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BOARD OF DIRECTORS A meeting of the Board of Directors will take place on

Thursday, 4 June 2015 at 9.30 am in Lecture Hall 2, The Academy, Great Western Hospital, Swindon

A G E N D A

Our Vision Working together with our partners in health and social care we will deliver

accessible, personalised and integrated services for local people. We will provide high quality care whether at home, in the community or in hospital empowering

people to lead independent and healthier lives

Our Strategic objectives 1. To deliver consistently high quality, safe services which deliver desired patient

outcomes 2. To improve the patient and carer experience for every aspect of care we deliver 3. To ensure that staff are proud to work at the Trust and would recommend the Trust

as a place of work or receive treatment 4. To secure the long term financial health of the Trust 5. To adopt new approaches and innovation so that we improve services as healthcare

changes whilst continuing to become more efficient 6. To work in partnership with other so that we provide seamless care for patients

Our strategic priorities

Integrated Care - We will make the patient the centre of everything we do Transformation Cost Efficiency - We will work smarter not harder to make best use of

limited resources Service Innovation - We will innovate and identify new ways of working

Building Capacity - We will build capacity and capability by investing in our staff, infrastructure and partnerships

A large print version of this agenda is available by request. Please contact Deborah Rawlings by email

[email protected] or by telephone 01793 604179 Please note that this meeting will be held in a wheelchair accessible venue. If you would like to attend and have any special access requirements, please let Deborah Rawlings know beforehand and she will do her best to meet your requirements.

The Great Western Hospital, Marlborough Road, Swindon, SN3 6BB

mailto:[email protected]

BOARD OF DIRECTORS

A meeting of the Board of Directors will take place on Thursday, 4 June 2015 at 9.30 am

in Lecture Hall 2, The Academy, Great Western Hospital, Swindon

A G E N D A Matters Open to the Public and Press

1 Apologies for Absence and Chairman's Welcome

2 Declarations of Interest

Members are reminded of their obligation to declare any interest they may have in any issue arising at the meeting, which might conflict with the business of the Trust.

3 Questions from the public to the Board relating to the work of the Trust

4 Minutes (Pages 1 - 14) Roger Hill, Chairman

30 April 2015 (public and summary of private minutes)

11 May 2015 (public minutes of extraordinary meeting)

5 Outstanding actions of the Board (public) (Pages 15 - 16)

6 Chairman's Report, Feedback from the Council of Governors Roger Hill, Chairman

7 Chief Executive's Report (Pages 17 - 20) Nerissa Vaughan, Chief Executive

LONG TERM FINANCIAL HEALTH 8 Finance Report for Month 1 (Pages 21 - 36)

Karen Johnson, Acting Director of Finance

SAFE SERVICES 9 Quality Report (Pages 37 - 88)

Hilary Walker, Chief Nurse

10 Quality Improvement Strategy - 2014/15 Key Performance Indicators Update (Pages 89 - 100) Hilary Walker, Chief Nurse

11 Operational Performance Report (Pages 101 - 114) Linda Power, Deputy Chief Operating Officer

12 End of Life Strategy and update on progress (Pages 115 - 128) Guy Rooney, Medical Director

13 Nursing Together - A strategy for improving patient care - progress report (Pages 129 - 134) Hilary Walker, Chief Nurse

PATIENT AND CARER EXPERIENCE 14 Safer Staffing Monthly Report (Pages 135 - 140)


15 Nursing & Midwifery Revalidation (Pages 141 - 148) Hilary Walker, Chief Nurse

OTHER 16 To ratify decisions as per Board Circular dated 28 May 2015

Carole Nicholl, Company Secretary & Head of Corporate Governance

To approve the Refreshed Powers Reserved to the Board, Scheme of Delegation and Terms of Reference of Board Committees

To approve the Development and Management of Policies and Procedural Documents (the ‘Policy on Policies’) – Recommendation on Policy Change

17 Urgent Public Business (if any)

To consider any business which the Chairman has agreed should be considered as an item of urgent business and to note the reasons for the urgency.

18 Date and Time of next meeting Date: Thursday 2 July 2015 Time: 9.30am Venue: Lecture Hall 2, The Academy

19 Exclusion of the Public and Press The Board is asked to resolve:- “that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest” when the following items are considered: -

Minutes

Transformation Update

Wiltshire Health and Care Update

Final Annual Report, Quality Accounts and Audited Accounts 2014/15

ECIST Update and Assurance Report

Referral to Treatment Improvement Plan

4 Hour Emergency Department Access Standard Update

Management of Carillion

Audit, Risk and Assurance Committee Minutes

Executive Committee Minutes

Finance, Investment and Performance Committee Minutes

Governance Committee Minutes

People Strategy Minutes

Remuneration Committee Minutes

Urgent Private Business (if any)

Roger Hill Trust Chairman, Great Western Hospitals NHS Foundation Trust 28 May 2015

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MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS HELD IN PUBLIC ON 30 APRIL 2015, AT 2.00PM

IN LECTURE HALL 1, GREAT WESTERN HOSPITAL SWINDON

Present Members Angela Gillibrand (AG) Deputy Chairman & Non-Executive Director Robert Burns (RB) Non-Executive Director Liam Coleman (LC) Non-Executive Director Oonagh Fitzgerald (OF) Director of Workforce & Education Karen Johnson (KJ) Acting Deputy Director of Finance Michelle Kemp (MK) Chief Operating Officer Jemima Milton (JM) Non-Executive Director Steve Nowell (SN) Non-Executive Director Guy Rooney (GR) Medical Director Julie Soutter (JS) Non-Executive Director Nerissa Vaughan (NV) Chief Executive Hilary Walker (HW) Chief Nurse Non-Voting Board Members Douglas Blair (DB) Director of Community Services Kevin McNamara (KM) Director of Strategy Also in attendance Deborah Rawlings Minute Taker Matters Open to the Public and Press

Minute Description Action by

whom

Action by

when

1/15 Apologies for Absence and Chairman’s Welcome Apologies for absence were recorded from Roger Hill, Chairman and Carole Nicholl, Company Secretary & Head of Corporate Governance.

2/15 Declarations of Interest None.

3/15 Questions from the public to the Board relating to the work of the Trust There were no questions form members of the public.

4/15 Minutes Minute 313/14 – Finance Report for Month 11 – Number (a) Deletion of “£6.6m” and substitute with “£7.6m” after “that it be agreed that the Month 11 financial position is an underachievement of…” Minute 314/14 – Quality Report – Clinical Incidents – After “JM raised concern at a serious incident…” deletion of the word “which”. Minute 314/14 – Quality Report – Whistleblowing – Addition of the words “a specialty sub-department for ENT within” before “the Royal College of Surgeons”. Minute 315/15 – Operational Performance Report – Admitted backlog over 18 weeks – Addition of the word “admitted” before the words “backlog would be significantly reduced before 500 by the end of March.”

5/15 Outstanding actions of the Board (public)

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Agenda Item 4

The Board received a list of outstanding actions arising from previous meetings and updates were noted.

6/15 Chairman’s Report, Feedback from the Council of Governors In the absence of RH, AG reported that both the Finance Report for Month 11 and Quality Report had been presented to the Council of Governors at their meeting on 16 April 2015. AG also confirmed that the Council of Governors had also approved the re-appointment of Robert Burns as Non-Executive Director for a further one year term and Liam Coleman as Non-Executive Director for a further three year term.

7/15 Chief Executive’s Report The Board received and considered a report from the Chief Executive on the following: -

Working with Monitor to improve our financial position

Trust shortlisted for national patient safety award

WiFi comes to GWH

Refurbished Minor Injuries Unit at Chippenham Community Hospital opens

New sexual health walk-in service trialled at GWH

Successful recruitment day for theatres NV also reported that a meeting with Monitor had taken place earlier in the day and that an action plan with key performance indicators would be developed to provide assurance that plans were in place to improve the Trust’s financial performance, sustainability and governance. Progress on this action would be reported directly to the Board for monitoring against this plan. RESOLVED that the report be noted.

-

-

8/15 Finance Report for Month 12 The Board received and considered the Finance Report which advised that: -

The position in March was an actual year to date operating deficit of £8.6m compared to a target surplus of £1.2m, giving an adverse variance of £9.8m from plan for the year. This was now being scrutinised by Monitor.

The cash balance was £2.1m which was £1.4m below plan.

The Trust had a Continuity of Service Risk Rating of 1. KJ reported that the Trust had closed contracts at year end at £6.4m above plan. Also the Gloucester MRET had been successfully renegotiated and as such peripheral contracts finished the year significantly above plan. KJ highlighted that outpatient activity was 714 spells down on 2013/14 and 167 spells below plan. She had asked the Informatics Team to undertake a deep dive exercise into inpatient activity and to determine that all information activity was being recorded on Medway and to challenge any activity information that had not been. It was noted that the Trust was currently showing vacancies of 4.6%, equivalent to 213 wte (4.5% and 209 wte in the previous month). OF commented that the downward trajectory had highlighted the need to reduce agency but was also to report that favourable steps had been made on e-rostering costs which had now been included in budgets. JS raised a query that creditors was £13.8m above plan and our performance against the requirement to pay creditors by 30 days. KJ responded that the current

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performance rate was 30% and that steps were being taken to improve this. She added that a new legislation had been introduced to pay creditors within 30 days and that a penalty could be incurred for non-achievement of this. An assumption around creditors would have an impact on our borrowing requirements. It was noted that the cash position was £2.1m which was £1.4m below plan. KJ reported that Deloitte had been commissioned to review our working capital and this had included a challenge on the Trust to monitor debtors and that Deloitte were confident that we could maintain this. A diagnostic test on stock would also be carried out. RESOLVED (a) that it be agreed that the Month 12 financial position is an

underachievement of £9.8m; and (b) that it be agreed that the current Continuity of Service Risk Rating is a 1.

- -

- -

9/15 Monitor Quarter 4 2014/15 Submission The Board received and considered a paper which reminded the Board that it was required to make in year declarations certifying on going compliance with the Trust’s Terms of Authorisation covering Finance, Governance and other exceptional items. It was noted that the Quality Declaration was now made to Monitor on an annual basis. The paper provided an overview of performance against these requirements for Quarter 4. (a) The Continuity of Service Risk Rating (CoSRR) was 1 as forecasted; (b) The Trust had not achieved the performance target for A&E in Q4; (c) The Trust had not achieved performance targets for RTT in Q4; (d) The Trust had not achieved the performance target which related to access to

healthcare for patients with a Learning Disability in Q4; (e) The Trust reported a Never Event that had occurred in March 2015 to Monitor; (f) There were no exceptional matters that had occurred in Q4 that required

reporting to Monitor which had not already been reported. It was noted that the Risk Assessment Framework (RAF) indicates that by having 4 or more metrics in breach in a quarter or the A&E target to be breached in any 2 quarters of any 4 quarter period, would represent a governance concern that may require further investigation by Monitor. MK reported that a detailed action plan to address performances and ensure compliance with the 4 hour target had been implemented. However MK informed the Board that it was anticipated that the ED recovery would not improve in Q1 and that the 95% target would start to be achieved from June onwards. MK also added that the three RTT targets that had not been achieved in Q4 was not expected to recover in Q1. Further validation work was being carried out and a RTT recruitment plan had been commenced. RTT improvement plans were currently with the CCGs for consultation and that these plans would be presented to the Strategic System Resilience Group meeting in June. It was noted that a new target for 2014/15 had been introduced on access to healthcare for people with a learning disability with six indicators for meeting the needs of people with a learning disability. HW was able to provide assurance to the Board that four of the six indicators had been met and that the Trust would be expected to the fully compliant with all six standards by Q1 2015/16. NV added that she was confident that plans would be in place to support this new target. The Board was satisfied that plans were being developed to be approved by the Board at its May meeting and that the RTT plan will be reviewed by the Executive

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Committee and the Finance, Investment & Performance Committee in May. It was also requested that the ED recovery plan should also include gaps identified by the ECIST recommendations.

RESOLVED

(a) that the Chief Executive and Acting Director of Finance sign the in-year

governance statement on behalf of the Board of Directors confirming:-

1. The Board is unable to confirm that it anticipates that the Trust will continue to maintain a continuity of service risk rating of at least 3 over the next 12 months;

2. The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 21 diagram 6) which have not already been reported.

(b) that having discussed the performance against the A&E 4 hour target

(87.3% year to date against a target of 95%), performance against the RTT target (Admitted 83.2% against a target of 90%; Non-Admitted 89.2% against a target of 95%; Incomplete 84.9% against a target of 92%); performance against access to healthcare for people with a learning disability and the actions being taken to recover the position, the Chief Executive and Acting Director of Finance sign the following statement on behalf of the Board: -

3. The Board is satisfied that a plan for RTT and A&E performance will be presented and implemented in May 2015.

- -

- -

10/15 Quality Report The Board received and considered a report which provided commentary and progress on activity associated with key safety and quality indicators. The key points to note were as follows: - Effective

The Hospital Standard Mortality Rate (HSMR) for December 2014 was 85.47, a decrease from the previous month.

GR highlighted that the Trust was still below 100 with the April 2014 to December 2014 relative risk of 86.92, while the rolling twelve month period of January 2014 to December 2014 was 90.06, and that the Trust was well within the lower quarter of the group, showing the continuing trend of improvement when compared to previous months. Dr Foster also produces a number of indicators to measure quality of service. JM raised a query on the on the number of deaths reported after surgery at 298 and GR agreed to check on the detail behind this data. Safe

There were 3 cases of Clostridium difficile reported in March. The Trust completed the financial year 9 cases below its trajectory of 28.

There was one case of MRSA Bacteraemia for March attributed to the Trust.

There was one Never Event reported in March under the classification of ‘Retained Foreign Body’.

There were 17 serious incidents reported by the Trust in March.

The number of IR1s overdue (by more than 14 days) had reduced from 377 to 326.

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The acute setting had seen a sustained reduction in the number of falls per 1000 bed days and in March there was 4.28 falls per 1000 bed days which was below the national average of 5.5 falls.

Infection Prevention & Control – The Trust had reported 19 C.diff cases for the financial year which was below its trajectory of 28. As no cases had been reported in January and February and 3 cases reported in March, work was being undertaken to address this rise and preventative actions being taken following a rise in the community. Cleanliness – It was noted that the cleaning scores for March were 95.2% overall and that maintaining weekly scores of 95% or above for wards had remained a challenge and was not being achieved in all areas. Revised action plans had been shared with the Trust by Carillion and HW said that she would continue to work with Carillion to implement and sustain the improvement plan. Never Events – There were 17 serious incidents reported by the Trust in March. Due to the increased rate of serious incidents, the Executive Committee had agreed that further analysis was required. Outcomes of this will be provided in the May report. Caring

134 concerns were received and resolved by the PALS team within timeframe.

High to extreme complaints was at 11 for March and low to moderate complaints had seen an increase to 97.

One new complaint case had been taken on by the Parliamentary Health Service Ombudsman (PHSO) in March.

There had been further improvements in Friends and Family Test (FFT), with the Emergency Department achieving an 18.5% increase and Acute Inpatients achieving a 5.7% increase.

Both the Emergency Department and Acute Inpatient areas had met requirements for both the March and overall Q4 CQUIN.

The detailed complaint themes was noted and it was requested that the information presented should show the actions being taken following complaints and also to highlight any possible trends. Responsive

There had been no whistleblower alerts in March.

The CQC Intelligent Monitoring report was published 21 April 2015, this draft report published a priority banding of 2 for the Trust.

Well Led

The National Inpatient Survey was released at the end of March 2015 and work had begun on identifying priority areas for improvement.

Four Patient Safety Visits had taken place in March in the Aldbourne Ward, HSDU, Mortuary and the Wren Unit.

Inpatient Survey – GR reported that the results of the inpatient survey undertaken in October 2014 had shown areas of deterioration and that an analysis of this information would be presented to a future Board meeting. A corporate plan would also be developed to address overarching issues. Sign up to Safety – It was noted that the Trust had formally signed up to the National Sign Up to Safety Campaign as part of the commitment to ensuring quality and safety remains the focus. A Safety Improvement Plan had been developed built on the campaign’s five key pledges which were put safety first, continually learn, honesty, collaborate and support. As part of the plan a number of safety priorities had been agreed, aligned to the national topic areas of the campaign, and these priorities have clear objectives, against which progress will be measured.

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RESOLVED (a) that it be agreed that the Patient Quality Report provides assurances to

the Board on quality; (b) that it be agreed that actions are being progressed as appropriate; (c) that GR would check on the detail behind the number of deaths reported

after surgery as 298; and (d) that the outcomes of further analysis into the increased rate of serious

incidents reported in March to be provided in the May report.

- -

GR

GR

- -

May 2015

May 2015

11/15 Operational Performance Report The Board considered a report which provided commentary on key operational performance indicators including a summary of actions being taken where performance improvements were required. A summary of the Trust’s performance against key patient safety, quality and operational performance indicators was included. Percentage of patients who stay a maximum of 4 hours in Emergency Department – It was noted that performance for March was 88.99%. 18 Week Referral to Treatment (RTT) – It was noted that all targets had failed for both February and March. This was part of the planned approach to resolve backlog issues during Quarter 4; however the incomplete pathways performance suggested that the Trust was not in a position to sustainably deliver RTT performance into Quarter 1 of 2015/16. The backlog of patients on a waiting list for treatment who had gone beyond 18 weeks had now grown significantly and the Board noted the reasons for this deterioration; as sub-optimal use of capacity as a result of cancellations, insufficient capacity to meet demand in some specialities (notably Orthopaedics) and delays in the outpatient element of the pathway. There had also been significant inefficiency throughout the winter period due to insufficient access to inpatient beds. MK added that it was likely that any clearance of outpatient backlogs and increase in the number of patients converting to admitted care for the surgical specialities would continue to compromise performance going forward in to Q1. SN expressed concern that it may be possible that the RTT target would also not be achieved in Q2 and NV agreed with this. Although ECIST had advised that we should be have a trajectory, an action plan would be required to underpin that. MK responded that assurance and guidance on RTT was being sought and support obtained from the elective IST on a recovery plan. Admitted backlog over 18 weeks – MK reported that there were 495 patients in the admitted backlog at the end of March waiting more than 18 weeks and that this had since increased again to 518 patients. The recommendation by ECIST was that there should be no more than 8% on the 18 week waiting list and that this would be standardised for the recovery plan. Non-admitted backlog over 18 weeks – MK reported that a small number of specialities (in particular Orthodontics and Gastroenterology) were contributing to the majority of the breaches of this standard as a result of capacity and workforce constraints and the 95% standard was unlikely to be achieved throughout Q1. Separate speciality level action plans to address these issues are currently being taken forward. OF added that a longer terms succession plan was being put in place to address the medical manpower issues in Orthodontics and NV also provided assurance that the Trust was working with Oxford to address the backlog of patients. Incomplete pathways – It was noted that following implementation of the new

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Medway, data quality issues had emerged in relation to the robust measurement of pathways, and that given the extent of backlogs present within the outpatient system it was possible that not all patients with an open pathway, from an RTT perspective, were being captured. Open pathways performance suggests that the Trust was not in a sustainable position for the ongoing delivery of RTT standards and although the measure improved slightly between February and March, focussed remedial action was needed from all Divisions throughout Q1. Following the ECIST review, significant validation of the incomplete pathways was being undertaken to enable delivery against the 92% open pathways measure. Hold File – MK reported that the number of patients on the historical file at the end of March was 941 and the Divisions were focussed on clearing all overdue follow ups by the end of Q1. OF questioned if this was being undertaken in the current number of SPAs and MK responded that to undertake the clinical validation, some additional SPAs were required but that Divisions were mindful to control their budgets for this. DTOC – Acute – The Board noted the increase in demand on the system and the compounding issues which result in delayed discharges and that further work was required to make the system as efficient as possible. This would be the role of the Strategic System Resilience Group to bring the solution together. NV also added that as part of the Monitor enforcement package, the Trust had agreed to work a Round Table with Monitor, NHS England and both Swindon and Wiltshire CCGs to ensure that they have the best indicator to see delays in discharges. Cancer Performance – All cancer performance standards had been achieved in February 2015. Average LOS – Community – DB reported that delays had been reduced from 2 April and that 83% of patients had now been discharged to their original place of residence. Care homes and intermediate beds had been used during January and that getting people to the right places can take longer than anticipated. Work was underway to reform the discharge processes across the whole system. RESOLVED that the report which provided assurance on key operational performance standards for March 2015 and associated remedial actions be received.

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-

12/15 Update on CQC New Fundamental Standards The Board received and considered a paper which outlined the new CQC Fundamental Standards that would come into force for all health and social care services on 1 April 2015. The three completely new standards being applied were Fit & Proper Persons, Duty of Candour and Requirement as to display of performance assessments and the Board noted the summarised requirements under each new standard. Fit & Proper Persons: Director – There would be a need to ensure that all existing and new Directors of the Trust (including Interims and Non-Executive Directors) meet and continue to meet the definitions of Fit & Proper and Good Character. OF added that this would be introduced in the Executive and Non-Executive recruitment process and also form part of the appraisal process. Each Director would now be requested to complete a self-declaration and that any changes in circumstances would need to be notified to the Chairman and Chief Executive immediately. Duty of Candour – The Board noted the current compliance with this new regulation and that a full report and detailed action plan would be monitored via the Patient Quality Committee with assurance of compliance with deadlines and actions reported up to the Governance Committee. Processes and letters were also to be designed for use by clinical staff and recognised complications with treatment would be covered through consent. The financial penalties for breach of duty of candour

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was also noted. Requirement as to display of performance assessments – All organisations now have to display their ratings following a CQC inspection within 21 calendar days to comply. The Trust currently has 53 locations in which a service is provided and an action plan was being developed with the Estates Team to fulfil this requirement. It was noted that a full report and action plan to achieve all changes would be provided to the Governance Committee in June 2015. RESOLVED (a) that the compliance actions required for Fit & Proper Persons: Directors

be approved and that each Director will be requested to complete a self-declaration;

(b) that the proposal for monitoring the action plan on Duty of Candour via the Patient Quality Committee with assurance of compliance with deadlines and actions reported up to the Governance Committee be endorsed; and

(c) that the proposal for the action plan for the Display of Ratings be developed and shared at the next Governance Committee in June 2015 be endorsed.

OF

OF

HW

immediate -

05.06.15

13/15 Safeguarding Children – progress update The Board received and noted a progress report which outlined how the Trust was fulfilling its responsibilities in relation to Safeguarding Children and updated on areas identified for improvement. These areas included: Improving training compliance following the refreshed guidance for healthcare staff published in March 2014; Finding meaningful approaches to listening and responding to the child’s voice and demonstrating the influence children have had on service provision; Information sharing, particularly in relation to consistency of policy implementation; Safeguarding supervision and assessing the impact of the new model; Improving services for Looked After Children in both Swindon and Wiltshire; and Strengthening assurance through robust audit reviews and a performance dashboard. It was noted that action plans in relation to this priorities were being monitored through the Safeguarding Forum to ensure progress was made in a timely way. It was agreed that in future a six-monthly report from the Safeguarding Forum to the Governance Committee would provide more meaningful assurance than an annual report to the Board. One particular area for improvement related to a requirement for enhanced levels of training for more members of staff who work regularly with children. It was noted that plans were now in place to deliver improvement of compliance in 2015/16 with an expectation to achieve 95% by the end of March 2016. The Board was assured that the on-going maintenance of Level 3 training would be more manageable due to the introduction of a ‘blended learning’ approach on a rolling 3 yearly basis. Named Professionals already have plans in place for the recording and monitoring of this approach. It was noted that Board members would now need a level of training and that this would be undertaken in a Board workshop in July 2015. RESOLVED (a) that the content of the report as a summary of assurance about progress

against key areas for improvement be noted; (b) that the Board be assured that the on-going maintenance of Level 3

training would be more manageable on a rolling 3 yearly basis; and (c) that in future a six-monthly report from the Safeguarding Forum to the

Governance Committee to provide a more meaningful assurance than an annual report to the Board be agreed.

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HW

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04.09.15

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14/15 Safer Staffing Monthly Report The Board considered a report which provided the monthly actual nursing and midwifery staffing compared to that planned and associated quality impacts. An update on the challenges in ensuring data was also provided. In March the proportion of actual versus planned nursing hours (fill rate) was as follows: -

Registered Nurses

Auxiliary Nurses

Day Shift 86.2% 110.7%

Night Shift 102.6% 134.1%

HW highlighted that the trend continued with a shortfall in registered nurse planned day hours and an increase in unregistered staff day hours. HW also reported that an investigation into the high ‘actual’ rates for unregistered nursing staff, particularly at night versus planned staffing levels for Neptune and Saturn Wards would be reported at the next Board meeting. It was noted that a key quality nursing indicator performance of note was a marked increase in the response rates to the Friends and Family test. There had also been a significant increase in category 2 and 3 pressure ulcers in Unscheduled Care and that these were being investigated. RESOLVED that the report be noted.

15/15 Urgent Public Business (if any) None.

16/15 Date and Time of next meeting It was noted that the next meeting of the Board would be held on 4 June 2015 at 9.30am in Lecture Hall 2, Great Western Hospital.

17/15 Exclusion of the Public and Press RESOLVED that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest when the following items are considered: -

Minutes

Outstanding Actions of the Board

Financial Governance Review

Draft Annual Plan 2015/16 Submission

2015/16 Budgets Update

Capacity Development Plan

Referral to Treatment Benchmarking Report

Delayed Transfers of Care and Medically Fit for Discharge

Charitable Funds Committee Minutes

Executive Committee Minutes

Finance, Investment and Performance Committee Minutes

Governance Committee Minutes

Mental Health Act and Mental Capacity Act Committee Minutes

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People Strategy Minutes

Remuneration Committee Minutes


PUBLIC SUMMARY OF ITEMS CONSIDERED IN THE PRIVATE PART OF THE BOARD MEETING


whom

Action by

when

18/15 Minutes The minutes of the meeting of the Board held in private on 26 March 2015 were adopted and signed as a correct record.

19/15 Outstanding Actions of the Board (Private) The Board received a list of outstanding actions arising from previous meetings of the Board.

20/15 Financial Governance Review – Draft Action Plan The Board received and considered the draft Action Plan to address the outcome of the Independent Financial Governance review undertaken by Deloitte; commissioned by the Board as part of its assurance process and now part of the undertaking required to make to Monitor. It was noted that the plan provided detail on the individual responsibilities and actions to address the Independent Financial Governance Review weaknesses; keep delivery under review and commission external assurance review following implementation of the plan. RESOLVED (a) that the Board be assured that robust arrangements were in place to

enable the Trust to fulfil its obligations to Monitor; and (b) that the Board members provide any comments on the Plan to Sharon

Beamish by 7 May prior to submission to Monitor on 14 May.

21/15 Assurance regarding leadership and management – submission to Monitor (draft) The Board received and considered a paper which detailed the actions being taken to strengthen leadership and management arrangements at a senior level within the Trust as part of the undertakings the Board would be required to make to Monitor. This paper would be submitted on 14 May alongside the Annual Plan. RESOLVED (a) that the Board be assured that robust leadership and management

arrangements were in place to enable the Trust to fulfil its obligations to Monitor; and

(b) that the submission and statement to Monitor Board be approved.

22/15 Draft Annual Plan 2015/16 Submission The Board received and considered a Short Term Plan which was a draft of the Annual Plan submission to be made to Monitor on 14 May 2015. It was noted that this plan had also been discussed at the Finance, Investment & Performance Committee in April and would then be further scrutinised as required and approved by the Board at an extraordinary meeting on 11 May ahead of the submission to Monitor.

