board papers october 2015

Surrey and Sussex Healthcare NHS Trust

Board Papers

October 2015

Trust Board Meeting – IN PUBLIC

Thursday 29th October 2015 - 11:00 to 13:30

AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA

1

11:00

GENERAL BUSINESS 1.1 Welcome and apologies for absence 1.2 Declarations of Interests 1.3 Minutes of the last meeting held on 24th September 2015 - For approval 1.4 Action tracker 1.5 Chairman’s Report

For assurance

1.6 Chief Executive’s Report For assurance

1.7 Board Assurance Framework & Significant Risk

Register – For approval & assurance

A McCarthy A McCarthy A McCarthy A McCarthy A McCarthy M Wilson G Francis- Musanu

Verbal

Verbal

Paper

Paper

Verbal

Paper

Paper

2

11:30

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1 Patient Story

For assurance 2.2 Chief Nurse & Medical Director’s Report

For assurance

2.3 Children’s Safeguarding Annual Report For approval 2.4 Adult Safeguarding Annual Report For approval 2.5 Safety & Quality Committee Update For assurance

F Allsop D Holden/ F Allsop F Allsop F Allsop R Shaw

Paper

Paper

Paper

Paper

Paper

3

12:15

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M06)

For assurance

3.1.1 Operational & Quality Key Performance Indicators

3.1.2 Workforce Key Performance Indicators 3.1.3 Finance Key Performance Indicators

A Stevenson D Holden/ F Allsop F Allsop P Simpson

Paper

3.2 Breaking the Cycle & Winter Planning For assurance 3.3 Finance & Workforce Committee Update

For assurance

A Stevenson R Durban

Presentation

Paper

4

13:05

RISK, REGULATORY AND STRATEGY ITEMS 4.1 Q2 Annual Plan Update For assurance 4.2 Virginia Mason – Progress Update For assurance

S Jenkins M Wilson

Paper

Verbal

5

13:25

OTHER ITEMS 5.1 Minutes from Board Committees

to receive & note 5.1.1 Finance and Workforce Committee

5.1.2 Safety & Quality Committee

5.2 ANY OTHER BUSINESS 5.3 QUESTIONS FROM THE PUBLIC

Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to: [email protected]

5.4 DATE OF NEXT MEETING

26th November 2015 at 11.00am

All A McCarthy A McCarthy

mailto:[email protected]

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Minutes of Trust Board meeting held in Public Thursday 24Th September 2015 from 11:00 to 13:30

Room AD77, PGEC East Surrey Hospital

Present

(AM) Alan McCarthy (MW) Michael Wilson

Chairman Chief Executive

(PS) Paul Simpson Chief Finance Officer / Deputy Chief Executive (FA) Fiona Allsop Chief Nurse (DH) Des Holden (AS) Angela Stevenson

Medical Director Chief Operating Officer

(PBi) Paul Biddle Non-Executive Director (RD) Richard Durban Non-Executive Director (PL) Pauline Lambert Non-Executive Director (RS) Richard Shaw Non-Executive Director In Attendance

(GFM) Gillian Francis-Musanu (ASC) Adam Stacy-Clear (JM) Janet Miller (CP) Colin Pink

Director of Corporate Affairs Responsible Officer for Consultant Re-Validation Deputy Director of Human Resources Head of Corporate Governance (Notes)

1. General Business

1.1 Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, Shadow governors, staff and members of the public. Apologies for absence from Alan Hall (Non-Executive Director) were noted in advance of the meeting.

1.2 Declarations of Interest The Chairman asked whether any of the Board members had any additional declarations of interest; none were recorded.

1.3 Minutes of the last meeting – 27th August 2015 The minutes of the meeting held on 27th August 2015 were discussed and were approved as a true and accurate record. RS highlighted the expectation that two annual safeguarding reports would be received at public board in October.

1.4 Action Tracker The following actions were updated and closed. TBPU-02: The Board noted that the FWC had discussed the BAF risk relating to liquidity focusing on the level of risk and the balance between the amount of liquidity and the controls that continue to mitigate against adverse effect and were content that the risk score should remain as 15.

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TBPU-03 : The Board noted that this issue was being considered by the AAC. TBPU-05 : The Board noted that this action was liked to action 1 and agreed to combine the expected output. TBPU-07: The Board noted that the standing agenda item had been passed to the FWC. The following actions remain open and are carried forward to the October public Board meeting. TBPU-01: FA agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. TBPU-04: The Board requested that Dr Julian Webb update the Board on findings and actions of the sample group. TBPU-06: The Board asked the SQC to focus on the management of FFT and patient feedback.

1.5 Chairman’s Report for Assurance The Chairman congratulated and welcomed Angela Stevenson to the Board in her new role as Chief Operating Officer, highlighting how rewarding it was to have internal progression of frontline management to the Board. The Chairman confirmed that Pauline Lambert had agreed to take up the role of Senior Independent Director, which is a key role that supports the Shadow Council of Governors. Finally the Chairman highlighted that Alan Hall had taken on the role of Chair of the Charitable Funds Committee. The Board noted the report.

1.6 Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW introduced the report welcoming the Health Secretary’s vision for use of technology across NHS, highlighting the efforts to improve outcomes and quality of care and stating that the Trust would be working with national teams. MW went on to discuss the implications of the New rules launched to reduce agency and temporary staff spend in the NHS. Assuring the Board that management had started to work through the implications for the Trust and was consistent in its thinking that recruitment and retention was a key issue to improve. The League of Friends had recently held its Annual General Meeting (AGM) which had been particularly interesting. MW stated that the League of Friends work was highly valued and thanked them for their individual contributions to the Trust. RS asked for further detail on what actions had been taken to influence the

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Trust’s recruitment and retention issues. MW highlighted the need to recruit and retain staff, focusing on the role of the local governing bodies to support efforts to train new Nurses, Doctors and Physicians Associates. The Board duly noted and took assurance from the report.

1.7 Board Assurance Framework (BAF) and Significant Risk Register (SRR) for Approval and Assurance GFM introduced the board assurance framework and significant risk register. Stating that the BAF had received its normal review and update of actions and assurances by the Executive Committee. GFM went on to highlight that the title of the risk relating to the Trust’s Foundation Trust process had been reworded to reflect changes in the current situation. The Board noted and discussed the 5 new risks which had been added to the SRR, 4 of which had been added because of financial position and a risk that was linked to the Trust’s capability to provide appropriate care and supervision of adolescent mental health patients. FA highlighted that this risk had been escalated following a prolonged period of increasing numbers of admissions with undefined support process from community mental health providers. MW stated that the situation was very complex and linked to shortfalls in community mental health beds and increases in emergency admissions. MW went on to assure the Board that he had met the CEO’s of both the local ambulance service and the police force to discuss the issue. FA stated that a review with local mental health providers was planned and there was an expectation that this risk would be resolved shortly. The Board agreed the rewording of BAF risk 5.6. GFM indicated that as discussed at previous Private Board the current plan is to re-engage with the Foundation Trust journey in January 2016. RD and PS confirmed that the FWC had discussed the scoring of the strategic liquidity risk and agreed that it went unchanged noting the mitigating £6 million loan secured in September 2015. The Board duly approved and took assurance from the report.

2. Safety, Quality and Patient Experience

2.1 Consultants Revalidation Annual Report & Presentation for assurance & approval The Board received and noted the report in advance of the meeting. ASC presented the annual report, bringing the Board to attention the requirement to review and sign off the annual return to the General Medical Council (GMC). ASC highlighted that 245 doctors with a GMC connection to The Trust had been included in an audit of appraisal and that 114 revalidation recommendations had been made. The Chairman asked for assurance as to how effective the appraisal and revalidation process was. In response ASC assured the Board that the Trust had a good medical appraisal system which was held in high regard amongst external peers. DH went on to highlight that there was a robust escalation

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process and that in the one instance of potential non-compliance with national policy a consultant had been given a deadline at which point they would be excluded without pay. The Board noted the results of the audit and agreed that this was an outstanding achievement for the Trust. The Board went on to discuss who could be a medical appraiser, noting that it was an elected position with effective peer support networks in place. The Board asked for assurance on the management of identified issues and sharing of information between organisations. ASC confirmed that there was strong communication between Responsible Officers’ and that if necessary issues would be escalated to the Medical Director. Action: The Board agreed to sign the Trust statement confirming compliance with The Medical Profession (Responsible Officers) regulations 2010. The Chairman thanked ASC for the presentation and continued good work. The Board approved and took assurance from the report.

2.2

Chief Nurse and Medical Director’s Report for Assurance The Board received and noted the report in advance of the meeting. FA presented Chief Nurses report highlighting the Trust’s overall ‘green’ rating for safer staffing and that issues in midwifery where close to being resolved with the appointment of 25 midwives. FA went on to highlight the Trust’s local and international drives to recruit new nursing staff. The Board discussed the issues highlighted by the recent PLACE assessment, noting that there are actions to take to improve the quality of experience for dementia patients relating to fixtures and fittings. The Board noted that in particular the new state of the art flooring that had been laid to reduce the level of falls with harm had been scored adversely as it had a matt finish. As such there is work to do to consider the scoring system and its implications. DH Highlighted that the Clinical Chiefs had spent ring fenced time considering how to they could lead and better contribute to the challenge of moving the Trust from good to outstanding. Going on to announce the launch of the ‘Ideas to Innovation’ factory that is an open platform for the sharing and review of new ideas. The initiative had had considerable buy in with 50 ideas logged in the first week. The Board asked what conclusions had been drawn from the Chiefs’ away day. DH stated that all had agreed that they need to spend more time focusing on their Chief roles, to effect more change and drive strategy. This would intern lead to greater accountability and visibility at Board level. The Board duly noted and took assurance from the report.

2.3 Quality Governance Assurance Framework Update (QGAF) for Assurance The Board received and noted the report in advance of the meeting.

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DH reminded the Board that Trust had been given an initial QGAF score of 3.5 which met the expected target score. Going on to highlight that from the verbal feedback it was felt that a lower score was within the Trust’s gift and that the Executive team had resolved to further strengthen quality governance systems. As such the QGAF action plan had been updated to reflect areas of improvement and possible actions. The Executive team are confident that a score of 2 is achievable by the end of the financial year. The focus of actions is linked to strengthening data quality and assurance and improvements in Board review of Cost Improvement Programmes and Quality Impact Assessments. PL noted that it was a significant achievement to have received a score of 3.5 at the first assessment by Monitor and noted the significant improvements in quality governance over recent years. The Board duly noted the report for assurance.

3. Operational Performance

3.1 3.1.1 3.1.2

Integrated Performance Report (M5) for Assurance The Board received the Integrated Performance report in advance of the meeting. AS introduced the section of the report that related to performance management. Highlighting the pressures on the Emergency Department and continued growth in attendances and admissions. AS discussed issues relating to ambulance handover times, surge management and issues that contributed to the 62 day cancer rate. The Board asked that plans be considered on how to best manage those patients with late referrals to the Trust within the 62 day target. Action: The Chairman asked DH for to provide an update on recent trends in E-Coli numbers. MW reminded the Board of changes to national referral to treat KPIs highlighting that now the emphasis is on clinical priority some patients may end up waiting longer for routine surgery. FA introduced the safety section of the report indicating no new significant concerns and strong mortality indicators. FA highlighted the drop in achievement of KPIs linked to harm free care. In month there had been an increase in observed urinary tract infections. FA commented on the ‘Friends and Family Test’ response rates highlighting improvements in ED rates and ongoing issues with response rates for maternity. The Chairman thanked AS and FA for their review and asked for increased focus on maternity ‘FFT’. JM introduced the workforce sections of the report bringing the reducing sickness absence and ongoing turnover issues to the Board’s attention. RD commented on the completion rates of the non-medical achievement reviews

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3.1.3

which were below trajectory. JM confirmed that performance was below plans and that a recovery plan was in place with targets to achieve 90% by the end of October. This issue is being monitored by the Executive team and the Finance and Workforce Committee (FWC). PS introduced the financial section of the IPR noting the error of the 3rd bullet which should read ‘end of August’. PS highlighted the worsening financial position at the end of month 5, which is being driven by reduced elective income and non-elective activity admissions running at 5.5% above plan and growth in activity of 7.5%.This issue is compounded by excess bed days, agency usage and reductions in elective work. The Trust is adverse to plan by £1.9m at month 5 with a £2.6million deficit. This position is however being supported by budgetary reserves. The £1.6 million surplus forecast still stands and has been considered by the FWC. The current worst case deficit forecast is £4.2 million. The Board noted that it had not been paid for £1.2 million pounds of activity and were reassured by recent impacts of ‘breaking the cycle’ week and discussion of financial controls including divisional PMO. The Board duly noted and took assurance from the report.

3.2 Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting. RD introduced the report from the FWC referring to earlier conversations regarding financial position and liquidity risk. RD stated that the risk was being monitored monthly and indicated that cash flow problems were an issue. As stated earlier the FWC had recommended that the BAF liquidity risk remain unchanged. The Board noted that a significant sum of cash would be required at the transition point to Foundation Trust status to effectively deal with the underlying problem. The Board noted that liquidity was a significant national issue. The Board duly noted the report for assurance.

3.3

Audit and Assurance Committee (AAC) Update for Assurance The Board received and noted the update in advance of the meeting. PBi introduced the report from the AAC. The Committee had reviewed the BAF and took assurance that it was appropriately reported. The AAC had asked for changes to financial risk description to reflect strategic risk prior to the September Board. In particular focussing on income plan and conversations relating to Foundation Trust application and the 2016/17 national tariff. The Committee received management’s review of workforce controls. The Committee took assurance from the planned mitigations and actions already taken. The Board duly noted the report for assurance.

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4. Risk, Regulatory and Strategy Items

4.1 Serious Incidents Report for Assurance The Board received and noted the update in advance of the meeting. FA introduced the report which detailed the Trust’s current and recent declared serious incidents. The Board took assurance from the Trust’s current SI position noting that the Trust had only 8 open investigations at the time of the meeting which is not only a significant improvement on recent performance but is below the Trust’s earlier target of no more than 10 open investigations at any time. The Board asked for clarity as to when the SI declared in August had occurred. Action: FA agreed to provide a verbal commentary on the time period involved in reporting the August SI which had occurred in 2008. The Board duly noted and took assurance from the report.

4.2 Agency Nursing Ceiling Plan to the Trust Development Authority (TDA) for Approval The Board received and noted the update in advance of the meeting. FA introduced the report highlighting that Monitor and the TDA had issued rules on managing agency nursing costs and required all TDA trusts to submit a plan describing how they will reach the target “ceiling” spend. These plans have been signed off by the Trust’s CFO and Chief Nurse, endorsed by the Executive Team and required approval by the Board. The Board noted the plan that had been supplied with the report and discussed the need to meet and sustain targets by March 2016. This included a significant decrease in agency spend to £600K and was supported by a list of actions and noted that the key was the Trust’s plan to increase permanent staff ratios. The Board discussed the particular issues that affected the situation focusing on both the need to ensure safer staffing levels and reduce agency which is driving significant competition for permanent staff. Noting that the Trust had opened 5 wards in the last five years and that there is a nursing vacancy gap within the local health economy of circa 2000. The Board went on to discuss the need to ensure turnover is managed and planned for. MW highlighted that the first years of employment with the Trust are the period of highest turnover and that every effort should be made to use resources and opportunities to make the Trust the most attractive place for new staff to work. The Board was assured by the plan and contingency actions listed in the appendices. Noting the formal powers that the TDA had to intervene. The Board duly approved the plan.

4.3 Equality Delivery System and Workforce Race Equality Scheme for Approval The Board received and noted the update in advance of the meeting.

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JM introduced updated the Board on the two new requirements which support the Trust’s obligations under the Public Sector Equality Duties. These are the Equality Delivery System and Workforce Race Equality Standard. Highlighting that this was a long term national drive which would require regular monitoring and reporting. The first year was being used to establish a baseline. The report included a range of indicators and expectations which the Trust is aiming to achieve and exceed. JM highlighted the specific expectations for senior managers. The Board noted the development of the revised Equality Objectives for 2016/17 and the baseline data for WRES submitted to Department of Health on 1 July 2015. The Board duly approved the plan.

Other Items

5.1 Minutes of Board Committees to receive and note

5.1.1 Finance and Workforce to receive and note The minutes of the Committee were noted with no questions raised.

5.1.2 Audit and Assurance Committee The minutes of the Committee were noted with no questions raised.

5.2 Any Other Business No further business was discussed by the Board.

5.3 5.3.1

Questions from the Public There were no formal questions from the public. Len Roberts, Shadow Governor for Tandridge, asked how the Governors could be included in the ‘Ideas to Innovation’ project. Lesley Copus, Shadow Governor for non-clinical Staff, offered to liaise with Governors who didn’t have access to the system to log ideas or thoughts. Len Roberts also asked whether there would be an opportunity over time for Governors to be involved in some way in the process for consultation re-validation. The Trust would discuss with ASC and consider the possibilities. There were no other questions.

5.4 Date of the next meeting Thursday 29th October 2015 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation.

These minutes were approved as a true and accurate record. Alan McCarthy Chairman: Date:

TRUST BOARD ACTION TRACKER

Action Ref Forum Subject Action RO Date Open Date Due Date Closed Status

TBPU-01 TB Public Chief Nurse report

FA agreed to provide an update to the Trust Board in

relation to the Temporary

Staffing Contract in the coming months. PS added

that an update on the Agency

Contract variations will also be reported to the FWC

in advance. FA 25/06/2015 29/10/2015 Closed

TBPU-02 TB Public Patient story

The Board requested that Dr Julian Webb update the

Board on findings and actions of the sample group. DH 28/08/2015 30/11/2015 OPEN

TBPU-03 TB Public

Integrated Performance

Report

The Board asked the SQC to focus on the

management of FFT and patient feedback.

RS 28/08/2015 29/10/2015

Closed

On SQC

agenda

planner

TBPU-04 TB Public

Integrated Performance

Report

DH to provide an update on recent trends in E-Coli

numbers. DH 24/10/2015 29/10/2015 OPEN

TBPU-06 TB Public Public SI report

FA agreed to provide a verbal commentary on the

time period involved in reporting the August SI which

had occurred in 2008 FA 24/10/2015 29/10/2015 OPEN

TBPU-07 TB Public Consultants Revalidation

To sign the Trust statement confirming compliance

with The Medical Profession (Responsible Officers)

regulations 2010 AM 24/10/2015 30/10/2015 CLOSED

ACTIONS FROM PUBLIC BOARD MEETINGs

1 An Associated University Hospital of

Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 29th October 2015 Agenda Item: 1.7

REPORT TITLE: Board Assurance Framework & Significant Risk Register

EXECUTIVE SPONSOR: Gillian Francis-Musanu Director of Corporate Affairs

REPORT AUTHOR (s): Colin Pink Head of Corporate Governance

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Committee 21/10/2015

Action Required:

Approval (√) Discussion (√) Assurance (√)

Purpose of Report:

The 2015/16 BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework.

Summary of key issues

The BAF details 13 risks to the trusts strategic objectives, 7 of which are recorded as key strategic risks and red rated. There are 13 significant risks recorded on the Trust risk register, including 1 new risk (relating to 62 day cancer target) and the downgrading of the risk relating to supervision of adolescent mental health patients.

Recommendation:

The Board is asked to discuss and approve the report and consider the following:

Review the BAF and its alignment to strategic objectives

Does the Board agree with the recorded controls and assurances

Note the updated risks included in the Significant Risk Register

Relationship to Trust Strategic Objectives & Assurance Framework:

SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Corporate Impact Assessment:

Legal and regulatory impact The report is a requirement for all NHS organisations.

Financial impact As discussed in sections 5 (Income generation linked to activity referred to throughout the document)

Patient Experience/Engagement Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

Discussed throughout the report but with the greatest detail in objective 3.

Attachment:

October 2015 BAF and the current SRR



TRUST BOARD REPORT – 29th October 2015 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1. Board Assurance Framework The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2015/16:

1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy

3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2. Current status The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows:

Objective Red (15-25)

Amber (8-12)

Green (1-6)

1.Deliver safe services and be in the top 20% against our peers

0 2 0

2.Deliver effective and sustainable clinical services within the local health economy

1 0 1

3.Ensure patients are cared for and feel cared about

1 0 0

4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex

1 0 0

5. Well Led - become an employer of choice and

deliver financial and clinical sustainability around

a clinical leadership model 4 3 0

Total 7 5 1



One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). 2.1 Updates since last Board Review Since the last board meeting the Executive Committee has reviewed and updated the BAF to reflect current as detailed in descriptions. There have been minor amendments throughout regarding controls, actions and assurances. 2.2 Headline information by objective (BAF)

Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.

S4 x L3 = 12 S4 x L2 = 8 S4 x L1 = 4

1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care

S3 x L4 = 12 S3 x L4 = 12 S3 x L3 = 9

Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy



Target Risk Score

2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties

S3 x L3 = 9 S3 x L2 = 6 S3 x L1 = 3

2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.

S5 x L3 = 15 S5 x L3 = 15 S5 x L2 = 10

Objective 3 - Caring – Ensure patients are cared for and feel cared about



Target Risk Score

3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.

S3 x L4 = 12 S3 x L5 = 15 S3 x L2 = 6



Objective 4 – Responsiveness – Become the secondary care provider for the catchment population



Target Risk Score

4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care

S4 x L4 = 16 S4 x L4 = 16 S4 x L2 = 8

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Target Risk Score

5.1 Failure to deliver income plan S5 x L3 = 15 S5 x L3 = 15 S4 x L2 = 8 5. 2 Failure to stop divisional overspending against budget

S5 x L3 = 15 S5 x L3 = 15 S3 x L2 = 6

5. 3 Unable to deliver realistic medium term financial plan S5 x L3 = 15

5 x 3 = 15

S4 x L2 = 8

5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S5 x L3 = 15 S5 x L3 = 15 S4 x L3 = 12

5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behaviour and performance.

S3 x L3 = 9 S3 x L3 = 9 S3 x L2 = 6

5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model.

S4 x L2 = 8 S4 x L2 = 8 S4 x L1 = 4

5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

S5 x L3 = 15 S4 x L3 = 12 S3 x L3 = 9

2.3. Key risks Strategic risks Identified The BAF highlights the following 7 key red risks to the Trust objectives that have been identified at time of updating the framework. These are:

Risk description Current rating

Target risk score

2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM.

S5 x L3 = 15 S5 x L2 =10


S3 x L5 = 15 S3 x L2 = 6


S4 x L4 = 16 S4 x L2 = 8

5.1 Failure to deliver income plan S5 x L3 = 15 S4 x L2 = 8 5. 2 Failure to stop divisional overspending against budget S5 x L3 = 15 S3 x L2 = 6



5. 3 Unable to deliver medium term financial plan S5 x L3 = 15 S4 x L2 = 8 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S5 x L3 = 15 S4 x L3 =12

3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 13 risks on the Trust significant risk register, one new risk is included and one risk has been downgraded following review by the patient safety subcommittee of the ECQR. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. The new risk escalated to the SRR relate to the management of the 62 day cancer target. It has been considered by the Elective Care Group and reviewed by the Executive team. 3.1 SRR Breakdown

ID Title Initial Rating

Current Rating

Residual Rating

Next Review

1401 Risk of outbreak of viral gastroenteritis 16 15 9

30/10/2015

1491 Failure to maintain Emergency Department performance

20 16 6 30/11/2015

1501 Patient admitted to the right bed first time 9 15 6

30/11/2015

1603 Unable to deliver realistic medium term financial plan

15 15 8 30/11/2015

1604

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position

15 15 12

30/11/2015

1663 Risk of not achieving Cost Improvement Plan 9 16 6

30/11/2015

1672

Increasing Sickness Absence Levels with impact on day to day management and expenditure

15 15 9

30/11/2015

1678 Cancelled and / or delayed elective operations 15 15 6

11/02/2016

1688 Risk of potential overspending from operational pressures

16 16 12 30/11/2015



ID Title Initial Rating

Current Rating

Residual Rating

Next Review

1689 Risk of Contract income below plan 15 15 12

30/11/2015

1696 Risk from agency overspending 16 16 9

30/11/2015

1697

Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report

15 15 9

30/11/2015

1724 Failure to maintain cancer access standards. 15 15 6

30/11/2015

4. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following:

Review the BAF and its alignment to strategic objectives

Does the Board agree with the recorded controls and assurances

Note the updated risks included in the Significant Risk Register

Gillian Francis-Musanu Colin Pink Director of Corporate Affairs Head of Corporate Governance October 2015



Appendix 1: Risk Appetite – 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board:

Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green

Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber

Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green

Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber

Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green

Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber



Appendix 2: SASH risk quantification matrix



Risk Type Insignificant Minor Moderate Major Extreme

Patient Safety No obvious injury / harm Non-permanent avoidable injury / harm requiring only first aid / minor treatment

Short-term avoidable injury / harm with recovery / treatment up to 1 month

Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following: Infant abduction Infant discharged to wrong family Rape or serious assault

Avoidable death

Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

Minor harm event involving >5 patients Moderate harm event involving >5 patients

Major harm incident involving >5 patients

Patient 'Experience' & Care Pathways and Involvement of Service Users

No significant impact on patient experience

Minor unsatisfactory patient experience related to treatment / care given

Unacceptable patient experience related to poor treatment / care

Major unsatisfactory patient experience related to poor treatment / care

Upheld complaints regarding death in the Trust

No complaints / concerns raised Informal complaints raised / PALS contacted

Formal complaints raised and/or MP / independent advice / advocacy contacted

Legal action against the Trust initiated / local media involvement

National media coverage / political action against the Trust

Care pathway problems resulting in short-term treatment / care delay <3 hours

Care pathway problems resulting in short-term treatment / care delays (3 hours – 1 day)

Care pathway problems resulting in medium term delays (up to 1 month) or 5-10 patients affected

Care pathway problems resulting in medium term delays (1-6 months) or 10-20 patients affected

Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

Health & Safety No harm injury Short term / non-permanent injury / ill health.

Medical treatment required Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

Death (RIDDOR reportable)

Injury / ill health resulting in 0-7 days absence from work.

Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

Financial Management Small loss <£1K Minor loss £2K to £100k Moderate loss, £100k - £1M Major loss, £1M-£10M Loss > £10M

Governance Arrangements

Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

Suspension of services provided due to a failure to provide “well led” services as described by the CQC

Permanent removal of services and / or prosecution due to a failure to provide “well led” services as described by the CQC

Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

Act or omission that could led to removal of the Board

Adverse Monitor continuity of service rating <1 month

Adverse Monitor continuity of service rating > 1 month

A breach of Monitor Terms of authorisation

Quality of Service

Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

Short term disruption to service(s) with minor impact on patient care

Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

Sustained loss of service which has serious impact on patient care resulting in major contingency plans being involved

Permanent loss of core service or facility

Abridged consequence chart



REPORT TITLE: CHIEF EXECUTIVE’S REPORT

EXECUTIVE SPONSOR: Michael Wilson Chief Executive

REPORT AUTHOR (s): Gillian Francis-Musanu Director of Corporate Affairs


N/A

Action Required:

Approval ( ) Discussion (√) Assurance (√)

Purpose of Report:

To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction.


National:

Temporary changes to restrictions on nurse recruitment from outside European Economic Area to ensure safe staffing levels across the NHS

Clampdown on NHS staffing agency costs

Announcement of Chief Executive of NHS Improvement Local:

Chair of Health Education England Visit

Dental and Maxillofacial Hot Topic Event

Nomination for Kent, Surrey & Sussex Leadership Awards

Commendation - Children’s Diabetes Team

Recommendation:

The Board is asked to note the report and consider any impacts on the trusts strategic

direction.


SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact Ensures the Board are aware of current and new requirements.

Financial impact N/A

Patient Experience/Engagement Highlights national requirements in place to improve patient experience.

Risk & Performance Management Identifies possible future strategic risks which the Board should consider


Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Attachment: N/A

2

TRUST BOARD REPORT – 29th October 2015 CHIEF EXECUTIVE’S REPORT

1. National Issues

1.1 Temporary changes to restrictions on nurse recruitment from outside

European Economic Area to ensure safe staffing levels across the NHS On 15th October the Government announced that nurses will be added to the government’s shortage occupation list on an interim basis. This means that nurses from outside the EEA that apply to work in the UK will have their applications for nursing posts prioritised. The independent Migration Advisory Committee will review the change and present further evidence to the government by February 2016.

The move is designed to ease pressure on the NHS at a time when the government is introducing tough new controls on costly agency spending. It will help the NHS improve continuity of care for patients, invest in the frontline and maintain safe staffing levels.

The Department of Health is working towards recruiting more home-grown nurses by significantly increasing training places, promoting return to practice programmes and improving retention of existing staff.

Health Education England has already increased nurse training places by 14% over the last 2 years and is forecasting that more than 23,000 additional nurses will be in place by 2019. A campaign is also being run to get experienced nurses who’ve left the profession back to work to co-ordinate plans across the health and care sector to improve the retention of nurses.

1.2 Clampdown on NHS staffing agency costs A further clampdown on staffing agencies and highly-paid NHS managers employed through agencies was announced by Health Secretary Jeremy Hunt on 13th October. This will cap the amount companies can charge per shift for all staff, including doctors and non-clinical personnel. Additionally, NHS regulators will be setting expectations on overall levels of agency spend for each NHS organisation.

Building on previously announced controls, which introduced mandatory use of frameworks for nursing staff and will introduce a cap on nursing spend coming into force shortly, these new measures should remove £1 billion from agency spending bills over three years so that savings can be re-invested in frontline patient care.

A new hourly price cap will be introduced for all types of agency staff, in addition to the nursing cap announced in June, ending the practice of some agencies charging up to £1,800 for a standard shift for a nurse and £3,500 for a weekend shift for a doctor.

The caps will be reduced over time, so that in future agencies cannot charge the NHS a shift rate that is more than the hourly rate paid to existing substantive doctors, nurses and other clinical and non-clinical staff. These measures will ensure that staff who undertake short-term agency work are not rewarded better than those in substantive posts, who provide better continuity of care for patients.

This should also mean that agencies will no longer be able to charge more than three times what a doctor might earn for a normal shift or expecting an hourly rate of more than £50 for a nurse who would usually be paid approximately £15 an hour.

Tackling high-cost staffing agencies is part of a package of measures which should help to cut costs so that every penny can be reinvested in frontline care and towards delivering a truly 7 day NHS.

3

Remuneration for interim very senior managers paid on an agency basis will also be subject to the Monitor / Trust Development Authority (TDA) consultancy approvals process. NHS England will take an equivalent approach for clinical commissioning groups.

The caps sit alongside rules announced earlier this year which include mandatory use of agencies from frameworks, putting a defined cap on total agency staff spending for all NHS trusts and each foundation trust receiving interim support from the Department of Health or in breach of their licence for financial reasons, and a requirement to obtain specific approval for any consultancy contracts over £50,000.

The cap will be introduced on 23 November, subject to responses from a consultation by Monitor/TDA. To begin with, caps will be set slightly higher than the pay that substantive staff receive but will be gradually reduced to the same level as substantive staff by April next year. This gradual reduction in the cap will mean trusts are better able to manage this change.

The full range of financial controls are intended to help the NHS bring down spiralling agency staff bills - which cost the NHS £3.3 billion last year, more than the cost of all that year’s 22 million Accident and Emergency (A&E) admissions combined.

The price caps have been developed with, and are supported by, clinical leaders in the Care Quality Commission (CQC) and NHS England. Trusts will be able to override caps where absolutely necessary to protect patient safety. Any overrides will be subject to scrutiny by Monitor and the NHS Trust Development Authority to ensure these situations are appropriate.

Monitor and TDA will shortly publish guidance on the price caps for agency staff in the NHS and launch a consultation on the rules, the specific caps and the associated impact assessment.

1.3 Announcement of Chief Executive of NHS Improvement Monitor and the TDA have announced the appointment of Jim Mackey as the Chief Executive of NHS Improvement and takes up his post from 1st November 2015. Jim has an exceptional track record in delivering change in the health sector, with 25 years’ experience in the NHS. He joins NHS Improvement from Northumbria Healthcare NHS Foundation Trust where he has been Chief Executive for the last ten years and where he leads over 9,000 staff. In July the Secretary of State for Health announced that NHS Improvement will be formed to drive and support both urgent improvements at the frontline and the long term sustainability of the healthcare system. Alongside that, NHS Improvement will be the health sector regulator.

