TRUST BOARD MEETING Wednesday, 5 November 2014

at 1.00 pm Board Room, Trust Headquarters

Queen’s Hospital

Contact: Andrea Saville, Head of Governance/ Trust Secretary

Barking, Havering and Redbridge University Hospitals NHS Trust

Queen’s Hospital Rom Valley Way

Romford Essex

RM7 0AG

Tel: 01708 435000 extension 3674 Email: andrea.saville@bhrhospitals.nhs.uk

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MEMBERSHIP AND QUORACY OF TRUST BOARD MEETINGS Chairman Dr Maureen Dalziel Trust Chairman Non-Executive Directors Mr Dusty Amroliwala Mr Mark Lam Miss Joan Saddler Mr Eric Sorenson Senior Independent NED Prof Anthony Warrens Mr Rob Whiteman Audit Committee Chairman Executive Directors Mr Matthew Hopkins Chief Executive Mr Steve Russell Deputy Chief Executive Mr Alan Davies Acting Director of Finance Ms Flo Panel-Coates Chief Nurse Mr Stephen Burgess Medical Director Ms Sarah Tedford Chief Operating Officer Non Voting Directors Mr Steven Huddleston Chief Information Officer Ms Deborah Tarrant Director of People and Organisational

Development Ms Jackie Nugent Director of Estates Ms Rachel Royall Interim Director of Communications Ms Angela Helleur Improvement Director Mr Rob Cooper Turnaround Director Quorum No business shall be transacted at a meeting unless at least one-third of the whole number of the Chair and members (including at least one member who is also an Officer Member of the Trust and one member who is not) is present. An Officer in attendance for an Executive Director (Officer Member) but without formal acting up status may not count towards the quorum. If the Chair or Member has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest (see SO 8) that person shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business. Secretariat Andrea Saville Head of Governance/ Trust Secretary Contact – Andrea Saville Tel/Ext: 01708 435000 ext 3674 Email: Andrea.saville@bhrhospitals.nhs.uk Dates of Next Board Meeting 2014/15 04.12.2014 (KGH) 04.02.2015 (QH) 07.01.2015 (KGH) 04.03.2015 (KGH) The Part 1 Board meeting is a meeting in public, not a public meeting. Members of the public are invited to ask questions at the end of the meeting and an agenda item is provided for this purpose. Wherever possible, the Trust will provide at the meeting, written answers to questions submitted to the Trust Secretary at least 48hrs before the meeting.

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TRUST BOARD MEETING AGENDA: 5 NOVEMBER 2014 (13:00hrs)

Time Ref Item Lead Format Action Page

1: OPENING ADMINISTRATION

13.00 1.1 Chairman’s Welcome Chair Verbal 1.2 Apologies for Absence Chair Verbal 1.3 Declarations of Interest Chair Verbal 1.4 Minutes of the Meeting held on 1 October 2014 Chair Paper Decision 5 1.5 Matters Arising and Action Log (items not

otherwise on the agenda) Chair

Paper Discussion

2: PROGRESS ON RESPONSE TO SPECIAL MEASURES

13.15 2.1 Unlocking our potential progress report ID Paper Assurance 17 13.30 2.2 Emergency Pathway DC/Exec Paper Assurance 34 13.45 2.3 Finance Report (M6) DoF Paper Assurance 39

3: QUALITY AND SAFETY

14.00 3.1 Nursing and Midwifery Safe Staffing Report CN Paper Assurance 76 14.05 3.2 Incident Report CN Paper Assurance 91 14.10 3.3 Infection Prevention and Control Annual Report

2013/14/ Strategy and Plan 214/15 MD Paper Assurance 106

4: TRUST PERFORMANCE

14.15 4.1 Trust a) Integrated Performance Report (M5) DC/Exec Paper Assurance 142 c) Communications Report DoC Verbal Assurance 14.25 4.2 Self Certification to NHS Trust Development

Authority Compliance Monitor and Board Statements 2014/15

DC/Exec Paper Decision 169

5: CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

14.25 5.1 Chair’s Report Chair Verbal Information 14.30 5.2 Chief Executive’s Report C/Exec Verbal Information

6: COMMITTEE REPORTS

14.35 6.1 Summary Reports from Committees of the Board

Cttee Chairs Paper Assurance 176

7: OPERATIONAL ITEMS

14.40 7.1 Winter Plan COO Paper Assurance 180 14.45 7.2 Revised Standing Orders and Financial

Instructions DoF Paper Decision 182

14.50 7.3 Business Standards Policy Update DoPOD Paper Decision 188

8: QUESTIONS, ANY OTHER BUSINESS, CLOSE

14.55 8.1 Questions from the Public Chair Verbal Information 8.2 Any Other Business Chair Verbal Information 8.3 Date of next meeting – 3 December 2014,

James Fawcett Lecture Theatre, King George Hospital

Chair Verbal Information

15.00 CLOSE

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DECLARATION OF INTERESTS Name Title Interests Declared

Matthew Hopkins Chief Executive Spouse is an Associate Director of North West London Commissioning Support Unit

Stephen Russell Deputy Chief Executive

Partner is Executive Director of Delivery & Improvement at St George’s NHS Trust.

Stephen Burgess Medical Director Consultant Private Practice, Hartswood Hospital, Brentwood

Board member Barking and Dagenham Health and Wellbeing Board

Flo Panel Coates Chief Nurse NED – NHS Innovations, South East (2011 – 2014)

Member of The Learning Clinic Advisory Board

Alan Davies Acting Director of Finance

No interests to declare

Deborah Tarrant Director of People and OD

Director Tarrant People Solutions Ltd

Partner is Senior Partner at Capsticks Solicitors LLP

Vice President London Healthcare People Management Academy

Sarah Tedford COO

Rachel Royall Director of Communications

Spouse will commence role as contract manager for Bromley CCG in July 2014

Steve Huddleston Chief Information Officer

No interests to declare

Jackie Nugent Director of Estates Husband is Works Manager for Sodexo Healthcare

Dr Maureen Dalziel Chairman Associate Zenon Consulting 1 Apr 2013 – Sept 2013

Director MD Health Consultancy Ltd (2004)

Ian Dalziel Company Secretary, MD Health Consultancy Ltd (2004)

Board Members, Intensive Care National Audit research Centre (ICNARC) (1994)

Board member British Pregnancy Advisory Service (BPAS) (2007 – April 2013

Prof Anthony Warrens Non-Executive Director

President British Transplantation Society

Chair of Council London School of Jewish Studies

Governor and CoChair Immanuel College, Bushey, Herts

Member Advisory Committee for Safety in Blood, Tissue and Organs

Member, UK (Transplant) Donation Ethics Committee (ceased 31 December 2013)

Consultant Private Practice at Wellington Garden, London Bridge, Princess Grove and the Physician’s Clinic London Independent Hospitals

Private Medic-legal Practice

Professor and dean for Education, Barts and London School of Medicine and Dentistry, Queen Mary, University of London

Honorary Consultant and (paid) Clinical Director, Education Academy

Clinical Director Transplantation Laboratory, Barts Health NHS Trust

Eric Sorensen Non-Executive Director

Mark Lam Non-Executive Director

Executive BT Group plc

Company Director & Company Secretary, Insomnia Consulting Ltd

Dusty Amroliwala Non-Executive Director

MD of Synagee Ltd

Partner is senior DG in HMG (Home Office)

Trustee of Combat Stress (Armed Services Mental Health Charity)

Rob Whiteman Non-Executive Director

Director, CIPFA Business Ltd

Non-Executive Director, NHS Whittington Hospital

Mark Lam Non-Executive Director

Executive BT Group plc

Company Director & Company Secretary, Insomnia Consulting Ltd

Joan Saddler Non-Executive Director

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AGENDA ITEM 1.4

MINUTES OF THE TRUST BOARD MEETING HELD ON 1 OCTOBER 2014,

BOARD ROOM, TRUST HEADQUARTERS, QUEEN’S HOSPITAL

Present Dr Maureen Dalziel Chairman Mr Matthew Hopkins Chief Executive Mr Stephen Burgess Interim Medical Director Ms Flo Panel-Coates Chief Nurse Mr Alan Davies Acting Director of Finance Mr Mark Lam Non-Executive Director Ms Eileen Moore Acting Chief Operating Officer Mrs Jackie Nugent Director of Estates Ms Rachel Royall Interim Director of Communications Mr Steve Russell Deputy Chief Executive Miss Joan Saddler Non-Executive Director Mr Eric Sorensen Non-Executive Director Ms Deborah Tarrant Director of People and Organisational Development Prof Anthony Warrens Non-Executive Director Mr Rob Whiteman Non-Executive Director In attendance Mr Robert Cooper Turnaround Project Manager Secretariat Ms Andrea Saville Head of Governance/ Trust Secretary 2014/134 APOLOGIES FOR ABSENCE

134.1 Apologies for absence were received from Mr Dusty Amroliwala, Non-Executive

Director, Ms Angela Helleur, Improvement Director and Mr Steve Huddleston, Chief Information Officer. A quorum was present.

2014/135 DECLARATIONS OF INTERESTS

135.1 The Chairman asked Board Members if there were any declarations of interest to be made relating to agenda items. None were made.

2014/136 MINUTES OF MEETING HELD ON 3 SEPTEMBER 2014

136.1

136.2

136.3

136.4

136.5

136.7

The minutes of the meeting held on 3 September 2014 were approved as a correct record with the following amendment: Page 5, Title should read, “Minutes of the Trust Board meeting held on the 3 September 2014….” Page 6, Minute 2014/117, line 3 should read, “…. She had personally seen improvement in staff engagement as a result of the work undertaken by the Trust in organisational development and……” Page 10, Item 2014/124, 124.2, first line should read, “The three Ward Sisters/ Managers, one from the Emergency Department, one Manager of Midwives…” Page 10, Item 2014/126, 126.1, final sentence should read, “Going forward she intended to report quarterly within the Patient Experience Report.” Page 16, Matters Arising and Action Log, the DoN is now entitled Chief Nurse and

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136.8

the Director of people Development is now the Director of People and Organisational Development. Subject to these changes, the Chairman signed the minutes.

2014/137 MATTERS ARISING AND ACTION LOG

137.1

The Patient Experience Q1 Report and the Staff Survey Update were included on the Agenda and the Board agreed that these actions should be closed.

2014/138 CHAIRMAN’S REPORT

138.1

138.2

138.3

138.4

138.5

Welcoming three new Non-Executives, Mr Mark Lam, Mr Rob Whiteman and Miss Joan Saddler to their first Board meeting, the Chairman was delighted to report that the Trust was continuing to strengthen the Board and a full complement of non-executive directors had been appointed. Introducing each Non-Executive Director, Dr Dalziel advised that Mark Lam is currently the IT director for UK telecommunications, working at BT Group; Joan Saddler OBE, a former National Director of Patient and Public Affairs at the Department of Health is now responsible for national policy and practice in patient and public engagement for the NHS Confederation; and Rob Whiteman is Chief Executive of the Chartered Institute of Public Finance and Accountancy. He had previously worked as CEO of the UK Border Agency in the Home Office. She also took the opportunity to congratulate Deborah Tarrant, who had been working as the Interim Director of People and Organisational Development and had now been permanently appointed to the role. Dr Dalziel advised the Board that she had attended a meeting of the Improving Patient Experience Group (IPEG) that morning and had been pleased to hear the rate of MRSA and C. Diff within the Trust continued to be low. She also provided an update on progress towards making BHRUT hospital sites ‘smoke-free’. Almost 300 people had completed the online survey since the last board meeting and events were scheduled to take place at Queen’s and King George Hospitals in support of Stoptober in partnership with local authority colleagues to encourage people to live smoke-free lives. One of the Trust’s Consultants, Robert Fowler had taken the lead in the Trust’s non-smoking campaign. In addition, she thanked particularly:

the staff and volunteers who baked (or donated) over 500 cakes to support Macmillan's “world’s biggest coffee morning” on 26 September 2014 where over £1,300 was raised breaking last year’s £1,100.

the executive team for implementing and promoting the Guardian Service

which is an independent and confidential service for staff enabling them to speak up about their concerns. It is led by National Patient Champion Ashley Brooks and was introduced following a pledge made at last year's NHS Change Day and in response to the Francis Report. Since its launch, almost 100 of our staff have benefitted from the service, helping to address concerns about patient care and safety. A video has been launched to raise the profile of the service which is available on the intranet, website and our YouTube channel. https://www.youtube.com/watch?v=kGLtcIlfGxk

Members NOTED the report

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AGENDA ITEM 1.4

2014/139 CHIEF EXECUTIVE’S REPORT

139.1

139.2

139.3

139.4

139.5

Mr Matthew Hopkins, Chief Executive reported that, during September he had welcomed 117 Junior Doctors and the first seven of the nurses from Portugal. He had been present for part of the induction of many of these new staff where he had set out the Board’s expectations of them. As a firm believer in experiencing things from the patient’s point of view, Mr Hopkins had visited Bluebell A in the last month, to talk to patients, help them to eat and to taste for himself the food served to patients. The ward had successfully trialled serving meals course by course meaning Health Care Assistants had time to sit with patients and support them to eat in between courses. He reported he had very much enjoyed the experience and had been pleased with the standard of food he sampled. Patients were also positive about the new meal system and about the standards of food and service. Mr Hopkins attended the Havering CCG Patients’ Engagement Forum and he particularly thanked the Chair Peter Willig for the opportunity to talk about the Trust’s improvement plan and the work being undertaken to ensure patients waiting for treatment receive it on time. He also attended the first ‘Listening Event’ supported by the local Healthwatch in Havering on 30 September 2014. He listened to patients’ views of services and heard that the Trust needed to be more responsive and accessible and show more compassion to patients. Two further events are scheduled, following which he agreed to evaluate the events and report back to the Board. Continuing, Mr Hopkins advised the Board that the 2014/15 Flu campaign had been officially launched on 29 September to encourage staff to have the flu vaccination to protect themselves, their family and their patients. The first person to receive the vaccination was a Trust Pharmacist to show that it was safe. Local professional boxer, Ollie Pinnock, joined Mr Hopkins in the flu boxing ring to have the jab on Monday and flu clinics are being held at both of main Hospital sites for staff. He recommended that all staff should have the jab.

2014/140 ESTATES STRATEGY

140.1

140.2

140.3

Mrs Jackie Nugent, Director of Estates presented this revised document which had been developed originally in line with Health for North East London and alongside the Trust’s Clinical Strategy. The aim of presenting it at this time was to provide an up-to-date position of the Trust’s estate within the health economy to provide a platform from which to move forward in the context of the Trust Improvement Plan. In answer to questions from Mr Mark Lam, Mr Rob Whiteman, Mr Eric Sorensen, Miss Joan Saddler, Non-Executive Directors and Dr Maureen Dalziel, Chairman the following points were made: The strategy would be refreshed annually The Trust needed a ‘position statement’ in relation to its estate in order to record

and measure changes resulting from approved, individual business cases. There were a few issues outlined that the Trust needed to progress, for example

DDA requirements Some rationalisation of Trust estate had taken place this year including the sale

of Upney Lane. Services were now provided using two leased sites. The reference to reconfiguration of A&E services was to provide context rather

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140.4

than revisit previous plans. The Trust Board confirmed that changes would not be progressed unless and until services at Queen’s Hospital were safe. 2014/15 was a year of stabilisation.

Some business cases were already under consideration, some as a result of patient feedback.

Proceeds of the sale of the old Harold Wood and Oldchurch Hospitals had been returned to the DH. Going forward the Trust may be able to negotiate some of the proceeds of the sale of land depending on the Trust’s requirements.

PropCo was an independent company managing all properties owned by Primary Care Trusts up until their abolition in 2013. The new company had invoiced the Trust for lease of accommodation not previously charged for. Invoices were being validated and the Trust was seeking to rationalise the accommodation it used.

Summarising the report, Dr Dalziel advised that is was ‘work in progress’ and highlighted where the Trust Board needed to focus going forward

DECISION: The Board accepted the Estates Strategy as the Trust’s current position in terms of its estate.

2014/141 BHR STRATEGIC PLAN

141.1

141.2

141.3

141.4

Introducing this report, Mr Steve Russell, Deputy Chief Executive advised that it was the 5 year commissioning strategy for the five Clinical Commissioning Groups (CCGs). In line with NHS Trusts, all CCGs were required to produce a five year strategy. The document set out the CCGs’ vision for the health economy and, in particular, the outcomes patients could expect. In broad terms the commissioning plans were entirely consistent with the Trust’s own plans. The development of the strategy had been led by the CCGs and the Integrated Care Coalition was consulted. The Integrated Care Coalition is a unique group chaired by the Chief Executive of the Havering Borough Council attended by local healthcare providers, the Ambulance Service and two other Local Authorities. This is a powerful coalition that can bring about economy wide change and agreement. Members NOTED that the strategy did not include some matters that were important to the Trust, for example obstetric care (primary and secondary) but acknowledged that the Trust needed to take account of the BHR strategy in developing its own. Members also noted the reference to underfunding and the stated intention to move CCGs to ‘target’ over time although no timescale or pace was defined.

2014/142 ACUTE RECONFIGURATION UPDATE

142.1

142.2

Mr Russell linked this detailed paper to the previous two documents advising that the Trust continued to work to support change. He described the five projects detailed in the update and advised they would be taken forward through the Trust’s Capital Planning Group. These schemes had been agreed with Commissioners and did not divert focus from the Improvement Plan. Going forward, between now and January 2015, the intention was to bring together the clinical model that will support the strategy, decide the space requirements and staffing model and then look to determine the estates changes that may be necessary. During discussion the following was highlighted:

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142.3

Trust clinicians view the separation of elective and emergency services as

the right thing to do; There are political and public concerns relating to reconfiguration. One of

the main concerns is the safety of Queen’s Hospital if all emergency services were concentrated on that site including that it would require significant reconfiguration to manage.

Focus has been on what is lost at each site not what could be gained and the significant opportunities for services.

Members noted the update and agreed that future reports should be aligned to the Estates Strategy. Quarterly updates would be expected and the next update should be February 2015.

2014/143 ACTIONS REQUIRED FOLLOWING THE REPORT OF THE HILLSBOROUGH INDEPENDENT PANEL

143.1 Members considered the letter from NHS England setting out the recommendations following the Hillsborough Inquiry. Mrs Eileen Moore, Acting Chief Operating Officer explained that the Trust was non compliant in one area, that of Executive training. This was because of the recent changes to the Trust Executive Team.

DECISION: The Board APPROVED the response subject to completion by Executives of Emergency planning ‘Gold’ training, the single outstanding non-compliance. Post meeting Note: Executives completed Emergency Planning ‘Gold’ training on 22 October 2014. Confirmation of compliance with the recommendations from the Hillsborough report was signed by Chair and returned to NHS England on 28 October 2014.

2014/144 ‘UNLOCKING OUR POTENTIAL’: IMPROVEMENT PLAN UPDATE

144.1

144.2

144.3

144.4

144.5

Mr Steve Russell, Deputy Chief Executive provided an update for August on the Improvement Plan on behalf of Ms Angela Helleur, Improvement Director. He invited each responsible executive to report on their work stream and answer questions from Members as they arose. Ms Tarrant, Director of People and Organisational Development advised that this report included the first status report for the Leadership & OD work-stream which focussed on stabilising the organisation. The first priority had been to recruit a substantive Board and now that was almost complete the precedence was Board development and review of clinical leaders. The work stream had demonstrated good progress but had been rated as amber due to the size of the challenge. Mr Russell, Deputy Chief Executive reported on the Outpatient work stream advising that it had been rated red to reflect the scale of the changes still required. Significant progress had been made in changing processes but the only measurable change in outcomes had been a reduction PALS contacts in relation to appointments since resolution of the telephone system challenges. Ms Panel Coates provided highlights from the Patient Care and Clinical Governance work stream mentioning Sepsis training of clinical staff which remained behind plan, the introduction of new observation charts for adult patients, recruitment of a risk manager and patients to act as ‘Mystery Shoppers’. Ms Eileen Moore, Acting Chief Operating Officer outlined the progress with the Patient Flow and Emergency Pathway work stream highlighting the establishment of the Medical Receiving Unit (MRU) which was now open 24/7, the roll out of the

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AGENDA ITEM 1.4

144.6

144.7

144.8

Joint Assessment team (JAD) to every ward to support discharge from hospital and the efforts to reduce unnecessary admissions by providing a dedicated consultant in the Ambulatory Care Unit. Discussion took place relating to times of discharge and putting pace into filling vacant beds as they became available. Ms Tarrant, Director of People and Organisational Development advised the reason for the red RAG rating of the Workforce Work-stream was the continuing significant challenge relating to recruitment of senior medical staff for A&E with candidates failing to take up posts although recruitment to other medical posts remained of concern. The safety of patients was the Trust’s first priority and therefore, a high locum fill rate was maintained. The position was being closely monitored and, a number of initiatives were being discussed with partners to look at alternative recruitment and workforce strategies. Summarising, Mr Russell advised the Board that, overall delivery remained behind plan and all work streams other than the leadership work stream had seen a deterioration in RAG status. The Trust had made requests for additional funding to support delivery of the Improvement Plan and some funding had been confirmed by the Trust Development Authority (TDA). Members NOTED the progress report and thanked the TDA for clarity on funding..

2014/145 NURSING AND MIDWIFERY WORKFORCE REPORT

145.1

145.2

145.3

145.4

Ms Flo Panel Coates, Chief Nurse provided a brief background to the report and highlighted the key areas. She informed members that August had been a more difficult month than July and risks had been mitigated by transferring nurses from non-clinical areas to clinical areas to ensure patient safety. Ms Panel Coates outlined 5 key areas of risk and the actions being taken. By way of summary, Ms Panel Coates assured the Board that staffing levels were monitored on a daily and weekly basis and they were sufficient to ensure patient safety. During discussion about the pace of the recruitment process, Ms Tarrant confirmed the actions being taken to reduce the recruitment time. Members NOTED the report.

2014/146 MEDICAL WORKFORCE APPRAISAL AND REVALIDATION ANNUAL REPORT

146.1

146.2

Mr Stephen Burgess, Medical Director presented both the Medical Workforce Appraisal & Revalidation paper and the Revalidation Annual Report 2013/14. He assured the Board that the Trust was on trajectory to achieve the revalidation of all substantive medical staff by the end of 2016. Continuous concerns were being addressed by maintaining an adequate number of trained Appraisers and ensuring awareness by fixed term Doctors and locums of the Appraisal process. There were 92 Appraisers in 2013/14, but this year there were now 101, with a further 20 due to be trained. These Appraisers were responsible for 528 Doctors providing a ratio of approximately 1 Appraiser to 5 doctors. Compared to similar sector Trusts, BHRUT’s performance was, on the whole, better than average with 81.2% Doctors completing the annual Appraisal. Across all sectors, this figure increased to 83.8%. Of the missed Appraisal group, three Doctors were cited as having been subject to performance concerns. The Medical Director would provide the Trust Executive Committee with quarterly monitoring reports.

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AGENDA ITEM 1.4

146.3

146.4

Summarising, Mr Burgess advised the Board that, in his professional opinion, the Trust was able to assure itself, through revalidation, that the medical staff at BHRUT could evidence appropriate doctor behaviours and competences. Members NOTED the Medical Workforce Appraisal & Revalidation paper and Annual Report.