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The paper outlined the key planning themes for this year, detailed the strategic context, key priorities and associated KPIs, together with a headline overview of the financial plan for 2015/16. RESOLVED that feedback on the draft plan be provided to KMc within the next seven days to allow for amendments to be made in time for final approval at the Board on 11 May in order to meet the Monitor deadline.

23/15 2015/16 Budgets Update The Board received and considered a paper which set out the proposed budgets for 2015/16 to be included within the annual plan submission to Monitor on 14 May 2015. RESOLVED (a) that the proposed final budget for 2015/16 for submission to Monitor on

14 May 2015 be noted to Monitor; and (b) that the financial implications of the Capacity Planning Strategy in terms

of the Trust’s capital programme be noted.

24/15 Capacity Development Plan The Board received and considered a paper which set out the results of the capacity planning work and proposed developments to maximise performance, operational efficiency and provide flexible additional capacity during 2015/16. RESOLVED (a) that the predicted effects of forecasted future activity growth on the

hospital during 2015-16 be noted; and (b) that the relocation of the Ambulatory Emergency Care (AEC) unit and

Triage and Assessment Bay (TAB) to Clover Ward (near ED) to be explored further in line with the above discussions at the Extraordinary Board meeting on 11 May.

25/15 Referral to Treatment (RTT) Benchmarking Report The Board received and considered a paper which provided the Board with a position statement as to where the Trust sits in relation to benchmarking against nationally available statistics on consultant-led RTT standards against national and regional performance. The outline of the TT Improvement Plan was also noted. RESOLVED (a) that the current GWH RTT performance status against the national and

regional benchmarking and the associated improvement measures be noted; and

(b) that further data be provided to the Board in six months’ time.

26/15 Delayed Transfers of Care and Medically Fit for Discharge The Board received and considered a paper which set out the Trust’s position in relation to delays in transfers of care (DTOC) and the management of patients medically fit for discharge/transfer (MFFD). It was noted that the paper also summarised the discharge improvement action plan specifically in relation to the stretch targets set by Monitor and NHS England in their letter to Swindon and Wiltshire Systems Leaders on 23 March 2015. Lorraine Austen, Programme Director for Community Integration, attended to present this item.

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RESOLVED (c) that the Trust position in relation to Delayed Transfers of Care and

Medically Fit for Discharge be noted; and (d) that the actions taken to improve the discharge and transfer of patients

by 31 May 2015 be noted.

28/15 Charitable Funds Committee The minutes of the meeting of the Charitable Funds Committee held on 12 March 2015 were received. Furthermore, it was noted that a meeting of the Charitable Funds Committee had been held on 28 April 2015.

29/15 Executive Committee The minutes of the meeting of the Executive Committee held on 17 March 2015 were received. Furthermore, it was noted that a meeting of the Executive Committee had been held on 21 April 2015.

30/15 Finance, Investment and Performance Committee The minutes of the meeting of the Finance, Investment and Performance Committee held on 17 March 2015 were received. Furthermore, it was noted that a meeting of the Finance, Investment and Performance Committee had been held on 21 April 2015.

31/15 Governance Committee The minutes of the meeting of the Governance Committee held on 6 March 2015 were received.

32/15 Mental Health Act and Mental Capacity Act Committee The minutes of the meeting held of the Mental Health Act and Mental Capacity Act Committee held on 6 March 2015 were received.

Chair ………………………………………… Date …………………………………… The meeting ended at 3.30pm

Page 12

Public Minutes

MINUTES OF THE EXTRAORDINARY MEETING OF THE BOARD OF DIRECTORS HELD IN PUBLIC ON 11 MAY 2015, AT 3.45PM

IN LECTURE HALL 1, GREAT WESTERN HOSPITAL SWINDON

Present Members Roger Hill (RH) Chairman Robert Burns (RB) Non-Executive Director Liam Coleman (LC) Non-Executive Director Oonagh Fitzgerald (OF) Director of Workforce & Education Karen Johnson (KJ) Acting Deputy Director of Finance Michelle Kemp (MK) Chief Operating Officer Jemima Milton (JM) Non-Executive Director Steve Nowell (SN) Non-Executive Director Guy Rooney (GR) Medical Director Julie Soutter (JS) Non-Executive Director Nerissa Vaughan (NV) Chief Executive Hilary Walker (HW) Chief Nurse Non-Voting Board Members Douglas Blair (DB) Director of Community Services Kevin McNamara (KM) Director of Strategy Also in attendance Deborah Rawlings Minute Taker Number of members of the public: None Matters Open to the Public and Press


whom

Action by

when

34/15 Apologies for Absence and Chairman’s Welcome Apologies for absence were recorded from Angela Gillibrand, Non-Executive Director and Carole Nicholl, Company Secretary & Head of Corporate Governance.

35/15 Declarations of Interest None.

36/15 Questions from the public to the Board relating to the work of the Trust There were no questions from members of the public.

37/15 Date and Time of next meeting It was noted that the next meeting of the Board would be held on 4 June 2015 at 9.30am in Lecture Hall 2, Great Western Hospital.

38/15 Exclusion of the Public and Press RESOLVED that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest when the following items are considered: -

Financial Governance Review

Annual Plan 2015/16 Submission

Leadership and Management

GWH Capacity Development Plan 2015-2017

Page 13

Public Minutes


Chair ………………………………………… Date …………………………………… The meeting ended at 3.50pm

Page 14

DATE OF

BOARD

MEETING

MINUTE SUBJECT ACTION LEAD DATE COMMENTS

Nov-14 204/14Finance Report -

Management of debtors

Management of debtors needed to be reviewed

with an update included in the report to the

next meeting of the Board

MM Jan-15

The Trust has received approval of

£10m external borrowing, of this £5m

will be drawn down in Q4 to pay

creditors, this will enable staff resource

to be used for recovery of debt.

ACTION CLOSED

Nov-14 206/14Operational Performance

Report - Resilience Plan

Nv advised that the operational resilience plan

for the whole system should be presented to the

Board in January to include an assessment of its

anticipated effectiveness.

MK Jan-15

05.01.15 - Executive Directors agreed

that this item should be deferred until

February. Discussions now held with

Commissioners on ORCP schemes and

resilience schemes to be funded.

Swindon has now agreed; decision

awaited from Wiltshire.

Nov-14 202/14

Chairman's Report - Non-

Executive Director

recruitment

The Board noted that OF would be seeking to

recruit a further non-executive director in the

New Year for appointment by the Council of

Governors in February

OF

Feb 15

deferred to

new date to be

advised by OF

02.01.15 - OF advised that she would

not be ready to comply with this

timescale and would advise of a new

date. ACTION CLOSED

Nov-14 210/14Safeguarding Children -

Board Member Training

HW undertook to consider the training

requirements for members of the Board tailored

around the needs and responsibilities of

directors and arrange training as appropriate

HW01/03/2015

Apr 2015

July 2015

Governance Committee to consider the

training requirements for the trajectory

target. Training for Board members

planned for July.

Feb-15 282/14Quality Report - Safety

Thermometer

HW will look further into the reasons why the

quality of information captured in respect of the

Safety Thermometer continues to be an issue

and report thereon to the next meeting

HW01/03/2015

May 2015

Review of safety thermometer being

undertaken to ensure accurate data for

the organisation. ACTION CLOSED as in

Quality Report.

Jan-15 249/14Quality Report - Dementia

Measures

HW to provide a short summary on the impact

of the new dementia measures on Jupiter Ward. HW

01/04/2015

May 2015

July 2015

Presentation from Wendy Johnson to 2

July meeting

Nov-14 205/14Quality Report - Sign up to

Safety

HW undertook to report back quarterly on

priorities and key performance indicators and

this was supported

HW

Feb 15

amended to

Apr 15

onwards as

part of Quality

report

23.02.15 - Executive Directors advised

that this would be presented in April.

Sign up to Safety workstreams and

outcome measures in Quality Report.

CLOSED

Nov-14 210/14Safeguarding Children -

Improvements

As requested by RH, HW undertook to provide

an update to the Board in March on actions to

deliver improvements.

HW

Mar 15

amended to

Apr 15

23.02.14 Executive Directors advised

this would be deferred until April. On

April agenda. ACTION CLOSED

Feb-15 282/14Quality Report - Patient

Story (Video)

that a report on improvements made as a result

of learning from the patient feedback detailed in

the training video be presented to a future

meeting of the Board

HW tbc

Chairman had now met with patient

who featured in video to provide

feedback. ACTION CLOSED

Mar-15 313/14Finance Report for Month

11

that KJ undertake a detailed piece of work on

the cash position for Monitor KJ Apr-15

Engaged with Deloitte regarding cash

and borrowing - in progress

Mar-15 314/14Quality Report - CQC

fundamental standards

that a briefing be provided on the Duty of

Candour, Speak Up and the Fit and Proper

Persons Test in light of the new fundamental

standards being published by CQC in April

OF/HW Apr-15

Full report and action plan to achieve

all changes to be provided to

Governance Committee in June 2015

Mar-15 315/14Operational Performance

Report - Admitted backlog

that an update on the Admitted backlog over 18

weeks be provided to confirm at what point the

organisation would be stabilised to clear the

backlog

MK Apr-15 Report to be received in private session


Report - RTT benchmarking

that benchmarking information on RTT be

providedMK Apr-15 Report to be received in private session


Report - Discharges

that an assessment against the ECIST gap

analysis and trajectory for discharges be

provided

MK01/04/2015

May 2015

ACTIONS ARISING FROM MEETINGS OF THE TRUST BOARD (matters open to the public)

OF - Oonagh Fitzgerald, NV - Nerissa Vaughan, HW - Hilary Walker, KM - Kevin McNamara, GR - Guy Rooney, DB - Douglas Blair, MK- Michelle Kemp, CN - Carole Nicholl, KJ -

Karen Johnson

JANUARY

FEBRUARY

MARCH

APRIL

MAY

$dsbum1ez.xlsPage 15

Agenda Item 5

Mar-15 314/14 Quality Report - End of Life

that a paper be provided to the May Board on

End of Life, to coincide with the re-audit and

launch of EOL Strategy

GR May-15

Apr-15 10/15 Quality Report - HSMRthat the detail behind the numberof deaths

reported after surgery as 298 be checkedGR May-15

Apr-15 10/15Quality Report - Serious

Incidents

that the outcomes of further analysis into

increased rate of serious incidents reported in

March be provided in the May report

GR May-15

Mar-15 317/14Annual Staff Survey Results

2014

that the People Strategy Committee would

review and address the results of the staff

survey and report back to the Board in six

months' time on progress

OF Sep-15

SEPTEMBER

$dsbum1ez.xlsPage 16

Meeting and date:

BOARD OF DIRECTORS – 4 JUNE 2015

Title:

Chief Executive’s Report

Summary of paper:

This report provides members of the Trust Board with information on some of the latest developments within the Trust and other topics relevant to the business of the Board covering:

Radiotherapy fundraising appeal launched

More training places for local nurses

New Outpatients Centre at Savernake Hospital

Events in May

Promotion of end-of-life care during awareness week

Focus on dementia during awareness week

International Nurses’ Day celebrations

Recommendations/ decisions required:

that the Board note the report.

Link to Trust Priorities (a) We will make the patient the centre of

everything we do.

(b) We will innovate and identify new ways of working.

(c) We will build capacity and capability by investing in our staff, infrastructure and partnerships.

Link to Quality (1) Safety (staffing, falls, never events, handover,

SI, safeguarding, infection control, environment, medicines, equipment)

(2) Caring (patient experience, patient surveys, friends and family test, patient stories, response to call bells)

(3) Well led (staff survey, staffing levels, sickness rates, flu vaccinations rates, board/ward interactions, staff reports, governance and reporting, risk management, financial control)

Risk issues:

None

Resource Implications: (financial / human / other resources)

None

Regulations and legal considerations: (CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements)

None

Quality consideration and impact on patient and carers:

Impact on patient services in the event of further strike action in the future.

Page 17

Agenda Item 7

Consultation/ Communication:

None required

Confidentiality: This report does not contain any confidential information.

Equality Impact Assessment:

Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust’s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics.

Name of Lead Executive Director:

Nerissa Vaughan, Chief Executive

Name of Author:

Nerissa Vaughan, Chief Executive

Page 18

1. Radiotherapy fundraising appeal launched The Board will know that the Trust is working with Oxford University Hospitals NHS Trust (OUH) and Swindon Clinical Commissioning Group to bring radiotherapy treatment for local cancer patients closer to home at GWH. Currently, around 700 local patients currently have to travel to the OUH Churchill Hospital in Oxford each year for radiotherapy treatment. On 28 May, Brighter Futures, the Trust’s charity, publically launched a £2.9 million fundraising appeal to equip OUH’s radiotherapy centre at GWH. A total of 284 balloons were launched into the air to mark the monthly number of patients diagnosed at GWH with cancer. The centre, subject to final approval, would be built and staffed by OUH. It could be operational by late 2017. A series of fundraising events are planned over a two-year period to get the local community in Swindon and Wiltshire behind the appeal. More details are available on the new Brighter Futures website www.brighterfuturesgwh.nhs.uk 2. More training places for local nurses The Trust will benefit from Oxford Brookes University’s decision to increase the number of places on its nursing courses to 880. In May the university announced that the majority of the student nurses were likely to be taught at its Ferndale campus in Swindon, where places would rise from 400 to 700. I welcome the university’s decision as it complements our work to recruitment more permanent staff and supports local people into a rewarding career in healthcare. 3. New Outpatients Centre at Savernake Hospital Building work on Prospect Hospice’s new Outpatients Centre at Savernake Hospital started in May. This development was made possible thanks to the Trust’s special partnership with Prospect Hospice. The refurbishment will mean that people living in and around Marlborough no longer need to travel to the Prospect Hospice in Wroughton for end-of-life care. New facilities will include a welcome room, a day hospice room, a counselling room and a therapy room. The new centre is expected to be open in the summer. 4. Events in May The Trust supported a range of awareness weeks and special events throughout May. 5. Promotion of end-of-life care during awareness week The Trust worked with Prospect Hospice and other local healthcare organisations during national Dying Matters Week (18-22 May) to raise the profile of local end-of-life care services.

Page 19

http://www.brighterfuturesgwh.nhs.uk/

The new Advanced Care Plan was launched in the week, which is a personalised plan, held by each patient, where they can record decisions about their care. The public were also encouraged to complete a questionnaire as a way of sharing what they saw as their main end-of-life care priorities. 6. Focus on dementia during awareness week The Trust staged a series of public and staff information events at GWH during national Dementia Awareness Week (18-22 May). The Dementia Care Team shared information about their work over the past year to support people living with dementia and their families. This included the refurbishment of Jupiter Ward at GWH to make it dementia-friendly and more recently the launch of a dedicated welcome service to support people with dementia when they visit hospital. 7. International Nurses’ Day celebrations The public and staff attended a dedicated day of activity at GWH to mark International Nurses’ Day on 12 May. Attendees had the opportunity to learn about the history of nursing and nursing as a career. The celebrations attracted significant local media interest.

Page 20

Meeting and date:


Title:

Finance Report for Month 1 (Ending 30th April 2015)

Summary of paper:

The report highlights the Trust financial position as at Month 1.

1. The position for April is an actual operating deficit of £1.6m compared to a target deficit of £1.7m, giving a favourable variance of £0.085m from plan for the month.

2. Cash balance is £2.4m, which is £0.1m below plan.

3. The Continuity of Service Risk Rating is 1 (CoSRR).


that the Board of Directors is required to agree:

(a) the Month 1 financial position

(b) the current Continuity of Service Risk Rating is a 1

Link to Trust Priorities (a) We will work smarter not harder to make best

use of existing resource.

(b) We will build capacity and capability by investing in our staff, infrastructure and partnerships.

Link to Quality None

Risk issues:

Impact of increased activity demand on the Trust and overall health economy if current increase continues. Continue pressures on the finances linked to activity demands and agency cost pressures would continue to impact on the Trust CoSRR. The Trust is now reporting a CoSRR of 1, which has triggered an investigation by the regulator Monitor.


None


None


None

Page 21

Agenda Item 8


None



Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt.

This report has been assessed against the Trust’s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics.


Karen Johnson, Acting Director of Finance

Name of Author:

Anne-Marie Howroyd, Acting Deputy Director of Finance

Page 22

Finance Report:

2015/16 Month 1

Karen Johnson

Acting Director of Finance

Page 23

Summary as at 30th April 2015

� The deficit for April is £1.6m, £0.085m

better than budget

� Savings plan of £8m of which £6.8m

identified.

� Cash balance is £2.1m which is

£0.1m below plan.

� Continuity of Service Risk Rating of

1

Annual

BudgetBudget Actual Variance

£'000 £'000 £'000 £'000

Income 304,814 24,907 24,223 (684)

Expenditure (300,429) (24,635) (24,076) 559

EBITDA 4,385 272 146 (125)

Depn/ Interest & PDC (23,127) (1,979) (1,768) 210

Net Surplus / (Deficit) (18,742) (1,707) (1,622) 85

EBITDA % Income 1.4% 1.09% 0.60% (0.5%)

Current Month

Page 24

1.1 NHS Clinical Income – Contractual income� The Trust has prepared a financial position utilising Civica for PbR services. This has allowed for the first

time, real time reporting of income for the period.

� For all main commissioners the GWH performance is below plan.

� The plan has growth in line with trend (adjusted for surgical assessment coding) which has not been

achieved

� A provision for CQUIN under performance at 24%. A provision for contractual challenges/fines has been

incorporated in line with 2014-15 levels.

� A high level reconciliation to the same point in 2014-15 is included on the next slide

� NB although every effort has been made to ensure Civica is complete, there may be minor items omitted

but these would be immaterial.Page 25

1.2 NHS Clinical Income – Contractual income

� An analysis of movement between years has been completed and is included in table

below

� Whilst activity is above the previous year (as demonstrated in the next slide) the

removal of the Bath area maternity contract and the impact of the tariff deflator are

the reasons that NHS Clinical Income is lower.

Page 26

1.3 NHS Clinical Income – Activity

� The trust has invested in Civica SLAM to report contractual income and activity and this is used to present PbR activity lines below.

� The majority of income and activity is now being reported in the system however the final plan has not been uploaded in time for M1 reporting so has been completed offline.

� There may be some small areas of PbR activity omitted but these are immaterial

� The main points to note are that the trust is only slightly off plan for Elective inpatients and day cases

� Non elective admissions are above prior year but below plan. This suggests the projected growth ha snot materialised. The variance to prior year can be largely attributed to change in surgical assessment activity

� A&E is slightly above out turn but below plan, again where high growth was planned.

� A more in depth analysis will be available in the May board report when it is expected the plan will have been uploaded into Civica and more granularity of reporting will be available

� Outpatient actual information is unavailable but this will be updated when back the system is back on line

� GP referral will also be included in the monitoring report for month 2

Page 27

1.4 NHS Clinical Income – Emergency and Non Elective

� A&E activity is marginally up on prior year but significantly down on plan which suggests that either demand has dropped or QIPP is delivering transfer of activity to other providers

� Non elective activity is above 2014-15 levels but below plan. The increase on prior year is largely as a consequence of surgical assessment coding changes but a small element would be as a result of growth in A&E. There was a high level of growth assumed in emergency activity which has not materialised.

Page 28

1.5 NHS Clinical Income – Elective and Day Case

� Elective inpatient activity is at plan, and in line with trend from previous 4

months

� Day Case is marginally above both plan and prior year actual.

Page 29

2. Trust Income and Expenditure2.1 The table shows income and

expenditure compared to plan. The budget has been uplifted to recognise historical non-recurring overspends.

� Expenditure is under plan but not to the same extent as clinical income.

� Pay under budget £0.038m in month.

� Clinical supplies under budget £0.2m

� Drugs over budget £0.02m

� Other Costs are under budget by £0.4m. This relates to expenditure not yet released relating to activity growth

Annual

Budget Budget Actual Variance

£'000 £'000 £'000 £'000

Income

NHS Clinical Income 273,737 22,374 21,526 (848)

Private Patients 3,129 218 222 4

Other Non Mandatory/Non Protected Revenue3,141 262 400 138

Research & Development Income 860 72 80 9

Education and Training Income 9,016 751 799 47

Misc Other Operating Income 14,931 1,230 1,196 (35)

Total Income 304,814 24,907 24,223 (684)

Expenses

Pay Costs (202,803) (16,284) (16,245) 38

Drugs Costs (22,705) (1,971) (1,991) (20)

Supplies (Clinical & Non Clinical) (30,361) (2,728) (2,532) 196

PFI Costs (11,810) (1,004) (1,017) (13)

Other Costs (32,750) (2,648) (2,292) 356

Total Costs (300,429) (24,635) (24,076) 559

EBITDA 4,385 272 146 (125)

Depreciation (9,259) (772) (679) 92

Pension Unwinding (46) 0 0 0

Net Interest (13,229) (1,102) (1,040) 63

PDC Dividend (593) (105) (49) 55

Profit / (Loss) On Asset Disposals 0 0 0 0

Net Surplus / (Deficit) (18,742) (1,707) (1,622) 85

EBITDA % Income 1.4% 1.09% 0.60% (0.5%)

Financial Performance £'000sCurrent Month

Page 30

2.2 Pay Expenditure� This table shows actual pay expenditure in

April 15 compared to pay spend in March

15 by Division

� Pay spend is higher in Integrated

Community Health and lower in Diagnostics

due to the transfer of the following services

� Community Dietetics

� - Community Diabetes

� - Community Physiotherapy

� - Wheelchair Services

� The table below shows that permanent staff

costs increased in April compared to

March, but that agency spend has reduced.

� In month permanent pay included £0.15m

of one-off costs.

March 2015

Actual April 2015 Actual

Directorate Pay Group £'000 £'000

Central Allocations Bank (4) 0

Perm (11) 0

Locum 0 0

Agency 6 7

Central Allocations Total (10) 7

Corporate Bank 50 34

Perm 1,674 1,801

Locum 0 (0)

Agency 34 69

Corporate Total 1,758 1,904

Diagnostics & Outpatients Bank 61 45

Perm 2,773 2,315

Locum 8 9

Agency 54 56

Diagnostics & Outpatients Total 2,897 2,425

Integrated Community Health Bank 66 92

Perm 1,501 2,054

Locum 10 1

Agency 251 257

Integrated Community Health Total 1,828 2,404

Planned Care Bank 47 40

Perm 3,437 3,465

Locum 60 19

Agency 196 157

Planned Care Total 3,740 3,681

Private Patients Bank 5 9

Perm 91 92

Agency 6 3

Private Patients Total 102 104

Unscheduled Care Bank 110 71

Perm 2,850 2,924

Locum 93 49

Agency 627 354

Unscheduled Care Total 3,680 3,398

Womens & Childrens Bank 59 68

Perm 2,195 2,210

Locum 18 1

Agency 41 44

Womens & Childrens Total 2,314 2,322

Grand Total 16,310 16,245

March 2015

Actual

April 2015

Actual

Pay Group £'000 £'000

Bank 394 359

Perm 14,510 14,860

Locum 190 79

Agency 1,215 948

Total 16,310 16,245

Page 31

3. Cost Improvement Programme

� Total target for the year is £8m:

� All are cash releasing, efficiency savings

� Includes - Income generation of £0.473m / Pay of £4.16m / Non Pay of £3.367m

� Position per Trust Annual Plan:

� Identified £6.8m

� Unidentified £1.2m

� CIP budgets have been re-profiled within the ledger to reflect the phasing applied within the Trust

Annual Plan. Gradual increase in CIP target throughout the year

� Shortfall against YTD plan of £0.137m. This is due to the profiling of the unidentified schemes in

month. All schemes for which relevant finance budgets have been removed and Quality Impact

Assessment’s (QIA) signed have achieved the profiled saving.

CIPs

Recurrent / Non Recurrent

Annual

Plan YTD Plan

Actual

Achieved

YTD

Variance

to Plan

Recurrent 8,000 145 8 - 137

Non Recurrent - - - -

Grand Total 8,000 145 8 - 137

CIP Performance Annual

Plan YTD Plan

Actual

Achieved

Variance

to Plan

Corporate 1,587 29 - 29

Diagnostics & Outpatients 1,708 34 6 - 28

Integrated Community Health 429 8 - 8

Planned Care 1,785 32 1 - 31

Unscheduled Care 1,475 25 - 25

Women's & Children's 958 16 - 16

Private Patient 57 1 - 1

Grand Total 8,000 145 8 - 137

Page 32

5.Balance Sheet

5.1 Stock levels have reduced in

month due to a movement in

pharmacy stock

5.2 Debtors above plan £2.8m.

� NHS Debtors are £1.2m below

plan

� Other Debtors are £1.3m above

plan

� Prepayments are £2.4m above

plan

5.3 Creditors is £2m above plan

� Trade Creditors above plan £2.2m

� Capital Creditors £0.4m below

plan

Balance sheet £m

Actual Plan Variance

Non-Current Assets £m £m £m

Intangible Assets 2.2 2.3 (0.1)

Property, Plant and Equipment 83.6 84.0 (0.4)

On balance sheet PFI assets 120.2 119.8 0.4

Total Non-Current Assets 206.1 206.1 (0.0)

Current Assets

Inventories 5.6 6.3 (0.8)

NHS Trade Receivables 6.1 7.2 (1.2)

Non-NHS Trade Receivables 7.3 6.0 1.3

Other Receivables 0.4 0.2 0.3

Accrued Income 2.8 2.8 (0.0)

Prepayments 19.7 17.4 2.4

Cash 2.3 2.4 (0.1)

Total Current Assets 44.1 42.3 2.0

Total Assets 250.2 248.3 2.0

Current Liabilities

Deferred Income 2.1 2.1 0.0

Trade Creditors 22.0 19.8 2.2

Other Creditors 10.5 10.2 0.3

Payment on Account 9.6 9.7 (0.0)

Capital Creditors 1.5 2.0 (0.4)

Provisions current 0.2 0.2 0.0

Accruals 6.4 6.4 (0.1)

Total Current Liabilities 52.3 50.2 2.0

Non current Liabilities

Deferred Income 1.6 1.5 0.1

Trade Creditors 0.0 0.0 0.0

Provisions non current 1.5 1.5 0.0ITFF Funding 5.0 5.0 0.0

PFI leases non-current 123.0 123.0 (0.0)

Total Non-Current Liabilities 131.1 131.0 0.1

Total Assets Employed 66.8 67.0 (0.2)

Taxpayer's and Others Equity

PDC 30.4 30.4 (0.0)

Retained Earnings 6.6 6.8 (0.2)

Donated Asset Reserve 0.0 0.0 0.0

Revaluation Reserve 29.8 29.8 (0.0)Miscellaneous Other Reserve 0.0 0.0 0.0

Total Assets Employed 66.8 67.0 (0.3)

As at 30 April 2014

Page 33

7. Cash Position

Cash is £2.3m which is £0.1m below

plan

� Reduction in Stock £0.8m

� Increase in Prepayments £2.4m

� Increase in Creditors as payments

managed within available cash

Actual Plan Variance

£m £m £m

EBITDA 0.3 0.1 0.1

Debtors (5.5) (3.5) (2.0)

Creditors 6.4 4.8 1.6

Other change in WC (1.9) (2.1) 0.2

Non cash I&E items 0.0 0.0 0.0

CF from operations (0.7) (0.7) (0.1)

Capital Expenditure 0.0 0.0 0.0

Asset sale Proceeds 0.0 0.0 0.0

Net Interes t (1.0) (1.0) 0.0

Dividends paid 0.0 0.0 0.0

Movement in loans 0.0 0.0 0.0

PDC received / (repaid) 0.0 0.0 0.0

Other (0.4) (0.4) 0.0

Net cash inflow/(outflow) (2.1) (2.1) (0.1)

Opening Cash balance 4.4 4.4 0.0

Clos ing Cash Balance 2.3 2.4 (0.1)

Cashflow £m

Page 34

8. Continuity of Services Risk Rating (CoSRR) Scenarios

� 8.1 The current CoSRR is 1.

