under development

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Target Completion



Frimley Health

Seven Day ServicesTo ensure that all specialities meet the 4 key clinical standards required as being 'must do' by 2020 in terms of providing a 7-day service including:* patients wait no longer than 14 hours to initial consultant review* patients get access to diagnostic tests with a 24-hour turnaround time, for urgent requests (12 hours) and for critical patients, one hour* patients get access to speciality, consultant directed interventions* patients with high-dependency care needs receive twice-daily speciality consultant review, and those patients admitted to hospital in an emergency will experience daily consultant-drected ward rounds

From last national audit of 7-day services the Trust benchamarked well against peers & nationally but below target, actions to be taken include:

*Audit findings to be analyzed by site to see where key issues lie

*To review and improve access to diagnostics at WPH, i.e echocardiography and MRI out of hours

*To reinforce the requirement to Document name & seniority of clinician to provide around who is reviewing patient and when


Deputy Medical

Directors FPH & WPH

Quality Committee

March update: We have raised awareness of standards and are using a poster pull-up to endorse these.▪ National audit now underway.Overall achieved better than national average for most indicatorsDirectors of Ops to review audit findings and develop gap analysisNovember update: September audit now underway, results will be shared when published.Sept December update: Audit completed internal analysis underway. Results will be sent to the Deputy Medical Directors for review once analysed. January update: Audit report being finalised this week.

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Report Title Month 09 Finance Report to The Board of Directors

Meeting Public Board

Meeting Date Friday, 2nd February 2017

Agenda No. 8.

Report Type To receive assurance on the current and forecast financial position of the Trust

Prepared By Edward John (Director of Operational Finance) / Hugh Cronshey (Assoc. Dir of Finance)

Executive Lead Nigel Foster (Director of Finance and IM&T)

Executive Summary

The Trusts’ operational surplus was £0.3m in month which was £0.3m better than plan. The year to date is £3.9m deficit which is £6.0m adverse to plan. This reflects the Trusts’ underlying deficit position and on‐going higher than expected cost base. Income in month was close to expectations but as negotiations move closer to conclusion with commissioners the Trust was able to reverse some provisions for challenges and queries to allow a position £1m better than plan. Spend however was £0.9m overspent: agency and substantive pay costs reduced from last month but were overspent by £0.24m, non‐pay costs were also down from last month, but overspend by £0.54. The Trusts bottom line is, still, buoyed by non‐recurrent stock transfers and donated assets. This means the year to date plans have been achieved and therefore STF payments have been earned and accrued. CIP was 92% in month (89% ytd) Winter pressure funding of £1.9m is not available to spend as NHSI have directed that this money will increase Trust surpluses commensurately. Because of the deterioration in the month 09 forecast the Trust has not increased its surplus by the same amount. An element of Waiting List Initiative money has assumed to be released to help the year end position.

Background

The Trust had set a budget of £22.8m surplus for 2017/18 against which this report is monitored. This surplus plan includes £18.6m of STF; £22.6m of DH support inc £6m of Cap‐to‐Rev, and assumes delivery of £30.5m of cost reduction CIP.

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The plan is to generate a surplus of £4.2m before STF.

Issues / Actions

The forecast for the year end has been held to show an achievement of the control total. This is possible because of the expectation on a positive income deal with commissioners which covers the worsening position on month 9 costs extrapolated to the year end. CIP was 92% in month (89% ytd) and is forecast at £28.9m against the £30.5m target which is a 95% delivery. Of this forecast £3.2m is non‐cash releasing. The Capital forecast has been revised at Q3 due to continued slippage on Heatherwood and some slippage on EDAR and estates maintenance. This will mean a year end underspend of £36m. The knock impact of this on cash is to push the year end cash balance to just over £102m Risks to the delivery of the Trusts forecast outturn are: Year end income deals with commissioners are less favourable than currently

on the table given both the Trust and system control total needs to be achieved

Expenditure continues to increase above expected levels RTT drifts outward due to the WLI monies assumed in the forecast A&E performance at Delivery Board level are below target which if not

achieved would mean a £1.9m risk to STF money (not control total)

Recommendation This report is for assurance only

Appendices

Finance and Commercial Board Report: Note – all variance are reported against budgets and not original NHSI Plan.

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Finance & Commercial Board Report

Financial Performance

December 2017

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M09 Dashboard

Plan £m Actual £mVariance

£m RAG Plan £m Actual £mVariance

£m RAG Plan £m Actual £mVariance

£m RAG

Income 55.0 55.6 0.6 490.5 490.8 0.3 658.3 659.4 1.1

Expenditure (50.4) (50.3) 0.1 (453.0) (453.6) (0.6) (604.1) (604.6) (0.5)

Financing costs (2.6) (2.5) 0.1 (23.3) (23.1) 0.2 (31.4) (31.8) (0.4)

Net / Surplus Deficit 2.0 2.8 0.8 14.2 14.1 (0.1) 22.8 23.0 0.2

CIPs 2.7 2.5 (0.2) 23.2 20.8 (2.4) 30.5 28.9 (1.6)

Cash Balance 76.7 81.0 4.3 76.7 81.0 4.3 67.1 102.7 35.6

Capital Expenditure 9.0 4.8 (4.2) 67.6 36.8 (30.8) 96.9 60.5 (36.5)

Use of resources score (1‐4) 1 1 1 1 1 1

Month 09 Year to Date (Month 09) Full Year Outturn

Key points: Income is much improved due to expectations of a better negotiated year end deal Expenditure continues to be above expected levels esp in medical agency and non‐pay but is supported by ytd non‐recurrent stock adjustments

which make the net surplus position lol healthy (see later pages) The above positions include full STF money and also includes £1.9m of winter pressure funding which would have increased the Trusts surplus

commensurately were it not for a worse than expected month 09 bottom up forecast CIPs are delivering at a good rate 92% in month and forecast to be at 95% for the year end but £3.2m of that will be non‐cash releasing Capital slippage is significant due to Heatherwood and this has an impact on year end cash which is now forecast to be at £102m

Summary:The Trust is likely to achieve it’s financial targets at the year end due to non‐recurrent measures in year which cover net overspends on cost budgets. Any further risks crystallising before the year end could be covered by additional non recurrent measures. However, all non‐recurrent measure used in 2017/18 will re‐appear as a pressure in 2018/19 so it is vital that costs are contained and CIP mitigations are delivered.

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Income & Expenditure ‐ Month 09 and Year to Date – Summary

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Key Points:

STF: NHSI plan is for a YTD surplus of £1.1m (excl. STF) and the Trust is reporting a surplus of £2m. But as a result of changing the classification of impairments, the position is £1.9m better than the control total.

Operating Income: Clinical income from Commissioners is £1.2m over plan, however this was supported by the release of provisions, rather than a strong activity performance in month. Other income was also behind plan in month.

Operating Expenditure: Agency and substantive pay costs reduced from last month but still generated an overspend of £0.24m, non‐pay costs were also down from last month, but still generated an overspend of £0.54.

Forecast: The forecast has been increased to reflect the additional Winter Pressures money (£1.9m) and the current income assumptions. However, this has been largely offset by expenditure. Based on the current methodology of calculation, the trust will achieve the NHSI financial control total.

Please note: The phasing of the internal plan differs from the APR submitted to NHSI. This is largely due to the profile of the CIP plans and the profile of the budgets held in reserves.

Plan Actual Variance Plan Actual Variance Plan Actual Variance£m £m £m £m £m £m £m £m £m

Income 52.6 53.6 1.0 474.3 474.9 0.6 634.3 635.4 1.1Expenditure (49.9) (50.7) (0.9) (448.9) (455.8) (6.9) (598.7) (606.7) (7.9)Trust Financing (2.6) (2.5) 0.1 (23.3) (23.1) 0.3 (31.4) (31.7) (0.4)

Net Revenue Surplus / (Deficit) 0.1 0.3 0.3 2.1 (3.9) (6.0) 4.2 (3.0) (7.2)

Exceptional Items 0.0 0.5 0.5 0.0 5.9 5.9 0.0 7.5 7.5Net Position 0.1 0.8 0.8 2.1 2.0 (0.1) 4.2 4.4 0.2

STF Funding 1.9 1.9 0.0 12.1 12.1 0.0 18.6 18.6 0.0Integration Funding 0.5 0.1 (0.4) 4.1 3.8 (0.3) 5.4 5.4 0.0Integration Costs (0.5) (0.1) 0.4 (4.1) (3.8) 0.3 (5.4) (5.4) 0.0

Net Revenue Surplus / (Deficit) after one-off items

1.9 2.7 0.8 14.2 14.1 (0.1) 22.8 23.0 0.2

Frimley Health

Current Month Year to Date Full Year Out-turn

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Income & Expenditure ‐ YTD month high level variances

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Theme Key Issues

Variance M9

YTD £m

IncomeCCG/NHSE Income Pass Through Drugs & Devices, Uncoded Activity at average prices 2.7Clinical Income Delayed commisioner funding for Clinical Schemes (Frality, Ambulatory Care) (0.0)Non CCG Income Private Patient, Overseas, RTA, Pharmacy Repackaging Unit (2.1)Corporate Income Car Park, Accomodation, EDMS Project, Catering (0.0)

Total Income 0.6

PayMedical Pay Agency and Locum Costs above substantive Vacancy (3.3)Nursing & Ancillary Nursing underspends offset through HCA overspends (2.2)Prof/Tech & Scientific Agency Cover above vacancies (1.1)

Admin & Management Vacancies not all covered through bank/Agency3.3

Total Pay (3.3)

Non PayDrugs Lower overall issues, mostly PbR Excluded, Higher FP10s 2.3Clinical Supplies Theatre items, some maintenance contracts (2.3)Other Non Pay Mostly Corporate Areas (Rates, Ulitilities, Maintenance, IM&T, ) (3.2)

Total Non Pay (3.3)

Total Before Exceptional Items (6.0)

Excpetional Items Stocktake, Donated Assets, Winter Pressures 5.9

STF Central Strategic Transformation Funding 0.0

Grand Total (0.1)

Key points: Income is favourable but

because of contracting rules does not reflect true costs of provision of services

The trust is reporting a favourable variance of £1.2m against the plan for NHS commissioned activity. However, this position is being supported by £1.6m improvement from a re‐assessment of provisions from challenges. This has masked the poorer underlying performance in month

PPU has returned to an adverse variance in month

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I&E Month 09 – Subjective Analysis – Adj. to show impact of Exceptional Items