2014/147 NHS STAFF SURVEY UPDATE

147.1

147.2

147.3

147.4

The Chairman invited Ms Deborah Tarrant, Director of People and Organisational Development to present this report. Ms Tarrant provided an overview of the NHS Staff Survey for new members of the Board advising that the findings of the 2013 Survey were published on 25 February 2014 and in June, Directorates had been asked to develop local action plans to focus on the specific areas of concern in their Directorates; these were discussed at the Monthly Performance Review meetings. Some progress had been made but the quality was variable. Ms Tarrant informed the members that the next Staff Survey was about to start and this provided the opportunity to listen to staff and respond. The HR Department was working with the Communications Department on the preparations for the 2014 Survey and all Clinical Directors and senior managers had been asked to encourage their staff to complete the on line Survey, stressing to staff that the Survey is confidential, as the data is collected by an external organisation. In answer to a question from Ms Saddler, Non-Executive Director, Ms Tarrant and Ms Panel Coates described improvements since the establishment of the Guardian Service and the roll out of the PRIDE initiative. The Trust was working hard to become an Employer of Choice and bringing together all the initiatives for staff engagement & experience to enable this. It is proposed to establish a Staff Engagement steering group to manage this year’s survey and to develop targeted longer term plans, measures and ensure their delivery.

DECISION: The Trust Board NOTED the requirements and issues of the NHS staff survey and ENDORSED the approach going forward.

2014/148 SERIOUS INCIDENT (SI) REPORT

148.1

148.2

148.3

Introducing this report, Mr Burgess, Interim Medical Director highlighted to the Board the increase in the number of serious incidents reported in August and assured members that the number remained in the expected range. He outlined the Trust’s performance against the Serious Incident Key Performance Indicators and the actions being taken to improve. Following consideration of the paper, Board members requested better validation of the data, clearer explanation of them and assurance that the Trust was getting better at investigating and responding to serious incidents, learning lessons and changing practice. The Trust Board NOTED the report

2014/149 Q1 PATIENT EXPERIENCE REPORT

149.1 Flo Panel Coates, Chief Nurse presented the quarter 1 Patient Experience report

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AGENDA ITEM 1.4

149.2

149.3

which provided an overview of patient feedback consolidated from the ‘friends and family test’ (FFT), complaints, Patient Advice and Liaison Service (PALS) and NHS Choices website. This report included benchmark data from other similar London Trusts and a number of Trusts described by the Care Quality Commission (CQC) as those most likely to be receiving safe, effective, high quality care. During discussion it was highlighted that in the next report members would wish to be able to identify the top five things patients are concerned about overall and clear links with the ‘Unlocking our Potential’ Improvement Plan. Thanking the Chief Nurse for a much more readable and accessible report, Members NOTED the report

2014/150 QUALITY ACCOUNT 2014/15 Q1 UPDATE

150.1

150.2

150.3

150.4

This report, presented by Mr Stephen Burgess, Medical Director, provided progress with the priority actions described in the Quality Account 2014/15. For the benefit of the new Non-Executive Directors he described the aim of the Quality Account. Although it was a statutory requirement, the method of developing priorities with partners ensured a focus on what was important in the local health economy. The Quality Account was one of the means by which the Trust demonstrated public accountability on quality of services. Mr Burgess stated that the results for the first quarter of the year were not as expected and he acknowledged that more work needed to be done. He particularly highlighted the adoption of a new system to provide additional mortality data improving the Trust’s ability to look forward. It was agreed that the next update should include clear statements on what was ‘business as usual’ and what was exceptional and how the priorities linked to the Improvement Plan. Members NOTED the report

2014/151 SAFEGUARDING UPDATE

151.1

151.2

151.3

Introducing this report Ms Panel Coates assured the Board that appropriate processes and procedures were in place to safeguard children, young people, adults and people with a Learning Disability cared for at the Trust. Staff could access appropriate training. Support and guidance was available and accessed and any issue or incident was investigated thoroughly. Ms Panel Coates alerted the Board to the complexities of the system as the Trust had to work with eight different Safeguarding Boards which were all very active. NOTING the report, members requested that they were informed of any recommendation which the Trust needed to address.

2014/152 LETTER FROM THE ROYAL COLLEGE OF EMERGENCY MEDICINE

152.1 Members NOTED the risk to patient safety called ‘exit block’ outlined in the letter from the Royal College of Emergency Medicine and the Trust’s response.

2014/153 PERFORMANCE REPORTS

153.1 Mr Steve Russell, Deputy Chief Executive presented his report providing the Board

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AGENDA ITEM 1.4

153.2

153.3

153.4

with an assessment of the Trust’s performance against the accountability framework. Mr Russell highlighted the standards where the Trust had underperformed and what managers and clinicians were doing to reach the required standards. He also made mention of where the Trust was performing well. Reporting on the challenges highlighted in the report, Mr Russell advised:

The Trust was still not reporting to the Trust Development Authority on the Referral to Treatment Standard (RTT). The Trust had completed additional activity in August in line with the recovery plan but a significant risk for the Trust was its ability to increase the number of operations further.

The number of diagnostic waits had been met for three consecutive months. The cancer two week wait was met in August for the second consecutive

month. The Trust failed the 62 day cancer standard in August in line with trajectory.

Enhanced oversight of the process is in place. Performance in Emergency Care deteriorated in August from 87.7% in July

to 85.5%

In answer to questions from Mr Mark Lam, Ms Joan Saddler and Prof Anthony Warrens, Non-Executive Directors, the following points were made:

The Trust was addressing the RTT backlog in two ways – by outsourcing operations to be performed at the Independent Sector Treatment Centre (ISTC) and by increasing activity at the Trust

The funding secured to date did not cover the cost of clearing the backlog and sustaining performance. The gap was approximately £7m for inpatients only. The risk for the Trust was that the Clinical Commissioning Groups (CCGs) also needed to meet their control total and they had not budgeted for the increase in activity now required. Meetings with the Commissioners, the Trust Development Authority and NHS England were ongoing.

The Trust had yet to identify the patients requiring treatment in the ‘non-admitted’ category.

Members requested monthly updates on progress.

Finance report

153.5

153.6

153.7

Mr Cooper reported the in-month position, which showed a recorded deficit of £2.7m, in line with budget. This increased the year to date deficit to £17.1m, but reduced the adverse variance to £0.2m, against the budget of £17m. The in-month QCIP position was £1.2m adverse to target and the year to date QCIP delivery was £2m against a target of £5.8m, a shortfall of £3.8m. This position meant that currently the Trust would miss its control total at the year-end by £4m, if the organisation continued at the current level. Overspending month on month needed to cease and the Trust needed to focus on reducing temporary staff expenditure which would contribute to the shortfall in QCIP. Ms Tarrant described the efforts undertaken to ensure Clinical Directors and managers understood what was expected and how monitoring was taking place weekly in order to manage expenditure. Staff were being held to account for non-performance. Acknowledging the financial position, the Non-executive Directors expressed their concern and frustration and offered any strategic support needed. They asked for assurance that any reductions in temporary staff were assessed for safety and the risks were owned at the front line.

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AGENDA ITEM 1.4 Communications Report

153.8

153.9

Mrs Rachel Royall, Interim Director of Communications, advised the Board of the following events:

‘Listening events’ - the first of which took place on 30 September 2014 ‘Breakfast with the Boss’ – an initiative where 10 members of staff who have

a birthday on that date are invited to have breakfast with Matthew and discuss any topic they wish

Sepsis campaign – the Trust is working with national sepsis experts and using patient’s stories to bring the campaign to life

The BBC came to the Hospital and interviewed Matthew and several midwives about improvements to maternity services since 2001.

Members NOTED the performance reports.

2014/154 SELF CERTIFICATION TO NHS TRUST DEVELOPMENT AUTHORITY

154.1

Introducing this report, Mr Russell, Deputy Chief Executive, reported the risks to compliance and the actions required. There were no changes from the previous month.

DECISION: The Board APPROVED the self certification.

2014/155 SUSTAINABILITY ANNUAL REPORT

155.1

155.2

Jackie Nugent, Director of Estates introduced this report which presented the Trust’s progress and plans for Sustainability and reducing the impact on the environment of its operations. It outlined the key challenges going forward in relation to increasing business activities impacting on the energy consumption and associated operational costs due to increasing energy prices. The report also described opportunities for “invest to save” projects. Welcoming the report and commending the progress made to date, members NOTED the report.

2014/156 SUMMARY REPORTS FROM COMMITTEE OF THE BOARD

156.1 Dr Dalziel introduced the reports from the Committees of the Board, which were NOTED.

2014/157 USE OF THE TRUST SEAL

157.1 The Board NOTED the occasions on which the Trust Seal had been used since the

last meeting. The full register was available from the Trust Secretary.

2014/158 COMMITTEE STRUCTURE/ MEMBERSHIP OF COMMITTEES

Dr Dalziel reported that she would be meeting with each of the Non-Executive

Directors over the next few weeks to agree membership of Committees.

14

AGENDA ITEM 1.4

2014/159 QUESTIONS FROM THE PUBLIC

159.1 Members of the public agreed that questions could be taken outside the meeting

2014/160 ANY OTHER BUSINESS

160.1 There were no items of other business. The meeting closed at 17.20hrs

Signed……………………………………………… Date…................................... Chairman

15

TRUST BOARD MATTERS ARISING FROM 1 OCTOBER 2014 MEETING

Board Minute Ref No. /

Action Date Action Lead

Target Closure

Date Current Position Status

TRUST BOARD ACTION LOG 2014

Board Minute Ref No. /

Action Date Action Lead

Target Closure

Date Current Position Status

2014/142

Schedule next Acute reconfiguration Qtrly report for February 2015 meeting DC/Exec 04.02.2015 Scheduled for 04.02.2015 Open

16

AGENDA ITEM 2.1

Meeting: Trust Board Date: 5th November 2014

Title of Paper: Unlocking our potential progess report

Introduction: This paper presents a summary of the progress made in relation to our improvement plan and relates to our corporate objective - We will provide excellent quality care, outcomes and safety (Objective 1). The paper provides an update on progress for each of the workstreams, the public facing summary document and the key metrics.

Patient Safety implications: The improvement plan aims to improve quality of services.

Risks: Delivery of the improvement plan is behind schedule, delaying the impact of the actions being taken to improve services.

Financial implications: The implementation of the improvement plan requires additional resource which has been agreed with local commissioners and the NHS Trust Development Authority.

Legal advice and implications: N/A

Consultation (including patient and public involvement): N/A

Communications: The Trusts progress is reported publicly and forms part of the team brief.

Equality Impact implications: N/A

Reviewed by: Trust Executive Committee, 28th October 2014

Recommendations:

To note the progress detailed in the Workstream Status Reports

Formally endorse the Unlocking our Potential September 2014 progress report

Author: Liam Slattery, Programme Director, Acute Reconfiguration

Lead Officer: Angela Helleur, TDA Improvement Director

Date(s) for further review: 25th November 2014 (Trust Executive Committee)

Author and Lead Officer (if different): Steve Russell, Deputy Chief Executive

Date(s) for further review. Trust Executive Committee, 25th November 2014

17

AGENDA ITEM 2.1

Section 1: Summary

1. We have strengthened the management of the programme and taken into account feedback from members of the Oversight Group. We have adopted a new RAG rating for the monthly Status Report as follows:

Progress against actions for completion Impact of completed workstream actions 

RAG Status 

 Definition RAG Status 

Definition 

 0   

Risk to delivery of the Workstream Improvement Plan actions with no resolution / mitigation  

 0   

Desired benefits yet to be realised  

 1  Risk to delivery of the Workstream Improvement Plan actions with resolution / mitigation identified  

 1 Desired benefits being partially realised  

3 Workstream Improvement plan actions on track to be delivered on time   

3 

 Benefits are being realised 

2. Overall delivery is behind our original plan, with the status of each workstream as follows:

- Workforce: Red-Amber

- Patient Flow: Red-Red

- Outpatients: Amber-Red

- Patient Care and Clinical Governance: Amber-Red

- Leadership and Organisational Development: Green-Amber

3. An initial review of the programme and progress to date was undertaken by the Improvement Director along with SROs and Delivery Directors. This will now be followed up with a detailed Work-Stream-by-Work-Stream review of activity with the goal of further sharpening focus as we enter into the last six months of the plan.

4. The Oversight meeting took place on 24th October 2014, with a focus on the outpatient workstream. Key members of the team presented their work on engagement, actions to date and next steps. This ‘deep dive’ was positively received by all partners and the team should be congratulated. A summary of each workstream is set out in the following sections.

18

AGENDA ITEM 2.1

Section 2: Workforce (Red-Amber)

Achievements for this period include:

The number of applications to join the In-House Bank has increased significantly by 144% (from 26 to 67 applications / week), since the rate increase in September.

The time to hire (advert to unconditional offer made) has continued to reduce from 52.3 days to 41.9 days.

The proportion of permanent HCA’s reached 90% in the month.

Version 10 of the e-Rostering system went live on the 13 October. V10 enables improved roster management, visibility of staffing and accessibility to the service.

Areas of risk are:

Turnover rose slightly, and the proportion of registered nursing posts filled with permanent staff fell by 2% to 83% (-19 WTE), although the number of posts in the process of recruitment rose by 64.

Recruitment to senior medical posts remains a risk, with the proportion of posts filled by permanent staff remaining stable. The Trust is maintaining a high locum fill rate. The position is being closely monitored and a set of proposals to improve the attraction offer was discussed and agreed at the Trust Executive Committee.

Section 3: Patient Flow (Red-Red)

Achievements for this period include:

The focus on discharge at Queens Hospital for the last 6 weeks has delivered significant increases in morning discharges (these almost tripled in September '14 compared to September '13)

The ambulatory service continues to be well used, and staff are now actively ‘pulling’ patients from A&E.

Areas of risk are:

Despite the improvement in discharge performance for the Trust against the emergency access target was 85% for September, and 80% for QH (the site where the majority of improvements are aimed) and such these have yet translated into improved performance against the 95% 4 hour access target.

Without losing the focus on discharge, the focus for this workstream in the next month is:

Emergency Department: Releasing space to implement majors 'light' to improve the non-admitted performance.

Acute Assessment: Agreeing the staffing arrangements to increase the Elderly Receiving Unit from 10 to 30 beds from middle of November. Reviewing and improving assessment unit 'ways of working' to move patients into the freed-up beds more quickly.

19

AGENDA ITEM 2.1 Ward discharge: Embedding and sustaining morning discharges to reduce

variability and increase total discharges by a further 30% to meet demand.

Bed management: Completing observations of the process from bed declaration to fill process and commence delivery of the action plans.

Section 4: Outpatients (Amber-Red)

Achievements against this plan for this period include:

50% of the Directory of Services has been reviewed and updated meaning more patients will be booked into the correct clinics.

The reduction in short term cancellations has be maintained

The appointment to 9 out of 17 vacancies

Agreeing a 4 day training and education plan for front line staff, which will enable them to process patients more effectively

The call centre pilot has seen the number of calls answered rise to above 90% from a start point of 40%.

A trial of changes to the clinic preparation process is starting on 10th October and will run for approximately 6 - 7 weeks. After this time there should be an improvement of the time in advance that clinics are being prepared, increasing from half a day to 3 days meaning more notes are available to clinicians.

Areas of risk are:

The clinic profiles have not yet been updated and the process for reviewing referrals on Medway is not embedded.

The scale of the administrative workload in reprofiling the clinics is significant and may result in some changes to patient appointments.

The back-office improvements have yet to translate into an improved experience for clinical staff.

Section 5: Patient Care and Clinical Governance (Amber – Red)

Achievements against this plan for this period include:

Sepsis: 87% of staff in A&E and 92% of staff in acute wards have now been trained in sepsis.

Nursing documentation: Compliance against the ten standards has improved to over 70%, but has remained static over the last 3 months. External expertise has been identified to support a full review of nursing documentation, which is still regarded by staff as unwieldy and repetitive.

Patient Experience: The first of a series of listening events with our three local Healthwatch Groups was held on 30th September

Areas of risk are:

20

AGENDA ITEM 2.1 Trust-wide clinical governance: Not all directorates have a full clinical governance

team in place or support to enable these teams to work effectively.

Whilst the number of risks reviewed has improved, the risk register and the risk management processes require further development

Section 6: Leadership and Organisation Development (Green Amber)

Achievements against this plan for this period include:

The executive team has been appointed to and interviews for the Medical Director took place on 29th October.

The non-executive director posts have also been appointed to.

The engagement of a provider for Board Development which will commence in October.

The cascade of the Corporate objectives has commenced and a communications plan is in place.

Extra PRIDE workshops have taken place to help embed our values and behaviours throughout the Trust.

The PRIDE Awards 2014 ceremony took place on 15th October.

Areas of risk are:

Ensuring the consistency of communication and message throughout the organisation and alignment to the corporate objectives.

Section 7: Public Update Summary

5. The proposed public facing update is set out in the following pages. It is recommended the Board note the progress and agree the publication of the update.

21

Monthly progress report, June 2014

Get involved in your local hospitals

Join our Improving Patient Experience Group - email elaine.clark2@bhrhospitals.nhs.uk

P a g e  | 1 

Become a volunteer – email http://www.bhrhospitals.nhs.uk/getting-involved/volunteering.htm Be a mystery shopper – email mysteryshoppers@bhrhospitals.nhs.uk or call 01708 503 466

Have your say

Tweet it, shout it, share it! Follow us @bhr_hospitals

Encourage others to share their good experiences

Visit our website: http://www.bhrhospitals.nhs.uk/

Comment on NHS Choices

Unlocking our Potential

Our Improvement Plan for King George and Queen’s hospitals

September 2014 progress report

22

P a g e  | 2 

23

How we’re improving your local hospitals

It’s been another exciting month at our Trust, as we strive to give great care to every patient, every day, and we have now delivered 40 per cent of our improvement plan. We have yet to see the full impact of all our actions so far – it can sometimes take time from putting the building blocks in place to seeing them take shape - however, we are making progress and are confident that we are on the right path and driving the right changes to improve the quality of care for our patients.

Top highlights for September include:

‐ 3,000 staff completed sepsis training ‐ Launch of our Listening Events ‐ Improved patient discharges

So what does this mean for our patients in terms of improving their care?

Following our hard hitting, true-life Spot it, Treat it, Beat it campaign, more than 3,000 staff have been trained to recognise and treat sepsis, which means we can keep our patients safer than ever from this potentially life-threatening condition. Sepsis arises when the body’s response to an infection injures its own tissues and organs. We are using a care bundle called the Sepsis Six – three simple tests and three simple treatments – which has been shown to double a patient’s chances of survival when used within the first hour. It is used in 15 countries. Managing sepsis will be further supported through our new observation charts which prompt staff to consider sepsis and our recently launched antibiotic app, which allows clinicians to look up guidelines without having to leave the patient’s bedside.

Giving our patients and local communities a voice is extremely important to us and we are delighted to announce that we have launched our new listening events. We had a great turn out at the first event, which we hosted jointly with Healthwatch Havering at Harefield Manor in Romford. The sessions give our local residents an opportunity to have an open and honest conversation about their experiences at our hospitals. Attendees shared their views on our Emergency and Outpatient Departments, our discharge processes, and care on the wards, with Chief Executive Matthew Hopkins and our Senior Management Team. We have had extremely positive feedback, with comments such as: “It was great being able to communicate with those who are in charge of the different areas within the hospitals, including senior management, and getting immediate feedback.” Another resident said they were impressed by “the willingness of staff to admit there were problems and inform us of the steps being taken to improve patient’s experience of healthcare in our local hospitals.” We will host listening events with Healthwatch Redbridge and Healthwatch Barking and Dagenham too, and would like to invite patients, service users and local residents to join us. We will use the information to help us focus further on where we need to make improvements.

Whilst we do everything we can to make our patients comfortable in our hospitals, we know that it’s not the same as being in their home environment, so we are doing as much as possible to discharge patients as soon as it is safe to do so. In addition, we are trying to discharge them as early in the day as possible. This also benefits our patients who are waiting for beds, as we can admit them more quickly, so they have a better experience and better outcomes. In turn, this frees up our Emergency Departments for those patients who arrive needing emergency care.

These are just some of our achievements for September. Read on to find out more about how we have been improving your local hospitals this month.

P a g e  | 3 

24

1. Leadership and Organisational Development Workstream overview Key achievements Next steps

To create a high performing leadership team that will ensure we put the right systems, structures, checks and balances in place to make sure our Trust is properly managed from Board to ward. Executive lead: Deborah Tarrant Director of People and Organisational Development

We have almost completed building our new Executive Team. This month we appointed Deborah Tarrant as our Director of People and Organisational Development. Deborah has been with us on an interim basis since June, leading on the Workforce and the Leadership and Organisational Development workstreams of our improvement plan. She has worked as a director in the NHS for the last ten years, most recently as Director of Workforce at the Royal Marsden NHS Foundation Trust

We ow have a full complement of non- executive directors following the recent appointments of Mark Lam, Joan Saddler OBE and Rob Whiteman. They bring a wealth of invaluable expertise. Mark is currently the IT director for UK telecommunications with BT Group. Joan is responsible for national policy and practice in public and patient involvement at the NHS Confederation, whilst Rob is Chief Executive of the Chartered Institute of Public Finance

n

We will hold interviews for our Medical Director post at the end of October. This will complete the recruitment of our Trust Board. The role is currently held by Dr Stephen Burgess

We will review the structure of our clinical directorates to ensure that we have the right leaders to deliver the best care. This work will be led by Sarah Tedford, the new Chief Operating Officer when she joins the Trust in November

We are reviewing our development opportunities for all our staff to ensure that we attract and retain the best staff

Workstream Updates

25

and Accountancy We have

selected Foresight Partnership to work with us on our Board Development Programme, to ensure our Trust is well-led and delivers improvements for our patients. They will start work with us shortly

2. Outpatients Workstream overview Key achievements Next steps

To ensure effective management of our outpatient services so appointments run on time, every time. Executive lead: Steve Russell Deputy Chief Executive

We have reduced the number of clinics cancelled within six weeks by around 87 per cent since May. We cancelled 117 clinics in May - we cancelled 15 in September, mainly due to staff illness. This is a huge achievement in just four months

We have started a trial within our Clinic Preparation Department, who are responsible for getting patient notes ready for clinics. This will allow us to retrieve patient notes from our Library and other parts of the hospital in ample time for the patients’ appointments, meaning fewer appointments will get delayed or even cancelled due to missing notes

A full training programme has now been commissioned. Every member of Outpatients will attend a four day course, which incorporates a full day of customer service training, giving us the foundations to build on

Following the trial in Team 1, we will then roll out the Clinic Preparation trial across all Outpatient teams

Once the second phase of our Call Centre trial is complete, at the end of October, the new staffing schedule will become permanent

We will provide new uniforms for all our Outpatients staff, giving a refreshed, professional look and identity to all our teams across our hospitals

26

3. Patient Care and Clinical Governance Workstream overview Key achievements Next steps

To support all our care with effective management of patient care records, and information and systems which alert us quickly to problems with the quality of our services. Executive lead: Flo Panel-Coates Chief Nurse

More than 3,000 staff have now been trained in how to recognise and treat sepsis, which means we are able to keep our patients safer from this potentially life-threatening condition

We held our first ‘listening event’ with Healthwatch Havering, with further events planned with Healthwatch Redbridge and Healthwatch Barking and Dagenham. The events give our patients and local residents a voice, and enable them to have an open, honest conversation about their experiences

Our Friends and Family Test (FFT) adult inpatient score was 71. Our Maternity scores were also very good for September, with our Antenatal Ward and antenatal community midwives scoring 78, and our Birth Centre scoring 80. The FFT is a national test which asks patients if they would recommend services to their friends and family, and helps to highlight where we need to focus to improve our patients’ experiences

We will launch our new World Health Organisation (WHO) Surgical Checklist mandatory training module for theatre staff, which includes a customised training video. The WHO checklist was designed to keep surgical patients safer by minimising the most common and avoidable risks

We have planned additional Risk Management Database Training workshops for October and November. So far we have trained 65 per cent of staff identified as needing this training, which will help us to review risks across our Trust more quickly and identify actions we can take to reduce them.