2. Local Issues

2.1 Chair of Health Education England Visit I was delighted to welcome Sir Keith Pearson, chair of Health Education England to SASH on Wednesday 14th October. His visit was to learn about two initiatives; the first, presented by our Mili Doshi, consultant in special care dentistry is the recently launched Mouth Care Matters project that focuses on improving the mouth care of adult patients on our wards and providing training for doctors, nurses and therapists about the importance of oral health and the impact it can have on the overall health of our patients. Secondly we also heard from Sarah Vigor, physician associate, Dr Natalie King, clinical lead for acute

4

medicine and Dr Sarah Rafferty, chief of clinical education, about our innovative physician associate programme and the important role our physician associates play on our wards. Paul Sutton, chief executive of SECAmb, also joined us to talk about their community paediatric Vanguard project. I would like to thank everyone involved in the visit, especially the Postgraduate Education staff who organised the day. I was proud that we were able to showcase our achievements and plans for the future and know that Sir Keith was impressed with our innovative thinking and success. 2.2 Dental and Maxillofacial Hot Topic Event On Thursday 15th October our adult and children’s dental and maxillofacial team hosted our fourth Hot Topic event. Many of our members, governors, patients and local dentists came along to hear about the specialist care the team provide for children and adults with special needs and those with more complex dental issues and to show them our excellent dental simulation suite too. Local Mum, Lesley Tinker, spoke movingly about the amazing and compassionate care the team have provided for her daughter and the difference it has made. Thanks to the team and everyone involved in organising the evening.

2.3 Nomination for Kent, Surrey & Sussex Leadership Awards The Trust is pleased to hear that we have been shortlisted for Kent, Surrey and Sussex Leadership Recognition Awards – Mili Doshi, special needs dental consultant, for NHS Innovator of the Year and Alan McCarthy, chair, and our Board for NHS Board of the Year. The winners will be announced next month. 2.4 Commendation - Children’s Diabetes Team Congratulations to Dr Neemisha Jain and our children’s diabetes team who have been commended for ‘embracing technology to promote self-care’ for local children and young people with diabetes in the Best Initiative in Specialised Services in the national Quality in Care Awards.

3. Recommendation

The Board is asked to note the report and consider any impacts on the trusts strategic

direction.

Michael Wilson Chief Executive October 2015

Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers

Priority ID and reference 1.A Consistently meet national patient safety standards in all specialties and across divisions

Director responsible Chief Nurse

Initial Risk S4 x L3 = 12 Key Action for 2015/16 objectives and description of any potential significant risk to this priority

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.

Current rating S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk 1009,1055

Controls in place (to manage the risk) Gaps in Control 1. Clinical teams to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance. 4. Policies, procedures and guidelines provide the framework by which risks and incidents are managed. 5. Matron on site 7 days a week 6. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 7. Nursing staffing levels with daily real-time escalation 8. Incident reporting policy to be reviewed to include recent structural changes 9. Ward safety boards 10. Serious incident review group established to monitor and evaluate investigation progress and progress against actions 11. Training undertaken for clinical staff in the assessment and management of

patients at risk of falls 12. Patient falls strategic group meet monthly and report KPIs to the patient safety

and clinical risk committee. 13. System developed to split Trust and Community acquired VTE events

1) Developing and embedding ward safety dashboards 2) Updating and planning RCA analysis training for new managers/leaders 3) Embedding DATIX incident review process within 14 day timeframe

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) External reports and visits both scheduled and unscheduled 2) Patient tracking and analysis (Whiteboard project)

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Increase in reporting trends (+) Meeting minutes and action plans, evidence of presentations and board discussion (+) Patient safety related KPI agreed and monitored at Board and Divisional Level (+) Datix incident reporting and analysis (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15 (+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program

(+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Strong evidence of improved SI investigation management and closures

(+) Improved reporting of patient falls has enabled the Trust to understand fall profile and

identify gaps in the falls management strategies available (+) Established links with falls team within community Negative (-) Never events incidence low (2) (-) NRLS reporting

Gaps in assurance Assurance Level gained: RAG Ability to benchmark in real time

Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) Develop Emergency Department falls pathway

1) Ongoing

Update by FA 13/10/15

Date discussed at board To be discussed at October Board

Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers

Priority ID and reference 1.A.1 Consistently meet national patient safety standards in all specialties and across divisions

Director responsible Medical Director

Initial Risk S3 x L4 = 12

Key Action for 2015/16 objectives and description of any potential significant risk to this priority

1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care


Target risk score S3 x L3 = 9

Linked to Risk 1049, 1050, 1401, 1514

Controls in place (to manage the risk) Gaps in Control

1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). All cases C. diff joint review by CCGs and Trust. 7) Discussion group being setup to discuss any lapses of care in C. diff cases. 8) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 9) 3 ICE-POD units in place – ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci.

1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)



1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff

cases

Positive (+)0 MRSA BSI so far in 2015/16 (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated July 2015) (+)1

st TDA visit inspecting controls and procedures

(+)2nd

TDA visit comparison with other Trusts and brokered meeting with CCGs (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Management of diarrhoea agreed as one of first ‘VMI Value Streams’ (+)Initiation of ‘Stop, Access, Send’ initiative for the management of Negative (-)Incidence of CDI 2015/16

Gaps in assurance Assurance Level gained: RAG

Extensive auditing and monitoring in place. Trust position known


1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C. diff Antibiotics (Fidoxamicin and Chloramphenicol IV)

1) Embedding 2) 2015/16 3) Ongoing 4) Under review

Update by DH 21/10/15

Date discussed at Board To be discussed at October Board


Priority ID and reference 2.A Achieve the best possible clinical outcomes for our patients

Director responsible Medical Director



2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties


Target risk score

S3 x L1 = 3

Linked to Risk 1460


1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR, Effectiveness committee and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads

1) Evidence of learning from incidents/audit 2) Time lag with which some data sets are released



1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk

subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced

02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network

Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic

code 10. Working with the 4 other successful Trusts in the TDA/Virginia Mason

development program

Positive (+) Sharing data through VM program with identified peers (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 116


Ability to benchmark in real time National Safety Dashboard to be implemented when available


1) Development of ward based performance dashboards 1) Start date 01/04/2015

Update by DH 18/09/15



Priority ID and reference 2.B Deliver services differently to meet need of patients, the local health economy and the Trust

Director responsible Chief Operating Officer



2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.


Target risk score

S5 x L2 = 10

Linked to Risk 1221, 1480, 1601, 1405, 1547


1) Transformation Team in place 2) System Resilience Group 3) 3x3 meetings 4) CEO strategic meetings 5) Partnership boards 6) Trust part of national Virginia Mason transformation Programme

1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Repatriation of tertiary services effected and influenced by external factors 3) Clear action plans linked to root causes of efficiency issues and using service improvement methodologies not yet fully embedded



1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle 6) Divisional Performance Reviews 7) Productivity reporting

Positive (+) Contract 14/15 signed with BICS (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) Joint working with Royal Surrey County ( Chemo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Extended theatre working days Crawley (20% increase capacity) (+) Second Cath Laboratory in place (+) VMI Guiding Team established, initial Value Streams agreed Negative (-) Medically ready for discharge (100 pts vs target 90) (-) Nationally an outlier on emergency length of stay by 1 day (-) Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)


Agreed activity modelling across SECNational policy decisions and effective of general election


1) Full action plan development for transformation programme (theatres, outpatients, VMI Value streams) 2) Breaking the cycle and reducing LOS action plan 3) Integrated Discharge Unit being built

1) End of quarter 3 2) Ongoing 3) January 2016

Update by AS 16/10/2015 Date discussed at Board To be discussed at October Board

Objective 3 - Caring – Ensure patients are cared for and feel cared about

Priority ID and reference 3.B Deliver high quality care around the individual needs of each patient

Director responsible Chief Nurse and Medical Director






Linked to Risk 770, 1295, 1580, 1652


1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Workforce subcommittee, Exec Committee and the Board

2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level

3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken

4. PMO in place to monitor agency use and progress of the five related work streams

a. E-roster- migration to v10 approved b. Nursing recruitment plans developed by DCN and DCM in

response to Right Staffing review and monitored through Agency PMO, Workforce subcommittee and divisional team meetings

c. Recruitment process reviewed, KPIs under development to provide assurance

d. Bank recruitment in progress to reduce use of agency nursing staff

e. International recruitment undertaken but start date has been delayed. Further local and EU recruitment in progress. Monitored via temp staffing PMO

f. Nursing temporary staffing utilization (hours/costs) monitoring using Base Usage Value reports monthly

5. SNCT/Birthrate Plus tool utilized to monitor patient acuity and dependency presented to relevant committees including Board to determine future staffing demand

6. Work underway to develop SASH recruitment brand and retention strategy including the development of new nursing roles

7. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC

8. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients.

9. Strong relationship with HEKSS who place junior doctors in the organisation

1. E-Roster system is not updated out of hours 2. Unfilled agency shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically within theatres 4. Imperfect induction for short notice, short term medical locums 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 6. Medical trainees select a preference that affects the decision



1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs.

2. Staff absence reports 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilistation and spend at PMO

Positive (+)SNCT data (+) Recruitment plans developed by ward and reported monthly (+) Matron for workforce recruited (+) International recruitment for nurses undertaken (+) CQC Chief Inspector of Hospitals Report - Good rating

(+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit (+) Junior Doctors feedback regarding quality of experience and breadth of exposure Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-) Vacancy rates and turnover rates (-) Temporary staffing Internal Audit (-) Junior Doctors feedback relating to high workload


Trust position known - no identified gaps in assurance


1. Continue to monitor effectiveness of recruitment plans 2. 7 day working plans for medical staff under development across the Trust 3. Implement e-roster upgrade and utilize core functionality (bank and messaging)

4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016

1. Ongoing 2. Being implemented 3. Embedding and under review 4. Being implemented 5. February 2016

Update by FA 13/10/2015 and DH 18/09/2015


4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population

Priority ID and reference 4.A.1 Deliver access standards Director responsible Chief Operating Officer






Linked to Risk 1220, 1491


1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Tilgate annex opened providing extra surgical capacity 10) 10

th Theatre opened (May 15)

11) Increasing hospital at home capacity

1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed (New Consultant undertaking review) 4)Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge



1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations

9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions.

Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) ED Standard delivered April, May, Aug and Sept 2015 (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) Top 20 patient delay weekly meetings (+) Monitoring and managing compliance #NOF, Stroke and medical outliers (+) Bed modelling refreshed including emergency demand increases Negative (-) ED standard not delivered June and July 2015 (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity Circa 100 medically fit for discharge patients (-) Local availability of Nursing home beds / ability to start complex packages of care (-)Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)


Winter plans and local health economy position going into winter months


1) Integrated Discharge Unit being built 2) Comparison between 2014/15 Q1 vs on 2015/16 Q1 assumptions and activity to identify variance 3) Refresh winter capacity plans based on assessment of Q1 activity 4) Planned local health economy summit regarding emergency growth

5) Agreed breaking the cycle 2 encompassing internal and external bodies

6) Planned breaking the cycle throughout weeks throughout winter

1) January 2016 2) Complete 3) Oct 2015 4) Complete 5) Complete 6) March 2016

Update by AS 16/10/15 Date discussed at Board To be discussed at October Board

Objective 5 – Well Led

Priority ID and reference 5.A Live within our means to remain financially sustainable

Director responsible Chief Finance Officer



5.1 Failure to deliver income plan Current rating S5 x L3 = 15


Linked to Risk 1689


1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Agreed contracts in place with main sets of commissioners (NHSE and CCGs) – all Contracts were finally signed in August. 3) Contract management process in place (this operated effectively in 2014/15). 4) Financial reporting, including periodic forecast scenarios, is in place and effective – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) Chief Officer meeting (which includes coordination of has been in place since Nov 2014. Its structures are still embedding.

1) Original risk share agreement (for emergency activity) with Sussex CCGs and Sussex Community Trust could not be agreed – ongoing discussion over MRET adjustments are now looking more favorable and a new risk share possible. 2) Issues in Sussex over delayed decision on investment in community schemes is subject to discussion. 3) The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so – progress on data sharing with new system (SHREWD), however. 4) CCG plans make assumptions on activity reductions that are only partly adjusted in Contract plans – to be reviewed – dialogue is ongoing with CCGs; 4) Some actions long stopped to resolve – this includes ambulatory attendance pricing and payment for hospital @ home services – not all deadlines have been met but all are in an agreed process. 6) NHS England instruction for CCGs to increase volume of activity in plans not being applied to local CCGs, with NHS England agreement.



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Resilience Groups and Chief Officer Meetings) 5) Output of Contract Management Process .

Positive (+) 2014/15 activity and income met the Plan (noting that individual elements (e.g.: elective activity) did not) (+) Reconciliation process working with CCGs in 2014/15 and year end settlement achieved with all commissioners in 2014/15 with no outstanding disputes. (+) Contracts include clauses to allow inclusion of growth in indicative activity plans, and (vice versa) for any emergency activity reductions Negative (-) Risk over income growth assumptions. (-) Adverse income variance at M06 (although forecast remains on track) (-) Monitor response to MRET complaint provided no useful application in 2015/16 (-) Too much non elective activity, not enough elective – risk over emergency demand in 2015/16. Neither positive or adverse: no serious contractual disputes yet.


Red because of level of risk, activity planning differences, issues with strategic health system management of urgent care activity and transactional processes with CCGs.

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) COO meetings have been held, COG updated - there is clear progress in Surrey, not clear in Sussex. 2) Complete all contractual commitments by revised long-stop dates (end date – now Q2 reconciliation); 3) Revised forecast for elective activity completed, now being monitored 4) Specific action around dermatology, diabetes and cardiology where there is under delivery (and there

is some improvement in these areas) 5) Action around integrated discharge/social care unit is now at the next stage with Surrey County

Council and East Surrey CCG – in Sussex the risk share with the community trust is back on the table, with the potential for new schemes ahead of winter to improve Trust capacity.

6) Robust contractual processes being operated.

Actions proceeding to timetable.

Update by PS 19/10/15 Date discussed at Board To be discussed at October Board






5. 2 Failure to stop divisional overspending against budget



Linked to Risk 1663,1688


1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) TDA agency reduction plan now submitted

1) Management of increased levels of emergency activity subject to review; 2) Investment in incremental changes to meet additional activity demand subject to

review (at M04 budget changes were been made – this is less of a gap) 3) At M06 cost improvement plans are not fully delivering with adverse performance

on agency and escalation in particular. Red rated savings have been partially mitigated. The forecast provides a £3.3m risk to savings delivery.

4) There is overspending against agreed forecast control totals at M06 (although continued action is ongoing and robust)



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board UIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Positive (+) Budget changes made to match activity to Q1, and recovery plan actions largely complete in Medicine; (+) New agency reduction plan now agreed, with realistic basis [needs to be delivered] Negative (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant. (-) At M06 there continues to be overspending in Divisions and adverse delivery on the medical/nursing agency and escalation CIPs. (-) The forecast describes significant risk to delivery of the Plan.


Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately.


1) PMO/Performance structure continues - Divisions have been required to produce recovery plans and PMO meetings have become weekly, now, for all Divisions. Weekly nursing agency PMO and fortnightly agency steering group.

2) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement.

3) Decisions on business cases are now taken in light of affordability against forecast.

Actions proceeding to timetable







5. 3 Unable to deliver medium term financial plan



Linked to Risk 1603


1) Items referred to in 5.A.1 and 5.A.2 above 2) V7.0 long term financial model and integrated business plan

completed (submitted to Monitor in April 2015) 3) TDA Plan submitted in April 2015

4) Board to Board held with the TDA in November 2014, Monitor assessment now in train culminating in Monitor Board to Board in June 2015.

5) Cost improvement plan process in place (including PMO structure) 6) Elective/outpatient activity growth and income plan in place –

capacity created

7) Contracts with CCGs allow for payment for “over performance”

1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Lack of alignment between CCG activity plans and actual performance. 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider

NHS finance regime. 4) Risk over capacity from other operational pressures 5) Overall health system financial view (Chief Officer’s Finance Sub-Group)

describes significant loss of resource to BCF funding – this reduces resource available for health and social care overall.

6) Lack of clarity over tariff assumptions for 2016/17 – this is crucial to medium term planning [some information now available]

7) Central actions over NHS overspend may have an adverse impact on Trust because of manner of application (e.g.: withholding capital).



1) Delivery of 2014/15 financial position and delivery of 2015/16 financial plan 2) Production of 2016/7 budget, revised long term financial model and integrated business plan documentation, and delivery against them

Positive (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) Negative (-) alignment with CCG plans is not complete with significant variances between actual performance on activity and CCG plans [CCGs are paying over performance] (-) overall health system loss of resource Overall, on basis of current assumptions, RAG has turned red with the impact of urgent care activity and the level of risk to the forecast. Assurance RAG red.


Central actions to manage costs across the NHS are not yet clearly described and the tariff is not yet defined, plus cumulative impact of other finance risks here.


Please see items above. Additional CIP contingency is identified, more is being sought. Monitor have agreed postponement of FT process. Board will review in November the suggested timetable. Tariff information is now emerging, but is nowhere near coherent or complete. The 2016/17 budget process will begin in September.

Progress is on timetable







5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position



Linked to Risk 1604


1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital management processes 3) Annual cash plan linked to business plan and capital plan ( see link with Risk 1134)

NOTE: This risk was reviewed at FWC 22 September and agreed to be maintained noting working capital facility. Additionally capital loan is now secure.

1) No agreement on medium term solution to liquidity – being pursued during 2015/16 – a loan application has been drafted and submitted, but has not been actioned.

2) Contractual over-performance may see delay means delay in receiving cash payments to match accrued income from CCGs

3) Threat of central cash controls in line with control totals (nb: which the Trust has not agreed) – need to hear more detail on operation.



1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance

2) Monthly finance reporting to Executive Committee, Finance and Workforce Committee and Trust Board

3) Confirmation of working capital injection (either through a loan, working capital facility or, if available, PDC)

Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations (+) Cash has been managed well in 2015/16 to date, largely as a follow on from income agreements with CCGs at end of 2014/15, capital slippage and now use of an agreed working capital facility. Negative (-) no confirmed additional cash to resolve underlying liquidity problem – can only be resolved in FT application process (through a working capital loan) and which is now paused (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved.


In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness.


1) Day to day cash control is main action currently, coupled with actions to maintain service income and manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses.

Actions proceeding to timetable


Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Priority ID and reference 5.E We are an organisation that is clinically led and managerially enabled.

Director responsible Director of Human Resources



5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behavior and performance.


Target risk score

S3 x L2 = 6

Linked to Risk 910, 1674

Controls in place (to manage the risk) Gaps in Control 1) New Achievement Review Policy with implementation /communication and

training plan. 2) Personal objectives are being linked to Trust/Divisional and team

objectives and the SMART methodology is being used to assess performance

3) New AR process includes assessment of Behaviours against Trust value 4) Personal Development Plans as part of AR identify development needs 5) Training Need’s Analysis at Divisional level extrapolated to Trust level

inform strategic planning of development priorities. 6) AR Task and Finish group continues to embed new process and

implement for medical staff during 2015/16

1) New system yet to reap full benefits 2) Activity levels in the Trust affecting capacity for compliance 3) Change to annual timetable with delivery in first part of financial year yet to embed 4) An agreed model for medical and dental Achievement Review yet to be agreed.



1) AR review audits focusing on objective setting and linked to quality of services 2) staff survey results 3) Feedback from junior doctors 4) Monthly reporting against AR completion timetable at Divisional and Trust level at ECQR&CC – Workforce Committee and Finance Investment and Workforce Committee through 5) Development of behavior based recruitment systems will support the long term strategic implementation of achievement reviews.

Positive (+) Task and Finish group successful launch of new policy and process slides and comms plan for launch at ESH and Crawley (+) development of toolkit and intranet resources (+)TNA update to August 2015 Finance Investment and Workforce Committee (+) recent audit personal quality objectives in appraisals (+) 2014 staff survey results for quality of appraisals puts us in the top 20% of Trusts (+) Culture champion led initiative on standards of behavior (+) 64% compliance achieved following significant focused effort Negative (-) 2014 staff survey Q on appraisal in last 12 months is in bottom 20% (-) compliance rates for Achievement Review remains adverse to plan

Gaps in assurance Assurance Level gained: RAG New AR process is yet to provide any evidence that demonstrates mitigation of this risk or completion of AR’s


1) Recovery plan for compliance in place 2) Series of training courses to support implementation commenced and will run throughout 2015/16 3) T&F to support development of AR for Doctors and dentists – acceptance that AR process needs to be the

same across all staff groups 4) Trust wide culture champion launch to include significant focus on the trust values and behavioural anchors 5) Establish process for annual performance review to identify and talent map for Medical Dental, 8a’s and

above

1) 31 December 2015

2) 31 March 2016 3) 30 October 2015 4) Complete and ongoing 5) February 2016

Update by 20/10/2015 JM Date discussed at Board To be discussed at October Board

Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Priority ID and reference 5.G.2 We are a well governed organisation

Director responsible Director of Corporate Affairs



5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model.



Linked to Risk 1531


1) Successful outcome from the formal Monitor assessment process 2) Achievement of FT project plan milestones 3) Formal approval by TDA Board to move to Monitor assessment phase target 4) Successful elections to the Council of Governors 5) FT Project Board 6) Implementation of Board development programmer

No significant gaps in control identified



1) LTFM agreed by the Board 2) Submission of Integrated Business Plan to TDA & Monitor 3) Public Consultation completed with positive outcome 4) QGAF External assessment completed with implementation of action plan 5) TDA Formal approval to move to the Monitor stage 6) Chief Inspector of Hospitals Inspection 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of Monitor information requests

Positive (+) Completion of Monitor pre-assessment phase (+) Monitor formal assessment underway (+) Election to the Council of Governors complete (+) FT membership over 10,000 (+) Monitor Exe to Exe Challenge took place on 1

st June 2015

(+) External assessment of QGAF score 3.5 (+) Quality Governance Memorandum submitted to Monitor with score of 2.0 (+) Monitor has confirmed timescales & remainder milestones (+) Monitor confirmed QGAF score as 3.5 – Further actions being implemented (+) Shadow Council of Governors in place (+/-) Awaiting national guidance on future FT model


Completion of Historical Due Diligence


1) Elections to the Council of Governors completed in July 2015 and shadow Council being set up 2) Monitor formal assessment in progress

1) Ongoing 2) Plans are on track

Update by GFM 07/10/15 Update by To be discussed at October Board

Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Priority ID and reference 5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication

Director responsible Director of Information and Facilities



5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems



Linked to Risk 1428, 999, 1483


1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2)IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 3) Clinical Informatics Group 4) Clinical IT leads 5) Various project groups (EPMA etc.) 6) Project management controls (Descried in Internal Audit of project management) 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive

1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits



Efficiencies being delivered through IT enabled change

Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Business Continuity System now in place (7/24)


Trust position known, no identified gaps in assurance


1. Procurement and implementation of replacement EPR 2. Establishment of Chief clinical Information Officer role 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2015/16 and future years

1. Completed 2. 724 Go-live November 2014. 3. PC Upgrade plan in-place, funded and business

continuity almost complete 4. Network review first draft now complete and

action plan being prepared.

Update by IM 14/10/15 Date discussed at Board To be discussed at October Board

Appendix 1

Abridged consequence table taken from Trust guidance

Risk Type Insignificant Minor Moderate Major Extreme

Patient Safety No obvious injury / harm Non-permanent avoidable injury / harm requiring only first aid / minor treatment

Short-term avoidable injury / harm with recovery / treatment up to 1 month

Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following: Infant abduction Infant discharged to wrong family Rape or serious assault

Avoidable death

Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

Minor harm event involving >5 patients Moderate harm event involving >5 patients

Major harm incident involving >5 patients

Patient 'Experience' & Care Pathways and Involvement of Service Users

No significant impact on patient experience

Minor unsatisfactory patient experience related to treatment / care given

Unacceptable patient experience related to poor treatment / care

Major unsatisfactory patient experience related to poor treatment / care

Upheld complaints regarding death in the Trust

No complaints / concerns raised Informal complaints raised / PALS contacted

Formal complaints raised and/or MP / independent advice / advocacy contacted

Legal action against the Trust initiated / local media involvement

National media coverage / political action against the Trust

Care pathway problems resulting in short-term treatment / care delay <3 hours

Care pathway problems resulting in short-term treatment / care delays (3 hours – 1 day)

Care pathway problems resulting in medium term delays (up to 1 month) or 5-10 patients affected

Care pathway problems resulting in medium term delays (1-6 months) or 10-20 patients affected

Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

Health & Safety No harm injury Short term / non-permanent injury / ill health.

Medical treatment required Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

Death (RIDDOR reportable)

Injury / ill health resulting in 0-7 days absence from work.

Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

Financial Management Small loss <£1K Minor loss £2K to £100k Moderate loss, £100k - £1M Major loss, £1M-£10M Loss > £10M

Governance Arrangements

Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

Suspension of services provided due to a failure to provide “well led” services as described by the CQC

Permanent removal of services and / or prosecution due to a failure to provide “well led” services as described by the CQC

Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

Act or omission that could led to removal of the Board

Adverse Monitor continuity of service rating <1 month

Adverse Monitor continuity of service rating > 1 month

A breach of Monitor Terms of authorisation

Quality of Service

Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

Short term disruption to service(s) with minor impact on patient care

Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

Sustained loss of service which has serious impact on patient care resulting in major contingency plans being involved

Permanent loss of core service or facility

ID Co

mm

itte

e

Op

en

Da

te

Dir

ect

ora

te

Sp

eci

alt

y

Ris

k O

wn

er

Ris

k T

yp

e

Title (Policies) Description (Policies) Existing controls

Init

ial

Ra

tin

g

Cu

rre

nt

Co

nse

qu

en

ce

Cu

rre

nt

Lik

eli

ho

od

Cu

rre

nt

Ra

tin

g

Treatment Plan Due date Done date

Re

sid

ua

l R

ati

ng

Ne

xt R

evie

w

1401

Safe

ty

23/0

1/2

013

CO

RP

Medic

al D

irecto

r's O

ffic

e

Des H

old

en

Patient S

afe

ty

Risk of outbreak of viral

gastroenteritis

Risk of outbreak of viral gastroenteritis (outbreak

of diarrhoea and vomiting). Impact on patient

safety and trust reputation. Has operational impact

due to bed closures.

D&V policy

Hydrogen peroxide system for terminal cleaning

Use of Actichlor Plus for environmental cleaning

Use of Tristel Jet for commode and bed pan cleaning

Use of SEC Norovirus Toolkit

Outbreak control Group

Surveillance of diarrhoea and vomiting

Red aprons system

Stat and mandatory training

Policy

Communications messages to staff, visitors and patients

Norovirus leaflets

Hand hygiene facilities

Restricted visiting

Use of signs at entrance to wards and bays, and red aprons to facilitate

communication that an outbreak is taking place.

16 3 5 15

Develop RAG rated system for terminal

cleaning

Audit terminal cleaning

Implement ATP testing

Dedicated internal norovirus planning

meeting.

Use of red aprons during outbreaks of

D&V

Meeting with stakeholders regarding

norovirus preparedness

Audit of post-outbreak cleaning

Pilot Patient Hand Hygiene Champions

in Elderly Care

Stakeholders meeting to discuss health

system norovius planning

Monitor use of ED risk assessment for

patients admitted with diarrhoea and/or

vomiting

Monitor ward refurbishment programme

Stakeholder norovirus study day

Prepare options appraisal for emptying

bays to facilitate terminal cleaning

following outbreak

31/03/2013

30/06/2013

01/04/2013

02/09/2013

31/03/2014

31/03/2013

22/09/2014

31/03/2014

30/03/2013

25/09/2013

31/01/2013

06/12/2013

26/07/2013

26/07/2013

02/09/2013

11/02/2014

06/12/2013

22/09/2014

21/05/2014

26/07/2013

25/09/2013

26/07/2013

9

30/10/2015

1491

Responsiv

ene

ss

29/0

8/2

013

CO

RP

Opera

tions

Angela

Ste

venson

Involv

em

ent of

Serv

ice U

sers Failure to maintain Emergency

Department performance

Failure to maintain Emergency Department

performance because of lack of capacity in health

system to manage pressures has a significant

impact on the Trust's ability to deliver high quality

care.

1) EDD Patient Pathway

2) Discharge management

3) Plans for escalation areas agreed and management tools in place

4) Reviewing all breaches on weekly to implement lessons learnt20 4 4 16

As described on the board assurance

framework

31/03/2014

6

30/11/2015

1501

Responsiv

eness

19/0

9/2

013

CO

RP

Opera

tions

Angela

Ste

venson

Involv

em

ent of S

erv

ice U

sers

Patient admitted to the right bed

first time

If the Trust does not maintain and improve ability

to allocate the right bed first time there is an

increased risk of receiving poor quality of our care

(effectiveness, experience and safety)

1) Operational meeting three times a day chaired by Chief / Deputy Chief

Operating Officer with clinical involvement from Matrons, Nurse Specialists and

therapists

2) Daily Board rounds by clinical site team. Focusing on #NOF, Stoke and

Medical outliers

3) Live 'To come In' lists available to view in all specialty wards to encourage

active pull of patients from AMU to the correct specialty bed 4)Matrons walk

round

5) Additional screens arriving to reduce chance of mixed sex accommodation

breaches during winter pressures

6) Matron on site 7 days a week

9 3 5 15

As described on BAF

Reviewing compliance to establish a

key baseline target

27/06/2014

31/08/2015

31/03/2014

6

30/11/2015

1603

Executive

Com

mitte

e

18/0

6/2

014

CO

RP

Fin

ance -

Fin

.

Managem

ent

Paul S

impson

Fin

ancia

l

Managem

ent

Unable to deliver medium term

financial plan

As described on the BAF 1)Items referred to in 5.A.1 and 5.A.2 above

2)V3.0 long term financial model and integrated business plan completed

(submitted to TDA in February 2014) V4.0 now approaching completion

3)TDA Plan submitted January 2014

4) Timetable for refreshed IBP and LTFM going forward is part of national

planning guidance (next iteration due 20 June)

15 5 3 15

As described on the BAF 31/03/2016

8

30/11/2015

1604

Executive

Com

mitte

e

18/0

6/2

014

CO

RP

Fin

ance -

Fin

.

Managem

ent

Paul S

impson

Fin

ancia

l

Managem

ent Liquidity: Inability to pay

creditors/staff resulting from

insufficient cash due to poor liquid

position

Risk of not being able to pay suppliers from in

sufficient cash due to poor liquidity problem

1) Bi weekly review of forward cash flow by finance team and CFO

2) Cash and working capital policy and strategy

3) Annual cash plan linked to business plan and capital plan15 5 3 15


12

30/11/2015

1663

Executive

Com

mitte

e

09/1

2/2

014

CO

RP

Fin

ance -

Fin

.

Managem

ent

Paul S

impson

Fin

ancia

l

Managem

ent Risk of not achieving Cost

Improvement Plan

Risk of not achieving financial plan as a result of

non-delivery of Cost Improvement Plans

i) Delivery of savings managed through PMO (ongoing)

9 4 4 16


6

30/11/2015

1672

Work

forc

e

01/0

2/2

015

CO

RP

HR

- W

ork

forc

e

Yvonne P

ark

er

Sta

ffin

g -

genera

l

Increasing Sickness Absence

Levels with impact on day to day

management and expenditure

Continuing risk to the delivery of effective services

and Trust Strategic Objectives caused by the

resources required to actively manage the Trusts

rising Sickness Absence rate and ensure safe

services. This is also having a significant effect on

the ability to control the Trusts temporary staffing

costs.

Firstcare real time sickness absence monitoring reports and daily updates to

managers inbox.

Daily sit reps at ward level used to ensure shift by shift safe levels of service.

eRostering software to manage rota's prospectively.

Agency PMO. 15 3 5 15

Actions described in the Agency PMO

Focused interventions to support the

Trust's Stress Management Policy

(Anxiety/Stress/Depression has been

highest reason for absence for past 8

months)

31/03/2015

31/08/2015

9

30/11/2015

1678

Responsiv

eness

23/0

3/2

015

SU

RG

Adm

issio

ns /

Waitin

g L

ist

Nata

sha H

are

Serv

ice A

ccess

Cancelled and / or delayed elective

operations

Due to on-going operational pressures and

increasing demand for emergency inpatient beds,

elective inpatient surgery is being cancelled and /

or postponed. Longer waiting times result in poor

patient experience and increase the number of

formal and informal complaints.

1. Access Policy revised 2014

2. Weekly PTL / performance meetings to monitor progress.

3. Plans to increase elective surgery from May, with an additional theatre and

ward approved and on track. 15 3 5 15

Manage the number of IPs booked on

lists to avoid cancellations

Improve Theatre Utilisation

Ring-fencing of Tandridge and

Woodland Wards

27/02/2015

20/06/2015

15/05/2015

09/02/2015

05/08/2015

18/09/2015

6

11/02/2016

1688

Executive

Com

mitte

e

20/0

5/2

015

CO

RP

Fin

ance -

Fin

.