I&E by Subjective Heading Mth Bud £m

Month Act £m

Mth Var £m

YTD Bud £

YTD Act £

YTD Var £

IncomeIncome From Activities (47.68) (48.68) (0.99) (429.86) (430.82) (0.96)Other Operating Income (4.94) (4.97) (0.02) (44.63) (44.23) 0.40Income Total (52.63) (53.64) (1.01) (474.50) (475.05) (0.55)PayMedical And Dental 8.89 8.82 (0.07) 79.78 77.35 (2.44)Nursing & Midwifery 10.38 9.71 (0.67) 93.02 87.00 (6.03)HCAs & Other Support Staff 4.01 4.41 0.40 36.28 40.56 4.28AHPs, Prof, Scientific & Technical 4.36 4.21 (0.15) 39.24 37.23 2.66Agency Staff External 0.54 1.71 1.17 4.67 17.79 13.12Other Staff 5.29 4.85 (0.44) 47.12 43.50 (8.28)Pay Total 33.49 33.72 0.24 300.11 303.42 3.31Non-PayClinical Service And Supplies 9.70 9.90 0.21 87.24 87.29 0.05General Supplies And Services 0.80 0.82 0.03 7.21 6.73 (0.48)Premises & Fixed Plant 5.08 5.28 0.20 46.38 48.80 2.41Other Non Pay 3.51 3.61 0.11 31.49 32.77 1.28Non-Pay Total 19.07 19.61 0.54 172.33 175.59 3.26

Underlying Net Position (0.07) (0.30) (0.24) (2.06) 3.95 6.01Exceptional ItemsIncome from Donated Asset 0.00 (0.01) (0.01) 0.00 (0.72) (0.72)Stock Adjustment (0.00) 0.00 0.00 (0.00) (4.73) (4.73)Winter Pressures Funding 0.00 (0.50) (0.50) 0.00 (0.50) (0.50)Net Impact of Exceptional Items (0.00) (0.01) (0.01) (0.00) (5.45) (5.45)

Grand Total (0.07) (0.32) (0.25) (2.06) (1.50) 0.56STF Funding (1.86) (1.86) 0.00 (12.09) (12.09) (0.00)Net of STF (1.93) (2.18) (0.25) (14.16) (13.59) 0.56

Key points: Pay costs were lower that the

previous month, although overspent, the adverse variance was less that 1%. Temporary staff costs have also reduced, some of which has been offset by increased permanent staff.

Although lower than last month, non‐pay costs continue to overspend. A high month in drug costs the main cause for the over‐spend on clinical supplies & services and IM&T support contracts is the main reason for the overspend on premises and fixed plant

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Total Trust Bank Expenditure (Excl. Integration funded spend)

Bank Costs have reduced from M08.

Key points: Bank costs have reduced on both

sites, with the largest reduction being in Nursing.

Further analysis is being done to evaluate whether this is driven by volume of bank shifts or whether the pay‐rate changes has reduced the cost per shift.

6

Hospital Bank

2016/17 Q4 Average M07 M08 M09

FPH Admin 101,911 72,867 109,036 100,520

AHP 22,455 29,307 24,853 24,167

Ancillary 509,561 383,206 423,763 457,292

Nursing 521,993 513,568 519,915 428,879

Prof Tech & Scientific 65,318 112,138 111,272 117,394

FPH 1,221,238 1,111,086 1,188,838 1,128,252WPH Admin 6,701 47,202 57,802 72,575

AHP 17,040 60,556 51,100 39,024

Ancillary 267,797 254,842 290,695 278,885

Nursing 536,698 647,152 573,378 545,100

Prof Tech & Scientific 8,433 9,409 9,348 12,239

WPH 836,670 1,019,161 982,324 947,823

Total 2,057,907 2,130,247 2,171,162 2,076,0768

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Total Trust Agency Expenditure (Excl. Integration funded spend)

Agency Costs have reduced £260k from M08

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Hospital Agency

2016/17 Q4 Average M06 M07 M08 M09

FPH Medical 564,574 284,387 239,212 258,957 169,946Nursing 239,956 196,788 170,853 137,504 143,091Prof Tech & Scientific 125,480 55,519 42,524 44,039 73,517AHP 166,390 74,323 117,281 109,709 86,371Admin 136,964 26,989 6,561 41,904 14,334Ancillary 6,493 5,186 648 1,460 10,933MOD Agency 0 0 60 0 -93Other Staff 0

FPH 1,239,856 643,194 577,139 593,573 498,098WPH Medical 401,237 748,660 608,791 533,339 446,601

Nursing 398,465 355,127 352,530 314,430 303,494Prof Tech & Scientific 121,280 129,953 106,114 186,448 137,630AHP 196,174 47,010 87,599 51,491 32,618Admin 106,570 54,985 43,956 37,266 38,383Ancillary 1,977 5,195 2,101 -1,801 3,572MOD Agency 1 0 0 0 0Other Staff

WPH 1,225,703 1,340,930 1,201,092 1,121,173 962,299

Total 2,465,560 1,984,124 1,778,230 1,714,746 1,460,397

Key points: Agency costs have

reduced for the third month running and are at the lowest level for this financial year.

Although part of the reduction is a timing effect, which takes the underlying in‐month improvement to £130k.

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Notes: In this analysis adverse variances are shown as a positive numberThe budget shown in this schedule is the Trust’s internal plan. The exceptional items are recorded within CCG income and financing costs

Income & Expenditure Month 09 – Directorate Positions

8

The clinical directorates variance has deteriorated from M08, most notably in Medicine FPH and Theatres, Crit Care & Anaesthetics. The position for the corporate areas has improved modestly from the previous month.

I&E by DirectorateYTD Bud

£mYTD Act

£mYTD Var

£mYTD Bud

£mYTD Act

£mYTD Var

£mYTD Bud

£mYTD Act

£mYTD Var

£mYTD Plan

YTD Total

YTD Var % Var

Directorate: ClinicalMedicine: Frimley 44.0 45.0 1.0 24.2 24.6 0.4 (1.2) (1.2) (0.0) 67.00 68.36 1.35 2.02%Medicine: Wexham 41.2 43.0 1.8 17.4 17.4 (0.0) (1.6) (1.3) 0.3 56.98 59.07 2.09 3.66%Orthopaedics & Plastics 16.9 17.5 0.6 8.7 8.1 (0.6) 0.0 (0.0) (0.0) 25.58 25.59 0.02 0.06%Paeds, Maternity & Gynae 36.0 36.1 0.2 4.3 4.7 0.4 (0.3) (0.6) (0.3) 39.93 40.19 0.27 0.66%Pathology 14.1 14.9 0.8 10.2 10.9 0.7 (3.8) (3.9) (0.1) 20.48 21.82 1.34 6.55%Private Patients 4.3 4.1 (0.1) 1.3 1.3 0.0 (8.2) (7.3) 0.9 (2.57) (1.80) 0.77 -29.89%Radiology 10.8 10.9 0.1 7.0 7.7 0.7 (0.4) (0.3) 0.1 17.40 18.31 0.91 5.26%Surgery 28.9 28.2 (0.7) 9.6 10.5 1.0 (0.9) (0.8) 0.1 37.62 37.93 0.31 0.81%Theatres, Crit Care & Anaes 34.4 35.7 1.4 9.3 9.3 (0.0) (0.1) (0.1) (0.0) 43.59 44.88 1.30 2.98%

Clinical Total 230.5 235.5 5.0 91.9 94.4 2.5 (16.4) (15.5) 0.9 306.01 314.4 8.35 2.73%Directorate: CorporateDirector of Integration 1.3 2.9 1.6 2.8 0.9 (1.9) (4.1) (3.8) 0.3 (0.00) (0.00)Finance & Strategy 10.4 10.3 (0.1) 4.1 5.9 1.8 (0.2) (1.6) (1.3) 14.24 14.66 0.42 2.94%HR & Corporate Services 20.1 20.0 (0.2) 18.4 18.8 0.4 (7.7) (6.5) 1.2 30.83 32.35 1.52 4.93%Medical Director 0.6 0.6 (0.0) 1.0 0.8 (0.3) (1.7) (1.5) 0.2 (0.00) (0.12) (0.12) 23330.12%Nursing & Quality 4.3 4.4 0.1 1.6 1.5 (0.0) (1.5) (1.6) (0.1) 4.41 4.35 (0.07) -1.53%Operations: Frimley 18.1 18.3 0.2 5.2 5.3 0.1 (1.3) (1.2) 0.1 22.05 22.43 0.38 1.74%Operations: Wexham 11.8 11.5 (0.3) 5.6 5.7 0.1 (4.8) (4.1) 0.7 12.60 13.04 0.43 3.44%

Corporate Total 66.7 68.1 1.3 38.6 38.9 0.3 (21.2) (20.3) 1.0 84.13 86.7 2.57 3.05%

CCG Income and financing cost 4.1 2.7 (1.4) 44.6 38.5 (6.1) (453.0) (456.3) (3.4) (404.30) (415.1) (10.85) 2.68%

Grand Total 301.4 306.3 4.9 175.1 171.8 (3.3) (490.6) (492.1) (1.5) (14.16) (14.1) 0.06 -0.45%

Pay Non Pay TOTAL inc Income

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Trust Overview – 2017/18 Total Savings Programme

All values in £0009

The monthly position 92.4% (93.5% last month), however the YTD position has increased from 89% to 89.4 % achievement. In the YTD position, £1.495m of CIP is classified as non‐recurrent and a further £2.374m is non cash releasing. The forecast position stands at just under 95% delivery or £1.5m shortfall by year end. Of this £3.2m will be non‐cash releasing.

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October

Actual £m

November

Actual £m

December

Actual £m

December

Plan £m

December

Variance £m

Assets, Non‐Current

Intangible Assets 4.718 4.842 4.833 1.375 3.458

Property, Plant and Equipment 334.664 337.010 340.186 381.796 (41.610)

Assets, Non‐Current, total 339.382 341.852 345.019 383.171 (38.152)

Assets, Current

Inventories 7.936 7.878 7.976 3.500 4.476

Trade and Other Receivables, Current 70.906 69.062 67.212 55.800 11.412

Cash and Cash Equivalents (excluding overdrafts) 88.878 84.593 80.953 76.718 4.235

Assets, Current, total 167.720 161.533 156.141 136.018 20.123

TOTAL ASSETS 507.102 503.385 501.160 519.189 (18.029)

Liabilities, Current

Trade and Other Payables, Current (64.030) (62.217) (57.834) (61.400) 3.566

Deferred Income, Current (22.260) (17.721) (17.206) (9.750) (7.456)

Borrowings, Current (0.287) (0.287) (0.308) (0.200) (0.108)

Provisions, Current (0.259) (0.259) (0.256) (0.400) 0.144

Liabilities, Current, total (86.836) (80.484) (75.604) (71.750) (3.854)

NET CURRENT ASSETS (LIABILITIES) 80.884 81.049 80.537 64.268 16.269

Liabilities, Non‐Current

Provisions, Non‐Current (0.051) (0.051) (0.051) (0.400) 0.349

Borrowings, Non‐Current (1.584) (1.567) (1.524) (2.000) 0.476

Liabilities, Non‐Current, total (1.635) (1.618) (1.575) (2.400) 0.825

TOTAL ASSETS EMPLOYED 418.631 421.283 423.981 445.039 (21.058)

Taxpayers' and Others' Equity

Taxpayers Equity

Public dividend capital 243.126 243.126 243.125 259.615 (16.490)

Income and expenditure reserve 64.115 66.768 69.467 62.124 7.343

Taxpayers' equity, total 307.241 309.894 312.592 321.739 (9.147)

Other Reserves

Revaluation Reserve 111.389 111.389 111.389 123.300 (11.911)

Total Equity & Reserves 418.630 421.283 423.981 445.039 (21.058)