We will work with external advisors to streamline our nursing documentation processes. This will enable our nurses to spend more time with their patients, and will also help to improve the standard of documentation

4. Patient Flow and Emergency Pathway Workstream overview Key achievements Next steps

To make sure our patients are assessed and treated promptly, are supported to return home as soon as they are medically fit to leave

We want to help our patients back into their home environment as early in the day as possible. We have agreed discharge procedures for our Acute Medicine, Care of the

We will increase the number of beds in our Elderly Receiving Unit (ERU) at Queen’s Hospital from ten to 30. The ERU is a unit for our elderly patients who may need admitting, where they are cared for by a specialist

27

hospital, and ensure that patients are cared for in the right place with the right follow up care. Executive lead: Eileen Moore Acting Chief Operating Officer

Elderly and Haematology and Cancer wards to support staff with this process, and established individual discharge numbers for each ward based on their specialty and type of patient. As this feeds in to our work on improving patient flow, we now provide wards with a daily Emergency Department (ED) status update so they fully understand their role in helping ensure efficient flow from ED to the wards

We are launching an accreditation system to improve how we use our live bed state system, which allows us to see in real time where beds are available across our hospitals. By improving use of this technology we can move patients more quickly across our hospitals, meaning better care and a better experience

We are rolling out training to help improve end of life care for our patients. The training is designed to ensure staff understand, and feel able to, focus on the key priorities identified by the Leadership Alliance for the Care of Dying People now that the Liverpool Care Pathway is no longer used. These include individualised end of life care plans, sensitive communications, for example, around nutrition hydration, supporting the needs of family and friends, and involve the dying person and those important to them in their own end of life plans

team before either being admitted or discharged. This also frees up our clinicians in our Emergency Departments to treat our patients who need emergency care

We will launch our Frail Older Person’s Advisory and Liaison Service (FOPAL) at King George Hospital. GPs will be able to contact the service and get advice on the best care and treatment options for their patients, helping to reduce unnecessary Emergency Department admissions, and ensuring our elderly patients are treated in the best place for their condition or illness

We will work closely with our Medical Assessment Unit, ward and bed management teams to continue to improve the flow of our patients between the Emergency Department, the assessment unit, the wards and the discharge lounge, ensuring they receive the best care and have a great patient experience

28

P a g e  | 8 

5. Workforce Workstream overview Key achievements Next steps

To recruit, retain, develop and deploy the right number of permanent staff we need to provide high quality care 24/7 Executive lead: Deborah Tarrant Director of People and Organisational Development

We launched our increased In House Bank (IHB) rates on 1 September to encourage staff to join the IHB instead of agencies. Enquiries to join have risen on average by 144 per cent each week, from 27 to 67. This increased interest should mean more use of Bank staff and less use of agency staff from around mid Nov, which will benefit our patients through better continuity of patient care. It will also help to address our financial situation

Through streamlining our recruitment processes we have reduced the time it takes to hire (from advert to an unconditional offer made) even further. Originally 52.3 days we reduced this to 48.4 days in August, and to 41.9 days in September, ahead of the set October target date

Seven of our 33 newly recruited nurses from our Portuguese campaign have now started with us. They have been featured in our local media and two of the nurses featured in a BBC London focus on NHS staffing, with our Chief Executive Matthew Hopkins. The remaining 25 nurses will start in November

We will launch our updated version of eRostering – the system we use to roster staff our permanent staff – which is much more comprehensive and efficient than the current version, and has a greatly improved reporting facility. This will help us to make sure we have the right staff in the right places at the right time so that our patients get better care from staff that know our hospitals, systems and processes. Allocating our permanent staff more effectively is one of a range of measures to minimise our reliance on temporary staff

We will continue to develop our staff benefits pack to ensure prospective applicants are aware of the benefits and opportunities we are able to offer as an employer of choice

As staffing levels in our Emergency Department (ED) have begun to improve, we will complete our (ED) staffing review and publish our action plan for the next stage in our improvement process

29

Unlocking Our Potential - Improvement Plan 2014/15

End state

objective Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

RN establishment 1062 1059 1061

RN in post 956 893 888 869

% permanent 90% 84% 84% 82%

Vacancies 106 169 171 192

New appointments in process (WTE) 131 80.61 145.17

HCA establishment 457 458 453

HCA in post 411 391 388 407

% permanent 90% 86% 85% 90%

Vacancies 46 66 70 46

New HCA appointments in process (WTE) 66 64.6 63.41

Number of ENPs (WTE) in post 10 6.7 4.7 3.53

Number of ANPs (WTE) in post 3.8 3.8 3.8 4.8

Consultant in post 18 9.9 9.9 9.9

% consultants permanent 90% 56% 56% 56%

Middle Grade required (tier 1) 12 12 12

Middle Grade in post (tier 1) 11 5 7 6

% permanent (tier 1) 90% 67% 58% 50%

Middle Grade required (tier 2) 24 24 24

Middle Grade in post (tier 2) 22 9.60 11.60 11.00

% permanent (tier 2) 90% 50% 45.8% 45.80%

% permanent (all middle grade) 90% 56% 54% 54%

Turnover (all staff) 10% 13% 13% 14%

Turnover (ED) 10% 22% 20% 20%

Turnover (Registered Nurses) 10% 15% 15% 15%

Time to Hire (days) 40 53 48 42

A&

E se

nio

r m

edic

alO

ther

Nu

rsin

g

Improvement Plan Dashboard - October 2014

MetricWorkforce

17/10/2014 1 30

Unlocking Our Potential - Improvement Plan 2014/15

End state

objective Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Improvement Plan Dashboard - October 2014

Metric

% of patients treated within 4h in A&E (Trust) 95% 87.70% 85.50% 85.00%

% of patients treated within 4h in A&E (QH) 95% 83.40% 80.50% 79.80%

% of patients treated within 4h in A&E (KGH) 95% 94.10% 93.00% 92.50%

Trust A&E admitted performance 95% 66.30% 60.80% 59.00%

Trust A&E non-admitted performance 95% 91.20% 90.60% 90.40%

Conveyances to hospital of patients >75 - QH 1311 1281 1243

Conveyances to hospital of patients >75 -KGH 482 490 448

MRU trollies 18 6 to 12 6 to 12 6 to 12

Number of patients seen in MRU 510 305 340 440

Median time (mins) in ED for patients admitted to Trust 221 229 235

% discharge from MRU 30% 24.59% 24.41% 15.00%

% patients discharged from MAU/MRU within 24h - QH 50% 58.10% 57.69% 49.60%

% patients discharged from MAU/MRU within 24h - KGH 50% 43.78% 44.38% 44.79%

% patients discharged from MAU/MRU between 24h to 48h - QH 85% 28.52% 29.72% 30.65%

% patients discharged from MAU/MRU between 24h to 48h - KGH 85% 31.84% 33.14% 31.25%

Number of discharges per ward 6 4 5 4

Non Elective Length of Stay for Medical Specialties 7.53 7.48 7.31

% of discharges pre midday 12.46% 14.79% 15.06%

Percentage of discharges from 1200 - 1400hrs 17.16% 17.21% 16.68%

Percentage of discharges before 1400 - 1700hrs 39.22% 35.62% 35.22%

% of discharges post 1700hrs 31.14% 32.39% 33.03%

Percentage Utilisation Review - Occupancy (Medicine - QH) 95% 97.10% 95.70% 92.50%

Percentage Utilisation Review - Occupancy (Medicine - KGH) 95% 106.60% 102.70% 98.10%

Percentage Utilisation Review - Occupancy (Surgery - QH) 95% 101.70% 103.30% 96.30%

Percentage Utilisation Review - Occupancy (Surgery - KGH) 95% 96.60% 90.10% 86.70%

Percentage Occupancy 90.62% 87.81% 88.43%

Utilisation Review - Outlier Bed days (Surgery - QH) 112 171 100

Utilisation Review - Outlier Bed days (Surgery - KGH) 242 230 518

Utilisation Review - Outlier Bed days (Medical - QH) 365 386 436

Utilisation Review - Outlier Bed days (Medical - KGH) 330 275 294

Readmissions to hospital within 30 days 4% 8.40% 6.20% 6.20%

Beds consumed by readmissions 184 144 109

Pat

ien

t Fl

ow

ED &

Acu

te A

sses

smen

t

Patient Flow

17/10/2014 2 31

Unlocking Our Potential - Improvement Plan 2014/15

End state

objective Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Improvement Plan Dashboard - October 2014

Metric

Number of staff trained 1500 1981 2746 3081

Number of key medical staff trained 85% 31% 54% 84%

Nursing staff trained in ED 85% 76% 79% 87%

Nursing staff trained in acute ward 85% 70% 73% 92%

% of patients with sepsis six in 1 hr (ED) 95% 0% 0% 0%

% of patient with a diagnosis of sepsis with sepsis six in 1 hr 95%Data not

available

Data not

available

Data not

available

Mortality from septicaemia 9.50% 6.60% 4.50%

Transfer documentation 100% 91% 88%

Percentage of Risk Register reviewed and up to date 100% 59% 62% 66%

Inpatient Friends and Family Score 65 73 71 71

A&E Friends and Family Score 43 20 26 31

Staff trained on risk management system 100% 48% 65% 65%

Number of Directorates with a Assurance Review Panel 13 9 11 12

Nursing documentation meeting all standards 95% 73% 75% 78%

Patient Care and Quality Governance

Sep

sis

Do

cum

enta

tio

n/

Clin

ical

Go

vern

ance

/ P

atie

nt

Exp

eri

en

ce

17/10/2014 3 32

Unlocking Our Potential - Improvement Plan 2014/15

End state

objective Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Improvement Plan Dashboard - October 2014

Metric

Cancelled operations (not treated within 28 days of cancellation) 2 1

Number of patients with 1 hospital change 1197 546 707

Number of patients with 2 hospital changes 58 16 23

Number of patients with 3 hospital changes 5 0 2

Number of patients with more than 3 hospital changes 0 0 0

DNA rate (New appointment) 12.22% 12.41% 12.60%

DNA rate (Follow up) 12.23% 12.57% 12.86%

% seen < 9 weeks 73.49% 72.06% 69.62%

% reffered to another clinician 0.13% 0.14% 0.68%

Choose & Book referals reviewed 55.22% 54.94% 53.06%

Time from cancellation to new - Median (days) 14 14 14

Time from cancellation to follow up appt - Median (days) 42 47 56

Time from cancellation to new - upper quartile (days) 35 39 49

Time from cancellation to follow up appt - upper quartile (days) 98 99 126

Call Centre - Time to answer 00:05:14 00:05:08 00:05:33

Call Centre - Abandonment rate 42.70% 40.10% 39.80%

Number of patients seen in ambulatory care 357 336 348

Ou

tpat

ien

ts

Outpatients

17/10/2014 4 33

AGENDA ITEM 2.2

 

Trust Board meeting: 5th November 2014

Title of Paper: Emergency Pathway

Introduction/Summary:

This paper relates to the following corporate objectives:

Objective 2: We will continuously improve the effectiveness, efficiency and accessibility of our services

Objective 3: We will retain, recruit, deploy and develop an engaged and motivated workforce

At the last Board meeting it was agreed that the Board would receive a more detailed review of the emergency care pathway performance and the actions being taken to reduce the waiting times for patients. The Board will receive a presentation that provides additional detail and context as part of this item.

Patient Safety implications:

Patients who spend more than 6 hours in the department have a higher likelihood of experiencing harm, mortality, and extended length of stay

Risks:

Performance has deteriorated with up to 70% of patients who need to be admitted to hospital waiting more than 4 hours for a bed.

Financial implications: The underperformance against the operational standard would allow CCGs to impose significant financial penalties on the Trust.

Legal advice and implications: The Trust is not compliant with the NHS constitution standards.

Consultation (including patient and public involvement): N/A

Communications: This forms part of our regular internal communications

Equality Impact implications: N/A

Reviewed by/action taken? Trust Executive Committee

Recommendations:

That the Board notes the ‘diagnosis’ of the drivers of the current performance across the emergency care pathway, and notes and agrees the actions being taken to reduce waiting times and mitigate risk.

Author and Lead Officer (if different):

Author: Steve Russell, Deputy Chief Executive

Date(s) for further review. Trust Executive Committee, 25th November 2014.

34

AGENDA ITEM 2.2  

Section 1: Background 1. The Trust has experienced long standing difficulties with the emergency

pathway. The effective operation of a health economy pathway is measured by the A&E operational standard, but it is a measure of the effectiveness of the overall emergency care pathway rather than just a reflection of the effectiveness of the A&E department.

2. The national standard is that 95% of patients are treated and discharged or admitted to hospital bed within 4 hours of arrival.

3. The A&E operational standard was introduced in 2004 with an expectation

that 98% of patients would be discharged or admitted within 4 hours and this was reduced to 95% in June 2010, following a review.

4. The Trust met the 95% standard in June 2010 and in July and August

2011. The standard has not been achieved in any of the other 49 months up to and including September 2014. This indicates a long standing and significant set of underlying challenges.

Section 2: Drivers of current performance 5. Since April 2013 performance has ranged from 80% to 93%, with

performance on average at levels between 85% and 87%.

6. Performance against the standard is shown below, and a deterioration can be seen. Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14

All types A&E performance

QH 95% 84.5% 78.8% 78.2% 83.4% 80.5% 79.8%

KGH 95% 93.9% 93.1% 93.9% 94.1% 93.0% 92.5%

Trust 95% 88.4% 84.7% 84.7% 87.7% 85.5% 85.0%

7. The table below shows the drivers of underperformance by pathway type (against performance of 85%).

8. These individual pathways each have a series of components which

represent the key drivers of underperformance in that group of patients. These are summarised at a high level in the table below:

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AGENDA ITEM 2.2

Pathway Key drivers High bed occupancy Discharges occuring late in the day, after the peak demand for admissions Higher length of stay (internal processes and availability of senior decision makers in wards and assessment units) Higher length of stay (discharge arrangements)

Admitted

Bed management system Availability of senior medical staff (Consultants & Middle Grade doctors relative to demand) Workforce availability and productivity relative to demand

Non-admitted

Physical capacity for the non-admitted stream compromised due to congestion in the department arising from patients waiting for beds

UCC Workforce availability and productivity relative to demand

Paeds Availability of beds/short stay paediatric assessment beds

9. In addition to these factors, there has been a change in demand, with a

rise of A&E attendances and admissions to hospital.

Section 3: Current improvement interventions 10. There is an improvement programme established to support patient flow

which has 5 key components. Linked to this, is a programme to improve the level of permanent staffing across the emergency care pathway, but with a particular focus on A&E and Acute Medicine.

11. The key components are aligned to our diagnosis of the drivers of the

problem as shown in the table below. The focus to date has been substantively on moving discharges to earlier in the day.

Pathway Key Interventions Status Impact

1. Discharge of patients earlier in the day 2. Increase discharges through improved

discharge arrangements for simple and complex discharges

3. Improved assessment units with senior clincial decision makers

4. Alternatives to admission 5. Increased bed capacity

Admitted

6. Improved bed management 7. Implementation of majors-lite 8. Match workforce availability to demand

Non admitted

9. Improve the proportion and availability of permanent senior decision makers

UCC 10. Improve workforce model and productivity

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AGENDA ITEM 2.2

12. To date, the key area of focus has been on improving the timing of bed availability and good progress has been made, indicated in the chart below.

Wards in the scope of the improvement programme

All wards (QH)

13. The increase in earlier discharges has not on its own been sufficient to

improve performance, in part because it remains subject to significant variation and is not matched to the required number of beds being available at specialty level relative to the demand, and in part because it has exposed other areas that require improvement such as communication and bed management and the assessment units.

14. Therefore the next stages of the improvement work focus on:

a. Embedding and stretching earlier discharges, and increasing overall discharges through process and capacity changes

b. Better matching of required bed availability to actual discharges at specialty level

c. A significant programme of work focused on implementing the London quality standards in the assessment unit, and implementing a dedicated frailty unit

d. Improving bed management systems e. Increasing the role of ambulatory care in all specialities f. Implementing majors-lite, and embedding the team based approach

in ED. g. Creating a focused workforce for UCC, with increased capacity.

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AGENDA ITEM 2.2

15. A set of proposals to support these areas has been submitted to the NHS TDA and NHS England for winter resilience funding, which would build on the initial allocation which has been focused on out-of-hospital services to support discharge.

16. The Trust is being supported by additional external resource and expertise across these areas. In addition the Intensive Support Team is providing support and guidance.

17. The availability of senior permanent clinical decision makers remains a key driver of improvement, and remains a key area of risk for the Trust.

18. The Trust has made contact with external clinicians who may offer

support, advice and coaching to internal clinicians and is seeking to develop and offer a bespoke attraction package encourage and support clinicians to take up roles at the Trust. This would be focused on both identifying and encouraging established clinical leaders as well as cohorts of trainees coming to the end of their training programmes.

Section 4: Expected impact of interventions 19. The analysis that has been undertaken estimates that the collective

improvement interventions, both in hospital and out of hospital could lead to an improvement of 10% up to the end of the financial year. The Trust is currently discussing the phasing of the interventions with partners.

Section 6: Strategic implications 20. The improvements described are largely tactical in nature, and it is

important that some of the strategic considerations are at least referenced for context at this stage, for the Board to be aware of and to return to at a future date as performance is stabilised. The key issues are considered to be

The separation of emergency and elective flows An ability to attract and retain senior clinical decision makers The clinical model and sizing of acute services Creating a culture of continuous improvement and implementation

of best practice

Recommendation 21. It is recommended that the Board note the diagnosis of the

underperformance, and agree the proposed interventions and consider further actions required of the Executive.

Steve Russell Deputy Chief Executive

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1

Date of Trust Board: 5th November 2014

Title of Paper: Finance Report – Month Six (September) 2014/15

Summary

The September in-month position shows a deteriorating financial position, due to increasing Agency spend and the failure of some QCIP schemes. The income and expenditure deficit in month was £3.8m, which was £1.4m adverse to budget. This increases the year to date deficit to £21.0m, which is £1.5m adverse to the budget of £19.4m.

There was a significant increase in retrospective temporary staff bookings across the Trust in Month 6 (up from £0.2m on average, to circa £0.7m, i.e. an increase of £0.5m in one month), which is evidence of uncontrolled and escalating pay costs. See graph on Agency usage on page 4.

Rising Agency usage is against a backdrop of Directorates being tasked with delivering a £3.0m reduction in agency costs compared to last year as part of the QCIP programme. Weekly meetings with Directorates are continuing to take place to agree prospective bookings, and a review of retrospective bookings is being undertaken by the COO, however Agency costs continue to rise. Overspending in the Acute Medicine Directorate increased further in Month 6 (£0.5m in M6, compared with an average of £0.3m to M5), including overspending of £0.3m on medical staffing due to higher agency costs. Overall staffing in the Directorate was 53 FTE over- budgeted establishment in Month 6 (see page 30)

Improvement Plan. Costs of £0.9m were booked to the Improvement Plan as at Month 6, including £0.4m of professional fees. Additional funding of £0.8m relating to the Improvement Plan was accrued to offset these costs.

Overall funding for the Improvement Plan has yet to be formally confirmed, but is likely to be £2.25m from CCGs, with a further £1.3m from the TDA/NHS England.

The forecast of green & amber rated QCIP savings has reduced to £7.0m for the full year, against the QCIP target of £19.6m (from a forecast of £7.9m in Month 5), a shortfall of £12.6m. However there are a further £3.8m of red CIP schemes (including £3.0m related to the agency staff expenditure) which would increase delivery to £10.8m, a shortfall therefore of £8.8m against the target. Uncommitted budget reserves are covering £6.5m of the QCIP shortfall, leaving a residual gap of £2.3m.

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2

The current Full Year Financial Forecast for 2014/15, and the actions necessary to meet the financial control total is summarised as follows:

In-year performance

Balance Sheet Releases

Net of Balance sheet

releases

£000's £000's £000's

Underlying 48,737 (3,837) 44,900

RTT - 50% of income recovered 5,500

5,500

Worst Case 54,237

50,400

Improvement Plan funding (3,000)

(3,000)

RTT - 75% of income recovered (2,750)

(2,750)

Likely Case 48,487

44,650

Agency Savings (3,000)

(3,000)

RTT - 100% of income recovered (2,750)

(2,750)

Red CIP (800)

(800)

Best Case 41,937

38,100 It is important for the Trust Board to note that for the Financial Control Total for 2014/15 to be met; - that due to the increase in agency usage reported in September, plus the reduction in QCIP

delivery reported in September, that the current full year financial forecast described above, even though the financial control total is still forecast to be met, will create a cash shortfall of £3.8m (the balance sheet reserves), which can only be met by increasing creditors.

- that the red rated QCIPs of £3.8m, including the £3m agency reduction target will need to be delivered in full.

- that the expenditure currently badged against the Improvement Plan at Month 6, (£0.9m year to date, and full year cost £2.6m) will need to be covered by Improvement Plan funding, otherwise additional QCIPs over and above the red rated £3.8m will be required if the Control Total is still to be met.

- that any new expenditure authorised on the Improvement Plan (which will be principally additional

agency/locum posts) is done so at extremely high financial risk due to the lack of control on temporary staffing, particularly agency usage.

- and that RTT backlog clearance costs are covered by the additional RTT funding. This risk is

explained in more detail below.

In conclusion the Board should note that;

- the Trust’s Financial Position has deteriorated significantly in September, principally due

to the lack of control of temporary staffing usage and declining QCIP delivery.

- and that without immediate and effective management action to reduce expenditure, and

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3

a halt on any additional investments, the Trust will at best be left with a significant cash

shortfall of £3.8m, and will also fail to meet the 2014-15 Financial Control total.

Following consideration of the M6 Finance Report at the TEC and FIC, the CEO has written

to all Corporate & Clinical Directors setting out the following requirements:

1. Executive and Clinical Directors are expected to personally review agency staff costs with

ADOs/GMs/FMs/HRMs, on a post by post basis, and identify how the £3m agency target will be delivered for your directorate. The baseline for this reduction is the Month 6 forecast outturn expenditure position for the directorate and the savings must be net, i.e. there cannot be increases in other expenditure headings, which offset these savings.

2. Dr Magda Smith with assist with a critical line by line review of the Medical Staff agency costs in

each directorate.

3. Requiring Directors to ensure that all of their management teams are clear that retrospective staff bookings (i.e. being entered onto the system after the shift has been worked) must stop, and hold any staff member to account that is unable to comply with your reasonable management instruction.