Weighting Metric Rating

4 3 2 1

Capital Service Cover 50% 0.13 1 2.5 1.75 1.25 <1.25

Liquidity 50% -54.92 1 0 -7 -14 <-14

Continuity of Service Risk Rating 1

Rating Categories

Page 35

The Committee is required to agree:-

a) the Month 1 financial position is a deficit of £1.62m

b) that the forecast year end Continuity of Service Risk Rating is a 1

Recommendations / Decisions Required

Page 36

Meeting and date:


Title:

Patient Quality Report

Summary of paper:

This report has been received by the Executive Committee and the main areas to note were identified as: Effective: The HSMR for December 2014 (the most recent data available from Dr Foster) is 85.47, a decrease from the previous month. The Trust is still below 100 with the April 2014 to December 2014 relative risk of 86.92, while the rolling twelve month period of January 2014 to December 2014 is 90.06. The data has not been updated as Hospital Episode Statistics data is currently not available from Dr Foster. Safe: There were seven cases of Clostridium difficile reported during April (Quarter 1). Six cases were Acute patients and one Community patient. This is a significant increase to numbers reported during one quarter in recent years. A C.diff improvement plan has been introduced. This focuses on antibiotic prescribing and EPMA roll out; cleaning of patient equipment; the IP&C risk assessment; hand hygiene of patients prior to meal times; environmental hazards to reduce the risk of cross-infection and IP&C review of all cases. This review will consider all patient hospital admissions to rule out potential cross-infection, antibiotic use, risk factors and assessments. IP&C have requested a short report from matrons triangulating cleaning results, environmental and care equipment, staffing levels/vacancy rate, red flags and any known equipment shortages. Findings will be monitored through the Infection Control Committee. There has not been any Trust attributed MRSA Bacteraemia (MRSAB) reported during April 2015 There was 1 Serious Incident reported by the Trust in April 2015. The number of IR1’s overdue (by more than 14 days) for April is 329 The average number of days that IR1s are overdue has increased slightly from 73 to 79 days. Caring 130 concerns were received and 95% of these concerns were resolved within 24 – 48 hours There have been 11 High to extreme complaints and 80 low to moderate complaints received in April No complaints were reopened during April. There has been 1 new case taken on by the Ombudsman in April. There are currently 12 cases awaiting outcome from PHSO investigations and 5 cases which the Ombudsman have investigated and recommendations have been made. Responsive There have been no whistle blower alerts in April 2015

Well Led Three Patient Safety Visits took place in April: Beech Ward, Surgical

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Agenda Item 9

Assessment Unit, Acute Cardiac Unit & Linnet Acute Medical Unit (all as one visit) and Theatres


a) that the Patient Quality Report provides assurances to the Trust

Board; and

b) that actions are being progressed as appropriate


everything we do.

(b) We will work smarter not harder to make best use of existing resource.

(c) We will innovate and identify new ways of working.

.



(2) Effectiveness (HMSR, SHMI, Mortality, Clinical audits, care bundles, deteriorating patient)


(4) Responsiveness (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors – TV and seating)


Risk issues:

Contractual Financial – CQUIN Regulatory – CQC/ Monitor


Financial implications will be associated with CQUIN


Regulatory implications for some indicators as shown in appendix A (dashboard)


Assurances of the quality of care provided


Directorate Performance Meetings Patient Safety Committee



Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible,

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at the first attempt.


Name of Lead Executive Directors: Name of Author:

Hilary Walker, Chief Nurse Guy Rooney, Medical Director Julie Marshman , Deputy Director of Quality Governance

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Quality Report May 2015*

*All data relevant to April 2015, unless otherwise specified

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Table of Contents Effective ......................................................................................................................................................................................................................................................... 3

Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster ....................................................................................... 3 Hospital Standard Mortality Rate (HSMR) .............................................................................................................................................................................................. 3 Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster ....................................................................................... 4 Palliative Care – Coding Levels - ............................................................................................................................................................................................................ 4 Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster ....................................................................................... 5 Standardised Hospital Mortality Indicator (SHMI) ................................................................................................................................................................................... 5 Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster ....................................................................................... 6 Patient Safety Indicators ......................................................................................................................................................................................................................... 6 Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster Mortality Alerts .............................................................. 7 Clinical Audit & Effectiveness .................................................................................................................................................................................................................. 7 Infection Prevention & Control................................................................................................................................................................................................................. 9 Environment .......................................................................................................................................................................................................................................... 13 Triangulation of one Ward with Cleaning Concerns from April’s data – Woodpecker Ward................................................................................................................. 15 Catheter Associated Urinary Tract Infections (UTI) – Safety Thermometer data ................................................................................................................................. 16 Clinical Incidents.................................................................................................................................................................................................................................... 16 Safety Thermometer – New Harm Free Care ....................................................................................................................................................................................... 20 Falls ....................................................................................................................................................................................................................................................... 21 Pressure Ulcers ..................................................................................................................................................................................................................................... 22 Staffing .................................................................................................................................................................................................................................................. 23 Safeguarding Adults & Mental Health ................................................................................................................................................................................................... 24 Deprivation of Liberty Safeguards ......................................................................................................................................................................................................... 25 Patients Detained under the Mental Health Act .................................................................................................................................................................................... 25 Mandatory Training – Acute Services ................................................................................................................................................................................................... 26 Mandatory Training – Community Services .......................................................................................................................................................................................... 26 Safeguarding Children ........................................................................................................................................................................................................................... 26 Serious Case Review ............................................................................................................................................................................................................................ 27 Mandatory Training for Safeguarding, MHA, MCA and DoLS .............................................................................................................................................................. 27 Learning Disabilities Do Not Attempt Cardiac Pulmonary Resuscitation (DNACPR) Audit Findings ................................................................................................... 28 Medicines Safety ................................................................................................................................................................................................................................... 29

Caring........................................................................................................................................................................................................................................................... 31

Complaints, Concerns & Compliments ................................................................................................................................................................................................. 31 Detailed Complaint Themes .................................................................................................................................................................................................................. 31 You Said… We Did ............................................................................................................................................................................................................................... 37 Division Concern/Complaint Activity April 2015 .................................................................................................................................................................................... 39 Friends and Family (FFT) ...................................................................................................................................................................................................................... 43 Deep Dive Analysis ............................................................................................................................................................................................................................... 44 Patient Experience ................................................................................................................................................................................................................................ 47

Responsive .................................................................................................................................................................................................................................................. 47

Whistle Blower Alerts ............................................................................................................................................................................................................................ 47 CQC ....................................................................................................................................................................................................................................................... 47

Well Led ....................................................................................................................................................................................................................................................... 48

Executive Patient Safety Walkabouts ................................................................................................................................................................................................... 48

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Effective

Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster

Hospital Standard Mortality Rate (HSMR)

Dr Foster has introduced a rolling quarterly re-base of the mortality relative risk baseline (the new baseline is the period July 2013 to September 2014, previously it was the last financial year 2013/14), which, as expected, has increased our monthly and overall HSMR slightly (the nationally expected baseline remains 100). Because of this, the full year re-base will now not be as great as previous years. The HSMR for December 2014 (the most recent data available from Dr Foster) is 85.47, a decrease from the previous month. The Trust is still below 100 with the April 2014 to December 2014 relative risk of 86.92, while the rolling twelve month period of January 2014 to December 2014 is 90.06. The chart below shows the HSMR trends for both the Trust and SHA against the crude total deaths by month. It can be seen that while there seems to be a link between crude mortality and the HSMR for the Trust, it is not necessarily an exact match and should only be used a possible indictor. The divergence of the HSMR figure from the crude mortality rate seen in December suggests that while the crude rate is higher, these patients had conditions/comorbidities that made an outcome of death more likely. It is expected that there will an increase in the HSMR for January 2015.

Southern Acute Trust HSMR November 2013 – October 2014

The graph below shows the HSMR performance for 35 Acute Trusts in the former South West SHA and in the south of England area for the period January 2014 to December 2014. With the HSMR at 90.06 the Trust is the well within the lower quarter of the group, showing the continuing trend of improvement when compared to previous months.

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15 Month HSMR Trend for the Trust & SHA with Crude Mortality Figures

Overall Trust Deaths

Dr Foster Mortality HSMR Relative Risk - Trust Overall

Dr Foster Mortality HSMR Relative Risk - SHA

Nationally Expected

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Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster Palliative Care – Coding Levels -

Palliative care is the holistic care of a patient who has been diagnosed with a life limiting illness with the goal of maintaining a good quality of life until death. By definition patients receiving palliative care have a higher risk of in-hospital death than that of non-palliative patients. Trusts which provide specialist palliative care services have a higher proportion of patients admitted purely for palliative care rather than treatment compared to trusts without specialist services. To account for this, the Hospital Standardised Mortality Ratio (HSMR) adjusts for patients who have received specialised palliative care when calculating the expected risk of death of a patient. Two codes are used by Dr Foster to identify patients receiving palliative care - Palliative Medicine specialty code 315 and the ICD-10 code Z51.5. The presence of either of these codes in any episode of a patients’ spell will result in a palliative flag being applied to the entire period of care for that patient. The charts below show the levels of Palliative Care coding; the first against the national average (for all Acute Trusts in England) since April 2011; the second chart is a comparison of Palliative Care coding rates within the southern region. When looking at the first chart it can be seen that for the period December 2012 through to the end of 2013 the level of Palliative Care coding was generally below the national rate but since early 2014 there has been a marked improvement in the levels of coding and the Trust is now slightly above the national average. Within the southern region the Trust is just above average for the period January 2014 and December 2014.

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GWH Percentage Pallative Care Coded Spells (HSMR Basket Only)

GWH Trust Rate (%) National Rate (%)

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Palliative Care Coding Rates Within Southern Region - Jan 2014 to Dec 2014

% Palliative Care Codeing Regional Average

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Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster Standardised Hospital Mortality Indicator (SHMI) The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at Trust level across the NHS in England. This indicator is produced and published quarterly as an experimental official statistic by the Health and Social Care Information Centre (HSCIC). The SHMI is the ratio between the actual number of patients who die following treatment at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.

Standardised Hospital Mortality Indicator (SHMI) GWH and National Comparison

The Trust’s SHMI for the rolling period July 2013 to June 2014 is 97.65. This is lower (better than) the expected value of 100, although this is a slight increase from 96.0 for the previous period (April 2013 to March 2014). This is showing a similar trend to the HSMR figures. NB the SHMI is always at least 6 -9 months in arrears

The chart shows how the Trust’s SHMI compares nationally and demonstrates we were positioned within the lower (better) half overall between July 2013 and June 2014. The red line depicts the GWH, and the green horizontal line is the nationally expected norm

9092949698

100102104106

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GWH SHMI Trend

SHMI Value Nationally Expected

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National SHMI July 2013 to June 2014 (GWH in red)

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Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster Weekend and Week Day Mortality Rates

Day of admission

Actual Mortality Rate (%)

Expected Mortality Rate (%)

Relative Risk

Low Confidence

Limit

High Confidence

Limit Rating

ALL 6.09 6.80 89.60 84.16 95.29 Better Than Expected

The table shows mortality for Non-Elective patients (please note that previous reports covered admissions for both Elective & Non-Elective patients) by admitting day of the week for the year January 2014 to December 2014. The data has been reviewed at the Mortality Group with the Dr Foster representative. There is no suggestion currently of raised mortality rates for patients admitted at the weekend. It is worth noting that the relative risk for Saturdays is 120.82 but the lower confidence interval is well below 100 (86.54) and therefore not significant. A more detailed analysis of weekend mortality by month does not suggest a problem (although weekend deaths continue to be monitored and audited).

Sunday 7.30 7.47 97.62 81.68 115.77 As Expected

Monday 5.72 6.45 88.77 75.18 104.12 As Expected

Tuesday 5.59 6.59 84.78 71.67 99.60 Better Than Expected

Wednesday 4.90 6.55 74.86 62.16 89.38 Better Than Expected

Thursday 6.15 6.65 92.53 78.40 108.46 As Expected

Friday 6.10 6.82 89.54 76.32 104.39 As Expected

Saturday 7.62 7.43 102.62 86.54 120.82 As Expected

The nationally expected Relative Risk (RR) is 100, the ‘Low’ and ‘High’ figures show the confidence levels around the RR; If the ‘LOW’ number is greater than 100 then the RR will be statistically significantly higher than nationally expected, if the ‘HIGH’ number is lower than 100 then the RR will be statistically significantly lower than nationally expected.

Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster Patient Safety Indicators Dr Foster produces a number of indicators to measure quality of service. All are within expected limits however the indicator of Postoperative Hip Fracture is slightly high with 3 instances compared to an expected number of 1.5. This is being investigated.

Patient Safety Indicator - Jan 2014 to Dec 2014 Volume Observed Expected Observed

Rate/K Expected

Rate/K Relative

Risk CUSUM Indicator

Deaths in low-risk diagnosis groups* 34304 14 20.5 0.4 0.6 68.0

Decubitus Ulcer 9170 169 367.4 18.4 40.1 46.0

Deaths after Surgery 298 37 36.0 124.2 120.8 103.0

Infections associated with central line* 17410 0 0.9 0.0 0.1 0.0

Postoperative hip fracture* 22784 3 1.5 0.1 0.1 194.0

Postoperative Haemorrhage or Haematoma 18743 7 9.8 0.4 0.5 71.0

Postoperative Physiologic and Metabolic Derangement* 15688 3 2.9 0.2 0.2 104.0

Postoperative respiratory failure 14152 17 11.1 1.2 0.8 154.0

Postoperative pulmonary embolism or deep vein thrombosis 19024 36 38.0 1.9 2.0 95.0

Postoperative wound dehiscence* 784 0 0.8 0.0 1.0 0.0

Accidental puncture or laceration 65745 27 73.8 0.4 1.1 37.0

Obstetric trauma - vaginal delivery with instrument* 751 57 65.5 75.9 87.3 87.0

Obstetric trauma - vaginal delivery without instrument* 3848 158 154.9 41.1 40.3 102.0

Obstetric trauma - caesarean delivery* 1653 1 6.5 0.6 3.9 15.0

Postoperative sepsis 903 3 6.0 3.3 6.6 50.0

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Please Note: This Is March Data as Hospital Episode Statistics data is not currently available to Dr Foster Mortality Alerts The Dr Foster data tracks trends in mortality and uses statistical techniques to flag possible emerging trends and these are termed red bell alerts and are detailed in the table below. There are two new alerts, both for procedures. The first is for ‘Therapeutic Endoscopic Procedure on Ureter’. This was last an alert in December 2013, and as last time, it only affects a small number of patients as can be seen in the table below. The second alert is for the procedure group ‘High Cost Drugs’, which also alerted in the past, last time being January 2013. The usual patient level analysis will be carried out for both these alerts.

Latest Alerts - Apr 15 Rolling 12 Month (Jan 14 - Dec 14) Year to Date (Apr 14 - Dec 14)

Diagnosis Group Relative Risk Observed

Deaths Expected Deaths

Relative Risk Observed


None

Latest Alerts - Apr 15 Rolling 12 Month (Jan 14 - Dec 14) Year to Date (Apr 14 - Dec 14)

Procedure Group Relative Risk Observed


Relative Risk Observed


Therapeutic Endoscopic Procedure on Ureter 495 4 0.8 393 2 0.5

High Cost Drugs 202 10 5.0 238 9 3.8

Clinical Audit & Effectiveness National Audits

Progress with the National projects continues as planned, as individual projects commence, they are assessed accordingly for relevance and participation; there are currently 12 National projects that are not applicable for the trust to participate. Up to 20 National projects are in the process of producing reports from previous financial year/s, of which, the majority are expected to be published during Q3 of 2015. Of the 19 National projects where the national reports have been received, up to 14 are in the process of being locally assessed, of which, 6 local reports are now overdue. Where National projects have been locally assessed, there are 5 reports which are awaiting an appropriate action plan, and 15 are awaiting action plan evidence. Divisional Boards have been directly informed of their activity with particular attention to the overdue status; projects are now being managed and monitored by the divisional leads to ensure a prompt completion.

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National Audits

Clinical Audit Title Key Assurances Key Areas to Develop Division

National Cardiac Rhythm Management (CRM) 2013/14

GWH are performing better than the national average and meet the NHS England Specialist Commissioning requirements for implant numbers for complex device therapy.

No local issues have been raised as GWH out performs the national average in every key criteria

USC

National Chronic Obstructive Pulmonary Disease (COPD) 2013/14

Improvements shown include: Proportion of patients receiving Respiratory specialist input, Provision of supported discharge services, Staffing levels and Length of stay.

Increase specialist reviews especially at weekends; provision of Level 2 care beds; work with community partners to improve local discharge care, formalise referral pathway and accessibility for patients.

USC

Re-audit Falls and Fragility Fractures Audit Programme (FFFRAP) includes National Hip Fracture Database 2013/2014

Performed extremely well in ‘time to theatre’ <36hrs, appropriate operative management, a reduction in LOS by 3.5 days and 76% of patients seen pre-op by Geriatrician. Improvement in Best Practice Tariff (5th out of 17 Trusts in South West).

Timely transfer to appropriate ward for MDT input: Trauma Unit or Ampney only and no Hip fractures should go to any other ward. Implementation of a Fracture liaison Service.

USC

National Mental health (care in emergency departments) 2014/15

Very good risk assessment with documentation and referrals to psychiatric team.

Improve recording a formal Mental state exam and provisional mental health diagnosis.

USC

Paracetamol Overdose (care provided in emergency departments) 2013/2014

GWH performs well in testing patients who needed treatment within 8 hours of overdose. Few patients refused treatment and there were no serious omissions in treatment.

Improve recording of when plasma levels are done (this affects compliance with Guidelines), improve local education on use of poisoning paperwork and use of extra blood bottle stickers on notes.

USC

National Coronary Angioplasty/ National Audit of Percutaneous Coronary Intervention (PCI) 2013/14

GWH exceeds the national average in ‘Call to Balloon’ (CTB); % of procedures performed using radial approach; in line with BCIS recommendations for PCI’s conducted.

‘Door to Balloon’ (DTB) - is just below the national average but well within the clinical indicators.

USC

No Participation/Not relevant to services – National Intra-Thoracic Transplantation 2015-16 National Liver Transplantation 2015-16

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Safe

Infection Prevention & Control

April 2015 blood culture contamination rate was 2.9%. Our median blood culture

contamination rate is currently at 3.45%

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Clostridium difficile

Total CDI Median

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There were seven cases of Clostridium difficile reported during April (Quarter 1). Six cases were Acute patients and one Community patient. This is a significant

increase to numbers reported in recent years. This places the Trust at a high risk of breaching the annual limit set for 2015-16 at 20.

Two wards have been placed on periods of increased incidence (Neptune and Meldon Wards, GWH) as two hospital acquired cases were reported on the same

ward within a 28 day period. Four of the seven patients have been inpatients for over a month. All had received antibiotics with half also receiving PPI therapy. A

number of specimens have been sent to the PHE laboratory for further testing (ribotyping) to identify the strain of Clostridium difficile to exclude cross-infection.

A C.diff improvement plan has been introduced. This focuses on antibiotic prescribing and EPMA roll out; cleaning of patient equipment; the IP&C risk

assessment; hand hygiene of patients prior to meal times; environmental hazards to reduce the risk of cross-infection and IP&C review of all cases. This review

will consider all patient hospital admissions to rule out potential cross-infection, antibiotic use, risk factors and assessments. IP&C have requested a short report

from matrons triangulating cleaning results, environmental and care equipment, staffing levels/vacancy rate, red flags and any known equipment shortages.

Findings will be monitored through the Infection Control Committee.

A critical friend review was undertaken by two external senior IP&C nurses. Initial findings identified some use of multi-use products such as body wash. Stool charts were also not always up to date and delays in obtaining specimens were a potential problem in some areas. Concern was raised that with e-Prescribing patients on antibiotic therapy were not easily identifiable and hence the risk of developing C.diff not clear to staff. IP&C have also lost the capacity to apply an alert sticker to the electronic drug chart, to flag patients with a history of C.diff to staff. An alternative solution is currently being scoped with the EPMA team.

Clostridium Difficile

Quarter 1

Quarter 2

Accumulative (Q1 & Q2)

Quarter 3

Accumulative (Q1, Q2 &Q3

Quarter 4

Accumulative total to date

C.diff trajectory 5 5 10 5 15 5 20

GWH Reported cases 7 7

CCG C.diff Reviews

Unavoidable

Avoidable

Other reportable infections

MRSA Bacteraemia April – 0 Year to date - 0

MSSA Bacteraemia April – 1 Year to date - 1

Ecoli Bacteraemia April – 3 Year to date - 3

GRE Bacteraemia April – 0 Year to date – 0

CPE colonisation April – 0 Year to date – 0

Influenza During April four cases of influenza were confirmed within the Trust, a mixture of all three strains was identified.

ICU SAU Delivery

2 1 1

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Public Health England – Flu Vaccine Update Following the Publication of Provisional Frontline Health Care Workers (HCWs) Flu Vaccine Uptake Data 2014/15 from Public Health England, the attached table shows the performance of the Great Western Hospitals NHS Foundation Trust against national figures and local Trusts. The Trust’s delivery was 50% and compares favourably with local Trusts.’

England Total - National and local flu totals 2014/2015 and comparisons to 2013/2014 February 2014/15 January 2013/14*

Response summary Vaccine uptake Response summary Vaccine uptake

No. of organisations

No. of organisations making a return

% of organisations making a return

Number of HCWs with direct patient care

Seasonal flu doses given since 1 September 2014

Vaccine uptake (%)

No. of organisations

No. of organisations making a return

% of organisations making a return

Number of HCWs with direct patient care


Vaccine uptake (%)

267 267 100.0 987,310 541,757 54.9 271 269 99.3 974,632 534,090 54.8

Trust Name Number of HCWs involved

with direct patient care Seasonal flu doses given since 1 September 2014

Vaccine uptake (%)

Number of HCWs involved with direct patient care


2gether NHS Foundation Trust

1,415 774 54.7 1,394 717

Avon & Wiltshire Mental Health Partnership NHS Trust

3,085 1,359 44.1 3,078 1,378

Bath, Gloucestershire, Swindon & Wilshire Area Team

5,023 2,664 53.0 3,067 1,542

Bristol, North Somerset, Somerset And South Gloucestershire Area Team

5,085 3,076 60.5 6,422 3,549

Buckinghamshire Healthcare NHS Trust

5,483 3,061 55.8 4,390 3,355

Great Western Hospitals NHS Foundation Trust

4,368 2,186 50.0 4,491 2,351

Oxford University Hospitals NHS Trust

8,988 5,634 62.7 9,266 6,150

Royal United Hospital Bath NHS Trust

3,835 1,851 48.3 2,661 1,868

Salisbury NHS Foundation Trust

2,413 1,100 45.6 2,316 1,211

Page 51

of 48

There has not been any Trust attributed MRSA Bacteraemia (MRSAB)

reported during April 2015.

There was one MSSA bacteraemia attributed to the Trust during April 2015. The case attributed to Jupiter ward, GWH attributable, with the primary source being skin and soft tissue. The patient was receiving treatment for an MSSA infection in a foot ulcer.

0

1

2

3

4

5

6

7

2009-1

0

2010-1

1

2011-1

2

2012-1

3

2013-1

4

2014-1

5

2015-1

6

Acute Cases of Trust Apportioned MRSA Bacteraemia

0

1

2

3

4

Ap

r-14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-1

4

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Acute Cases of MSSA Bacteraemia

MSSAB

Page 52

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There were three E coli Bacteraemias attributed to the Trust during April.

Two cases were on Meldon Ward and one on Woodpecker.

The sources are likely to be a catheter associated urinary tract infection,

hepato-biliary and one urinary tract infection not associated with

catheterisation.

Environment

Cleanliness standards

The cleaning scores for April was maintained at 95.2% overall. The fourth

floor is now beginning to improve its cleaning scores each week.

Carillion responded positively to the increased numbers of C.diff by cleaning

the acute site with Chlorine for a period of two weeks upon the request of

IP&C.

0

1

2

3

4

5

6

Ap

r-14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-1

4

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Acute Cases of E coli Bacteraemia

E coli Bacteraemia

70%

75%

80%

85%

90%

95%

100%

Jan

uary

Fe

bru

ary

Ma

rch

Ap

ril

Ma

y

Jun

e

July

Au

gust

Se

pte

mb

er

Octo

ber

Novem

ber

Decem

ber

Jan

uary

Fe

bru

ary

Ma

rch

Ap

ril

Cleaning Performance - Jan-14 to Apr-15

Average Score Audit Pass Rate Target Contracted Target

Page 53

of 48

GWHFT Data – Including Clinical Equipment

Managerial/IP&C Inspections

Ward//Department Date Comments

LAMU 9.4.15 Equipment generally dusty. Contamination with blood and tape on other equipment.

Orthopaedic

outpatients

16.4.15 Standard of cleaning was very good – department clean and clutter free. some dust found in the corners, windowsills and high dust

Pathology South 23.4.15 laboratory eye wash sinks need removing Water damage to window sills. The department is difficult to keep clean – due to the nature of the work

Sexual Heath 30.4.15 Environment very clean. Some of the clocks required batteries. Waiting room chairs are worn and holes are developing in the fabric. Water damage to window sills

Matron spot checks – clinical equipment focus

Ward Date Compliance Level

Comments

Longleat 31.3.15 Very good The trolley for the resuscitation equipment had some dust evident. A stand aid was dusty and had evident debris on the base.

Patient Care Equipment – Departmental self-audits

Trust wide patient equipment audits, completed by the wards are scoring

between 95.5% and 98%.

Individual ward scores are returned to the wards in a chart to display; scores

are reviewed at the cleaning standards group, and triangulated with

housekeeping scores and infection data.

90.0

91.0

92.0

93.0

94.0

95.0

96.0

97.0

98.0

99.0

Ap

r-14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-1

4

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Trust Wide Patient Care Equipment - Departmental Self-Audits

Trust Wide Patient Equipment Median Target >95%

Higher is better

Page 54

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Triangulation of one Ward with Cleaning Concerns from April’s data – Woodpecker Ward

IP&C spot check visit identified issues with nursing cleanliness: Dusty drawer rails

Isolation doors left open Cluttered window sills, inhibiting daily cleaning Tiger stripped bins smelly and not emptied by ward staff Suction and oxygen points dusty Commodes not always clean when taped as clean Bedside tables dusty

Fans dusty

House Keeping data Consistently 97% and above

Environmental Care Bundle cleaning scores Environmental Care bundle data was not submitted for 3 consecutive months

Reported infections during April Ward closure 10th April due to Norovirus. 1 C.diff case 1 Ecoli bacteraemia

Friends and family feedback

Staffing February March

Vacancies 3.25% 9.95%

Sickness Rate 5.97% 5.54%

85

90

95

100

Jan

15 W

k 1

Jan

15 W

k 2

Jan

15 W

k 3

Jan

15 W

k 4

Fe

b 1

5 W

k 1

Fe

b 1

5 W

k 2

Fe

b 1

5 w

k 3

Fe

b 1

5 w

k 4

Ma

r 15

wk 1

Ma

r 15

wk 2

Ma

r 15

wk 3

Ma

r 15

wk 4

Ap

r w

k 1

&2

Ap

r w

k 2

&3

Ap

ril w

k 3

Woodpecker Carillion scores

Page 55

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Catheter Associated Urinary Tract Infections (UTI) – Safety Thermometer data

The numbers of new UTI’s reported remains low for the past three months with a maximum of five new UTI’s being reported. This data is now being validated by the Matron prior to submission. The Trust has joined the Oxford Health Science Network to partake in a collaborative piece to work to standardise catheter use and insertion practice. Two pilot wards have been identified and work is underway to test staff knowledge and put a process in place prior to staff selecting a urinary catheter in the first instance. This project will run over the next 12 months.