Balance Sheet M9Key points: Frimley Health total assets employed

at 31st December 2017 are £424m. The combined assets across all 3 sites

fell by £2m to £501m, £18m lower than plan

Non‐current assets of £345m lower than plan by £34m primarily due to the b/fwd impact of the 16/17 site valuation and enhanced by the slippage in capital programme

Net current assets limited movement in month although remain high relative to plan

Current assets dropped by £5m in month due mainly to the cash balance and a slight reduction on trade and other receivables, however this was offset by a similar decrease in trade and other payables

Equity and reserves increased by £3m in month to £424m due to the net surplus in month

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Report Title FHFT Proposed Revised Board Report vs HfMA Suggested Area for Board Scrutiny



Agenda No. 8.1

Report Type

To receive assurance that the proposed shorter Board pack contains relevant and critical information to enable the Board to discharge it’s duty in relation to financial governance and accountability

Prepared By Edward John (Director of Operational Finance)

Executive Lead Nigel Foster (Director of Finance and UM&T)

Executive Summary

The revised Finance Board pack will be included in the February Board of Directors meeting. This has been reviewed by Finance Assurance Committee (FAC). In addition the pack has been reviewed against an HfMA checklist which focuses on key questions that may be helpful and relevant when discussing different aspects of financial performance by Trust Boards. The elements that may require discussion where the revised form report may fall short or where the information is not covered elsewhere are listed below alongside FAC’s opinion: 1. Include run rate expenditure info – FAC agreed this would be useful to include 2. Include BSPS summary – FAC agreed this is covered under separate governance

process and should be reported in exception only 3. Provide detail on bade debts or write offs - FAC agreed this is adequately

covered elsewhere by the Audit Committee 4. Included a summary Cash Flow Statement and cash balances over time - FAC

suggested that while cash is not an issue for the Trust this was less relevant

Background

In May 2017, the HFMA’s Governance and Audit Committee published a briefing to provide non-executive directors (NEDs) and lay members with a series of questions that could be asked when reviewing an NHS body’s annual accounts. The HfMA briefing sets out a series of questions to be asked during the year to assess the financial position of an NHS body and to identify any areas of potential concern.

8.1

Tab 8.1 FHFT Proposed Revised Board Report vs HfMA Suggested Area for Board Scrutiny


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Issues / Actions None

Recommendation

The Board are asked to accept the revised Finance Board pack as giving all necessary and appropriate information on the Trust financial performance for the needs of Trust Board.

Appendices

The revised Board pack is included within the Board papers and full comparison against the HfMA checklist was presented to FAC

8.1

Tab 8.1 FHFT Proposed Revised Board Report vs HfMA Suggested Area for Board Scrutiny


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Report Title

2017/18 CIP Summary – Month 09

Meeting

Public Board

Meeting Date


Agenda No.

9.

Report Type

Note

Prepared By

Hugh Cronshey, Associate Director of Finance

Executive Lead

Helen Coe, Director of Operations, FPHLisa Glynn, Director of Operations, HWPH

Executive Summary

Performance of CIP schemes are given in the attached paper. 1. CIP Programme Performance Month 9

At the close of month 9, the Trust delivered £20.8m against the plan of £23.2m, which is an adverse variance of ‐£2.5m and a delivery of 89.4%. The in‐month delivery was £2.5m (92.4%).

The main areas of underperformance are largely unchanged from previous months. Although Pathology is now reporting a significantly improved postion and is forecasted to deliver their target in full. Whilst this is a positive development, the CIPs appear to be largely due to efficiency rather than a reduction in the cost run rate. Offsetting this improvement, there has been a deterioration in the performance of IM&T. This is due to a review of the expenditure forecast and an adjustment to the basis of CIP calculation, which had previously included the reduction of costs charged to Integration.

2. Forecasted Outturn

The forecasted outturn has been refreshed for M09 and is showing a modest improvement from M08. The trust is reporting a delivery of £29m or 95.2% of the total savings programme.

The trust recognises that within the £29m, there are £3.2m of non‐cash releasing CIPS, mainly relating to lower High Cost Drugs. The cost of which are passed on to Commissioners and therefore benefit the wider health economy, rather than to FHFT directly. The cash releasing CIPs are forecasted to deliver

9

Tab 9 CIP Update 2017/18


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£25.8m, which is 93% of the original target for that class of CIPs.

Background

Annual Savings Programme

The Trust’s combined CIP and synergy target for 2017/18 is £30.5m.

Issues / Actions

The Trust continues to work on delivering both the core CIP schemes and

address the mitigating actions.

Focus remains on closing the 17‐18 shortfall and any opportunities that can also be carried forward into the 18‐19 plans.

Recommendation

The Board is asked to note the content of this report, progress made, and continued focus on delivery of existing schemes and ensure mitigating items are followed through to delivery.

Appendices

2017/18 CIP Summary Report – Month 09

9

Tab 9 CIP Update 2017/18


2017/18 CIP Summary Report M09December 2017

9

Tab 9 C

IP U

pdate 2017/18

143 of 184P

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Trust Overview – 2017/18 Total Savings Programme

All values in £0002

The monthly delivery of 92.4 % has improved the YTD position to 89.4%. The forecast position has also improved by 1.2% to 95.2% due to the additional mitigations and continued positive performance of original schemes. The CIP gap is now forecast at just under £1.5m by year end, an increase of £0.4m compared to month 08.

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Year to Date and Forecast Out‐turn by Directorate

The Table shows the current YTD and FOT position by Directorate with the key messages of the variances by schemes. The Pathology forecast has improved based on the analysis provided from BSPS, however it is understood that this is efficiency related rather than a reduction in the expenditure run rate. The IM&T position has deteriorated following a recalculation of expected maintenance costs.

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Cash and Non Cash Releasing CiP

Mitigations to Date

The tables show the split of cash and non cash releasing CIPs. Non cash CIPs do not fully impact on the Income and Expenditure position of the Trust and therefore we will not see the full benefits within the run rate. The current forecast predicts £504k over performance on non cash releasing schemes and £1.953m underperformance on cash releasing schemes .

As mentioned earlier, the FOT as at month 09 has improved by £2.6m (64% of original gap) compared to the month 04 FOT.

This is due to new mitigating schemes totalling £496k and improvements to earlier forecasts totalling £2,101k. The forecast variance is now £1.449m (5% overall).

4

The % shown is against the original target of £30.5m

24,000 25,000 26,000 27,000 28,000

Cash Releasing

FOT

Original CIP Plan

0 1,000 2,000 3,000 4,000

Non Cash Releasing

FOT

Original CIP Plan

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Report Title

Complaints and Patient Advice and Liaison Service (PALs) Report Q1,Q2,Q3 2017-18

Meeting

Public Board

Meeting Date


Agenda No.

10.

Report Type

For Information

Prepared By

Karen Roberts Trust Complaints Lead Alison Stevens Interim Deputy Director Nursing Wexham Park

Executive Lead

Duncan Burton Director of Nursing

Executive Summary

In summary FPH has seen a decrease of 24% in complaints in comparison to 16/17 Q1-Q3, WPH has seen an increase of 18%. WPH PALs has seen a decrease of 23% which may be due to a focus on ensuring the relevant contacts are investigated as a formal complaint. The site specific monthly complaints forums will be in place from January 2018 which will provide timely insight to the trends identified with a focus on task driven actions.

Background

As outlined in attached report.

Issues / Actions

As outlined in attached report.

Recommendation

To note the report and summary.

10

Tab 10 Frimley Health Complaints & Patient Advice and Liaison Service Half Year Report 201/2018


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Introduction

1.0 Formal Complaints HWPH and FPH Overview April-December (Q1, Q2, Q3) The Trust received a total of 687 formal complaints Trustwide in Q1-Q3 2017-18 compared to 728 in same period 2016-17. This is a decrease of 6% overall. Frimley sites experienced a 24% decrease on year and Wexham sites experienced an increase of 18% on year. Generally over the three quarters this remains within the target set of 0.07 complaints per 100 patient contacts. The chart below illustrates the numbers of complaints received for 2016-17 and 2017-18.

1.1 Complaints Received by Top 5 Directorates April-December The Directorates which received the highest numbers of complaints are outlined below; generally they are those with the highest levels of activity. In comparison to last year 16/17 the following is noted: FPH Medicine shows a 28% reduction FPH ED are identical in number WPH Medicine are in line with numbers received 16/17 WPH Maternity & Gynaecology experienced a 30% increase Frimley Sites Wexham Sites General Medicine 84 Medicine 105 Accident & Emergency 78 Maternity & Gynaecology 57 General Surgery 45 Orthopaedics & Plastics 43 Orthopaedics 31 Emergency Department 36 Specialist Surgery 18 General Surgery & Urology 34

0

10

20

30

40

50

60

70

Apr May Jun Jul Aug Sep Oct Nov Dec

FPH 16/17

FPH 17/18

WPH 16/17

WPH 17/18

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1.2 Response rates The table below outlines the % of complaints answered within 25 days

15/16 16/17 Dec-

16

Jan-

17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec-17 YTD Target Threshold

Local Surveys * Complaints

Number of complaints per

100 patient contacts 0.00 0.07 0.07 0.08 0.07 0.04 0.06 0.06 0.07 0.07 0.09 0.08 0.07 0.07 <=0.07 >0.09

% of complaints answered within 25 working days 60% 37% 46% 33% 29% 8% 47% 64% 55% 48% 42% 47% 40%

in arrears >85% <70%

Number of complaints re-opened 71 97 10 5 11 9 2 12 11 11 13 12 9 11 <=8 >9

There is no national mandated target for responding to formal complaints. In line with the “My Expectation” ethos developed by the Parliamentary Health Service Ombudsman (PHSO) the investigation should be proportionate to the concerns being raised. The Trust maintains a target of responding to complainants within 25 working days. In Q3 we have instigated logging those complaints that can achieve the 25 day target separate from those that for various reasons would not fall within that timescale. This could be due to the complaint being referred to safety colleagues to review where appropriate and may following review be managed as an SI. This may be due to us having to contact another provider/organisation for their input, for example the ambulance service, GP, social care colleagues, other hospital providing care etc. or waiting for appropriate consent if the complaint is not made by the patient. This will ensure we inform the reports in more detail in future, and greater targeted focus on those that can be achieved within the 25 day target. Agreed timescales Detailed below is the response % to those complaints that do fall within 25 days by site. FPH Q3 No Received

in Total No Outside 25 Day Target

No Responded to Within 25days

October 42 16 24 92% November 36 11 14 56% December 33 5 - - WPH Q3 No Received

in Total No Outside 25 Day Target

Responded to Within 25days

October 36 13 7 30% November 44 12 10 31% December 22 2 - -

- Data not available at time of report completion as responses are completed one month in arrears. Since September 2017 Wexham Park has had a full team, for both complaints and PALS, who have focused on inducting and training, alongside ensuring there was no backlog of complaints accrued. The team are continuing to influence staff in providing full evidenced and open responses to complaints. Where appropriate we have asked staff for further input to ensure we respond to the complaint fully, this can lead to a delay however the complainant will be updated. This is reflected in the low number referred to the PHSO. In Q4 the focus will be on ensuring that those where 25 days is achievable are monitored by the Trust complaints lead. The complaints team will ensure a timely and focused prompt to those staff who are delaying responses. At day 15 the Trust Complaints Lead will escalate to the Chief of Service and Associate Director for support