4. That Directorates will be advised of their financial allocations for agency staff expenditure (based

on the M6 forecast less the directorate’s share of the £3m target) and are required to develop a plan for how they will meet the required reduction. This plan will be monitored on a weekly basis at the Monday morning meetings chaired by the CEO. Any directorates exceeding their target will be held to account at the meeting & authorisation rights may be removed and/or escalated.

Other Key Risks & Mitigations

RTT backlog clearance. Income of £1.4m has been accrued for the additional work undertaken to date to clear the RTT 18 week backlog. £1.0m of this relates to the work outsourced to the ISTC, with expenditure budgets allocated to the relevant clinical Directorate, and £0.4m to the cost of additional internal theatres session. Funding of £4.2m has been confirmed to support the backlog clearance, with a further £4.25m earmarked from phase 2 of the Winter Resilience funding and the CCGs indicating that they will increase this by a further £3.0m to the total £11.3m that the Trust is projecting it will require to clear the admitted backlog. However RTT clearance remains a significant financial risk because

- not all the RTT funding available has been confirmed,

- the Trust may not be able to demonstrate to commissioners that it has increased activity over and above 2014/15 contracted levels, and therefore may not receive all the additional RTT income, even though additional expenditure has been incurred,

- and the costs incurred in delivering increased RTT activity may exceed the income received,

due to premium rates being used for internally generated activity.

Agency Controls – see graph below

Patient Safety implications: n/a

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Risks: Reported Above

Financial implications: Reported Above

Legal advice and implications: CORPORATE OBJECTIVE To achieve financial security for the Trust, with reduced costs, improved productivity and collecting income due

Consultation (including patient and public involvement):n/a

Communications: n/a

Equality Impact implications: n/a

Reviewed by/action taken? n/a

Recommendations: The Trust Board is requested to note this report, and the actions required to deliver the control total.

Author and Lead Officer (if different):

Author: Nick French, Head of Financial Management Lead Officer: Alan Davies, Acting Director of Finance

Date(s) for further review n/a

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5

43

6

CONTENTS

1. SUMMARY I&E POSITION .................................................................................................................................... 7

2. KEY DRIVERS OF PERFORMANCE ....................................................................................................................... 10

3. CLINICAL INCOME ..................................................................................................................................... 15

4. ANALYSIS OF PAY SPEND ................................................................................................................................... 20

5. ANALYSIS OF NON-PAY SPEND .......................................................................................................................... 25

6. COST IMPROVEMENT PROGRAMME ................................................................................................................. 26

7. BALANCE SHEET ................................................................................................................................................. 26

8. CAPITAL AND CASHFLOW .................................................................................................................................. 30

APPENDICES

A. Pay Spend and WTE’s by Directorate ................................................................................................................ 31

B. Weekly Agency Trend ........................................................................................................................................ 32

C. Non-Pay Spend by Directorate .......................................................................................................................... 33

D. CQUIN Update ................................................................................................................................................... 35

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1. SUMMARY I&E POSITION

Key Performance MetricsYTD Actuals

£000'sYTD Variance

£000'sYTD

Variance % Plan £000's

Income (235,881) 891 2.2% (467,207) Expenditure 256,833 (2,402) (5.3%) 505,177Net Position 20,952 (1,512) (55.2%) 37,970EFL 44,669CRL 25,585Cash 1,000

Summary of Year to date variances £000's

£000's

Total

Operational

Variances

Allocation of

reserves to pay

or non-pay Sub Total

Allocation of

CIP to pay /

non-payUnderlying Variance

Income 891 891 891Pay (210) 2,642 2,432 (4,313) (1,882)

Non-Pay (566) 1,389 824 (1,056) (232) Uncommitted Reserves 4,032 (4,032) -

CIP (5,369) (5,369) 5,369 () Non-Operating (289) (289) (289) Net (1,512) - (1,512) (1,512)

Adverse variance against plan of £1.5m to Month 6, with unallocated budget reserves of £0.4m partially offsetting CIP shortfall of £1.6m

Note that the External Financing Limit (EFL) and Capital Resource Limit (CRL) are provisional year-end figures in the annual plan, and should be confirmed by the Department of health in the 4th quarter.

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The table above shows I&E performance, both before and after allocation of any undelivered CIP in the month, in order to show the underlying expenditure position. Forecast assumes £3.0m improvement plan funding to offset committed expenditure, £3.0m additional agency savings, and £3.8m of provisions from balance sheet.

Trust I&E Summary (+ve variances = favourable, -ve = adverse)

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9

Financial Risk Rating & KPIs (from 2014 TDA NHS Trust Accountability Framework)

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10

2. KEY DRIVERS OF PERFORMANCE

Key Drivers of Performance Income

Income was £0.9m favourable in month, largely related to a£0.8m income accrued into the position to offset expenditure related to the improvement plan. As with month 6, the income position includes an accrual of £1.3m in relation to RTT 18 week backlog clearance, via the ISTC and additional operating sessions internally. The Trust has been formally notified of £4.1m additional central funds for RTT, and the Trust is undertaking further work to assess the full financial impact of the 18 week backlog going forward. The Trust’s assessment of the value of the work required to fully clear the admitted backlog is c. £11m (see section 3 for further details on

income performance).

Pay

£0.4m over-spending in month, with £0.1m of uncommitted central pay budget reserves included in the budget (so an underlying overspend of £0.5m). Pay cost in month includes an additional £0.5m of retrospective agency bookings over and above recent levels, across most Directorates. Overspends in Medical Staffing (£0.6m), primarily in Medicine, Specialist Surgery and Surgery, and in Nursing (£37k) largely in Anaesthetics, are offset by underspends in Management & Admin Staff budgets, mainly in Chief Executive (mainly PMO and Acute reconfiguration), although expenditure on professional services (classified under non-pay) in these areas partially offset this. Actual pay increased by £1.0m in M06 compared with M05, with agency up £308k, Bank up by £349k, and Substantive Staff up by £338k (Bank and Agency in part due to the increase in retrospective bookings referred to above). At a staff group level, Medical Staff have increased by £510k, Nursing by £353k and Management & Admin by £91k.

YTD underspend of £2.4m largely driven by £2.6m profiled from uncommitted central pay budget reserves, therefore an over-spend against operational budgets £0.2m. Medical Staff overspending (£2.0m) largely driven by high agency costs in Medicine, Pathology, Specialist Surgery and Surgery. Underspending In Management & Admin (£1.8m) is primarily Strategy & Planning (largely IT, where there are a significant number of vacancies), and Chief Executive (including PMO and Reconfiguration ) (see section 4 for further details)

Non-Pay

Non-pay is £0.3m adverse to budget in month, with in month spend of £13.6m In month overspend is largely in Other Non-Pay (£0.7m), due to professional fees for the Improvement Plan which have been offset by accrued income anticipated in support of this.

The YTD position is underspent by £0.8m, which is primarily made up from uncommitted Reserves (see section 5 for further details), and high cost drugs (offset by pass-through income)

QCIP

The in-month QCIP position is £1.6m adverse to plan, largely due to unidentified schemes rather than slippage on identified schemes. The main focus now is on delivery of the identified schemes, and on bearing down on agency costs to close the gap (see section 6 for further details)

Action / Mitigation

Complete work to assess cost impact of RTT 18 week backlog and confirm with commissioners and the TDA funding available.

Continued review of high cost agency staff and review of medical staff rotas, to mitigate overspend on medical agency staff. Trust exec has adopted agency reduction as a form CIP target, with an anticipated saving of £3.0m in this financial year Further work to establish cost of delivering 18 week RTT backlog clearance internally (as opposed to out-sourced element, which is included in Non-Pay)

Weekly agency review meetings with Directorates, chaired by CEO, to review temporary staff bookings, to continue Additional actions agreed by Executive team to review high cost agency staff and medical staff rotas, including formalisation of £3.0m agency savings target over the remainder of the year.

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11

Directorate Financial Performance, ranked in descending order of YTD overspend

Clinical / Executive Director General Manager

Budget £000's

Actual £000's

Variance £000's

Budget £000's

Actual £000's

Variance £000's

Variance %

CIP Gap £000's

Underlying Variance £000's

Forecast £000's

Var to Budget £000's Var %

CIP Gap £000's

Underlying Variance £000's

Central Income (430,713) (36,065) (36,145) 80 (215,756) (215,853) 97 0.0% 97 (431,504) 791 0.2% 791

RTT (1,400) (320) (320) (1,400) (1,400) 0.0% (4,100) 2,700 192.9% 2,700

Clinical Directorate

Medicine Sreeman Andole Ben Conw ay 43,252 3,612 4,103 (491) 22,034 23,864 (1,830) 8.3% (955) (875) 47,887 (4,634) (10.7%) (2,181) (2,454) Anaesthetics Oluremi Odejinmi Jeff Middleditch 45,436 3,903 4,122 (219) 23,157 24,236 (1,079) 4.7% (467) (613) 48,360 (2,924) (6.4%) (1,726) (1,198) Specialist Surgery Gabriel Sayer Joyce Hartzenberg 19,101 1,780 2,143 (363) 10,254 11,010 (756) 7.4% (279) (477) 20,751 (1,649) (8.6%) (558) (1,092)

Radiology Zoltan Nagy Seeni Naidu 20,160 1,660 1,690 (30) 10,119 10,698 (579) 5.7% (295) (284) 20,704 (543) (2.7%) (697) 153Women Dele Olorunshola Laura Beck 35,521 2,885 2,941 (56) 17,729 18,155 (426) 2.4% (593) 167 36,491 (970) (2.7%) (1,224) 254

Surgery Dip Mukherjee Julia Bell 20,424 1,731 1,907 (175) 10,501 10,909 (409) 3.9% (261) (148) 21,702 (1,279) (6.3%) (709) (570) Support Services Neil Hardy n/a 9,135 753 866 (113) 4,617 5,024 (407) 8.8% (212) (195) 9,984 (849) (9.3%) (531) (318) Neurosciences Jonathan Pollock Cass O'Reilly 13,649 1,159 1,209 (50) 6,915 7,298 (383) 5.5% (309) (74) 14,595 (946) (6.9%) (723) (223) Pathology Geraldine Soosay Len Kemp 21,668 1,794 1,759 36 10,976 11,327 (350) 3.2% (457) 107 22,415 (746) (3.4%) (984) 238

Children Ambalika Das Aleks Hammerton 14,884 1,254 1,307 (52) 7,513 7,700 (187) 2.5% (272) 85 15,461 (578) (3.9%) (709) 131Emergency Care Donna Kinnair Will Harrison 23,914 1,985 2,104 (119) 12,079 12,174 (95) 0.8% (153) 58 24,391 (477) (2.0%) (350) (128) Care of the Elderly Ayo Ahonkhai Jo Barrett 15,877 1,299 1,347 (48) 8,159 8,197 (38) 0.5% (81) 43 16,359 (482) (3.0%) (449) (33) Specialist Medicine Jane Stevens Lucy Gladman 34,876 2,892 3,105 (213) 17,696 17,727 (31) 0.2% (170) 139 35,175 (299) (0.9%) (725) 425Therapies n/a Vikki Butler 9,415 776 819 (43) 4,758 4,768 (10) 0.2% (142) 132 9,477 (62) (0.7%) (397) 336

Subtotal - Clinical Directorates 327,313 27,483 29,421 (1,937) 166,509 173,090 (6,582) 4.0% (4,648) (1,933) 343,753 (16,439) (5.0%) (11,961) (4,478)

Subtotal - Corporate Directorates 87,931 7,272 7,886 (614) 44,046 44,396 (350) 0.8% (721) 370 89,125 (1,194) (1.4%) 216 (1,410)

- Sub-total (16,869) (1,629) 842 (2,471) (6,602) 233 (6,834) (103.5%) (5,369) (1,465) (2,726) (14,143) (83.8%) (11,745) (2,398)

Central adjustments 130 (130) (829) 829 0.0% 829 (829) 829 0.0% 829-Improvement plan funding (750) 750 (750) 750 (3,000) 3,000 0.0% 3,000-Agency Saving (CIP) & Red CIP (3,800) 3,800 0.0% 3,000 800-Balance sheet provisions (3,837) 3,837 0.0% 3,837Reserves - Winter Pressures 4,000 0.0% 4,000 0.0%Reserves - RTT 0.0% 3,000 (3,000) 0.0% (3,000) Other Reserves 6,818 414 414 4,032 () 4,032 (100.0%) 4,032 1,144 5,674 83.2% 5,674Depreciation 16,430 1,369 1,389 (19) 8,215 8,334 (119) 1.4% (119) 16,549 (119) (0.7%) (119) PDC & Net Interest 27,772 2,314 2,211 103 13,886 13,960 (74) 0.5% (74) 27,600 172 0.6% 172Subtotal - Non-Operating Budgets 55,020 4,098 2,980 1,118 26,133 20,715 5,418 (20.7%) 5,418 40,827 14,193 25.8% 9,503 4,691

Total 38,151 2,469 3,821 (1,353) 19,531 20,948 (1,416) 7.3% (5,369) 3,202 38,100 51 0.1% (2,242) 2,293

IFRS reversed (181) (15) (13) (2) (91) 5 (95) 105.2% (95) Net position 37,970 2,453 3,808 (1,355) 19,441 20,952 (1,512) 7.8% (5,369) 3,107 38,100 51 0.1% (2,242) 2,293

2014/15 In MonthMangement Team

2014/15 Annual

Budget/Plan

£000's

2014/15 Year to date 2014/15 Forecast

A bullet point commentary on the key variances for each Directorate is given on the following pages:-. It can be seen that a recurrent theme apart from the QCIP shortfall is overspending on medical staff budgets (see page 17), due in part to the use of high cost agency staff Acute Medicine and Anaesthetics account for 44% of the overspending (including QCIP shortfall) within clinical directorates. Acute Medicine is reporting 53.17WTE over establishment (ref page 28.)

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Directorate Comments

Medicine Medicine were overspent in month by £491k and is overspent by £1,830k YTD. The Key drivers for the YTD position are: • Income £122k Overachieved- local income has improved due to increase in Bowel Cancer Screening £25k and overseas paying patient £46k • Pay £976k Overspent- Medical Staff is overspent by £883k due to usage over and above funded establishment, c£150k of this is attributable to the implementation of the Improvement Plan. Nursing is overspent by £160k, predominantly due to sickness cover and 1:1 Specialling. The Business Unit is still working on delivery of a recovery plan to reduce the monthly spend, primarily throug recruitment and retention initiatives and restructuring of the medical staff rotas. • QCIP - The YTD QCIP failure is £955k. The Full Year Gap stands at £2,191k (90% of the target).

Anaesthetics Anaesthetics reported an overspend of £(0.2m) in month and are overspent £(1.1m) YTD. The Key drivers for the YTD position are: • Pay £(0.5m) overspent mainly from Nursing £(0.4m) due to high acuity of patients and use of recovery in ITU. • QCIP £(0.5m) CIP slippage {Forecast gap of £(1.6)m}.

Radiology Radiology has overspent by (£30k) with a YTD overspend of (£579k). The main drivers for the YTD position are; Income has underperformed by (£98k), which is driven by the expected non-payment by the Local Commissioners regarding their contribution to the Community X-Ray service that Radiology provides at Harold Wood, currently under dispute. Pay overspent by (£476k) YTD as QCIP slips by (£266k) and Scientific staff overspend by (£173k) due to additional Bank & Agency spend to meet

demand and cover vacancies. Non-Pay overspends (£5k) YTD. There are large variances within this as Clinical Supplies under-spending of £236k is offset by underperforming

QCIP (£29k) & the cost of hiring a mobile scanner (£110) together with an (£80k) adverse variance against budget to clear e backlogged scans.

Specialist Surgery Specialist Surgery reported an overspend of £(0.4m) in month and £(0.8m) YTD. The YTD position is driven by the following reasons: • Pay £(0.5m) adv primarily from Medical staff £(0.4m) due to (1) high cost agency staff (2) Additional sessions in relation to RTT. • QCIP £(0.3m) YTD slippage.

Pathology Pathology underspent by £36k in month, with a YTD overspend of (£350)k. The main drivers for the YTD position are; Income has underperformed by (£80)k due to an historic income target which is no longer applicable and has been removed going forward. Pay is overspent by (£420k) due to Medical Staff spend on Bank & Agency (£209k) to cover vacancies, which have now been recruited to, and

QCIP slippage (£316)k. Non Pay is underspent by £149k as Clinical Supplies and Blood Products underspend by £283k, which is partly offset by QCIP Slippage of (£141)k.

Women Women reported an in month overspend of £(60)k and overspent YTD by £(430)k. The key drivers for the YTD position are: •Income: £(70)k under-recovered on overseas patients income, •Pay: £360k underspent - Medical Staff is £240k under-spent due to vacant posts, and £60k underspent on nursing posts. These posts have not been covered to their full level by temporary staff. Posts are due to be filled imminently as the recruitment process is completed. •Non Pay: £(70)k overspent YTD driven by £(100)k bad debt provision. •QCIP £(600)k slippage with an unidentified gap of £(1.26m) .

Neurosciences Neurosciences overspent in month by £(50)k, increasing the year to date overspend to £(383)k. The key drivers for the YTD position are:- •Income: £(225)k under-performance YTD, of which £54k relates to shortfalls in private/overseas income, and £170k from a shortfall against budget for consultant clinical recharges. An unrealistic income target had been found to have been brought fwd from the previous year, which will be reviewed going forward.

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• Pay::Ytd underspend of £113k overall. Overspends in Medical Staff (98k) and healthcare assistants (£67k) are outweighed by underspends in management/admin £87k, qualified nursing £95k and technical staff £96k. Vacancies and use of temporary staff, particularly medical locums account for the variances. • Non Pay Ytd underspend £39k on non-pay, mainly on med/surg equipment across the portfolio. • QCIP slippage is £296k Ytd, with unidentified FOT gap of £723k. £50k of the identified schemes are rated red.

Support Services • In-Month: For the month of September the support services directorate reported an over-spend of £(113)k. The business unit used 28.37 WTE over funded establishment, some of which is used to support RTT and Improvement Plan initiatives. CIP Slippage of £(53)k on unidentified schemes for the month. • Year-to-date: YTD the directorate reports a £(407)k overspend. £(212)k of this is CIP Slippage on unidentified schemes. Pay is overspent by £(150)k and non-pay £(45)k. This expenditure follows the in-month spend with WTE usage over and above funded budgets due to improvement plan and RTT work. Non-Pay expenditure is the employment of an external consultant for the role of Outpatients Improvement Manager. • QCIP £(212)k slippage YTD with a slippage gap of £(530)k

Surgery Surgery reported a position of £(0.2m) adv in month & £(0.4m) adv YTD. The Key drivers for the YTD position are: (1) Pay £(0.3m) adv: Medical staff in General Surgery driven by high agency premiums & extra breast / colorectal activity due to cancer waiting lists. (2) Non Pay £0.1m fav: driven by (a) Reduced theatre usage £0.2m fav (b) Drugs overspend £(0.1m) adv. (3) CIP £(0.2m) adv: CIP slippage

Children Children reported an in month over spend of £(50)k and is £(190)k overspent YTD. The key drivers for the YTD position are: • Pay Excluding CIP, pay is underspent by £30k YTD. Slippage on CIP is £(270)k YTD. Resulting in a net pay position of £(240)k overspent YTD. The business unit used 7.88 WTE less than the funded establishment for the month of September. This is across all staff groups with the exception of medical staffing which is overspent. • Non Pay £70k underspent mainly due to Clinical supplies and appliances within neonates, and drugs underspend • QCIP: YTD £(270)k slippage due to unidentified CIP schemes, with a forecast gap of £710k

Care of the Elderly Care of the Elderly was overspent by £48k in month bringing the YTD to a £38k overspend; Pay - Underspent by £33k YTD - Nursing Staff drives the underspend in month (£18k) mainly due to vacancies at Band 5 which haven't been covered with Temp staff (unfilled IHB shifts). QCIP- Overspent by £81k YTD - The main scheme (Length of Stay) has now slipped to start towards the end of the financial year. The underlying position for Care of the Elderly is that of an underspend, as £130k of the YTD spend was due to the continuation of the winter contingency ward for the first 39 days of the year. The Key risk to the Year End forecast is the failure of the QCIP programme. The gap now stands at £450k.

Emergency Care Emergency Care are overspent by £119k in month and is now £95k overspent YTD; The Key drivers for the YTD position are: • Pay - £153k Underspent YTD - Nursing Staff are now £207k underspent YTD due to the level of Qualified Nursing vacancies. There is a recruitment plan underway and it is anticipated that by the end of the year nursing staff vacancies will significantly reduce. Medical Staff is £64k overspent In month and YTD, this is due to additional staff rostered at KGH overnight (£30k) and staff assigned to the department without the knowledge and authorisation of the Departmental Management (£20k). • Non Pay - £101k Overspent YTD - Overspends on Clinical Supplies and Appliances (£57k) and Drugs (£36k) are the main components of the YTD overspend of £122k for Non Pay. Finance and Proceurement to look into Floorstock processes to ensure appropriate level of stock/usage • QCIP - The YTD QCIP gap stands at £153k YTD with a delivery rate of 70%.

Therapies Therapies overspent in month £(43)k, making the year to date overspend £(10)k. The Key drivers for the YTD position are: • Income (£51k) under-achieved YTD against a budget for central income over-performance, (which is unlikely given cap/collar contract.) • Pay - £232k Underspent YTD due to therapist vacancies in the service • Non Pay - £49k overspent, due to expenditure on orthotics appliances • QCIP slippage is £142k Ytd, with unidentified FOT gap of £397k.

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Specialist Medicine Specialist Medicine have overspent by (£213k), with a YTD overspend of (£31k). The main drivers for the YTD position are; Income has over performed by £253k YTD as the Business Unit is reimbursed for High Cost Drugs this is offset by the overspending Drugs line. Pay is overspent by (£126k) YTD as a failing QCIP drives the position. Non-Pay is overspent by (£159k) YTD as Drugs overspend by (£232k), which is offset by income above, and QCIP underperforms by (£47k). These are both offset by under spending Clinical Supplies £129k which relates to a one off adjustments in Pharmacy £81k and on-going consumable underspends in Oncology £56k.

Corporate Corporate reported an in month overspend of £614k, and is £350k overspent YTD. The key drivers for the YTD position are: • Pay £1,292k underspent YTD largely in the Chief Executive Office £694k mainly due to PMO and Reconfiguration teams £410k and Trust Board various Director vacancy savings of £255k, and in Strategy and Planning £577k. • Non Pay £(773)k overspent due to PMO and Acute Reconfiguration professional fees covering vacancies, and £550k professional fees for the improvement plan • QCIP £(720)k slippage with a forecast over achievement of £216k due to Estates schemes.

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3. CLINICAL INCOME Income Summary

• The Trust has signed contracts with all commissioners.

• The NELC contract has a cap of £305m and a collar (floor) of £304m. This is net of commissioner QIPP of £18.6m and additional funding of £12.6m. All other contracts for 2014-15 are full PbR contracts. This means that PbR tariffs apply and that the actual payment made is wholly linked to the volume of activity undertaken by the Trust adjusted for any performance related penalties.

• All tables in this report reflect Trust performance after adjustment for the Cap and collar contract with NELCSU. The performance includes a YTD value of £1.4m and FOT of £4.1 for 18 weeks referral to Treatment backlog clearance income In relation to funding formally confirmed). The graph on the left shows the current year actuals for Months 1 to 5 and a forecast for the rest of the year.