Clinical Incidents Never Events May 2014 Jun 2014 July 2014 Aug 2014 Sept 2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

0 0 0 0 0 1 0 0 0 0 1 0

Apr14

May14

Jun14

Jul14Aug1

4Sep1

4Oct1

4Nov1

4Dec1

4Jan1

5Feb1

5Mar1

5Apr1

5

Catheter & New UTI 3 5 4 5 6 3 1 7 7 5 5 5 2

Mean 4.46 4.46 4.46 4.46 4.46 4.46 4.46 4.46 4.46 4.46 4.46 4.46 4.46

Patients 1184 1182 1208 1290 1163 1041 1223 1148 1119 1021 1145 1161 1103

0

1

2

3

4

5

6

7

Page 56

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Serious Incidents Reported Year on Year Comparative 2013/14 & 2014/15

Serious Incidents There was one Serious Incident reported by the Trust in April 2015. A total number of 99 serious incidents were reported and investigated during the period April 2014 to March 2015; an increase of 28 incidents from 2013/14. This increase can be in part attributed an additional 6 safeguarding concerns reported (increasing from 2 to 8), 17 additional category III and IV pressure ulcers (increasing from 26 to 43). Excluding the main incident cause groups for falls, pressure ulcers and safeguarding there were no significant themes within the other cause groups.

Serious Incidents Reported April 2015

Incident number Division Area/Department Incident type

77024 Unscheduled Care Woodpecker Category III Pressure Ulcer

Serious Incidents Rate - Acute

This demonstrates the rate of the number of Serious Incidents per 10,000 bed days for Acute Adult Inpatients within GWH and the Community Hospitals

0

2

4

6

8

10

12

14

16

18

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Serious Incidents reported Median

0

1

2

3

4

5

6

7

8

9

10

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Rate SI's per 10,000 bed days Median

Combined Adult Inpatients Serious Incident Rates per 10,000 Bed Days

Page 57

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Serious Incidents Rate - Community Integrated Teams

There are currently 14 Serious Incident Action Plans in progress, three of which are overdue (displayed in graph).

153

89

30

0

20

40

60

80

100

120

140

160

180

65984 69118 72281

Planned Care Women & Children Diagnostics & Outpatients

Total Number of Overdue Action Plans

This graph is based on the number of “contacts” [visits to] with patients within the Community

0.00

1.00

2.00

3.00A

pr-

13

Ma

y-1

3

Jun

-13

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Jun

-14

Ju

l-1

4

Au

g-1

4

Se

p-1

4

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14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Rate SI's per 10,000 bed days Median

Community (Contacts) Serious Incidents Rate per 10,000 Bed Days

Page 58

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Incident Number

Due Date Ward Incident Description Action/Issue Lead

65984 30/11/2014 Meldon Rescue of Deteriorating patient 1. Discussions regarding improving surgical documentation to be held at surgeons meeting. Complete

Urology Consultant

72281 30/03/2015 Dermatology Wrong Lesion Removal 1. To implement a standard electronic document that communicates between clinic and operation lists. Update: Confirmation that Hugo Mathias from Informatics is supporting development of the electronic documentation. Planned completion July

Michael Wilson/Lindsay Whittam/ Alison Koster

69118 31/01/2015 Children’s Unit Failure to follow child safeguarding process- Paediatrics – Delay in referral to Social Services to commence a Child Protection Core Care Plan

One outstanding action: 1. Regarding supervisory role of nurse in charge. Staff

skill mix paper to Divisional Board in June and Executive Committee in July.

Sarah Merritt

Overdue IR1 Investigations

Since last month the number of IR1’s overdue (by more than 14 days) in April is 329. These are constantly being reviewed and updated and this figure can change daily. The average number of days that IR1s are overdue has increased slightly from 73 to 79.

Top Overdue IR1 Departments Number

Marlborough ICH Team 23 Saturn Ward 23

Linnet Ward - Acute Medical Unit 20

Chippenham ICH Team 17 Ailesbury Ward 15 Tissue Viability 14 Trauma Unit 14 Cedar Ward 12

Corsham ICH Team 10

0

100

200

300

400

500

600

700

Jul-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

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3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

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-14

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4

Au

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Se

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14

Nov-1

4

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4

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-15

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b-1

5

Ma

r-15

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r-15T

ota

l N

um

be

r o

f o

verd

ue

In

cid

en

ts

All overdue IR1 investigations Median

Page 59

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IR1 Rates per 10,000 Bed Days – Acute IR1 Rates per 10,000 Contacts - Community

Safety Thermometer – New Harm Free Care The Safety Thermometer is a national initiative that records the presence of four harms on all patients on one day every month. The rationale for focusing on the four harms is because they are common and because clinical consensus is that they are largely preventable through appropriate patient care.

New Harm Free Care

April’s New Harm Free Care was 94.92 % (March was 96.47%) Matrons have been actively encouraged to lead their individual areas and in an attempt improve patient outcomes. Each ward Area within the acute initially will be given their individual areas % of harm free care around the safety thermometer domains.

0

100

200

300

400

500

600

700

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Rate IR1's per 10,000 bed days Median

Combined Adult Inpatients

0

20

40

60

80

100

120

Ap

r-13

Ma

y-1

3

Jun

-13

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Jun

-14

Ju

l-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Rate IR1's per 10,000 Contacts Median

IR1 Rates

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Falls

The Acute Site ended the last Financial year below the national average of 5.6 falls per 1000 bed days with 4.28 falls per 1000 bed days. In April 2015, the Acute Site performance matched the national average with 5.6 falls per 1000 bed days. This is an increase of 1.32 falls per 1000 bed days. The Fall Safe Operational group continues to work on reducing the amount of falls within their individual wards. The group continues to meet on a monthly basis where the top 5 wards with the highest number of falls present to the group with actions they are taking to reduce falls numbers. The group supports the top 5 wards with initiatives that are working in other areas and ideas on the reduction of falls. Serious incidents of falls are also presented to the group including lessons learned and actions being taken to prevent recurrence.

The Community Site performance is above the national average of 8.6 falls per 1000 bed days. The Community Site finished the last financial year at 9.22 falls per 1000 bed days. In April 2015, Community performance went up by 3.8 falls per 1000 bed days to 13.02 falls per 1000 bed days.

0

2

4

6

8

10

12A

pr-

14

Ma

y-1

4

Jun

-14

Jul-1

4

Au

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4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Acute Falls per 1000 Bed Days

Falls per 1000 bed days Average

Upper Control Limit National average

0

2

4

6

8

10

12

14

16

18

20

Ap

r-14

Ma

y-1

4

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-14

Jul-1

4

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4

Se

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4

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14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Community Falls per 1000 Bed Days

Falls per 1000 bed days Average

Upper Control Limit National average

Page 61

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The total number of moderate to severe harm across the Trust between February and April 2015 was 10. There were 4 severe harms and 6 moderate harms resulting from falls. Unscheduled Care Division recorded the highest number of severe and moderate harm (7 in total). This is due mainly to the high number of patients with diagnosed Dementia. Patients who are at very high risk are managed through close support monitoring with the aim of reducing harm from falls. Planned Care Division recorded x 1 severe harm and x1 moderate harm from falls. Integrated Community Health recorded x 1 moderate harm.

Pressure Ulcers Acute Inpatients GWH Data (Rate per bed days)

The total number of pressure ulcers reported in April 2015 was ten, one category III and nine category II. The hot spot is Teal with two category II pressure ulcers. Woodpecker reported one category III pressure ulcer. CCU, ITU, Jupiter, Mercury, Neptune, Saturn and Trauma have had one pressure ulcer develop per ward. The Tissue Viability Nurse Consultant (TVNC) is leading a Harm Free Care action plan to reduce pressure ulcers with Think Skin: Your Actions Relieve the Pressure. The actions include:

Roll out of the new Pressure Ulcer Risk Assessment Tool (PURAT), new Pressure Ulcer Prevention Core Care Plan and wound documentation is complete on all wards and is being audited weekly by the TV team.

Provision of pressure relieving mattresses from point of entry within two hours of the risk assessment. This provision is being monitored with the Equipment Library Manager.

Completion of PURAT from all points of entry including ED.

Stepping down to a foam mattress for patients no longer requiring an air mattress in an attempt to use the equipment more effectively. This is being monitored by the Equipment Library Manager and is being audited by TV in a new TV patient pathway audit.

Trial of new heel protectors is underway on the hot spot wards.

0

1

2

3

Moderate(Short Term

Harm)

Severe(Permanent

Or LongTerm Harm)

Moderate(Short Term

Harm)

Moderate(Short Term

Harm)

Severe(Permanent

Or LongTerm Harm)

Moderate(Short Term

Harm)

Severe(Permanent

Or LongTerm Harm)

Apr-15 Mar-15 Apr-15 Feb-15 Mar-15 Apr-15

IntegratedCommunity

Health

Planned Care Unscheduled Care

Nu

mb

er

of

Inc

iden

ts r

ep

ort

ed

Falls by Actual Harm (Rolling 3 months February to April 2015)

0

0.2

0.4

0.6

0.8

1

1.2

Ap

ril 2014

Ma

y

Jun

e

July

Au

gust

Se

pt

Octo

ber

Novem

ber

Decem

ber

Jan

uary

Fe

bru

ary

Ma

rch

Ap

ril 2015

Rate per 1000 bed days

Page 62

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Community - GWH Data Incidence (Bed days not relevant)

The total number of pressure ulcers developed in April 2015 was twenty, all at category II. The ICHD Quality Lead and the Tissue Viability Lead have devised an improvement plan, Reduction of Avoidable Pressure Ulcers which is being review at the Harm Free Care Focus Group on a quarterly basis. The action plan includes:

Embedding revised PURAT and wound documentation throughout ICHD. Measuring success of the rollout of new documentation using the TV pathway audit. First audit May 2015 across ICHD.

Work progressing with care agencies and ICHD regarding the use of the SSKIN Bundle Tool.

Development of comprehensive ‘Introduction to the Community’ programme with the aim for staff members to attend as soon as possible after start date. This will include training from experts from the Clinical Risk team, Tissue Viability etc. to set standards and expectations and support new team members.

Tissue Viability to provide training and support to Therapists on patients at risk or with pressure ulceration.

Ensuring effective management of patients with concordance issues in relation to pressure relief, this is being led by the Safe Guarding Lead.

Staffing

April 2015 Skill Mix

Day Night

Planned Actual Planned Actual

Registered Nurse

67.01% 61.50% 71.54% 65.32%

Unregistered Nurse

32.99% 38.50% 28.46% 34.68%

There continues to be a shortfall in the number of Registered Nurses (RN), in the day, compared with planned hours. There is an associated increase in Unregistered (UR) staff. Actual staffing skill mix at night is more consistent with the desired ratio of RN/UR (65/35). Staffing and skill mix continues to be monitored on a daily basis, by Matrons and Deputy Head of Locality. Review and planning is carried out by Divisional Directors of Nursing and Head of Locality.

0

5

10

15

20

25

Ap

ril 2014

Ma

y

Jun

e

July

Au

gust

Se

pt

Octo

ber

Novem

ber

Decem

ber

Jan

uary

Fe

bru

ary

Ma

rch

Ap

ril 2015

Monthly actual patient numbers

Page 63

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Monthly Data

Number of IR1s regarding staff issues

February March April

Cause 1- 23 Cause 2- 44

Total: 67 55 44

There are two sections within the Serious Incident System that staff can use to enter an incident; these are called Cause 1 and Cause 2 respectively. Previously this data was extracted from ‘Cause 1’ only; however this has now been amended and updated to include ‘Cause 2’ data. This accounts for the difference in numbers of staffing IR1s previous to March. In order to provide a comparison for the previous months’ figures the total figure has also been added for January and February. On-going this will be a combined number as per the March figures and not split between Cause 1 and 2

Number of F&FT mentioning poor staffing levels

6 1 6

Safeguarding Adults & Mental Health

GWH Safeguarding Adults Team has recorded the following data as the Trust’s submission of our reported Safeguarding Adults alerts and Deprivation Of Liberty applications. This data was obtained via the current standard reporting processes which include all alerts and applications being forwarded centrally to the GWH Safeguarding Adults Administrator. The team continue to explore streamlined systems and promotion of the current process, including an audit in this area. In total 51 safeguarding alerts were raised by Great Western Hospital NHS Foundation Trust in Quarter 4 for 2014/15 showing an increase in reporting from Q3. Neglect is the top category of harm reported this quarter by the Trust with the remainder of the figures being split between all other categories There were thirteen Safeguarding alerts in total reported against the Trust in Q4. Eight of the reported alerts were against the Acute services, five of these investigations are on-going; two investigations have outcomes with no action against the Trust and one investigation is awaiting the outcome. Community: One investigation on-going with no action expected and four are complete with no action against the Trust.

0

5

10

15

20

25

30

Ap

r

Ma

y

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Nov

Dec

Jan

Fe

b

Ma

r

Alerts raised

Raised by Staff (not against the Trust) Alerts against the Trust

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Deprivation of Liberty Safeguards

There were 50 DoLS applications made during Quarter 4. The Safeguarding Adults at Risk Team are working with the Divisional Directors of Nursing, Matrons and Ward Managers in raising awareness of the reporting process. 10 Extension of Urgent Applications were recorded although the Safeguarding Adults Team are aware that the Supervisory Bodies are acknowledging the 7 days urgent extension as they are still lacking the capacity to provide an assessment under a DoLS within the 14 day urgent application. GWH Safeguarding Adults team are raising awareness and supporting staff to ensure that the wider provisions of the MCA (2005) are adhered to. Death under a DoLS: ICHD: No deaths occurred whilst patient was under a DoLS Acute Services: No deaths occurred whilst patient was under a DoLS

Patients Detained under the Mental Health Act

Section 2: Admission for Treatment – Detention for a period not exceeding 28 days including the day the patient was detained. Section 2 – Other Hospital. Inpatient at GWH receives mental health assessment and detained under Section 2 of MHA to another hospital. Patient transferred to the other hospital. Section 3: Admission for Treatment. Detention for up to six months including the day the patient was detained. Section 5(2): Report on Hospital In-Patient. Doctors holding order that lasts for up to 72hrs during which time the patient should receive a full Mental Health Act assessment. Section 17: Authorised Leave of Absence – Patient is detained to another Hospital under the Mental Health Act and attending GWH for medical assessment/treatment. Section 19: Authority to transfer patient detained under the Mental Health Act from Hospital to another under Different Managers. Section 23: An Oder for Discharge. Registered Responsible Clinician assesses patient under the MHA and discharges patient from their Detention Order. Death under a Detention of Mental Health Act:

No deaths occurred in the Trust whilst patient detained under the Mental Health Act.

0

5

10

15

20

25

30A

pril

Ma

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e

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gust

Se

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mb

er

Octo

ber

Novem

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Decem

ber

Jan

uary

Fe

bru

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Ma

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Total number of DoLs Applications made

Total number of Patients Referred Under Deprivation of Liberty Act

0

1

2

3

4

5

6

7

October November December January February March

Use of Sections of the Mental Health Act

2 2 other hospital 3 17 5(2) 19 23

Page 65

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Mandatory Training – Acute Services January February March Quarter 4 training data:

Consent, Mental Capacity Act & DoLS 85.79% 90.78% 88.96% 87.60%

Dementia 86.25% 90.28% 89.02% 88.35%

Mental Health Act 80.45% 85.03% 82.89% 81.86%

Adult Safeguarding 96.37% 97.65% 97.36% 96.93%

Mandatory Training – Community Services January February March Quarter 4 training data:

Consent, Mental Capacity Act & DoLS 97.93% 98.43% 95.96% 91.63%

Dementia 92.09% 91.85% 91.42% 89.77%

Mental Health Act 87.11% 87.07% 87.86% 85.73%

Adult Safeguarding 99.06% 99.47% 99.40% 99.00%

Safeguarding Children The Trust continues to show commitment to improving work to safeguard children. The Quality Data/Dashboard for safeguarding children is under development and data collation is being reviewed in some areas to ensure this reporting is robust going forward. This quarter we are able to report on Child Protection strategy meetings attended by maternity services in addition to those attended by community children’s services.

Wiltshire Child Protection Strategy Discussions – Total number and attendances by GWH Community Children’s Staff.

A Strategy Discussion is called after receipt of a child protection referral and should involve local authority children’s social care, the police, health and other bodies as appropriate. The purpose of the discussion is to share information, ascertain what action is required immediately and whether a Section 47 investigation needs to be undertaken. In Wiltshire, for children not open to social care teams, strategy discussions take place in the Multi-agency Safeguarding Hub (MASH) and one of our safeguarding specialist nurses is permanently sited in the MASH to advise of safeguarding issues and to input into these discussions. Strategy meetings on children who are already open to social care continue within the locality teams and community staff, such as health visitors and school nurses, attends these meetings. A central referral point coordinates and monitors attendance at these meetings. In Swindon midwives are invited to strategy discussions on ‘at risk’ unborn babies or pregnant teenagers.

101

141

165

189

99 (98%)

134 (95%)

154 (93%)

188 (99.4%)

0

20

40

60

80

100

120

140

160

180

200

Dec-14 Jan-15 Feb-15 Mar-15

TOTAL INVITED

TOTAL ATTENDED

Page 66

of 48

Total number and attendances by Swindon Midwives:

Our aspiration is to attend all strategy meetings but this is challenged by the short notice that is sometimes given for strategy meetings held within the community.

Serious Case Review Following the death of a 3 week old baby, the Swindon Local Safeguarding Children Board has determined a serious case review is required. This is because there is concern as to the way the local authority and their LSCB partners have worked together to safeguard the child. The purpose of a serious case review is to ensure appropriate action is taken to learn from serious incidents and to share those lessons through the publication of the final serious case review report. GWH teams will be involved with the multi-agency review, in particular our Maternity Services. Serious case reviews, by their very nature, often take a number of months to conduct. The findings from the review will be reported once known.

Mandatory Training for Safeguarding, MHA, MCA and DoLS

December January February March April Threshold

Child Protection Level 1 96.92% 97.18% 97.93% 97.41% 95.04% 80-100% - Green

70-79% - Amber

<70% - Red

Child Protection Level 2* 44.31% 47.83% 54.40% 59.16% 62.42%

Child Protection Level 3 23.28% 32.26% 35.60% 38.73% 41.99%

The organisational Safeguarding Children & Young People Training Strategy has been reviewed and is being implemented. The aim of the revised strategy is to ensure that the organisation fully meets the requirements of the “Intercollegiate Document: ‘Safeguarding Children & Young People: Roles and Competencies for Health Care Staff’, published in March 2014.

0

3

1

0

3 (100%)

1 (100%)

0

1

2

3

4

Jan-15 Feb-15 Mar-15

TOTAL INVITED

TOTAL ATTENDED

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Learning Disabilities Do Not Attempt Cardiac Pulmonary Resuscitation (DNACPR) Audit Findings LD DNACPR AUDIT: Background / Rationale In light of findings from reviews conducted by MENCAP, DH and the University Of Bristol a mortality review of 23 patients who were coded as having learning disabilities (date of death between June 2012 and October 2013) took place by a multidisciplinary team to review the DNACPR decision making process. Strategic Driver – Treat Me Right, MENCAP 2004

Death by Indifference, MENCAP 2007 Healthcare for All, Department of Health 2008 Six lives, Parliamentary and Health Service Ombudsman 2008 Valuing People Now, Department of Health 2009 Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD), University of Bristol 2013

Methodology A review of 23 patient’s care took place on the 9

th of January 2015 by a multidisciplinary team including a Consultant Anaesthetist and Intensive Care, Consultant

Respiratory Medicine and Intensive Care and a Matron, Care of the Elderly. Areas of concern The review highlighted that two patient notes had evidence of failure to plan in their diagnoses or treatment, including “no additional steroids given when unwell” & “Needed to make DNACPR decision earlier then discuss with family”. The reviewing team also highlighted that one patient’s notes had evidence of failure to identify Heart Rate and Respiratory Rate as an early warning score, the reviewing team also highlighted that 1 patient had evidence of failure to communicate between doctors in regards to a CPR arrest call being made for a patient that should have had a DNACPR completed earlier in the patients care. One patients had evidence of an adverse event that occurred in the proximity of progression to the unexpected cardiac arrest. Two patients’ notes shown evidence that an intervention could have been made in the first 24hrs preceding the patient’s death that potentially would have impacted the patient’s outcome.(Medication and/or IV fluids missed, delayed or cancelled x1; Failure to complete DNACPR documentation after patient is identified as approaching end of life x 1) Key Assurances

Two patients had evidence of rescue or response to changes in the patient’s clinical indicators (heat rate and respiratory rate, 02 saturations)

High level review in the vast amount of cases

DNACPR completed in vast amount of cases

12% of DNACPR decisions had been discussed with patients

43% of DNACPR decisions had been discussed with the patients family either in conjunction with a discussion with the patient or as a standalone conversation

Where a DNACPR discussion was not held with the patient or family member a reason why was documented (63%)

Evidence of appropriate decision making, senior level consultation and good conversations at an appropriate time of patients deterioration

Good practice against national guidelines

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Key Areas for development Overall 87% of patients had no issues with their care or DNACPR decision making process. However 13% (2) of patients had issues regarding recognising a deteriorating patient and initiating a DNACPR conversation. It should be noted that if it is in the best interest of the patient the DNACPR decision making process should not be delayed when contact with the patient’s family cannot be made. However, this should be clearly documented and they should be contacted at the earliest opportunity. Risks identified This audit has identified No Significant Risk Recommendations Areas highlighted as a concern or as an area for development will be addressed via the following work streams

EOL care strategy updated 15/01/2015

Treatment escalation plan (TEP) will be updating will be replacing DNACPR; this will transfer across services and is being implemented by the EOL group.

Recognising a deteriorating patient CQUIN (2015/16)

The ‘Conversation Project’ will be conducted throughout 2015/16

Medicines Safety

69 medication incident reports. Increased reporting compared to March No moderate harm incidents reported 9 EPMA related incident reports in April – To be reviewed by the EPMA group on a monthly basis.

13 3 3 3 4 3 3 8 4 4 3

72

59 60 65 59

40

88 67

42 49

60

3

2 7 3

2

3

6

11

10 3

7

1

3

1

1

0

20

40

60

80

100

120

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Nu

mb

er

of

Inc

iden

ts

Medicine Incidents by Harm

Near Miss None (No Harm Occurred)

Low (Min. Harm) Moderate (Short Term Harm)

Page 69

of 48

No “unaccounted for” Controlled Drugs for 2015/2016

Missing Controlled drug incidents IR1s 2015/2016

5 missing CDs reported in April of which 4 have been accounted for.

1 missing CD incident yet to be investigated on Delivery Suite.

0

1

2

Linnet Jupiter Neptune Trauma Delivery

Nu

mb

er

of

Inc

iden

ts

CD Incidents by Ward 2015/2016

Accounted Unaccounted Yet to be investigated

USC, 3, 60% PC, 1, 20%

ICH, 0, 0% WC, 1, 20%

DO, 0, 0%

Total Missing CD IR1s - 5 Trust Wide 2015/16

0

1

2

3

4

5

6

Mar-15 Apr-15

Nu

mb

er

of

Inc

iden

ts

CD Incidents by Month 2015/2016

Accounted for Unaccounted for Yet to be investigated

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Caring

Complaints, Concerns & Compliments

A slight increase in concerns received for April to 130, whilst Complaints saw a steady decrease for low – moderate complaints to 80. 95% of Concerns were responded to within timeframe avoiding the concern escalating through the complaints procedure. Booking Centre, ED, Orthodontics, Elective Admissions, Saturn and Urology have been identified as the top areas for concerns/complaints received for April. Themes Themes identified for April relate to Communication, Telecommunication, Waiting Times and Cancelled appointments. A full summary for April themes are detailed below.

Detailed Complaint Themes Concern Themes Summary Complaint Themes Summary Administration And Clerical Error Waiting time for appointment Behaviour / Attitude Of

Medical Staff Consultant Care on Teal Ward

Information on letter incorrect Attitude of staff Internal referral overlooked. Lack of support, Wrong appointment Consultant’s attitude. Advice Provided Husband came to pals regarding discharge of his wife from Jupiter Behaviour / Attitude Of

Non Clinical Staff Attitude of wheelchair services.

Attitude of Eye Clinic Receptionist and appointment issue Behaviour / Attitude Of Medical Staff Attitude of Staff on A & E A&E Receptionist Attitude Wife called to raise concerns care of husband on Teal Behaviour / Attitude Of

Nursing Staff Attitude of Staff at Chippenham MIU

Behaviour / Attitude Of Non Clinical Staff

Attitude of Car parking attendant

Concerns regarding lack of care in Obstetrics

Competency of Staff Member on Woodpecker Ward Behaviour / Attitude Of Nursing Staff Treatment in A&E Attitude of Sister at Warminster. Cancelled Cancelled Operation Behaviour / Attitude Of

Other Cold Restaurant

0

50

100

150

200

250

300

May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15

Number of Complaints Received

Concern Complaints (Low to Moderate) Complaints (High to Extreme)

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Incorrect Admission Date Sent Out Cancelled appointment by hospital Cancelled Orthotic department at Chippenham Discharged back to GP. Cancelled eye op due to administrative error. Orthodontic follow up appt Discharged from list in error. Delay in treatment Orthodontics Unhappy with amount of Gynae cancellations. Cancelled appointment by hospital Chasing Referral Choice - Access And

Waiting Delay to orthodontic treatment

Cancelled appointment Orthodontic follow up appt Clinical Care Care on Teal Ward Mix up over ultra sound appointment. Care and discharge from Gynaecology Time to get diagnosis and operation wait time. Choice - Access And Waiting Advice on General Surgery Procedures Clinical Treatment whilst recent inpatient automated remind Patient requesting further consultation instead of Physio. Clinical Care Clinical Care Care on Kingfisher Ward Emergency surgery Care on Saturn Ward Incorrect diagnosis. Cannula left in arm Issues relating to care on SAU and ED Obs Unhappy with care, Breast centre Concerns with care of patient's end of life care Unhappy with Colonoscopy Communication Insurance form for oncology treatment. CPAP Machine not used when airway support removed Unhappy with operation Lack of Care on Kingfisher Ward Chasing Spinal Injection Not happy with care Chasing Urology appointment Care on Mercury Ward Communication Lack of cancer support. Unable to find telephone numbers Issue with Anaesthetist and Pre-Op Assessment Unable to access medication. Transfer to JR from GWH and issues relating to inpatient stay Lack of communication regarding appointment Delayed operation. Delays at Eldene Discharge Meldon and appointments re pain clinic Chasing details of mother's death Inaccuracies concerning Cystoscopy procedure and notes Dermatology appt DNA in error. Neptune - unable to take down to scan. No one to help with booking transport for op Concern over incomplete patient records. Patient demanding to speak with CEO. Delay due to missing paperwork. Chasing Appointment for operation Unable to get through to Chippenham Podiatry Chasing appointment Appointment Cancelled

Concerns about Treatment for Husband on Teal Ward

Complications During/following Treatment

After care after left breast lump removal.