Managem

ent

Paul S

impson

Fin

ancia

l

Managem

ent Risk of potential overspending from

operational pressures

Risk of failure to meet the Trusts financial plan

due to overspending.

i) Divisions to implement action plans and contingencies to control/or recover

overspending. Specific action is required in all Divisions.

ii) Agency PMO to deliver outputs in respect of reduced agency usage following

recruitment. Position being reviewed (ongoing).16 4 4 16


12

30/11/2015

1689

Executive C

om

mitte

e

20/0

5/2

015

CO

RP

Fin

ance -

Fin

. M

anagem

ent

Paul S

impson

Fin

ancia

l M

anagem

ent

Risk of Contract income below plan Risk the Trust does not achieve its financial plan

as a result of lower than planned contract income.

i) Quarterly reconciliation with CCGs will inform variations to the monthly

contract values (over performance at Q1 is likely to reduce the risk).

ii) Manage emergency activity within capacity through structural changes to

ward configuration, improving length of stay (notably in cardiology to release

beds) and other actions to improve efficiency.

Iii) Ring fence elective beds after new capacity has opened and monitor

delivery.

15 5 3 15


12

30/11/2015

1696

Executive

Com

mitte

e

11/0

6/2

015

CO

RP

Fin

ance -

Fin

.

Managem

ent

Paul S

impson

Fin

ancia

l

Managem

ent

Risk from agency overspending Risk of failure to achieve financial plan as a result

of overspending on agency staff.

CIP PMOs and nursing agency PMO to deliver outputs in respect of reduced

agency usage following recruitment. Position being reviewed (ongoing).

16 4 4 16


9

30/11/2015

1697

Executive

Com

mitte

e

11/0

6/2

015

CO

RP

Fin

ance -

Fin

.

Managem

ent

Paul S

impson

Fin

ancia

l

Managem

ent

Financial risks linked to National

Quality Board Paper, 7 day working

and Carter productivity report

Risk of failure to meet the financial plan as a result

of a) increased costs to deliver staffing ratios, 7

day costs and expectations detailed in national

guidance and plans, and b) failure to deliver

adequate adjusted treatment index (Carter).

The Trust has set aside reserve budget for the cost of proposals to increase

nurse/midwifery staffing, but this is funded partly by income from CCGs, which

is not secure. 7 day working is already in place partially (part of the forecast).

Additional nursing staff to deliver agreed ratios have been agreed, with

implementation spread over 2 years and recruitment starting when agency is at

acceptable levels.

15 3 5 15

Review and develop plans; to brief the

Board on progress against risks of

establishment targets not being met

and any potential action to review the

Board's decision on implementation.

30/09/2015

9

30/11/2015

1724

Responsiv

eness

07/1

0/2

015

Cancer

Genera

l C

ancer

Serv

ices / O

ncolo

gy

Jayne O

liver

Serv

ice A

ccess

Failure to maintain cancer access

standards

Failure to maintain cancer access performance

due to capacity (Outpatients, Diagnostics) /

pathway issues (Trust and wider network) can

impact on the effectiveness of treatment as well

as the experience for the patient.

Dedicated cancer tracking team and system

Patient Tracking List with associated escalation processes

Cancer network

15 3 5 15

Quantify the demand vs capacity gaps

Implement actions identified to resolve

demand vs capacity

Enhancements to tracking system being

implemented

Recruiting to agreed increase in

tracking team

Pilot of streamlined lung pathway

commenced

30/06/2015

31/03/2016

30/11/2015

31/01/2015

30/11/2015

30/06/2015

6

30/11/2015


Date: Agenda Item:

REPORT TITLE: A Patient Story

EXECUTIVE SPONSOR: Fiona Allsop, Chief Nurse

REPORT AUTHOR (s): Dr Tessa Fayers, Consultant Ophthalmologist and Suzanne Robinson, Risk and Governance Manager, Surgical Division


Patient Safety and Clinical Risk Committee September 2015

Action Required:


Purpose of Report:

This report tells the story of a patient who was unaware that she had a basal cell carcinoma of the eye, and the life-changing consequences that occurred.


It is not possible to cross-reference abnormal histology results for basal cell carcinomas with ongoing clinical care. There is currently no failsafe in place should the clinical pathway of the patient fail. The consultant who saw the patient in 2009 did not follow best practice with regard to the care pathway.

The patient was not informed of the abnormal result and therefore not able to monitor her own condition effectively.

The case was not discussed at either a skin or head and neck MDT.

The failure in the diagnosis process was not reported as an incident and was unknown to the Trust until receipt of the patient’s complaint.

Recommendation:

For the Board to review the patient’s story and the findings to ensure that it is satisfied that enough measures are being taken to prevent future occurrence.


SO1: Safe - Deliver safe services and to be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care-provider and employer of choice our catchment population



SO5: Well-led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact Claim for compensation

Financial impact

Patient Experience/Engagement Loss of confidence in East Surrey hospital by the patient and her family

Risk & Performance Management Re-occurrence could have major consequences for patients


Attachment:



TRUST BOARD REPORT – 29th OCTOBER 2015 PATIENT STORY The patient, a 74 year old lady, was seen in the Ophthalmology outpatient clinic at Horsham in June 2014. She presented with green sticky mucus from her right lower lid, which had been present since September 2013. The patient had tried various over-the-counter medications, but these had only provided temporary relief. The patient’s notes were not available at the time of the Horsham consultation because they were at Crawley out-patients for an appointment the next day, for a different on-going condition. The patient reported that she had previously had a lump excised at East Surrey Hospital in February 2009 and was told it was a "fluid-filled cyst”; she said it "took ages" and that the lump never went away. At this time she was not given any further follow-up other than suture removal by a nurse. On examination in June 2014, she had a large diverticulum in the lower fornix, which was assumed to be a complication from her previous surgery. At surgery in October 2014, a biopsy was performed, which was reported as a basal cell carcinoma. There was a note at the bottom of the histology report stating that she had previously had a basal cell carcinoma ‘incompletely excised’ from the same lid in 2009. After consideration of a number of options the patient was referred to an oculoplastic surgeon at Queen Victoria Hospital, where the patient had an exenteration (removal of the eye and socket). The delay of the cancer diagnosis was not reported as an incident in 2014 by the treating clinician, who just did not think of raising it as an incident, so the Trust was unaware that this had happened until the patient made a formal complaint in May 2015. A serious incident investigation was declared in May 2015, led by a consultant ophthalmologist. The investigation found that whilst the GP was informed of the histology result in 2009, the patient was not and this lack of contact had falsely assured her that it was just a cyst, so she was not alarmed when it reoccurred. Basal cell carcinomas are a non-reportable cancer and are not required to be tracked by the cancer information team. Consequently the patient was lost to further follow up. A copy of the investigation report was sent to the GP and invited to comment on the findings but as yet has not replied. The following lessons were learned from this investigation:- There is currently no failsafe in place should the clinical pathway of the patient fail. It is not possible to cross reference abnormal histology results for basal cell carcinomas with ongoing clinical care. As a result, the Cancer Service Department is working on an electronic system which will directly alert the cancer information and clinical teams of malignant results in pathology. The patient’s case was not discussed at either a skin or head and neck MDT. As a result of this incident, the management of patients with periocular tumours has been incorporated into on-going teaching sessions within the region by the lead for this investigation, to raise awareness to ensure that incompletely excised basal cell carcinomas are discussed at the appropriate multi-disciplinary meeting and followed up for a minimum of 5 years.



The consultant who saw the patient in 2009 did not follow best practice with regard to her care pathway. As a result, a retrospective audit of patients is being undertaken to ensure that patients have received the correct follow up. The consultant involved has since retired.

The patient was not informed of the abnormal result and therefore not able to monitor her own condition effectively. The information given to patients regarding their conditions and how to remain vigilant for other tumours is being reviewed by the ophthalmology department.

Following the failure of the reviewing consultant in 2014 to recognise the failure of diagnosis as an incident, the Risk and Governance Manager for Surgery has presented a refresher on incident reporting to the ophthalmology department at their audit afternoon in September 2015.

Once the serious incident investigation was declared, the patient was contacted by the Risk and Governance Manager for Surgery and regular contact was established in accordance with the duty of candour regulations. During discussions with the patient it was clear that she was having great difficulty coming to terms with this traumatic experience but was trying to manage alone, despite offers of help from MacMillan nurses at the Queen Victoria Hospital. A duty of candour meeting was arranged for October 2015 which the patient attended with her husband and the investigation team. The difficulty the patient was experiencing was discussed, together with the disappointment that the options for a prosthetic eye were limited due to the extent of the surgery. During the meeting the Legal Affairs Manager joined the meeting and offered her assistance, which the patient and her husband greatly appreciated. Also before the patient left the hospital, she was introduced to the Low Visibility Nurse to discuss with her the problems associated with single eye vision and the possible ways of managing them. Whilst their confidence in East Surrey hospital has been severely damaged, the patient and her husband left after the meeting appreciating the efforts that had been made to help them at this stage and knew that they could contact the Trust at any time if we could be of any assistance. Fiona Allsop Chief Nurse October 2015


Date: 29 October 2015 Agenda Item: 2.2

REPORT TITLE: Chief Nurse & Medical Director Report

EXECUTIVE SPONSOR: Fiona Allsop, Chief Nurse Des Holden, Medical Director

REPORT AUTHOR (s): Fiona Allsop, Chief Nurse Des Holden, Medical Director


N/A

Action Required:


Purpose of Report:

To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports.


The Safer Staffing report (September 2015 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template.

An update is provided regarding safer staffing monitoring

A summary is provided of the recent correspondence in relation to staffing and efficiency

The current progress on nursing recruitment is outlined.

Recommendation:

To note the report and approved the recommendation regarding safer staffing monitoring




Legal and regulatory impact Yes

Financial impact Yes

Patient Experience/Engagement Yes



Risk & Performance Management Yes


Yes

Attachment:



Chief Nurse/ Medical Director Report – 29 October 2015 Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring, a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2. Staffing Planned versus Actual – September 2015

Ward Ward Specialty Entries RN Day RN Night NA Day NA Night Total Day Total Night Overall

Abinger Ward 430 - GERIATRIC MEDICINE 30 90.17% 100% 95.53% 98.73% 92.94% 99.28% 95.34%

Acute Medical Unit 300 - GENERAL MEDICINE 30 94.38% 99.51% 91.32% 89.83% 93.47% 95.98% 94.57%

Birthing Centre 501 - OBSTETRICS 30 79.42% 75% N/A N/A 79.42% 75% 77.21%

Bletchingley Ward 300 - GENERAL MEDICINE 30 98.1% 99.33% 97.26% 100% 97.7% 99.63% 98.37%

Brockham Ward 502 - GYNAECOLOGY 30 98.92% 98.85% 90.52% 89.66% 96.14% 96.55% 96.3%

Brook Ward 100 - GENERAL SURGERY 30 98.92% 98.31% 97.89% 100% 98.57% 98.36% 98.49%

Buckland Ward 101 - UROLOGY 30 93.93% 100% 93.74% 93.33% 93.87% 96.67% 94.92%

Burstow Ward 501 - OBSTETRICS 30 93.04% 73.33% 77.68% 93.33% 87.92% 81.33% 84.93%

Capel Annex l Ward 100 - GENERAL MEDICINE 30 98.88% 100% 100% 100% 99.36% 100% 99.59%

Capel Ward 430 - GERIATRIC MEDICINE 30 96.45% 95.56% 96.3% 100% 96.4% 97.33% 96.81%

Chaldon Ward 300 - GENERAL MEDICINE 30 95.58% 96.43% 95.28% 89.29% 95.45% 92.14% 94.36%

Charlwood Ward 301 - GASTROENTEROLOGY 30 97.15% 98.33% 91.49% 100% 95.11% 99.15% 96.69%

Copthorne Ward 301 - GASTROENTEROLOGY 30 99.16% 98.28% 100% 100% 99.43% 99.14% 99.32%

Coronary Care Unit 320 - CARDIOLOGY 30 84.88% 96.72% 213.04% 93.55% 91.93% 95.65% 93.8%

Delivery Suite 501 - OBSTETRICS 30 90.72% 95% 76.59% 86.67% 87.19% 92.92% 90.05%

Discharge Lounge 300 - GENERAL MEDICINE 30 91.5% 100% 80.63% 96.67% 85.81% 98.33% 89.95%

Godstone Ward (Haem) 303 - CLINICAL HAEMATOLOGY 30 100% 100% N/A N/A 100% 100% 100%

Godstone Ward (Med) 300 - GENERAL MEDICINE 30 86.87% 100% 97.39% 96.67% 90.82% 98.3% 93.98%

Holmwood Ward 320 - CARDIOLOGY 30 95.77% 100% 95.62% 100% 95.73% 100% 97.21%

ITU/HDU 192 - CRITICAL CARE MEDICINE 30 97.07% 96.44% 96.11% 93.33% 96.92% 96.2% 96.58%

Leigh Ward 110 - TRAUMA & ORTHOPAEDICS 30 97.28% 100% 97.84% 106.9% 97.52% 103.45% 99.44%

Meadvale Ward 430 - GERIATRIC MEDICINE 30 91.26% 100% 96.69% 100% 94.17% 100% 96.16%

Neonatal Unit 420 - PAEDIATRICS 30 92.53% 94.21% 98.86% 98.21% 94.47% 95.48% 94.96%

Newdigate Ward 110 - TRAUMA & ORTHOPAEDICS 30 94.47% 100% 97.19% 100% 95.62% 100% 97.11%

Nutfield Ward 430 - GERIATRIC MEDICINE 30 97.16% 100% 98.08% 100% 97.5% 100% 98.34%

https://bi01/information/ddc-monthview-ward.php?period=2015-09&ward=O000000096



























Outwood Ward 420 - PAEDIATRICS 30 96.98% 98.71% 81.11% 96.67% 94.79% 98.38% 96.3%

Rusper Ward 501 - OBSTETRICS 30 95% 96.67% N/A N/A 95% 96.67% 95.56%

Surgical Assessment Unit 100 - GENERAL SURGERY 30 94.17% 98.33% 96.67% 93.33% 94.67% 95.83% 95.19%

Tandridge Ward 300 - GENERAL SURGERY 30 93.3% 100% 83.39% 93.33% 89.04% 96.67% 91.81%

Tilgate Annex 100 - GENERAL MEDICINE 30 95.77% 89.29% 96.63% 96.67% 96.09% 92.36% 94.69%

Tilgate Ward 300 - GENERAL MEDICINE 30 108.23% 93.33% 103.36% 93.55% 106.37% 93.39% 101.89%

Woodland Ward 100 - GENERAL SURGERY 30 89.3% 96.67% 108.89% 98.33% 96.65% 97.5% 96.93%

Total

95.04% 96.36% 95.11% 96.43% 95.07% 96.39% 95.59%

Commentary The Trust has delivered planned versus actual staffing profile for September. The continued variance on Burstow Ward is due to staffing shortfalls in the maternity service and has been actively managed by the matrons with no adverse outcomes in relation to clinical care. The Birthing Unit has experienced staffing pressures this month with 27 shifts working at 50% of the planned staffing level. The Birthing Unit cares for low risk women and comprises six beds managed by two registered midwives. The Hands on Help process and support for practice development staff ensured that there were no clinical concerns on these shifts. 25 registered midwives are planned to start in the WaCH d u r i n g O c t o b e r w h i c h w i l l a d d r e s s t h e s t a f f i n g i s s u e s .

Safer Staffing Monitoring

The National Quality Board paper regarding nursing safer staffing, published in November 2013, states in expectation 7 that Boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review. The monthly updates are described above and the board has received six monthly nursing establishment reviews, last presented in June 2015. A further review was to be commenced in September 2015 using the Safer Nursing Care Tool. It is proposed to postpone this data collection until February 2016 for the following reasons;

1. The ward configuration and function has not changed since the last audit was undertaken in March 2015

2. Nursing professional judgement and the qualitative and quantitative data reviewed daily and monthly to date have not highlighted areas of clinical concern in relation to ward nursing staffing levels.

3. The electronic data collection tool used to collect the data required for the SCNT analysis is no longer available and would mean a manual data collection across clinical areas. This means that data collected is open to interpretation, does not allow for robust comparison and is an onerous task that would take nurses away from direct clinical care delivery.

4. Version 10 of Healthroster, currently being implemented, contains a tool to allow electronic data collection to be utilised from January 2016. This will support efficient and timely data collection

This proposal has been discussed with and is supported by the Associate Nurse Director for TDA South, Pippa Hart.










The Board is asked to support this approach.

Safe staffing and efficiency The Trust has received a letter on 14 October from NHS Improvement, the CQC, NHS England, the CNO and NICE providing advice and clarification in relation to recent staffing guidance. The letter, titled Safe staffing and efficiency, describes the intent behind the staffing guidance issued by the National Quality Board and NICE. The key messages are that

1. The current safe staffing guidance has been designed to support decision makers at service levels and Boards and that responsibility for safe staffing and efficiency rests with provider Boards

2. Providers should take a rounded view of staffing and demonstrate that they are able to ensure safe, quality care and make the best use of resources

3. Staffing levels should be focussed on care quality, patient safety and efficiency rather than numbers and ratios.

The letter is embedded for further reference

Safe staffing and efficiency 13 October 2015.pdf

Nursing Recruitment National and international nursing recruitment continues. The Filipino recruitment is continuing but remains protracted. Four recruits have received NMC approval and are finalising visa requirements, the majority are anticipated in February, March and April 2016. The impact of recent visa changes with nursing becoming a recognised area of shortage is not yet clear. European recruitment is continuing. 23 nurses have commenced in October with a further six expected in November with further Skype dates planned. New English language testing for EU recruits comes into effect in January which is expected to impact on the timeliness of recruitment. A local recruitment event held on 26 September yielded approximately 20 nursing assistants and one potential registered nurse. 3. Recommendation 1. To note the report

2. The Board is asked to support the approach to safer staffing data collection and reporting outlined in section 2.

Medical Director To give a verbal update. Fiona Allsop Chief Nurse October 2015

To: NHS foundation trust and NHS trust Chief Executives Cc: NHS foundation trust and NHS trust Nurse Directors, Medical Directors, Finance Directors and Operations Directors

13 October 2015

Dear colleague

Safe staffing and efficiency

We know that many organisations have taken a systematic and thoughtful approach

to staffing wards and services safely over the past two years, by responding

positively to the guidance issued by the National Quality Board and by NICE,

embracing transparency about their planned versus actual staffing, and focusing on

how to make services as safe as possible within available resources. We are also

aware that recent messages to the system on safe staffing and on the need to

intensify efforts to meet the financial challenge have been seen as contradictory. We

recognise that it is important to offer clarity to the system as we work together to

close the gaps in health and wellbeing, care and quality, and funding and efficiency

identified in the Five Year Forward View.

The current safe staffing guidance has been designed to support decision makers at

the ward/service level and at the Board to get the best possible outcomes for

patients within available resources. The guidance supports - but does not replace -

the judgements made by experienced professionals at the front line. The

responsibility for both safe staffing and efficiency rests, as it has always done, with

provider Boards.

As set out in the guidance, it is important for providers to take a rounded view of

staffing. Providers should be able to demonstrate that they are able to ensure safe,

quality care for patients and that they are making the best use of resources. This

should take account of patient acuity and dependency, time of day and local factors,

such as line of sight for those caring for patients. In some cases, these factors will

mean a higher number of nurses per patient, and in other cases it will mean a lower

number or different configuration of staff can be justified. Some trusts have taken

innovative approaches whereby Allied Health Professionals are included in their

ward based teams, and this can have a positive impact on patient outcomes. We

support this approach where appropriately implemented.

It is therefore important to look at staffing in a flexible way which is focused on the

quality of care, patient safety and efficiency rather than just numbers and ratios of

staff. We would stress that a 1:8 ratio is a guide not a requirement. It should not be

unthinkingly adhered to: achieving the right number and balance of clinical and

support staff to deliver quality care based on patient needs in an efficient way that

makes the best possible use of available resources is the key issue for provider

Boards. Where trusts are able to maximise the proportion of time spent by clinical

staff focusing on care that contributes most directly to patient outcomes (including

through the use of innovation and technology) there are likely to be benefits for both

patient care and for efficiency.

Trusts are responsible for ensuring that they get the balance right by neither under-

staffing nor over-spending, and are able to secure the right complement of clinical

staff to meet local patient need and circumstances.

CQC always assesses staffing levels as part of rating a service on safety in its

programme of comprehensive inspections. These assessments include observation

of care delivery, listening to staff and patients, assessing outcomes of care and

discussions with nurse managers about assessment of acuity levels and

achievement of planned staffing levels. Staffing ratios are never the sole determinant

of a rating.

We will continue to work with and support trusts to secure both safe staffing and

greater efficiency. This will include:

• further progress on the Model Hospital led by Lord Carter, who will be working

with providers to develop a way to use data on the nursing and care hours per

patient, so that staffing arrangements remain safe across a range of different

times and situations. Lord Carter’s team will be working closely with front-line

staff to put in place a more sophisticated approach to measurement of nursing

time and its connections with outcomes, costs and other critical measures;

and

• development of further safe staffing guidance. We are currently reviewing the

responses we had to the letter dated 4 August 2015 and will confirm further

details on the development of the guidance and timescales in due course.

In order to support your efforts to manage your agency staffing costs, the mandatory

use of approved frameworks for procuring nursing agency staff will come into effect

from 19 October. Further work is being taken forward at pace by Monitor and the

NHS TDA to introduce a national rate-cap for all agency staff, to include medical and

other agency staff later this autumn.

As we collectively work on both the efficiency and the safe staffing agendas, we

recognise the need for clarity and consistency across the work of all teams in the

arm’s length bodies in this area. We will be working hard across the national

organisations and in close partnership with providers and all clinicians to ensure

these are delivered in the next phase of work.

The financial and quality challenges that you are grappling with are unprecedented,

and we thank you for all you are doing for patients and their families.

Yours sincerely

Ed Smith, Chairman-Designate NHS Improvement

Sir Mike Richards, Chief Inspector of Hospitals

Dr Mike Durkin, National Director of Patient Safety, NHS England

Jane Cummings, Chief Nursing Officer for England

Sir Andrew Dillon,

Chief Executive, National Institute for Health and Care Excellence



TRUST BOARD IN PUBLIC Date: 29/10/2015 Agenda Item: 2.3

REPORT TITLE:

Safeguarding Children Annual Report 2014 / 2015


REPORT AUTHOR:

Vicky Abbott and Sally Stimpson Named Nurses for Safeguarding Children


Patient Safety & Risk Committee – 15/07/15 Trust Safeguarding Children Committee – 04/06/15 Safety and Quality Committee – 06/07/15

Action Required:

Approval () Discussion () Assurance ()

Summary of Key Issues

The Annual Report for Safeguarding Children provides the board with assurance regarding statutory compliance with Section 11 of the Children Act (2004) and enables the Board to review safeguarding activity across the Trust. Areas discussed include:

Annual comparison trends for information shared with other agencies and referrals to children’s services

Key activities implemented in 2014/15

Evidence of progress made in relation to ongoing work plans.

Priorities for children’s safeguarding in 2015/16

Surrey and Sussex Section 11 Self Assessments and review

CQC Inspection Key points to note are:

8.5% increase in information shared with members of the multiagency team

Commencement of 6 monthly Level 3 multi-professional Safeguarding Children Training at East Surrey Hospital which has increased our training compliance for Level 3 training to 72%.

Hospital Link Social Worker from Surrey Social Services in attendance at Weekly Safeguarding Meetings held at the Trust.




SO1: Safe -Deliver safe services and be in the top 20% against our peers SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex


Legal and regulatory implications Yes

Financial implications Yes




Yes

Attachments:

Nil



Executive Summary Safeguarding activity across the organisation is increasing, demonstrated by the increase in safeguarding referrals and daily contact through the safeguarding office. Safeguarding principles are well ingrained in hospital practice throughout the Trust. Staff from a range of specialities consistently demonstrate they have considered vulnerable children in relation to any patients attendance at East Surrey Hospital, regardless of their age. They enthusiastically embrace new themes and key messages from the Safeguarding children team, most recently Child Sexual Exploitation awareness. Since the introduction of in house training at level 3 the percentage of staff being appropriately trained is currently at 72%. This is a very significant achievement for a second year for which the Safeguarding Children Team should be commended. The CQC inspected West Sussex Safeguarding in February 2015, and as part of that spent a day reviewing cases and safeguarding children practices at East Surrey. We are still awaiting the formal report from the CQC; however we have had feedback that the inspectors were very impressed with the safeguarding activity they audited at the hospital. We have been involved in one serious case review for Surrey Safeguarding Board which is due for publication in July 2015. Any actions identified from the report will be embedded into our overarching action plan to ensure progress against the action is monitored closely. We are not anticipating any significant areas for action from this serious case review.



1.0) Introduction This annual report demonstrates how the organisation is discharging its statutory duties in relation to safeguarding children under Section 11 of the Children Act (2004). 1.1) The aim of this report is:

a) To provide assurance that the Trust fulfills safeguarding activity to meet national

safeguarding children standards. Key to this is the implementation of actions from the Section 11 Audits and Serious Case Review recommendations.

b) To provide an update on service developments in relation to safeguarding children. c) To demonstrate continuous improvement in safeguarding children systems. d) To address any existing or potential areas of risk in relation to statutory

responsibilities. 1.2) Safeguarding and promoting the welfare of children is defined as:

Protecting children from maltreatment

Preventing impairment of children’s health and development

Ensuring children grow up in circumstances consistent with the provision of safe and effective care

Taking action to enable all children to have the best outcomes (Working Together 2015)

1.3) During 2014/15 the Safeguarding Children Team has worked with many internal and external partners across both Surrey and Sussex in a variety of activities to ensure that children are appropriately safeguarded. These activities range from attendance at child protection conferences, child death reviews, strategy meetings with police and social services, training, external and internal safeguarding meetings and supervision; alongside daily management of child protection and safeguarding cases throughout the hospital. 2.0) Section 11 of the Children Act (2004) 2.1) Improving the way key people and bodies safeguard and promote welfare of children is crucial to improving outcomes for children. Section 11 of the Children Act 2004, places a duty on key persons and bodies to make arrangements to ensure that in discharging their functions, they have regard to the need to safeguard and promote the welfare of children. 2.2) Section 11 compliance is a statutory requirement for Surrey and Sussex Healthcare NHS Trust. Compliance is assessed and monitored by the safeguarding boards in both Surrey and West Sussex by the submission of a RAG rated Self-Assessment Audit. Outstanding actions (appendix 1) identified from the audit are uploaded to the overarching Trust Safeguarding Children Committee action plan. This action plan is and reviewed bi-monthly at the Trust Safeguarding Children Committee meeting and activity around the actions is recorded providing a clear governance structure. Surrey & Sussex Healthcare NHS Trust last submitted their Self-Assessment to Surrey Children Safeguarding Board on 19/08/14 and is attached as Appendix 1.



2.3) The Self-Assessment for Sussex was last submitted on 30/04/14 and reviewed at the Section 11 Scrutiny Panel in August 2014. We have responded to the review and provided additional clarification and information as requested by 30th September 2014. The Self-Assessment is attached as Appendix 2. Appendix 3 shows our current action plan with actions embedded. It should be noted that the Trust demonstrates compliance with section 11 and this was further endorsed by the CQC inspection. As with any standard there will inevitably be work and actions which are generated but these are monitored and actioned through the Trust Safeguarding Children Committee. 3.0) Care Quality Commission Inspection February 2015. 3.1) An inspection was carried out in February and the feedback from the inspectors was extremely positive, with them taking away safeguarding template documents and criteria as examples of best practice. There will be a formal report in the coming months which will be disseminated via the Trust Safeguarding Children Committee. 4.0) The Safeguarding Children Team

4.1) The Children Act (2004) requires each acute Trust to appoint Named Professionals to take the lead on children and young people safeguarding matters within the Trust, and to advise all staff employed by the Trust on awareness and processes related to safeguarding children. 4.2) The Safeguarding Children Professionals at East Surrey Hospital for 2014 are

Vicky Abbott Named Nurse (job share)

Sally Stimpson Named Nurse (job share)

Miranda Johnson Named Midwife*

Salli Alihodzic Specialist Midwife**

Dr Yekta Dymond Named Doctor (job share)

Dr Katie McGlone Named Doctor (job share)

Laura Lewis Administrative Assistant to Safeguarding Team *Miranda Johnson is currently covering the Named Midwife post for Janice Blythman **Salli Alihodzic is currently covering the Specialist Midwife post for Maureen Royds-Jones. The Executive Lead for Safeguarding Children is the Chief Nurse, Fiona Allsop 4.3) Designated Doctor and Nurses. The Designated Professionals for Surrey and Sussex CCGs provide supervision for the Trust’s Named Nurse, Midwife and Doctor who meet with the designated person for supervisory sessions and personal review. The Designated CCG professionals for Surrey and Sussex NHS Trust (SaSH) are:

Designated Doctor Surrey Dr Kate Brocklesby Sussex Vacant post since August 2014, Dr Jamie Carter, Designated

Doctor from Brighton providing some cover.



Designated Nurse Surrey Amanda Boodhoo Sussex Sarah Smith

4.4) The safeguarding team continue to work closely with key staff at SaSH

Joanne Farrell - Matron for Children and Young People

Ingrid Marsden – Neonatal Matron

Sarah Muller - Paediatric ENP Emergency Department

Fiona Crimmins - Vulnerable Adults Lead 5.0) Safeguarding Referrals from East Surrey Hospital 5.1) Any member of Trust staff can raise a concern about a child or family to the

safeguarding children team. We currently have a two tier referral system

a) An Information Sharing form – for low level risk, these forms are mainly shared within health

b) Direct referral to Children’s Social Services using a multi-agency referral form (MARF)

The Trust Intranet has been updated to enable easy access of forms by all staff. Guidance for staff regarding the completion of safeguarding referral forms is given during their annual statutory and mandatory update. 5.2) All referrals are discussed in detail at Multidisciplinary Weekly Safeguarding Meetings and all are recorded on a specified database. The weekly meetings are held within the Neonatal Unit, ED and Outwood / Child Assessment Unit. The Maternity Department have monthly Safeguarding Meetings. The majority of referrals continue to be generated through the Emergency Department. 5.3) Following the success of the Emergency Department completing all their referrals electronically, all areas now complete Information Sharing Forms and referrals to Children’s Services electronically. The electronic completion of referral forms is to be rolled out in the maternity department in 2015. Electronic referrals have been welcomed by Health Visitors, School Nurses, GP’s and Children’s Services across both Surrey and Sussex.

5.4) The total number of Information Sharing Forms completed by the Trust in 2014 was 4872; in addition 1296 referrals were sent to social services regarding vulnerable children and families. This demonstrates an 8.5% increase in Information Sharing activity and a 9% decrease in referrals to social services from the previous year. The hospital has seen a 5.6% increase in attendances this year from the previous year and therefore we would expect to see a similar increase in activity though the safeguarding children office. For our increase to be higher than the overall attendance increase demonstrates that staff are identifying vulnerable families at an earlier stage and sharing information appropriately which could explain the decrease in referrals to social services. 5.5) Identifying and referring vulnerable children and families is a key role for all clinical and non-clinical staff across the hospital. This ensures that vulnerable children do not pass through the hospital undetected and the Trust, as an organization, does not fail in its statutory duty to share concerns. Training is essential to continue to raise staff awareness



and enable staff to recognise when a child is being, or is at risk of being abused to ensure that the relevant information is shared appropriately as soon as possible. 5.6) When children and young people make an allegation against a member of staff (employed within the Trust or employed externally) the information is shared with the Local Authority so they may investigate the incident. The Trust has a policy for allegations against staff whom are employed at SaSH. 6.0) Safeguarding Children Training This section is broken down into Safeguarding Training for Hospital Staff (not including doctors) and Safeguarding Training for Doctors. Explanation of the different levels of training as set out in the Intercollegiate Document (RCPCH 2014)

Course Trust Frequency

Government Recommendation

Child Protection Level 1, required for all Trust Staff, both clinical and non-clinical. All staff at SaSH now receive Level 2 training.

Annual Minimum 2 hours every 3 yrs.

Child Protection Level 2, required for all staff with access to patients, both paediatric and adult

Annual (45minute session)

Minimum 3-4 hours every 3 yrs.