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in requesting a timely response, this will be monitored throughout Q4 with reporting on 25 day target complaints and the remainder with extended timescales agreed. Reasons for the timescale not being met will be logged and monitored. By March the trajectory is for 75-80% of the 25 day complaints to meet the target. 1.3 Reopened Complaints The reason for complaints reopening is varied. Some will reopen as soon as the response is received, others will wait some months whilst their care is on-going and write back some months later when a further outcome is known. For WPH and FPH reopens were generally within 3 months of receiving our response, the odd one has reopened over a year after the initial response. There is no theme to the complaints that reopened either by specialty or complaints coordinator however those relating to clinical care are the majority of those reopened. 1.4 PHSO FPH PHSO Referrals Q3 FPH had 1 complaint referred to the Ombudsman in Q3. This complaint relates to care provided by the GP, ambulance services and FPH. We await the outcome. We await the outcome of 3 PHSO complaints that were referred in Q1, Q2. HWPH PHSO Referrals Q3 WPH had 1 complaint referred to the Ombudsman in Q3. This complaint relates to care provided in respect of a wound infection and was initially responded to in 2016. We await the outcome of 2 PHSO complaints that were referred in Q1,Q2. 1.5 Independent reviews The Trust instigated three independent reviews with Royal Colleges in Q3; one has been completed with the initial recommendations being taken forward by the specialty lead. The complainant however has raised further concerns and these have been referred back for review to the Royal College Physicians. The second relates to care across specialties of a complex patient. The third is an orthopaedic case that the Royal College of Surgeons are reviewing in respect of an outcome of surgery. 1.6 Themes from Formal Complaints The main directorate subjects differ for both sites however the top 2 are the same with the predominant subject of clinical treatment and communication for both sites. The top four subjects remain the same each quarter for FPH and HWPH. Formal Complaints by Subject Q1,Q2,Q3 FPH WPH Clinical Treatment 187 Clinical Treatment 145 Communications 132 Communications 40 Admissions, discharges and transfers 21 Patient Care 36 Appointments including delays and cancellations 12 Values and behaviours (staff) 20

Facilities Services 2 Appointments including delays and cancellations 18

1.7 Learning from Complaints

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Some examples are included below of changes in practice as a result of formal complaints. These changes are captured from the response letters. We have trialled a new process for ensuring evidence of the change is captured. The Clinical Matron for Education was temporarily available to support a trial process for capturing evidence of the changes made; this will be evaluated in March 18. The table below highlights some examples from a range of directorates Directorate/Site

Issue Learning/Actions

WPH AMU Patient with PEG feed not managed in correct position.

Practice Development to deliver training session to ward staff on managing patients with PEG.

FPH Opthalmology

Patient referred to high risk anaesthetic clinic for review had surgery date reset prior to review

Clinical Matron advises new pathway developed within ophthalmology for high risk General Anaesthetic patient referrals to Anaesthetists

WPH ED Failure to identify elbow fracture

Training session instigated for juniors within the department to be led by the Drs that managed this patient, for their own reflection and to share the learning.

FPH Minor Ops Suite

Patient complains that was not aware that a “trainee” junior Dr would be performing the procedure.

Textbook consent took place, however Practice Development Lead is working within the Dept to produce standard operating procedure to avoid repetition.

2.0 Patient Advice and Liaison Service HWPH and FPH Overview April-December (Q1, Q2, Q3) FPH PALs managed 1058 PALs throughout Q3 compared to 1164 the previous year. This is a 9% decrease compared to 16/17. In total Q1, Q2, Q3 overall saw a 3% decrease in contacts at Frimley compared to Q1, Q2, Q3 16/17. WPH PALs in Q3 logged 486 contacts compared to 680 in the previous year. This is a decrease of 29%. This may have been influenced by the fact the focus has been on ensuring those PALs that raise more serious concerns are passed up to formal complaints to process as appropriate. In total Q1, Q2, Q3 overall saw a 23% decrease in contacts at Wexham compared to Q1, Q2, Q3 16/17. We are exploring the options for moving the Patient Liaison office to a more prominent position nearer main reception to mirror that of Frimley. This would encourage patients and service users to approach PALs whilst in the Trust.

0

100

200

300

400

Apr May Jun Jul Aug Sep Oct Nov Dec

FPH 17/18

WPH 17/18

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The 5 top directorates for PALs contacts for both sites are outlined below. The themes are similar across the Trust with Clinical Care, Appointments/Waiting Times and Communication being in the top 3 concerns raised. 2.1 Themes from PALs PALs by Directorate Q1, Q2, Q3 FPH WPH General Medicine 718 Medicine 728 General Surgery 330 Orthopaedics & Plastics 193 Specialist Surgery 300 Emergency Department 125 Accident & Emergency 234 Maternity & Gynaecology 118 No Directorate allocated 228 Estates and Facilities 96 PALs by Subject Q1, Q2, Q3 FPH WPH Clinical Care 684 Communication 475 Communication 592 Clinical Care 255 Appointments Process 459 Appointments Process 224 anything else 327 Thanks 132 Waiting Times 235 anything else 94

3. Clinical Concerns (GP/CCG) Q1, Q2, Q3 The clinical concerns management process has since 1st May 2017 been managed fully by the new GP Clinical Concerns Coordinator role based at Frimley. The GP clinical concerns email address was set up at Frimley over three years ago to receive those clinical concerns that GPs may wish to raise directly or via their CCG. Previously this was managed by PALs at Frimley and the contract department at Wexham. There is a target of 30 days to respond to clinical concerns. . The clinical concerns are investigated and managed in line with our usual complaints process and are logged on our central PALs logging system so trends and themes can be monitored. Changes to practice are logged from clinical concerns as well as complaints. These will be reported to the site specific complaints forums alongside PALs and complaints. The Trust Complaints Lead and the coordinator recently met with some of the CCG’s to ensure the process of managing the concerns is sufficient. We are assured that the process is robust and that the concerns are investigated and a response provided in a timely way. The clinical concerns email address has been used by other providers such as ambulance services, residential homes more recently and this needs to be further explored. The Q3 data for clinical concerns received is outlined below. Clinical concerns Wexham for Q3 – 35 Clinical concerns Frimley for Q3 – 52 Themes are both the same this quarter for each site: Clinical Care Wexham 19 Frimley 21 Communication Wexham 7

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Frimley 15 Discharge Wexham 3 Frimley 11 4. Summary The site specific monthly complaints forums will be in place from January 2018 which will provide timely insight to the trends identified with a focus on task driven actions. The meeting will be supported by education/practice development leads, Heads of Nursing and clinical representation. Where trends are identified representatives from the specialty will be expected. In addition complaints will now provide a focused report to the monthly performance meeting as part of the quality agenda providing current insight and noting the outcomes of the monthly complaints forums.

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Report Title

Corporate Risk Assurance Framework – January 2018

Meeting

Board of Directors (Public)

Meeting Date

February 2018

Agenda No.

11.

Report Type

To present Frimley Health NHS Foundation Trust’s high level risks to the Board of Directors

Prepared By

Debbie Barrow Governance Manager

Executive Lead

Sir Andrew Morris Chief Executive

Executive Summary

The Frimley Health Risk Assurance Framework (RAF) is the primary mechanism for high level risk management within the organisation. This report summarises the discussions regarding ‘high level’ risks facing Frimley Health NHS Foundation Trust at the January 2018 meeting of the Corporate Governance Group.

Background

Frimley Health NHS Foundation Trust is dedicated to establishing an organisational philosophy that ensures risk management is an integral part of corporate objectives, business plans and management systems. Compliance with legislative requirements is only a minimum standard. The specific function of risk management is to identify and manage risks that threaten the ability of the Trust to meet its objectives.

Issues / Actions

In this version of the RAF, There are 2 ‘extremely high’ graded and 15 ‘high’ graded identified and these are summarised in the attached paper. Four risks were regraded and two new risks identified

Recommendation

The Board of Directors is asked to note the high level risks included in the Trustwide Risk Assurance Framework

Appendices

Corporate Risk Assurance Framework – January 2018

11

Tab 11 Corporate Risk Assurance Framework


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Risk Assurance Framework - Risk Scoring Guide

Risks included in the Risk Assurance Framework (RAF) are assessed as extremely high, high, medium and low based on a Impact/Consequence x Likelihood matrix. Impact/Consequence- The descriptors below are used to score the impact/ consequence of the risk occurring. If the risk covers more than one column, the highest scoring column is used to grade the risk.

Level Descriptor Risk Type

Injury/Harm Service Delivery Financial Reputation/Publicity

1 Negligible No injuries or injury requiring no treatment or intervention

Service Disruption that does not affect patient care

Less than £10,000 Rumours

2 Minor

Minor injury or illness requiring minor intervention.

Short disruption to services affecting patient care or intermittent breach of key target

Loss of between £10,000 and £100,000

Local media coverage

< 3 days off work if staff

3 Moderate

Moderate injury requiring professional intervention

Sustained period of disruption to services/sustained breach of key target

Loss of between £101,000 and £500,000

Local media coverage with reduction in public confidence RIDDOR reportable

incident

4 Major

Major injury leading to long term incapacity requiring significant increased length of stay.

Intermittent failures in a critical service Loss of

between £501,000 and £5M

National media coverage and increased level of political/public scrutiny Total loss of public confidence

Significant underperformance of a range of key targets

5 Extreme

Incident leading to death Permanent closure/loss of a service Loss of >£5M

Long term or repeated adverse national publicity

Serious incident involving a large number of patients

Removal of Chair/CEO or exec team

High Risk Tracking Matrix

Likelihood

Consequence

Insignificant Minor Moderate Major Catastrophic

Rare

Unlikely

Possible FGK

Likely ABCDHIJLMN0 EP

Almost Certain

11

Tab 11 Corporate Risk Assurance Framework


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High Risk Summary January 2018

Chart Ref Risk Name Source

Current Score

Target Score

Score Trend

Date Risk Added C L R

Previous Month

3 months ago

6 months ago

Corporate Objective 1: Pursuing the highest level of quality, patient experience and clinical outcomes