• In line with the NELC contract performance has been adjusted to reflect the cap and collar arrangement. The YTD over- performance for the contract prior to the cap and collar adjustment is £8.4m and this is mainly due to CCG QIPP non-delivery of £9.3m. The YTD position has therefore been adjusted by £8.1m and FOT by £15.5m to bring it in line with the contract. The delivery of CCG QIPP schemes could bring the performance back in line with the contractual values as the year progresses. The NELC income position also assumes £5m winter pressures funding.

• The current Trust plan does not reflect the agreed contract value for NHSE

for £53m. Due to the late signing of the contract and the over performance on the NHSE contract, the view has been taken to retain the Trust’s original plan for NHSE.

• The NHSE contracts show an over-performance of £756K YTD, and £1,354k FOT against the Trust plan of £61.8m. The main areas of over-performance in the specialist element of the contract are Drugs and Devices and Regular day attenders. This month, the over- performance on Drugs has been devolved to the directorates.

• The financial position includes PFI funding of £16.4m, showing an increase of £400k on prior year. The increase represents indexation on the PFI funding.

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Directorate Income

Income

Annual

Budget

£000

YTD

Budget

£000

YTD Actual

£000

YTD

Variance

£000

Education (13,515) (6,919) (7,003) 84HCA (3,207) (1,603) (1,571) (32)Estates (3,521) (1,760) (1,773) 13Oncology (2,598) (1,559) (1,809) 250R&D (1,748) (874) (698) (176)Private Patients Revenue(190) (95) (234) 139Non NHS Overseas Patients(1,005) (503) (422) (81)Other (9,309) (4,520) (5,115) 595Total (35,094) (17,835) (18,627) 793

Directorate income is under-performing YTD The over performance in Oncology mainly relates to Individual request cancer drugs. The income received is currently above plan. R&D is down on performance due to timing differences in the raising of the invoices. Overseas patients’ income is currently underperforming; however there is a risk around that income as on average, the Trust is only able to recover 30% of all invoices raised to overseas patients. Private patients are performing better to date.

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Clinical Income by Directorate

Business Unit FOT £'000

FOT Var

£'000

YTD Actual

£'000

YTD Var

£'000

% on

Plan

Medicine (83,457) 286 (41,810) 46 0%Anaesthetics (21,037) (1,214) (10,545) (610) -5%Care of the Elderly (9,387) (1,207) (4,704) (604) -11%Children (22,387) 1,319 (11,214) 645 6%Emergency Care (24,709) 608 (12,403) 322 3%Neurosciences (29,428) 78 (14,737) 48 0%Pathology (11,018) (36) (5,509) (7) 0%Radiology (14,635) (887) (7,318) (422) -5%Specialist Medicine (43,868) 2,345 (21,953) 1,108 5%Specialist Surgery (45,883) (337) (23,167) (89) 0%Surgery (45,582) (838) (21,966) (328) -1%Therapies (2,600) (338) (1,300) (163) -11%Women (56,148) 610 (28,123) 386 1%Corp (9,066) 528 (4,305) (33) -1%Central income Total(419,204) 919 (209,053) 300PFI Funding (16,400) 0 (8,200) 0Grand total (435,604) 919 (217,253) 300

Summary of YTD Performance

Desc

Total

£'000

NELC

£'000

Other

Commisoners

£'000 Comments

Net under-performance 300 500 (200)

Breakdown:QIPP 9,336 9,336 0NELC adjusment (8,118) (8,118) 0Performance (918) (718) (200)

- Non Elective 744 652 92 - Other (1,662) (1,370) (292)Total (918) (718) (200)

Directorate Summary • Commissioner QIPP is currently shown against Corporate, so is

the £8.1m NELC cap & collar adjustment. The Clinical Directorate’s position therefore reflects an activity based position excluding QIPP and contract adjustments.

• The movement in the corporate Directorate mainly relates to the cap and collar adjustment.

• Anaesthetics has moved adversely due to CC-ITU data process change in bed days number and reduced activity in month 5

• Specialist Medicine has the highest level of over-performance; this mainly relates to Non- Elective activity. The over-performance is across all specialties in the Directorate.

• The over-performance in Women mainly relates to ante-natal pathway and outpatient first attendances in Gynaecology.

• Children over-performance is driven mainly by Critical care • Emergency Care’s over performance is mainly due to

improvement in coding in A&E. • The underperformance in Care of the Elderly mainly relates to

Non elective activity. • Radiology underperformance mainly relates to unbundled

radiology, there was an anomaly in the data for the first 4 months of the year, which has now been corrected.

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Clinical Income by POD

POD Group £ FOT £ FOT Var YTD £ Actual YTD £ Var

AandE (22,150) 601 (11,121) 318Ambulatory Care (1,176) 155 (588) 76Breast Screening (2,197) (187) (1,098) (89)CQUIN (6,633) (2,212) (3,317) (1,106)Critical Care (25,970) 105 (13,021) 57Daycases (35,748) (884) (17,873) (376)Devices & Drugs (21,002) 389 (10,501) (108)Direct Access (17,626) (224) (8,813) (79)Elective (26,202) 1,025 (13,104) 558HIV Contract (5,458) 0 (2,729) 0Unbundled Radiology (6,014) (735) (3,007) (352)ISTC Contract (395) 104 (197) 52Maternity Pathway (17,967) (353) (9,008) (117)Metric 2,500 0 1,250 0Non Elective (132,192) 1,462 (66,279) 744OP First Attendances(26,318) 126 (13,159) 156OP Follow Ups (24,851) (985) (12,425) (447)OP Procedures (7,479) (671) (3,735) (326)Other (22,399) (14,699) (10,342) (7,667)Patient Transport Services(4,642) 28 (2,321) 14QIPP 0 18,620 0 9,336Radiotherapy (4,410) 691 (2,211) 359Readmissions 4,603 0 2,301 0Regular Day Attenders(5,822) (128) (2,919) (51)Road Traffic Accidents(2,402) 28 (1,201) 14XBD (7,252) (1,336) (3,636) (667)Central income Total(419,204) 919 (209,053) 300PFI Funding (16,400) 0 (8,200) 0Grand total (435,604) 919 (217,253) 300

• Overall the Trust activity YTD is higher compared to the same period last year. This is most noticeable in Critical care, radiotherapy activity and Outpatient first attendances.

• The 18 week backlog clearance has started and the activity has started to come through, leading to a modest over performance on the Elective in-patient line, although Day Cases remains marginally below Plan.

• The under-performance in Outpatients mainly relates to late out-coming of patients. This month, the total un-outcomed activity in Outpatients is 1.5%. (Un-outcome activity is where the activity takes place but the recording is not fully completed on Medway, hence it is not billable).

• Non-elective activity continues to over perform; there appears to be improvement in coding particularly in Trauma and Orthopaedics and General medicine and Geriatric medicine.

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4. ANALYSIS OF PAY SPEND

Analysis of Pay Spend by Category & Type

Summary Level Staff Type Budget WTE

Adj Actual

WTE

Adj

Variance

WTE

In Month

Budget

£000's

In Month

Actual

£000's

In Month

Variance

£000's

YTD Budget

£000's

YTD Actual

£000's

Ytd

Variance

£000's % of Total

Reserves in YTD

Budget £000's

Reserve

Adjusted

Variance

£000's

Medical Staff 1,008.92 1,028.6 (19.7) 7,818 8,443 (625) 48,745 48,748 (3) (0.1%) 2,055 (2,058) Nursing & Midwifery - Qual. 2,208.73 2,155.6 53.1 8,596 8,353 243 51,108 49,567 1,540 63.3% 587 953Nursing & Midwifery - Unqual. 788.18 856.9 (68.7) 1,768 1,975 (206) 10,267 11,342 (1,076) (44.2%) (1,076) Ancillary Staff 307.08 306.2 0.9 857 885 (28) 5,205 5,318 (114) (4.7%) (114) Scientific, Therap & Technical 997.53 980.4 17.1 3,742 3,747 (5) 22,473 22,192 281 11.5% 281Management & Admin Staff 1,153.57 1,142.8 10.8 3,574 3,314 260 21,446 19,642 1,803 74.2% 1,803

Total 6,464.01 6,470.57 (6.56) 26,355 26,715 (361) 159,242 156,810 2,432 100.0% 2,642 (210)

Memorandum - CIP Adjusted 6,139.95 6,470.57 (6.56) 25,033 26,715 (1,682) 154,929 156,810 (1,882) 100.0% 2,642 (4,524)

Action / Mitigation

A review for the Executive team of agency spend on a post by post basis is underway. It has been agreed by the Trust exec team to formalise this into a CIP. Medicine Directorate subject to additional performance meetings with the Director of Finance and Chief Operating officer, to develop a credible plan to restore financial balance. This is on-going.

Key Drivers

Increase in pay spend of £1.0m in month compared to Month 05, driving a £0.4m overspend in month. This position is made up of underspends in Management & Admin (£260k), and in Nursing (£37k) offset by overspends in all other staff groups, but most significantly in Medical Staff (£625k). After discounting the reserve budget of £126k in month, pay spending is £487k overspent. In month position includes £0.5m of retrospective bookings over and above that seen in recent months adding further volatility into the position. On an YTD basis, budgets are underspent by £2.4m. However, this includes £2.6m YTD of reserve budgets. Discounting the reserve budget changes this to an overspend of £210k, mainly in Medical Staff (£2.1m), and Nursing (£123k) offset by underspend in Management & Admin (£1.8m) Overall number of staff WTEs used is 6.56 less than budget, with booking of Medical and Nursing Staff in excess of vacancies of vacancies (19.7 and 15.6 respectively), offset by vacancies in other areas. The YTD Medical Staff overspend of £2.06m was largely in Medicine (£0.9m), Specialist Surgery (£0.6m), Surgery (£0.3m) and Pathology (£2.0m). Underspend In Management & Admin (£1.8m) is largely in Strategy & Planning (£0.6m – where there are have been a significant number of vacancies), and Chief Executive (£0.5m - PMO and Reconfiguration and trust board, partly offset by Non-pay overspend of £0.8m, due in part to use of professional services rather than permanent staff (see non-pay section) )

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Summary Level Staff Type Budget WTE

Adj Actual

WTE

Adj

Variance

WTE

In Month

Budget

£000's

In Month

Actual

£000's

In Month

Variance

£000's

YTD Budget

£000's

YTD Actual

£000's

YTD

Variance

£000's % of Total

Reserves in

YTD Budget

£000's

Reserve

Adjusted

Variance

£000's

Medical Staff

Agency 5.11 100.81 (95.70) 215 1,330 (1,115) 1,412 7,297 (5,885) 15.0% (5,885) Bank 1.95 43.51 (41.56) 22 686 (664) 135 3,348 (3,213) 6.9% (3,213) Permanent 1,001.86 884.30 117.56 7,581 6,427 1,154 47,198 38,103 9,094 78.2% 2,055 7,039

Medical Staff Total 1,008.92 1,028.62 (19.70) 7,818 8,443 (625) 48,745 48,748 (3) 100.0% 2,055 (2,058)

Nursing & Midwifery - Qual.

Agency 0.00 87.11 (87.11) 0 517 (516) 1 2,639 (2,638) 5.3% (2,638) Bank 12.29 172.40 (160.11) 95 655 (560) 637 3,397 (2,760) 6.9% (2,760) Permanent 2,196.44 1,896.12 300.32 8,501 7,181 1,320 50,470 43,531 6,939 87.8% 587 6,352

Nursing & Midwifery - Qual. Total 2,208.73 2,155.63 53.10 8,596 8,353 243 51,108 49,567 1,540 100.0% 587 953

Nursing & Midwifery - Unqual.

Agency 0.0%Bank 4.30 158.64 (154.34) 7 408 (401) 34 2,136 (2,101) 18.8% (2,101)

Permanent 783.88 698.26 85.62 1,761 1,567 194 10,232 9,207 1,026 81.2% 1,026Nursing & Midwifery - Unqual. Total 788.18 856.90 (68.72) 1,768 1,975 (206) 10,267 11,342 (1,076) 100.0% (1,076)

Ancillary Staff

Agency 0.00 3.10 (3.10) 0 9 (9) 0 73 (73) (100.0%) (73) BankAgency 0.80 50.86 (50.06) 11 318 (306) 73 1,811 (1,738) 8.2% (1,738)

Bank 0.00 19.92 (19.92) 0 85 (85) 0 532 (532) 2.4% (532) Scientific, Therap & Technical Total 997.53 980.43 17.10 3,742 3,747 (5) 22,473 22,192 281 100.0% 281

Management & Admin Staff

Agency 0.30 14.67 (14.37) 111 111 (0) 732 606 126 3.1% 126Bank 0.31 138.15 (137.84) 46 347 (301) 356 1,684 (1,328) 8.6% (1,328) Permanent 1,152.96 989.99 162.97 3,416 2,855 561 20,357 17,352 3,005 88.3% 3,005

Management & Admin Staff Total 1,153.57 1,142.81 10.76 3,574 3,314 260 21,446 19,642 1,803 100.0% 1,803

Total (Agency) 6.21 256.55 (250.34) 337 2,285 (1,947) 2,218 12,426 (10,208) 7.9% (10,208)

Total (Bank) 18.85 532.62 (513.77) 171 2,181 (2,010) 1,163 11,097 (9,934) 7.1% (9,934)

Total (Permanent) 6,438.95 5,681.40 757.55 25,847 22,250 3,597 155,861 133,287 22,574 85.0% 2,642 19,932

Grand Total 6,464.01 6,470.57 (6.56) 26,355 26,715 (361) 159,242 156,810 2,432 100.0% 2,642 (210)

Memorandum - CIP Adjusted 6,139.95 6,470.57 (6.56) 25,033 26,715 (1,682) 154,929 156,810 (1,882) 100.0% 2,642 (4,524)

- There remains a high proportion of agency staff expenditure in Medical staffing (15.7%. of pay total, up from 14.8% last month), compared with the average for other staff groups (8.6% Trust average, including Medical, up from 7.8% last month). - 6.56 WTEs used less than establishment (compared to 4.15 WTE’s under establishment in Month 05). Majority of increase was in Medical Staff, which went from 6.96 wte over to 19.70 wte over established. - Reserves have been excluded in the final column

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Overall pay spend has increased significantly in month, with an increase across all areas. Agency has increased by £308k and Bank by £349k, However a significant amount of this increase relates to retrospective bookings, which have increased by £0.5m in the month. Permanent staff costs are up £335k Increase is across all staff types, with Medical staff up £507k, Nursing £354k and Other Staff £131k.

Increase in Agency Staff (£308k), with increase in reduction in Medical Staff (£269k) and Other Staff (£47k), partially offset by slight reduction in Nursing (£8k). Increase in Medical Staff largely in Emergency Care (£142k), Surgery (£51k) and Specialist Medicine (£46k).

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59.9%

-

200

400

600£

Th

ou

san

ds

Rolling 13 Months

Acute Medicine

-

200

400

600

800

£ T

ho

usa

nd

s

Rolling 13 Months

Emergency Care

-

50

100

150

200

250

£ T

ho

usa

nd

s

Rolling 13 Months

Pathology

-

50

100

150

200

250

£ T

ho

usa

nd

s

Rolling 13 Months

Specialist Surgery

Top four spending Directorates (by current spend) are shown above, over the last 13 months (September 2013 to September 2014) Agency spend for these 4 Directorates represented 52% of total Trust agency spend in M06, compared with 29.6% of total Trust pay spend. Acute Medicine’s upwards pay trend is now the highest in terms of both current and historic levels. Problem primarily relates to control issues where bookings are greater than funded establishment. Temporary staff bookings are increasing month on month for specialling in 1:1 care.

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The graph above shows the weekly spend on bank and agency over the last 13 weeks. The overall trend is flat, with no evidence of the reduction required in order to hit the control total. The COO is reviewing individual agency staff posts & work is planned to review medical staff rotas where vacancies are covered by agency

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5. ANALYSIS OF NON-PAY SPEND

Summary Level

In Month

Budget £000's

In Month

Actual £000's

In Month

Variance

£000's

Ytd Budget

£000's

YTD Actual

£000's

YTD Variance

£000's

Reserves in

YTD Budget

£000's

Reserve

Adjusted

Variance £000's

Drugs 3,121 3,173 (52) 18,949 18,564 385 681 (296) Clinical Supplies & Appliances 3,173 2,772 401 17,859 17,523 337 337General Supplies & Services 1,531 1,520 10 9,126 9,531 (405) (405) Premises & Fixed Plant 1,628 1,603 25 9,818 9,610 208 208Other Non Pay 3,776 4,494 (718) 22,795 22,497 299 708 (410) Total 13,229 13,563 (334) 78,547 77,723 824 1,389 (566)

Memorandum - CIP Adjusted 12,957 13,563 (606) 77,492 77,723 (232) 1,389 (1,621)

Action / Mitigation

Confirmation needed around contractual arrangements for commissioner payment for Transport Costs (courier services). This is currently in discussion with NHS England. High level analysis has been done to estimate the extent of the internal additional costs incurred for 18 week backlog clearance. Funding has been added to Directorate budgets to offset the cost of work transferred to the ISTC. Further work is required to validate the costs and allocated funding accordingly, as indications are that activity levels are actually lower than the corresponding period last year. Clarity needed on the costs of the improvement plan, and the financial support available to deliver it.

Key Drivers

In month non-pay expenditure of £13.6m is £0.3m adverse to budget, with actual spend up £1.6m compared to month 05. Year to date, spend is £0.8m favourable to plan. However, budgets contain £1.4m of reserve budgets, primarily related to drugs and Non-Pay inflation, thus making the underlying variance £0.6m overspent year to date. In addition, there is unmet CIP of £1.0m for non-pay, making the underling variance £0.6m adverse. The main drivers for the in-month overspend are Other Non-Pay (£0.7m) primarily due to a Professional fees associated with the improvement plan (matched by accrued local income) and drugs overspend £52k, offset by underspend in Clinical Supplies & Appliances of £401k, in Anaesthetics (£66k), Neurosciences (£91k), Pathology (£99k) and Radiology (£81k). General Supplies and Appliances are overspent by £405k year to date, largely in central, £354k primarily related to a prior year charge for Patient Transport (G4S), Stationary costs of £56k largely due to timing, and Courier costs of £141k, funding of which needs to be resolved with commissioners. Other Non-Pay is £299k underspent YTD, due to an overspend in Consultancy Fees (£846k), primarily in Chief Executive, related to PMO and Improvement Plan, offset by reserve budget of £708k and other smaller underspends.

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6. COST IMPROVEMENT PROGRAMME QCIP Planning is currently risk assessed based on delivery risk, related to the confidence in delivery of the scheme. The following table shows the forecast overall delivery, regardless of any risk rating, based on the overall value of schemes identified.

Plan Actual Variance Plan Actual Variance Plan Outturn Variance

Anaesthetics 9 263 45 (218) 1,053 586 (467) 2,632 906 (1,726)

Care of the Elderly 8 101 29 (72) 156 74 (81) 821 372 (449)

Children 9 82 10 (73) 329 57 (272) 823 114 (709)

Emergency Care 12 133 62 (71) 546 393 (153) 1,388 1,039 (350)

Medicine 16 237 14 (223) 973 18 (955) 2,395 214 (2,181)

Neurosciences 11 76 8 (67) 312 16 (296) 774 51 (723)

Pathology 23 126 37 (89) 504 47 (457) 1,260 276 (984)

Radiology 12 105 32 (73) 418 115 (303) 1,048 352 (697)

Specialist Medicine 6 93 20 (73) 373 203 (170) 933 208 (725)

Specialist Surgery 10 101 6 (95) 404 125 (279) 1,010 453 (558)

Support Services 3 63 9 (53) 251 38 (213) 624 94 (531)

Surgery 14 109 26 (83) 437 175 (261) 1,092 383 (709)

Therapies 6 51 7 (44) 203 61 (142) 508 111 (397)

Women 11 177 35 (141) 703 106 (597) 1,749 525 (1,224)

Bed & Site Management 4 20 3 (17) 81 3 (77) 198 21 (178)

Chief Executive 3 23 4 (18) 90 27 (63) 225 118 (107)

Director of Finance 5 59 21 (38) 236 127 (109) 591 504 (87)

Director of Human Resources 7 25 3 (22) 85 19 (66) 199 99 (100)

Director of Nursing 4 33 4 (29) 83 23 (60) 166 180 13

Director of Performance & Planning 2 3 0 (3) 10 0 (10) 26 1 (26)

Head of Estates 11 52 22 (30) 209 80 (129) 523 1,729 1,206

Medical Director 3 6 0 (6) 25 2 (23) 62 24 (38)

Strategy & Planning 2 50 3 (47) 200 17 (184) 500 33 (467)

Subtotals 191 1,987 402 (1,585) 7,680 2,312 (5,369) 19,550 7,805 (11,745)

Agency Saving 1 0 0 0 0 0 0 0 3,000 3,000

Totals 192 1,987 402 (1,585) 7,680 2,312 (5,369) 19,550 10,805 (8,745)

Directorate No of

Schemes

In Month (£000's) Year To Date (£000's) Forecast Outturn (£000's)

64

27

Risk Profile of QCIP Plan The table below shows the forecast of the plan in descending order in terms of delivery against target. The delivery as % of requirement is based on value of Green and Amber schemes.

- In month the Trust was £1.6m behind plan (£5.4m year to date), largely due to unidentified gaps in Directorate CIP plans - Approximately 28% (£5.5m) of the £19.6m target is assessed as Green, with a further 7% rated as Amber, leaving a gap of £11.7m unidentified or red-rated. This includes a £3m Central scheme which has been added to the plan this month, to represent anticipated savings from agency over the remainder of the year. This scheme is rated as Red) see pages 18 – 20).

- The red CIP shown in the monthly run rate

chart below relates mainly to the agency scheme.

- The high level of Amber schemes represents

an increasing risk, given that we have now reached the mid-point of the year, with the most material Amber rates schemes in Estates, Women and Emergency Care.