Queries over wife's death last week on ICU Breast screening injury. Error with appointment type. Poor Care in Delivery Unit Organising further blood test at GWH - Gastro Childbirth issues re twins Chasing Appointment Not happy with outcome of operation on her ankle Chasing up referral to Orthopaedics from SAU Concerns relating to Endoscopy Concerns about care of father-in-law on Teal Ward Post op care Mum is concerned over issues relating to Dr and communication Experience on Hazel ward and aftercare Not informed of Cancelled Appointment for General Surgery Confidentiality Incorrect Details on Scan Delayed Clinic delay. Delays to Community Paed appts Complications During/following Treatment

Staff unable to do procedure on Falcon Ward Delays to Surgery

Delay in Orthodontics appt Confidentiality Wrong prescription given in clinic. Delay to treatment Delay to operation (General Surgery) Delayed Chasing MRI results.

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Waiting for op. Diagnosis Diagnosis cancer Operation date now moved to September Concern re diagnosis. Delay in date for procedure. Misdiagnosis in A&E Chasing appointment for ENT Medical Care on Children's Unit Delay in Orthodontics appt Unhappy with planned Caesarean Section Misdiagnosis of infection. Discharge Arrangements Care of Mother on Cardiac Ward. Unhappy with Consultation Discharge arrangements Son is worried about his mother’s discharge currently on Woodpecker Discharge

Arrangements Care and discharge

Discharge from A & E Follow Up Treatment Rescheduling of Appointment in Plastics Discharge from Saturn Ward Lost/misplaced/delayed Test Results Chasing up blood results for on-going treatment Follow Up Treatment Appointment and follow ups in Urology Delay in test result Unhappy with Malmesbury care team. Chasing results from Dermatology Chasing results and follow up from Urology Health Records Unhappy that radiology do not send X-Rays Medication Delivery of medication. Information Provided Interrogation in A & E by Medical Team Other - Safe, High Quality Co-Ordinated Care

Care sister is receiving on Saturn Lost/misplaced/delayed Test Results

Delay in appointment from Paediatrics

Parking Unable to attend appt (Traffic) Medication Prescription error upon discharge. Prescribing error. Personal Property Lost property reimbursement query. Parking Car parking Privacy & Dignity Delay with Dermatology appointment - patient terminally ill. No Parking Spaces Referral Between Clinicians Blood test results only received from Public Health England. Request Information

On Dermatology Department

Request Information On Request for CCTV Service Denied Removed of waiting list for cancelling Patient not happy with diagnosis. Requests review of podiatry case. Telecommunications Unable to get through to Booking Centre Unable to get through to orthodontics Service Not Available Lack of Tinnitus Unable to get through to Salisbury Podiatry Given GW as option re choose and Book for ENT but no

appointments Unable to contact Chippenham Chasing results from scans. Waiting Time Waiting time in A&E Unable to contact Dermatology Unhappy with waiting time for orthodontic appointment Chasing Admission Date for Surgery Orthodontics - time between appointments. Unable to get through to Falls Clinic Care in A&E Unable to contact Chippenham Waiting time for appointment Unable to contact Chippenham Treatment at Trowbridge MIU Unable to get through to Urology for results Waiting time for appointment Unable to get through to orthopaedics Date for follow up. Unable to attend Physio appointment Delay to discharge Unable to get through to ENT Wife breached date for her hernia op Advice on Automated Messages Wait time to see orthopaedic consultant after scan Unable to get through to Chippenham Podiatry

Unable to contact Chippenham Unable to get through to Physiotherapy department Issues with Urology Appointment Chippenham podiatry Unable to contact Orthodontics

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Waiting Time Chasing Referral Waiting time for Gastro appt Chasing appointment Waiting for operation Waiting time in A&E Delay in Eye clinic Delay in Appointment for Gynaecology Chasing Referral Expedite ENT appt Orthodontic follow up appt Chippenham podiatry Waiting time pre assessment for Mr Yates re foot op Daughter waiting for date for knee op Unhappy with eye clinic

No complaints were reopened during the month of April.

0

1

2

3

4

5

6

7

8

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Number of Complaints Re-opened

Low/Medium complaint High/Extreme complaint

Page 74

of 48

Although the overall complaint response rate is low for April, this is due to the backlog of complaints being closed which are out of timeframe.

Directorate Concerns Complaint

L/M Complaint

H/E

D&O 98% 100% -

W&C 83% 100% 100%

Planned Care 92% 30% 29%

Unscheduled 100% 38% 50%

Corporate 100% 40% -

Carillion 100% 0% 100%

Integrated Community Health Services 100% 100% -

Performance Indicator 80% 80% 80%

Overall response rate 95% 50% 46%

Five Cases investigated and recommendations made by PHSO apology/action plan

Date complaint Received

Ombudsman contact

Investigated by Ombudsman & recommendations

Actions Required

09/11/2011 21/07/2014 EOL-Inappropriate discharge Apology & Action Plan

25/06/2013 28/03/2014 EOL-Care of son on ward Apology & Action Plan

31/07/2013 10/04/2014 EOL-Care on the ward Apology & Action Plan

14/11/2013 22/08/2014 EOL- Care of Mother Apology & Action Plan

18/01/2014 08/09/2014 Maternity Care at RUH Apology & Action Plan

Twelve Ombudsman Cases awaiting outcome from PHSO investigation

Date complaint Received

Ombudsman contact Awaiting investigation outcome from PHSO

17/01/2012 08/02/2012 Lack of SLT service for son

20/02/2012 09/04/2014 Concerns Over Discharge Summary

03/08/2012 03/02/2014 Admission And Referral

14/01/2013 27/02/2015 Equipment supplied for home use

06/03/2013 06/09/2013 Breach of Confidentiality

10/06/2013 11/02/2015 Patient kept informed

15/01/2014 13/06/2014 EOL - care of wife

17/07/2014 11/11/2014 Concerns in the Community

21/07/2014 17/04/2015 Misdiagnosis/behaviour attitude of staff

28/07/2014 18/03/2015 Follow up treatment

22/01/2015 12/02/2015 EOL- Care of father

23/04/2015 30/04/2014 Unhappy With Not Knowing Results Of MDT

0%

20%

40%

60%

80%

100%

120%

Ma

y-1

4

Jun

-14

Jul-1

4

Au

g-1

4

Se

p-1

4

Oct-

14

Nov-1

4

Dec-1

4

Jan

-15

Fe

b-1

5

Ma

r-15

Ap

r-15

Trust overall complaint response rate

Concern Complaint L/M complaint H/E KPI

0

2

4

6

8

D&O ICH Planned Care UnscheduledCare

W&C

Open Ombudsman Cases

Page 75

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Ombudsman National Comparisons table

Position Body

Enquiries received by the Ombudsman Q1, Q2 2014-

2015

Enquiries accepted for

investigation by the Ombudsman

Investigations completed by

the Ombudsman

Investigations fully upheld by

the Ombudsman

Investigations partly upheld by the Ombudsman

Investigations not upheld by

the Ombudsman

31 Royal Berkshire NHS Foundation Trust 12 3 5 2 1 1

33 Salisbury NHS Foundation Trust 12 4 3 0 1 2

55 South Devon Healthcare NHS Foundation Trust

17 4 8 2 2 3

62 Royal Devon and Exeter NHS Foundation Trust

18 3 9 1 2 6

70 University Hospitals Bristol NHS Foundation Trust

19 5 11 1 4 5

77 Royal United Hospital Bath NHS Trust 21 4 3 0 1 2

84 Great Western Hospitals NHS Foundation Trust

24 7 4 0 1 2

96 Royal Cornwall Hospitals NHS Trust 27 4 6 0 1 5

105 Buckinghamshire Healthcare NHS Trust 30 8 5 1 2 1

131 North Bristol NHS Trust 44 11 7 1 1 5

132 Oxford University Hospitals NHS Trust 44 8 5 2 2 1

140 Gloucestershire Hospitals NHS Foundation Trust

48 13 18 1 6 11

The Parliamentary Health Service Ombudsman (PHSO) has published figures for

the first two quarters for 2014/2015 on the overall performance of each trust.

This is related to enquiries received, investigated and completed and overall

outcome.

Out of the 156 organisations listed nationally the Trust position for enquires

received to the PHSO was 84th.

The above table and graph show the Trust position against local trusts.

For the period Q3 and Q4 the PHSO accepted a further seven cases details of these enquiries will be reported later in the year

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Enquiries received by the Ombudsman Q1, Q2 2014-2015

Enquiries accepted for investigation by the Ombudsman

Page 76

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Divisions have been focused on resolving and closing of complaints and this has contributed in a reduction in the number of complaints in a backlog.

Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Number of complaints overdue.

79 97 109 113 97 69

At the end of April 2015 Total

Carillion 2

Corporate 1

Diagnostics and Outpatients 1

Finance (Inc. IT And Estates) 1

Integrated Community Health 1

Planned Care 26

Unscheduled Care 37

Women's and Children's 0

Total 69

You Said… We Did You said We did

“On my discharge from Day Surgery they said they would fax a referral for removal of my drain on Thursday but they were not sure if I would have to make my own arrangements with my practice nurse as I was mobile and had my own transport. Advised District Nurse would be in contact. Unfortunately on the Wednesday my pump stopped working so I phoned the Breast Clinic. They said there was nothing they could do but gave me a bleep number for the breast care team and they would try and get hold of the district nurse team. I asked switch to bleep the breast care team on bleep 1087 but after about 15 minutes of holding no one answered. Then I received a call from the DN team who said they would send an emergency DN out sometime that evening. She arrived at 18:30 and said she had been advised to remove the drain and asked me for my dressing and suture remover. I explained that I hadn’t seen anyone and hadn’t been given anything by the hospital”.

Redi vac instruction leaflet for patients is being produced which will include contact details of the District Nurse teams in Swindon, Wiltshire and other surrounding counties so patients know who to contact directly if they have concerns about their aftercare.

0

20

40

60

80

100

120

Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

Backlog - number of overdue cases

Backlog

Page 77

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“Attended GWH for a mammogram as part of the National breast Screening Programme. We understand that an injury was caused to the underside of her left breast requiring a gauze dressing. The injury occurred when attempting to take a scan from the side and the patient states that her breast was manipulated in a harsh and vicious manner causing an area of the skin to be pulled away leaving a tear and raw patch of about one inch under the breast. Staff did not apologise. Patient in pain as a result of the injury and that her breast bone is also causing discomfort”.

As well as a full discussion of the difficulties of imaging patients with mobility restrictions, learning points such as the need to review the height of the x-ray particular care of sensitive skin and the need to involve carers in examinations were discussed. The patient experience team and a small group of staff will be taking this further with a dedicated group seeing whether anything else could be done to improve the experience of patients with limited mobility.

Death certificate mentioned other reasons and these were not communicated to family of the deceased patient.

Junior Doctors to be informed of validating documentations before communicating information to relatives.

Delay in the discharge due to medications not being ready.

Matron is doing work with SAFER and Patient Flow re: TTA process

Family raised difficulty visiting patient urgently out of hours in the Brunel Treatment Centre, could not access the building.

Signs are being produced to make families aware of how to access the Brunel Treatment Centre out of hours. The Security Advisory Group are looking at access and alternative routes for ease to families when urgently need to attend the ward areas in the BTC.

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Division Concern/Complaint Activity April 2015

0 20 40 60

Communication

Telecommunications

Waiting Time

Cancelled

Clinical Care

Behaviour / Attitude of staff

Delayed

Complications During/following Treatment

Diagnosis

Discharge Arrangements

Lost/misplaced/delayed Test Results

Administration And Clerical Error

Choice - Access And Waiting

Follow Up Treatment

Medication

Parking

Confidentiality

Request Information On

Service Denied

Service Not Available

Advice Provided

Health Records

Information Provided

Other - Safe, High Quality Co-Ordinated Care

Personal Property

Privacy & Dignity

Referral Between Clinicians

Response

Overall Trust Concern/Complaint Theme April 2015

0 5 10 15 20 25

Booking Centre, BTC

A&E/ED

Orthodontics

Bed Bureau

Saturn Ward

Urology

Childrens Outpatients

ENT

Gynaecology OPD

Surgical Assessment Unit

Physiotherapy

Wren Clinic

Anaesthetics

Car Parks/Transport

Haematology

Kingfisher Ambulatory Care

Neptune Ward

Oral Surgery

Radiology

Audiology

Cardiology Outpatients

Childrens Unit

Diabetes - GWH

Falcon Ward

Gynaecology

Information Team

Longleat Ward

Mercury (Cardiac) Ward

MIU Trowbridge

Orthotics

Plastic Surgery

Rheumatology

Wheelchair Services

Concern/Complaint by area April 2015

Page 79

of 48

0

1

2

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4

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0

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Friends and Family (FFT)

Update on changes to NHS England guidance

From 1 April 2015, the Trust is required to offer FFT to all patients across all services and

submit monthly performance data under the categories below (previously this was only

required for Acute Inpatients Wards, A&E and Maternity services):

Acute inpatients areas and day cases (to include paediatric inpatient areas)

A&E (to include MIUs)

Community healthcare services (to include community inpatient wards)

Outpatients (across all sites)

Maternity (continue to offer across all four touch points, but submit eligible population data for birth experience only).

Key changes from 1 April 2015

The removal for FFT-related CQUINs for 2015/16.

The removal of token methods in ED to collect FFT responses.

The inclusion of children and young people (with no lower age limit).

The additional collection and submission of FFT for data for all outpatient areas, day

cases and minor injury units.

The removal of the requirement to collect and submit eligible population data for

maternity FFT questions 1, 3 and 4.

The mandatory collection of free-text comments

The encouragement to collect demographic variables

Overall performance

April saw a decrease in the response rate for the Emergency Department (ED) and the

overall response rate for Acute Inpatients:

ED saw a decrease of 47.4% from March (March 53.8%; April 6.4%).

Acute inpatients saw a decrease of 23% from March (March 53.9%; April 30.9%).

In each area, this decrease was largely impacted by:

ED - the removal of tokens as a key collection method. ED continued to use tokens for

the first two-weeks of April which could not be included in the return.

- a significant increase in the discharge figure for ED for April from March (1269

additional patients through ED during April).

Acute inpatients/day cases – a change to the reporting requirements for these

categories to include all inpatient areas (April’s return has the inclusion of Day Surgery

and the Discharge Lounge; and the addition two new paediatric areas offering FFT: the

Children’s Ward and SCBU).

Focussed support will be offered to these areas over the coming months to increase and sustain response rates.

4.6

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May June July August Sept Oct Nov Dec Jan Feb March April

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Friends and Family Response

ED Actual ED TARGET

Inpatient Actual Inpatient TARGET

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Deep Dive Analysis Due to the number of concerns/complaints received for April, the following areas have been identified for a deep dive analysis:

1. Orthodontics

2. Saturn

3. Urology

Orthodontics (Deep Dive)

Friends and Family comments February - April 2015 NB: Data collected for Orthodontics and Oral Surgery

“Delays between appointments 2 years before a decision was made. Totally unacceptable”. “Medical practice very poor. Appointment 6 months apart unacceptable”. “The dentist wasn't delicate”. “Waiting for my son's dental appointments took over a year then to wait another 6 months next one - his teeth are changing all The time, it this ok to wait this long”. “Lack of appointment long appointments too long. Appointments running late no information”.

“The consultant wasn't particularly gentle and made me bleed, also looked like he was about to fall asleep”. “The waiting time was a bit long but my treatment was good and All staff were pleasant”. “Swift excellent service. First class”. “Very polite and clear comms”. “Good customer service. Timings for appointments often delayed or have been cancelled”.

April FFT Scores April 2015 Average score for all questions Review this period Response Rate Concern 7

4.31 Stars 145 6.6% Complaint 4

SI 0

% likely to recommend % unlikely to recommend IR1 13

88.8% 6.29% Staff vacancies Community Dental Services Swindon 23.96% Community Dental Services Wiltshire 59.65% Community Dental Services Management 30.72%

Dental Access Centres Management 0% Dental Access Centres Swindon 13.58% Dental Access Centres Wiltshire 0% Dental Lab (over established) -53.33%

Oral Surgery Medical Staff 6.48% Oral Surgery Nursing (over established) -28.52%

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Complaint Summary February 2015 – April 2015 Cancelled Orthodontic follow up appt x 3

Delay in treatment Orthodontics Choice - Access And Waiting

Delay to orthodontic treatment

Delayed Delay in Treatment x 6

Communication Unhappy with Orthodontics Delay to Orthodontics treatment x 6 Delay in appointments being issued Delay in Orthodontics appt x 5

Unable to get through to Orthodontics Telecommunications Unable to get through to Orthodontics x 7 Orthodontic query Delay in treatment Waiting Time Orthodontic follow up appt x 2

Delay in Orthodontics Unhappy with waiting time for orthodontic appointment

Orthodontics - time between appointments

Saturn (Deep Dive)

Friends and Family comments February - April 2015

“Everybody friendly. Just a shame when the patient was told she could go home it took over 5 hours to remove a Cannula from her hand and change her catheter bag and sort out her tablets”. “This is my second stay within 3 months, and all the staff are a True credit to themselves and the hospital. Under extreme demands and staff shortages, they are great professionals, always pleasant and caring and on many occasions go above and beyond their normal responsibilities”

“I was very happy with the standard of care I received at all Times there were times when I was admitted in the start I was too unwell to communicate, but afterwards I was improving. The food standards were very very good indeed. I was unfortunately restricted by way of my water/tea fluid intake”. “Treatment was excellent. Possibly communication to relatives could be better. Staff were all friendly”.

April FFT Scores April 2015 Average score for all

questions Review this period Response Rate

Concern 3

4.27 Stars 13 11.20% Complaint 2

SI 25

% likely to recommend % unlikely to recommend IR1 0

90.9% 9.09% Staff vacancies 8.51%

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Complaint Summary February 2015 – April 2015 Clinical Care Care on Saturn Ward x 2 Communication Unable to get response from Saturn Ward Delay with discharge meds. Discharge Arrangements Care and discharge Chasing details of mother's death Discharge from Saturn Ward

Other - Safe, High Quality Co-Ordinated Care

Care sister is receiving on Saturn

Urology (Deep Dive)

Friends and Family comments February - April 2015

“Don't need to improve anything. I'm very happy with the care my son had today”. “Excellent from start to finish”. “Good communication, willingness to treatment”.

“10/10 v/g. Staff and Drs fine”. “Very poor people skills”. “Both times I have attended I've been seen almost an hour late even though I was told the doctor was running on time”.

April FFT Scores April 2015 Average score for all

questions Review this period Response Rate

Concern 4

5 Stars 1 0.1% Complaint 1

SI 0

% likely to recommend % unlikely to recommend IR1 None recorded

100% 0.00%

Staff vacancies Urology (Ampney) 14.35% General Surgery Medical

6.19% NB: 100% response only one response received for April

Complaint Summary February 2015 – April 2015 Communication Chasing Urology appointment Telecommunications Unable to get through to Wren Unit

Delay due to missing paperwork Unable to get through to Urology for results

Issues with Urology appointment

Lost/misplaced/delayed test results

Chasing results and follow up from Urology

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Patient Experience Complaint figures have been submitted for the last financial year to the collections agency in the form of the annual K041a (complaints annual return). Due to a change in the complaint process being more accessible and transparent with an enhanced complaints process this has resulted in an increase in the number of written complaints received to the Trust for 2014/2015. 735 written complaints were received for 2014/2015 against the reported 360 written complaints for 2013/2014. Changes have been made to the K041a complaints return and it has now become a requirement that the return will be collected quarterly. The information also reportable will be number of Parliamentary Health Service Ombudsman cases open and outcome of the PHSO investigations. Category themes have also changed from the 1

st April and this information has been updated onto iCasework (complaints database).

Responsive

Whistle Blower Alerts Staff, Users or Patients have, on occasion felt the need to raise anonymous concerns either internally or via external agencies. These concerns are essential for the organisation to understand and listen to. Actions are taken where necessary and appropriate.

Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15

Internal Alerts 0 0 0 0 0 0 0

External Alerts 0 0 0 2 0 0 0

CQC Rolling program of Light Touch mini visits In line with CQC style inspections, a comprehensive programme of internal light touch mini visits throughout all the core services including community, to address compliance against the CQC Fundamental standards and CQC Key Line of Enquiry Focusing on quality and standards, these visits identify areas of good practice but also areas where improvements need to be made. The mini visits have provided Staff with understanding the process of inspection and prepares staff with the type of questioning that will be used. There have been 15 mini visits to date, themes from the inspection include: Equipment (testing) Cleanliness Staffing levels Staff awareness of incident reporting Communication Areas visited are provided with a summary of findings of the visit for direct action, in addition learning themes are shared across the organisation.

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Well Led

Executive Patient Safety Walkabouts Three Patient Safety Visits took place in April: Beech Ward; Surgical Assessment Unit/Acute Cardiac Unit /Linnet Acute Medical Unit; and Theatres Emerging themes from these visits are:

Beech Ward SAU/ACU/LAMU Theatres

Complicated Discharges

Challenges with nurse staffing

Buddy system in place – sharing medical staff

EPU beds used to be blocked now being used for patients

Falls have reduced

Challenges with nurse staffing

Weekend trial of 2 day week - 7 day service to offer best care to patients went well

Equipment availability issues at times

Benefits of new documentation were discussed

Increase in Multi-disciplinary staffing

More joined up working

Good reporting culture

Raised issues with consistency of Theatre list

More pillows, wheelchairs and chairs required

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Meeting and date:


Title:

Quality Improvement Strategy – 2014/2015 Key Performance Indicators Update

Summary of paper:

The Quality Improvement Strategy was launched in 2014 The strategy contains seven priority goals for improvement. Key performance indicators (KPI’s) for 2014/2015 were agreed by the Board to ensure progress towards these goals were achieved. This paper provides an update against these KPI’s and set out focus for 2015/2016


a) that this update provides assurances to the Board of achievement and progress against KPI’s for 2014/2015; and

b) that the Board notes the focus for Quality Improvement KPI’s

2015/2016 aligned with the Sign up to Safety priorities.


everything we do.



.







Risk issues:

Without identified clear KPI’s there is the potential for lack of impact from the Quality Improvement Strategy and risk of underachievement of the ambitions contained within.


Commitment from directorate teams to embed the identified priorities and KPI’s within their service planning and governance frameworks

Regulations and legal considerations:

CQC, Monitor, NHS Outcomes Framework, CQUIN and all national and local drivers require quality improvements and have regulatory legislative

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Agenda Item 10

(CQC considerations / Monitor requirements / link to NHS Constitution rights and pledges as necessary / Trust Constitution / legislative requirements)

requirements, by delivering on the ambitions and priorities set out in the strategy we will also be ensuring we meet all quality standards expected.


The delivery of high quality care has been considered and achievement of KPI’s has had a positive effect on patient care.


Directorate Performance Meetings Patient Quality Committee





Name of Lead Executive Director: Name of Author:

Hilary Walker, Chief Nurse Julie Marshman , Deputy Director of Quality Governance

Page 90

Quality Improvement Strategy Update

Introduction

Improving Quality is about making healthcare safer, effective and patient centred, improving the quality of services is a key requirement of all NHS

organisations. Our Quality Improvement Strategy underpins this improvement work within Divisions, providing a framework of goals and ambitions to work

towards. We are starting to see a shift from focusing on individual harms to one of assessing, maintaining and improving safety and quality of care. This

together with investment of time and expertise into quality improvement capability, staff are beginning to feel more confident at recognising the need for

change and then being able to implement that change and improvement.

There has been great progress over the last year with ensuring Quality and Quality Improvements are held as high priorities against a backdrop of increasing

operational pressures and financial challenges and there is a unity amongst staff with the desire to deliver high quality care to our patients. We have

continued to maintain focus on quality during a time of increased pressure on financial stability, there is substantial evidence to show that high quality care

costs less and as we strive to be in the upper quartile of Trusts for our patient safety and quality of services we will achieve high quality of care for patients

that is more effective and financially efficient. For example the Sepsis 6 pathway has provided a far greater quality of care for our patients and a positive

impact on patient experience, overall cost per patient episode and bed flow, with patients staying an average of 12.04 days in Q 1 2014/2015 reduced to

9.8days in Q4 2014/2015.

Our Quality Improvement Strategy is now just over a year old; it is quite rightly ambitious with the aim to move the organisation from good to excellent.

The priorities within the strategy are grouped under seven main areas of focus:

1. Delivering safe, effective care, delivering excellence

2. Leading the best patient experience

3. Releasing time to care

4. Visible inspirational leadership

5. Culture of innovation and embracing of continuous quality improvement

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6. Measurement of essential quality standards, providing assurance of patient safety and clinical effectiveness

7. Staff will understand their contribution to the whole organisation

Key Performance Indicators 2014/2015

In June 2014 the Board agreed a set of Key Performance Indicators to measure the achievements during year one. The table below shows progress against

these.

Priorities KPI’s Milestones Year One update

Delivering safe, effective care, delivering excellence

Reduce avoidable mortalities/ HSMR Falls rate below national average

Reduce HSMR to below 90 by

December 2014

Maintain HSMR <90 for 2015 so that

“rebased” figure remains <100

Move to top quartile of Southern acute trust performance by December 2015 To reduce to 5.6 falls per 1000 bed days (national average) for the Acute Trust by the end of Quarter 3 Dec. 2014.

Achieved

Improvements with HSMR have been sustained with the Trust currently in the lower quarter of southern acute Trusts, showing the continuing trend of improvement. Not Achieved This year’s average number of falls per 1000 bed days was 7.3 for Acute care From April 2014 to March 2015, there were six months that the Community wards performed at or below the community national average of 8.6 falls per 1000 bed days (April, May, June, August, September and October 2014). The other six months of the year, the Community wards performed above the national average. The Trust Launched a Fall Safe Operational Group on 1st June 2014, which has a mandatory attendance of Ward Managers to further strengthen its importance. The community wards are also part of the falls Safe Operational Group and are working with the acute teams to share learning and quality improvements to further reduce and sustain a reduction in the number of patient falls.

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To achieve below (better than) the national average by the end of Quarter 4 March 2015.

In March 2015, the Acute setting recorded an average of 4.28 falls per 1000 bed days which is below (better than) the national average. This achievement was mostly due to the Ward Managers working with their local teams in identifying root causes of falls incidents in their clinical areas and putting actions and processes in place to prevent recurrences.

Leading the best patient experience

Friends and family response rate

To reach a response rate of: Quarter 1 15% in the Emergency Department 25% for inpatient areas By 31st July 2014 Quarter 4 20% in the Emergency Department 30% for inpatient areas By 30th April 2015 (matches CQUIN requirement)

Achieved

The targets for the Friends and Family Test were achieved and the Commissioning for Quality incentive met.