A Staff Retention FPH/WPH 4 4 16 5 Nov-14

B Bed Capacity FPH/WPH 4 4 16 4 Jul-15

C Recognition of Deteriorating Patient FPH/WPH 4 4 16 6 Apr-15

D Critical Care Capacity FPH/WPH 4 4 16 6 Jun-15

E A&E 4-hour target FH 4 5 20 8 Sep-12

F Medical Staffing Capacity FH 5 3 15 8 Nov-12

G Management of Patients with Mental Health issues & LD FH 5 3 15 4 Oct-16

H Cardiology WPH 4 4 16 4 Jul-17

I Delays in Discharge FH 4 4 16 8 Jun-16

J Infection Control FH 4 4 16 4 Aug-17

K Access to MRI OOH for Cauda Equina Patients WPH 5 3 15 4 Sep-17

L Specialist Commissioning FH 4 4 16 8 Nov-17

M Sepsis FH 4 4 16 6 Dec-17

N 18-weeks FH 4 4 16 8 Jan-18

Corporate Objective 2: Transforming our infrastructure

N Delivery of Informatics Strategy 2017/18 FH 4 4 16 4 Apr-13

Corporate Objective 3: Developing our Staff and our Culture

O Participation in Mandatory Training & Appraisals HWP/FPH 4 4 16 4 Jan-12

Corporate Objective 4: Breaking through traditional healthcare boundaries

Corporate Objective 5: Keeping Control of Resources & Delivery Key Standards

P Failure to achieve Medium Term Financial Sustainability FH 4 5 20 4 Sep-11

Corporate Objective 6: Developing sustainable clinical services

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Risk Name Current Risk

Rating

Actions Assurance

Failure to achieve financial sustainability (FPH/HWPH)

1. Project Initiation Documents to be produced for all remaining savings schemes. 2. Quality Impact assessments to be completed for all remaining schemes. 3. Head of PMO appointed to ensure that all schemes are tracked and remedial actions developed where necessary. 4. Medium-term transformation projects to be developed. 5. CIP under achieving, over spend on medical staff but mitigation agreed to deliver £30m 6. Projected income is now above plan at £2-4m 7. CIP Board refocusing Performance Meeting around CIP delivery

• Reported to Board through Financial Assurance Committee. • Financial Assurance Committee

A&E 4-Hour Target Risk to Monitor governance rating due to failure to deliver A&E 4 hour target as per trajectory reaching 95% in March 18, potential 12-hour breaches, and pressures on bed capacity and patient flow with potential to impact ability to deliver routine and critical services, delay in patient treatment, quality of care, and patient safety..

1. Ambulatory Care Unit to open 7 days a week from Oct 17 2. Physicians now in ED at WPH 3. Establisihing GP streaming at Wexham. Alternative ESI model at FPH, awaiting sign off 4. Potential better staffing with Middle Grades (recruitment in Qatar) 5. Joint A&E Delivery Board established with STP delivery plan. North/South delivery plan in draft to support STP plan 6. Urgent Care Operational Group established on both sites with operational task and finish groups in place 7. Winter Plan signed off by Board 8. 91% admitted or discharged within 4 hours achieved in November 17, target 95% 9. Triggers document in draft with action cards 10. Managing flow in Paeds/Minors a challenge on both sites New Key Action To implement SAFER discharge bundle to improve discharge planning and length of stay where possible Commissioners to implement actions to reduce DeToC Risk reduced from 'Extremely high' to High'

• Weekly performance meetings. • Daily monitoring of breaches of A&E 4 hour target. • Daily alerts to CEO. • Performance on standard reported directly to the Board. • Reviewed by Hospital Executive Board and Quality Assurance

Committee on behalf of the Board.

Participation in Mandatory Training & Appraisals

1. Development of single metric for inclusion on Trust and divisional balanced scorecards. 2. Subject Training Leads meeting monthly 3. Hot spots and priorities identified and presented at Quality Committee, targetting shortfalls that may impact on patient safety 4. To evaluate e-learning to assess impact on training requirements 5. Monthly report with compliance and RAG status sent to all SME’s MAST group now established to include SME’s and review training on a regular basis 6. All specialities tasked with achieving 85% by 1/10/17 in high risk submect matter by CEO. 7. November 17 Currently at 76.84 % FH, further push to achieve 85% by March 18 Next Key Action All level 1 stat man training to be on micro site by 1/12/17 Focused improvement actions for November & December for Resus training in Paeds & Adults

• Board will be updated via the Trust Corporate Governance Group

• Workforce Group established which monitors management of risk, reporting into Hospital Executive Board

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Email from CEO to all senior managers including CoS, ADs & HofN to achieve ambition of 85% by end Q4

Bed Capacity Risk to patient experience due to potential for lack of sufficient bed capacity to meet demand during Winter months 15/16

1. Hospital hub for the Integrated Referral Information Service (IRIS). 2. Reviewed use of Ward 1 Heatherwood for medical long stay patients 3. Submitted bed capacity to NHSI to achieve 87% capacity for winter 4. Schemes being looked at to bridge gap including reducing LOS in ortho, ambulatory care position at 'front door' in an effort to keep conversion rate down 5. Total bed occupancy currently at 92% 6. Hale Ward at Farnham Hospital opened to support bed capacity Next Key Action To undertake bed modelling (underway) To ensure Commissioners deliver DToC & CHC assessments

• 6-monthly updates presented to BOD

Critical Care Capacity Risk of poor outcome through failure to provide sufficient flow out of ICU and to generate increased level 2 capacity outside of Critical Care, potentially impacing on flow out of A&E

1. Difficulties in recruiting to Critical Care Consultant posts at Wexham 2. New MADU at WPH live June17 3. Critical Care Strategy Meeting 21/6/17, concluded need more capacity for level 3 4. Business case to Commissioners regarding additional level 3 critical care capacity 5. New cross-site Critical Care Lead appointed for Critical Care services to lead on development on new Critical Care strategy & vision for future Next Key Action To evaluate effectiveness of new MADU on the Wexham site To review capacity on the Frimley site

• Work of Trustwide M&M Committees monitored through Quality Committee and reported to Board verbally by Medical Director

Medical Staffing Capacity Risk of inadequate, appropriately trained staff, particularly in Middle and Junior Grades in A&E and Middle Grade Surgeons and difficulty in recruiting, with potential to impact on, and cause delays to, patient diagnosis and treatment, and lead to clinic cancellations, gaps in the on-call rota, lack of immediate urgent specialty support and compromise patient care.

1. Trust-wide workforce planning exercise commencing in September 2017 2. Locum agency bookings are now centralised at FPH apart from ED and anaesthetics; their centralisation is planned for September 2017 3. There are plans to form a shared doctor bank with Ashford and St Peters, Chertsey and the Royal Surrey County Hospital, Guildford and to extend this to cover the North of the FHFT patch – a benefits paper is going to be presented at Top Team 4. There are currently rolling adverts on NHS jobs for both ED and general surgery doctors of specialty doctor level and junior doctor grade 5. IR35 having a greater impact than first envisaged due to locums withdrawing from shifts at short notice 6. Skype Interviews (Qatar) in May for junior /middle grade positions. 6 recruited for each site, 2 for each site for ED. 7. Medicine 15% more doctors in post compared with last year 8. By Q4 FPH will be in a better place but WPH remains a concern. Next Key Action: Hard to recruit posts identified and action plans in place

• Board will receive assurance via the Quality Assurance Committee.

• A Workforce Group established to monitor management of risk, reporting into the Hospital Executive Board.

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Recognition of the Deteriorating Patient Risk of poor outcome through failure to recognise a patient with a deteriorating condition. To ensure that all clinical staff have the right skills, knowledge and tools to recognise & deliver timely treatment to the deteriorating patient.

1. In depth review of recent cluster of SIs relating to deteriorating patient on Wexham site being undertaken 2. Marked improvement in Cardiac Arrest Audit, FHFT now at 30.60% against national average of 20% patients that survice a cardiac arrest in hospital and go home 3. Introduction of Adult Deteriorating patient study day with assessmnet 4alled ESCALATE (october 2017) 5. Deteriorating Patient Improvement Plan in place 6. New plan for improving compliance with mandatory training for resucitation being developed 7. Resus team now part of Patient Safety team 8. Continued improvement in compliance in Resus training stats, Adult Level 1 72.77% against target of 85% 9. 2 x Band 7 posts appointed to, one for each site Next Key Action Focus over next 6 weeks targetting compliance with Paediatric Resus training Electronic observations to be a priority as part of IT Strategy

• Work of Trustwide M&M Committees monitored through Quality Committee and reported to Board verbally by Medical Director

Cardiology Interventional Service Potential risk to patient safety and patient experience due to staffing difficulties in maintaining continuity in pPCI 24/7

1. Spike in SIs from Cardiology 2. Lookback exercise of pPCI cases since 24/7 service started, Deputy Medical Director (FPH) reviewing on behalf of Medical Director 3. Temporary staffing changes leading to reduced numbers on pPCI rota 4. External case reviewer appointed 5. Extraordinary SI Panel Meeting to be held 18th October with Commissioners & NHS England 6. 75 patient case lookback undertaken, awaiting final report, report to go to Private BOD Next Key Action FPH senior Cardiologist appointed as Cardiology lead cross-site. To review effectiveness of Clinical Governance & Morbidity & Mortality in speciality To develop common patient pathways & strategy for Cardiology Awaiting final report February 18 Interviews for additional Consultants to take place 25/1/18

• Mortality Surveillance Group

Management of Patients with Mental Health issues & Learning Disabilities Potential risk to safe management of both adults & children with mental health needs or learning disabilities, to review with mental health colleagues the increase in number and complexity of these patients

1. Specialist Simulation Training to be provided for key stakeholders including security team around accountability and duty of care when managing patients sectioned under the MHA including use of restraint 2. 'Managing Challenging Behaviour' incidents roles & responsibilities in-house awareness video being developed. On-line roll out anticipated end Q3 3. On Wexham site, plan to arrange meeting with LA leads to address lack engagement in finding placements for young people with behavioural issues admitted following DSH and deemed not to have MH issues by CAMHS 4. Mental Health post financing through STP - awaiting confirmation 5. Learning Disabilities Specialist Nurse appointment for Wexham site to be confirmed 6. Current significant issues with CAMHS service on FPH site with long term young patients with behavioural issues but no acute clinical problems and no suitable placements in the community 7. Positive proposal from Berkshire CCG around CAMHS

• Annual Report to Board of Directors

11

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8. Liaison Service at Wexham to be fully recruited to by February 18 Next Key Action Berkshire Healthcare to recruit Liaison posts for Wexham site

Infection Control Lack of engagement & compliance of staff with the Trust Hand Hygiene Policy leading to potential increased in risk of HCAIs & possible outbreaks

1. Greater clinical engagement has been requested at HICC, HEB and RCA including higher visibility of senior nursing staff within wards/depts to act as role models for junior staff 2. The Clinical Matrons' monthly audits are often carried out by junior ward/department staff 3. Evidence from Winning Ways audits are that those that attend sometimes do not feedback to their clinical areas 4. IPC Clinical Leads to re-inforce the message about hand-hygiene to clinicans at eductional half days 5. Performance in HCAIs deteriorated although incidence of CDiff increased nationally. 39 cases of CDiff as at January 18, target for year 31. MRSA at 3, CQC work on 2, EColi at 85 6. Hand hygiene compliance WPH 93%, FPH 95% Next Key Action Further revision of antibiotics but requires costing Risk rating increased further as Trust will exceed target for 17/18 Whole System action plan to be implemented

• Infection Prevention & Control meetings • Quarterly Report to Board of Directors • Trust Quality Assurance Committee

Delays in Discharge Potential risk to patients becoming unwell with hospital acquired infections, i.e. UTI, pneumonia due to delays in discharge