65

28

66

29

7. BALANCE SHEET

Key points:

Current Previous Last

(£m) Period Period Yr EndSep-14 Aug-14 Mar-14

Non-current assets £353.0 £354.0 £358.3Current assets

Inventories £6.3 £6.1 £6.2Trade and other receivables £64.8 £65.8 £33.2Cash and cash equivalents £0.4 £0.6 £1.4

£71.5 £72.5 £40.8Current liabilities

Trade and other payables (£72.3) (£70.5) (£44.2)PFI \ Borrow ings (£7.5) (£7.5) (£7.1)Provisions (£1.9) (£2.1) (£1.8)Net current assets/(liabilities) (£10.2) (£7.6) (£12.4)Non-current liabilities:

PFI \ Borrow ings (£249.5) (£249.5) (£253.3)Trade and other payables (£4.3) (£4.3) (£4.5)Provisions (£6.2) (£6.0) (£6.5)Total assets employed £82.8 £86.6 £81.7

Financed by taxpayers' equity:

Public dividend capital £460.4 £460.4 £438.4Retained Earnings - P&L (£388.3) (£384.4) (£367.3)Retained Earnings - Donated Assets - - -Revaluation reserve £10.6 £10.6 £10.6Donated asset reserve £0.0 £0.0 £0.0Total taxpayers' equity £82.8 £86.6 £81.7

Current Prior Last

KPIs Period Period Yr EndSep-14 Aug-14 Mar-14

Average Debtors days 24 22 15

Debtors >90 days (£'000s) £936 £841 £1,417Debtors >180 days (£'000s) £805 £689 £1,359Debtors >365 days (£'000s) £1,266 £1,210 £1,084

Total Bad Debt Provision (£'000s) £1,242 £1,171 £1,335>365 days provided (£'000s) £745 £708 £710

Average creditor days 29 28 31

Current ratio 79% 83% 68%

Better payment practice code performance:

- Non-NHS

- Volume - paid on time 3,839 4,283 4,585 - Volume - % paid on time 91.82% 88.62% 90.84% - Value - paid on time (£'000s) £7,634 £10,975 £14,698 - Value - % paid on time 76.87% 88.95% 92.53%

- NHS

- Volume - paid on time 128 213 225 - Volume - % paid on time 70.33% 73.20% 66.96% - Value - paid on time (£'000s) £1,048 £1,132 £2,126 - Value - % paid on time 52.93% 84.33% 88.39%

Key points:

The downward movement in trade receivables of £1.4m is mainly in relation to the expired advance quarterly payment of the PFI contract

Key points:

The Better payment practice code performance (volume and % paid on time) for NHS have decreased by 85 and 2.87% respectively. Also within the Non- NHS category the total invoices paid on time has decreased by 444 from previous level replicating an overall reduction in invoices processed for payment within the month

67

30

8. CAPITAL AND CASHFLOW

Summary Cashflow - Year to date £000's

Operating Deficit (8,390)Interest Paid (12,655)PDC Dividend Paid -Interest received 223Impairments 389Transfers (64)Proceeds from sale of Upney Lane -Net I&E deficit (cash impact) (20,497)

Depreciation and Amortisation 8,334

Movements in w orking balances:Decrease in Inventories (87)Increase in Trade and Other Receivables (6,786)Increase in Trade and Other Payables 2,714Decrease in Provisions (173) - sub-total (16,495)Capital expenditure (4,289)Revenue Rental Income 1,404

Net cashflow before f inancing (19,380)

Capital Element of Finance Leases and PFI (1,761)Loans repaid (1,740)Public Dividend Capital Received 22,000

Net Increase/(Decrease) in Cash and Cash

Equivalents(881)

Opening cash balance 1,301Closing cash balance 420

Funding Source Category

Sum of 2014-15

Available

Funding

Year To

Date Budget

Year To

Date

Expenditur

e

Year To

Date

Variance

Total

Forecast

Outturn

Sum of 2014-

15 Total

Forecast

Variance

External Cardiac Cath Lab (1) (1) (1) - (1) -

Digital Mammography (146) (146) (146) - (146) -

Improving Birthing Environment Award 182 67 70 - 184 2

MLU 12 12 - 12 12

SCBU Ward Reconfiguration 7 5 7 - 7 -

PAS Replacement 2,505 426 825 - 1,725 (780)

Pathology Centralisation 3,313 (70) 2 - 950 (2,363)

SAN Virtualisation (Server) 58 56 58 - 58 -

Winter Pressure 1,509 - - - 1,509 0

Life Support Study 560 23 58 - 560 0

External Total 7,988 374 886 - 4,860 (3,128)

Internal Estates 3,679 333 609 - 3,317 (362)

Information Technology - Hardware 87 25 29 - 78 (9)

Information Technology - Software/Intangibles 921 469 614 - 1,157 235

Medical Equipment 2,975 220 758 - 2,935 (39)

Furniture 86 38 52 - 89 3

Schemes in Preparation - Post Natal Beds TVE 150 132 132 - 132 (18)

Schemes in Preparation - Cath Lab TVE 107 - - - - (107)

Schemes in Preparation - CDU TVE 100 - - - - (100)

Schemes in Preparation - ITU Extension TVE 90 - - - - (90)

Schemes in Preparation - Design, Architects, Legal Costs, and Support 300 - - - - (300)

General Business Case Preparaton 74 47 52 - 52 (22)

KGH Car Park Machines Upgrade 18 18 18 - 18 -

MES Gamma Camera Enabling Works 25 - - - 25 -

CT Enabling Works 1 45 - 68 - 68 23

CT Enabling Works 2 90 - - - 90 -

MRI Enabling Works 1 60 - - - 60 -

MRI Enabling Works 2 228 - - - 228 -

Nursing - Bed Contract 1,000 - 786 - 1,001 1

Finance 311 5 148 - 311 0

Extension of Resus Area 828 468 828 - 828 -

Unallocated Funding 2,644 - - - - (2,644)

Internal Total 13,817 1,756 4,096 - 10,388 (3,429)

Managed Equipment Service PFI (IFRIC 12) Managed Equipment Service 2,207 (29) (29) - 2,206 (0)

Maternity Medical Equipment 41 41 41 - 41 -

Visual Field Analysers 51 51 51 - 51 -

Additional emergency defibrillators 15 15 15 - 15 -

Cardio Respiratory additional equipment 27 27 27 - 27 -

Managed Equipment Service Total 2,340 105 105 - 2,340 (0)

Grand Total 24,145 2,235 5,087 - 17,588 (6,557)

Cashflow - Key points:

Receipt of £10m temporary borrowing funding in April Additional temporary borrowing of £12m received in July bringing the total year to date received to £22m. Additional temporary borrowing of £10m is planned to be drawn down in October

Capital - Key points:

The total Capital financial envelope remains at £24,145k with £2,644k now remaining unallocated having agreed further allocations at the recent Capital Planning Group (CPG) meeting. Based on the current forecast outturn of £17,588k, the entire capital program is heading for an underspend forecast variance of £6,557k, an reduction of £553k from the previous level mainly as a result of further expenditure on the Resus extension project. A significant part of the favourable forecast is related to the anticipated underspend in the Pathology Centralisation program of £2,363k due to expected delays in the completion of the project as well as the unallocated funding of £2,644k although there are business proposals in the pipeline for this to be allocated to. The rest of the forecast movement is related to a number of TVE’s for various projects now put on hold with no expected spend in current financial year, mainly Cath Lab TVE £107k, CDU TVE £100k, ITU Extension £90k, Design, legal and architect’s costs for various Business Cases £300k.

68

31

APPENDICES A. Pay Spend and WTE’s by Directorate

Summary Level Staff Type Budget WTE

Adj Actual

WTE

Adj

Variance

WTE

In Month

Budget

£000's

In Month

Actual

£000's

In Month

Variance

£000's % Variance

Ytd Budget

£000's

Ytd Actual

£000's

Ytd

Variance

£000's % Variance

YTD CIP

Shortfall

£000's

CIP Adjusted

Variance

£000's

Anaesthetics 719.07 712.13 6.94 3,122 3,297 (175) 0.97% 18,430 18,948 (518) (2.81%) (434) (952)

Bed & Site Management 58.84 48.35 10.49 245 233 12 17.83% 1,469 1,392 78 5.29% (62) 16

Care of the Elderly 354.65 358.59 (3.94) 1,316 1,298 18 (1.11%) 7,902 7,869 33 0.41% (86) (53)

Central Income & Expenditure 0.00 0.00 0.00 126 (35) 161 - 2,642 (332) 2,975 112.58% 2,975

Chief Executive 34.60 24.10 10.50 304 160 144 30.35% 1,824 1,130 694 38.02% (120) 573

Children 262.96 255.08 7.88 1,221 1,233 (12) 3.00% 7,294 7,263 31 0.43% (272) (241)

Director of Finance 93.09 87.90 5.19 345 284 61 5.58% 2,066 1,899 167 8.07% (34) 133

Director of Human Resources 88.83 98.76 (9.93) 280 288 (8) (11.18%) 1,679 1,752 (72) (4.31%) (40) (112)

Director of Nursing 50.72 57.04 (6.32) 205 217 (12) (12.46%) 1,253 1,360 (108) (8.59%) 0 (108)

Director of Performance & Planning 4.00 2.00 2.00 23 12 11 50.00% 137 81 57 41.27% (10) 47

Education 85.02 85.75 (0.73) 241 250 (9) (0.86%) 1,223 1,258 (35) (2.88%) (35)

Emergency Care 388.87 385.60 3.27 1,809 1,842 (33) 0.84% 10,757 10,603 153 1.42% (132) 21

Head of Estates 297.80 296.31 1.49 909 919 (11) 0.50% 5,454 5,481 (27) (0.50%) 0 (27)

Medical Director 14.08 14.97 (0.89) 104 95 9 (6.32%) 601 558 44 7.27% (37) 7

Medicine 758.07 811.24 (53.17) 3,201 3,509 (307) (7.01%) 19,299 20,275 (976) (5.06%) (889) (1,866)

Neurosciences 228.29 229.53 (1.24) 1,010 1,006 4 (0.54%) 6,062 5,950 113 1.86% (217) (104)

Pathology 286.46 284.28 2.18 1,208 1,193 15 0.76% 7,411 7,514 (104) (1.40%) (316) (420)

R&D 36.81 37.86 (1.05) 109 107 2 (2.85%) 653 735 (81) (12.45%) (81)

Radiology 325.99 327.87 (1.88) 1,445 1,489 (44) (0.58%) 8,719 8,928 (209) (2.40%) (266) (476)

Specialist Medicine 439.05 440.21 (1.16) 1,774 1,815 (41) (0.26%) 10,561 10,564 (2) (0.02%) (123) (126)

Specialist Surgery 242.17 241.52 0.65 1,264 1,385 (121) 0.27% 7,504 8,001 (498) (6.63%) (201) (698)

Strategy & Planning 158.03 158.80 (0.77) 510 480 31 (0.49%) 3,079 2,501 577 18.75% (71) 506

Support Services 317.69 346.06 (28.37) 777 845 (69) (8.93%) 4,654 4,804 (150) (3.21%) (212) (362)

Surgery 359.06 356.95 2.11 1,539 1,649 (110) 0.59% 9,215 9,513 (299) (3.24%) (210) (509)

Therapies 198.31 188.59 9.72 677 652 25 4.90% 4,047 3,815 232 5.74% (142) 90

Women 661.55 621.08 40.47 2,590 2,490 100 6.12% 15,307 14,949 359 2.34% (438) (80)

Total 6,464.01 6,470.57 (6.56) 26,355 26,715 (361) (0.10%) 159,242 156,810 2,432 1.53% (4,313) (1,882)

Key Points to note are that the overall position has changed from 5.46 posts over in Month 04, to a 4.15 in Month 5. The adverse variance in Medicine variance has reduced from 48.06 to 32.56, and similarly has reduced in Support Services from 26.18 to 17.85

69

32

B. Weekly Agency Trend

In House Bank - Temporary Staffing Figures

Data Provided 29/09/2014

Bank or Agency Agency

.Total Booking Cost Week EndingNew Directorate New Business Unit 06/07/2014 13/07/2014 20/07/2014 27/07/2014 03/08/2014 10/08/2014 17/08/2014 24/08/2014 31/08/2014 07/09/2014 14/09/2014 21/09/2014 28/09/2014

Corporate Corporate £22,225 £23,722 £23,103 £22,261 £22,088 £18,318 £21,621 £21,257 £19,211 £21,277 £18,119 £19,823 £6,692£22,225 £23,722 £23,103 £22,261 £22,088 £18,318 £21,621 £21,257 £19,211 £21,277 £18,119 £19,823 £6,692

Pathology £30,939 £33,054 £40,209 £34,276 £37,764 £31,452 £42,360 £27,636 £22,178 £19,060 £16,780 £18,876 £19,087Radiology £21,289 £23,947 £24,415 £17,505 £18,127 £24,395 £22,912 £23,654 £24,105 £24,047 £26,869 £18,291 £12,809

Specialist Medicine £34,144 £42,395 £33,268 £30,044 £33,915 £31,696 £31,223 £37,154 £29,581 £33,109 £35,191 £40,914 £31,806Therapies £19,844 £21,155 £23,727 £21,848 £18,464 £19,602 £20,107 £18,094 £18,406 £21,330 £19,810 £19,875 £17,995

£106,216 £120,551 £121,618 £103,672 £108,270 £107,145 £116,602 £106,538 £94,270 £97,546 £98,650 £97,956 £81,697Acute Medicine £100,869 £97,429 £95,732 £100,253 £102,479 £93,742 £127,902 £129,781 £120,034 £120,838 £107,294 £94,530 £105,093

Care of the Elderly £23,011 £17,735 £23,789 £25,304 £16,641 £14,578 £27,714 £27,805 £23,792 £24,813 £22,552 £26,840 £24,341Emergency Care £88,350 £80,372 £93,062 £82,419 £75,365 £90,652 £81,662 £82,232 £88,124 £72,840 £95,507 £100,206 £89,048Neurosciences £9,423 £11,164 £13,049 £11,121 £14,295 £17,602 £22,293 £19,031 £28,364 £17,690 £5,713 £7,570 £8,041

£221,654 £206,701 £225,632 £219,096 £208,780 £216,574 £259,572 £258,849 £260,312 £236,182 £231,065 £229,147 £226,522Anaesthetics £32,196 £22,461 £29,878 £37,743 £33,568 £29,655 £28,514 £33,109 £31,989 £28,044 £28,601 £32,674 £34,403

Specialist Surgery £38,025 £32,093 £29,898 £31,419 £35,338 £40,701 £35,237 £36,342 £31,856 £37,177 £40,681 £33,546 £31,997Surgery £20,662 £18,117 £20,940 £24,820 £35,972 £29,275 £29,082 £34,923 £35,622 £37,706 £31,374 £31,518 £31,236

£90,883 £72,671 £80,715 £93,982 £104,878 £99,630 £92,833 £104,374 £99,467 £102,927 £100,657 £97,738 £97,636Children £20,940 £26,182 £25,096 £28,859 £20,417 £18,252 £33,605 £33,307 £15,574 £26,260 £21,551 £16,260 £26,214

Support Services £7,834 £6,726 £5,553 £7,097 £8,555 £6,646 £7,480 £7,957 £4,637 £3,541 £5,325 £2,979 £2,920Women £2,195 £2,850 £4,594 £4,798 £5,947 £8,533 £10,693 £11,174 £8,803 £13,660 £5,103 £8,650 £14,380

£30,969 £35,758 £35,244 £40,753 £34,919 £33,431 £51,778 £52,438 £29,013 £43,462 £31,979 £27,888 £43,514£471,947 £459,402 £486,311 £479,765 £478,936 £475,098 £542,407 £543,456 £502,273 £501,393 £480,469 £472,552 £456,061

Surgical Services Total

Women's, Children and Support Services

Women's, Children and Support Services TotalGrand Total

Corporate Total

Diagnostics and Specialist Medicine

Diagnostics and Specialist Medicine Total

Emergency Care, General Medicine and Neurosciences

Emergency Care, General Medicine and Neurosciences Total

Surgical Services

70

33

In House Bank - Temporary Staffing Figures

Data Provided 29/09/2014

Bank or Agency Agency

.Total Booking Cost Week EndingNew Directorate Staff Group 06/07/2014 13/07/2014 20/07/2014 27/07/2014 03/08/2014 10/08/2014 17/08/2014 24/08/2014 31/08/2014 07/09/2014 14/09/2014 21/09/2014 28/09/2014

Admin & Clerical £20,185 £20,422 £20,463 £19,141 £18,779 £14,598 £18,141 £19,217 £18,521 £18,517 £16,079 £16,703 £4,772Nursing & Midw ifery £2,040 £3,300 £2,640 £3,120 £3,309 £3,720 £3,480 £2,040 £690 £2,760 £2,040 £3,120 £1,920

£22,225 £23,722 £23,103 £22,261 £22,088 £18,318 £21,621 £21,257 £19,211 £21,277 £18,119 £19,823 £6,692Allied Health Professionals £37,684 £41,521 £44,970 £41,690 £36,499 £44,417 £45,298 £42,733 £39,450 £36,940 £40,842 £30,709 £26,197

Medical & Dental £39,220 £43,108 £41,767 £27,679 £36,125 £28,593 £37,624 £32,649 £30,848 £27,707 £25,252 £31,887 £22,485Nursing & Midw ifery £3,057 £6,478 £2,026 £2,016 £4,584 £2,878 £3,098 £4,465 £2,148 £4,143 £4,330 £4,891 £3,310

Professional, Technical & Scientif ic £26,256 £29,443 £32,855 £32,288 £31,062 £31,256 £30,583 £26,692 £21,825 £28,756 £28,225 £30,469 £29,706£106,216 £120,551 £121,618 £103,672 £108,270 £107,145 £116,602 £106,538 £94,270 £97,546 £98,650 £97,956 £81,697

Admin & Clerical £431 £718 £718 £718Allied Health Professionals £1,235

Medical & Dental £183,410 £165,239 £175,762 £171,208 £162,789 £162,545 £201,994 £207,831 £202,700 £186,039 £177,163 £187,346 £180,884Nursing & Midw ifery £34,514 £39,657 £48,072 £45,712 £42,365 £51,105 £54,970 £47,693 £55,500 £48,343 £49,965 £38,132 £42,553

Professional, Technical & Scientif ic £2,496 £1,804 £1,798 £2,176 £3,627 £2,925 £2,608 £3,326 £1,681 £1,082 £3,219 £2,952 £3,085£221,654 £206,701 £225,632 £219,096 £208,780 £216,574 £259,572 £258,849 £260,312 £236,182 £231,065 £229,147 £226,522

Allied Health Professionals £1,089 £1,178 £2,780 £2,393 £589 £1,152 £2,126 £2,349 £2,236 £1,338 £2,909Medical & Dental £55,840 £47,360 £48,582 £47,539 £65,816 £63,473 £59,950 £61,015 £59,971 £63,219 £64,485 £63,480 £53,783

Nursing & Midw ifery £33,954 £24,133 £29,354 £46,443 £36,669 £35,568 £31,731 £41,233 £37,148 £37,473 £36,172 £32,920 £40,944£90,883 £72,671 £80,715 £93,982 £104,878 £99,630 £92,833 £104,374 £99,467 £102,927 £100,657 £97,738 £97,636

Admin & Clerical £7,834 £6,726 £5,553 £7,097 £8,555 £6,646 £7,480 £7,957 £4,637 £3,541 £5,325 £2,979 £2,920Medical & Dental £12,581 £16,268 £15,482 £18,863 £14,258 £9,345 £23,098 £19,466 £7,608 £18,294 £10,431 £7,037 £15,633

Nursing & Midw ifery £10,554 £12,763 £14,208 £14,794 £12,106 £17,441 £21,200 £25,015 £16,768 £21,626 £16,222 £17,873 £24,961£30,969 £35,758 £35,244 £40,753 £34,919 £33,431 £51,778 £52,438 £29,013 £43,462 £31,979 £27,888 £43,514£471,947 £459,402 £486,311 £479,765 £478,936 £475,098 £542,407 £543,456 £502,273 £501,393 £480,469 £472,552 £456,061

Surgical Services Total

Women's, Children and Support Services

Women's, Children and Support Services TotalGrand Total

Corporate

Corporate Total

Diagnostics and Specialist Medicine

Diagnostics and Specialist Medicine Total

Emergency Care, General Medicine and Neurosciences

Emergency Care, General Medicine and Neurosciences Total

Surgical Services

71

34

C. Non-Pay Spend by Directorate

Directorate

YTD Budget

£000's

YTD Actual

£000's

YTD Variance

£000's

YTD Variance

%

YTD CIP

Shortfall

£000's

CIP Adjusted

Variance

£000's

Anaesthetics 5,397 5,545 (148) (2.7%) (33) (181) Bed & Site Management 302 328 (25) (8.4%) (14) (40) Care of the Elderly 659 651 8 1.3% 4 13Central Income & Expenditure 1,785 191 1,594 89.3% 1,594Chief Executive 716 1,509 (793) (110.7%) 57 (736) Children 554 485 69 12.5% 69Director of Finance 3,439 3,633 (195) (5.7%) (76) (270) Director of Human Resources 410 441 (31) (7.5%) (20) (51) Director of Nursing 8,321 8,266 55 0.7% (44) 12Director of Performance & Planning 9 9 99.8% 9Education 559 573 (14) (2.5%) (14) Emergency Care 1,480 1,581 (101) (6.8%) (21) (122) Head of Estates 19,395 19,066 329 1.7% (152) 177Medical Director 31 5 26 85.0% 15 41Medicine 3,984 4,004 (20) (0.5%) (66) (86) Neurosciences 1,523 1,484 39 2.5% (92) (54) Pathology 4,519 4,229 290 6.4% (141) 149R&D 100 5 95 95.5% 95Radiology 2,048 2,024 24 1.2% (29) (5) Specialist Medicine 11,604 11,716 (112) (1.0%) (47) (159) Specialist Surgery 3,118 3,114 4 0.1% (78) (74) Strategy & Planning 2,442 2,671 (229) (9.4%) (113) (342) Support Services 176 221 (45) (25.3%) () (45) Surgery 1,601 1,488 113 7.0% (51) 62Therapies 918 967 (49) (5.4%) (49) Women 3,458 3,527 (70) (2.0%) (155) (224) Suspense () 0.0% () Total 78,547 77,723 824 1.0% (1,056) (232)

72

35

D. CQUIN Update (Based on M5 data)

Indicator Name

National

or

Regional

indicator Requirements

Indicator

weighting

(% of

CQUIN

scheme

available)

NELC Expected

Financial Value

Project

Lead

Clinical

Lead

Executive

SponsorBaseline April May June Q1 Outcome RAG July RAG

Progress to date Risks/Mitigation

0.50% £1,428,643

F&F staff

National Implement Staff FFT 10% improvement of Staff FFTAction plan to be developed and bi annual staff survey

0.0370% £105,298Claire

O'Toolen/a Deborah

Tarrantn/a Staff Surveyed

in SurgeryCompleted FFT

in SurgeryQ1 Surgery

FFT -31

FFT staff survey was conducted in Surgery in June 2014. The FFT will roll out to Medicine in Quarter 2. The National Staff survey will be undertaken in Quarter 3. The Trust will roll out the internal survey in Q4.

F&F patient early

implementation -

outpatients and day

surgery

National Early implementation of FFT in day surgery and outpatients

0.0370% £105,298Concepta Wayment

Neil Hardy Eileen Moore

n/a DSU 19%OPD n/a

DSU 18%OPD 834

DSU 21%OPD 737

DSU 19%OPD 1,571

DSU 20%363 OPD

Survey responses for OPD are gained from KGH, Loxford Polyclinic and Harold Wood at present, along with Dermatology at QH. Discussions around electronic solution are in progress before rollout to other areas. Day surgery's response rates are monitored on a monthly basis.

CCG's have sent through some comments regarding the action plan around FFT rollout for OPD. The team are currently reviewing this to send a response

F&F Cancer patient

experience

National/Local

Improve cancer patient experience by improving scores, response rates and developing an action plan

0.0270% £76,839Lucy

GladmanJane

StevensStephen Burgess n/a

FFT Score 69

Coverage68%

FFT Score 69

Coverage68%

Survey commenced Monday 23rd June 2014. Results received and overall positive. An action plan is being put together around areas for improvements. The next survey will be undertaken during the last week of August 2014

F&F increase and

maintain (A&E and

Inpatients)

National Increase response rate for inpatient and A&E areas as prescribed nationally 0.0190% £54,072

Emma James

Gary Etheridge

Flo Panel-Coates

A&E 24%

AIP 47%

A&E 22%

AIP 54%

A&E 18%

AIP 44%

A&E 18%

AIP 43%

A&E 19%

AIP 47%

22% A&E

45% AIP

Performance has improved - however a plan is in place to increase response rates going forward to ensure delivery of the CQUIN

Wards with a response rate of less than 50% will be visited by the Patient Experience Facilitators for support. Volunteers are being recruited to assist with the provision and collection of patient experience surveys.