Child Protection Level 3, required by those staff working in key paediatric areas e.g. maternity, paediatric ward and paediatric ED

Annual (1/2 day or full day depending on personal educational requirement)

Minimum 6-16 hours every 3 years

6.1) Safeguarding Training for Hospital Staff (not including doctors) Figures for the period up to 31/03/15

Required % Attained % To Achieve

Level 2 3232 69% 85%

Level 3 615 61%* 85%

*following Level 3 course in May 2015, 75% of eligible staff will be trained Figures provided by the Training Department from OLM database. 6.2) Children's safeguarding training continues to be delivered as part of Trust Statutory and Mandatory training and meets the criteria outlined in the Intercollegiate Document (RCPCH, 2014) however following an audit by Sarah Smith – Designated Nurse for Sussex



in November 2014, it was identified that the session should be 60 minutes instead of its current 45 minutes. The MAST program is currently being extensively reviewed and those involved in the review are aware of the timing issue. Level 2 training is now given to all members of SASH staff which exceeds recommendations. Compliance with training has been a challenge due to the availability of places on statutory updates. There is also an e-learning package for all three levels of safeguarding training which allow staff to complete some training online. This is to be used in addition and to complement the face to face training which is given to all staff members for example for new starters until they are able to access the relevant training days. 6.3) The Named Nurses are continuing to run Level 3 days and these have been well received and there is currently a waiting list for places. Sarah Smith – Designated Nurse West Sussex audited the day in November 2014 and gave excellent feedback. We are awaiting confirmation from Amanda Boodhoo, Designated Nurse for Surrey, that the day meets the Safeguarding Board requirements for level 3. The Level 3 single agency update sessions continue to be provided by the Specialist Midwife and Named Nurse within the key areas. Safeguarding Training for Doctors 6.4) 182 junior doctors work across the various specialities in the trust all of whom require Level 2 safeguarding training. 32 (17%) receive face to face safeguarding training from the Named Doctor, the remaining 150 (83%) all complete the Trust e-learning safeguarding children level 2 package. The 21 junior doctors in paediatrics also receive face to face Level 2 safeguarding training in their departmental induction. The Named Doctor delivers level 2 safeguarding training for the Consultants Annual Mandatory Training Day. Anaesthetics and Emergency Dept trainees receive a safeguarding session as part of their education programme. Many Doctors across the Trust have attended the level 3 training days, but exactly who should receive this training from the Consultant workforce remains to be clarified. Surrey SCB are working on a Surrey Wide Training Strategy for medical staff which will address this very issue. 6.5) From January 2014 monthly SPEER (Safeguarding Peer Review) meetings take place to discuss and review recent safeguarding cases to improve areas of weakness in these cases and provide a forum for open discussion. These meeting have been very well attended by all Pediatricians. 6.6) The Named Doctor presented a case of Fabricated Illness at the Hospital Medical Grand Round in March 2015 to multi-specialty audience, this resulted in healthy debate and audience discussion. The paediatric department commenced weekly Simulation Teaching in April 2015 which incorporates Non Accidental Injury into some of the scenarios. These sessions have participants from a multidisciplinary audience including doctors, nurses and midwives. 7.0) Criminal Records Bureau 7.1) The Trust complies with NHS Employers Guidance on all pre-employment checks and with the Disclosure and Barring Service Code of Practice. Following changes to the DBS checks the Trust has recently undergone a review of which posts within the Trust require a DBS check and at what level.



7.2) DBS Report

92% are cleared.

8% forms with agency awaiting clearance. 8.0) External Meetings 8.1) The Surrey Safeguarding Children Board Health Group and the Sussex Safeguarding Board invite the Trust Executive Lead for Safeguarding Children to attend their quarterly meeting. Named professionals are invited to sub groups of the board across both Surrey and Sussex. 8.2) Multiagency work around Domestic Abuse is increasing and from May 2015 Trust Representatives from the Safeguarding Team will be attending the MARAC (Multi Agency Risk Assessment) meetings in Surrey. 8.3) The Surrey MAECC (Missing and Exploited Children Committee) will be attended by the Named Nurses to identify and safeguard children who are currently victims of CSE in Surrey. 8.4) The SASH / 0-19 team meeting continues and has made a positive difference to the working practices for the staff working on the frontline. 9.0) Named Staff Supervision and Training 9.1) The Named Nurses and Named Midwife receive formal supervision from the Designated Nurse from Surrey and Sussex CCGs. The Named Doctor receives supervision from the Designated Doctor. 9.2) Dr Yekta Dymond returned from maternity leave in February 2015 to the role of Named Doctor which she now job shares with Dr Katie McGlone. Both doctors are in the process of securing places on level 4 safeguarding training. 9.3) Vicky Abbott, Named Nurse has completed her PGCert / MSc (60 credits) in Safeguarding Children at Brighton University graduating in February 2015. Sally Stimpson, Named Nurse has taken on the role as Child Sexual Exploitation Champion and has rolled out a bespoke training program for all key areas at the hospital. Sally has also attended a Surrey Safeguarding Board Domestic Abuse training day. 9.4) The Maternity Matron is the Named Midwife for Safeguarding and oversees the Specialist Midwife, Salli Alihodzic. Within the Department, the Specialist Midwife for Safeguarding carries delegated responsibility for the role of the Named Midwife and she directly reports to the Named Midwife. Salli is planning on attending safeguarding supervision training and a level 4 safeguarding session when one becomes available. 10.0) Serious case reviews / Individual Management Reviews. (SCR / IMR). 10.1) The Safeguarding Children Team have been involved in a Serious Case Review following an incident in June 2014 and are awaiting the final report from the Safeguarding Board. Once published, the SCR will be shared through the Trust Safeguarding Children



Committee. Any identified actions will be monitored through the overarching Trust Safeguarding Children Action Plan.

11.0) Audit 11.1) There is an audit program in place for safeguarding (appendix 4). The completed

audits are reported into the Trust Safeguarding Children’s Committee where any identified

actions are monitored through the action plan. 11.2) A deep dive audit of safeguarding notes by the CCG took place in February 2015 with good initial feedback.

12.0) Priorities for 2015-2016

12.1) The following are the priorities for the next twelve months:

• To continue working with the Training Department to improve compliance for Level 2

Training and ensure that the training compliance data is regularly received by the Trust Safeguarding Children Committee

• Working closely with the Emergency Department to ensure that safeguarding children paperwork is included in the development of electronic records. The templates should be available to use in Cerner from July 2015.

• Updating the skeletal survey protocol in line with Surrey Safeguarding Board guidance

• Securing a local agreement with a Paediatric radiologist to provide a second report

on all skeletal surveys to improve the quality of our reports given that children’s x-

rays are complex to interpret • To continue to provide training for Level 3 and ensure compliance is correctly

recorded • To adopt the Surrey Safeguarding Board Deliberate Self Harm pro-forma to improve

the initial psychological assessment of children presenting to hospital. • To review all safeguarding children policies and processes in line with new Working

Together 2015. • Redesigned the Maternity Information Sharing form to include a body map so the

staff can document birth marks clearly to improve communication with community practitioners.

• To amend current invite letters for Paediatric outpatients to include a statement informing parents of Trust process of sharing information regarding non-attendance with the safeguarding team.



Appendix 1

Surrey Section 11 Audit 2014-3.xls

Appendix 2

Sussex April 2014 review.doc

Appendix 3

TSCC Action Plan April 2015.xls

Appendix 4

Copy of Core Safeguarding Audit Programme 2015.xls

1


Date: 29th October 2015 Agenda Item: 2.3 & 2.4

REPORT TITLE: Adult and Child Safeguarding Annual Report – Executive Summary


REPORT AUTHOR (s): Victoria Daley, Deputy Chief Nurse


Annual reports presented to the Safety and Quality Committee – 6th August 2015

Action Required:

Approval () Discussion ( ) Assurance ()

Purpose of Report:

To provide an update of the activities of the safety and quality committee.


The Annual Report for Adult and Child Safeguarding enables the Board to review activity across the Trust in relation to the Boards Statutory Compliance with the Mental Capacity Act 2005 and the Care Act 2014 for Adult Safeguarding and Section 11 of the Childrens Act (2004) for Child Safeguarding, to provide assurance that the Trust is adhering to current legislation. Adult Safeguarding Areas discussed within the annual report include:

Enhancements of the Adult Safeguarding Team reflective of the service needs Activity trends

An analysis of the data collected during this time period and compared to previous years

Evidence of actions as a result of national regulatory changes and safeguarding reviews.

Key achievements and challenges throughout the year and future developments

Changes to the DOLS as a result of the Cheshire and Surrey Rulings in 2014

CQC Report August 2014 for Safeguarding Adults. Key issues of note are:

The number of alerts has risen for the third consecutive year

The increase in DoLs referrals following changes to legislation

50.35% of staff have received training during the last 3 years

Introduction of the Care Act 2014 on 01/04/2015 Child Safeguarding Areas discussed within the annual report include:

Annual comparison trends for information shared with other agencies and referrals to children’s services

Key activities implemented in 2014/15

Evidence of progress made in relation to ongoing work plans

Priorities for childrens safeguarding in 2015/16

Surrey and Sussex Section 11 Self Assessments and review

2

CQC Inspection Key points to note are:

8.5% increase in information shared with members of the multiagency team

Commence of 6 monthly Level 3 multi-professional Safeguarding Childrens Training at East Surrey Hospital which has increased our training compliance for Level 3 training to 72%

Hospital Link Social Worker from Surrey Social Services in attendance at the Weekly Safeguarding Meetings held at the Trust.

Recommendation:

Both safeguarding reports are presented separately for Board approval.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about


Legal and regulatory impact Yes

Financial impact Yes




Yes

Attachment:

Safeguarding Adults Annual Report 2014/15 Safeguarding Children Annual Report 2014/15

3

Safeguarding Annual Reports 2014/15 Executive Summary 1. Introduction The Annual Report for Adult and Child Safeguarding enables the Board to review activity across the Trust in relation to the Boards Statutory Compliance with the Mental Capacity Act 2005 and the Care Act 2014 for Adult Safeguarding and Section 11 of the Children’s Act (2004) for Child Safeguarding, to provide assurance that the Trust is adhering to current legislation. This covering paper summaries the specific areas of note, the areas of good and notable practice during the reporting period and recommendations/areas that would warrant further focus. Annual Adult Safeguarding Report: 2014/15 The number of alerts raised on Adult Safeguarding Alerts increased last year from 251 to 271. This has demonstrated a continuous improving awareness and understanding of the Trusts safeguarding processes and procedures and highlights that staff have confidence in raising concerns in a transparent and open manner. This in an environment where staff understand the importance of learning from incidents and alerts as actions are implemented following investigations carried out within the Trust, which may involve feedback to the teams involved and changes to practice. Following the Supreme Court Ruling on Deprivation of Liberty Safeguards (DoLS) in March 2014, there has been a sharp increase in the number of DoLS applications made by the Trust during 2014/15. The Trust has met with external partners from the Surrey Deprivation of Liberty Team and the NHS Clinical Commissioning Groups to ensure implementation of this ruling with actions is monitored via the adult safeguarding action plan. The Care Act came in to force in April 2015, meaning that the Department of Health ‘No Secrets’ publication (2000) is no longer in place as guidance. Over the last year, the Adult Safeguarding Team have worked closely with both Surrey and Sussex Social Care Teams to ensure that the Trust were fully compliant with the new regulations and a smooth transition into the new ways of working. The CQC report published in August 2014 following the inspection undertaken earlier in the year highlighted that there were no concerns raised regarding safeguarding adults procedures within the Trust. In addition, the report stated that support for patients with Learning Disabilities of Mental Health problems was readily available and that all patients observed were treated with respect and their privacy and dignity protected. Areas of good/notable practice

Of the 271 Adult Safeguarding Alerts raised during 2014/15, 34 were raised about the Trust of which only 1 case was substantiated.

The Adult Safeguarding Team have embraced the challenges of delivering the ruling on the Deprivation of Liberty Safeguards (DoLS) and engagement of nursing staff to address the learning and development needs involved with the implication of the Supreme Court Ruling. As such, mandatory training has been revised and updated and a programme of bespoke ward based training sessions has also commenced which has

4

been received extremely well by both staff and the Safeguarding Team. In addition, an MCA and DoLS training day was delivered on the 27th July 2015 by an outside specialist speaker, commissioned by NHS England to raise the profile and understanding of the Mental Capacity Act and DoLS.

The MAST training programme continues to be well evaluated by both the clinical and non-clinical teams. Involvement in the Doctors, Medical Students and Maternity training has also continued. Additionally, the Adult Safeguarding Team has facilitated some ward based bespoke training within the Medical Division, which has proven to be invaluable as it has given small groups an opportunity to reflect on practice within their own area.

CHANNEL as part of the Prevent Strategy are high on the national agenda with the purpose of having a multi-agency approach to identifying and providing support to individuals who are at risk of being drawn into terrorism. This area is particularly pertinent to the Trust as Gatwick and Crawley are designated as priority areas and therefore and greater level of awareness is needed within the training. The Trust has a HEALTHWRAP workshop in place, run on a monthly basis by the two Trust HEALTHWRAP trainers for small groups of staff. Due to changes in the Department of Health guidance on the facilitation of Prevent training, the Trust has now been able to deliver Prevent awareness as part of Safeguarding Adults training on the MAST programme.

The Trust participated in the gathering of information for the Serious Case Review in relation to Orchid View Nursing Home. 34 recommendations were made within the publication of the SCR report and whilst none were directly applicable to the acute setting, the organisation has acknowledged to the West Sussex Adult Safeguarding Board that the Trust has a part to play in the identification of potential risk to patients admitted from nursing homes in the local area. The Deputy Chief Nurse was a panel member of the SCR in her previous role capacity within a CCG. As such, a discussion on the learning from the Orchid View was delivered to the Patient Safety Executive in September 2015.

Recommendations/Areas of further work

Training is an ongoing priority for the Adult Safeguarding Team, particularly in light of the implementation of the Care Act 2014. The Act has made Adult Safeguarding statute in law and heralds a new way of working. This continues to be highlighted within the various methods of training delivery across the organisation. Capacity at MAST training remains an issue however the programme and delivery of this is currently under review.

The next one day MCA/DoLS training day is planned for February 2016, with bespoke training available to wards and departments on request, particularly those with specific requirements in relation to the legislation, such as critical care. In addition, MCA and Consent training has been introduced to the Consultant Training Programme for the coming year. To assist with this, the Adult Safeguarding Team will continue to work in Partnership with the Learning Disabilities Liaison Team in highlighting the importance of the Mental Capacity Assessments and Best Interests process.

Despite an initial peak following the changes in relation to DoLS, the Adult Safeguarding Team have noted that referrals now appear to be plateauing out. It is hoped that with the enhanced focus of this area at MAST training and the review of the programs capacity, that awareness and consequently appropriate referrals will improve. The team

5

will also roll out a robust audit programme in relation to the DoLS applications and the concerns raised.

It has been noted that awareness and reporting of Domestic Abuse and the subsequent links with the local MARAC (Multi-agency Risk Assessment Conference) could be enhanced. As such, the ED department and safeguarding teams for both adults and children have a plan to investigate how these processes can be streamlined and developed further in line with national guidance and legislation.

The link nurse programme needs to be established. It is intended that this will be a role within wards and departments, incorporating both safeguarding and learning disabilities.

the large majority of alerts (237) were raised by the Trust regarding concerns in the community. The Trust received no feedback on the outcome of these community alerts and therefore greater transparency would be helpful to gain assurance that these have been thoroughly investigated and action taken as needed. The Deputy Chief Nurse will raise this at a forthcoming Surrey Adult Safeguarding Board.

Annual Children’s Safeguarding Report Safeguarding activity across the organisation has increased, with an enhanced awareness demonstrated by an increasing number of safeguarding referrals and contact via the safeguarding office. Knowledge of child safeguarding is well embedded in to practice across the Trust, with staff form a range of specialties consistently demonstrating that they have considered vulnerable children in relation to any patient’s attendance at East Surrey hospital, regardless of their age. New themes and key messages from the Safeguarding Children’s Team are embraced, with the most recent being Child Sexual Exploitation awareness. Following a visit by the regulators in February 2015, the CQC report on the ‘Review of health services for Children Look After and Safeguarding in West Sussex is still due to be published. . At the verbal feedback provided by the regulators at the end of the visit, East Surrey Hospital and Surrey and Sussex Healthcare NHS Trust as a whole received mostly positive feedback, with particular emphasis around staff awareness of child safeguarding issues in ED and maternity. A full narrative on the outcomes of the review will be provided in a future Child Safeguarding update. Areas of good/notable practice

All referrals are discussed in detail at the multidisciplinary weekly safeguarding meetings. These are held within the Neonatal Unit, ED and Outwood/Child Assessment unit. The Maternity Department holds monthly safeguarding meetings.

All areas now complete their referrals electronically in addition to Information Sharing Forms. This allows the robust and effective sharing of intelligence with other agencies such as Health Visitors, School Nurses, GP’s and Children’s Services across both Surrey and Sussex. The Trust has seen an increase of 8.5% in Information Sharing activity and a decrease of 9% in referrals to social services. When equated with a 5.6% increase in attendances in comparison to the previous year, this demonstrates that staff are identifying vulnerable families at an earlier stage and sharing information appropriately which could explain the decrease in referrals to social services.

6

Level 2 training is now given to all members of Trust staff (excluding doctors), which exceeds recommendations although compliance with training remains a challenge due to the availability of places on the statutory updates. Compliance with level 3 training continues to improve following the delivery of a level 3 course in May 2015. These training days will continue to be delivered going forward. All doctors require level 2 training and the majority of these (83%) have completed this vis the Trust’s e-learning safeguarding children level 2 package with the remaining 17% who had received this training face to face from the Named Doctor.

The Executive lead for Safeguarding Children is invited to attend the quarterly Surrey Safeguarding Children’s Board and the Sussex Safeguarding Children’s Board.

Representatives from the Safeguarding Children Team attend the MARAC (Multi-agency Risk Assessment) meetings in Surrey and the MAECC (Missing and Exploited Childrens Committee) in Surrey also.

Recommendations/Areas for further work

Compliance with level 2 training needs to continue to improve to ensure that the Trust achieves the target of 85%. The Safeguarding Children Team are working with the Training Department to explore ways of training delivery to improve capacity and ensure awareness across the organisation remains. This data is reviewed on a monthly basis at the Trusts’ Safeguarding Children’s Committee which is chaired by the Chief Nurse or Deputy Chief Nurse.

Work with the Emergency Department to ensure that safeguarding children’s paperwork is included in the development of the Cerner electronic records.

Update the skeletal survey protocol in line with the Surrey Safeguarding Board guidance.

Secure a local agreement with the Paediatric radiologist to provide a second report on all skeletal surveys to improve the quality of the Trust’s reporting, based on the complexities of children’s’ x-ray interpretation.

Adopt the Surrey Safeguarding Children’s Board Deliberate Self Harm pro-forma to improve the initial psychological assessment of children presenting to hospital.

To review all safeguarding children policies and processes in line with the new Working Together 2015 publication.

Redesign the Maternity Information Sharing form to include a body map so that staff can document birth marks clearly to improve communication with community practitioners.

To reflect and develop actions in response to the CQC review of health services for Children Look After and Safeguarding in West Sussex.

Since the publication of the Annual Safeguarding Children Report, the Trust has seen an increasing presentation of children and young people with mental health/social needs. This has brought about a number of challenges to the paediatric department and highlighted for enhanced training, awareness and support for staff in dealing with these challenging situations. At the recent multi-agency Surrey Mental Health Crisis Care Concordat Acute Group meeting. It was announced at the meeting that the CCG’s are

7

developing plans with regard to additional non-recurrent funding to be used to support the provision of 24 hr psychiatric liaison support for all ages, thus enhancing the CAMHS provision. The area of Perinatal Mental health is also expected to receive focused attention via the CAMHS Transformation Plan proposals from NHS England.

2. Recommendation The Board is asked to note the content of the report. Victoria Daley Deputy Chief Nurse - October 2015




Date: 29th October 2015 Agenda Item:2.4

REPORT TITLE: Safeguarding Adults: Annual Report 2014/15


REPORT AUTHOR:

Fiona Crimmins & Julie Chivers,

Adult Safeguarding Leads


Safety and Quality Committee – 06/08/15

Action Required:

Approval () Discussion () Assurance ()

Summary of Key Issues

The Annual Report for Adult Safeguarding enables the Board to review activity

across the Trust in relation to the Boards Statutory compliance with the Mental Capacity Act 2005 and the Care Act 2014 to provide assurance that the Trust is adhering to current legislation. Areas discussed to evidence that compliance include:

Enhancement of Adult Safeguarding Team reflective of the service needs Activity trends

An analysis of the data collected during this time period and

compared to previous years

Evidence of actions as a result of national regulatory changes and safeguarding reviews

Key achievements and challenges throughout the year and future developments.

Changes to the DOLS as a result of the Cheshire and Surrey Rulings in 2014

CQC Report August 2014 for Safeguarding Adults

Key issues to note are:

The number of alerts has risen for the third consecutive year

The increase in DoLs referrals following changes to legislation

50.35% of staff has received training during the last 3 years.

Introduction of the Care Act 2014 on 01/04/2015.




SO1: Safe -Deliver safe services and be in the top 20% against our peers

SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice for

the catchment populations of Surrey & Sussex


Legal and regulatory implications Yes

Financial implications Yes




Yes

Attachments:

Nil



Safeguarding Adults Annual Report

2014/15 Executive Summary

With the introduction of the Care Act 2014 on the 1st April 2015, Adult Safeguarding is now

statute in law. The bulk of the specific safeguarding duties and powers are set out in Section

14 of the Act. This has given Adult Safeguarding an equal footing to its counterpart in

Safeguarding Children so that both services mirror each other. As outlined in the Act some

measures had to be in place by the 1st April 2015. The Trust already had a Safeguarding

Adults Board (SAB) in place, have signed up to an Information Sharing Agreement between

agencies and assigned the role of Designated Adult Safeguarding Manager (DASM) to the

existing Safeguarding Leads.

During 2014/15 the Safeguarding Team a total of 271 Adult Safeguarding Alerts were raised,

34 of which were raised about the Trust of which only 1 case was substantiated. This was

regarding pressure damage and staff communication with the patients family. The number

of alerts has risen this year on lasts years’ total of 251 alerts. This demonstrates a

continuous improving awareness and understanding of the Trust safeguarding processes

and procedures and highlights the staff confidence in raising concerns in a transparent and

open manner. This allows an environment where staff understand the importance of learning

from incidents and alerts as actions are implemented following investigations carried out

within the Trust, this may involve feedback to the teams involved and changes to practice.

Following the Supreme Court Ruling on Deprivation of Liberty Safeguards (DoLS) in March

2014, there has been a sharp increase to the number of DoLS applications made by the

Trust in 2014/15. During 2013/14, 11 DoLS applications were made, this increased to 53

applications for 2014/15. The Trust has met with external partners from the Surrey

Deprivation of Liberty Team and the Clinical Commissioning Group to ensure

implementation of this ruling with actions monitored via the adult safeguarding action plan.



Following the Trust’s CQC inspection there were no concerns raised regarding safeguarding

adults procedures within the Trust. However, the Trust was advised to review the Mental

Capacity training provided for staff. The Safeguarding Team have added this to the action

plan and have implemented ward based MCA training since the Autumn 2014.

1.1 Introduction

This report aims to provide assurance to the Board that there are robust arrangements in

place to ensure Adult Safeguarding is fully integrated into the Trust’s systems and meets the

required regulations and standards.

The Care Act 2014 has now been successfully introduced to law and came into force on the

01st

April 2015, meaning that ‘No Secrets’, Department of Health, 2000 is no longer in

place as guidance. However, it must be considered that the timeframe this report covers

falls under the “No Secrets” guidance.

The information contained in this report comprises from the period from 01st

April 2014 to

the 31st

March 2015 in respect of the following:

Adult Safeguarding Team

Activity

An analysis of the data collected during this time period and compared to previous years

Key achievements and challenges throughout the year and future developments.

The Safeguarding Adults Team continues to work closely with external agencies, in

particular with both Sussex and Surrey Social Care Teams and police.



2. The Adult Safeguarding Team

2.1 The Adult Safeguarding Team Structure at Surrey & Sussex Healthcare NHS Trust

Role Name & Job Title

Executive Lead Fiona Allsop, Chief Nurse

Strategic Lead Victoria Daley, Deputy Chief Nurse

Operational Lead Julie Chivers, Adult Safeguarding Lead

Fiona Crimmins, Adult Safeguarding

Lead Named Doctor Virach Phongsathorn, Chief of Medicine

Administration Support Laura Lewis, Administration Support

2.2 Executive Lead for Safeguarding Adults

Within the Trust, the Chief Nurse holds the overall responsibility for Safeguarding Adults.

The Chief Nurse is responsible for providing professional support for initiatives concerned

with the nursing practice in relation to Safeguarding Adults at risk of harm. She ensures

the Trust is committed to the provision of high quality care and continuous improvement of

standards through clinical governance and adherence to the National Frameworks and other

nation policy initiatives relating to Safeguarding.

2.3 Strategic Lead for Safeguarding Adults

The Deputy Chief Nurse is the Strategic Lead for Safeguarding Adults. The Deputy Chief

Nurse has Safeguarding Adults Board Level responsibility for Safeguarding Adults and is

responsible for ensuring that systems and processes are in place. She is an active

member of both Surrey and Sussex Adult Safeguarding Boards.

2.4 Operational Lead for Adult Safeguarding

In 2014 the role was expanded to cover five days a week to ensure that teams across all

Clinical Divisions and Non-Clinical Services had access to safeguarding advice. The

Safeguarding Adults Lead has responsibility to develop, monitor and enhance systems

and structures to support



Safeguarding process (e.g. procedures, monitoring activity & provide training). The role acts

as a local expert and offers support and advice to individuals and departments in their

engagement and implementation of the Mental Capacity Act 2005 and the Deprivation of

Liberty Safeguards 2007. The Team works closely with external partner agencies namely,

Social Services for both Surrey and Sussex and is the main point of contact for outside

agencies. The Operational Lead receives external supervision from the Sussex Designated

Nurse for Safeguarding Adults.

2.5 The Named Doctor for Safeguarding Adults

The Named Doctor for Safeguarding Adults is an advisory role held by the Chief of Medicine.

He assists the Safeguarding Team during investigations on request and when required

attends Strategy Meetings and Case Conferences as a Trust Representative.

2.6 Safeguarding Administration Support

The Safeguarding Team Administration Support has been in place since August 2013. This

is a joint role between the Safeguarding Adults & Safeguarding Children’s Team.

2.7 Adult Safeguarding Trust Committee

The Adult Safeguarding Trust Committee is held on a bi-monthly basis. This is chaired by

the Executive Lead for Safeguarding, Fiona Allsop. The meeting is attended by

representatives by Clinical Divisions, Surrey and Sussex Social Services, the Clinical

Commissioning Groups, Surrey Police, Learning Disabilities, Tissue Viability Nurse and

Matrons. This meeting reports to Patient Safety and Clinical Risk Committee.

2.8 Key Staff working with the Adult Safeguarding Team

Role Name

Tissue Viability Nurse Louise Evans

Learning

Disability Surrey

Liaison Nurse for Sarah Lalljee



Learning Disability Liaison Nurse

for Sussex

Christine Mazak / Jackie Haffenden

Matrons Surgical / Medical & WAC Divisions

Human Resources Business Partners Surgical / Medical & WAC Divisions

Falls Prevention Lead Frances Fernando

Quality & Risk Katharine Horner / Kim Rayment

Dementia Consultant Nurse Steven Adams

Compliments & Complaints Department Nicola Murray

Named Nurse for Safeguarding Children Sally Stimpson / Vicky Abbott

Specialist Midwife for

Safeguarding Children

Salli Alihodzic

3. Safeguarding Referrals at Surrey & Sussex Healthcare NHS Trust

3.1 Background

The Trust has a public Safeguarding Declaration in place stating that Surrey & Sussex

Healthcare NHS Trust is committed to protecting those most vulnerable in our

community. The Trust’s safeguarding policies are aligned with the Surrey Safeguarding

Multiagency Procedures.

In 2014/15 the Safeguarding Leads continued to focus on concerns and safeguarding alerts

that have been raised either by the community or the Trust regarding patients under the

care of Surrey & Sussex Healthcare NHS Trust. The Safeguarding Team meet with Surrey

Social Services on a weekly basis to discuss the alerts received and what action has been

taken as a result. This has proved to be an essential process as it fosters joint working with

the Trust’s partner agencies, thus ensuring management of information and enabling

meeting strict timescales for investigatory reports and actions that are given to the Trust

following Safeguarding procedures. All investigations and required actions with timescales

are added to a Safeguarding Action Plan which is reviewed regularly by the Safeguarding



Team. The Safeguarding Action Plan is also a standing item on the Trust’s Adult

Safeguarding Committee agenda which takes place every second month and is chaired

by the Chief Nurse. Lessons learned following investigations and changes to practice

within the Trust are also highlighted and discussed at the Safeguarding Meeting.

3.2 Activity

From April 2014 to March 2015, a total of 271 Adult Safeguarding Alerts were raised. None

of these have been reported as a serious incident (SI). Neglect continues to be the main

concern raised with a total of 144 alerts raised regarding this type of abuse, this is only

slightly less for the previous year (151 in 2013/14).

Below is a graph showing obvious comparisons over the last two years:

Broken down, 237 alerts were raised by Surrey & Sussex Healthcare NHS Trust regarding

concerns in the Community, this has increased on last year’s figure of 214. A further 34

alerts, (a decrease from 37 in 2013/14), were raised regarding care patients received

whilst being a patient in the Trust with just 1 case being substantiated. Of the 34, 16 were

raised internally; this has decreased from last year’s total of 22.

Total Number of Alerts 50

40

30

20

10

0

2013

2014



The police were involved in 37 of all 271 alerts raised with 9 of these being cases involving

the Trust (6 in 2013/14). Of the nine cases involving the Trust, one remains an open case

with the police. This case involves both an agency member of staff and a Trust Bank Nurse

Assistant. Of the cases referred to the Police for criminal investigation, none were

allegations made against substantive members of staff.

There has been a decrease on the previous year regarding alleged neglect within the Trust,

with only 15 concerns raised (23:2013/14). Alerts raised regarding physical assault have

increased from 10 in 2013/2014 to 13 for this year. There were 3 allegations of sexual

assault within the last year, these allegations were investigated by the police and the

Trust and proven to be unsubstantiated, this has slightly increased on last year where

there were 2 allegations of a similar nature. Lastly, there were 3 concerns raised

regarding emotional abuse, this is a similar to the previous time period, (2:2013/14).

During 2014/15, one case within the Surgical Division was substantiated on two parts and

partially substantiated on one part. This was regarding pressure damage, delay in provision

of pressure relieving equipment’s and staff interaction and communication with a patient’s

family. An action plan with recommendations was put in place following the Case

Conference. The Trust implemented training facilitated by the Tissue Viability Nurse around

skin integrity and the Matron worked in partnership with the Ward Manager to improve

communication. This was done by the introduction of a robust strategy within the ward

regarding information sharing with patient relatives, friends and carers.

A Review Case Conference took place in October 2014 for a case that had been open since

May 2012. Due to the complexities of this case, the Trust requested the assistance of

the Surrey Designated Nurse for Safeguarding Adults to carry out the investigation. This

case was substantiated however, since 2012, the Trust has introduced a number of

initiatives, including comfort rounds and the doctors rounds on Fridays, this ensures

improved communication regarding patients care and needs are met within an acceptable

time frame.



As expected, the Medical Directorate raised the most concerns during 2014/15. The

Emergency Department referred almost 50% (136) of all alerts made for this period.

One case from the Emergency Department remains open from the previous year, this

is due to go to Coroners Court in June 2015.

Overall there have been more safeguarding raised, demonstrating an increased reporting

culture within the organisation. The Adult Safeguarding Team have proactively enhanced

working relationships and communication with Trust staff in order to continue raising

awareness of this area.

3.3 Deprivation of Liberty Safeguards (DoLS).

DoLS applications must only be made as a result of Mental Capacity Act compliance and a

best interest’s decision. That is why the safeguards have been created: to ensure that

any decision to deprive someone of their liberty is made following defined processes and in

consultation with specific authorities as outlined in DOLS Code of Practice (Mental

Capacity Act 2005).

However, since the introduction of the Supreme Court ruling which was handed down on

the 19th

March 2014 regarding two cases, “P v Cheshire West and Chester Council” and

“P and Q v Surrey County Council”, the thresholds of what constitutes deprivation of

liberty have lowered dramatically. As a direct consequence of this ruling, the number of

Deprivation of Liberty Safeguards (DoLS) applications within the Trust has risen

considerably within this time period.

During 2014/15 there were a total of 53 DoLS applications from the Trust to both counties.