1. To appoint lead to manage private delays 2. 2 ED Delivery Boards focused on improving position 3. CCGs have target reductions 4. Discharge Groups established on both sites. Safer Discharge Bundle being implemented as first priority 5. IRIS planned to be launched on WPH site 11th December 2017 6. FPH delays escalated to CCGs & Social services for assistance 7. 5.6% of bed occupancy lost due to delays in transfer of care as at November 17 against target of 3.5% 8. Clinically fit list utilised daily to enable community teams to 'pull' patients from hospital to home 9. ADT & implementation of ECFD & EDD reluanched Dec 17, current uptake average of 82% Next Key Action To develop dashboard to monitor up-take of ADT

• Joint Urgent Care Delivery Board (Whole System) to HEB • Trust Monthly Performance Report to Board of Directors • Quarterly report to Trust Quality Assurance Committee

Sepsis Risk of poor outcome through failure to recognise a patient with potential sepsis

1. Training increased for all staff 2. New Sepsis bundle launched across all sites 3. Performance discussed at all cliical meetings 4. All clinical leaders aware of need to improve recognition, escalation and timely treatment of sepsis 5. Q2 CQUIN requirements partially met 6. Inpatient screening & antibiotics within 1 hour of trigger time remains a challenge

• 1. Sepsis Group in place on both sites • 2. Monitoring compliance with Sepsis Screening Tool

through quarterly audits

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7. Year to date percentage of acute inpatients screened for sepsis 35% 8. 2 band 7’s appointed to commence beginning of Jan one for each site. Next Key Action: Q3 audit in progress, initial data looks much improved Peer review for January 2018 to focus on sepsis bundle and compliance. Patient information leaflet to be developed to help patients understand sepsis. Sepsis clinician lead from WPH leaving the trust, to consider one clinical lead for FHFT to aid alignment.

Access to MRI OOH for Cauda Equina Patients Currently patients are going to Oxford as per pathway for scanning & treatment. However, there are some challenges for patients leading to potential poor patient experience

1. The change to commissioning of specialist spinal work has forced discussions regarding activity flow for spine. Discussions underway & a sector wide meeting planned for 28/4/17 2. Current staffing levels have stablised and there is a plan in place to restructure and further strengthen service 3. AVM has supported FPH support, however resistance from FPH Radiology to report on these patients overnight 4. Current process is for patients to go to St Georges although there is no contract for MRI and then returned to WPH and then on to Oxford for treatment. Services at WPH vulnerable to not haeing access to MRI from 8 p.m. to 8 a.m. Pathway to be drawn up by Chief of Service. Chief of Service and Radiology determining how out of hours MRI to be provided 5. Chief of Service pursuing St Georges solution as an interim Next Key Action Chief of Service to confirm agreement with referral pathway to St Georges and implement

• Process in place for patients to go to St Georges for Out of Hours MRI. Last MRI in Radiology at WPH is 8.00 p.m.

Specialist Commissioning Specialist Commissioning don’t recognise some of our established services. If this happens, the CCGs willnot be able to finance service

Series of meetings to Next Key Action be held with CCG to align List of services not recognised and value drawn up To review criteria and satisfy ourselves that Trust is compliant

•

18 Weeks Target The Trust failed the 18-week target for December 17. There is a risk to the Trust NHSI Quality Risk Rating should it fail the 18-week target for a 2nd consequetive month

Next Key Action Additional extraordinary meetings to monitor recovery actions put in place by Directorates

•

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Report Title SIRO January 2018 Report



Agenda No. 12.

Report Type For assurance

Prepared By Vicky Armstrong, Deputy Head of Information Governance

Executive Lead Nigel Foster, SIRO

Executive Summary

• All staff who still need to do their IG Training are receiving daily reminders, which is . There are currently 1,550 permanent staff who are outstanding.

• IG are trialling the use of iPDF as part of the MAST platform to enable staff to be able to complete their training for 2018/19.

• IG are continuing to prepare for the changes to the Data Protection Act 1998 by meeting key departments to inform them of the changes and how it may affect them and the way they process information

• The Access to Health Records Hub at Frimley has been up and running for 6 weeks and is progressing well. All requests are now being logged in a central location and on one numbering system. Staff at Frimley have access to the systems at Wexham and are able to progress with requests quickly and efficiently.

• Freedom of Information requests have fallen marginally but have increased in their complexity to answer. Key themes have been agency spend, IT spend, revenue from car parking charges and information relating to the STP

• Incident reporting has stayed consistent with more incidents being reported on the Frimley site. Current trends are staff emailing insecurely, letters being sent to the wrong patient, members of staff reviewing patient records with no legitimate need to do so

• The IG Work Programme is progressing well and the department has recently completed a major project of relocating the storage of corporate records to the new provider. This involved relocating over 20,000 boxes within 8 weeks

Background

This is the quarterly report from the Trust Senior Information Risk Owner (SIRO) to the Trust board as required by the Department of Health. The report details the 6 areas of the IG Work Programme for 2017-2018.

12

Tab 12 Senior Information Risk Owner (SIRO)


Page | 2

Issues / Actions

There has been an increase of incidents reported to the department in the last quarter, including concerns over staff accessing patient records inappropriately, staff emailing patient information insecurely and patients receiving incorrect information. The department will add details of incidents to training and quarterly Caldicott Bulletin to raise awareness. NHS Mail pilot will commence shortly, staff on the pilot have received information to support the transition to NHS Mail. However, there is still an ongoing risk of a member of staff sending patient information to someone outside of the Trust.

Recommendation None

Appendices January SIRO Report 2018

12



Page 1 of 7 January 2018 SIRO Report v1.1

Senior Information Risk Owner (SIRO) Report – January 2018 Below is a report on the third quarter of the financial year – October- December 2017 of the Information Governance Work Programme.

Data Protection Requests

To date there has been a total of 3,688 requests completed by the Access to Health Records Team across the Frimley and Wexham sites. There have been no further breaches of the legal 40 calendar day deadline since May 2017; this is entirely due to the change of working hours / shifts of the team and streamlined processes at the Frimley site. As a result of this excellent progress, and in preparation for the change in Legislation due in May 2018 (GDPR), a consultation took place in November 2017 involving the whole Access to Health Records Team (covering both the Frimley and Wexham sites). The outcome of the consultation is; that the team based at Frimley will become the main ‘Hub’, handling all of the enquiries and administration for this activity. A presence will be maintained at Wexham, functioning as a satellite office with a much smaller team, they will carry out tasks such as record pulling and copying etc. However all enquiries whether internal or from patients / members of the public, will be transferred to the ‘Hub’ to handle.

12




Freedom of Information Requests

For the financial year 2017-18, there have been a total of 485 FOI requests received. Over the last 6 years the number of FOIs has been increasing; however for the first 9 months 2017-18 this figure demonstrates a fall of 57 requests against the same 9 months last year. A large proportion of FOI’s relate to current topics or media stories; although there have been a number of requests relating to agency spend, information on the STP, revenue from car parking and IT Systems. There have been 476 responses sent since April, with only 6 taking longer than 20 working days so the Trust has a completion rate 98.8% within the 20 working days. On average, requests are being logged, processed and closed within an 11 day turnaround. Although the number of FOIs is lower for this period, their complexity continues to rise. However, the FOI Team have managed to maintain the low average number of days to respond to an FOI which was set at the end of the previous year (11 days) and have encouraged transparency with only 39 exemptions being used. During this period there has been 1 internal review and no complaints to the ICO, compared to 7 reviews this time last year.

12




IG Annual Refresher Training

Each year the Trust is required to train a minimum of 95% of staff in Information Governance. Last year, for the first time in 3 years, the Trust achieved this target. The table above shows the number of staff who have completed the training since it was first sent out in May. In total 79% of substantive staff have completed the training – this time last year 69% of staff had completed the training. Another major change was to use the same training approach for bank staff as substantive staff. Due to the data quality of the bank reports, it is not possible to determine active bank staff. Therefore training has now been sent out to all staff that could be identified on OLM and that were known to the Bank Office. In September 1,035 assessments were sent out to those identified, to date 279 (26.9%) have returned assessments to the department. These are not recorded in the table above. As we have entered the last financial quarter of the year, all outstanding staff with PolicyHub accounts have been resent the training with daily reminder emails instead of weekly reminder emails. It is hoped the additional prompts will push the compliance to 95% at a much faster rate. The training has been sent to 1475 substantive staff and 219 bank staff. In December, the Trust made the e-learning solution entitled iPDF available, this is a package that sits on the MAST (Mandatory and Statutory Training) platform and is accessible to all staff within the Trust. When a member of staff checks their training record, if they are showing as out of date then they can click on the e-learning link and be able to complete their training then and there. We have made the IG training available via this approach and so far since the 15th December, 20 people have already completed their training via this method without any advertising. We will be looking at how to utilise this approach more effectively in 2018/19.

12




IG Training of New Starters

The IG Department receives the new starters list at least 3 weeks after the completion of a month, the figures provided below document up to October 2017. At the time of this report, the November list had recently been sent to the department. Completion of IG training across the Trust for new starters is running on average about 85%, the table above reflects permanent staff only. Bank staff who are deemed to be new starters are currently running on average 52% compliance rate. There are a couple of factors which are resulting in compliance being lower than anticipated; for example, the Trust has recently agreed that any returning member of staff who has previously worked for the Trust in the last 3 years do not need to re-attend Trust Induction. For staff based at Frimley, we are able to capture them via the PC Induction process, consideration is being given to implementing the same process at Wexham but is currently dependant on the NHSMail2 project and the impact that this may have on PolicyHub. All staff that started prior to November will have now been picked up via the refresher training approach as documented above and will now be receiving daily reminders asking them to complete their training.

12




IG Work Programme

At the end of the 3rd quarter, the IG Work Programme is sat at 70% of work that has been completed. There are currently 9 pieces of work that are on hold due to extenuating factors such as, the NHSmail2 project and changes to national guidance that we are waiting on final confirmation to update procedures that are currently up for review. The department has recently concluded a major project of relocating the storage of corporate records to another provider. This was a project that included moving some 20,000 boxes and all data within an 8 week time frame.

IG Incidents

12




Incident reporting has stayed consistent into the third quarter of the financial year with staff actively reporting incidents, the gap between staff at Frimley being more likely to report an incident than Wexham staff is steadily decreasing with more Wexham staff reporting incidents this quarter. Incident trends continue to be staff insecurely or incorrectly emailing patient information, staff losing medical information offsite and patients receiving other patient’s information, there has also been an increase in staff members reviewing patient records when they do not form part of the care team of that patient. When an incident is reported it is thoroughly investigated and feedback is provided back to the member of staff, line manager and department to be used to highlight areas of concern and areas identified for improvement. This is also picked up in IG training to educate and remind staff about the importance of confidentiality and the Trust’s policies and procedures. The IG Team has also now conducted walkabouts in all patient facing areas which has identified areas of good practice and where improvements could be made. Each department audited has received feedback. The Trust has not reported a Serious Incidents Requiring Investigation (SIRI) during quarter 3. The Trust is required to report any IG incidents that meet NHS Digital’s level 2 requirements on the IG Toolkit which automatically notifies NHS Digital and the Information Commissioner’s Office (ICO).