Releasing time to care

Safer care bundle

Achieve implementation of the safer bundle as laid out within the ECIST recommendations By 31st August 2014

Partially achieved Monitor Senior Review: Morning ward rounds in all USC wards and the Trauma Unit with Matron led board rounds in all PC wards. Further action required to embed 4pm board rounds in USC wards to enable ‘next day planning’ Patient Information: Developing ‘Patient Discharge Information’ implementing phased roll out of the information pack during June 2015 Early flow from Assessment Units: Medical consultant attends morning LAMU board round. Further action required to make morning capacity on base wards to create flow, and increased use of discharge lounges. Discharge before midday:

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All wards have targets set, all wards identifying key issues for delay with the daily performance of each ward being monitored. 14 day Length of Stay reviews Currently establishing the baseline and categories in this group of patients, further action required to agree the weekly review process and feedback.

Visible inspirational leadership

Staff survey – staff satisfaction, Key Measure 24:“Staff recommendation of the Trust as a place to work or receive treatment” to be higher than the national average for Acute Trusts. To integrate a coaching style of management as a core competency in leadership roles, job descriptions and against which leaders are recruited and appraised.

To reach the national average for acute Trust by Quarter 3 To be above the national average by the end of Quarter 4 Coaching competencies are developed and integrated into appraisal paperwork by October 2014 Coaching audit completed with 70% of leaders responding to audit completed by 30th September 2014 Coaching skills gap identified and training commissioned

Partially Achieved Staff friends and Family results for Quarter1 and Quarter 2 showed the Trust was just below average for staff recommending the Trust as a place for receiving treatment and as a place to work.

Staff Recommend as place for receiving treatment

GWH Q1 & Q2 Average = 74.3% National Average for Q1 & Q2 = 74.8%

Staff Recommend as place to work

GWH Q1 & Q2 Average = 59.1% National Average Q1 & Q2 = 60.6%

Response Rates GWH Q1 & Q2 average response rate = 6% National Average Q1 & Q2 = 14.3%

Achieved Coaching service in place - 35 Trust managers who have received or who are currently receiving a series of coaching sessions, being provided by 8 Trust coaches. ‘Coaching Skills for Managers’ – 1 day course, providing managers with coaching skills to use with their teams. 40 places / yr. currently offered sessions also planned as part of the up-coming Leadership programme (numbers tbc) ‘Coaching & Mentoring’ – 1 day course delivered to 20 managers by Cathy Hackett in Jan 15. A Coaching Register has been developed and a quality assurance process for the coaching is in place We have 35 Managers now trained in the 2-day ILM mediation training, with a

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further 24 due to be trained by the end of June. This supports Managers to facilitate difficult discussions in their teams, and supporting each other across the Trust where there is a need to facilitate an informal discussion (so as to cut down the number of grievances).

Culture of innovation and embracing of continuous quality improvement

Adoption of innovation evidence within all Directorate Business Plans Established Trust resource and expertise for Quality Improvement sciences (2014-2016)

Directorate performance meetings to be revised to include a focus on quality and innovation alongside finance and operational performance from September 2014 Scope resources required during 2014

Not achieved Divisional Performance meetings have been revised to include scrutiny from Finance, Operations and Quality with attendance of the responsible Executive Directors. However there remains work to do to embed innovation and quality improvement as part of these discussions. Moving forward focus on quality and innovation sits well within the quarterly Strategic Service Reviews. Achieved Strong links established with the West of England Academic Health Science Network providing support, educational resources and potential funding for small projects. Institute of healthcare Improvement licenses (IHI) for on-line Quality Improvement knowledge and understanding training modules have been provided for 25 staff including, nursing, therapies, senior managers, junior medical staff and Consultants from across the Trust. Sue Harmsworth (Matron) and Rachel Jefferies (Head of Patients Safety) undertook the Quality Service Improvement Redesign programme offered by NHS Improving Quality (NHSIQ) equipping them to facilitate and enable clinical teams to lead the quality improvement programme. They are currently supporting the Sign up to Safety campaigns. Plans to establish a Quality Improvement post to support and facilitate Trust wide QI projects is currently on hold due to financial pressures.

Measurement of essential

Safer staffing and quality outcomes

Trust to meet deadline for uploading of safe staffing data onto NHS

Achieved Safer Staffing data uploaded as required monthly.

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quality standards, providing assurance of patient safety and clinical effectiveness

dashboard established Ward to Board Improved rate of new ‘harm free care’ as measured by Safety Thermometer

choices 10th June 2014 and establish robust processes for monthly returns by 30th June 2014 Monthly reports to Trust Board including quality data from June 2014 Adoption of NICE guidance for safer staffing (Once published) Achieve and maintain 95% harm free care December 2014

Divisional performance meetings have been revised with a clearer focus on quality, safety and financial performance. Monthly reports received and scrutinised at Trust Board Achieved 1. The Safer Nursing Care Tool (SNCT) was rolled out across the acute Trust in April 2015. This is a nationally recognised and validated tool to accurately assess acuity and dependency on the wards. Results will inform the 6 monthly skill mix review due to be undertaken in July 2015 2. The ‘Red Flag’ process is a formalised escalation process which enables any member of staff to escalate quality and safety concerns. This was rolled out across the wards in May 2015. 3. Rollout of Nurse Sensitive Indicators is planned for September 2015 – this process will focus on the welfare of our staff and will provide immediate support to resolve ward based issues and will endeavour to enhance team resilience. 4. A defined six monthly skill mix review which applies national guidance and good practice, acuity and dependency scoring and professional judgement Achieved >95% has been achieved and sustained for new harm free care

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Staff will understand their contribution to the whole organisation

Review and redesign of clinical governance systems, processes and structures

Fresh eyes’ review of current systems and processes Engagement with Directorates to review preferred options for governance processes and structures June – August 2014 Define and establish clinical governance systems, processes and structures for 2015 and beyond (Complete by Feb 2015)

Achieved Revised Quality Governance structures and reporting were ratified by the Board in November 2014.

Monthly Quality report has been established

Divisional Quality Governance facilitators recruited April 2014

Divisional Quality Governance reporting via Divisional Performance meetings commenced February 2015

Patient Quality Committee launched in April 2015

Senior post identified to strengthen patient engagement and patient experience ‘Head of Patient & Public Engagement’

Plans for 2015/2016

Moving forward it’s essential we have alignment with the quality and patient safety priorities and work streams already happening across the organisation.

The priorities listed below are either part of the ‘Sign up to Safety’ Quality Improvement campaign or are other key priorities for quality improvement that

align with the goals and ambitions described within the quality strategy.

2015/2016 Patient Quality & Safety Priorities

Link to Quality Strategy Goal

1. Reducing Falls - to reduce the rate of falls and avoidable harm due to falls by 20% within 3 years (2017/2018)

Delivering safe, effective care, delivering excellence Leading the best patient experience

Culture of innovation & embracing of continuous QI Measurement of essential standards, providing assurance of patient safety and

clinical effectiveness

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2. Reducing Pressure Ulcers - Reducing avoidable pressure ulcers to <5 per month

Delivering safe, effective care, delivering excellence Leading the best patient experience Culture of innovation & embracing of continuous QI

Measurement of essential standards, providing assurance of patient safety and clinical effectiveness

3. Management of Sepsis - Reduction of mortality from severe sepsis to

23% by 2017.


Leading the best patient experience Culture of innovation & embracing of continuous QI Measurement of essential standards, providing assurance of patient safety and


4. Recognition of The Deteriorating Patient - To reduce ‘in hospital’ cardiac arrests by 10% each year by 2018

Delivering safe, effective care, delivering excellence Leading the best patient experience

Culture of innovation & embracing of continuous QI Measurement of essential standards, providing assurance of patient safety and


5. Acute Kidney Injury - Reduction of avoidable AKI by 30% in the next two years



Culture of innovation & embracing of continuous QI

Measurement of essential standards, providing assurance of patient safety and


6. Maintain HSMR <90 for 2015/2016 so that “rebased” figure remains <100 Maintain position in top quartile of Southern Acute Trusts performance.



Visible Inspirational leadership



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7. Infection Prevention &Control Clostridium Difficile Target =< NHS England Less than 20 cases per year and 5 per quarter MRSA Bacteraemia 0 cases reported during 2015/2016








8. Inpatient Survey – improve feedback from patients to ensure the Trust is viewed as ‘Significantly BETTER’ than other Trusts in 2016/2017 inpatient survey





9. Staff survey – each division to agree three priority areas for improvement during 2015/2016 Staff survey – staff satisfaction, Key Measure 24:“Staff recommendation of the Trust as a place to work or receive treatment” to be higher than the national average for Acute Trusts - 2015/2016






Conclusion

The Key performance indicators agreed for 2014/2015 have either been met or have seen significant improvement; this first year has been a success with

quality remaining a top priority for the Trust. The Trust has received recognition for improved outcomes both locally by the Commissioners and nationally

with a nomination for the CHKS Patient Safety Award. We will continue to strive to make Quality Improvement ‘business as usual’ for everyone at all levels.

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Meeting and date:


Title:

Operational Performance Report

Summary of paper:

This report provides commentary on key Operational Performance Indicators, including a summary of actions being taken where performance improvements are required. A summary of the Trust’s performance against key Patient Safety, Quality and Operational Performance Indicators is appended to this report.

Purpose of report:

To provide assurance to the Executive Committee on key operational performance standards and associated remedial actions.


everything we do.



(d) We will build capacity and capability by investing in our staff, infrastructure and partnerships.

Link to Quality (1) Responsiveness (complaints, waiting times,

cancelled operations, ambulance stays, translation services, comfort factors – TV and seating)

Risk issues:

Contractual – SCCG and WCCG Regulatory – CQC/Monitor


Financial Implications


Regulatory Implications for some indicators – Monitor and CQC (This is shown in Appendix A)


Improved communications, and faster access to services, promotes patient choice. Assurances of the access to services provided.


Divisional Performance Meetings Executive Committee


Page 101

Agenda Item 11


Great Western Hospitals NHS Foundation wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust’s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics.


Name of Authors:

Linda Power, Deputy Chief Operating Officer Emily Beardshall, Divisional Director, Planned Care Judith Ratledge, Divisional Director, D&O Teresa Harding, Divisional Director, W&C Leighton Day, Divisional Director, US Care Douglas Blair, Director, Community Services GWH Jane Cheeseborough, Community Division Analyst Pilar Acosta-Sánchez Peter O’Driscoll, Information Services

Page 102

Exec Co Operational Performance Report

1. ED Patient Impact - % of patients who stay maximum of 4 hours in ED

Performance for Month 1 (April 2015) – 93.95% (Standard 95%)

Graph 1: 4 Hour ED Performance against Monitor trajectory

The number of ED attendances has fallen. In April there was a 5.1% decrease in patient attendances in comparison with the previous months (March) figures. Compared to April 2014, attendances decreased by 1.7% (109). Performance for non-admitted patients on the 4 hours standard was 95.98%. This was an improvement on the 93.92% in March. Performance for admitted patients on the 4 hour standard was 79.40% (60.42% in March), while overall performance for the ED department at GWH was 90.86% (83.23% in March). A full report to be presented later in the meeting.

Graph 2: ED Conversions to Admission

75%

80%

85%

90%

95%

100%

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

Pe

rcen

tage

Month

Attendances within 4 Hours or Less, Trajectory & Actual Performance

Trajectory of A&E & MIU AttendancesDeparted Within 4 Hours or Less

Percentage of A&E & MIU AttendancesDeparted Within 4 Hours or Less

Operational Performance Report

June 2014

Page 103

ECIST KPI’s

Target W/C 30th

March

W/C 6th

April

W/C 13th

April

W/C 20th April

W/C 27

th April

Total Breaches (week) <110 196 244 53 110 118

1st

assessment breaches (week) <15 66 50 19 30 13

Minors breaches (week) <15 21 31 7 22 10

Bed breaches (week) <20 106 122 16 49 25

Specialist breaches (week) <15 5 9 3 6 1

ED conversion to admission (week) <25% 30.8 30.4 27.8 31.1 32

Table 1: ECIST KPIs

Achievement of the ECIST KPIs shows improvement against first and minor breaches. The action plan and the performance continues to be monitored fortnightly.

Graph 3: Non-Elective Spells

During April the Trust continued on an upward trajectory for non elective spells. The Unscheduled Care Divison has introduced a SOP which facilitates the protection of ambulatory care in an attempt to manage the increased demand and achievement of the ED standard.

Graph 4: Bed Occupancy

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GWH Acute Total Non-Elective Spells by Month

(Excluding Midwife, Obstetrics & Well Babies spells)

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

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GWH Acute Bed Occupancy

Page 104

Graphs 4 above and 5 below highlight bed occupancy above trajectory with a reducing number of medical outliers.

Graph 5: Medical Outliers

2. 18 Week Referral to Treatment (RTT) RTT Performance Standards (A full report to be presented later in the meeting) The reported performance from month 12 (March 15) is available and an un-validated estimate of month 1 (April 15) performance is available from weekly returns, April performance is likely to increase slightly following validation, admitted performance is anticipated to reach the 90% target. The continued low performance for incomplete pathways demonstrates that the Trust is not sustainably reaching the RTT standards. A detailed RTT improvement plan in included in the meeting pack for Executive Committee on 19th May 2015 which outlines the planned improvement approach for 2015/16.

Standard Confirmed M12 (Mar) performance

Estimated M12 (Apr) performance

Admitted (target 90%) 86.0% 88.4%

Non-admitted (target 95%) 92.4% 89.5%

Incomplete pathways (target 92%) 86.7% 86.3%

Table 2: Achievement against RTT Standards 52 Week waits The number of patients waiting and being treated in excess of 52 weeks has reduced between March and April as the orthodontic situation has come under increased control. Two patients were waiting in excess of 52 weeks at the end of April. One is an oral surgery patient who converted from an orthodontic pathway and requires extractions; due to patient choice this patient will not have surgery until June. The other patient was a dermatology long waiter who has shown poor compliance with their care but is high risk, a root cause analysis is being completed.

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Medical Outliers (Friday 08:00 Snapshot)

Page 105

The Trust is closely monitoring the orthodontic situation and reporting to NHS England via fortnightly teleconferences. Medical staffing remains a significant risk. Month 12 March

(confirmed) Month 1 April (provisional)

Patients treated over 52 weeks in month

21 (all orthodontics/oral surg)


Patients waiting over 52 weeks at month end


2 (oral surgery & dermatology)

Total 28 10

Table 3: 52 week waits

Cancellations

Standard: % of operations cancelled on the day for non-clinical reasons

Standard Month 12 March

Month 1 April

% of operations cancelled on the day for non-clinical reasons

<0.8% 0.7% 0.7%

Table 4. Cancelled for non-clinical reasons

The standard has been achieved for March and April in line with reducing bed pressures.

Standard: % of operations cancelled on the day that are not rescheduled within 28 days Standard Month 12 March

Month 1 April

% of operations cancelled on the day not rescheduled within 28 days

<5% 0% 4.5%

Table 5: Not rescheduled within 28 days

The standard has been achieved for March and April in line with reducing bed pressures. There were no patients rebooked outside of 28 days in March and 1 patient in April. 3. Electronic Discharge Summary

Standard: >=90% April 2015 75.9% (provisional) eDS performance remains variable across the Divisions. As EPMA is rolled out the Divisions are focused on ensuring that performance against this standard is maintained and improved.

Graph 6: EDs Performance

Page 106

4. Clinic Letters

Standard: >=75% April 2015 63.3% (provisional) Initially this element was to be included in the quality schedule for the organisation. However, it is now understood this will be included in the quality agenda as a CQUIN for Swindon. We are still investigating this detail for Wiltshire. The nominated lead for the Trust is working with informatics to ensure consistency of reporting. 5. Over Due Follow-ups

The number of patients on the ‘Overdue’ file is 5330 as at the 22nd May. The Divisions are now reviewing their processes to support delivery of the RTT Plan. The priority is on validation to provide assurance on clinical risk. Please note: no clinical risks have been identified.

Graph 7: Historic Hold File Trajectory

Specialities contributing to the Backlog

03-Apr 10-Apr 17-Apr 24-Apr 01-May 08-May Variance from Apr-03

Accident & Emergency

44 47 54 54 54 57 13

Anaesthetics 28 29 17 16 3 7 -21

Audiology 0 0 0 0 0 0 0

Cardiology 151 147 142 127 81 58 -93

Clinical Haematology 34 38 35 35 31 30 -4

Clinical Oncology 82 88 85 85 86 87 5

Community Paediatrics

36 34 26 23 31 30 -6

Dermatology 258 204 159 153 193 232 -26

Dietetics 13 12 12 16 18 24 11

Ear, Nose & Throat 26 29 51 22 19 18 -8

Endocrinology 255 288 303 308 311 336 81

Gastroenterology 417 399 413 385 386 364 -53

General Medicine 20 20 20 20 20 12 -8

General Surgery 1258 1286 1308 1251 1233 1223 -35

Page 107

Geriatric Medicine 13 17 17 16 17 17 4

Gynaecology 23 31 25 4 5 5 -18

Medical Oncology 13 22 12 16 21 24 11

Midwife Episode 48 51 56 59 57 57 9

Neurology 97 103 107 120 115 120 23

Obstetrics 0 0 0 0 0 0 0

Ophthalmology 234 242 108 126 139 168 -66

Oral Surgery 57 47 29 52 24 53 -4

Orthodontics 510 511 405 384 358 366 -144

Orthotics 3 7 8 2 2 2 -1

Paediatrics 145 224 223 221 222 192 47

Pain Management 171 185 193 198 202 186 15

Physiotherapy 116 121 141 116 128 152 36

Plastic Surgery 71 79 76 83 83 90 19

Podiatry 3 6 5 6 7 8 5

Respiratory Medicine

52 59 68 71 77 39 -13

Respiratory Physiology

35 36 36 39 3 2 -33

Rheumatology 503 476 502 549 551 562 59

Trauma & Orthopaedics

243 387 375 309 307 305 62

Urology 601 640 661 653 678 703 102

Grand Total 5560 5865 5672 5519 5462 5529 -31

Table 6: Over Due Follow-ups by Speciality

The Out Patient Transformation Programme continues to support the clearance of these backlogs. 6. DTOC – Acute The DTOC target is ≤4 %, however NHS England in their recommended high impact actions to improve urgent and emergency care has identified that Strategic Resilience Groups should aim to reduce the DTOC rate to 2.5% . The Trust position in April shows unacceptably high levels of DTOC.

DTOC as a percentage of Acute bed Occupancy by Week

2-Apr

9-Apr 16-Apr 23-Apr 30-Apr

6.9%

8.1% 6.3% 6.5% 5.1%

Total number of patients with DTOC per week

2-Apr


Swindon 21

20 26 31 23

Wilts 14

25 20 10 12

Other 8

10 10 9 11

Page 108

Total number of bed days occupied due to DTOC per week

2-Apr


All 432

444 457 444 447

% of bed days occupied due to DTOC per week

All 6.9%

8.1% 6.3% 6.5% 5.1%

Swindon 2.5%

2.7%

4.4%

3.4% 2.5%

Wilts 2.5%

3.8%

0.7% 1.8% 0.9%

Other 1.9%

1.6%

1.3% 1.4% 1.8%

Table 7: DTOC

Graph 8: Acute Delayed Transfers of Care The snapshot on 30/04/14 showed the Trust reported 23 acute patients with a delayed transfer of care, 10 delays were due to the need for futher NHS care with ongoing assessment as the other significant cause for delay.

Graph 9: Delayed Discharges by Reason

This information will be shared with our partners at the fornightly system wide ‘Improving discharge planning and flow’ Group to drive performance improvement in discharge and capacity management across the local health and social care community.

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GWH Acute - Delayed Discharges

A. Awaiting Completion ofAssessment

B. Public Funding

C. Further Non-Acute Care

Di. Care Home Placement -Residential Home

Page 109

Graph 10: Medically fit by Service Provider

Graph 11: Delayed Discharges

Graph 12: Snapshot of Medical Outliers

7. Cancer Performance All Cancer Performance standards have been achieved in 2014/2015.

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Medical Outliers (Friday 08:00 Snapshot)

Page 110

% Targ

et Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

2013/14

2014/15

All 2-week >=93

% 93.5%

94.8%

93.6%

93.3%

93.6%

94.2%

94.3%

93.6%

94.1%

93.7%

95.3%

94.3%

94.7%

94.0%

Breast Symptomatic 2-week

>=93%

95.7%

94.7%

96.9%

99.3%

98.4%

98.8%

98.1%

96.4%

96.1%

96.2%

94.3%

93.8%

95.6%

96.6%

31-day wait to treatment

>=96%

97.0%

97.4%

98.1%

100%

99.0%

98.3%

98.3%

99.1%

97.8%

100%

99.1%

98.2%

98.8%

98.5%

31-day wait for subsequent treatment - Surgery

>=94%

100%

100%

100%

100%

94.4%

100%

100%

95.0%

100%

100%

100%

100%

98.3%

99.1%

31-day wait for subsequent treatment - Drug Treatment

>=98%

100%

98.1%

100%

98.2%

100%

100%

100%

100%

100%

100%

100%

100%

100% 100%

62-day wait GP referral to treatment

>=85%

93.2%

86.4%

87.4%

87.1%

88.2%

86.4%

91.7%

87.1%

90.1%

88.2%

87.1%

87.1%

89.0%

88.3%

62-day wait from Consultant/Screening Service to treatment

>=90%

100%

100%

100%

100%

90.9%

91.9%

100%

100%

100%

100%

100%

100%

98.8%

98.6%

Table 8: Cancer Performance

8. Average LOS - Community

Average LoS (inpatients/days) 31.1 Our April average LoS was affected by delayed days. 600 bed days were lost in April 2015 to DToCs.

CHC annual reviews 71% 1 delayed by 3 days due to staffing levels. The other was completed but paperwork temporarily mislaid; all CHC paperwork now received including care plan.

DToC 23% At the end of April we had 23 delayed patients on the community wards. The majority of these were due to unavailability of placement and care packages.

Table 9: LOS Community

Graph 10: Delayed Discharges – Community – For Information

0

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GWH Community - Delayed Discharges

Page 111

15_16

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

N Meeting avoidable MRSA bacteraemia 0 5 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 1 2 0

M/N Meeting CDIFF Objective <=28 23 2 0 1 3 4 1 0 3 2 0 0 3 3 8 5 3 19 7

N VTE risk assessment >=95% 95.5% 95.7% 95.9% 95.9% 97.7% 97.0% 98.3% 97.3% 98.4% 95.8% 97.2% 96.8% 98.8% 95.8% 97.7% 97.2% 97.6% 97.1% 96.3%

N Never events 0 4 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 1 2 0

M/C A&E 4 hrs arrival to Admission/Transfer/Discharge >=95% 94.1% 92.5% 92.8% 94.2% 97.5% 96.3% 96.2% 91.9% 93.4% 84.3% 88.0% 84.3% 89.0% 92.5% 96.7% 84.3% 84.3% 91.9% 90.8%

T 12 hrs trolley wait 0 1 0 0 0 0 0 0 0 0 1 14 0 0 0 0 1 14 15 0

C % Ambulance Handovers within 30 minutes >=95% 96.9% 95.9% 95.1% 95.9% 98.7% 96.5% 97.2% 94.6% 95.3% 88.2% 90.9% 88.2% 93.4% 95.6% 97.5% 92.5% 90.9% 94.3% 94.8%

M/C All 2-week wait referrals >=93% 94.7% 93.5% 94.8% 93.6% 93.3% 93.6% 94.2% 94.3% 93.6% 94.1% 93.7% 95.3% 94.3% 93.9% 93.6% 94.0% 94.4% 94.0%

M/C Breast Symptomatic 2-week wait referrals >=93% 95.6% 95.7% 94.7% 96.9% 99.3% 98.4% 98.8% 98.1% 96.4% 96.1% 96.2% 94.3% 93.8% 95.8% 98.8% 96.8% 94.7% 96.6%

M/C 31-day wait from diagnosis to first treatment >=96% 98.8% 97.0% 97.4% 98.1% 100% 99.0% 98.3% 98.3% 99.1% 97.8% 100% 99.1% 98.2% 97.5% 99.1% 98.2% 99.1% 98.5%

M/C 31-day wait for second or subsequent treatment - Surgery >=94% 98.3% 100% 100% 100% 100% 94.4% 100% 100% 95.0% 100% 100% 100% 100% 100% 100% 98.2% 100% 99.1%

M/C 31-day wait for second or subsequent treatment - Drug Treatment >=98% 100% 100% 98.1% 100% 98.2% 100% 100% 100% 100% 100% 100% 100% 100% 99.4% 99.3% 100% 100% 100%

M/C 62-day wait for first treatment from Urgent GP Referral to treatment >=85% 89.0% 93.2% 86.4% 87.4% 87.1% 88.2% 86.4% 91.7% 87.1% 90.1% 88.2% 87.1% 87.1% 89.3% 87.6% 88.8% 87.0% 88.3%

M/C 62-day wait from Consultant/Screening Service to treatment >=90% 98.8% 100% 100% 100% 100% 90.9% 91.9% 100% 100% 100% 100% 100% 100% 100% 93.7% 100% 100% 98.6%

M/C % Admitted >=90% 94.9% 94.6% 93.6% 92.9% 79.4% 72.8% 78.9% 93.3% 93.7% 95.5% 93.5% 89.2% 86.0% 93.7% 72.8% 94.2% 86.0% 88.6%

M/C % Non-Admitted >=95% 96.3% 96.8% 97.3% 98.3% 98.4% 97.3% 96.3% 95.8% 95.1% 95.0% 95.0% 89.9% 92.5% 97.5% 97.3% 95.3% 89.9% 95.6%

M/C % Incomplete Pathways < 18wks (monthly) >=92% 94.8% 93.3% NR 92.1% 90.3% 91.3% 92.1% 92.1% 92.0% 92.1% 88.4% 85.0% 86.8% 91.9% 90.3% 92.1% 88.4% 90.5%

C Admitted over 52-weeks: Adjusted 0 0 1 1 2 19 21 13 0 0 0 0 2 1 2 13 0 1 1

C Non-Admitted over 52-weeks 0 0 0 0 0 0 0 0 0 0 2 1 18 12 0 0 2 12 12

C Incomplete over 52-weeks 0 0 32 56 86 54 22 5 0 9 2 2 23 7 86 5 2 7 7

T Admitted backlog waiting over 18 wks Report - 781 907 1048 838 570 243 316 378 423 490 558 503 1048 243 423 503 n/a 577

T Non-Admitted backlog (Patient Fup overdue only) Report - n/a 5,462

C % Non-Admitted >=95% 97.1% 98.9% 99.3% 97.9% 97.4% 97.0% 96.5% 97.9% 98.0% 99.0% 98.2% 98.8% 98.8% 98.7% 97.0% 98.3% 98.6% 98.1% 98.6%

C % Incomplete Pathways < 18wks (monthly) >=92% 98.0% 99.2% 97.4% 97.5% 97.0% 96.6% 98.1% 97.2% 99.4% 96.0% 95.4% 96.7% 95.7% 98.0% 97.2% 97.5% 95.9% 97.2% 94.4%

Diagnostics C 6-week max wait >=99% 99.7% 99.7% 99.6% 99.4% 99.4% 99.2% 99.6% 99.7% 99.6% 99.8% 99.5% 99.6% 99.4% 99.6% 99.4% 99.7% 99.5% 99.5%

C 90% of Stay on a Stroke Unit >=80% 81.6% 82.5% 80.0% 83.3% 78.6% 76.7% 68.8% 84.8% 78.8% 82.1% 87.0% 60.0% 71.0% 81.7% 75.0% 81.9% 73.7% 77.2%