This can be broken down as Surrey, 26 applications made from the Trust and 27 for

Sussex. Due to the increased activity the pressures on the DoLS Teams in both counties

has been overwhelming for them resulting in a high percentage of patients not being

reviewed by the DoLs team within the legal timescales laid down. In 2013 there were 112

applications in the Surrey County; in 2014-2015 this had increased to 3,500. It is widely

acknowledged by both counties that there is, and will continue to be an escalation of



applications and the gap in the service will potentially widen. At present there are 35

part time best interests assessors in Surrey who carry out assessments in addition to

their substantive roles and duties. Surrey County have been granted funding of £500,000

to recruit additional full time best interest assessors, however for reasons that remain

unclear, are finding these posts difficult to recruit to resulting in escalating pressure on the

DoLS teams.

This can be further demonstrated by the activity within the Trust in 2014-2015. Of the 26

urgent applications made to the Surrey DoLs team, 11 remained outstanding, 10 had been

withdrawn, 4 were authorised and 1 was not authorised. Sussex DoLs Team have been

unable to provide a breakdown of these figures due to their workload pressures but it is

likely a similar picture would be presented. In contrast in 2013/14, only 11 Deprivations of

Liberty Safeguards (DoLS) urgent authorisations were requested by the Trust for patients.

All were assessed with 7 of the 11 applications upheld.

The Trust, however, must continue to adhere to this ruling and to apply for DoLS

authorisation for our patients who fall within the given criteria.* (Please see appendix A –

DoLS Ruling). The Trust must remain mindful that it does not make speculative applications

for DoLS as a result of this judgement, and patients are not subjected to unnecessary or

avoidable assessments which can be unsettling for them and their families.

As described above, the DoLS Teams within Surrey & Sussex remain stretched to capacity.

The Safeguarding Team will continue to adhere to the CQC regulations and inform them of

the DoLS activity within the Trust prior to assessment by a DoLS team. The CQC are aware

of the challenges regarding DoLS across the country and are happy to accept

notifications prior to assessments.

.3.1. Who does this new ruling apply to?

There are two key questions to ask? – the two step acid

test. Is the patient under continuous supervision and

control? AND

Is the patient free to leave?



It is now clear that if a patient lacks the capacity to consent to their arrangements and is

subject both to continuous supervision and control and are not free to leave, they

are deprived of their liberty.

Professionals must remember that the deprivation of liberty authorisations and Court of

Protection orders under the DoLS in the Mental Capacity Act 2005 are rooted in the principles

of that Act. DoLS exists to provide protection to individuals – to safeguard these individuals

when a deprivation of liberty is an unavoidable part of a best interests care plan.

Individuals who are identified as potentially deprived of their liberty must be considered on a

case-by-case basis and all appropriate steps taken to remove the risk of a deprivation of

liberty where possible.

Given the patient population that are served by the Trust, a significant proportion

of patients now fulfil the criteria e.g.

Patients who require continual 1:1 nursing care will require some form of safeguard

where they lack capacity to consent to this regime. This will include those patients for

instance with cognitive impairment who are at risk of falls (but who are not objecting

as such at being in hospital). The hospital would need to apply to the local authority

for a Deprivation of Liberty authorisation (unless the Mental Health Act was

applicable)

Patients who, though compliant with their care and therefore have no restrictions in

place, would not be allowed to leave the hospital without agreement from hospital

teams (as they would be at significant risk) would also need a form of safeguard. As

before the hospital would need to apply to the local authority for a Deprivation of

Liberty authorisation (unless the Mental Health act was applicable)

Patients who are in ITU under constant 1:1 nursing and who have not “consented” to

their care and treatment (e.g. planned operations where the patient has consented to

the risk of ITU treatment) may well be judged to be deprived of their liberty. As before

the hospital would need to apply to the local authority for a Deprivation of Liberty

authorisation (unless the Mental Health Act was applicable).



There is a legal view that in the worst case scenario it could be that all patients not

deemed free to leave the hospital would need some form of legal safeguard.

The Adult Safeguarding Team have embraced the challenge of ensuring that they are

engaging effectively with the nursing teams to address the learning and development

needs of staff on this contentious issue. The mandatory training has been revised and

updated to discuss fully the implications of the Supreme Court Ruling. Bespoke ward

based training sessions have also commenced during the last six months which have been

hugely beneficial to both the staff and the Safeguarding Team as a greater understanding

is being developed of this often complex ruling. This individual ward training will continue

to be rolled out across all departments during the coming year.

An MCA and DoLS Training day has been arranged for 27th

July 2015 which is be led

by an outside specialist speaker on the subject, who has been commissioned by NHS

England to raise the profile and understanding of MCA & DoLS. The Safeguarding Team

will then be in position to facilitate the training day themselves for the future on a rolling

programme to ensure there is continuous awareness throughout the Trust. These initiatives

for the year ahead will ensure a robust training programme is in place providing necessary

knowledge staff are required to have in relation to Deprivation of Liberty Safeguards.

3.4 The Savile Inquiry

Following the publication of the report, recommendations were made requesting all NHS

organisations to carry out a review of safeguarding procedures in place within their

individual organisations. On receipt of the published recommendations, Surrey & Sussex

Healthcare NHS Trust carried out a self-assessment will be submitted to the TDA, CCG’s

and Local Safeguarding Boards. From undertaking the self-assessment the Trust is assured

that safeguarding has a robust system in place in relation to some of the

recommendations made.

There are a number of areas that remain a work in progress, these have been added to

the Safeguarding Action Plan which is reviewed regularly. There are three areas work to be

completed:



The management of visiting celebrities, VIP’s and other official persons to the Trust.

The implementation of a trust-wide policy setting out access by patients and visitors

to the internet, to social networks and other social media activities such as blogs

and Twitter is managed and where necessary restricted

Ensure there are robust policies and procedures in place in relation to the

assessment and management of the risks to their brand and reputation, including as

a result of their association with celebrities and major donors, and whether their risk

registers adequately reflect this

3.5 The Care Quality Commission Report August 2014

In May 2014, the CQC carried out an inspection of Surrey & Sussex Healthcare NHS

Trust. The report was published in August 2014 with an overall rating as Good. There

were no concerns raised regarding safeguarding adults procedures within the Trust. The

report states that support for patients with Learning Disabilities or mental health

problems is readily available. It also states that patients were observed to be treated with

respect and their privacy and dignity were protected. There are robust systems in place for

monitoring safety and reporting incidents.

The CQC have advised that the Trust should review the training provided to clinical staff on

the Mental Capacity Act to ensure that all staff understand the relevance of this in relation

to their role. The Safeguarding Team have addressed this with a plan in place and training

is now being rolled out together with our first MCA and DoLS Training Day in July 2015.

4. The Care Act 2014

The Care Act 2014 came into effect on 1st

April 2015, putting Adult Safeguarding on a

statutory footing in line with Children’s Safeguarding. The Act has replaced the ‘No Secrets

‘guidance and sets out the legal requirements that the Trust to adhere to. Over the last year,

the Safeguarding Team have worked closely with both Surrey and Sussex Social Care

Teams to ensure that the Trust were fully compliant with the necessary regulations and a

smooth transition into a new way of working. The Safeguarding Team developed an Action



Plan to support the implementation.

As part of the Adult Safeguarding Boards for both counties, the Trust has signed up to a

locally agreed Information Sharing Policy. This involved liaison with departments within

the Trust including Information Governance, Legal Affairs and the Communications Team.

The fundamental shift however revolves around professional practice that puts the adult,

their wishes and their desired outcomes at the centre of safeguarding enquiries. It is about

making safeguarding a personalised experience, aiming to achieve the outcomes identified

by adults at risk of harm or abuse, rather than a person being taken through a process. It

is of paramount importance that this cultural change of thinking be articulated via training

and development to ensure that our staff are able, in reality, to change the way they

approach adult safeguarding within the Trust.

5. Training

5.1 Overview

Training continues to be an essential factor of the safeguarding agenda as it allows the team

to raise awareness, explore and evaluate practice within the Trust. The training session

on the MAST programme continues to be well evaluated by both the clinical and non

clinical teams. Involvement in the Doctors, Medical Students and Maternity training also

continues. Following CQC Trust report, the Safeguarding Team has facilitated some ward

based bespoke training in the medical directorate. This has proven to be an invaluable

exercise as it has given small groups an opportunity to reflect on practice in their area. It

has also provided the Safeguarding Team with an insight into what the training needs are at

ward level.

The reintroduction of establishing Safeguarding Link Nurses on the wards is essential to

our initiatives and this action is currently in progress. This is of particular importance at this

time as following the implementation of the Care Act 2014 on 01/04/2015 as the Trust is

now legally bound to act and share information in relation to safeguarding concerns.

Winterbourne, the Francis Report, the Savile Enquiry and Lampard’s investigation, continue



also to shape the Safeguarding Agenda. This is supported by Jeremy Hunt, Secretary of

State for Health’s introduction of a duty of candour throughout the NHS. Duty of

Candour has been introduced to the Trust incidents reporting system, the Safeguarding

Team are alerted if any incidents are reported that may have a safeguarding element. The

Safeguarding Team highlights the process of how to raise concerns, being open and

whistle blowing during each training session.

5.2 Training Figures for April 2014- March 2015

All staff are required to attend adult safeguarding training every three years. Based

on the figures received from the Training and Education Department, this gives an

overall percentage of 50.4 % of staff have received training during this 3 year period (April

2012 – March 2015).

The annual figure for the last year is calculated on the total staff head count for March

2015 which was 3768. From the numbers received from the Training Department, it

shows that overall 2060 members of staff have had Adult Safeguarding Training for this

period. This equates to 54.7 % of staff. Please see a further breakdown in the table

below:

Staff Group Total Staff Trained

Trust Headcount % Trained

Add Prof Scientific and Technical 55 78 70.51

Additional Clinical Services 434 699 62.09

Administrative and Clerical 308 719 42.84

Allied Health Professionals 102 168 60.71

Estates and Ancillary 190 320 59.38

Healthcare Scientists 40 90 44.44

Medical and Dental 242 536 45.15

Nursing and Midwifery Registered 689 1154 59.71

Students 0 4 0.00

Grand Total 2060 3768 54.7%

The Trust had set the Safeguarding training target at 85% compliance for all staff. The

Safeguarding Team continue to aspire to the set target. This has been added to the



Safeguarding Action Plan and the Safeguarding Team have met with the Training and

Education Department to discuss and plan for the training for this coming year. External

factors such as increasing room capacity for delegates will continue to be addressed

as this issue remains a challenge in improving compliance.

5.3 Prevent and CHANNEL

Prevent and CHANNEL are high on the national agenda. The Trust has the

HEALTHWRAP workshop in place which runs on a monthly basis for small groups of

staff. The workshop is facilitated by two Trust HEALTHWRAP trainers; it has been well

received with excellent feedback.

The Home Office and the Department of Health provided strict guidelines on how Prevent

training should be facilitated. This has recently changed, allowing the Safeguarding Team

to include Prevent awareness to the Safeguarding Adults training on the MAST

programme, thus highlighting the importance of Prevent to wider audience throughout the

Trust. It should be noted that the Crawley/Gatwick locality is a priority area and greater

level of awareness is built into the training delivery and generally across the organisation.

Prevent training is to become statutory in July 2015 meaning all staff must attend a one

off training session. This will be rolled out by the Safeguarding Team as the Trusts covers a

priority area as outlined by the Government.

6. Policies

6.1 Safeguarding Polices

The Safeguarding Adults, Management of Allegations and Intimate Care policies are in

place. The Safeguarding policy is currently being updated to incorporate the changes to

practice as a result of The Care Act 2014. These policies are discussed at all training

sessions, to ensure staff know how to access and use them in practice.



6.2 Supporting Policies

Over the last year, the Safeguarding Team have assisted with the Mittens Policy and the

Safer Holding Policy. The DBS referral guidance has also been incorporated into the

Disciplinary policy at the request of the Safeguarding Team.

6.3 Future Policies

Earlier this year, the Safeguarding Team met with a police officer from the Surrey MASH

(Multi Agency Safeguarding Hub) to discuss MARAC (Multi Agency Risk Assessment

Conference) referrals for domestic abuse. The Safeguarding Team plan to meet with

Safeguarding peers from other Trusts across Surrey County where this referral pathway has

already been introduced. The Care Act 2014 has highlighted domestic abuse falls within

Adult Safeguarding criteria. The Team hope to work closely with the Emergency

Department to ensure a Trust policy is introduced to ensure this this method of referral for

domestic abuse is followed.

The NHS Policy now states that there should be separate Safeguarding and Mental

Capacity Policies, the Safeguarding Team will work toward introducing this during 2015/16

period.

7. Independent Mental Capacity Advocate (IMCA) & Advocacy

7.1 IMCA

Where a person has been deemed to lack capacity or has substantial difficulty in being

involved in their care, the Trust must follow the Best Interests Principle. An IMCA must be

instructed if there is no other appropriate person available. Whenever possible the

Safeguarding Team attends any Best Interests meetings with IMCA involvement.

There were 28 referrals to KAG (Kingston Advocacy Group) during this year. The service

continues to be used regularly throughout the Trust, in particular in the Medical Division

and the Special Dentistry Unit.



7.2 Advocacy

Effective safeguarding is about promotion of an adults rights as well as protecting physical

safety, taking action against occurrence or prevention of reoccurrence of abuse or neglect.

This can enable an Adult to understand and recognise risk and know what actions to take or

request others to carry out actions on their behalf.

With the introduction of the Care Act 2014, if there is no advocate already in place, the

Local Authority (LA) must arrange, where necessary, for an independent advocate to

support and represent an adult who is the subject of a safeguarding enquiry or a

Safeguarding Adult Review (SAR).

The Trust must involve Adults in decisions made about them and their care and support

or a safeguarding enquiry or SAR. No matter how complex a person’s needs, staff are

required to involve the patient, to help them express their wishes and feelings, to support

them to weigh up options and to make their own decisions.

If an enquiry needs to start urgently, it can begin without an advocate being in place

however an advocate must be appointed as soon as possible. All staff must know how

to request an advocate and understand the role of an advocate.

Potentially, in April 2016, Advocacy will be offered to

All patients regardless of capacity

Patient Carers

Children approaching transition point to Adult Services

Adults who are subject to a safeguarding enquiry or Safeguarding Adults Review

(SAR) However, the introduction of this is subject to development, consultation and

parliamentary process.

8. Learning Disabilities

The LDLN (Learning Disability Liaison Nurses) play a vital role within the Trust, ensuring

that both patients and staff are supported when challenging situations arise. Their

assistance facilitates better experiences for patients with learning disabilities (LD). Sarah

Lalljee has taken up the position of learning disability liaison nurse at East Surrey for Surrey

patient and Christine Mazek has been covering maternity leave for Jaqueline Haffenden for



Sussex.

There has been a total of 161 referrals made to the Liaison Team, this can be broken down

by County:

Surrey, 73 referrals and Sussex, 88 referrals.

There were a total number of 19 Safeguarding alerts raised that involved a patient that had

a learning disability, this has decreased on last year’s figure of 23. Of these 19 alerts, 2

were raised against the Trust, one from each county and both raised externally to the Trust.

Recent data suggests that East Surrey Hospital have significantly higher rates of

admission of people with Learning Disabilities than any other acute hospital in Surrey. This

is in keeping with the fact that there is a larger population of people with learning

disabilities who live in the Trust’s catchment area. As a result the Learning Disability

Liaison Service receive a high number of referrals however we know that more people

access the hospital than we see therefore we are keen to increase the referral rates to

the service and ensure accurate data collection. In order to meet this demand the Learning

Disability Liaison Team has made a recommendation to the Surrey CCG collaborative to

increase the current commissioning.

A recent evaluation of the Surrey Learning Disability Liaison Service identified that a

significant amount of liaison nurse time was spent on providing Mental Capacity Act

(MCA) advice and support.

The Safeguarding team are aiming to commence monthly meetings with the Link Nurse to

discuss any safeguarding concerns on their wards or departments and promote this new way

of working around Adult Safeguarding. We plan to rotate each month with the Learning

Disabilities Team as we feel this will be beneficial to all parties involved and encourage

working together with different specialities.



9. External Meetings

9.1 Surrey

As the Trust geographically falls within Surrey boarders, the Trust follows Surrey

Safeguarding Multi agency procedures. The Surrey Adult Safeguarding Board invites the

Trust to send a representative from the Adult Safeguarding Team to attend the quarterly

meetings. The Strategic Lead attends this meeting with an Operational Lead as a

representative in her absence.

9.2 Sussex

The Sussex Adult Safeguarding Board invites the Trust to send a representative from the

Adult Safeguarding Team to attend the quarterly meetings. The Strategic Lead attends

this meeting with an Operational Lead as a representative in her absence.

9.3 Implementation of the Care Act 2014

Over the last six months, the Safeguarding Team have attended a number of meetings

across both counties in preparation of the new legislation which came into effect on the

01st

April 2015.

9.4 Training and Peer Meetings

As the Safeguarding Team now have more than one whole time equivalent in place, the

Team aspire to attend further external meetings and training as will not detract from the

service provided.

10. Serious Case Review

10.1 Sussex

The Trust was invited to assist with gathering information for a serious case review(SCR)

for Sussex during the high profile investigation into Orchid View Nursing Home. Following

the publication of the SCR, 34 recommendations were made. Whilst none were directly

applicable to the acute setting, the organisation has a part to play in the identification of

potential risks to patients admitted from nursing homes in the local area.



11. Audit

11.1 The Adult Safeguarding Team has an audit plan in place. This will be rolled out in the coming year.

12. DBS

12.1 Changes to the DBS

The DBS came into effect in 2012 following the joining of the CRB and the ISA. Under

the Safeguarding Vulnerable Adults Groups Act 2006, the Trust is placed with the legal

requirement to refer any person who has:

Harmed or poses a risk of harm to the a child or vulnerable adult

Satisfied the harm test: or

Received a caution or conviction for a relevant offence.

Following any safeguarding investigation involving a member of Trust staff, the

Safeguarding Adults Lead works in partnership with the Trusts HR Business

Partners to ensure that any member of staff or volunteer who falls within any of the

above criteria is referred to the DBS. This will be done in conjunction with the

introduction of the role of the Designated Adult Safeguarding Manager (DASM).

13. Priorities for 2014-2015

13.1 The Team have three areas of priority for the coming year, these are outlined below:

Training

This is an ongoing priority for the Safeguarding Team and the Trust, particularly in light of

the implementation of the Care Act 2014 on 01/04/2015. The Act has made Adult

Safeguarding statute in law and heralds a new way of working. The Safeguarding Team

will highlight the introduction of this and the changes that have occurred within Adult

Safeguarding ensuring compliance across the Trust.



Training will continue to highlight and promote the importance of the Mental Capacity

Assessments and Best Interests Process and ensure clear guidance is in place and

accessible for all staff. Further training days are already in the process of being rolled out

with a view to have MCA & DoLS training days on a continuous programme for the year

ahead.

MCA & Consent training has been introduced to the Consultant Training Programme for

the coming year. To assist with this, the Safeguarding Team will continue to work in

partnership with the Learning Disabilities Liaison Team in highlighting the importance of the

Mental Capacity Assessments and Best Interests process.

The Team will continue with ward based training and being visible in the clinical areas

thus highlighting the profile of the Adult Safeguarding Team.

Deprivation of Liberty Safeguards (DoLS)

Due to the recent change in the threshold for Deprivation of Liberty Safeguards applications,

the Safeguarding Team must ensure that there is a robust reporting system in place and

support for staff completing the application. This will include clear guidance and support for

staff. The creation and publication of an information leaflet for patients and their carers

regarding DoLS.

Risk & Compliance

The Team plan to roll out a robust audit programme for the Adult Safeguarding Team in

relation to DoLS applications and concerns raised.

The Team will continue to develop strong links between the Complaints and Patient Safety

& Risk Departments to ensure that safeguarding is considered at all times when

investigating a complaint or a patient safety issue.

The Safeguarding Team will continue to work closely with the Tissue Viability Nurse to

raise awareness regarding pressure area care.



The Safeguarding Team will continue to raise awareness around Domestic Abuse and

introduce direct links with the local MARAC (Multi Agency Risk Assessment Conference).

The Safeguarding Team to continue to raise awareness around Female Genital Mutilation

and assist to ensure that a robust reporting system is in place.

With the Trust migrating to NHS.net later this year, the Safeguarding Team plan to move

to electronic reporting of concerns, this will ensure immediate notification to both Social

Care and the Safeguarding Team enabling a timely and appropriate response.

14. Conclusion

The Safeguarding Team will continue to work towards ensuring that across the Trust

Safeguarding Adults remains everyone’s business. The level of activity and referrals made

to the Safeguarding Team continues to indicate that staff are concerned about real or

potential abuse of adults and are aware of how to report this and escalate their concerns.

Following on from the learning recommendations relating to the one substantiated case of

neglect against the Trust regarding pressure care, timely provision of appropriate

equipment and staff communication issues, the ward implemented the following series of

measures. Increased specialist training around tissue viability care, twice daily handovers

with key personnel at patient’s bedside, a robust information sharing strategy involving

patient’s relatives, a three minute response time to call bells and the introduction of a tool

to assess pain relief for patients with dementia and/or cognitive impairement. These

ongoing ward care standards by all staff will be displayed on ward and staff areas will be

assessed by their on-going appraisal process and also part of the assurance that this work

is successful will be feedback via Friends and Family tests.

The introduction the new Care Act 2014 has made a fundamental shift in approach toward

adult safeguarding, as it puts the Adult and their wishes and experiences at the centre of

any concern or enquiry. In the coming year, the Safeguarding Team will embrace this

and focus on highlighting the cultural changes that are taking place within Adult



Safeguarding.

The lowering of the Deprivation of Liberty Safeguards (DoLS) thresholds and a greater

understanding of this legislation through continuous training and presence of the

Safeguarding Team on the wards and departments will continue to produce increasing

levels of DoLS applications.

The Team is committed to continue to raise awareness across the Trust so that all staff

recognises the signs of abuse or potential abuse. Work will continue with both internal

and external agencies to create a climate in which abuse of adults is not tolerated.

The Trust Board is asked to receive this report and to continue to give its full support to

the Safeguarding Adults agenda.



Appendix A BRIEFING SHEET FOR HOSPITALS – The “Acid Test”

Deprivation of Liberty after Cheshire West

How to decide whether it is likely that a deprivation of liberty is occurring and when to make a

referral to the DoLS Team

The requirement for the Deprivation of Liberty Safeguards remain the same

There are still 6 requirements which need to be met

1. 18 and over

2. Suffering from a mental disorder

3. Lacking capacity for the decision to be accommodated in the hospital or care home

4. No decision previously made to refuse treatment or care, or conflict relating to this such

as LPA

5. Not ineligible for DoLS

6. The person needs to be deprived of liberty, in their best interests.

The difficulty comes in working out whether a situation in a hospital or care home amounts to a

deprivation of liberty.

The Supreme Court has now confirmed that here are two key questions to ask – the ‘acid test’:

(1) Is the person subject to continuous supervision and control? (All three aspects are

necessary)

AND

(2) Is the person free to leave? (The person may not be saying this or acting on it but the

issue is about how staff would react if the person did try to leave).

So this now means that if a person is subject both to continuous supervision and control

and not free to leave they are deprived of their liberty.

The following factors are no longer relevant to this:

(1) the person’s compliance or lack of objection;

(2) the relative normality of the placement and

(3) the reason or purpose behind a particular placement.



REMEMBER

The Deprivation of Liberty Safeguards applies in hospitals and care homes but this criterion to

decide what a deprivation of liberty is applies in any setting.



REPORT TITLE: Safety and Quality Committee Update

NON- EXECUTIVE SPONSOR: Richard Shaw, Chair Safety & Quality Committee

REPORT AUTHOR (s): Richard Shaw, Chair Safety & Quality Committee


n/a

Action Required:

Approval () Discussion ( ) Assurance ()

Purpose of Report:

To provide an update of the activities of the safety and quality committee.


The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in October 2015.

Recommendation:

To provide assurance to the Board.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about


Legal and regulatory impact Compliance with CQC, MHRA and Audit Commission

Financial impact Serious incidents often become claims

Patient Experience/Engagement Part of the SQC Remit

Risk & Performance Management Reporting, investigation and learning from serious incidents informs risk management


The report complies with the NHS Constitution

Attachment:

N/A

Trust Board Report – 29th October 2015 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 1st October 2015. It considered its standing agenda items; the reports from ECQRM and CQRM meetings and the SQC Dashboard and Quality Report. ECQRM and CQRM The Committee agreed that a presentation on the end of life pathway, which had recently been discussed by the Executive Committee, should be made to the Board as a patient story and should then be made to the Council of Governors. The Committee congratulated the Cancer team on being benchmarked highly in the south of England. In discussion it was stated that the two main challenges facing the Cancer service are: to maintain referral to treatment standards in light of increasing incidence of cancer and numbers of referrals; and to respond to the changing way in which patients are entering the system, for example through direct access and access to investigations. The Cancer team will report further to the Committee early in the New Year. A recent national news item prompted questions about the risk of gender bias in Surgery. While there is no evidence of discrimination or disadvantage here, it was agreed that some analysis should be conducted of gender ratios. The Committee welcomed the initiative to offer food packs to vulnerable patients to aid discharge and looked forward to a report to SQC in the spring. The Committee noted that weekly meetings were taking place to improve ambulance handover times with a view to achieving improvement through November and December, and matching the 2014 performance by year end. Quality Report and Safety Dashboard The Committee received a new version of the Quality Report which offers greater detail and analysis than previous reports and is being trialed for three months. Although there was concern at the large amount of data, which may be unwieldy for SQC to use, the new format helpfully identifies five top issues that emerge from the data, providing a useful focus for discussion and assurance. These were: bed capacity/management, elective access, staffing, VTE and diarrhoea management (including CDiff). The Committee discussed VTE assessments – not an issue that had been a focus at SQC previously - where the Trust’s performance of 95% is below national benchmarks. In discussion, it became clear that difficulties in carrying out the initial assessment were hindering the Trust from focusing on subsequent actions, such as ongoing assessments as the clinical picture changes and assessment at the point of discharge. It was agreed that next month’s report should contain more information on governance, actions and time frames for this and other top issues. In considering other issues to arise from the Safety Dashboard, discussion focused on:

Data on mortality in low risk conditions, a potential CQC risk, which is reducing steadily;

The spike in numbers of CDiff across the region, and the discussions between the Trust and the CCG about how many can be attributed to lapses of care – currently five but the number may be reviewed downwards;

The Trust’s below target performance in admitting Stroke and NOF patients to the right

bed within four hours: an audit is underway to identify the problems and a report will be made to a future SQC meeting.

Legal Services Report The Committee considered a report on legal and inquest casework. This gave assurance that there had been a relatively constant flow of casework. To understand better the significance of the data, the Committee asked that future reports should contain benchmarking information with Trusts of a similar size to compare data such as outcomes, damages paid and the number of open cases. Risk of Viral Gastroenteritis The Committee discussed a report on Viral Gastroenteritis, which is identified as a high risk on the Strategic Risk Register and is now seen as a year-round, rather than a seasonal, problem. Although the condition is unpleasant, it is normally short-lived and has not been cited on a death certificate as a cause of death. Owing to the need for deep cleaning where there has been an incidence of the illness, it is calculated that around 100-200 bed days per annum are lost. A task force is in place to promote bowel health, mouth care and the intelligent management of patients. Although this has had an impact it is not possible to benchmark performance against other Trusts. It was commented that nursing homes should be able to deal with norovirus patients, but that around half are not covered by their insurance to give intra-peritoneal fluids, despite having nursing staff employed. 18 Week RTT Target SQC was assured that the Government’s new target for referral to treatment, which measures the number of patients still waiting for treatment after 18 weeks, was aligned to the expectation of clinicians. A legal right to treatment within this period remains in force, and patients have the right to complain to the CCG if they are not treated within this time. Outpatients SQC emphasized the priority the Trust attaches to improving performance in Outpatients. The Committee was assured that a new group is established and is reviewing metrics, while patient safety is also being audited in clinics where notes were not available. The results will be considered in the forthcoming Deep Dive. The next SQC meeting is at 2pm on 5th November. Richard Shaw Non-Executive Director Chair of Safety & Quality Committee October 2015

An Associated University Hospital of

Brighton and Sussex Medical School 1

Integrated Performance Report

M06 – September 2015

Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer)




Brighton and Sussex Medical School 2 2

Patient Safety

• There were four SIs declared in September 2015 and no Never Events.

• Patient safety indicators continue to show expected levels of performance.

• The Trust had no MRSA bloodstream infections and two Trust acquired C-Diff cases in September 2015.

Clinical Effectiveness

• The Clinical Effectiveness Committee continues to monitor the latest HSMR data for the Trust and mortality is lower than expected

for our patient group when benchmarked against national comparators.

• Maternity indicators continue to show expected performance.

Access and Responsiveness

• The 4hr ED standard was achieved with performance of 97.1% in September 2015.

• The Two Week Wait and 62 Day Referral to treatment Cancer standards were not achieved in September 2015.

• The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month.

Patient Experience

• In September 2015 the Inpatient FFT increased from 95.3% to 96.1%. The ED FFT increased from 95.8% to 96.9%

Workforce

• The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local

and overseas recruitment.

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in

place and is reviewing recent Department of Health proposals for the management of temporary staffing spend, particularly for

nursing.

Performance – September 2015



Action: The Board are asked to note and accept this report

Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality

care (Including mortality).

Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license

care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/

engagement: This paper includes significant detail on both patient experience and access to services.

Risk & performance

management

This is the main Board assurance report for performance against quality and financial measures and is linked to risk management

through the SRR.

NHS constitution; equality &

diversity; communication. This report covers performance against access standards with the NHS Constitution.

Finance

• At Month 6, the Trust is adverse to the revised plan submitted to the TDA by £0.8m with a (£3.3)m deficit.

Key Risks

• The Significant Risk Register for the Trust includes six quality risks in relation to “Right bed first time”, ED Access standards,

Outbreak of viral gastroenteritis, Increasing sickness absence levels, Cancelled and / or delayed elective operations and Failure to

maintain cancer access standards.




Patient Safety


• There were no Never Events reported in September 2015.

• Safety Thermometer – the % of patients with harm free care (new harm) was 96.7%, returning to the normal levels seen in previous

months.

• VTE risk assessment performance for Q2 is undergoing validation following changes in system usage within the Surgical Division. This

action has not been necessary in previous months and the processes for recording are being checked in specific areas.

Patient Safety

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

No of Never Events in month 0 0 0 0 0 0 1 1 0 0 0 0 0

No of medication errors causing Severe Harm or Death 0 0 0 0 0 0 0 0 0 0 0 0 0

Safety Thermometer - % of patients with harm free care (all harm) 92.0% 95.0% 93.0% 93.0% 93.0% 92.0% 92.0% 91.3% 93.5% 92.0% 95.0% 92.2% 93.2%

Safety Thermometer - % of patients with harm free care (new harm) 94.5% 98.0% 96.0% 97.0% 96.0% 95.0% 96.0% 95.9% 97.3% 95.2% 97.7% 94.8% 96.7%

Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% TBC TBC TBC

WHO Checklist Usage - % Compliance 100% 100% 98% 100% 96% 96% 100% 98% 100% 98% 96% 100% 100%

Number of Sis 3 3 2 2 5 6 5 3 3 6 1 1 4

Serious Incidents - No per 1000 Bed Days 0.17 0.17 0.12 0.11 0.26 0.35 0.26 0.16 0.16 0.33 0.05 0.05 0.23

Percentage of Patient Safety Incidents causing Severe harm or Death 1.1% 0.7% 0.2% 0.2% 0.6% 0.7% 0.6% 0.2% 0.6% 0.5% 0.0% 0.2% 0.8%

Number of overdue CAS and NPSA alerts 0 0 1 0 1 1 0 0 0 0 0 0 0



• Four SIs were declared in September 2015 (in all cases full investigations have been started):

• Medication Administration - A patient death has been referred to the Coroner. On initial examination of the care received, there

appears to have been a significant delay in the administration of prescribed antibiotics.

• Fall - The patient was mobilising independently when he fell while attempting to close a door. The fall resulted in a fractured

neck of femur.

• Fall - A 91 year old lady sustained an unwitnessed fall on the Frail Elderly Unit, resulting in a significant head injury. Intervention

was not advised by the neurosurgical team; the patient was made comfortable and sadly passed away two days later.

• Treatment delay - There was a difference of clinical opinion between the medical and surgical teams on whether the patient’s

condition was caused by a bowel obstruction or colitis. There is a suspicion that an opportunity was missed to instigate

management of a bowel obstruction. The post mortem result has not yet been received.