IG Toolkit Evidence

At the end of the 3rd quarter, the evidence for the toolkit is progressing well. The Trust’s auditors have identified certain areas that this wish to audit this year and will also be looking at the Trust’s approach to the new General Data Protection Regulations that will be coming into force in May 2018. We are liaising with Information, Emergency Planning, IM&T and HR to collate evidence that is required for this year’s submission and identifying where evidence can be carried over to the revamped 2018/19 toolkit.

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Data Quality

Primary diagnosis is down across the Trust due to the impact of EDMS. The Trust has given resources to rectify this as soon as we can. The resource has helped and the primary diagnosis has risen at Frimley Park steadily. The Trust would expect to see a rise at Heatherwood and Wexham Park in the coming months as getting the resource up and running took longer.

NHS number at FHFT won't change unless NHS digital change the way that they calculate the indicator to exempt annoymised records.

Ethnic coding has risen at Frimley Park and now stands above the national average. Heatherwood and Wexham Park remain steady. Both sites are now above national average.

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Page | 1

Report Title

Annual Review of Board Effectiveness

Meeting

Public Board of Directors

Meeting Date


Agenda No.

13.

Report Type

For Completion

Prepared By

Susanne Nelson-Wehrmeyer, Company Secretary

Executive Lead

Pradip Patel, Chairman

Executive Summary

The Board reviews its effectiveness on an annual basis. The results of this exercise will also be fed into the Well-led Governance Review.

Issues / Actions

The individual members of the Board are asked to complete the attached Board Effectiveness Tool and return to the Company Secretary, Susanne Nelson Wehrmeyer, by Friday 16th February 2018.

Appendices

Board Effectivness Tool 2017/18

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Tab 13 Annual Review of Board Effectiveness


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BOARD EFFECTIVENESS TOOL 1= hardly ever/poor; 2= occasionally/below average; 3=some of the time/average; 4= most of the time/above average; 5= all of the time/fully satisfactory BEHAVIOURS NA 1 2 3 4 5 Understanding of core business All Board members have a good understanding of the different risks inherent in the hospital’s business activities

☐ ☐ ☐ ☐ ☐ ☐

Focus on appropriate areas The Board focuses on the right questions and can challenge effectively ☐ ☐ ☐ ☐ ☐ ☐

Quality of interaction with Council of Governors The Board actively engages with Governors regarding the development of the strategy, corporate objectives, performance reports and other relevant matters

☐ ☐ ☐ ☐ ☐ ☐

Quality of Board interaction with the wider organisation The Board demonstrates an effective working relationship with the wider organisation in the development of the strategy

☐ ☐ ☐ ☐ ☐ ☐

Understanding of key financial issues The Board has a good understanding of key financial issues ☐ ☐ ☐ ☐ ☐ ☐

Understanding Key Patient Safety and Quality Issues The Board assures itself that patient safety and quality issues are being addressed

☐ ☐ ☐ ☐ ☐ ☐

Rigour of debate Board meetings encourage a high quality of debate with robust and probing discussions

☐ ☐ ☐ ☐ ☐ ☐

Reaction to bad news The Board responds positively and constructively to bad news in order to encourage future transparency

☐ ☐ ☐ ☐ ☐ ☐

Quality of Chair The Chair operates satisfactorily in terms of promoting effective and efficient meetings, with an appropriate level of involvement outside of the formal meetings

☐ ☐ ☐ ☐ ☐ ☐

Frank, open working relationship between mentors Executive and Non-Executive Board members have a frank and open relationship with each other and each Director understands their own personal Board level responsibilities

☐ ☐ ☐ ☐ ☐ ☐

Open channels of communication The Board has clearly identified open channels of communication with Governors, Staff, other Members and external Stakeholders in order to improve patient care

☐ ☐ ☐ ☐ ☐ ☐

People Issues The Board has a good understanding of key people issues. ☐ ☐ ☐ ☐ ☐ ☐

Comments

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BOARD EFFECTIVENESS TOOL 1= hardly ever/poor; 2= occasionally/below average; 3=some of the time/average; 4= most of the time/above average; 5= all of the time/fully satisfactory PROCESSES NA 1 2 3 4 5 Directors with appropriate skills and experience The Board comprises members with an appropriate mix of skills and experience to deliver the purpose of the Trust

☐ ☐ ☐ ☐ ☐ ☐

Role of the Board Board Members are clear on the role of the Board as a whole ☐ ☐ ☐ ☐ ☐ ☐

Clear Governance Structure The Board is clear as to its role in relation to Governance across the Trust ☐ ☐ ☐ ☐ ☐ ☐

Structured and appropriate monthly agenda There is a structured monthly agenda of matters to be covered with focus on the right areas

☐ ☐ ☐ ☐ ☐ ☐

Sufficient number of meetings and access to resources The number and length of meetings and access to resources is sufficient to allow the Board to fully discharge its duties

☐ ☐ ☐ ☐ ☐ ☐

Concise, relevant and timely information Board papers are concise, relevant and timely and are received sufficiently far in advance of meetings

☐ ☐ ☐ ☐ ☐ ☐

Right people invited to attend and present at meetings Clinicians, Managers and others are asked to present on topics, as appropriate

☐ ☐ ☐ ☐ ☐ ☐

Sub-Committee Meetings Sub-Committee meetings are fulfilling the appropriate assurance role ☐ ☐ ☐ ☐ ☐ ☐

Attendance and contribution at meetings All Board members attend and actively contribute at meetings ☐ ☐ ☐ ☐ ☐ ☐

On-going personal development to remain up to date Board members undertake on-going personal development activities to update their skills and knowledge

☐ ☐ ☐ ☐ ☐ ☐

Comments

13



Report Title Summary report from the Performance & Remuneration Committee held on Friday 12th January 2018

Meeting

Board of Directors

Meeting Date

Friday 2nd February 2018

Agenda No.

14.1

Report Type

For information

Prepared By

Susanne Nelson-Wehrmeyer, Company Secretary

Executive Lead

Dawn Kenson, Senior Independent Director and Non-Executive Director

Executive Summary

The PRC met on Friday 12th January. The items it considered include the following:

1. The format of the Chairman’s and Directors appraisals 2. The format of Governor questions on board performance 3. Questions for the Directors and Governors on the Chairman’s

performance With regard to organisational development, it also considered:

• The draft Trust workforce plan • The Workforce Committee annual review and terms of reference • The People strategy • The Leadership development strategy

For Board renewal and effectiveness, the Chairman indicated that board development would be considered by the Board during its May Away Days when the new chief executive was in post. There were some standard items with regard to Board effectiveness that the committee also reviewed and this included;

• Reviewing and amending the format of the PRC and Board effectiveness tools

• Reviewing the last annual CoG feedback • Reviewing the progress in succession planning for senior

management

14.1

Tab 14.1 Performance & Remuneration Committee, 12th January


The Committee also confirmed an e-governance decision taken to confirm the salary and terms and conditions for the new chief executive and also reviewed the draft contract of employment for this post. Finally, the Committee designated the Deputy Chief Executive as the interim or acting chief executive and accounting officer for the period of time between Andrew Morris’ departure and the formal commencement of Neil Dardis as the chief executive for Frimley Health NHS Foundation Trust.

Recommendation

To note

Appendices

None

14.1

Tab 14.1 Performance & Remuneration Committee, 12th January


Page | 1

Report Title

Update Summary from the Commercial Development and Investment Committee (CDIC)

Meeting

Public Board

Meeting Date


Agenda No.

14.2

Report Type

Information

Prepared By

Mark Escolme, Chairman and Kevin Jacob, Asst. Company Secretary

Executive Lead

Janet King, Director of Human Resources and Corporate Services

Executive Summary

This report briefs the Board on the main items discussed at the 23rd January meeting of the Commercial Development and Investment Committee.

Background

1. Proposed extension to Community Services Contract (previously held by

Southern Health NHS Foundation Trust The Committee considered a proposal that the Trust extend its contract with North East Hants and Farnham Clinical Commission Group for the delivery of community services in north east Hampshire until 31st March 2019. 2. Maternity Backlog Refurbishment Scheme – First Floor Wexham Park (Ward 22) The Committee considered a report seeking approval to carry out backlog maintenance work to Ward 22 as identified in the condition element of the three facet survey completed in 2015, in respect of maternity facilities at Wexham Park Hospital. The work proposed had been designed to complement the recently completed women’s services department scheme and comprised the replacement of building services (lighting, power, etc.); redecoration of the internal fabric; replacement of selected floor coverings, the replacement of windows, and the provision of new bed head services. In addition, a number of service improvements to the patient testing and breastfeeding rooms and drug storage are proposed. The Committee approved the request. 3. Ground Floor Streets – Frimley Park Hospital The Committee considered a report seeking approval of a main contractor to carry

14.2

Tab 14.2 Commercial Development & Investment Committee, 23rd January


Page | 2

out the refurbishment of the ground floor corridors, (main streets) at Frimley Park Hospital. The Committee approved the award of the tender as specified in the report subject to a number of clarifications. 4. Heatherwood Redevelopment Project Update The Committee considered a paper providing an update on risks and mitigations associated with the project.

Recommendation

This Board is asked to note the issues highlighted in the reports and agree any further action as required.

14.2

Tab 14.2 Commercial Development & Investment Committee, 23rd January


Page 1 of 3

Report Title Summary minutes for FAC 26th January 2018

Meeting

Public board meeting

Meeting Date

2nd February 2018

Agenda No.

14.3

Report Type

For Information

Prepared By

Rob Pike, Chair of FAC and Susanne Nelson-Wehrmeyer, Company Secretary

Executive Lead

Nigel Foster, Director of Finance

Executive Summary

This report briefs the Board on the main items discussed at the 26th January 2018 meeting of the Finance Assurance Committee.

Background

Update on M9 Finances The committee considered and discussed the M9 finance report –incl. in-year cash and capital position. The headline messages are:-

• The pre STF position is ahead of plan • The number of un-coded spells had reduced but still represented a

challenge • Pay and non Pay were both overspent albeit agency and bank had

improved on prior months • The month 9 STF monies had been accrued because the ytd position

had been bolstered by the stock adjustment and winter pressures money.

• There has been good progress in negotiating year end agreements with commissioners

The underlying position and forecast • The underlying position is still some £7m worse than plan • The year end numbers presented had assumed that Q4 STF monies

would be achieved but AVM indicated that he thought it unlikely that the A & E 4 hr target could be achieved making it unlikely that STF would be paid in full.

14.3

Tab 14.3 Finance Assurance Committee Meeting, 26th January


Page 2 of 3

• The cash releasing CIP’s are now forecast to deliver 94/95% by year end

• There was much discussion about the year end position and although there are still significant risks there is a belief that we will “get over the line”

Capital expenditure remains significantly behind plan and is forecast to remain so at the year end. Consequently the cash position will remain very healthy for the foreseeable future. Proposed finance report for Board The committee had been given a briefing paper produced by the HFMA’s Governance and Audit committee which was drawn up to guide NED’s on how to review and scrutinise a Trust’s numbers. The finance team had used these guidelines to produce a proposed short version of a finance report for Board which the committee then discussed. One or two additional items, such as run rates numbers have been suggested and it is now proposed that an amended short form report will be trialled. Planning for 2018/19 and Medium Term Financial Plan Planning Guidance for 2018/19 was not available at the time of the meeting although it was imminent. NF is anticipating that it will provide clarity on how the additional money (nationally £1.6bn) from November’s budget might be distributed. Refreshed FHFT 5-Year Plan and Cash Forecasts including impact of major capital programme schemes The committee rec’d a report which had modelled three scenarios

• Best case which assumed full delivery of CIPs and then two scenarios with lesser CIP delivery.