C % High risk TIA are assessed and treated within 24 hours >=60% 63.9% 75.0% 73.7% 69.2% 75.0% 62.5% 43.8% 88.2% 88.2% 84.6% 94.1% 73.3% 93.3% 72.5% 60.4% 87.5% 88.5% 77.1%

T/C PPCI within 150 minutes CTB >=75% 95.0% 100% 100% 100% 100% 66.7% 100% 90.0% 100% 80.0% 100% 100% 100% 100% 88.9% 90.0% 100% 94.7% 100%

T/C PPCI within 90 minutes DTB >=80% 95.0% 100% 100% 100% 100% 66.7% 100% 90.0% 100% 80.0% 100% 100% 100% 100% 88.9% 90.0% 100% 94.7% 100%

N Rapid Access - Patients seen within 14 days >=98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

C Emergency re-admission rate within 30 days of discharge <=7.1% 7.5% 7.5% 7.7% 9.7% 9.4% 9.6% 10.1% 9.8% 9.0% 9.2% 8.9% 9.4% 9.9% 8.3% 9.7% 9.3% 9.4% 9.2%

C Emergency re-admission rate within 28 days of discharge Report 7.3% 7.4% 7.5% 9.3% 9.2% 9.5% 10.0% 9.5% 8.9% 9.1% 8.6% 9.3% 9.7% 8.1% 9.6% 9.2% 9.2% 9.0%

C Ave. LoS - community inpatients (days) <=20 24.7 27.1 26.2 25.2 26.8 29.9 28.8 29.8 31.6 25.5 33.4 38.8 31.0 26.2 28.5 29.0 34.4 28.4 31.1

C % of Operations cancelled on the day for non-clinical reasons <=0.8% 0.7% 0.6% 0.6% 0.9% 0.5% 0.5% 0.8% 1.4% 0.8% 0.8% 1.4% 1.7% 0.7% 0.7% 0.6% 1.0% 1.2% 0.9% 0.7%

C % not rebooked to come in within 28 days <=5% 1.5% 0.0% 0.0% 3.6% 0.0% 6.3% 0.0% 2.1% 0.0% 3.8% 2.2% 9.8% 0.0% 1.5% 1.6% 2.0% 5.1% 2.9% 4.5%

C Delayed transfers of care - Number of patients ACUTE <=4% 4.1% 2.5% 3.4% 3.4% 4.7% 2.4% 4.7% 6.0% 6.3% 12.1% 6.2% 6.2% 5.6% 3.1% 3.9% 8.1% 6.0% 5.3% 5.1%

C Delayed transfers of care - Number of patients ICH Report 11.4% 12.2% 10.2% 21.8% 25.3% 19.6% 11.2% 10.3% 12.2% 19.1% 8.2% 8.3% 13.3% 14.7% 18.7% 13.9% 9.9% 14.3% 24.5%

C Urgent referrals response compliance ICH >=95% 97.0% 65.0% 95.0% 98.0% 76.0% 94.2% 90.5% 95.6% 88.5% 75.0% 96.6% 94.1% 97.4% 86.0% 87.0% 86.0% 96.0% 88.0% 96.0%

C Sufficient appointment slots available C&B <=4% 10.1% 6.5% 3.4% 5.9% 6.4% 7.0% 5.5% 9.8% 15.5% 16.6% 12.0% 17.5% 19.2% 5.2% 6.3% 13.9% 16.6% 10.6% 20.7%

C EDS with GPs within 1 working day >=95% 69.2% 65.2% 75.0% 68.8% 73.3% 76.7% 73.1% 77.2% 78.0% 76.6% 79.5% 75.7% 77.7% 69.7% 74.4% 77.3% 77.6% 75.6% 75.8%

CQ Clinic letters to be typed and with GPs within 2 working days >=75% 37.2% 18.2% 18.3% 26.9% 28.6% 43.0% 33.1% 41.7% 47.5% 42.9% 59.1% 63.8% 70.2% 26.9% 33.1% 42.9% 70.2% 70.2% 63.3%

Key Indicators DashboardType

Year

to

Date

14/15

2014/1513/14

Outtur

n

Target

Change

Month

on

Month

Q1 Q2 Q3 Q4Complianc

eGWHNHSFT

NSF Coronary

Flow

Communication

Quality of Care

A&E Patient

Impact

Cancer

RTT

RTM

Stroke Care

Page 113

Meeting and date:


Title:

End of Life Strategy and Update on Progress

Summary of paper:

This paper presents the Trust’s End of Life (EoL) strategy to board. The main aspects to note:

The role out of the Conversation Project: initiative to equip staff with the skills to work with patients and carers to initiate discussion and form plans around EoL

The 3 key plans: 1) Advance Care Planning 2) The Treatment Escalation Plan (TEP) 3) Personalised Care Plan How these plans interact in an individuals EoL pathway

The formal collection of feedback


(a) The Trust Board support the End of Life Strategy Specifically: (b) The Trust Board support the Conversation Project (c) The Trust Board support the 3 plans to deliver EoL care to a high

standard

Link to Trust Priorities

(a) We will make the patient the centre of everything we do.










Risk issues:

The key risk is the role out of the Personalised Care plan. An action plan to deliver is underway and is being monitored through the EoL committee.


The Conversation project and related EoL work, was initiated in 2014/15 as part of a CQIN. There has been no identified funding for 2015/16, and it is currently a cost pressure. It has required additional resource: nurse to deliver the Conversation Project and additional Palliative care Consultant time: total £99.6K.

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Agenda Item 12


EoL is one of the Key areas under inspection when CQC attend in September. The Independent Review, led by Baroness Neuberger, recommended the withdrawal of the Liverpool Care pathway by July 2014. Thus the Trust was required to provide alternative plans and pathways


The Strategy follows National policy and is wrapped around providing high quality care to patients and their family & carers. Key performance indicators have been developed, and these will form part of the quality report that goes to Executive committee and Trust Board


Internally amongst staff, with broad representation.

With representation from the Trust Council of Governors (non-clinical member who is a member of the EoL committee).

With patients

With external stakeholders: Swindon CCG, Wiltshire CCG, Swindon BC, Wiltshire Council.






Dr Guy Rooney, Medical Director

Name of Author:

Dr Guy Rooney, Medical Director

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Great Western Hospitals NHS Foundation Trust

End of Life Care Strategy

2015 - 2018

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Great Western Hospitals NHS Foundation Trust End of Life Strategy

Our overall Trust strategy aims for us to achieve the following for our patients, users and

staff:

‘Working together with our partners in health and social care we will deliver

accessible, personalised and integrated services for local people.

We will provide high quality care whether at home, in the community or in

hospital empowering people to lead independent and healthier lives.’

This End of Life strategy is underpinned by this aim, and in addition aligns to the End of Life

strategies of both NHS Swindon and Wiltshire Clinical Commissioning Groups.

Purpose

The End of Life Care Strategy sets out how we will define, assure and improve the quality of

the End of Life service we provide.

Principle Objective

The patient and their family/carer receive the care and support that meets their

identified needs and preferences through the delivery of high quality, timely,

effective individualised services, ensuring respect and dignity is preserved

both during and after the patient’s life.

We will achieve this by:

Setting out priorities, allied to national policy and local plans, for delivering of End of

Life care services into the future

Ensure the patient and family are at the heart of End of Life Service development

Ensuring that the necessary planning occurs and that processes are in place to

deliver high quality, timely and effective individualised care

Involving service users in developing end of life care services

Engaging in on-going service review and development Key priorities:

Support patients to die in preferred place of care

Access to high quality care at all times

Informed choice for patients and families

Provide patients and family centred care

Flexibility of services

Provide value for money servcies

Individulas are empowered to plan for their end of life care

Improve patient and family experience

Ensure skilled and competent staff delivering end of life care

Reduce inappropriate transfers of care in all settings

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Scope

The scope of this strategy encompasses:

Adults (defined for the purposes of this document as over the age of 18 years old) with any advanced, progressive, incurable illness.

To plan for the transition of those transferring from children and young people’s services to adult services with end of life care needs.

To encompass all clinical care provided by Great Western Hospitals NHS Foundation Trust

The delivery of End of Life Care provided by the Trust in the last year(s) of life.

To include patients, carers and family members

To include bereavement and related aftercare

Definitions

Confusion exits around the terms ‘End of life care’ and ‘Palliative care. ’ They are not

synonymous. For the purpose of this document ‘End of life care’ should be considered

generalist and palliative care more specialist.

End of life care (National Council for Palliative Care):

‘End of Life care is care that helps all those with advanced, progressive, incurable

conditions to live as well as possible until they die. It enables the supportive and

palliative care needs of both patient and family to be identified and met throughout

the last phase of life and into bereavement. It includes physical care, management of

pain and other symptoms and provision of psychological, social, spiritual and

practical support’.

Palliative Care (WHO)

Palliative care is not time bound and is the total active care of patients with incurable

disease, encompassing physical, psychological, social and spiritual domains.

Traditionally the speciality has supported those with more complex needs, influencing the provision of End of Life care: - Management of complex symptoms

- Management of complex emotional/psychological issues - Management of complex social/family issues - Education in the provision of excellent care including communication skills,

assessment and care planning, symptom management and advance care planning

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National Context

People are living longer with serious illness. This increase in the ageing population means

by 2030 deaths will outnumber births, and it is anticipated that a significant proportion of

people will be dying with and from dementia.

These changing trends in the age of death, will lead to increasing numbers of deaths in

people aged 85 and over, and a decreasing trend in people aged 65 to 84. The older age

group has a greater likelihood of frailty and multi- morbidities.

Although 70% of the public say they are comfortable talking about death, most haven’t

discussed their end of life wishes or put plans in place.

The majority of deaths follow a period of chronic illness such as heart disease, cancer,

stroke, respiratory disease, neurological disease or dementia. Only 3 out of 4 people die of

non-cancer related illnesses, with minimal preparation for their End of Life care.

National data on peoples expressed preferences about place of death suggests the majority

would prefer not to die in hospital: 64% of people preferring to die at home, 21% in a hospice

and only 4% in hospital.

Local Service Provision

End of Life Care is one of the key priorities for commissioners. Both Swindon and Wiltshire

Clinical Commissioning Group’s ‘Clear and Credible’ plans 2013-15 include End of Life as a

key priority.

End of life care is delivered in the Great Western Hospital and within Wiltshire community by

the Integrated Community Health Division (community wards and people’s own homes).

Within the Great Western Hospital, acute clinical teams deliver End of Life care and are

supported by the in-reach palliative care service. The Great Western Hospital has a provider

to provider contract with Prospect Hospice to provide an in-reach palliative care service

which employs a consultant in Palliative Medicine and clinical nurse specialists. As part of

this provider to provider contract, the Great Western Hospital also purchases two hospice

beds.

CQUIN 2013-14 data revealed that of approximately 100 deaths per month in Great Western

Hospital, one quarter of the patients were known to the palliative care team. The team also

supports the care of many patients who are subsequently discharged, including via the rapid

discharge pathway for imminently dying patients.

Outside the Great Western Hospital, our clinical teams deliver End of Life care and work in

collaboration with 3 hospices and a range of specialist community End of Life care providers

geographically spread to meet the needs of patients in Swindon and Wiltshire.

Information from the End of Life Intelligence Network, derived from 2012 data shows that

annually there are about 1500 deaths in Swindon and 4100 deaths in Wiltshire. The

percentages of these deaths occurring in hospital are 52.3% and 49.9% respectively.

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Strategic Framework The National End of Life Care Strategy (Department of Health, 2008) identifies the following

elements of an End of Life care pathway and underpins this strategy.

In addition, the local actions from the National Care of the Dying Audit (April 2014) and findings from the “One chance to get it right” report (July 2014) have been combined to produce an action plan to influence service provision for dying patients locally. This is to ensure we are meeting national requirements and responding to patient and carer experience. This action plan links with the delivery of the strategic framework locally and provides the detailed response to service delivery for dying patients. Step One: Discussions as the end of life approaches Current provision There is evidence that patients are being identified, particularly those with cancer diagnoses, manifest by referrals to community palliative care teams from the acute side and discharges

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from in-reach palliative care team into the community. If identified, there is good local (supported by national) evidence that these patients are less likely to die in hospital. Explanation for this is likely to be multifactorial; including the provision of high quality support, pre-emptive work being undertaken and the more predictable disease trajectory of this group of patients However, evidence from 2013-14 CQUIN work suggests that patients with non malignant conditions are less likely to be identified until they are imminently dying. This precludes and limits discussion, and thus makes it difficult to deliver care reflective of patient preferences. Action Plan:

To develop a confident and compassionate workforce:

Motivation and opportunity

- Professionals to understand the benefits of discussions and to have opportunity in terms of time resource and support to introduce and progress such discussions

Education - Implementation of the 2014-16 Conversation project CQUIN (see below) - To develop a training strategy for End of life Care on a rolling programme for all

ward staff. Provision to reflect needs of professionals and responsibilities of their roles.

- To provide tools to demonstrate provision and learning. Co-dependencies - To develop stronger links with primary care Gold Standards Framework meetings

and hospital outpatient services, enabling coordination and communication (see Step 3)

- Integration with services and clinicians supporting patients with Long Term Conditions

The Conversation Project

The Conversation Project seeks to encourage and support people in expressing

their end-of-life wishes for care:

Earlier identification of patients approaching end of life

Ensuring that clinicians have conversations with these patients and their families about the uncertainties of their future

Documenting any conversations about the end of life ensuring these are visible to all health and social care professionals involved

Ensuring that there is a clear medical plan in the notes, that this is revisited regularly, and that family/carers are involved

Relaying all relevant discussions and decisions made to appropriate professionals in any transfer of care

Supporting and educating healthcare staff in delivering good end of life care

Support carers

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Step Two: Assessment, Care Planning and Review Current provision: With the loss of, and the issues surrounding the Liverpool care pathway, what has become clear is that even if people are indentified there is a need for replacement processes. These processes need to involve patients and their carers, and should be under regular review. Action Plan: The strategy sets out key tools to deliver End of Life care:

1. Advanced Care Planning 2. Treatment Escalation plan 3. Personalised Care Plan*

With a continuous evaluation (through formal feedback) process after the patient has died

Confident and Compassionate Workforce: building on the work in Step 1 to equip staff with the necessary skills to develop and deliver these plans

Stable disease

Increas-ing

in-stability

Deterio-rating

Dying

Advance Care Plan

Treatment Escalation Plan

PCP*

Evaluation of Care of the

Dying

Time

Family &

Carers

Patient

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Advance care planning (ACP)

This is a voluntary process of discussion about future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included.

It is recommended that with the individual’s agreement this discussion is documented, regularly reviewed, and communicated to key persons involved in their care. An ACP discussion might include: - the individual’s concerns and wishes, - their important values or personal goals for care, - their understanding about their illness and prognosis, - their preferences and wishes for types of care or treatment that may be beneficial

in the

Treatment Escalation Plan The Trusts, Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) document

has for some time been restrictive, non-transferable and poorly used. This will be

replaced by a Treatment Escalation Plan/ Resuscitation Decision document (TEP) a

new procedure and policy that engages the patient at an early stage in their care, to

support and help identify the patient’s ongoing health needs and clinical treatments

and wishes.

The TEP is transferable: it will be adopted across primary, community and secondary

care, both within Swindon and Wiltshire. Thus it will be only need to be completed

once (and can always be revised) yet formally recognised across all healthcare

organisations.

Personalised Care Plan See Step 5

Step 3 Coordination of Care It is well recognised that patients move between settings during the last year(s) of their lives. Concurrently multiple agencies including primary care, secondary care, third sector and social care and ambulance services are involved in their support and in the delivery of their care. An integrated, collaborative coordinated whole system approach with excellent communication is needed. Current provision Patients known to Prospect palliative care services (hospital, hospice and community) benefit from shared documentation via the Crosscare system. There is a weekly MDT meeting involving the in-reach team, Prospect@Home lead, integrated discharge team and SEQOL end of life care leads where Acute Trust inpatients are discussed. Prospects community team in turn liaises closely with GPs and community nursing services

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informally and also formally via Gold Standards Framework meetings. Coordination and communication mechanisms are less robust for patients who are not known to the in-reach palliative care team. The electronic discharge summary and out patient clinic correspondence are the main methods of communication Action plan:

Too ensure that when key plans are established this information is both recorded and shared (where appropriate) across health and social care systems.

To adopt the use of TEP (see above) across all local systems.

Co-ordinator clarity: Recent service re-design workshop hosted by Swindon CCG raised the importance of co-ordination of care. Collaboration is under way to develop a single point of access or key-worker system.

Communication: to promote the sharing of information across electronic platforms.

- The TPP IT system is soon to be adopted across Wiltshire and has an End of Life component.

- A similar initiative is being explored across Swindon. However, it is likely to

be a different IT platform

End of Life fields to be developed as part of the electronic discharge summary (EDS)

Step 4 Delivery of High Quality Services in Different Settings Current provision It is recognised that there are examples of high quality care, yet the delivery of this care is not always consistent or timely. By addressing Steps 1-3, we will go some way to ensuring the delivery of high quality across different settings. Action plan:

Rapid transfer between settings, responsive to patients needs including further enhancement of rapid discharge pathways including by working in collaboration with the Discharge Assessment Referral Team (DART) and social services

Provision of seven day working alongside availability of rapid access to care and equipment seven days per week

Step 5 Care in the Last Days of Life Current provision

The Liverpool Care Pathway and other similar tools were previously in place to support the care of patients identified as being in the dying phase. The Independent Review, led by Baroness Neuberger, recommended the withdrawal of the pathway by July 2014. The Leadership Alliance for the Care of Dying People (LACDP) has provided guidance on the development of a Personalised Care Plan focused around 5 Priorities of Care. The Five Priorities for Care are:

1. The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.

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2. Sensitive communication takes place between staff and the person who is dying and those important to them.

3. The dying person, and those identified as important to them, are involved in decisions about treatment and care.

4. The people important to the dying person are listened to and their needs are respected.

5. Care is tailored to the individual and delivered with compassion – with an individual care plan in place

Action plan:

To implement a Personalised Care Plan for all patients entering their dying phase across the Trust

Monitor via an Accreditation Process through End of Life Standards.

Step 6 Care after Death Current provision The Trust do not currently have a bereavement support service. Relatives and carers are offered support through Prospect Hospice. Although there has been feedback through National audits, Friends and Family, compliments and complaints; the Trust currently has no continuous in house process for monitoring or getting feedback on the quality of care it delivers around End of life. The Care of the Dying Policy informs staff of care of an individual following death. This is available on the Trust intranet. However, it needs to be updated to reflect recent changes Action plan:

Implementation of CODE- Care of the Dying Evaluation to ensure continuous feedback from families to support service development.

To evaluate the current provision of bereavement support services.

To update the Care of the Dying Policy

Priorities for delivery of Strategy over the next 3 years: To meet the key priorities the Trust work plan will include:

1. Involve patients and carers in all service redesign and delivery.

2. Introduction of CODE- Care of Dying Evaluation Bereavement survey

3. Introduction of a personalised care planning for all patients approaching end of life to

ensure individual needs are met

4. Implementation of Advanced care plan to be used across primary and secondary

care

5. Workforce development: Engage with staff across the Trust providing educational

opportunities so staff can identify end of life and diagnose dying.

6. Introduce Do Not Attempt Resuscitation and Treatment Escalation Plan (DNAR/TEP)

across acute and community settings. (EPaCCS requirement)

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7. Work with Swindon & Wiltshire CCGs to identify appropriate Electronic Palliative

Care Coordination Systems (EPaCCS) to ensure timely sharing of patient care

preferences across the health community.

8. Understand the increasing demand for end of life provision to address capacity

challenges within the system

9. Work with Clinical Commissioning Groups (CCGs) to streamline CHC fast track

process to ensure the process is simple and timely

10. Work closely with social & voluntary sectors developing hospital to home end of life

service supported by volunteers

11. Work closely with community colleagues to ensure an integrated approach to end of

life care supporting patient preferences.

Key Performance/Quality Indicators:

Monitor patient and family experience

Number of staff who have received education and training to support EOL care

Number of patients dying in preferred place of care

Number of patients approaching end of life with a DNAR/TEP in place

Number of patients with significant conversations documented in medical records and communicated with primary care.

How is our quality monitored?

The End of Life committee now provides a forum for monitoring and developing end of life care provision across the Trust. This committee reports quarterly to the Patient Quality Committee which reports to the Trust Board.

Representation from the Trust Council of the Governors is on the End of Life committee. They are non-clinical and their role is to provide public involvement and to link this work back through the governors and members processes.

The committee:

Oversee the delivery and management of care quality and patient experience by reporting monthly within the Trust Quality Report providing the End of Life Dashboard.

Monitoring of quality indicators quarterly with provision of a report to the Patient Quality Committee

The Trust participates in the bi-annual National Care of the Dying Audit and provides a robust response with appropriate action implemented. An End of Life Care quality indicator report is submitted quarterly to commissioners demonstrating progress against the measures of the Quality Schedule and CQUINS.

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Glossary

Useful Links: Leadership Alliance for the Care of Dying People http://www.england.nhs.uk/ourwork/qual-clin-lead/lac/ One chance to get it right document https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf • ELCQuA: www.elcqua.nhs.uk • on data and statistics: www.endoflifecare.nhs.uk/support-advice/data-statistics.aspx • National End of Life Care Intelligence Unit: www.endofllifecare-intelligence.org.uk • E-Learning End of Life Care for All (E-Elca):www.e-lfh.org.uk/projects/end-of-life-care • End of Life Care Coordination, Core Content, 2011: www.isb.nhs.uk/library/standard/236. For more information, please see the PublicHealth England website: www.gov.uk/government/ organisations/public-health-england. Currow, DC, Higginson I. Time for a prospective study to evaluate the Amber Care Bundle, BMJ Supportive & Palliative Care 2013;3:376-377.

National Council for Palliative Care Resources: Dying Matters: www.dyingmatters.org.• Find Your 1% – helping GPs deliver quality EOLC More Care, Less Pathway, Independent review of the Liverpool Care Pathway. July 2014 https://www.gov.uk/government/uploads/system/uploads/attachment data/file/212450/Liverpool Care Pathway.pdf. http://www.ambercarebundle.org/Implemetation-guidance.aspx

Marie Curie: • Marie Curie Atlas: www.mariecurie.org.uk/Commissioners-and-referrers/Resources/Marie-Curie-Atlas/,www.mariecurie.org.uk/Documents/HEALTHCAREPROFESSIONALS/commissioningservices/Q744_Atlas_end%20of%20life%20care_ V9_update.pdf. • Marie Curie publications and evaluations:www.mariecurie.org.uk/en-gb/healthcareprofessionals/commissioning-services/publications/?Tab=1. • Marie Curie Palliative Care Institute Liverpool:www.mcpcil.org.uk/.

Specialist palliative care: • Help the Hospices – What is Hospice Care?www.helpthehospices.org.uk/about-hospice-care/what-is-hospice-care/. • Association for Palliative Medicine: www.apmonline.org. • Association for Palliative Medicine –commissioning guidance for specialist palliative care: www.apmonline.org/documents/135764105191600.pdf.

Advance Care Planning • NEoLCP ACP Toolkit: www.endoflifecareforadults.nhs.uk/publications/acptoolkit. • Thomas K, Lobo B (eds). Advance CarePlanning in End of Life Care. Oxford: Oxford University Press, 2010. • GSF Centre – ACP: www. goldstandardsframework.org.uk/AdvanceCarePlanning.html.

Social care: • National Skills Academy for Social Care: www.nsasocialcare.co.uk/. • Social Care Institute for Excellence: www.scie.org.uk/. • National Homecare Council: www.nationalhomecarecouncil.co.uk/index.html.

Dementia • Department of Health, Living Well withDementia: a national dementia strategy: www.dh.gov.uk/prod_consum_dh/groups/dh_igitalassets/@dh/@en/documents/digitalasset/dh_094051.pdf. • Department of Health, Prime Minister’sChallenge on Dementia: delivering major improvements in dementia care and research by 2015: www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133176.pdf. • Dementia UK: www.dementiauk.org/. • Alzheimer’s Society – dementia-friendly communities: www.alzheimers.org.uk/.

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http://www.elcqua.nhs.uk/

https://www.gov.uk/government/uploads/system/uploads/attachment%20data/file/212450/Liverpool%20Care%20Pathway.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment%20data/file/212450/Liverpool%20Care%20Pathway.pdf

http://www.apmonline.org/documents/135764105191600.pdf

http://www.nationalhomecarecouncil.co.uk/index.html

Meeting and date:


Title:

Nursing Together – A strategy for improving patient care. Progress report.

Summary of paper:

This paper reports the progress made in implementing Nursing Together – A strategy for improving patient care against the ‘domains’ described within the strategy.


The Board is asked to:

(a) Note the content of the paper

(b) The Board supports the proposal to review, refresh and re-prioritise

the Strategy by November 2015


everything we do.








(4) Responsive (complaints, waiting times, cancelled operations, ambulance stays, translation services, comfort factors – TV and seating)


Risk issues:

Operational pressures including capacity management, nursing vacancies, management of temporary staffing and associated financial management impacts nurses’ ability to focus and implement the strategy within the desired timeframes. Nursing vacancies, corporate risk register 815, score 16.


There are no financial implications.


CQC Fundamental Standards:

Persons employed must be of good character, have the necessary qualifications, skills and experience, and be able to perform the work for which they are employed (fit and proper persons requirement).

Sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed.

Care and treatment must be appropriate and reflect service users'

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Agenda Item 13

needs and preferences


Implementation of the strategy sets out to improve patient care.


Divisional Directors of Nursing and Heads of Locality are expected to disseminate progress reports within their Divisions.



Great Western Hospitals NHS Foundation Trust wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust’s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics.



Name of Author:

Toni Lynch, Deputy Chief Nurse

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1. Introduction Nursing Together – A strategy for improving patient care was developed in 2012 led by the

Chief Nurse, in collaboration with the nursing team and set out ambitions and priorities over the coming years. The aims were to:

1. Set the strategic direction of travel for the Trust’s nursing workforce. 2. Provide clear framework for the nursing workforce to deliver the Trust’s vision and

strategy aligned to local service strategies. 3. Provide a framework for professional governance and assurance, including the

development requirements underpinning these. 4. Provide a framework for professional communication within and across the nursing

workforce.

This paper summarises the progress from November 2014 to April 2015.

2. Progress report

a) Leading the best patient, relative and carer experience

The creation and opening of the Dementia friendly ward in November 2014 has positively impacted the patient and carer experience. Feedback via compliments and the friends and family test suggest the new environment is easier to navigate and more comfortable for patients and their relatives. The early quality and safety indicators identify a reduction in harm, most notably with falls. The dementia friendly environmental changes include improved signage using pictures and words, improved flooring and colour scheming to support orientation. The dissemination of the staff into the patient bays away from a centralised nursing station is supporting and enabling nurses to be more responsive to patients’ needs.

In response to patient feedback, maternity services have built the ‘Woodlands Suite’ on

Hazel ward; this provides a private and comfortable family room and an area for breast feeding. A ‘Bereavement Suite’ is being built in the Delivery Suite for women who experience pregnancy loss; this suite will provide privacy and dignity for parents to spend time with their baby.

b) Strengthening leadership and professional practice

The roles of senior nurses at GWH NS FT support the delivery of modern healthcare. Sarah Jane Peffers (Head of Locality) is re focussing the nursing workforce within the

Integrated Community Health Division to ensure its practitioners meet the contemporary healthcare needs of patients. The Community Matron role is changing, and the aim is to provide a more responsive approach to patients in crisis in the community setting, avoiding admission to hospital where possible. This relies on nurses delivering advanced practice in patients’ homes whilst working in collaboration with colleagues across the health and social care network.