• The Patient Safety Risk in relation to an increased in number of adolescent patients with mental health issues being admitted to general

paediatric ward has been downgraded from the significant risk register following discussion at the Patient Safety Committee. However,

action has been instigated with CCGs over the pathway for these patients and the delays in getting patients into more appropriate care

for their mental health issues.

Patient Safety



Infection Control

• There were no cases of MRSA in September 2015 and two cases of Trust acquired C.diff.

• In light of the risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register:

• Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on

patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3).

Patient Safety


MRSA BSI (incidences in month) 0 0 0 0 0 1 0 0 0 0 0 0 0

CDiff Incidences (in month) 0 1 4 0 2 6 1 1 3 3 4 3 2

MSSA 3 0 1 1 0 2 1 1 0 1 0 0 0

E-Coli 22 18 15 16 14 18 12 11 23 20 18 34 27



Mortality and Readmissions

• Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national

comparators.

• The COPD audit has been commenced by the respiratory team, although most recent data showed the relative risk was better than

average at an index score of 96.

Maternity


Clinical Audit Programme

• The Clinical Effectiveness Committee reviewed the publication timetable for national audits and agreed the upcoming publications from

the National Falls audit and the Prostate Cancer audit to be the focus for future SQC meetings.

• The Cardiology Lead provided an update on improving compliance with NICE guidance for Atrial Fibrillation and Acute Heart Failure.



C Section Rate - Emergency 17% 12% 14% 17% 18% 16% 17% 13% 17% 18% 14% 17% 17%

C Section Rate - Elective 9% 12% 13% 11% 7% 11% 8% 11% 9% 10% 11% 13% 8%

Admissions of full term babies to neo-natal care 8.0% 5.4% 3.8% 6.3% 6.0% 6.0% 6.0% 7.0% 6.2% 4.0% 5.0% 5.1% 5.8%


HSMR (56 Monitored diagnoses - 12 Months) 92.7 91.6 93.0 94.4 93.5 93.0 93.5 93.2 93.8 93.3 92.2

Emergency readmissions within 30 days (PBR Rules) 6.8% 6.8% 7.2% 7.1% 6.9% 6.7% 6.6% 6.4% 7.0% 7.2% 7.7% 7.5%



Emergency Department

• Despite continuation of pressure on the emergency department with high levels of emergency admissions, the ED 4hr standard was

achieved in September 2015 with performance of 97.1%

• Over the first half of the year, overnight non-elective admissions are up 10% (7% for East Surrey CCG and 21% for Crawley CCG)

compared to last year.

• Ambulance turnaround performance remains a challenge and work is underway on internal processes and escalations as well as

alterations to the physical environment to support handover of multiple patients at times of “surge”.

• In light of the on-going operational pressures in the Trust, the following three risks are on the significant risk register:

• ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system –

Risk score 16 (Likelihood of 4 and consequence of 4)

• Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first

time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5

and consequence of 3)



ED 95% in 4 hours 95.4% 94.3% 95.7% 93.3% 92.0% 91.3% 95.0% 96.8% 96.0% 94.8% 94.3% 96.1% 97.1%

Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0

Ambulance Turnaround - Number Over 30 mins 97 151 183 344 163 259 247 199 170 206 238 220 225




Cancer

• In September 2015, the Two Week Wait and 62 Day referral to Treatment standards were not achieved. This also resulted in non

achievement of both standards for the quarter.

• On the Two Week Wait standard, 107 patients breached the standard with 58 of these in upper/lower GI, 12 in Dermatology and

10 in both Gynaecology and Breast. Patient choice was a key factor in a majority of these breaches but the trust recognises that

we need to be able to offer a wider variety of appointments over the 2 week period.

• Validation of the 62 Day referral to treatment standard is on-going with tertiary providers but issues remain in Lung (4 breaches)

and Urology (3 breaches) pathways.

• In light of the performance above, the following risk has been added to the Significant Risk Register:

• Failure to maintain cancer access standards - Failure to maintain cancer access performance due to capacity (Outpatients,

Diagnostics) / pathway issues (Trust and wider network) can impact on the effectiveness of treatment as well as the experience

for the patient. Risk score 15 (Likelihood of 5 and consequence of 3). Internal actions around capacity and tracking are

underway and work is being undertaken with tertiary providers where relevant.



Cancer - TWR 93.2% 93.8% 93.1% 93.1% 93.1% 93.1% 93.1% 93.3% 94.2% 93.1% 93.1% 93.0% 89.4%

Cancer - TWR Breast Symptomatic 93.2% 93.3% 93.6% 93.5% 93.4% 96.3% 93.8% 93.8% 93.8% 90.6% 93.2% 93.3% 94.2%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Diagnosis to Treatment 99.2% 100.0% 99.1% 98.4% 97.1% 100.0% 100.0% 98.2% 97.0% 96.2% 98.3% 99.1% 98.4%

Cancer - 62 Day Referral to Treatment Standard 78.8% 87.1% 86.3% 86.1% 85.4% 88.0% 83.7% 86.4% 83.9% 86.5% 80.7% 84.2% TBC

Cancer - 62 Day Referral to Treatment Screening 83.3% 83.3% 100.0% 100.0% 92.3% 100.0% 92.3% 84.6% 92.3% 100.0% 87.5% 88.9% 100.0%



Referral to Treatment (RTT) and Diagnostics

• At aggregate level, the trust continues to deliver against the incomplete pathways standard which measures % of patients waiting less

than 18 weeks at the end of each month. However, challenges remain in General Surgery, Trauma and Orthopaedics, Ophthalmology

and cardiology. A number of newly recruited consultants will increase capacity and support reduction in patients over 18 weeks..

• The diagnostic standard continues to be achieved and capacity across all areas is subject to review in order to plan for expected growth

over the coming 18 months as a result of the National Cancer Strategy.

• 44 patients were cancelled at the “last minute” for non clinical reasons, none of which were due to bed availability.

• The following risk is on the significant risk register:

• Cancelled and / or delayed elective operations - Due to on-going operational pressures and increasing demand for emergency

inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient

experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score

15(Likelihood of 5 and consequence of 3)



RTT Incomplete Pathways - % waithing less than 18 weeks 93.8% 93.5% 93.3% 92.2% 92.1% 94.0% 93.7% 93.6% 93.5% 92.6% 92.2% 92.0% 92.1%

RTT Patients over 52 weeks on incomplete pathways 0 0 0 0 0 0 0 0 0 0 0 0 0

RTT Admitted - 90% treated within 18 weeks 90.7% 88.1% 81.4% 91.1% 90.2% 82.1% 88.4% 91.6% 90.1% 92.0% 84.0% 81.5% 77.9%

RTT Non Admitted - 95% treated within 18 weeks 93.2% 93.9% 92.8% 95.0% 91.7% 91.0% 93.5% 93.6% 95.3% 93.4% 89.4% 89.1% 88.7%

Percentage of patients waiting 6 weeks or more for diagnostic 0.0% 0.0% 0.4% 0.1% 0.9% 0.7% 1.4% 1.0% 0.2% 0.8% 1.0% 0.1% 0.5%

Last Minute Elective Cancellations for non clinical reasons 98 62 71 50 18 26 45 11 37 45 24 25 44

% of operations cancelled on the day not treated within 28 days 1.0% 1.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0%



Patient Voice

• Inpatients - The September Friends and Family Test (FFT) score for inpatients has improved and the figure is the highest it has

been since February 2015. The inpatient FFT response rate remains high, at 41%

• Emergency Department – The FFT score for ED continues to improve and is the highest it has been for six months. There has also

been a further increase in the response rate, from 14% in August to 20% in September

• Maternity - The FFT scores for the antenatal touchpoint has dropped back from to 98.8% in August to 94.3% in September. The

score for the delivery touchpoint has improved from 87.9% in August to 95.4% in September the postnatal score remains similar. For

both these touchpoints the response rate has recovered from the low of 9% in August to 18% in September

• National FFT comparisons August - Inpatients – The national average FFT score for inpatients in August was 95.5%. SASH scored

very slightly below this at 95.3%. ED - Our combined adult and paediatric ED Friends and Family Test score for August was 95.8%,

well above the national average of 88.1%, ranking the Department 18th in England.

Patient Experience


Inpatient FFT - % positive responses 96.0% 97.0% 97.0% 95.0% 95.7% 96.9% 94.2% 94.4% 95.1% 94.7% 95.1% 95.3% 96.1%

Emergency Department FFT - % positive responses 98.0% 95.0% 96.0% 93.0% 95.8% 97.1% 94.7% 95.4% 95.3% 93.7% 91.4% 95.8% 96.9%

Maternity FFT - Antenatal - % positive responses 96.0% 97.0% 95.0% 90.0% 97.6% 97.1% 97.0% 96.3% 100.0% 83.3% 94.1% 98.8% 94.3%

Maternity FFT - Delivery - % positive responses 95.0% 95.0% 93.0% 100.0% 95.5% 97.2% 100.0% 94.7% 97.0% 94.9% 93.8% 87.9% 95.4%

Maternity FFT - Postnatal Ward - % positive responses 93.0% 90.0% 92.0% 96.0% 85.9% 91.0% 97.3% 86.7% 91.0% 86.5% 90.0% 87.7% 87.9%

Maternity FFT - Postnatal Community Care - % positive responses 100.0% 94.0% 100.0% 85.0% 100.0% 100.0% 100.0% 100.0% 77.8% 100.0% 100.0% 100.0%

Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints (rate per 10,000 occupied bed days) 17 30 24 20 18 26 22 25 22 27 29 33 28



Workforce

• Sickness absence increased to 4.4% in September 2015. Actions following an audit of long term sickness absence have been

implemented.

• Increasing Sickness Absence Levels with impact on day to day management and expenditure remains on the Trust’s significant

risk register – Risk score 15 (Likelihood of 5 and consequence of 3)

• Streamlined nursing recruitment with a new recruitment tracker with ward dashboard to highlight blockages is now in place and

is discussed on a weekly basis. Activity around international recruitment continues. New staff are in post but do not all have

their PINs which means there are short term double running costs.

• Staff Turnover remained at 15.2% in September 2015 and the Trust is developing initiatives to improve retention and staff

experience.


place.

Workforce


Average fi l l rate – registered nurses/midwives (%) - Day 95.4% 96.4% 97.1% 95.1% 94.8% 95.9% 96.5% 96.8% 95.7% 96.9% 93.3% 92.5% 95.0%

Average fi l l rate – care staff (%) - Day 96.4% 95.3% 95.0% 93.1% 92.6% 93.8% 94.5% 96.1% 93.8% 93.5% 94.3% 94.5% 95.1%

Average fi l l rate – registered nurses/midwives (%) - Night 98.1% 99.2% 99.4% 97.3% 97.2% 97.7% 96.7% 96.5% 97.1% 94.1% 95.2% 94.3% 96.4%

Average fi l l rate – care staff (%) - Night 96.7% 97.4% 95.3% 93.7% 93.3% 94.9% 94.9% 95.2% 95.9% 94.9% 94.4% 93.8% 96.4%

Overall Sickness Rate 4.0% 4.4% 4.0% 4.5% 4.3% 4.4% 4.2% 4.2% 4.3% 4.1% 3.9% 3.7% 4.4%

%age of staff who have had appraisal in last 12 months 74% 72% 69% 72% 67% 68% 73% 71% 68% 58% 56% 57% 64%

Staff Turnover rate 15.6% 15.3% 15.3% 15.6% 15.7% 15.7% 15.2% 15.5% 15.9% 15.6% 15.6% 15.2% 15.2%



Finance

• The Trust is reporting against the revised plan submitted to the TDA in September 2016.

• At the end of month 6 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(3.3)m which is £(0.8)m

adverse to the revised TDA plan.

• The position reflects the same issues as past months (emergency activity greater than plan, affecting costs and elective work), but in

addition the delivery of increased elective activity is 3 weeks behind plan.

• The underlying position at the end of September is a £(3.8)m deficit, reflecting the non recurrent use of the Trust’s balance sheet

provisions.

• At M06 over £2.0m of income has not been paid to the Trust in respect of the marginal rate emergency threshold, readmission

deduction and specialist commissioning base value deduction.


Outturn £m Surplus / (Deficit) - Plan 2.3 2.3 2.3 2.3 2.3 2.3 2.3 1.6 1.6 1.6 1.6 1.6 1.6

Outturn £m Surplus / (Deficit) - Forecast 2.3 2.3 2.3 2.3 2.3 (2.5) (2.4) 1.6 1.6 1.6 1.6 1.6 1.6

YTD £m Surplus / (Deficit) - Plan (1.3) 0.1 0.4 1.0 1.9 1.4 2.3 (0.8) (1.2) (2.0) (1.1) (0.7) (0.6)

YTD £m Surplus / (Deficit) - Actual (1.3) 0.1 0.5 1.0 1.9 (2.9) (2.4) (0.8) (1.1) (2.0) (1.3) (2.6) (3.3)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.8 3.8 3.8 3.8 3.8 3.8

Outturn UNDERLYING £m Surplus / (Deficit) - Actual 1.0 1.0 (0.7) (5.2) (5.2) (5.2) (5.2) 3.8 3.3 3.3 3.3 3.3 3.3

YTD Savings £m - Actual 3.8 5.0 6.2 7.4 8.6 9.8 11.0 0.3 0.5 0.8 1.3 1.9 2.1

OT Risk £m Surplus / (Deficit) - Assessment (8.5) (8.5) (6.3) (6.3) (5.5) (0.7) 0.0 0.0 (1.0) 0.0 0.0 0.0 0.0

Outturn Cash position £m Fav / (Adv) - Forecast 2.6 2.6 2.6 2.6 2.6 2.6 2.6 7.6 7.6 7.6 2.6 1.2 2.4

YTD Cash position £m Fav / (Adv) - Actual 3.0 3.8 2.8 4.8 3.8 3.8 2.6 3.2 2.9 2.6 2.5 3.0 3.9

YTD Liquid ratio - days (10.0) (7.0) (4.0) (8.0) (8.0) (18.0) (21.0) (20.0) (21.0) (23.0) (22.0) (25.0) (19.0)

YTD BPPC (overall) volume £m 94% 90% 85% 88% 87% 86% 82% 62% 75% 78% 78% 76% 69%

YTD BPPC (overall) value £m 87% 92% 78% 84% 83% 83% 81% 65% 73% 75% 75% 74% 68%

Outturn Capital spend Fav / (Adv) - forecast 19.4 19.4 19.4 19.3 19.3 19.3 19.3 17.1 17.1 17.1 17.1 17.1 17.1



Finance

• The Trust has retained its £1.6m surplus forecast position. A separate paper covering the forecast will be discussed in the Private

Board Meeting.

• The Trust’s cash balance at the end of September 2015 was £3.9m. £6.0m of the temporary working capital facility was drawn down

in September. Cash is currently being managed adequately, but the position is tight.

• The £4.4m capital loan was received in October and has allowed the urgently needed capital investment programme to continue. The

capital spend forecast this year is £17.1m.



Integrated Performance Report

M06 – September 2015

Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer)





Patient Safety

• There were four SIs declared in September 2015 and no Never Events.


• The Trust had no MRSA bloodstream infections and two Trust acquired C-Diff cases in September 2015.


• The Clinical Effectiveness Committee continues to monitor the latest HSMR data for the Trust and mortality is lower than expected

for our patient group when benchmarked against national comparators.



• The 4hr ED standard was achieved with performance of 97.1% in September 2015.

• The Two Week Cancer standard was not achieved in September 2015.

• The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month.

Patient Experience

• In September 2015 the Inpatient FFT increased from 95.3% to 96.1%. The ED FFT increased from 95.8% to 96.9%

Workforce

• The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local

and overseas recruitment.


place and is reviewing recent Department of Health proposals for the management of temporary staffing spend, particularly for

nursing.




Action: The Board are asked to note and accept this report

Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality

care (Including mortality).

Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license

care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/

engagement: This paper includes significant detail on both patient experience and access to services.

Risk & performance

management

This is the main Board assurance report for performance against quality and financial measures and is linked to risk management

through the SRR.

NHS constitution; equality &

diversity; communication. This report covers performance against access standards with the NHS Constitution.

Finance

• At Month 6, the Trust is adverse to the revised plan submitted to the TDA by £0.8m with a (£3.3)m deficit.

Key Risks

• The Significant Risk Register for the Trust includes six quality risks in relation to “Right bed first time”, ED Access standards,

Outbreak of viral gastroenteritis, Increasing sickness absence levels, Cancelled and / or delayed elective operations and Failure to

maintain cancer access standards.




Patient Safety


• There were no Never Events reported in September 2015.

• Safety Thermometer – the % of patients with harm free care (new harm) was 96.7%, returning to the normal levels seen in previous

months.

• VTE risk assessment performance for Q2 is undergoing validation following changes in system usage within the Surgical Division. This

action has not been necessary in previous months and the processes for recording are being checked in specific areas.

Patient Safety


No of Never Events in month 0 0 0 0 0 0 1 1 0 0 0 0 0

No of medication errors causing Severe Harm or Death 0 0 0 0 0 0 0 0 0 0 0 0 0

Safety Thermometer - % of patients with harm free care (all harm) 92.0% 95.0% 93.0% 93.0% 93.0% 92.0% 92.0% 91.3% 93.5% 92.0% 95.0% 92.2% 93.2%

Safety Thermometer - % of patients with harm free care (new harm) 94.5% 98.0% 96.0% 97.0% 96.0% 95.0% 96.0% 95.9% 97.3% 95.2% 97.7% 94.8% 96.7%

Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% TBC TBC TBC

WHO Checklist Usage - % Compliance 100% 100% 98% 100% 96% 96% 100% 98% 100% 98% 96% 100% 100%

Number of Sis 3 3 2 2 5 6 5 3 3 6 1 1 4

Serious Incidents - No per 1000 Bed Days 0.17 0.17 0.12 0.11 0.26 0.35 0.26 0.16 0.16 0.33 0.05 0.05 0.23

Percentage of Patient Safety Incidents causing Severe harm or Death 1.1% 0.7% 0.2% 0.2% 0.6% 0.7% 0.6% 0.2% 0.6% 0.5% 0.0% 0.2% 0.8%

Number of overdue CAS and NPSA alerts 0 0 1 0 1 1 0 0 0 0 0 0 0



• Four SIs were declared in September 2015 (in all cases full investigations have been started):

• Medication Administration - A patient death has been referred to the Coroner. On initial examination of the care received, there

appears to have been a significant delay in the administration of prescribed antibiotics.

• Fall - The patient was mobilising independently when he fell while attempting to close a door. The fall resulted in a fractured

neck of femur.

• Fall - A 91 year old lady sustained an unwitnessed fall on the Frail Elderly Unit, resulting in a significant head injury. Intervention

was not advised by the neurosurgical team; the patient was made comfortable and sadly passed away two days later.

• Treatment delay - There was a difference of clinical opinion between the medical and surgical teams on whether the patient’s

condition was caused by a bowel obstruction or colitis. There is a suspicion that an opportunity was missed to instigate

management of a bowel obstruction. The post mortem result has not yet been received.

• The Patient Safety Risk in relation to an increased in number of adolescent patients with mental health issues being admitted to general

paediatric ward has been downgraded from the significant risk register following discussion at the Patient Safety Committee. However,

action has been instigated with CCGs over the pathway for these patients and the delays in getting patients into more appropriate care

for their mental health issues.

Patient Safety



Infection Control

• There were no cases of MRSA in September 2015 and two cases of Trust acquired C.diff.

• In light of the risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register:

• Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on

patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3).

Patient Safety


MRSA BSI (incidences in month) 0 0 0 0 0 1 0 0 0 0 0 0 0

CDiff Incidences (in month) 0 1 4 0 2 6 1 1 3 3 4 3 2

MSSA 3 0 1 1 0 2 1 1 0 1 0 0 0

E-Coli 22 18 15 16 14 18 12 11 23 20 18 34 27



Mortality and Readmissions

• Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national

comparators.

• The COPD audit has been commenced by the respiratory team, although most recent data showed the relative risk was better than

average at an index score of 96.

Maternity


Clinical Audit Programme

• The Clinical Effectiveness Committee reviewed the publication timetable for national audits and agreed the upcoming publications from

the National Falls audit and the Prostate Cancer audit to be the focus for future SQC meetings.

• The Cardiology Lead provided an update on improving compliance with NICE guidance for Atrial Fibrillation and Acute Heart Failure.



C Section Rate - Emergency 17% 12% 14% 17% 18% 16% 17% 13% 17% 18% 14% 17% 17%

C Section Rate - Elective 9% 12% 13% 11% 7% 11% 8% 11% 9% 10% 11% 13% 8%

Admissions of full term babies to neo-natal care 8.0% 5.4% 3.8% 6.3% 6.0% 6.0% 6.0% 7.0% 6.2% 4.0% 5.0% 5.1% 5.8%


HSMR (56 Monitored diagnoses - 12 Months) 92.7 91.6 93.0 94.4 93.5 93.0 93.5 93.2 93.8 93.3 92.2

Emergency readmissions within 30 days (PBR Rules) 6.8% 6.8% 7.2% 7.1% 6.9% 6.7% 6.6% 6.4% 7.0% 7.2% 7.7% 7.5%



Emergency Department

• Despite continuation of pressure on the emergency department with high levels of emergency admissions, the ED 4hr standard was

achieved in September 2015 with performance of 97.1%

• Over the first half of the year, overnight non-elective admissions are up 10% (7% for East Surrey CCG and 21% for Crawley CCG)

compared to last year.

• Ambulance turnaround performance remains a challenge and work is underway on internal processes and escalations as well as

alterations to the physical environment to support handover of multiple patients at times of “surge”.

• In light of the on-going operational pressures in the Trust, the following three risks are on the significant risk register:

• ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system –

Risk score 16 (Likelihood of 4 and consequence of 4)

• Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first

time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5

and consequence of 3)



ED 95% in 4 hours 95.4% 94.3% 95.7% 93.3% 92.0% 91.3% 95.0% 96.8% 96.0% 94.8% 94.3% 96.1% 97.1%

Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0





Cancer

• In September 2015, the Two Week Wait standard was not achieved. This also resulted in non achievement for the quarter.

• On the Two Week Wait standard, 107 patients breached the standard with 58 of these in upper/lower GI, 12 in Dermatology and 10 in

both Gynaecology and Breast. Patient choice was a key factor in a majority of these breaches but the trust recognises that we need to

be able to offer a wider variety of appointments over the 2 week period.

• While the 62 Day Standard was achieved in September 2015, it was not achieved for Q2 as a whole.

• In light of the performance above, the following risk has been added to the Significant Risk Register:

• Failure to maintain cancer access standards - Failure to maintain cancer access performance due to capacity (Outpatients,

Diagnostics) / pathway issues (Trust and wider network) can impact on the effectiveness of treatment as well as the experience

for the patient. Risk score 15 (Likelihood of 5 and consequence of 3). Internal actions around capacity and tracking are

underway and work is being undertaken with tertiary providers where relevant.



Cancer - TWR 93.2% 93.8% 93.1% 93.1% 93.1% 93.1% 93.1% 93.3% 94.2% 93.1% 93.1% 93.0% 89.4%

Cancer - TWR Breast Symptomatic 93.2% 93.3% 93.6% 93.5% 93.4% 96.3% 93.8% 93.8% 93.8% 90.6% 93.2% 93.3% 94.2%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Diagnosis to Treatment 99.2% 100.0% 99.1% 98.4% 97.1% 100.0% 100.0% 98.2% 97.0% 96.2% 98.3% 99.1% 98.4%

Cancer - 62 Day Referral to Treatment Standard 78.8% 87.1% 86.3% 86.1% 85.4% 88.0% 83.7% 86.4% 83.9% 86.5% 80.7% 84.2% 85.0%

Cancer - 62 Day Referral to Treatment Screening 83.3% 83.3% 100.0% 100.0% 92.3% 100.0% 92.3% 84.6% 92.3% 100.0% 87.5% 88.9% 100.0%



Referral to Treatment (RTT) and Diagnostics

• At aggregate level, the trust continues to deliver against the incomplete pathways standard which measures % of patients waiting less

than 18 weeks at the end of each month. However, challenges remain in General Surgery, Trauma and Orthopaedics, Ophthalmology

and cardiology. A number of newly recruited consultants will increase capacity and support reduction in patients over 18 weeks..

• The diagnostic standard continues to be achieved and capacity across all areas is subject to review in order to plan for expected growth

over the coming 18 months as a result of the National Cancer Strategy.

• 44 patients were cancelled at the “last minute” for non clinical reasons, none of which were due to bed availability.

• The following risk is on the significant risk register:

• Cancelled and / or delayed elective operations - Due to on-going operational pressures and increasing demand for emergency

inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient

experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score

15(Likelihood of 5 and consequence of 3)



RTT Incomplete Pathways - % waithing less than 18 weeks 93.8% 93.5% 93.3% 92.2% 92.1% 94.0% 93.7% 93.6% 93.5% 92.6% 92.2% 92.0% 92.1%

RTT Patients over 52 weeks on incomplete pathways 0 0 0 0 0 0 0 0 0 0 0 0 0

RTT Admitted - 90% treated within 18 weeks 90.7% 88.1% 81.4% 91.1% 90.2% 82.1% 88.4% 91.6% 90.1% 92.0% 84.0% 81.5% 77.9%

RTT Non Admitted - 95% treated within 18 weeks 93.2% 93.9% 92.8% 95.0% 91.7% 91.0% 93.5% 93.6% 95.3% 93.4% 89.4% 89.1% 88.7%

Percentage of patients waiting 6 weeks or more for diagnostic 0.0% 0.0% 0.4% 0.1% 0.9% 0.7% 1.4% 1.0% 0.2% 0.8% 1.0% 0.1% 0.5%

Last Minute Elective Cancellations for non clinical reasons 98 62 71 50 18 26 45 11 37 45 24 25 44

% of operations cancelled on the day not treated within 28 days 1.0% 1.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0%



Patient Voice

• Inpatients - The September Friends and Family Test (FFT) score for inpatients has improved and the figure is the highest it has

been since February 2015. The inpatient FFT response rate remains high, at 41%

• Emergency Department – The FFT score for ED continues to improve and is the highest it has been for six months. There has also

been a further increase in the response rate, from 14% in August to 20% in September

• Maternity - The FFT scores for the antenatal touchpoint has dropped back from to 98.8% in August to 94.3% in September. The

score for the delivery touchpoint has improved from 87.9% in August to 95.4% in September the postnatal score remains similar. For

both these touchpoints the response rate has recovered from the low of 9% in August to 18% in September

• National FFT comparisons August - Inpatients – The national average FFT score for inpatients in August was 95.5%. SASH scored

very slightly below this at 95.3%. ED - Our combined adult and paediatric ED Friends and Family Test score for August was 95.8%,

well above the national average of 88.1%, ranking the Department 18th in England.

Patient Experience


Inpatient FFT - % positive responses 96.0% 97.0% 97.0% 95.0% 95.7% 96.9% 94.2% 94.4% 95.1% 94.7% 95.1% 95.3% 96.1%

Emergency Department FFT - % positive responses 98.0% 95.0% 96.0% 93.0% 95.8% 97.1% 94.7% 95.4% 95.3% 93.7% 91.4% 95.8% 96.9%

Maternity FFT - Antenatal - % positive responses 96.0% 97.0% 95.0% 90.0% 97.6% 97.1% 97.0% 96.3% 100.0% 83.3% 94.1% 98.8% 94.3%

Maternity FFT - Delivery - % positive responses 95.0% 95.0% 93.0% 100.0% 95.5% 97.2% 100.0% 94.7% 97.0% 94.9% 93.8% 87.9% 95.4%

Maternity FFT - Postnatal Ward - % positive responses 93.0% 90.0% 92.0% 96.0% 85.9% 91.0% 97.3% 86.7% 91.0% 86.5% 90.0% 87.7% 87.9%

Maternity FFT - Postnatal Community Care - % positive responses 100.0% 94.0% 100.0% 85.0% 100.0% 100.0% 100.0% 100.0% 77.8% 100.0% 100.0% 100.0%

Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints (rate per 10,000 occupied bed days) 17 30 24 20 18 26 22 25 22 27 29 33 28



Workforce

• Sickness absence increased to 4.4% in September 2015. Actions following an audit of long term sickness absence have been

implemented.

• Increasing Sickness Absence Levels with impact on day to day management and expenditure remains on the Trust’s significant

risk register – Risk score 15 (Likelihood of 5 and consequence of 3)

• Streamlined nursing recruitment with a new recruitment tracker with ward dashboard to highlight blockages is now in place and

is discussed on a weekly basis. Activity around international recruitment continues. New staff are in post but do not all have

their PINs which means there are short term double running costs.

• Staff Turnover remained at 15.2% in September 2015 and the Trust is developing initiatives to improve retention and staff

experience.


place.

Workforce


Average fi l l rate – registered nurses/midwives (%) - Day 95.4% 96.4% 97.1% 95.1% 94.8% 95.9% 96.5% 96.8% 95.7% 96.9% 93.3% 92.5% 95.0%

Average fi l l rate – care staff (%) - Day 96.4% 95.3% 95.0% 93.1% 92.6% 93.8% 94.5% 96.1% 93.8% 93.5% 94.3% 94.5% 95.1%

Average fi l l rate – registered nurses/midwives (%) - Night 98.1% 99.2% 99.4% 97.3% 97.2% 97.7% 96.7% 96.5% 97.1% 94.1% 95.2% 94.3% 96.4%

Average fi l l rate – care staff (%) - Night 96.7% 97.4% 95.3% 93.7% 93.3% 94.9% 94.9% 95.2% 95.9% 94.9% 94.4% 93.8% 96.4%

Overall Sickness Rate 4.0% 4.4% 4.0% 4.5% 4.3% 4.4% 4.2% 4.2% 4.3% 4.1% 3.9% 3.7% 4.4%

%age of staff who have had appraisal in last 12 months 74% 72% 69% 72% 67% 68% 73% 71% 68% 58% 56% 57% 64%

Staff Turnover rate 15.6% 15.3% 15.3% 15.6% 15.7% 15.7% 15.2% 15.5% 15.9% 15.6% 15.6% 15.2% 15.2%



Finance

• The Trust is reporting against the revised plan submitted to the TDA in September 2016.

• At the end of month 6 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(3.3)m which is £(0.8)m

adverse to the revised TDA plan.

• The position reflects the same issues as past months (emergency activity greater than plan, affecting costs and elective work), but in

addition the delivery of increased elective activity is 3 weeks behind plan.

• The underlying position at the end of September is a £(3.8)m deficit, reflecting the non recurrent use of the Trust’s balance sheet

provisions.

• At M06 over £2.0m of income has not been paid to the Trust in respect of the marginal rate emergency threshold, readmission

deduction and specialist commissioning base value deduction.


Outturn £m Surplus / (Deficit) - Plan 2.3 2.3 2.3 2.3 2.3 2.3 2.3 1.6 1.6 1.6 1.6 1.6 1.6

Outturn £m Surplus / (Deficit) - Forecast 2.3 2.3 2.3 2.3 2.3 (2.5) (2.4) 1.6 1.6 1.6 1.6 1.6 1.6

YTD £m Surplus / (Deficit) - Plan (1.3) 0.1 0.4 1.0 1.9 1.4 2.3 (0.8) (1.2) (2.0) (1.1) (0.7) (0.6)

YTD £m Surplus / (Deficit) - Actual (1.3) 0.1 0.5 1.0 1.9 (2.9) (2.4) (0.8) (1.1) (2.0) (1.3) (2.6) (3.3)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.8 3.8 3.8 3.8 3.8 3.8

Outturn UNDERLYING £m Surplus / (Deficit) - Actual 1.0 1.0 (0.7) (5.2) (5.2) (5.2) (5.2) 3.8 3.3 3.3 3.3 3.3 3.3

YTD Savings £m - Actual 3.8 5.0 6.2 7.4 8.6 9.8 11.0 0.3 0.5 0.8 1.3 1.9 2.1

OT Risk £m Surplus / (Deficit) - Assessment (8.5) (8.5) (6.3) (6.3) (5.5) (0.7) 0.0 0.0 (1.0) 0.0 0.0 0.0 0.0

Outturn Cash position £m Fav / (Adv) - Forecast 2.6 2.6 2.6 2.6 2.6 2.6 2.6 7.6 7.6 7.6 2.6 1.2 2.4

YTD Cash position £m Fav / (Adv) - Actual 3.0 3.8 2.8 4.8 3.8 3.8 2.6 3.2 2.9 2.6 2.5 3.0 3.9

YTD Liquid ratio - days (10.0) (7.0) (4.0) (8.0) (8.0) (18.0) (21.0) (20.0) (21.0) (23.0) (22.0) (25.0) (19.0)

YTD BPPC (overall) volume £m 94% 90% 85% 88% 87% 86% 82% 62% 75% 78% 78% 76% 69%

YTD BPPC (overall) value £m 87% 92% 78% 84% 83% 83% 81% 65% 73% 75% 75% 74% 68%

Outturn Capital spend Fav / (Adv) - forecast 19.4 19.4 19.4 19.3 19.3 19.3 19.3 17.1 17.1 17.1 17.1 17.1 17.1



Finance

• The Trust has retained its £1.6m surplus forecast position. A separate paper covering the forecast will be discussed in the Private

Board Meeting.