F&F increase

response rate

(inpatient services)

National Increase inpatient response rate of 40% of more for the month of March 2015

0.0500% £142,295Emma James

Gary Etheridge

Flo Panel-Coates AIP 47% AIP 54% AIP 44% AIP 43% AIP 47% AIP 45%

Wards with a response rate of less than 50% will be visited by the Patient Experience Facilitators for support. Volunteers are being recruited to assist patients in completing surveys.

NHS safety

thermometer -

Pressure Ulcer (New

& Old)

National NHS safety thermometer - Pressure Ulcers (new and old)

0.1700% £483,803Beverley Wilson

Tracey Thorne

Flo Panel-Coates

New 0.35

All TBC

New 0.18

All 2.87

New 0.55

All 4.19

New 0.33

All 3.25

New 0.35

All 3.43

0.36 New

3.19 All

Development of action plan with NELFT to reduce pressure ulcers across health economy with support from Accelerate (outside company funded by the CCG's) has been agreed. Work is underway and a further meeting with NELFT is booked for 1st September 2014 to review

Dementia FAIR

National Find, Assess, Investigate and Refer 75+ and targeted 65+ on specific clinic 0.0750% £213,443

Joanne Barrett /

Lee Hamilton

Khalid Haque

Stephen Burgess

F 90%A 90%R 90%

F 64%A 46%R 45%

F 67%A 83%R 68%

F 74%A 81%R 68%

F 68%A 70%R 60%

F 71%A 62%R 57%

Performance has declined during July, but final data will not be available until 28/8. However, as the directorates are now taking ownership of Dementia assessments this is being escalated to the performance meetings and is expected to be rectified by August 2014. Mid month scores have shown an improvement.

Historical issues with collection of data from the Medway and BI system which is under review.

Dementia training

National Clinical leadership and appropriate training and evaluation of training for staff, including use of Health Analytics to enter the This is Me documentation

0.0270% £76,839

Joanne Barrett /

Lee Hamilton

Khalid Haque

Stephen Burgess

Training plan to be

written

Clinical leadership has been identified.Training plan to be created for sign off and submission to the CCG's.

Not yet met with Health Analytics to discuss development of "This is Me" - CCG's are tasked to organise this. The Trust has chased on several occasions.

This part of the CQUIN is reliant on development of Health Analytics to provide the Trust with relevant fields and access. Formal Letter sent to the CCG's to ensure payment if not met by HA

National CQUINs

73

36

Indicator Name

National

or

Regional

indicator Requirements

Indicator

weighting

(% of

CQUIN

scheme

available)

NELC Expected

Financial Value

Project

Lead

Clinical

Lead

Executive

SponsorBaseline April May June Q1 Outcome RAG July RAG

Progress to date Risks/Mitigation

Dementia supporting

carers

National Dementia - Supporting carers of people with dementia and appropriate onward referral

0.0600% £170,754

Joanne Barrett /

Lee Hamilton

Khalid Haque

Stephen Burgess

94% Support

77% Info

89% support

90%info

96% support

76%info

97% support

82%info

94% Support

83% Info

93% support

84%info

A report for 2013/14 has been completed and submitted to the CCG's. This report demonstrates the Trust has been very successful in supporting carers of people with Dementia with a YTD score of 94%. A plan for how to maintain scores and to increase response rates in the Dementia Carer's survey during 2014/15 has been completed and submitted to commissioners.

Intention to recruit 4 band 2 HCAs who will have a ‘special interest’ in dementia. Trained in effective communication etc they will also be utilised to act as 1:1 or ‘specialling’ nurses for those patients with behaviours that challenge. They will be used across the Care of the Elderly wards which will also mean that they will be available to increase the level of contact/communication with carers and

LOCAL CQUIN 0.80% £2,271,030

Integrated Care -

Notification

Local Notification and Communication of admission CTT team between 8am and

10pm

0.0280% £79,685William Harrison

Donna Kinnair

Eileen Moore n/a

95% 8am to 4pm

0%4pm to 10pm

54%

8am to 10pm

96%8am to 4pm

0%4pm to 10pm

57%

8am to 10pm

97%8am to 4pm

0%4pm to 10pm

55%

8am to 10pm

96%8am to 4pm

0%4pm to 10pm

55%

8am to 10pm

99%8am to 4pm

TBC4pm to 10pm

TBC8am to 10pm

Resource issues , no process within ED to flag patients between 4pm and 10pm - currently only covered between 8am and 4pm

However, this data does not include the telephone referrals coming directly to CTT regularly throughout the evening from Trust staff. The evidence from Symphony is available and has been sent to the CCG's to review

An electronic solution for flagging patients is currently being scoped to allow the Trust to notify the CTT within hours when the patient arrives and is booked in at ED

A process within ED to cover the email flagging system is under discussion with the reception team

Integrated Care -

Data sharing &

information flows

Local Data sharing and information flows - Health analytics, flagging patients

0.085% £241,902

Joanne BarrettHeather Wright

Ayo Ahonkhai

Eileen Moore

n/a 546 patients 401 patients 695 patients 547 patients 596 patients

The Trust and NELFT have discussed and agreed a referral criteria and process for the Trust to refer into the ICM for high risk patients, using the LACE score. One member of the FOPAL team, and Palliative Care Team are now able to enter information regarding patients to HA, however there are still issues around the single log-in functionality to allow rollout to all

This part of the CQUIN is reliant on development of Health Analytics to provide the Trust with relevant fields and access. Formal Letter sent to the CCG's to ensure payment if not met by HA

Integrated Care -

Identification and

admissions

Local Identification of high risk patients, Admissions, writing Care plans on Health Analytics

0.050% £142,295Joanne Barrett

Ayo Ahonkhai

Eileen Moore

n/a

5 LACE Referrals

5 HA Updates FOPAL

2 HA Updates Palliative Care

Identification of high risk patients using LACE score. Score of >11 will generate a referral to ICM. Pilot to started on Sunrise B and Fern for 6 weeks with NELFT.1 member of the FOPAL team is now able to enter information regarding patients to HA. Palliative care also has access.However, until the new CAPS system for HA is in place, this will not be rolled out to other areas due to multiple log-ins required

This part of the CQUIN is reliant on development of Health Analytics to provide the Trust with relevant fields and access. Formal Letter sent to the CCG's to ensure payment if not met by HA

Integrated Care -

Discharges

Local Discharge planning, weekly MDT pilot Havering, roll out in other boroughs Q3 & Q4

0.150% £426,885Donna Walker

Ayo Ahonkhai

Eileen Moore

n/a 2 MDT's held

First MDT meeting held on 17th July 2014 with community teams for Cluster 3 in Havering GP's with lead geriatrician from the Trust, first reports were very positive. However, there is issues with GP engagement .

Due to lack of GP engagement, the Geriatrician is going out to meetings in the community. To enable rollout on a larger scale, this will need to be reverted back to a conference call style meeting.

Integrated care -

supporting self care -

cancer surivorship

Local Stratification criteria and process (Breast, prostate, Colorectal), data management system, audit, prepare Health and Well being event

0.085% £241,902Lucy

GladmanJane

StevensEileen Moore

The service has met with London Cancer who are holding events for clinical engagement. This CQUIN links with the London Cancer work and has been delayed - The CCGs are awareRecovery package is under discussion with CNS event in September to agree and provide to commissionersHealth and Wellbeing event to be held in September for Prostate patients. Breast event is currently being arranged. Colorectal is in discussion.Management of invitation process needs to be streamlined and agreed with additional administrative support

The London Cancer network is currently developing stratified pathways for breast, colorectal and prostate. The Trust will adopt and implement these pathways once completed. Escalated to the CCG's. Milestones to be reviewed

Administrative Management of Health and Wellbeing events needs to be supported as soon as possible. IHB to provide suitable candidate

Integrated Care -

outcomes

Local Outcome measures: Reduction in Admission, LOS, readmission and A&E attendances

0.400% £1,138,361Eileen Moore TBC

Results available quarterly - end July 2014

74

37

Indicator Name

National

or

Regional

indicator Requirements

Indicator

weighting

(% of

CQUIN

scheme

available)

NELC Expected

Financial Value

Project

Lead

Clinical

Lead

Executive

SponsorBaseline April May June Q1 Outcome RAG July RAG

Progress to date

0.30% £853,771

Falls - Identification,

Register, Training

Local Falls handbook, staff training, creation of falls risk register on Health Analytics 0.20% £569,181

Debbie Watkins

Gary Etheridge

Flo Panel-Coates

Falls team working with other providers, NELFT and LAS to complete the handbook. Falls register to be created on Health Analytics - not available as yet.Training for relevant staff for falls prevention is ongoing

Falls - outcomes

Local Reduction in preventable

moderate/severe falls by Q4 - to not more than 30% 5% reduction in all falls by End Q4

0.10% £284,590Debbie

WatkinsGary

EtheridgeFlo Panel-

Coates

All Falls 5.63

Moderate 54%

preventableSevere

59%

preventable

All 5.34

Moderate 0.03

Severe 0.03

All 5.33

Moderate 0.03

Severe 0.09

All 5.31

Moderate 0.03

Severe 0.00

All 5.32

Moderate 0.03

Severe 0.04

4.54 All

Moderate 0.03

Severe 0.03

Tracked monthly per 1000 bed days.Baseline information confirmed.

Trust to reach target by end Q45% reduction Moderate/Severe preventable falls to not more than 30% per 1000 bed days

0.90% £2,561,312

Urgent Care Local 0.25% £711,476Eileen Moore

Emergency Local 0.45% £1,280,656Eileen Moore

Paeds pathway in

A&E

Local0.20% £569,181

Eileen Moore

2.50% £7,114,757

CQUIN scheme requirements discussed with the CCGs. Proposals to be written

around increasing GP utlisation of Ambulatory Care, Providing Hot Clinics for other specialties, Paediatric utilisation of PAU and UCC and Staffing levels in ED

75

Date of Trust Board Meeting: 5 November 2014 

Title of Paper: Nursing and Midwifery Safe Staffing Report for September 2014

Introduction/Summary: Ensuring our wards and departments are adequately staffed is a core responsibility of the Chief Nurse working with the Chief Operating Officer and Directorates. The following report is part of our monthly nursing staffing update. All organisations have a duty to monitor, and report against their nursing workforce and staffing fill rates every month. Enclosed is an executive summary and the full report as published on our NHS Choices website. There has been a deterioration in fill rate across the wards in September, with a number of wards below 80% and a reduction in the cover of RN and HCA’s at the KGH site for this month. This has been harder to mitigate using other staff groups so a greater use of temporary staff was requested but not all filled. All known actions have been taken to ensure the risk to wards are reduced and patient safety is not compromised. This remains an area of concern for the chief Nurse who reviews the impact on a daily basis.

Patient Safety implications: Safe staffing is critical to delivering patient safety.  

Risks: In order to mitigate risks the following actions are taken: A daily review of acuity & dependency is undertaken by Matrons and Senior Sisters/Charge

Nurses and entered onto an electronic system. This is considered alongside professional judgment and key clinical indicators.

Flexing of staff across wards and departments to ensure areas remain safe, to include specialist nurses. If required, Matrons base themselves in clinical areas.

Utilisation of temporary staff and specials is considered and agreed if necessary.

Financial implications: Failure to deliver improvements in the management of patient safety (including learning from incidents) can result in increasing incidents, reduced efficiency and rising NHSLA costs. 

Legal advice and implications: Failure to deliver improvements in the management of patient safety can result in increased litigation. 

Consultation (including patient and public involvement): N/A 

Communications: To be shared monthly on the NHS Choices website. 

Equality Impact implications: This affects all patients equally. 

Reviewed by/action taken? Reviewed at the TEC in October 2014. 

Recommendations: Members are asked to note: There are a number of wards where there has been a risk based on vacancy levels and

unfilled temporary shift fill rates. Actions are put in place on a daily basis to mitigate risks relating to nurse staffing, including

the use of temporary staff.

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Author and Lead Officer: Flo Panel-Coates, Chief Nurse Date(s) for further review: Monthly reports/update to TEC and the Trust Board.  

77

SAFE STAFFING LEVELS SEPTEMBER 2014 EXECUTIVE SUMMARY

The attached paper (appendix 1) provides an overview of the Trust’s current status (September 2014) for the provision of appropriate nurse and midwife staffing levels, and provides the Trust Board with assurance of the work in progress to monitor and manage safe levels of nursing and midwifery staff in the Trust. Staff bank have been able to achieve within registered nurses, a 53.9% fill rate for bank and a 14.76% fill rate for agency leaving a 19.58% unfilled rate across the trust. More work is required to establish staffing, in the short term, for the departments where temporary staff is consistently requested, reduce the vacancy rate and improve the fill rate on a day to day basis. Eight of the new nurses from overseas arrived with us on Friday 26 September and have undertaken a robust induction course. They have had a period of supervision and mentorship in clinical areas. A further 17 overseas nurses arrive on 14th November 2014. All at risk areas are receiving additional support and review to reduce any risks to our patients and therefore based on the mitigations in place we have delivered safe staffing during September. This has resulted in more staff being pulled from CNS and other roles to enable this. A full copy of the staffing fill rates and key nursing quality indicators are attached as appendix 1. This data is available as individual ward data which is presented to the Trust Executive Committee and the Trust Board as ward to board indicators. A summary of the fill rate for September 2014 is as follows:

September 2014 Day  Night 

Site Name Average fill rate – registered (%)

Average fill rate – unregistered (%)

Average fill rate – registered (%)

Average fill rate – unregistered

(%)

King George Hospital

88.48% 90.03% 99.97% 116.38%

Queen’s Hospital 87.50% 97.83% 98.73% 109.86%

Trust Overall 87.75% 95.58% 99.03% 111.52%

All at risk areas are receiving additional support and review to reduce any risks to our patients and therefore based on the mitigations in place we have delivered safe staffing during September. The enclosed report is published on the NHS Choices website and has received positive feedback from the National Trust Development Authority as a good model to use.

JG and FPC final ‐ 28/10/14                                                3 

 

78

APPENDIX 1

SAFE STAFFING LEVELS ACROSS THE TRUST - SEPTEMBER 2014

1. Purpose

Barking, Havering & Redbridge University Hospitals NHS Trust (BHRUT) is committed to ensuring that the levels of nursing staff, including registered nurses, midwives and care support workers are correct for the acuity and dependency needs of individual patient groups within clinical ward areas. This includes an appropriate skill mix and levels of nursing and midwifery staff to provide safe and effective care. These levels of staff are viewed along with registered nurse to patient ratios, the percentage skill mix ratio of registered nurses to care support workers, and the numbers per shift to provide safe effective patient care. Ensuring our wards and departments are adequately staffed is a core responsibility of the Chief Nurse working with the Chief Operating Officer and Directorates. This paper provides an overview of the Trust’s current status (September 2014) for the provision of appropriate nurse and midwife staffing levels, and provides the Trust Board with assurance of the work in progress to monitor and manage safe levels of nursing and midwifery staff in the Trust. 2. Background In November 2013, the National Quality Board (NQB) and the Chief Nursing Officer published information that set out the current guidance on safe staffing. The guidance ‘How to ensure the right people, with the right skills, are in the right place at the right time’ clarifies the expectation on all NHS bodies to ensure that every ward and every shift have the right number of staff on duty to ensure that patients receive safe care. It requires Trust Boards to take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability. There are 10 expectations within the NQB guidance with three key reporting elements that each Trust were required to have in place by June 2014:

The clear display of information at ward levels about the nurses, midwives and care staff

present on each ward on each shift The publication of ward level information on staffing requirements and if these are being

achieved on a ward by ward, shift by shift basis through the publication of planned versus actual nursing and midwifery staffing levels. This is a national template and reporting requirement which relates to the wards enclosed but excludes outpatients, accident and emergency, theatres and other non-ward areas at this time.

The completion of a detailed skill mix review which was presented to Trust Board on the 4th

June 2014. This will be presented every 6 months and includes nurse staffing across all wards and departments.

All of these actions have been completed and continue to be monitored.

JG and FPC final ‐ 28/10/14                                                4 

 

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3. Recruitment to Nursing & Midwifery Vacancies The data (ESR) shows there are currently 191 whole time equivalent (WTE) registered nurse vacancies and 45.86 WTE unregistered vacancies in the areas covered by the safer staffing report. However for all areas across the organisation this is 300 whole time equivalent (WTE) registered nurse vacancies and 85 WTE unregistered vacancies. There are currently 157.32 WTE registered nurse posts and 43.82 WTE health care assistant (HCA) posts in the recruitment process in the areas that fall within the boundaries of the safer staffing report (as per the recruitment tracker system). In total there are 188 WTE registered nurses and 63 WTE unregistered vacancies within the recruitment process across the whole organisation which leaves a gap of 112 registered nursing posts and 22 unregistered posts. In an attempt to help reduce the impact of the lag time from a staff member giving notice to leave and the recruitment process, we have agreed to attempt to over-recruit to key at risk areas such as Medicine. Safer

staffing Advert Shortlist /

Interview Offer Start date Total in

recruitment process

Not in process

RN 191 14.3 29.49 37.6 58 157.32 33.68

HCA 45.86 2 7.7 30.12 4 43.82 26.47

Nursing and midwifery post vacancies are monitored on a monthly basis by the directorates with an overview by the Chief Nurse in conjunction with the Matrons. This is to identify any key areas of shortfall, and identify any alternative staffing movements from non-ward areas and any requirement for long standing temporary staff to fill the vacancies until an appointment is made to areas at risk. The Trust is continuing to implement a recruitment strategy, aimed at appointing suitable staff to vacancies whilst focusing on the need to improve retention. The areas of particular on-going challenge to consistently reduce vacancies are as follows: Ash (KGH) Bluebell B (QH) Clementine B (QH) Gentian (KGH) Harvest B (QH) Sahara B (QH) Heather (KGH) Tropical lagoon (QH) – Registered Sick Children’s Nurses remain a local and national challenge ITU - in line with the national challenge to Specialist units SCBU – in line with the national challenge to Specialist units MAU (QH) A proportion of the vacancies have already been recruited to and are awaiting staff to start, some are covered through temporary staffing. 7 Nurses from Portugal arrived in October who have completed their induction programme and a further 17 arrive on 14th November 2014 to start their two week induction on 18th November There are a further 6 scheduled to arrive later in the year. These nurses require extensive induction and training and receive an extended supervised period. There remains pressure on areas where maternity leave and sickness is high as this puts additional pressure on the wards and departments.

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There is considerable focus on the recruitment process within nursing with an emphasis on rapid and efficient recruitment processes. This time to appointment has reduced significantly and should be evident in the October/November data, There is also an emphasis on cross speciality and directorate recruitment. More work is required to reduce the turnover of band 5 registered nurses, in these and other ward areas. Very little useful information is received via the leaving questionnaires and meetings at this time. All of these indicators are monitored as workforce indicators by the directorates and through the monthly Integrated Performance meetings. 4. Nursing & Midwifery Staff Levels & Skill Mixes at BHRUT In relation to nurse staffing levels, the Safer Nursing Care Tool (SNCT) is advocated nationally as the most reliable method of calculating accurate levels of staff. This evidence based methodology for the data collection, uses individual patient’s acuity and dependency levels (amount of nursing time to manage differing levels of care in acute illness), against previously determined multiplies to calculate the number of staff needed to manage patient care effectively. The daily acuity and dependency is undertaken by Matron and Senior Sisters/Charge Nurses and entered onto the Trust’s electronic system (Synbiotix). This information is used on two levels. In real time this forms part of the daily staffing escalation as described later in this update. In addition, this data is collected to create a level of information regarding the levels of acuity and dependency versus the staffing establishments. This will form part of the six monthly reporting process. The data cannot be viewed in isolation, but as an overall ‘picture’ that includes the registered nurse to patient ratio, the percentage skill mix of registered nurses to care support workers, the number of beds and the geographical layout of the ward with side rooms, and the registered nurse to bed ratio. The nurse to bed ratio shows that the establishments are set so that no ward nurse has more than 8 patients during the day hours. This moves to a 1:10 ratio on a number of wards during the night shifts, which has improved from a 1:15 in 2013, as a result and as referred to in the recent NICE guidance any area that has less than a 1:8 ratio is required to monitor its activity and make an assessment on a daily basis. On reviewing the full set of RN and HCA data it shows, as expected the areas where additional specials are used to at night relate to every ward/department that has over 50% of alerts raised. This use is being monitored and will feed into the next nursing workforce review in October. Midwifery staffing levels are determined through national guidance from The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives (2007). The recommendation for the minimum midwife to woman ratio is 1:28, to achieve a safe level of service, thus providing 1:1 care in labour. The Trust’s Maternity Unit is currently achieving this ratio. The areas of good compliance relate to registered nurse cover at night, unregistered cover at night and therefore the risks associated with these shifts have been reduced. Staffing cover is reviewed monthly via the roster planning, weekly to ensure adequate cover by the directorate and daily as part of the staffing escalation policy, as explained below. Staff are often moved to protect nights as there are less staff both ward and non-ward based, to call upon out of hours, the ratio is lower than during the day hours and staff are often more flexible with night shifts.

81

Fill Rate May – September 2014 The trend in the fill rates have increased since the data collection began in May 2014 with a stepped improvement in August 2014. This improvement has in part been due to

Ensuring the roster templates and hours requested match such as long day versus two short shifts. There is a high level of long days worked routinely by staff.

Optimising a number of the specialist area templates in order to be more reflective of the staffing demand.

Ensuring that mitigations taken to cover rosters are documented clearly and moved on our roster system.

JG and FPC final ‐ 28/10/14                                                7 

 

The September fill rate position is 87.75% as a Trust overall.

September 2014 Day  Night 

Site Name Average fill rate – registered (%)

Average fill rate – unregistered (%)

Average fill rate – registered (%)

Average fill rate – unregistered

(%)

King George Hospital

88.48% 90.03% 99.97% 116.38%

Queen’s Hospital 87.50% 97.83% 98.73% 109.86%

Trust Overall 87.75% 95.58% 99.03% 111.52%

The day shifts coverage has decreased slightly since last month across the organisation on both sites. There were 7 wards showing a less than 80% fill rate during the day shifts. These wards are:

King George Hospital - Fern Ward (Care of the Elderly) 75.1% – this area relates to a staff on

shift rostering issue which is resolving. It was expected that this would have improved in September but this has not happened. There are no reported elevated risk indicators and the FFT score is very high.

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King George Hospital – Gentian Ward (Care of the Elderly and Gastroenterology) 77.6% – this relates to a high vacancy within both the registered and unregistered workforce. The staff have worked hard to ensure this has not resulted in any risks to patients.

Queen’s Hospital – HASU (Neuroscience – Hyper-acute Stroke) 70.1%– this area is supported by a high level of specialist stroke nurses who are being incorporated into the rota, therefore, the quality indicator remains high and the risk is low for patients. If we remove these from the rota we do not meet the Specialist Stroke requirements.

Queen’s Hospital – MAU (Acute Medicine – Medical Assessment) 78.3% - This area is

carrying a high risk as shown by some of the quality indicators and has a daily review of the patients and staffing risks with support from the deputy Chief Nurse.