• AVM and the committee considers it prudent to maintain a cash position of £50m minimum (circa one months expenditure).

• The five year plan indicates that this will only be achieved if CIP’s are delivered in full and are cash releasing.

• Failure to deliver fully on CIP’s will inevitably mean we could not afford to do the full range of schemes coming before CDIC and that some form of rationing or delay would be needed.

Review CIP 2018/19 A full review of the 2018/9 CIP’s was deferred to the next meeting as the Directors of Operation were unable to attend the January meeting.

14.3



Page 3 of 3

Issues/Actions

Recommendation

This Board is asked to note the report and any issues highlighted.

Appendices

NA

14.3



Page 1 of 4

ACRONYMS BUSTER

A A&E - Accident and Emergency ACS - Accountable Care System AD - Associate Director ADT - Admission, Discharge and Transfer AfC - Agenda for Change AGM - Annual General Meeting / Annual Governance Meeting AHP - Advanced Health Professional AKI - Acute Kidney Injury AMM - Annual Members Meeting AMR - Antimicrobial Resistance AMU - Acute Medical Unit AOS - Acute Oncology Service ANP - Advanced Nurse Practitioner AR - Annual Report ASPH - Ashford and St. Peter’s Hospital

B BAU - Business As Usual BBE - Bare Below Elbow BME - Black and Minority Ethnic BCF - Better Care Fund BMA - British Medical Association BMI - Body Mass Index BoD - Board of Directors

C CAMHS - Child and Adolescent Mental Health Services CAS - Central Alert System CAU - Clinical Assessment Unit CCG - Clinical Commissioning Group CCU - Coronary Care Unit CDI - Clostridium Difficile Infection CDIC - Commercial Development and Investment Committee Cdif / C.Diff - Clostridium Difficile CEA - Clinical Excellence Awards CEO - Chief Executive Officer CFO - Chief Finance Officer CHC - Continuing Health Care

CHD - Coronary Heart Disease CIO - Chief Information Officer CIP - Continuous Improvement Plan CoG - Council of Governors CoS - Chief of Service CoSec - Company Secretary CoSRR - Continuity of Service Risk Rating CPA - Care Programme Approach CQC - Care Quality Commission CQUIN - Commissioning for Quality and Innovation CRAB - Copeland’s Risk Adjusted Barometer C.Section - Caesarean Section CSU - Commissioning Support Unit CT - Computerised Tomography CTG - Cardiotocography CVC - Central Venous Catheter

D DBS - Disclosure Barring Service DGH - District General Hospital DH / DoH - Department of Health DIPC - Director of Infection Prevention and Control DNA - Did Not Attend DNACPR - Do Not Attempt Cardiopulmonary Resuscitation DNAR - Do Not Attempt Resuscitation DNR - Do Not Resuscitate DoLS - Deprivation of Liberty Safeguards DoN - Director of Nursing DoO - Director of Operations DPA - Data Protection Act DSU - Day Surgery Unit DVT - Deep Vein Thrombosis

E E&D - Equality and Diversity EAU - Emergency Assessment Unit EBITDA - Earnings Before Interest, Taxes, Depreciation and Amortization ECG - Electrocardiogram ECIST - Emergency Care Intensive Support Team ED - Emergency Department EDD - Estimated Date of Discharge EDMS - Electronic Document Management System

Acronyms Buster


Page 2 of 4

EEG- Electroencephalogram EHR - Electronic Health Record EHRC - Equality and Human Rights Commission EIA - Equality Impact Assessment ELSCS - Elective Caesarean Section EM - Emergency Medicine EMLSCS - Emergency Caesarean Section ENT - Ear, Nose and Throat EOLC - End of Life Care EOLCA - End of Life Care Audit EPR - Electronic Patient Record EPRR - Emergency Preparedness, Resilience and Response ESD - Early Supported Discharge ESR - Electronic Staff Record ETP - Electronic Transmission of Prescriptions EEA - European Economic Area

F FAC - Finance Assurance Committee FBC - Full Business Case FFT - Friends and Family Test FH - Frimley Health FHFT - Frimley Health NHS Foundation Trust FOI - Freedom of Information FPH - Frimley Park Hospital FRR - Financial Risk Rating FT - Foundation Trust FTE - Full Time Equivalent FYE - Financial Year End

G GI - Gastrointestinal GMC - General Medical Council GMS - General Medical Services GP - General Practitioner GRE – Glycopeptide Resistant Enterococci

H HAI - Hospital Acquired Infection HASU - Hyper Acute Stroke Unit HCA - Health Care Assistant HCAI - Healthcare-Associated Infection HDU - High Dependency Unit

HEB - Hospital Executive Board HED - Healthcare Evaluation Data HEKSS - Health Education Kent, Surrey and Sussex HETV - Health Education Thames Valley HH - Heatherwood Hospital HICC - Hospital Infection Control Committee HoN - Head of Nursing HR - Human Resources HSE - Health and Safety Executive HSMR - Hospital Standardised Mortality Ratio HTC - Hospital Transfusion Committee HWB - Health and Wellbeing Board HWD - Heatherwood HWP - Heatherwood and Wexham Park HWPH / H&WPH - Heatherwood and Wexham Park Hospitals

I I&E - Income and Equity IC - Information Commissioner ICM - Integrated Case Management ICP - Integrated Care Pathway ICU - Intensive Care Unit IG - Information Governance IGT / IGTK - Information Governance Toolkit IM&T - Information Management and Technology IPCN - Infection Prevention and Control Nurse IPCT - Infection Prevention and Control Team IPR - Individual Performance Review ITU - Intensive Therapy Unit / Critical Care Unit IV - Intravenous

J JAG - Joint Advisory Group

K KPI - Key Performance Indicator

L LA - Local Authority LCFS - Local Counter Fraud Specialist LD - Learning Disability

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LHRP - Local Health Resilience Partnership LiA - Listening into Action LINAC - Linear Accelerator LOS / LoS - Length of Stay LUCADA - Lung Cancer Audit Data

M M&M - Morbidity and Mortality MAU - Medical Assessment Unit MDT - Multi-Disciplinary Team MHPS - Maintaining High Professional Standards MIDU - Medical Investigations Day Unit MiG - Medical Interoperability MIU - Minor Injuries Unit MRI - Magnetic Resonance Imaging MRSA - Methicillin-Resistant Staphylococcus Aureus

N NBOCAP - National Bowel Cancer Audit Programme NCASP - National Clinical Audit Support Programme NED - Non-Executive Director NEH&F - North East Hants and Farnham NHS - National Health Service NHS FT - NHS Foundation Trust NHSE - NHS England NHSI - NHS Improvements (formerly Monitor) NHSLA - NHS Litigation Authority NHSP - NHS Professional NICE - National Institute for Health and Care Excellence NICU - Neonatal Intensive Care Unit NMC - Nursing and Midwifery Council NNU - Neonatal Unit NOGCA - National Oesophago-Gastric Cancer Audit NRLS - National Reporting and Learning System / Service

O O&G - Obstetrics and Gynaecology OBC - Outline Business Case ODP - Operating Department Practitioner OHD - Occupational Health Department OLM - Oracle Learning Management OOH - Out of Hours

OP - Outpatient OPD - Outpatient Department OSCE support - Observed Structured Clinical Exam OT - Occupational Therapist/Therapy

P PACS - Picture Archiving and Communications System PACU - Post-Anesthetic Care Unit PALS - Patient Advice and Liaison Service PAS - Patient Administration System PAU - Paediatric Assessment Unit PbR - Payment by Results PCI - Percutaneous Coronary Intervention PD - Practice Development PDC - Public Dividend Capital PDD - Predicted Date of Discharge PE - Pulmonary Embolism PEAT - Patient Environment Action Team PFI - Private Finance Initiative PHE - Public Health England PICC - Peripherally Inserted Central Catheters PID - Patient / Person Identifiable Data PILS - Patient Information Leaflets PID - Project Initiation Document PLACE - Patient-Led Assessments of the Care Environment PMS - Personal Medical Services PMO - Programme Management Office POD - Pre-Operative Department POSSUM - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity PPE - Personal Protective Equipment PPI - Patient and Public Involvement PSED - Public Sector Equality Duty

Q QA - Quality Assurance QAC - Quality Assurance Committee QI - Quality Indicator QIP - Quality Improvement Plan QIPP - Quality, Innovation, Productivity and Prevention QIA - Quality Impact Assessment QOF - Quality and Outcomes Framework

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R RAF - Risk Assurance Framework RAG - Red Amber Green RBH - Royal Berkshire Hospital RCA - Root Cause Analysis RCN - Royal College of Nursing RCP - Royal College of Physicians RCS - Royal College of Surgeons RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RN - Registered Nurse RSCH - Royal Surrey County Hospital RTT - Referral to Treatment

S SADU - Surgical Day Unit SAU - Surgical Assessment Unit (FPH) / Surgical Assessment Unit (WPH) SCAS / SCAmb - South Central Ambulance Service SCT - System Control Total SDIP - Service Development and Improvement Plan SECAMB - South East Coast Ambulance Service SH - Surrey Heath SHMI - Summary Hospital-level Mortality Indicator SHO - Senior House Officer SI - Serious Incident SIRI - Serious Incident Requiring Investigation SIRO - Serious Incident Risk Owner SID - Senior Independent Director SLA - Service Level Agreement SLR - Service-Line Reporting SLT / SaLT - Speech and Language Therapy SME - Subject Matter Expert SMR - Standardised Mortality Ratio SoS - Secretary of State SPS - Surrey Pathology Service SSI(S) - Surgical Site Infections (Surveillance) SSNAP - Sentinel Stroke National Audit Programme SSS - Short Stay Surgical Unity STF - Sustainability and Transformation Funding STP - Sustainability and Transformation Plan SUI - Serious Untoward Incident

T TACC - Theatres and Critical Care directorate TIA - Transient Ischaemic Attack TLC - Turn off, Lights out, Close doors TMG - Theatre Management Group TNA - Training Needs Analysis TPN - Total Parenteral Nutrition TTA - To Take Away TTO - To Take Out TUPE - Transfer of Undertakings (Protection of Employment) Regulations 1981

U UCB - Urgent Care Board UI - Untoward Incident UGI - Upper Gastrointestinal UTI - Urinary Tract Infection

V VfM - Value for Money VSM - Very Senior Manager VTE - Venous Thromboembolism

W WAM - Windsor and Maidenhead WHO - World Health Organization WLI - Waiting List Initiative WPH - Wexham Park Hospital WTE - Whole Time Equivalent

Y YTD - Year to Date

Acronyms Buster