• The Trust’s cash balance at the end of September 2015 was £3.9m. £6.0m of the temporary working capital facility was drawn down

in September. Cash is currently being managed adequately, but the position is tight.

• The £4.4m capital loan was received in October and has allowed the urgently needed capital investment programme to continue. The

capital spend forecast this year is £17.1m.

Breaking the Cycle Update & Winter Plan

Angela Stevenson

Chief Operating Officer

29.10.15

Tuesday 1st to Friday 4th September Objective

Try something different with the aim of improving patient care, improving patient flow and reducing the number of patients ready for discharge in our beds.

What did we do (that was different)?

• All patients are reviewed twice daily by a Consultant ( Full Ward round in the morning / Board Round review in the afternoon)

• All patients that are medically ready for discharge on the Care of the Elderly Wards will be reviewed in an MDT meeting with all relevant staff present.

• All wards will need a dedicated team of juniors to carry out tasks arising from the ward round in a timely manner

• All wards should have a liaison officer to help ward teams chase and resolve patient delays and coordinate outputs from the MDT

• Simple management structure during the week at SASH and in the CCG , CHC and Social Services that ensures any delays which cannot be resolved at ward level are escalated to nominated leaders with a view to rapid resolution.

Everyone helped

• Commitment and energy from everyone

• Pharmacy, Radiology, Porters, Cardiology Technicians, Phlebotomy and all support staff increased their capacity and bought into the target time to discharge.

Breaking the Cycle at SASH

2

How did we do?

No decrease in attendance or admission

Small increase in discharges over the week, mainly in Medicine

Discharges exceeded admissions on three consecutive days

20% gone by 1300hrs, 55% gone by 1600, 97% gone by 1900

No increase in discharges to community providers 66 for the week (4, 10, 8,23,21)

100% of patients in Care of the Elderly Wards had EDD on Cerner

Increase in MRD list

Reduction in Longest wait (149 days on 13th August down to 81 on 4th September)

Reduction in average time on MRD List (15 days on 13th August down to 13 on 4th September)

Increase in patient's over 28 days (13 on 13th August up to 17 on 4th September)

Outcome

By Friday we successfully:

Closed Transfer Bay, Angio and Medical Escalation

Reduced Medical patients in surgery from 44 to 25 spread across 3 wards

Delivered performance against the 4hr standard of 98%

Reduced agency spend on Escalation in September


3


4

Mon 3

1 A

ug

Tue 0

1 S

ep

Wed 0

2 S

ep

Thu 0

3 S

ep

Fri 0

4 S

ep

Sat 05 S

ep

Sun 0

6 S

ep

ED Attendances

ED Attendances Total 245 250 226 233 253 247 276

ED Attendances Total - Ambulance 89 76 84 83 86 95 111

Non Elective Admissions and Discharges

Non Elective Admissions Adult Total 75 77 81 80 99 73 69

Non Elective Discharges Adult Total 63 73 102 122 109 69 34

Non Elective Bed Balance - Adult - On Day -12 -4 21 42 10 -4 -35

Acute Bed Stock

Empy Beds (8am) 17 8 15 12 34 40 32

Escalation Beds (8am) 2 17 19 9 6 0 0

MRD 85 85 104 125 114 114 114

Performance

ED Breaches 4 8 8 7 2 1 7

ED Performance 98.4% 96.8% 96.4% 97.0% 99.2% 99.6% 97.5%

Elective Cancellations (On Day) 0 0 0 0 0 0 0

What was it that made the difference?

• Increased effective leadership on the wards

• Improved consultant presence and review of patients including outliers

• Ensured juniors wrote TTO’s in a timely manner

• Created one point of escalation within the division and with silver command

Things we could do better

• Improve co-ordination of ward clerks

• More pharmacy rounds by portering staff

• Review the functionality of the discharge lounge

• Ensure each patient has a weekend plan.

• EDD’s on Cerner

• Improve the discharge process for patients with continuing needs

Actions

• Matron Pilot on Respiratory and Cardiology

• Morning Ward Walks by the Executive Team


5

Objective

Focus the entire organisation on improving patient care, improving patient flow and reducing the

number of patients ready for discharge for one week each of the winter months from

November through to February.

Aims

• Facilitate discharge and maximise flow

• Ensure the ED department is able to deliver safe, quality care

• Maximise cancer and elective performance

• Achieve the emergency 4hr standard

When

• 9th to 13th November 2015

• 7th to 11th December 2015

• 4th to 8th January 2016

• 1st to 5th February 2016

Breaking the Cycle- Winter Plan

6


Date: 29 October 2015 Agenda Item:

REPORT TITLE: Finance & Workforce Committee Chair Update – Part 1

EXECUTIVE SPONSOR: Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s): Richard Durban (Non-Executive Director and FWC Chair)


No – Board Update

Action Required:

Approval ( ) Discussion ( ) Assurance (√)

Purpose of Report:

To update the Board on the discussions and actions from the Finance and Workforce Committee.


The Finance and Workforce Committee met on the 27th October 2015 and was quorate.

M06 reports were received for Finance & the 15/16 CIP, Workforce and Organisational Development, Capital and IT. In addition reports were presented on the Digital Dictation PIR, 16/17 Budget Setting, Long Term Sickness, Achievement Reviews, and the Workforce Internal Control Framework Action Plan.

The Trust is £0.8m adverse to the revised plan at month 6 with a £3.3m deficit.

The Cash position remains tight despite drawing down the £6m temporary working capital facility. The £4.4m capital loan was received in October

The 15/16 CIP is forecast to deliver £4.9m against a target of £8.2m

Recommendation:


SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact

The FWC reviews assurance in respect of workforce, capital and investment projects, business planning (which includes financial planning) and cash aspects. Employment law: laws governing the rights of individuals and terms and conditions terms include: National Minimum Wage Act 1998; the Working Time Regulations 1998; Employment Rights Act



1996; Equality Act 2010; Employment Rights Act 1996, and; the Transfer of Undertakings (Protection of Employment) Regulations 2006. Other key laws affecting employees include the Pensions Act 2004 and the Trade Union and Labour Relations (Consolidation) Act 1992.

Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”. Legal aspects related to capital works will depend on the nature of the works.

The main regulators, are as follows:

- External audit (the Grant Thornton for this Trust) gives an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.

The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services

Financial impact The report provides assurance about savings, capital spend and the structure of the business planning process.

Patient Experience/Engagement Indirect impact through Trust planning and workforce.

Risk & Performance Management The committee, and this report, provides assurance about workforce and capital management.


Attachment:

Report Paper



TRUST BOARD REPORT – 26 October 2015

Finance & Workforce Committee Chair Update

The Finance and Workforce Committee met on 27 October 2015 and it was quorate. The key points from Part 1 were as follows:

- The Month 6 Financial Report was discussed. The Trust was £0.8m adverse to the revised TDA

plan with a £3.3m deficit. The Committee noted that the overall picture was a continuation from the previous month - high level of NEL admissions which drives costs and restricts elective work. As in previous months contract income is adverse to plan. The Trust’s year end position is dependent on increasing elective income in the second half of the year, a positive impact from the Breaking the Cycle programme and agency and other cost reductions. The cash position remains tight. The Trust has received the £4.4m capital loan and this has allowed the urgently needed capital investment programme to continue.

- The Month 6 15/16 CIP report was presented to the Committee. The overall forecasted delivery was £4.9m against a target of £8.2m – a shortfall of (£3.3m). The Committee discussed the risk associated with the delivery of the forecast and noted the high required monthly run rate.

- The Committee received a 2016/17 Budget Setting paper that recommended the approach and

assumptions to be adopted. The Committee agreed the approach - that the 16/17 budget be based on 2015/16 annual budgets adjusted for variations in activity/income levels, together with a zero based approach to key specific key areas. The assumptions were discussed and confirmation sought later in the process on the 8% non-elective admissions growth, agency costs, CIPs and centrally held reserves.

- The Digital Dictation Post Implementation Review was received by the Committee. It showed

that the project had delivered on quality objectives eg letter turnaround times averaged 3.4 days and there was a 99.2% accuracy level. The initial financial savings target (£300k) was seen as having been unrealistic and the project had broken even. There was an opportunity to build on the changes made. The Committee sought assurance that appropriate organisation learnings had been made. These were seen as being the need for clinical buy in and leadership and involvement from all relevant parties. They were now embedded in the decision making and change management processes of the Trust.

- The Month 6 Workforce and Organisational Development paper was presented to the

Committee. It was noted that the annual training plan was being developed and will be brought to the Committee in due course. The MAST programme definitions and reporting are being reviewing in line with TDA guidelines. A report was received on Long Term Sickness which indicated that greater compliance with the process would improve the facilitation of a return to work. A report on short term sickness would follow.

- An Achievement Reviews report was presented which showed a 66% completion rate (v a target

of 90%). The rate varied between directorates ranging from 87% in Medicine to 44% for Corporate. Plans to reach the target would be in place by the end of October. The Committee



requested that a hierarchical view of completion rates ie by grade be presented to the next meeting. An updated Workforce ICF action plan was presented which gave the Committee assurance that the red and amber ratings were being addressed. A re-evaluated ICF would come to the FWC before March 2016.

- An oral update was given on Workforce/OD KPI reporting. Measures are being developed at

the Services level which will initially complement those at Divisional level. A proposed revised suite of KPIs for the Board, the FWC and the SQC would come to the next meeting.

- The Month 6 Capital and IT reports were noted by the Committee. Full Business Cases for the

Managed Print Service and the Medical Records/Maple Annex Build will come to the November meeting. The Executive team will discuss and agree the IT Roadmap and then present it to the FWC.

[END]


Date: 29 October 2015 Agenda Item: 4.1

REPORT TITLE: Annual plan 2015/16 update

EXECUTIVE SPONSOR: Sue Jenkins Director of Strategy

REPORT AUTHOR (s): Sue Jenkins Director of Strategy


Executive Committee

Action Required:

Approval Discussion Assurance (√)

Purpose of Report:

The purpose of this report is to provide assurance to the Board that the annual operating plan for 2015/16 has been delivered


The annual plan for 2015/16 was approved by the Board in April 2015. This report provides progress against each of the 107 actions for Quarter 2, July to September 2015. Of the 107 actions the status for the quarter is reported as follows:-

Status Q1 – April to June 2015

Q2 – July to September 2015

Red 1 <1% 4 4%

Amber 27 25% 29 27%

Green 75 70% 70 65%

Blue 4 4%

4 4%

This quarters performance has generally not moved in a positive direction. 4% of the actions have already been completed and 69% are being delivered according to plan or have been completed. There are four actions with a red status. These are;

1.15 – Healthcare acquired infection. 20 cases have now been reported against a target of 15. This target reduced from 24 cases last year. The management of diarrhoea has been identified as a value stream for VMI work to better understand the detail and areas for improvement around this

2.2 – Manage non elective demand. Non elective demand, particularly for those patients that stay >1 day is currently 8.6% growth against a 2% forecast. This has caused significant operational pressures for the Trust. Winter plans are currently being reviewed to ensure that capacity is available and the quality and safety of care is not compromised going forward. The focus has also supported the further development of ambulatory care pathways and an AMU consultant with a special



interest in ambulatory care has started and is working closely with the ED team

4.6 & 4.7 – Expand market share for elective activity. These plans have been compromised due to levels of non elective activity and dealing with the 18 week back log

Recommendation:

The Board are asked to confirm that this report provides assurance that the annual plan 2015/16 is being delivered




Legal and regulatory impact The annual plan demonstrates delivery of key actions to support the strategic objectives

Financial impact Business cases will be developed for any significant resource developments.

Patient Experience/Engagement The annual plan includes a number of objectives linking to patient experience and engagement

Risk & Performance Management Delivery of the annual plan is monitored by the executive Committee and reported to the Trust Board


The annual plan demonstrates delivery of the organisations strategic objectives

Attachment:

Annual plan 2015/16 Q2 update

Work stream off track and unlikely to

deliver as describedA

Work stream off-track but plans in

place to recoverG

Work stream on track

and to planB Complete

RefNew

or bfSource Lead director Lead manager/clinician Q2 Update

RAG

status

1.1 NEW Strategic objectives delivery plan Sue Jenkins -

Recall of digestive diseases still o/s

Some reports still o/s

Additional deep dive for outpatients planned for

November

A

1.2 NEW Strategic objectives delivery plan Fiona Allsop - Good rating still in place

Included on divisional board agendasG

1.3 NEW Strategic objectives delivery planFiona Allsop/ Des

HoldenKatharine Horner

Medicine, Cancer and WaCH are now producing regular

newsletters that highlight learning from incidents and

complaints. Reporters of incidents now have the facility

to request automatic feedback from incidents. An e-mail

is generated from Datixweb outlining the action taken by

the reviewing manager. This went live 21/9/15 and will

be monitored over the coming months.

In medicine division, comms folders, safety briefings and

lessons learned are shared across teams

G

1.4 NEW Strategic objectives delivery plan Des Holden - Fully signed up. Leads for emergency laporotomy and

sepsis identified. Attended all relevant events G

1.5 NEW Strategic objectives delivery plan Yvonne Parker Janet Miller

Compliance with new Achievement Review process is at

64% (Medical division at 83% with plan in place for those

awaiting review) for Q2 which is behind plan for this

transitional year. Managers submitting dates for

outstanding ARs by end of October 15 and weekly

reports are being provided to Director of HR. Workforce

Committee have agreed to include a specific risk on the

Trust risk register recognising the impact of embedding

the Trust values and behaviours and the ability to pilot

the '9 blocker' for 8As and above

A

1.6 NEW Quality account Fiona Allsop Kim Rayment

The strategic project meetings have taken place as

scheduled. Q2 report being submitted to Patient Safety

Committee and Exceutive Committee for Quality and

Risk October meetings as planned. The communications

plan has been approved by the Executive lead and

members of the strategic project group.

G

1.7 BFClinical strategy

Divisional plansDes Holden Barbara Bray

SSIs are discussed monthly at Divisional Board. Every

orthopaedic infection has an RCA that is reported to

Divisional Board. Woodland elective beds are not

consistently ring-fenced.

G


Divisional plansAngela Stevenson Ben Emly

ED - achieved Q2 95.8%

Failed TWR mainly due to patient choice

Key concerns for 62 day target for lung and skin - plans

in place to address these

RTT - achieved incomplete standard at aggregate level

A

SO1 - Safe - Deliver safe services and be in the top 20% against peers

Action

Complete deep dive process for all relevant specialties

Maintain a CQC inspection rating of good or outstanding

Evidence compliance with Sign up to Safety

Maintain the low incidence of surgical site infections

Implement achievement review and include safety goals for all staff

Meet all access targets including ED, 2 weeks referral, 31 days and

62 days

RR

Annual plan 2015/16 v1.3 - Q2 update

Actively participate in national Patient Safety Collaborative in Kent,

Surrey and Sussex area

Demonstrate improved learning from incidents across the Trust

1.9 NEW Quality account Des Holden Jonathan Parr

Some delays in data collection for Discharge local

CQUIN. MH CQUIN delayed due to lead going on locg-

term sick. Targets for ERP require significant worek to

achieve, however improvements already seen.

A


Divisional plansFiona Allsop Michelle Cudjoe

The Birthrate Tool analysis was undertaken by the author

of the workforce tool based on last years activity. There

is a shortfall of 8wte midwives and 3.75 wte Senior

Midwifery roles to achieve a ratio of 1:28 using the lcoal

agreement (which includes a 10% skill mix of untrained

staff). A business case was presented to the Executive

team in relation to the senior roles and funding was

agreed for 1 wte senior midwife in line with the trajectory

previosuly agreed

G

1.11 NEW Quality Account Des Holden Sue Jenkins

KPO leader confirmed

Part 1 of Initial training for advance lean training

completed for 2 people in September. Part 2 planned in

November

Trust Guiding Team membership agreed and trip to

Seattle planned for October

Dates for key meetings being agreed with VMI and TDA

G

1.12 BFQuality Account

Quality strategy

Avoidable falls/ falls resulting in

harm

Demonstrate further improvement

in number of fallsFiona Allsop Francis Fernando

The objective of reducing the total number of falls by

10% is challenging.

The reduction in falls with harm by 6% may be achieved.

The 2 deaths in Q2 are of concern and are being

investigated.

Falls prevention strategies are continously being

evaluated and reviewed. Work with the Community Falls

Teams and the Emergency Department has started.

A


Quality strategyPressure damage

Maintain achievement of no

hospital acquired major pressure

damage and aim to reduce hospital

acquired minor damage

Fiona Allsop Louise Evans

Year to date we have had 21 minor pressure damage

incidents against a target of 40. Target to have no major

pressure damage on track. G

Explore opportunities of improving the safety journey by learning

from international best practice i.e. Virginia Mason

Deliver CQUIN plans for 2015/16:-

Local - Discharge to Assess (Sue Jenkins)

Local - Improving Discharge (Angela Stevenson)

Local - Enhanced Quality (Jonathan Parr)

Local - Ward accreditation (Fiona Allsop)

National - Acute Kidney Injury (Phil Williams)

National - Sepsis (Julian Webb)

National - Dementia and delirium (Steve Adams)

National - Avoid emergency admissions Angela Stevenson)

National - Improving diagnosis of mental health patients in ED (Julian

Webb)

Monitor compliance with national midwifery staffing guidance


Quality StrategyDementia

Develop community facing

approach to dementia careFiona Allsop Steve Adams

Currently working with East Surrey CCG to ensure that

SASH participates actively in wider dementia care

initiatives and are active visible participants in local

community developments. Awaiting feedback from

ESCCG lead about their progress in developing the local

strategy. Working with services in West Sussex to

develop an integrated community care focused model of

dementia care. This requires review of progress. In terms

of feedback from carers, we are working with the patient

experience team to plan a series of focus groups to

measure carers experiences and help develop plans to

continually improve the way in which we support carers

of people with dementia. This is part of a wider piece of

work aimed at improving the experience of carers. We

are also currently running a pilot scheme look at the use

of “comfort blankets” to improve the experience of people

with dementia in hospital. This work sees us engaging

with a wide array of community groups to help provide

the blankets for patients to use. The project has been

formally adopted by one local school as project that the

students will complete as part of their GCSEs and will

involve them learning more about dementia from staff at

ESH.

G

Meet the DH central infection

control targets of <15 Cdiff cases

and no preventable MRSA blood

stream infections

20 cases of Trust apportioned Cdiff have occurred within

the year against a target of 15.

Management of diarrhoea has been identified as a value

stream for VMI work to better understand detail

surrounding this

R

Continue to screen patients for

MRSA and administer MRSA

suppression treatment in a timely

way

0 cases reported and screening in place

G

NEWImprove completion of assessment

on dischargeDes Holden -

VTE group established. VTE nurse appointment

increased from temporary part time to substantive full

timeG

BFContinue risk assessment on >

95% of patients on admissionDes Holden -

Q2 in process of being validated. Risk of non

achievement A


Quality strategy

World Health Organisation

(WHO) safer surgery checklist

Continue to audit quality of safer

surgery processesDes Holden Barbara Bray

100% compliance with use of the checklist. On-going

qualitative audit to provide Divisional Board additional

reassurance such as observation by other staff and

feedback to team leaders; video recording and feedback

and improvement of the data collection.

G

Maintain and further improve timely

admission and operative

intervention

Improve length of stay for #NOF

1.15 Des Holden

Quality Account

Quality Account

Quality Strategy

Venous thromboembolism

(VTE)

Ashley FloresHealthcare acquired infection

1.16

BFQuality Account

Quality Strategy

Time to theatre remains good with the exception of one

week in Q1 where the trauma load was extremely high.

Patients not having surgery within 36 hours have co-

morbidity that needs addressing. FIB for analgesia is

expected but not always achieved early - anaesthetic

Improve follow up data collection

and reporting

To improve SSNAP audit

performance to at least a B ratingDes Holden Ben Mearns

Action Plan in development to improve position esp flow.

Business case in development to provide support to

stroke pathwayA

Improve use of safety information

at divisional meetings

Dashboard used live in the Patient Safety sub-committee

in September. Dashboard is still being developed and

refined.

G

Increase number of audits that

impact on patient safety

Audit programme reviewed at September clinical

effectivness committee and assurance gained on

progress of audit programmes. Some work still to be

done to ensure all audits registered.

G

Make patient safety data more

transparent for staff and patients

Patient safety dashboard show compliance with metrics

at service level for staff. G

1.21 BF CQC improvement plan Sue JenkinsNatasha Hare

Linda Judge

Outpatient governance structure in process of being

reviewed.

Deep dive planned for November

FWC summary to be provided in October

Outpatients to be confirmed as VMI value stream - exec

sponsor to be appointed

A

1.22 BF CQC improvement plan Ian Mackenzie Phil StonePlanning permission for medical records new build

obtainedG

1.23 BF CQC improvement plan Jim Davey Angela Stevenson Completed Q1 - Plan delivered and savings realised B

1.24 BF Quality Account Angela Stevenson David Heller

Cerner e-discharge letter pilot due to start 13/10/2015

ePMA project business case and roll out plan due for end

Nov

Improved pharmacy process means quicker turnaround

of TTOs when released for screening so more medicines

available on the ward for nurses to go through (potential

audit for the division)

MaPPs leaflets remain in use

G

1.25 NEW Quality Account Safety thermometer

Maintain compliance of 95% and

increase average compliance to

97% from January to March 2016

Fiona Allsop Vicky Daley

Developing pilot of the Medicines Safety Thermometer.

Compliance with the safety thermometer continues to be

monitored and discussed at the Patient safety and

Clinical Risk sub-committee.94.8% compliance of harm

free care (new harm) for August .

G

Improve communications and information around medication on

discharge

1.20 Fiona Allsop

Katharine Horner

Jonathan Parr

DCNs

Deliver medical records improvement plan

Fractured neck of femur (hip)

1.19

Action Plan in development to improve position esp flow.

Business case in development to provide support to

stroke pathway

A

Incident reporting

1.18 BF

BF

Quality Account

Quality strategy

Clinical strategy

Divisional plans

BF

Des Holden

Patients admitted with stroke

Deliver Dictate IT improvement plan

Deliver outpatients improvement plan

Des Holden Barbara Bray

Ben Mearns

Quality Account

Quality Strategy

Quality Account

Quality strategy

Further improve scanning time

expected but not always achieved early - anaesthetic

dept are setting out strategy to improve. Resource for

follow-up data is now in place. Time to ward still a

challenge - pathway has been adjusted to allow to go to

theatre on the way to the ward for FIB or for surgery and

for this to count as time to ward.

A

1.26 NEW Quality Account Fiona Allsop Vicky Daley

Infection control remains a standing item at the PSCRC

and the NMPC as per the previous quarter. In addition,

there is an Infection Control Taskforce meeting held on a

weekly basis to discuss operational and strategic issues

pertinant to improving and maintaining standards of

cleanliness. A formal CCG CDI review meeting has also

been established with the purpose of reviewing RCA

investigation of the cases, determining whether there

have been lapses in care and identifying areas of

learning. Noise at night remains on the inpatient survey

action plan, which is monitored via the Patient

Experience sub-committee.

G

RefNew

or bfSource Lead Director Lead Manager/clinician

2.1 BFIBP service development

Estate strategyAngela Stevenson -

New labs open and 2x new consutlants start 2nd

November. Unit due to be fully complete by end of

DecemberG

2.2 BFIBP service development

Strategic objectives delivery planAngela Stevenson -

Considering how we can further develop ambulatory care

to support increase in non elective growth

AMU consultant with special interest in ambulatory care

has started and is working closely with the ED team

Changes in outpatient admission policy also being

considered

R

2.3 BF Strategic objectives delivery plan Sue Jenkins -

Key members of discharge flow work with west Sussex

Discussions still underway re urgent integrated

assessment unit G

2.4 NEW Strategic objectives delivery plan Ian Mackenzie -Completed Q1 - Procurement was completed in October

2014B


Divisional plansDes Holden Ben Mearns

Continuing to work with Surrey and Stroke networks to

develop whole system pathway for strokeG


Divisional plansDes Holden Ben Mearns

Further developing the frailty pathway

A


Divisional plansDes Holden Virach Phongsathorn

Completed Q1 - High dependency respiratory bay

developed on Tilgate Annexe and now operationalB


Divisional plansDes Holden

Debbie Pullen

Michelle Cudjoe

20% of patients used birthing unit for Q1

G



Ed Cetti

Mo Luqman

Actions being followed up in Radiology at the 'Seniors

team meeting' as standard agenda item. Group meets

every 2 weeks to progress action plan.G

2.10 BF

Clinical strategy

Divisional plans

Estate strategy

Angela StevensonEd Cetti

Mo Luqman

FBC being finalised with view to have new unit

operational in Jan 16 G



Ed Cetti

Mo Luqman

Awaiting TDA formal approval (due now end Oct 15).

Intention to award contract to Medipass has been

annouced, going ahead to prepare FBC to be tabled to

the Excs in Nov 15 once the TDA have approved OBC.

Already working with Medipass to ensure Go Live at the

earliest opputunity (ETA April 2016)

G

Manage non elective care

SO2 - Effective: Deliver effective and sustainable clinical services within the local health economy

Develop second cardiac angiography suite

Redesign the stroke pathway to create a seamless in and out of

hospital patient centred pathway across all providers

Redesign the pathways in elderly medicine to create seamless

patient care across all providers including early supported discharge

Continue participation in wider health system transformation forums

to influence development of new models of care

Develop plans to support re-procurement of EPR and EPMA

To consider recommendations from the strategic review of radiology

services undertaken in autumn 2013 and agree and implement

action plan

Redesign of service to ensure that the birthing unit provides intra-

partum and postnatal care for 20% of women booked for maternity

services at East Surrey hospital

Redesign service to create HDU respiratory beds

Action

Continue to maintain high standards of cleanliness and to ensure

patients are not disturbed unnecessarily

Redesign of service to support the installation of a digital

mammography machine on the ESH site

Implement a managed equipment service which is supported by a

rolling equipment replacement schedule

Focus on categories of death

rather than individual and make

recommendations via clinical

effectiveness committee to make

improvements

Roll out enhanced review of all

patient deaths

Maintain “better than expected”

rating for mortality by Dr Foster

Latest data reports the Trust remains 'Better than

Expected (July14 - June 15)G

2.13Quality Account

Quality strategyReadmissions

Undertake review of one month’s

clinical readmission data and

implement any lessons learned

Jim Davey -

Trust still has one of lowest readmission rates and

therefore agreed with CCGs to replace planned audit

with joint review of common patient pathways which is

underway

G


Quality strategy(NICE) technology appraisals

Increase statement compliance.

Audit against NICE technology

appraisals and post on audit

intranet

Des Holden Jonathan Parr

Audits identified and underway. One reported, stating the

Trust was fully compliant.G

Reduce LOS Chiefs

Focus is on highest LOS for each division and this is

reviewed at performance meetings

Cardiology set a target to be in top centile and

highlighted as VMI value stream

A

Maintain core hospital at home

beds all yearPaula Tooms

Increasing capacity from 29 to 40G

Review pathways to develop

alternatives to admissionJim Davey

Rapsid group established and reviews pathways

including reductions in ED attendances, hospital

admissions and expediting discharges. Liaised with

SECAmb to implement IBIS and facilitate access from

community and hospital clinicians.

Have reviewed ED top 20 attendances

G

2.16 BF 7 day working SDIP Sue Jenkins -

Medicine currently developing business case for medics,

pharmacy and therapies G

2.17 NEW Quality account Enhanced recoveryCommence enhanced recovery

pathways for breast and C-sectionsDes Holden Jonathan Parr

Awaiting launch from AHSN. Breast pathway likely to be

delayed until 16/17 by AHSN A

2.18 NEW Quality account Enhanced quality

Commence new enhanced quality

pathways for COPD, fractured neck

of femur and emergency

laparotomy

Des Holden Jonathan Parr

COPD data collection continues. Trust represented at

#NoF meetings and data collection about to commence..

Emergency Laparotomy regional meetieng attended by

Trust leads.

G

RefNew

or bfSource Lead Director Lead Manager/clinician

Q2 Update RAG

status

3.1 BF Strategic objectives delivery plan Des Holden Jonathan Parr

Audit programme reviewed at September clinical

effectivness committee and assurance gained on

progress of audit programmes. Some work still to be

done to ensure all audits registered.

G

Jonathan Parr2.12 Des Holden

BFQuality Account

Quality strategy

A

Mortality group met in Septemeber and programme of

work underway to improve reporting and learning

Implement 7 day working for all relevant specialties

Mortality

Angela Stevenson

BF

2.15

Demonstrate that audit plans include issues raised by YCM, FFT and

inpatient survey

Quality Account

Quality strategy

Reducing need for admission

Action

SO3 - Caring - Ensure patients feel cared for and cared about

3.2 BFStrategic objectives delivery plan

Nursing & Midwifery strategyFiona Allsop

Vicky Daley

DCNs

Providing safe and effective care continues to be central

to the work of the corporate and divisional nursing teams,

with identification of themes, trends and learning being a

key outcome of the various forums including PSCR,

Complaints and the Patient Experience Committee.

The Nursing and Midwifery Strategy remains a regular

item for monitoring and discussion at the Nursing and

Midwifery Professionals Committee. In addition, a

Nursing Education Strategy meeting was held on the

29th September where it was discussed how

development and implementation of a training strategy

would support the 3 objectives including objective 1: "we

will provide safe and effective patient care in all that we

do"

G

3.3 NEW Strategic objectives delivery plan Fiona Allsop Cathy White

Focus groups have been undertaken among endoscopy

patients. Carers discussions are being planned for

October 2015 and a maternity listening event is planned

in November

G

3.4 NEWStrategic objectives delivery plan

Nursing & Midwifery strategyFiona Allsop DCNs

Nursing documentation group to be recommenced by

Deputy Chief Nurse. Matrons audits regarding

documentation to be reviewed as part of this group work

plan.

G


Divisional plansAngela Stevenson Jane Penny

Volunteers to support the centre being actively recruited

into, aim to open end January to the public G

Continue to ensure there are no

mixed sex breachesAngela Stevenson -

No mixed sex breaches for Q2G

Share and implement learning from

Breaking the CycleAngela Stevenson -

Longer term plan being developed for ongoing breaking

the cycle events and considering how this work can be

incoporated into VMI improvement workG

Participate in 5th National Audit of

Care of the Dying patient

SASH data submitted 9th October 2015. 85 cases

audited

G

Complete internal audit of end of

life care documentation

Draft report written awaiting sign off

G

Develop and introduce second

version of SaSH end of life care

plan

The New EOL care plan has been through clinical

effectiveness group and cancer division. To be ordered

through the printers, aim to launch in Nov 15A

3.8 NEW Estates strategy Ian Mackenzie Shaun CunninghamProject underway to refurbish the East Entrance foyer

which will complete in November 2015. A

3.9 NEW Quality Account Des Holden Mili Doshi

Mouth Care Matters is being rolled out across East

Surrey Hospital. Mouth Care Team in place and the

programme is continuously being refined and improved.

Qualitative data very positive and showing excellent

examples of improvements to patient care. Working

with nursing staff to maximise integration of MCM team

into the wards. Planning role out to all Hospital in KSS

from January

G

Demonstrate that nursing review and assessment reflects individual

needs of patients

BF

Demonstrate delivery of “Provide safe and effective care in all that

we do” objective from nursing and midwifery strategy at safety and

quality committee

NEW

Work with Olive Tree, Friends of east Surrey and Macmillan Cancer

Support to develop and implement a Cancer Information and Support

Centre at East Surrey Hospital

Implement oral healthcare initiative and demonstrate improvement of

patient and clinical care

Quality Account

Quality strategyFiona Allsop Jane Penny

Quality Account

Quality strategyRight bed, right time

3.7

3.6

Establish and undertake a programme of patient listening events

End of life care

Review and develop scheme to modernise East Entrance

environment and facilities including additional retail outlets.

3.10 BF Quality Account NutritionContinue to make improvements to

protected meal timesFiona Allsop Vicky Daley

Protected Mealtimes remains a regular item agenda at

the Nutritional Steering Group of which the Deputy Chief

Nurse is a standing member.