Nursing leadership capability and capacity meet the needs of evolving delivery of modern

healthcare services The Matron review is complete, culminating in a new job description and job plan which

better reflects the contemporary priorities of health care provision. The Matrons are presenting their work at the Nursing Strategy review in June 2015 prior to sharing it more widely across the Trust.

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Matrons have extended their working pattern to provide clinical expertise and leadership until 2000 hours Monday to Friday. In a quest to enhance nursing leadership out of hours, Senior Sister/Charge Nurses are now working weekends covering the acute site.

Caroline Wretham is the interim Divisional Director of Nursing for Unscheduled Care Division and the Division will be interviewing for the substantive post in June 2015. Sarah Merritt has commenced as the Divisional Director of Nursing within Women’s and Children Division. The Academy have developed a leadership programme for band 6 Sister/Charge Nurses, designed to support, challenge and enhance leadership at this level to ensure we are actively creating the next generation of nurse leaders.

The NMC Code of Conduct is embedded in the daily practice of all registered nurses The NMC launched a new Code of Practice in March 2015 and this forms an integral part of the proposed nursing and midwifery revalidation process which will come into effect in April 2016. The appraisal paperwork is being revised to incorporate revalidation.

c) Driving improvements in safety and quality of care

Nursing teams deliver consistently safe care Sign up for Safety focusses on 5 key areas to reduce harm:

I. Pressure Ulcer II. Falls

III. Sepsis IV. Acute Kidney Injury V. Deteriorating patient

Three of the five work streams are led by senior nurses; however the focus is on applying a collaborative approach, engaging all members of the multi-professional team to drive innovation and deliver sustainable change in clinical practice. Record keeping supports the delivery of safe high quality care Nursing documentation and care planning has been reviewed and newly developed documentation packs will be rolled out across the Trust in July 2015. The documentation is designed to ‘tell the clinical story’ to support safe, effective and responsive care delivery.

d) Delivering effective and efficient services

Nursing establishments, skill mix and rosters reflect the requirements for delivering top class, evidence based practice. A number of work streams are being undertaken to provide safe staffing whilst being financially accountable, these are:

I. The rollout of the Safer Nursing Care Tool - The Safer Nursing Care Tool (The Shelford Model) measures acuity and dependency and is advocated nationally as the most reliable method of calculating accurate levels of staff. The tool is designed for adult inpatient wards and rollout commenced in the acute Trust in April 2015. The tool will be applied continually seven days per week to provide an accurate assessment of acuity and dependency and required staffing levels. The results will form part of the skill mix review in July 2015.

II. The rollout of ‘red flags’ and ‘nurse sensitive indicators’ as recommended by NICE – this formalises the escalation process from wards to the Divisional

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triumvirate relating to patient quality, safety and staffing levels. This is being launched in May 2015.

III. The rollout of the ‘live and paperless’ e-roster system which will be complete by 29 May 2015. This ensures the most effective use of resources and enables monitoring of safe staffing levels by Senior Sister/Charge Nurses and Matrons and forms part of the assurance framework for the Divisional triumvirate.

The Divisional Quality Governance facilitators have been recruited and will start in their Divisions over the next weeks. This role will be pivotal in supporting the Divisional triumvirate to effectively lead the quality governance agenda, ensuring the focus is on applying lessons learned and enhancing services.

e) Leading a healthy and happy work life

Feedback from the staff survey tells us we need to focus on and improve the appraisal process. As a result three initiatives are being developed:

I. A structured ‘talent management’ process across the nursing team. A pilot is being developed with the Divisional Directors of Nursing, following this; talent management will be rolled out across the organisation. This will provide a framework on which to develop all staff and enable leaders to recognise and identify exceptional talent with potential for career fast tracking.

II. Review the appraisal process and documentation to support the concept of talent management to ensure it is embedded across all bands of nursing staff.

III. A review of shift patterns is being undertaken to align start times and in some instances change to 13 hour shifts at the request of the workforce. This reduces the overlap between shifts and supports a more streamlined rostering process.

f) Measuring impact and improvement

Nursing services establish their unique contribution to outcomes for patients Sue Harmsworth (Matron) and Rachel Jeffries (Head of Patients Safety) undertook the Quality Service Improvement Redesign programme offered by NHS Improving Quality (NHSIQ) equipping them to facilitate and enable clinical teams to lead the quality improvement programme. They are currently supporting the Sign up to Safety campaigns. Toni Lynch (Deputy Chief Nurse) is developing the ward accreditation programme which will be launched in January 2016. The programme, developed by the multi-professional team will set standards and raise the bar within a culture which respects Trust values. The programme aims to integrate best practice from other organisations and apply learning from Trusts who have achieved Magnet status.

g) Delivering a workforce fit for 21st Century

We advance nursing practice Diagnostic and Outpatient Division have recruited Lyndel Moore to the role of Consultant Nurse where her focus will be on clinical practice, leadership, education and widening the influence of GWH nursing nationally and internationally through conference presentations, publications and research. Education and development is targeted to deliver greater quality, effectiveness and efficiency. As part of the work stream to develop bands 1 to 4, the Trust has secured places to train unregistered staff to become Assistant Practitioners with local Higher Education Institutes. This offers an opportunity to train staff to undertake specific care to meet patients’ needs

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and complement the ward/department skill mix. In addition this provides a career path for unregistered staff, which has the potential to increase morale and improve staff retention. The Divisional Directors of Nursing and Heads of Locality are developing roles to support patients with specific needs for example cognitive impairment, rehabilitation and respiratory conditions.

3. Conclusion The nursing strategy continues to drive and support development across clinical services and within the nursing profession. Progress is less rapid than desired; however, frontline teams continue to contribute to operational priorities through a number of work streams: a) SAFER bundle b) Emergency Care Intensive Support Team (ECIST) c) rollout of EPMA, d) recruitment and managing demand and capacity priorities. The strategy has now been implemented for 3 years, the Senior Nursing Team is meeting in June 2015 to refresh and re-prioritise the strategy.

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Meeting and date:


Title:

Safer Staffing monthly report

Summary of paper:

This paper provides the monthly report advising the Board of the actual nursing and midwifery staffing compared to that planned and any associated quality impacts. In April the proportion of actual versus planned nursing hours (fill rate) was as follows: Day shift: RN 86.2% NA 109.6% Night shift RN 93.5% NA 134.1% There was a marked reduction in the fill rate for Registered Nurses fill rate at night. The trend for day fill rate continues, with a shortfall in registered nurse planned day hours, and an increase in unregistered staff day hours. The key quality indicators identify a reduction in category 3 and 4 pressure ulcers, a reduction in harm resulting from falls and a reduction in reported serious incidents. However the Trust reported 7 clostridium difficile cases in April 2015 across three Divisions.


that the Board notes the contents of this report.


everything we do.








Risk issues:

Continuing difficulty in recruiting sufficient Registered Nurses poses a risk to delivering consistently safe staffing. (Risk 815)

Resource Implications: (financial / human / other

Significant human resource continues to be required to establish reliable and robust systems and processes for the collation and validation of Safer Staffing data

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Agenda Item 14

resources)


None


Safe staffing is a key determinant of high quality care.


The staffing data and this report are published monthly on the NHS Choices website.

Confidentiality:

This report does not contain any confidential information.






Name of Author:

Julie Brown, Senior Nurse, Safer Nursing Care

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1. Introduction This report provides a summary overview of Safer Staffing. The detailed Safer Staffing data by Division and Ward being accessible on the Trust T drive (http://www.gwh.nhs.uk/about-us/our-staff/safer-staffing/unify/), as well as being published on NHS Choices. Therefore the report that follows identifies the key issues only. 2. Publication of data

The planned and actual hours of nursing and midwifery staffing continue to be reported monthly to NHS England via UNIFY and published on NHS Choices. For the month of April 2015, data was made public on 15th May. The associated Trust Board report (this paper) will continue to be available via a link from the Trusts NHS Choices page to the public to provide a narrative to the figures published, following Trust Board. The most common themes remain the same as those reported previously, including: an on-going difficulty in recruiting Band 5 Registered Nurses (RN), the ratio of RN to Care Staff reflects this. Nursing models on a number of wards, particularly in the Unscheduled Care Division, have changed in the short term to provide a higher number of unregistered staff per shift.

Higher than average care staff fill rates particularly on night duty is due to high acuity and close support requirements of several patients during the month. The close support requests were all appropriately assessed and monitored. Close support for patients, following risk assessment, continues to account for a significant proportion of temporary staff. This is closely monitored by Matrons and Divisional Directors of Nursing. Fill Rate A detailed review, to understand the high fill rates of unregistered staff for Saturn and Woodpecker wards, has been completed. This work follows concern being raised about the night fill rates, of ‘care staff’ in March 2015. The fill rates were 247.95% and 295% respectively.

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http://www.gwh.nhs.uk/about-us/our-staff/safer-staffing/unify/

http://www.gwh.nhs.uk/about-us/our-staff/safer-staffing/unify/

Both wards have a number of registered nurse vacancies and are unable to work to the agreed nursing model. Therefore, in the interests of care standards and patient safety, modified models are in place, increasing the numbers unregistered staff to meet patients care needs. This has impact on the accuracy of reporting planned hours, and thus the fill rates. For example, the modified model for Saturn ward gives a fill rate, for unregistered staff, of 137.21% over 24 hours. There has also been a continued requirement for close support on a regular basis to maintain patient safety. A total of 1637 hours was used on Woodpecker Ward during March. The total planned staffing numbers for Woodpecker, remain as model. However, we are not always successful in filling vacant shifts. This will also account for the low fill rate for RN’s for the day period. A review of patient dependence, by the previous Saturn Ward Matron, resulted in an increase in unregistered staff at night. This is for review by the current Matron, Senior Sister, and Divisional Director of Nursing. In summary, there needs to be a process to capture a change to planned hours, this is being developed by the Division in preparation for May’s report. Skill mix ratio Skill mix ratio is an indicator on which we have based our staffing models (65/35), and recognised good practice. Overall Trust skill mix ratio for services included in safer staffing reporting

April 2015 Planned day Actual day Planned night Actual night

RN 67.01% 61.28% 71.54% 65.32%

AN 32.99% 38.50% 28.46% 34.68%

The ratio for actual hours, day, has remained stable since last month. There has been an increase in the ratio of registered nurses at night. 3. Divisional Directors of Nursing reports Planned Care Division

a) Harm free care (Safety Thermometer) 94.3%, a reduction of 4.7% from the previous month. Safety Thermometer harms: 1 inherited pressure ulcer and 1 new VTE (Ampney ward) 1 inherited catheter associated urinary tract infection (ITU)

b) Clinical Incidents (IR1’s) - (April n=144). Trauma Unit and Surgical Assessment Unit reported two moderate harms, all others reported low or no harm.

c) Serious Incidents – zero. d) Falls are reducing for the Division including on the Trauma Unit where focussed

interventions are demonstrating improvements. e) Hospital acquired category 2 pressure ulcers - Trauma Unit (n=1), an investigation in

progress. f) Hospital acquired category 3 & 4 pressure ulcers - zero. g) MRSA bacteraemia, Trust acquired – zero. h) C. difficile cases, Trust acquired n=2 on Meldon ward, a period of increased intervention

has now been completed, the Trust is awaiting confirmed typing/finger printing to agree source.

i) Complaints related to Nursing and Midwifery -1 Surgical Assessment Unit complaint related to communication with a patient with complex care needs. A focussed plan focussing on communication is underway.

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j) Friends and Family Test responses (% of discharges) – Meldon ward and Shalbourne ward reported lowest returns below 40%, the Senior Sisters are leading an improvement plan.

Unscheduled Care Division

a) Harm Free Care (Safety Thermometer) 90.3%, a reduction of 2.6% from the previous

month. Safety Thermometer harms:

New category 1 and 2 pressure ulcers on Teal and Woodpecker wards. b) Clinical Incidents (IR1’s) April n=165, an increase of 23.

The increase can be attributed to an increase in falls and pressure ulcers. There were no reported incidents of moderate or serious harm caused to patients and 10 incidents reported for shortage of staff in April, highest number of staff shortages were reported from Saturn ward (n=3) and Acute Cardiac Unit (n=3).

c) Serious Incidents – the Division reported one SI in April, a category 3 pressure ulcer on Woodpecker ward compared to 7 in March. An investigation is underway.

d) Falls - there has been an increase in falls on Mercury and Neptune wards during April but no incidents reported of moderate or severe harm to patients. Both areas have reported an increase in patients admitted with confusion and multiple fallers. The correct procedures were followed post fall and assessed the need for closer support were appropriate for patient safety. There were no moderate or severe harm incidents in April 15.

e) Hospital acquired category 2 pressure ulcers Reporting of hospital acquired category 2 pressure ulcers reduced by one between March and April

f) Hospital acquired category 3 & 4 pressure ulcers One reported category 3 pressure ulcer on Woodpecker, an investigation is underway.

g) MRSA bacteraemia, Trust acquired - no reported incidents in April. h) C. difficile cases, Trust acquired

Two reported cases on Neptune ward, 1 case on Teal ward and 1 on Woodpecker ward. The Division are working with Infection, Prevention and Control, Carillion and the ward team to identify learning and actions to minimise the risk of further cases. Meetings have taken place and actions agreed.

i) Complaints - related to Nursing/Midwifery There were 12 complaints relating to nursing compared to 14 in March. There was an increase in complaints regarding nurses’ behaviour and attitude from 1 in March to 3 in April. This is being addressed by the areas concerned.

j) Friends and Family Test responses (% of discharges) Overall Divisional percentage = 47.59% with a star rating of 4.7 compared to 47.84% in March. Saturn ward responses reduced from 47% in March to11% in April and this has been addressed with the team.

Integrated Community Health Division

a) Safety Thermometer – no data available. b) Clinical Incidents (IR1s) n=55, compared to n=68 in March 15. Wards are regularly reporting transport issues as impacting on patient flow. Seven medication errors were reported with no harm. One prescription and administration error (double dose of paracetamol) has been addressed with the agency nurse. c) Serious incidents – zero. d) Falls – n=32, Longleat and Ailesbury ward reported the highest rate of falls. Ailesbury ward

has a high number of patients with cognitive impairment. Use of sensor alarms, high low beds, close support paperwork and close support has been used to reduce falls. Falls with harm – zero.

e) Pressure ulcer, hospital acquired category 2, n=1 This pressure ulcer was assessed to be unavoidable due to clinical condition.

f) Pressure ulcer, acquired category 3 and 4 – zero g) MRSA Bacteraemia – zero

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h) C. difficile – 1 reported case on Cedar ward. i) Complaints – n=1

This relates to staff attitude, which has not been reported previously. J) Friends and Family Test = 36.55%

This is a lower than expected response rate, Ward Clerks are champions and the Deputy Head of Community Inpatients is leading improvement.

Women’s and Children’s

a) Harm Free Care (Safety Thermometer) 100% on Children’s Unit and Special Care Baby Unit. Beech ward 88.9% DDON did the audit with the Ward Manager in May. Harm free care within maternity services = 100%.

b) Clinical Incidents (IR1’s). on Beech relating to the falls, 4 on Children’s Ward reporting staffing issues, recruitment drive underway, 5 on SCBU, 2 relating to omitted medication where short notice staff sickness led to staffing difficulties with skill mix. Learning embedded with roster management in future. Maternity services reported 100 clinical incidents, a culture of reporting exists and this rate is within those expected.

c) Serious Incidents – zero. One serious case review is underway in maternity services. d) Falls - 2 falls on Beech, one low, the other no harm.

Falls with moderate or severe harm – zero. e) Hospital acquired category 2 Pressure Ulcers – zero. f) Hospital acquired category 3 & 4 Pressure Ulcers – zero. g) MRSA bacteraemia, Trust acquired – zero. h) C. difficile cases, Trust acquired – zero. i) Complaints - related to Nursing/Midwifery – zero. j) Friends and Family Test responses (% of discharges)

19% on Beech with a 4.79 * rating, a reduction in the number of returned forms but still positive feedback, the ward manager has reminded all staff to encourage the return of FFT forms, 4% on children’s and 8% on SCBU both 5*. In Maternity services the star rating across Division = 4.79. Feedback from patients states they are 96.8% likely to recommend the service.

Diagnostics and Outpatients

a) Harm free care (Safety Thermometer) 100%. b) Clinical incidents n=7, a reduction from last month. c) Falls n=2. d) Falls with moderate or severe harm = zero. e) Hospital acquired category 2 pressure ulcers = zero. f) Hospital acquired category 3 and 4 pressure ulcers = zero. g) MRSA bacteraemia – Trust acquired = zero. h) C. difficile cases – zero. i) Complaints reported to Nursing and Midwifery n=1. j) Friends and Family responses 41%.

4. Composite safe staffing indicator – update There has been no further guidance from NHS England. However, we believe that the information they require is standard and we have a plan to address any shortfall in the data.

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Meeting and date:


Title:

Nursing and Midwifery Revalidation

Summary of paper:

The Nursing and Midwifery Council are proposing a change to the nursing and midwifery three yearly revalidation processes with the aim of enhancing public protection by ensuring all registrants are fit to practice. This paper outlines the proposed changes, the Trust’s operational resilience plan which focusses on workforce preparedness and risk mitigation.


The Board is asked to note the content of the paper.


everything we do.







Risk issues:

Significant numbers of staff fail to revalidate impairing the Trust’s ability to provide safe nursing and midwifery care. Risk 1320 on the Corporate risk register. Risk mitigation is detailed within the paper.


There are no financial implications. Further guidance is required from the NMC pilot sites to assess implications.


CQC Fundamental Standards:

Persons employed must be of good character, have the necessary qualifications, skills and experience, and be able to perform the work for which they are employed (fit and proper persons requirement).

Sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed.


The revalidation process offers a more robust process to ensure nurses and midwives are fit to practice and seek to enhance public assurance and confidence.


This document does not require formal consultation however it does require a robust communication strategy as detailed within the report.

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Agenda Item 15



Great Western Hospitals NHS Foundation Trust wants its services and opportunities to be as accessible as possible, to as many people as possible, at the first attempt. This report has been assessed against the Trust’s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics.



Name of Author:

Toni Lynch, Deputy Chief Nurse

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1. Introduction All nurses and midwives must be registered with the Nursing and Midwifery Council to practice. The Nursing and Midwifery Council (NMC) is in the process of reviewing the three yearly revalidation processes which is designed to improve public protection by applying greater rigour to the process of revalidation.

2. Background The current revalidation process relies on self-declaration to determine the registrant’s fitness to practice. Each nurse or midwife is expected to declare they have met the NMC revalidation requirements over the preceding three years. Each registrant is advised by the NMC to keep a portfolio of evidence to support the self-declaration and the NMC are at liberty to request this evidence at any time. The proposed changes (detailed below) are due to be finalised by October 2015 and likely to come into effect in April 2016; however the NMC are yet to confirm these dates. In 2016 The Great Western Hospitals NHS Foundation Trust has 832 nurses and midwives who are due to revalidate across all clinical services. This number is likely to change dependent on recruitment and turnover.

3. NMC proposed changes Following a period of consultation, the NMC published the proposed revalidation process which is being piloted in a number of NHS and private healthcare organisations across the United Kingdom. The results are due to be shared across the NHS in October 2015. The proposed revalidation process is summarised in table 1 and provided in greater detail in appendix 1.

Table 1: Summary of proposed revalidation process Revalidation criteria Until December 2015 From December

2015 (new system) What has changed

Pay annual fee

Undertake practice hours 450 practice hours per registration.

Undertake continuing practice development CPD

The total number of hours has increased to 40 CPD hours.

Gain 5 written practice related feedback

x This element is new from April 2016.

Provide 5 written reflections on the Code, your CPD and practice related feedback

x This element is new, from April 2016 each registrant is expected to provide 5 written reflections and have a professional discussion with another NMC registrant, covering the reflections on the Code, their CPD and practice related feedback.

Health and character declaration

This is not new.

Professional indemnity This is not new.

Confirmation by a third x This element is new. Each

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party registrant is required to gain third party confirmation that they have demonstrated to an appropriate third party that they have complied with the NMC revalidation requirement.

4. Operational preparedness Following the anticipated feedback from the pilot sites the NMC plans to confirm the revalidation process in October 2015 and propose the first registrants revalidate under the new system in April 2016, providing a six month period for staff to prepare. Table 2: Total number of nurses and midwives revalidating by month, based on current workforce. This is will change as a result of turnover and recruitment.

Month Number of nurses and midwives due to revalidate

April 50

May 37

June 49

July* 192

August 36

September* 161

October 36

November 71

December 58

*Totals correspond with the end of the academic year and reflect student nurses registering with the NMC for the first time.

Operational preparedness and resilience is split into two phases 1) pilot phase 2) confirmed revalidation phase. Phase 1: Preparedness is focusing on:

a) Communication – all nurses and midwives b) Workforce preparedness – individual preparedness/leadership preparedness c) Performance framework to monitor Divisional compliance and risk d) Continual learning from the pilot sites and adapting the operational plan

Table 3: Summary of phase 1 operational resilience plan

Communication

Target date Lead Action status

Develop a nurse revalidation intranet site containing all information 04/15 RP Complete

Write to all registrants at their home address informing them of NMC revalidation changes (Letter and local guidance)

04/15 TL Complete

Write to all registrants who are due to revalidate in 2016 to alert them to their professional responsibilities

04/15 TL Complete

Write to all bank staff who are not employed substantively by the Trust

04/15 TL Complete

Amend interview paperwork to include revalidation information:

Interview checklist

03/15 AK Complete

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Offer letter

Develop local GWH guidance to support guidance published by the NMC

04/15 TL Complete.

Publication:

Hot news – sequential countdown - monthly

Staff room – November 15

Horizon – December 15

Facebook updates – sequential countdown

Twitter updates – sequential countdown

11/15 12/15

TL/RP A number of publications will be required to ensure this remains high profile.

Add to mandatory training – either give out written advice or 5 min update

05/15 RP Complete

Add to Trust Induction, day 2 – GWH guidance and general letter 04/15 RP Complete

Trust wide open staff sessions for all staff across all sites GWH acute (10) Savernake (2) Chippenham (2) Trowbridge (2) Devizes (2) Melksham (2) Prison (1) Neighbourhood teams (3) More sessions will be provided as required.

RP/TL/DDON/M

Commenced

Appraisals

Amend appraisal policy and paperwork to include nurse and midwifery revalidation

06/15 CP, TL, VO, RP

Commenced

Amend human resource policy

Add failure to revalidate into conduct policy 16/15 CP

Performance management/assurance

Monthly monitoring and refresh of staff due to revalidate to capture turnover and new starters

05/15 RP First draft shared with Divisions

Failure to revalidate could have a significant impact on staffing levels and quality of care. Divisional Directors of Nursing will provide situation reports at their monthly Performance Reviews with the Executive teams

11/15 DDON Agreed action

GWH pilot

Undertake an internal pilot with nurses and midwives who are due to revalidate in 2016 to enhance internal learning in advance of the national guidance

09/15 TL/RP Commence 05/15

Phase 2: This will be fully scoped and developed following the release of the confirmed revalidation process by the NMC. The principles applied in phase 1 are likely to apply.

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5. Risk and mitigation Risk 1320, score 9 on the corporate risk register

Risk no.

Risk Score Mitigation

Risk 1

Significant numbers of staff fail to meet revalidation criteria resulting in staff being unable to practice as registered nurses or midwives – this could negatively impact the Trust’s ability to provide safe and effective care.

High Operational plan aims to mitigate risk through a zero tolerance approach to revalidation failure:

a) Workforce preparedness. Every nurse and midwife is aware of the changes and how they can meet the revalidation requirements.

b) Comprehensive communication plan. c) Training and supporting nursing and midwifery

leaders to lead and manage the process at ward and department level.

d) Performance plan will monitor each registrant due to revalidate in 2016 and onwards.

e) Performance will be monitored through the Divisional Business and Governance meetings, reporting to the Divisional Performance Reviews and Executive Committee. Revalidation performance will be added to the Divisional Performance score card.

Risk 2

Failure to meet revalidation criteria will result in suspension without pay, this could negatively impact workforce morale

Med

The mitigation plan above applies. The Conduct Policy is being revised to include failure to prepare adequately resulting in a failure to revalidate.

Risk 3

NMC finalised plans change significantly from those in the draft proposal leading to staff confusion.

Med The operational plan will be amended to address any changes.

a) Evaluate the phase 1 communication plan b) Amend and improve communication strategy

c) New communication will be sent (mirroring the current plan with learning) to ensure all staff receive the finalised NMC guidance.

d) Inform staff the proposals are in draft and likely to be amended prior to formal roll out.

6. Conclusion The NMC revalidation process is scheduled to become operational in April 2016. Based on the draft NMC guidance the Trust has a resilience plan in place which is focussed on individual and leadership preparedness underpinned by an operational framework to identify organisational risk. This requires on-going focus and attention to ensure our staff are well prepared, successfully revalidate first time and the organisation has sufficient staff to meet the needs of patients.

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Appendix 1

The NMC proposed changes are described in greater detail.

a) Practice hours Each registrant must undertake a minimum 450 practice hours over three years. If the registrant holds dual registration, for example a nurse and midwife or midwife and Specialist Community Public Health Nurse, they will be required to undertake 900 hours – 450 hours per registration.

b) Continuing Professional Development (CPD) Each registrant must provide evidence of 40 hours of continuing professional development (CPD) activity and their associated learning. 20 hours of CPD must be participatory learning which can include classroom, webinars and conferences. Staff cannot use statutory training, for example fire training, however they can use some mandatory training. .

c) Practice related feedback This element is new: Each registrant is expected to obtain five written practice related pieces of feedback and this can come from a variety of sources which include colleagues, students, patients, service users. We are advising registrants can think broadly how they receive this and can include appraisal feedback, STAR awards or nominations, feedback from patients via friends and family or compliments and feedback from student nurses. If staff ask patients or colleagues for feedback they should inform them how they intend to use the feedback.

d) Reflections on the Code and discussion This element is new: Each registrant is expected to provide five written reflections on the Code, their CPD and practice related feedback. Once these have been written these staff need to have a professional discussion with another NMC registrant, covering the reflections on the Code, their CPD and practice related feedback. The NMC registrant with whom they are having the discussion must sign a form recording the discussion. We recommend this discussion takes place as part of the appraisal process, however until the changes are embedded it may be another NMC registrant with whom they work. The reflections must identify how this relates to their practice.

e) Health and Character Each registrant must provide a health and character declaration. Staff must declare if they have been convicted of any criminal offence or issued with a formal caution over the three years prior to the renewal of their registration. They are also expected to be in a state of health that ensures they are capable of safe and effective practice without supervision, after any reasonable adjustments are made by the employer.

f) Professional indemnity

Each registrant must complete this declaration as part of their revalidation application. As part of employment by GWH, the Trust provides professional indemnity.

g) Confirmation by a third party This element is new and provides a significant change for all nurses and midwives. This is a declaration that each registrant has demonstrated to an appropriate third party that they have complied with the NMC revalidation requirements. Third party confirmation is where a third party can confirm that they have discussed revalidation portfolio with the registrant and in their judgment have met the revalidation requirements.

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