Spot checks are being undertaken on wards to see if

Protected Mealtimes are in good practice. Results are

variable, and the DCN and Nutritional Nurse Specialist

are working with the divisions to continue to promote the

importance of this area. In addition, the Nutritional Nurse

Specialist has been in discussion with Radiology to

ensure that wherever it is possible and safe, patients are

not called for tests during these periods.

G

Seek ways to broaden how we get

feedback from wider communityFiona Allsop

Vicky Daley

Cathy White

Continue to promote FFT and YCM

and make changes on basis of

feedback

Fiona AllsopVicky Daley

Cathy White

RefNew

or bfSource Lead director Lead manager/clinician

Q2 Update RAG

status

4.1 NEW Strategic objectives delivery planGillian Francis-

Musanu

Laura Warren Draft engagement plan due for discussion at CoG

meeting in Oct 15.A

4.2 BF IBP service development Anglea Stevenson Jane PennyBusiness case delayed to Q3

A

4.3 BFStrategic objectives delivery plan

Membership strategy

Gillian Francis-

Musanu

Laura Warren

Colin Pink

Election to the shadow Council of Governor complete

with all seats filled, Selection of nominated governors

98% complete. G

4.4 BF

Clinical strategy

Divisional plans

Estate strategy

Paul BostockBill Kilvington

Barbara Bray

All clinical areas are now fully operational, including the

post anaesthetic recovery area. The changing rooms and

anaesthetic department are also fully operational and

temporary structures have been removed from the site.

The only outstanding works is the completion of the

reception area refurbishment

G

4.5 BF Market Development strategy Paul Simpson Larisa Wallis

The first SASH Market Share Report for 2014-15 has

been produced and shared with Finance & Workforce

Committee.

The next Hot Topic event for all stakeholders will be held

on 15 October with presentation from the dental and

maxillofacial team.

AQP for Non-Invasive Ventilation has been published by

CCGs. Trust is considering to apply to qualify to deliver

this service (deadline - 30th October-15).

G


Plans for additional elective activity are compromised

due to levels of non elective activity and 18 weeks

backlog.

Mechanism for shift of activity to be facilitated by CCGs

(Trust is awaiting for CCGs' plan). Monitored via regular

contracting meeting.

R

Develop programme of engagement activities with patients and

members

SO4 - Responsive - Become the secondary care provider of choice for our catchment population

NEW

Chemotherapy service development

Quality Account

To expand market share for elective activity targeted market that

have traditionally referred patients to other providers

Establish CoG and demonstrate meaningful engagement which

shapes our services

Complete refurbishment of and open theatres

3.11

Action

The Patient Experience Sub-Committee meets on a

monthly basis, and there are standing items on the

agenda on FFT and YCM. A series of hot topic events

provide an opportunity for attendees to give feedback

and seek clarification on relevant service areeas. An

option also exists for patients and the public to feedback

direct on our website.

GPatient feedback

To maintain market share through excellent service provision and

securing AQP contracts where CCGs have given notice on the

service that was previously part of the acute contract


Plan to support repatriation of activity is at risk /

compromised by continuing pressures from non elective

activity.R


BSUH/SaSH joint venture for pathology services

progressing. New name agreed as Frontier. Final

business case to be considered by both Boards later this

yearG


New Cardiology Angio lab went live on 28th Sept-15

which should bring additional activity and income to the

Trust. This is initially compromised by waiting list activity

which will be first priority to clear

A

4.10 BF QGAFDes Holden/ Fiona

AllsopColin Pink

QGAF reviewed and updated and considered by ECQR

A

RefNew

or bfSource Lead director Lead manager/clinician

Q2 Update RAG

status

5.1 BF Strategic objectives delivery plan Paul Simpson Larisa Wallis

Market Share Report for 2014-15 (for 3 main CCGs)

shows that whilst the Trust's level of market share

remained flat for elective, emergency and outpatient

activity, there has been a growth in activity.A

5.2 BF Strategic objectives delivery plan Fiona AllsopSue Carr

DCNs

43 european nurse have arrived since August

6 more due at end of October

PIN numbers are starting to come through

18 overseas programme nurses all awaiting PIN

numbers - due November

European recruitment continuing with Skype interviews

booked for November and December

First of Phillipino nurses due to arrive in december

Succesful recruitment to Bank for nursing assistants with

a proprtion of applicants who are student nurses from

across the region

A

5.3 NEW Strategic objectives delivery plan Paul Simpson Catriona Tait

The handover meeting with CEO, Medical Director and

GE not yet taken place.

A

5.4 NEWStrategic objectives delivery plan

IBP service developmentSue Jenkins Natasha Hare

Business case due in Winter 2015G

5.5 NEW Strategic objectives delivery plan Yvonne Parker -

Planning for additional questions in Q4 Staff FFT survey.

Action plans from 2014 National Staff Survey have been

used in "You said we did" comms in advance of 2015

Staff Survey.

Output from 2015 Survey to be shared in teams in Q4

thus building virtous cycle of action in response to

feedback and compliance

G

SO5 – Well led – Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Demonstrate increase in market share due to repatriation of services

Develop and implement SLM model with clinical leads

Develop plans for new outpatient facilities

Establish multisource feedback system for all staff

Develop nurse recruitment plan, monitor delivery and report to

workforce committee

To explore opportunities for further joint ventures/partnership

arrangements to continue to develop the East Surrey Hospital

campus so that local patients can receive an increasing range of

specialist services at ESH whether provided by SASH or a partner

organisation

To move to new markets, such as private practice, where this is

clinically and financially viable and supports the long term strategic

intentions of the Trust

To expand market share for elective activity by working with CCGs

and other providers to repatriate elective activity from distant tertiary

providers where this is clinically appropriate

Deliver QGAF action plan

Action

5.6 BF Strategic objectives delivery plan Des Holden Colin Pink

Service line management and reporting sessions

delivered

G

5.7 BF Strategic objectives delivery planGillian Francis-

Musanu-

Board development on-going. Main programme with

Foresight completedG

5.8 NEW Strategic objectives delivery planGillian Francis -

MusanuColin Pink

Changes to ECQR in place, effectiveness review to be

completed early Q3. Review of new intelleginece

monitoring system underway. A

5.9 NEW Membership strategyGillian Francis -

MusanuLaura Warren

Draft engagement plan due for discussion at CoG

meeting in Oct 15.A

Hold election for Council of

Governors

Gillian Francis -

MusanuLaura Warren

Election to the shadow Council of Governor complete

with all seats filled, Selection of nominated governors

98% complete.G

Complete induction for CoGGillian Francis -

Musanu-

CoG Induction currently in progress due for completion

by end of Q4A

Establish CoG meetings and

effective engagement and

communications strategy

Gillian Francis -

MusanuLaura Warren

Draft Communication Plan due for discussion with CoG

in Oct 15. A

5.11 BF IT strategy Ian Mackenzie Peter Hodgetts

Out of 2,300 Trust computers, 3 remain on XP – i.e.

99.8% completed so far. These are connected to clinical

devices, such as pathology analysers, so upgrades need

to be done very carefully and in full collaboration with

relevant clinicians. At the same time we are undertaking

a health-check of all devices ensuring that all has a

minimum hardware specification.

G


The national move to NHS Mail 2 means that the Trust

will be able to move to NHS Mail in early 2016. This will

bring the following key benefits, e-mail accessible from

anywhere (including mobile), secure and recommended

by the BMA, secure instant messaging and at additional

cost secure video conferencing including patient access.

The Trust currently awaits the release of the Accenture

Service Catalogue (expected within the next 4 weeks) so

their migration service can be reviewed.

G


Network SOC being developed. A proposal from Cerner

was prodcued in September. The Procurement strategy

is being reviewed, and a proposal paper for the Exec

Board will be produced now anticipated by end of

December 2015

A

5.14 BF Estate strategy Ian Mackenzie Shaun CunninghamThis is on-going to deliver 5 year capital programme.

G

5.15 NEW Quality AccountDes Holden

Yvonne Parker

Adam Stacey-Clear

Janet Miller

Audit of SMARTer objectives to be completed in Q3 to

check for inclusion of personal goals which have an

impact on quality of service.G

Provide upgraded email solution

Deliver estates capital programme

5.10

Establish and deliver engagement and communications strategy for

members following FT authorisation

NEW Council of Governors (CoG)

Complete delivery of Foresight board development programme

Complete delivery of SaSH plus GE clinical leadership programme

Complete Network Upgrade

Membership strategy

IBP

Governance processes adapted to support clinical leadership model

and remain effective

Upgrade of end-of-life Trust operating systems

Continue to embed the setting of personal goals that effect the

quality of service for all staff in annual achievement reviews

5.16 BF Workforce and OD strategy Yvonne Parker Nathaniel Johnston

The Trust is currently reviewing its offer for leadership

development in response to the recent rose review into

management and leadership in the NHS. Jean

Arokiasamy (Medical Leadership Tutor) and Nathaniel

Johnston and developing a multi-professional strategy for

leadership development in partnership with Health

Education Kent, Surrey and Sussex. A key piece of this

work is to embed the healthcare leadership model

(HLM)as the tool for supporting medical staff now that

the HLM is multi-professional in its context and there no

longer a separate clinical tool.

G

5.17 BF Workforce and OD strategy Yvonne Parker Janet Miller

Workforce plan revised in line with revised LTFM.

Business cases for consultant posts to support Service

Developments (including 24/7 working) are being

considered at Executive Committee. Business Planning

guidance to include specfic reference to workforce

changes required for all business developments/service

changes.

G


The induction programme is currently under review in

order to identify how best to separate out a new starter

programme from our update programme. In addition to

this, the standards of behaviour focus group is meeting

twice a week and an output of this group will be materials

that describe our values and behaviours for our new

starters to be shared as part of the on boarding process,

ready for new year 2

G

5.20 BF Workforce and OD strategy Yvonne Parker Janet Miller

Return to Work risk assessment for all stress absences

included in FirstCare script. Wellbeing Strategy being

revised and Wellbeing Group relaunched to identify

further interventions. Support for managers to utilise HSE

Management Standards, CIC services and occupational

health support, accelerated access to physiotherapy and

dermatology, flu immunisation campaign

G


We have launched our "Be a SASH Nurse" Campaign in

September 2015 and work continues on regular

recruitment events will be held during summer/autumn.

Winter 2015. We are updating our recruitment material

so that it has the latest information about the Trust

including our recent inclusion in the HSJ Top Employers

list and our Virginia Mason work

G

-

Focus on increasing workforce productivity

Yvonne Parker

• realise the benefits of technological business processes across

the Trust

Launch the Leadership Framework and an effective assurance

process for the organisation to assess how each line manager is

performing against the key people performance requirements

BF Workforce and OD strategy

Have in place a range of interventions to reduce the top reasons for

absence such as workplace stress musculoskeletal disorders (MSD),

flu.

5.18

• harness productivity gains identified in service developments -

advances in medical/surgical innovations e.g. telemedicine,

Refocus of induction to support OD intervention around behaviours

and values.

Create the SaSH identity and brand so that we are recognised as the

‘Employer of Choice’

Develop integrated workforce plans (demand and supply) at

divisional/ business unit level - identifying workforce changes

required for 24/7 working in appropriate areas

Further Eroster developments approved and project

manager to be recruited to supprt implementation in the

autumn

e Expenses introduced from July 2015 providing web

based claim and authorisation process

G

5.22 NEW Workforce and OD strategy Yvonne Parker Nathaniel Johnston

NJ met with Amanda Grindall, Director of Leadership at

Health Education Kent, Surrey and Sussex and the

Edward Jenner Plus programme and leaderhip e-

learning is to be launched in SASH in the new year. The

Trust is currently exploring the development of coaching

and mentoring networks and will be piloting a mentoring

skills programme for physicians associates in Winter

2015.

G


The 9 Blocker will be implemented in April 2016.

Following the utilisation of the blocker, the Trust will

consider its succession planning programmeG


The training team will work with the the Trusts new

innovation team to support the delivery of systems

thinking and service improvement in learning and

development opportunities. We are currently reviewing

the service improvement module on the essentials of

management programme to ensure it is up to date with

the latest thinking in the NHS around innovation and

improvement.

G


Currently undertaking a review into our offer for conflict

resolution, to explore what the need is to support staff in

difficult situations. Will be exploring this during autumn

2015 to introduce a new approach in winter 2015G


HR and the corporate nursing teams are working closely

with Health Education Kent, Surrey and Sussex to

connect with schools and colleges in out local area to

promote health careers to young people. We have just

concluded our annual work experience programme and

we are preparing for an apprenticeship launch in October

2015

G


HR and the corporate nursing teams are working closely

with Health Education Kent, Surrey and Sussex to

connect with schools and colleges in our local area to

promote health careers to young people. Just concluded

our annual work experience programme and we are

preparing for an apprenticeship launch in October 2015

G

5.28 NEWIBP service development

IT strategyPaul Simpson Bruce Stewart

New LIMS procurement part of main new build

procurement, with current anticipated go-live of March

2017. Four suppliers expected to express an interest

Currently arranging site visits. One particular LIMS, if

chosen to be the preferred solution could be aquired

without procurement.

A

Promoting schemes to recruit local people into the NHS careers and

posts.

Positively engaging parents, young people, careers advisors,

university advisors, through individual contact and Trust initiatives.

Develop a Talent Management framework and succession planning

tool to help identify potential leaders to fill key positions within the

organisation.

Develop knowledge and skills vital for innovative thinking and service

improvement

Joint venture for pathology - As part of the proposed pathology

development with BSUH procure laboratory system that meets long-

term Trust requirements.

Ensure access to a range of leadership programmes, to cover the

range of levels and focused on leading our values and behaviours.

Ensure effective processes are in place for the prevention and

management of violence and aggression against staff.

Minutes of the Finance and Workforce Committee Held on 22 September 2015 at 8.30am In AD77, East Surrey Hospital, Redhill

PART 1

Present Richard Durban Paul Biddle Alan Hall Paul Simpson Fiona Allsop Angela Stevenson Ian Mackenzie Gillian Francis-Musanu

Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Finance Officer Chief Nurse (Part Meeting) Chief Operating Officer Director of Information and Facilities Director of Corporate Affairs

In attendance Alan McCarthy

Janet Miller Sue Jenkins Peter Burnett Catriona Tait

Chairman Deputy Director of Human Resources Director of Strategy Deputy Chief Finance Officer Head of Costing and SLR (Minute Taker)

1 WELCOME AND APOLOGIES FOR ABSENCE Apologies: Apologies were received from Yvonne Parker (Director of Human Resources). Declarations of Interest: There were no declarations of interest.

2 MINUTES AND ACTIONS OF THE PREVIOUS MEETING The minutes of the 25th August 2015 were approved. Review of Actions The action tracker was presented. Janet Miller reported that the updated Workforce KPIs and the achievement reviews progress had to be discussed at the Executive team meeting before coming to this Committee. Angela Stevenson gave a verbal update on the actions around the Integrated Discharge Unit business case and will give a further report to the October meeting.

3

BUSINESS PLANNING Business Planning Cycle Sue Jenkins presented the Business Planning Cycle paper and advised that it would also be discussed at the Board Seminar on Thursday. The paper circulated had the last 3 pages missing so no further discussion could take place. Action: Complete document to be circulated SJ/CT Paul Biddle then asked whether it will include a consideration of our FT processes. Sue Jenkins responded that the output from the business planning cycle process would inform the IBP. Paul

2

Simpson added that there would be a paper to the Board in November regarding the FT finances.

4 FINANCE Financial Performance M05 The finance performance paper was presented by Paul Simpson. There has been a small reduction in emergency activity in month but it is still above plan. The other highlights included

The Trust is adverse to plan by £1.9m at month 5 with a £2.6m deficit.

The Trust now has limited reserves to cover the adverse variances.

The phasing of the income plan is that it is adverse for the start of the year and then additional activity starts when the 10th theatre is fully operational.

The forecast has been reviewed and it is recommended that it does not change for M05.

The Trust has not stretched its plan as requested by the TDA.

Paul Simpson added that the outputs from the Breaking the Cycle work had been striking in terms of the closure of escalation areas and that by the end of the week the Trust had 30 empty beds. Activities such as closing escalation reduce the cost to the Trust of the additional emergency activity and allows for more elective work. Angela Stevenson added that the focus for the week had been on Care of the Elderly and Community to ensure that patients were ready for discharge, This strengthens the case for the Integrated Discharge Unit to be run by the CCG and the Community as 125 patients in that week were medically ready for discharge, The Trust now needs to analyse the consequence of changing the ways of working and how we can sustain it. Paul Simpson then advised the Committee that Trust had £2.1m of income that is not included in the Trust position but discussions are ongoing with the CCGs and NHS England about recouping it. This income relates to Marginal Rate tariff (£1.2m), Readmissions (£0.4m) and NHS England Gain Share (£0.5m). Alan Hall sought clarification if this figure was included in the current aged debt of the Trust or was in addition to it. Paul Simpson confirmed that it was in additional to it. Alan hall then questioned the level of the Trust aged debt as it seemed high at £1.8m. Paul Simpson advised that there is a cash flow issue with the CCGs, we have a reconciliation process every 3 months to agree and then invoice which gives the Trust a delay in payment for over performance. Paul Biddle asked if there was still a dependency on an increase in elective income. Paul Simpson replied that the M06 elective activity would be an important indicator for the Trust’s forecast position. Richard Durban asked about the Trusts cash position and the £6m working capital loan. Paul Simpson confirmed that the loan had been drawn down. Alan Hall queried whether it was intended to pay it back in the current financial year noting that the cash flow showed a projected year end position of £2.3m. Paul Simpson replied that to make the loan application the Trust had presented a cash flow that showed the loan being repaid in the first quarter of 2016/17. Paul Biddle requested that the Committee be given a rolling 12 month cash flow in the finance papers so they can see the projection of cash over the year end and the repayment of the loan. Action: A rolling 12 month cash flow forecast to be included in the Finance Report PS Paul Simpson advised that the Trust’s draft reference cost index was 88 against an average of 100,

3

noting that the cost base of the trust is below average and the impact on the Trusts financial position of the £7m of marginal rate income that was not received in 2014/15. Alan McCarthy commended that Executive for their management of the financial position. 2015/16 CIP Update Paul Simpson presented the 2015/16 CIP update to the Committee. Alan Hall queried the difference between the CIP paper and the recent Nurse Agency paper to the TDA. Paul Simpson advised that this was a timing issue and that there are changes that need to be made to the agency budget to reflect the Trusts revised position. This will then flow through to the CIP plans.

4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M05 Richard Durban highlighted that the Committee had not receive the required papers on Sickness Absence, Achievement Reviews Progress and the Workforce Internal Control Framework action plan. Janet Miller presented the M05 report and highlighted that the Trust was now able to report on time to recruit metrics and managers can see the blockages in their recruitment. Richard Durban queried the progress of the new achievement review process, which is currently at 56%. Originally the target was 90% by the end of October but this report states only managers are required to produce a plan by then. Janet Miller replied that they are getting the data back from the business partners this week on progress and this will allow the production of a timetable. Fiona Allsop added that different directorates have varying numbers to review and we need to be more sophisticated about agreeing dates for completion. Alan McCarthy expressed concern that these reviews had not yet been completed and as objectives should be set at the start of the year not part of the way through it, and that it was disappointing that we have not done them before we sent out the staff survey. Janet Miller advised that some staff are in transition between appraisal systems and will still have had an appraisal in the last 12 months. Alan Hall expressed concern over the level of staff that has completed the annual Mandatory and Statutory Training. Janet Miller replied that MaST has been restricted by the IT infrastructure and automatic updates from the centre. HEKSS are looking into local updates. Alan Hall asked if that gave us assurance and Janet Miller said not currently and that it is still work in progress. Richard Durban asked about the revised Workforce/OD KPI reporting to the Board, FWC and other meetings. It was agreed to present an outline of what this would look like to the next FWC. Action: An outline of future Workforce/OD KPI reporting to be presented to the next FWC JM In summary the following Workforce papers were required for the October Finance and Workforce Committee: Workforce and Organisational Development Report M06 Sickness Absence Report Achievement Review progress Workforce Internal Control Framework Action Plan Outline of future KPI reporting

4

5 CAPITAL AND ESTATES Capital & Estates Report M05 Ian Mackenzie presented the Capital report to the Committee. The Theatres project is finished. The Macmillan Cancer Information Centre building work is largely finished, the boards will come down and the grounds landscaped. Within the Cardiology Unit laboratory 1 is open and with laboratory 2 opening next week. Alan Hall asked how much capital expenditure had been committed. Paul Simpson confirmed that £6.3m of the 2015/16 programme had yet to be committed.

6 IT IT Report M05 Ian Mackenzie presented the report. Richard Durban asked if there had been a discussion at the Executive team regarding the EPR project/IT Roadmap. Ian Mackenzie said there had not been but it will happen before the next Finance and Workforce Committee and be reported back.

8 GENERAL Date of next meeting Tuesday 27th October 2015 8.30am – 11.00am – AD77

SQC Minutes 6th August 2015

Page 1 of 7

Safety & Quality Committee

Thursday 6th August 2015, 14.00-15.00 AD77 Trust Headquarters, East Surrey Hospital

Minutes of Meeting

Present: Richard Shaw RS Non-Executive Director (Chair) Pauline Lambert PL Non-Executive Director Paul Simpson PS Chief Financial Officer Angela Stevenson AS pp Chief Operating Officer Denise Newman DP pp Chief of WACH

Des Holden DH Director of Medicine Fiona Allsop FA Chief Nurse Ben Emly BE Head of Information Stephanie Biden SB Risk Manager for Medicine Presenting: Francis Fernando FF Consultant Nurse, Falls Management Dora Royal TGR Consultant, Care of the Elderly

Sally Stimpson SS Children Safeguarding Lead Victoria Abbott VA Children Safeguarding Lead Julie Chivers JC Adult Safeguarding Lead In attendance: Nick Roberts NR Patient Safety Administrator Apologies: Alan Hall, Des Holden, Fiona Allsop, Katharine Horner, Virach Phongsathorn, Paul Bostock, Colin Pink, Barbara Bray, Debbie Pullen, Ed Cetti, Ben Mearns, Victoria Daley, Jonathan Parr, Action 1 GENERAL BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were

noted. All attendees introduced themselves. It was noted that the meeting was not quorate.

1.2. Minutes of the previous meeting The July meeting minutes were agreed as an accurate record.

1.3. Actions from previous meeting were discussed as follows

There were seven actions, three of which appeared on the agenda. Three actions, with October 2015 completion dates, were reported as being on track, when raised by the Chair. FA reported on progress made on reducing noise at night, an action which was due for completion this month. She referred


Page 2 of 7

to this on-going project, highlighting ear plugs, comfort kit, self-closing bins, headphones and an information leaflet for patients who are the source of noise at night and those who suffer it.

COMMITTEE BUSINESS 2.1 Highlights from Executive Committee for Quality & Risk

The following areas were discussed, Clinical effectiveness RS raised the potential risk concerning the on-going low mortality rates. DS stressed the reduction in percentage terms from 190 to 143, adding that this was due to sustained focus on low-risk conditions. CQUIN update In clarification of the report’s statement outlining progress on agreeing these, PS stated that these are now agreed and are about to be signed off with Surrey CCG and NHS England. Workforce RS expressed concern that there remained issues with monitoring the cancellation and delay of achievement reviews, as the report had indicated the request for evidence of compliance made by the Medical Director. PS suggested that Ben might include a compliance-metric to manage this issue. The Workforce Committee has asked for a review of actions to improve training compliance. Scorecard and Intelligent Monitoring BE spoke to the meeting about the new scorecard, stressing the improved quality of monitoring with the interactive capabilities which enable a certain degree of drilling-down. RS asked about how up to date it was to which BE replied that it was not real-time, but completed at fixed points in the monthly calendar. PS stated that as well as being visually-appealing the new score card was more detailed and flexible for improvement. PS also stated that there is work to be done in ensuring that all thresholds are appropriate and understood.

2.2 Highlights from Clinical Quality Review Meeting This meeting was held on the 21st July 2015. No items were escalated to the Single Performance Conversation in respect of clinical quality performance PS stated that the next was due to take place on Tuesday 25th August. The following areas were discussed, Medication Incidents CCG received assurance from report presented by David Heller relating to these Performance in May 2015 As stated above, no items were escalated to the Single Performance Conversation in respect of clinical quality performance CQC Action Plan PS had informed CQRM about recent discussions with local health


Page 3 of 7

economy Chief Operating Officers. Here PS stressed that discussions included capacity and activity issues and warned of related potential winter-period difficulties. PS stated that health systems COO’s had met on the 5th of August and outputs from that meeting would be discussed at the Chief Officerperating meeting scheduled for 17th August. RS questioned whether this interaction amounts to a step-up in cooperation with community partners, to which PS replied that it was more about deepening their commitment to the Trust and its activity. PS added that BE will coordinate data on activity and capacity for the Single System Resilience Group.

3 QUALITY PERFORMANCE 3.1 Quality Report

The following issues were raised, Patient safety RS asked for further information about the Significant Risk Register reference to the risk of outbreak of viral gastroenteritis. DH indicated that this corporate risk needed to remain as potentially serious since this was no longer a predominantly “winter” occurrence. DH will present the risk at the next SQC meeting ACTION RS asked for clarification about the higher rate of Falls per 1000 bed-days ACTION RS asked about the increased number, in June, of Grade 2 pressure-damage wounds and Hospital-Acquired Pressure Damage (low-harm). FA replied that the single-month figures do not represent the recent trend, stating that there has been a very good Trust performance on this issue in the last few years. FA added that much of the current concern relates to a high level of community-acquired pressure damage often with returning patients with re-acquired damage. Clinical effectiveness RS returned to the matter of Deaths in Low Risk Conditions (143.3 norm-related figure in June) – see 2.1 above, asking if we are in danger of adverse attention from Intelligent Monitoring with this figure. DH reassured the Committee that our trend was positive and that all deaths in low-risk conditions are proactively reviewed by clinicians, with coding to ensure accuracy. He further added that as the CQC statistics had moved from an annual to quarterly bench-mark, Intelligent Monitoring would reflect this general improvement in performance. Access and Responsiveness RS asked if there has been sufficient discussion at Board level about our capacity issues, as suggested in this report. There was concern expressed that there was possible booking of procedures in the knowledge of possible cancellation. FA replied that much over-arching work was being undertaken in Corporate and divisional teams to understand the consistent increase in demand and sustained


Page 4 of 7

pressure that ensue, along with planning to manage this.

3.2 SQC Dashboard The Trust Quality Scorecard was considered. RS raised a question about Emergency readmissions within 28 days following non-elective admission, asking if this figure was a concern for the Trust. DH replied that we would need to drill down the data to give assurance and that these data are considered with the CCGs and not the subject of audit. A sample of cases will be considered by the relevant clinical teams - a course of action suggested by AS. The new Scorecard, as introduced by BE, will be available for the next SQC meeting and Non-Executive Members will be given a formal introduction before that meeting.

4 PATIENT EXPERIENCE 4.1 Annual Falls Report

This was presented by Francis Fernando, Nurse Consultant, Falls and Patient Safety and Dr Giokarini-Royal Consultant Care Of the Elderly. FF highlighted the following points

- Number of falls reported has increased from 1094 to 1195 due to improved reporting (Datix web implementation) and raised awareness

- Falls with harm have stayed the same at 315. NB there were 60 more beds in 2014/15.

- There have been no deaths within 72 hours of fall. - There has been a 65% reduction of known deaths within 4 months of

fall, a much improved picture. - 15 major harm falls have been reported, a 21% decrease from 13/14. - Extreme harm was reduced by 100% (from 1 to 0). - Serious Incidents involving falls have been reduced by 29%, from 24

to 17. - Hip fractures were also reduced by 49% from 14 to 8.

- 74% of patients experiencing 4 or more falls were found to have had more than 2 ward moves and experienced at least 1 fall following each transfer.

- Introduction of specific lead for patient falls. - Clinics and Falls-focused Ward rounds have been introduced to

heighten awareness and performance - Tilgate and Capel Annexe had sustained reduction in falls following

training and active leadership at ward level PS asked about the multiple falls of patients that were moved between wards and the meeting urged greater scrutiny of this issue. RS returned to this issue later, specifically asking about the statement that “4 of more falls were found to have had more than 2 ward moves and

experienced at least 1 fall following each transfer.” FA stated that these patients often had long in-patient stays with co-morbidity and medication issues. AS added that these patients were often confused and could become further disorientated with ward moves. PL expressed concern about the compliance with falls management training rate, which is reported by Education & Training as 34.63% (1305). The report states that work is underway within the Education and Training department to ensure accuracy of training data which is


Page 5 of 7

questioned by the Falls team. RS noted the improvement in falls rates on Tilgate and Capel Annexe and congratulated the Falls and Ward teams, asking how this had been achieved and how the lessons learnt might be cascaded. FA responded that there will not be one single or principal action that can be transferred. The meeting concluded that the contributory factors will include ward-based staff training, led by the Falls team and put into practice by proactive ward leaders with a high level of staff engagement. Also discussed was appropriate ward design, including non-slip flooring. The Capel annexe flooring is reported as having made falls less likely but at the cost of reduced manoeuvrability of beds, machinery, wheelchairs etc, as AS pointed out. She also added that the nursing staff had been consulted about ward design and this process had highlighted issues about bed-spacing and visibility to nurses. DH questioned the team about the evidence-base for the assertion that staff members are now more prepared to report falls. FF and TGR indicated that the increase in volume was suggestive rather than statistically indicative but that the correlation with injuries reported would support this suggestion. FA stated that the Trust is getting better at data validation but this evidencing does need to be generally improved. RS thanked the team for presenting a very encouraging report.

5 SAFETY 5.1 Under-reporting of incidents within the Trust

RS thanked the report author for highlighting the issues moving forward as maintaining efforts to focus on increasing numbers of incidents reported to improve benchmarking position and focusing on improving systems to improve sharing lessons and actions taken with wider staff groups. The meeting suggested that both these foci should be maintained, with PL emphasising the need to step-up the learning aspect. The meeting noted and considered the position of the Trust, relative to peers on incidents per 1,000 bed-days. With regard to Appendix 4 – staff feedback about changes made in response to reported errors, near-misses and incidents, there was concern that 17% feel that feedback was not given. DN added that the 50% non-participation rate was also worrying. FA agreed that there were significant improvements to be made but that feedback rates were improving.

5.2 Annual Adult Safeguarding Report JC referred to the following key points

- The number of alerts has risen for the third consecutive year - The increase in DoLs referrals following changes to legislation - 50.35% of staff members have received training during the last 3

years. - Introduction of the Care Act 2014 on 01/04/2015.


Page 6 of 7

JC stated that, during 2014/15, 271 Adult Safeguarding Alerts were raised, 34 of which were raised about the Trust and of which number of only 1 case was substantiated. This was regarding pressure damage and staff communication with the family. The number of alerts has risen this year on last year’s’ total of 251 alerts. Although this demonstrates a continuous improving awareness of the Trust safeguarding processes and procedures, it was agreed that even if cases against the Trust were not substantiated that does not mean that there are no consequent issues for the Trust. The remaining alerts (some 200) were raised with community partners and JC stated that there was no feedback to the Trust in these cases. There was discussion of this point along with the volume and the suggestion that we are not aware of how the issue is being managed. RS questioned whether the 54% training level was a matter of concern. FA stated that there are capacity issues for Safeguarding with MAST training, which the Trust are trying to ameliorate. PL added that although training is important it does not provide a panacea. The report was received for submission to the Board, with a note from RS 5.3 Annual Children Safeguarding Report VA & SS referred to the following key points

- 8.5% increase in information shared with members of the multiagency MARAC and MAECC teams

- Commencement of 6 monthly Level 3 multi-professional Safeguarding

- Children Training at East Surrey Hospital which has increased our training compliance for Level 3 training to 72%.

- Hospital Link Social Worker from Surrey Social Services in attendance at Weekly Safeguarding Meetings held at the Trust

DN stated that the case number for the hospital remains consistent despite the higher number of referrals. PL asked whether there any specific deep dives carried out to investigate our efficacy in dealing with Children safeguarding. It was established that this has not happened. PL went on to add that it is important there is a clear understanding of roles and responsibilities in Safeguarding and asked how staff members come together to appreciate ownership. SS replied that peer group meetings and reflection groups occurred and help to raise awareness. PL added that the report was very comprehensive, as well as clear and concise. It was recommended for submission to the Board.

6 QUALITY 6.1 Summary of new 18 week RTT target

Bearing in mind time constraints the Chair proposed this item be taken at the September meeting.

7 ANY OTHER BUSINESS


Page 7 of 7

None raised

DATE OF NEXT MEETING Thursday 3rd September 2015 14.00 – 16.00 AD77

board papers october 2015

Documents