Queen’s Hospital – Mandarin A Ward (Acute Medicine – Renal) 76.9% - This ward has a high vacancy rate within the registered nurses but has actively recruited and is now awaiting start dates for registered nurses. Lines of agency nurses have been requested and agreed to mitigate risk on the ward.

Queen’s Hospital / King George Hospital - Neonatal Intensive Care Unit. 77.8%- These units have high vacancies in line with national challenges. This variance can be explained also by roster discrepancies such as specialist / education registered nurses who are not covered during periods of annual eave and sickness appearing on the general roster. This is being currently worked through by the Directorate, and a further analysis will be undertaken in November.

Queen’s Hospital – Tropical Lagoon (Children’s). 75.2% - These areas also have specialist personnel within the nursing roster which is being worked through. There are also high levels of vacancies. The beds on Tropical Lagoon are flexed on a shift by shift basis to ensure patient safety depending on staffing levels and acuity of patients. This is difficult to change on our roster system at this time.

There are also 11 wards showing an 80 – 90% fill rate. This includes some wards which are known to have some quality of care issues. These include:-

King George Hospital –Ash Ward (Acute Medicine – Endocrinology) This area is carrying a

high risk as shown by some of the quality indicators and has at least a daily review of the patients and staffing risks with support from the Deputy Chief Nurse. This ward is on the directorate risk register and a full supportive programme is being placed on the ward following concerns raised.

Queen’s Hospital - Bluebell B Ward – (Acute Medicine – Respiratory) This area is carrying a

high risk as shown by some of the quality indicators and has at least a daily review of the patients and staffing risks with support from the Deputy Chief Nurse. This ward is on the directorate risk register; however, practice issues have reduced this month.

Queen’s Hospital – Harvest B Ward (Neuroscience - Stroke) 83.8% – this relates to a high

vacancy and the ward is being monitored. Additional support to assist with reducing vacancies is being given from the Deputy Chief Nurse.

These wards have all been reviewed by the Deputy Chief Nurse for roster efficiencies and quality of care. Matrons have all been asked to account for poor efficiencies and provide assurance to ensure quality and safety for our patients and staff.

83

In relation to the fill rate of over 100%, this is also being challenged. Some of this relates to the roster/budget clarity, some to offset where we have been unable to get adequate registered nurse cover but most relates to additional specials in medicine and older people ward areas. This forms part of the staffing utilisation challenge at directorate level. Trends for In-House Bank Fill Rates Our in house staff bank (IHB) have been able to achieve the following fill rates within registered and non-register requests September. This is across all nurses within the Trust and is not restricted to safer staffing areas. In-House Bank Fill Rates - September 2014 Registered Unregistered Bank 53.97% 86.67% Agency 22.35% 1.12% (nursery nurses) Unfilled 23.68% 12.21%

Whilst the fill rates for IHB are shown to be decreasing in terms of percentages, the total number filled has largely remained static. There has been an increase in terms of requested activity for temporary staffing. This increase is explained by the vacancy factor, special one to one nursing for high risk patients, additional unbudgeted activity and wards working more consistently to the agreed roster profile. 5. Real Time Management of Staffing Levels to Mitigate Risks In the event of shortfalls of staff or unexpected increase in patient acuity and dependency requirements, the agreed staffing levels are reviewed and RAG rated (red/amber/green) with escalation actions specified at each level. Green shifts are determined to be safe levels and would not require escalation as these

constitute the levels expected through the agreed ward establishment.

Amber shifts are determined to be at a minimum safe level. The Matron will be alerted, but no further escalation will be required. Staff will prioritise their work and adjust their workload through the shift accordingly, with a continual review of any changes to the acuity and dependency.

Red shifts are determined to be at an unsafe level. The Matron will be alerted. Mitigating actions will be taken, and documented, which may include the Matron working clinically, the movement of staff from another ward and utilisation of supernumerary staffing within the numbers or reducing the number of patients on the ward to match staff availability. In

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exceptional circumstances activity would be reduced through reduction in the number of beds. This addresses the risk and reduces the shift to an amber rating. Red shifts are escalated via the Matron to the Chief Nurse and Deputy Chief Nurse.

Further mitigations may include lines of regular agency staff and earlier escalation to agency for a specific speciality or high risk area. This would be on the professional judgement of the Chief Nurse.

4. Sensitive Quality Indicators

Nurse sensitive quality indicators have been agreed by the senior nursing and midwifery team i.e. number of falls and hospital acquired pressure ulcers. These are monitored to provide an indication of the quality of care provided in each clinical area, and this, with the workforce metrics provides a triangulated view as to the actual level and skill mix of staff, and the quality of care being provided. The majority of these already form part of the integrated performance framework with the exception of the acuity and dependency data (11-13 on the table below).

Nurse Indicator Definition Target September update

1 Total number of falls

The total number of patients who have sustained a fall in hospital this month

number 129 falls. 12 wards have a falls rate of over 5 falls in September – 2 of these high reporting areas resulted in harm and are being reviewed by the falls lead. A Falls Assessment review has been undertaken by the Deputy Chief Nurse and this will be revised in the short term on 3rd November 2014. There will then be a falls project to review all aspects of the falls pathway to ensure compliance with NICE and national best practice.

2 Number of patients that sustained severe harm from a fall

The total number of patients that sustained severe harm from a fall whilst in hospital this month

0 3 falls resulted in harm to a patient which are being investigated as a Serious Incident. Falls review process has been improved to include a full review of clinical care within 5 days of the fall with the nursing, medical and if appropriate therapy staff.

3 Number of new MRSA bacteraemias

The total number of patients with a newly diagnosed MRSA bacteraemia this month

0 0 cases

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Nurse Indicator Definition Target September update

4 Number of new Clostridium Difficile cases

The total number of patients with a new diagnosis of Clostridium Difficile this month

37 per year

2 cases – both are being investigated and no trends have been noted

5 Friends & Family Test Score (FFT)

The Friends and Family Test score is a national tool that indicates how likely a person is to recommend our services.

Green: 65 & above Amber: 42 to 64 Red: 41 & below

3 red QH Neuro HDU, 1

discharge ‘likely’ response

KGH ITU, nil returns but 2 eligible responses

Clementine B, Low response rate for eligible patients discharged. Within responses more ‘likely’ than ‘very likely’

12 amber 22 green The patient experience team are working with wards and departments to improve FFT scores

6 Number of hospital acquired Pressure Ulcers

The total number of patients who have acquired a pressure ulcer whilst in hospital this month

Zero grade 3/4

There were 2 grade 3 pressure ulcers being investigated as a SI’s.

7 Number of patients admitted with Pressure Ulcer's

This is the total number of patients on this ward who were admitted with a pressure ulcer (pressure ulcer present when they were admitted to hospital)

NA This remains high at 92 and relates to all grades 2,3 and 4.

8 Number of Complaints

Total number of new complaints this month

number 36 new complaints for these areas during September

9 Number of new Serious Incident's

Total number of new serious incidents this month

number 6 serious incidents

 

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Nurse Indicator Definition Target September update

10 % Harm Free Care Results of the monthly national safety thermometer audit which measures the percentage of patients that are free from four harms - pressure ulcers, falls, venous thromboembolism and catheter related urinary tract infection

≥95% 93.34% 20 wards are below the 95% with 3 below 80%. Each of these wards have been reviewed. The 3 wards with below 80% are: Beech KGH - 3 new DVT’s. This is a recognised complication following stroke with a high level of tolerance due to complex anti-coagulation issues. Harvest A QH - 3 new UTI’s with catheters and 5 falls. The ward have been questioned regarding the UTI’s with catheters and all were appropriately placed. We are currently reviewing the falls assessment and pathway. Sunrise B – 5 falls low harm. We are currently reviewing the falls pathway. Sunrise B has a robust action plan in place for falls and is working with the Falls Practitioner to improve practice. 3 admitted pressure ulcers also contributed to this score.

11 Number of entries The total number of days during this month that the ward entered nursing acuity & dependency scores

30/31 This has been inconsistent and is being monitored on a weekly basis

 

 

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Nurse Indicator Definition Target September update

12 Number of alerts The number of alerts generated by the acuity & dependency entries. An alert is generated when the recommended staffing is 10% or more above the actual current establishment. The recommended staffing levels are calculated using the Safer Nursing Care Tool

<10% A high number of alerts were raised against the criteria. These result in a daily review and movement of staff to cover areas of risk by the matron. Evident in the increased fill rate.

13 % of Entries generating alerts

Percentage of entries generating alerts

<50% 27 / 35 wards generated alerts which resulted in additional short term support

6. Summary This paper provides an overview of the Trust’s current status (September 2014) for the provision of appropriate nurse and midwife staffing levels, and provides the Trust Board with assurance of the work in progress to monitor and manage safe levels of nursing and midwifery staff in the Trust. Staff bank have been able to achieve within registered nurses, a 53.9% fill rate for bank and a 14.76% fill rate for agency leaving a 19.58% unfilled rate across the trust. More work is required to establish staffing, in the short term, for the departments where temporary staff is consistently requested, reduce the vacancy rate and improve the fill rate on a day to day basis. Eight of the new nurses from overseas arrived with us on Friday 26 September and have undertaken a robust induction course. They have had a period of supervision and mentorship in clinical areas. A further 17 overseas nurses arrive on 14th November 2014. All at risk areas are receiving additional support and review to reduce any risks to our patients and therefore based on the mitigations in place we have delivered safe staffing during September. This has resulted in more staff being pulled from CNS and other roles to enable this. A full copy of the staffing fill rates and key nursing quality indicators are attached as appendix 1. This data is available as individual ward data which is presented to the Trust Executive Committee and the Trust Board as ward to board indicators.

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A summary of the fill rate for September 2014 is as follows:

September 2014 Day  Night 

Site Name Average fill rate – registered (%)

Average fill rate – unregistered (%)

Average fill rate – registered (%)

Average fill rate – unregistered

(%)

King George Hospital

88.48% 90.03% 99.97% 116.38%

Queen’s Hospital 87.50% 97.83% 98.73% 109.86%

Trust Overall 87.75% 95.58% 99.03% 111.52%

All at risk areas are receiving additional support and review to reduce any risks to our patients and therefore based on the mitigations in place we have delivered safe staffing during September. The enclosed report is published on the NHS Choices website and has received positive feedback from the National Trust Development Authority as a good model to use. Flo Panel-Coates Chief Nurse 24 October 2014

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Date Trust Board: 5 November 2014

Title of Paper: Incident Data Report – including Serious Incident (SI) Report October 2014

Introduction/Summary:

The attached report provides the Trust Board with an update for: Reported incidents including top trends and actions. SI’s for September 2014. Learning from SI’s completed in month. SI Key performance indicators. Inquests summary.

The top categories for incident reporting in month were slips trips and falls, medication incidents, staffing and transfer/discharge of patients. These themes are the same as in the previous month.

The overall numbers of medication incidents and slips, trips and falls incidents are in keeping with other large acute trusts according to NRLS data.

The incident reporting policy and procedures are under review; this will include processes for escalation, investigation and monitoring of actions. Some corporate level changes are now embedded but the Trust has improvements to make in these areas overall.

Duty of Candour is now a mandatory field and so must be completed by the reporter before the incident can be submitted. The Trust continues to make positive progress against this.

It has been agreed to get additional support to help reduce the number of open SI cases.

Patient Safety implications:

The Trust Board has overall responsibility for ensuring that patients remain safe whilst in the Trust’s care, and that all steps are taken to reduce ‘avoidable’ accidents and incidents and to take the necessary action to improve practice and processes where risk to patients, staff and visitors is identified.

Risks: The Trust has a duty and is contractually obliged to minimise risks to patient safety and have systems and processes in place to identify, monitor and mitigate risks to patient safety.

Financial implications:

Potential for contract fines against poor performance on Quality indicators. NHSLA fee costs associated with risk profile resulting from Claims.

Legal advice and implications:

New regulations will allow CQC to prosecute for breaches of fundamentals of care without the need to issue a warning notice first.

A provider would breach the fundamentals of care if they did not follow nationally recognised procedures or practices to prevent or avoid harm, or they tolerated harm in a way that is unreasonable.

Consultation (including patient and public involvement):

The Trust is compliant with the Contractual Duty of Candour.

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Communications: - The SI report feeds into the Trust Learning Lessons Group in order to disseminate and embed key lessons learnt. The Integrated Governance Group has requested a review of the lessons learned group from November 2014.

Equality Impact implications:

Applies to all patients and staff equally

Reviewed by/action taken? This report has been reviewed at the TEC and the new Integrated Governance Group in October.

Recommendations:

The Trust Board is asked to:

o Note the content of the report and progress against improvement actions.

o Request additional assurance as appropriate in order to fulfil its duties.

Author: Mrs. S McConkey, Patient Safety Manager and Miss H Peakman, Deputy Chief Nurse.

Lead Officer: Flo Panel-Coates, Chief Nurse

Date(s) for further review. Monthly report.

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Incident Data Report including Serious Incident (SI) Report

October 2014

1. INTRODUCTION

This report contains a summary of incidents, and serious incidents for the month of September.

Monthly reports regarding incidents are sent to each Directorate for review at Clinical Governance Directorate meetings, which enable specific incidents and issues to be discussed and actions to be agreed.

The Trust has a duty to report any incident that compromises patient safety to the National Reporting and Learning System (NRLS) and to the CCG. NRLS state that it is increasingly recognised that the higher the organisational reporting rate, the stronger the reporting and learning culture is thought to be.

This report will be submitted to the Trust Board, Integrated Governance Group, CQRM and the Serious Incident Review Panel. Going forward when scheduling allows the SI Panel Meeting will agree the first draft of the report prior to QSC.

Information on lessons learnt from SI’s is included in Appendix 1.

2. INCIDENTS

A total of 798 incidents were reported via the electronic reporting system within the time frame 572 clinical and 226 non clinical.

Table 1 – Patient Safety Incidents by Rating

Summary Jan

Feb

March April May June July Aug Sept

All incidents 833 793 866 756 847 865 915 868 798

Incidents reported to NRLS

657 612 652 569 667 655 694 652 572

Extreme/Red 0 4 1 1 3 2 2 3 4

Extreme/Red – (no care management issues)

14 19 21 21 22 25 16 18 11

High 21 26 27 18 27 25 20 17 19

Moderate 140 109 114 120 114 129 123 113 96

Low/Near Miss 482 454 489 409 501 474 533 501 442

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Chart 1 - When do incidents occur?

Figures related to on what day the incident has occurred remains fairly consistent.

orning, The times of incidents occurring remains between 10.00 and 11.00 in the mconsistent with last month. Analysis of this information is currently not available however this is being monitored.

Action:

Reported timings of incidents to continue being monitored in order to identify and analyse

. SERIOUS INCIDENTS

is of information regarding the serious incidents (SI’s) that have

s reported across the Trust during the month.

ur CCG’s using a database known as STEIS (Strategic

s the

3.1. Top Patient Safety Incidents

as remained consistent throughout many months.

any themes or trends arising to the significance of these timings.

3

This report provides analysoccurred during the period September 2014.

There have been a total of 14 serious incidentThis shows a decrease by 2 incidents. There continues to be a review of all incidents reported within the previous 24 hrs by the daily (virtual) SI Review Panel1 to ensure incidents have not been graded inappropriately. Trends are discussed and monitored at the monthly SI Panel meetings. The Trust Patient Safety Manager now also screens new complaints to identify Serious Incidents which may not have been recognised and escalated/ reported at the time of occurrence.

The Trust is required to report to oExecutive Information System). There are three levels of grading for serious incidents. For Grade 0 and level 1 incident the Trust has 45 working days to investigate, and complete report before submission to the CCG for closure. If a Grade 2 incident has occurred (Never event etc) the Trust has 60 days to undertake the investigation. Once the CCG are satisfied with the outcome and is assured that the Trust has learned the cases are closed on STEIS.

The Trust has established a preference to escalate potential Serious Incidents early: Grade 0, and then step them down where appropriate rather than delay escalation in the first instance. This is consistent with a culture of openness and transparency and also meetexpectations of our CCG’s.

The top patient safety incidents reported hMedication Incidents and Slips, Trips and Falls remain the most commonly reported patient safety incidents.

1 For the purposes of clarity: the Daily SI Panel is an electronic review forum which is advised on a daily basis by the Patient safety Manager of potential SI’s arising from incidents, SI mailbox or complaints. It is in effect a “Virtual” panel.

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3.1.1 Slips, Trips, Falls

top reported patient safety incidents; this is in line with the

experienced by our patients remains fairly

eing recognised and preventative measures are being put in place to

hich can cause life threatening or serious debilitating

mployed. There is a falls clinical lead who is

5

t

.

Falls continue to be one of theNPSA Slips, Trips and Falls data update (2010). The Falls Prevention Group and the Falls Serious Incident Panel meet on a monthly basis.

Review of the data shows that the number of falls consistent and is in keeping with the number of falls reported via NRLS within other large acute hospitals

Falls risks are bmanage them. The Trust is currently piloting the use of slipper socks on a couple of wards, this has been financed by Charities.

In-patient falls are one area of harm winjury. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) have been working towards reduced falls for some years.

In March 2014 a full time falls practitioner was ea geriatrician with a specialist interest of falls who is very engaged. The corporate nursing lead for falls prevention is the Deputy Chief Nurse who commenced in post in August 2014.

During falls serious incident panels it has become evident that the falls assessment which BHRUT currently uses is not compliant with the National Institute for Health and Care Excellence (NICE) July 2013 or August 2014 guidance regarding falls assessment for in-patients. This is due to the use of stratification for risk and not including all patients over 6years of age and patients 50 to 65 years who have medical conditions with significant co-morbidities to increase their risk of falls.

A review of the patients who sustained moderate and severe harms following an in-patienfall have shown that 4 of the moderate harms and 3 of the severe harms would have been commenced on the falls pathway if the assessment had been compliant with NICE guidance

ctions: A

It is the recommendation that BHRUT move with immediate effect to:

ore risk factor has the

d continues to undertake deep dives and audits of the environment,

ired for patients

Including all patients over 65 years of age as a high risk of falls r m Stop stratification of risk so that every patient who scores one o

falls pathway started. Including all patients between the ages of 50 – 64 years who have high risk conditions to

be considered for commencing the falls pathway. A review of the current falls pathway to include the assessment and documentation to

ensure it is NICE and ‘Falls Safe’ compliant’ as per best national and international practice.

Ongoing actions:

The Falls Leaanalysing and assessing compliance with the Falls pathway. Feedback is given directly where improvement is required.

The management of patients who fall multiple times during one admission is currently being looked at by the Falls Lead who is informed of the falls that occur daily

The output of the Geriatric Care Teams audit discussed in the last 2 reports is still underway. Once the audit is completed the findings inform this report.

The application for funding for slipper socks that will be provided if requwhilst in hospital, has been agreed by Charities. Charities will fund an nine month trial of the non slip socks on the geriatric wards and the Medical Assessment Units on both sites

Warning symbols have been produced; these are magnetic and are to be placed on the board above the patient’s bed. These are an aid to staff and others that the patient is at risk of falling.

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3.1.2 Medication Incidents

ll of the month’s medication incidents are discussed at monthly Medication Incident Review dicines Practice Group of any trends/themes.

AMeetings which inform the Safe Me

Medication that is marked "do not take home/not for home use" has been given to a patient on discharge; this continues to occur.

Incidents involving insulin

When undertaking a review of NRLS data the numbers of medication incidents is in keeping with other large acute trusts.

Actions:

Weekly themes are communicated to staff via the Trust Link (Intranet newsletter).

Incidents of incorrect supply of discharge medication that is marked not to take home will when

cidents continue to be reported which relate to a shortfall in nursing/midwifery staff, these ility of staff. Whereas some shortfall is to be expected in any Trust at

continue to be monitored. Wards have been reminded to check for this meanwhile discharging patients with medication. The Pharmacy team have introduced enhanced labelling.

A working group looking at insulin administration within the Trust has been established, please see learning lessons section.

3.1.3 Staffing

Inrelate to non-availabtimes, there are a number of vacancies which require temporary staffing solutions whilst active recruitment initiatives progress.

Non filling of in house bank shifts is a common occurrence. Work is currently underway with the company that produced the automated in-house bank booking system as an issue was identified related to the booking process on line Shifts had been registered as being needed in an appropriate time frame however there were no staff available to work.

There were also incidents reported where the acuity on the ward was higher than expected and staff felt that there were insufficient numbers working to deal with the high demand of the ward.

Actions:

The In-House Bank service is proactive regarding filling the shifts and where this is not le will also support requests to external agencies if directed by the Directorate possib

leadership.

Monthly information is published about the numbers of nursing and midwifery staff that are working on each ward along with the percentage of shifts meeting safe staffing guidelines

An acuity and dependency tool is being used across the organisation to identify how nursing resources can be deployed most effectively. This is still relatively new to the organisation and work is ongoing to determine how this will be reported to the Trust Board on a regular basis.

The Trust has an active recruitment process in place with close monitoring of timescales to detect delays in process. The recent nursing staff recruited from Portugal have started.

A review is underway related to the automated booking process as it has become apparent that not all of the details are available to staff relating to the shift when they book on line.

Details of Trust staffing levels have been published both onto the NHS Choices and Trust websites.

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3.1.4 Transfer/Discharge of Patients

All of the discharge alerts received by the Trust are placed onto the Trust database. A mmunication to the district nursing service on common theme continues to be the lack of co

discharge.

Once the discharge alerts have been investigated, feedback is relayed back to the reporter.

Actions:

All discharge documentation must be completed on admission to the ward and a section 2 will bpatient

e completed within 24 hours of admission if needed. Wards will not discharge

nagement

he Trust is showing an improvement in the management of pressure ulcers and has taken specialist sub group.

s without confirmation from social services of care package

Staff have been informed that they must check that the faxed district nurse request form has been received by the District Nursing Service. A receipt should be obtained and also a follow up telephone call.

3.1.5 Pressure Ulcer Ma

Ta proactive stance in the management via a

There has been a significant decrease in the numbers of pressure ulcers grade 3 that have been reported this month. All of the investigation reports will be presented to the Pressure Ulcer Serious Incident Review Panel and the panel will deem if the pressure ulcers were avoidable or unavoidable. The classification is then scrutinised by our CCG’s.

Chart 2 - Serious Incidents Reported per Month – April 2013- August 2014.

Chart 3- Type of Serious Incident Reported

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e incidents reported by Acute Medicine the largest reporter within this month related to two pressure ulcers, grade 3 and one slip, trip, fall and one unexpected death that needs investigation.

Table 2 - Types of Serious Incident Reported

Type of Incident STEIS number Directorate where incident occurred

Th

Pressure Ulcer Grade 3 28230 Acute Medicine Slips, Trips, Fall 29393 Acute Medicine Pressure Ulcer Grade 3 30481 Acute Medicine Unexpected death 30488 Acute Medicine Child Death 28513 Corporate Delayed London Ambulance 29031 Emergency Child death 29194 Emergency Slips, Trips, Falls 28290 Geriatric Medicine Slips, Trips, Fall 29767 Geriatric Medicine Radiology/Scanning 29774 Radiology Slips, Trips, Fall 29766 Specialist Surgery Transfer to NICU 28705 Womens Transfer to NICU 29712 Womens Transfer to NICU 30097 Womens

Chart 4 - Breakdown by Director rious Inciate – Se dents

3.1.6 Sign up to Safety Campaign

The Trust has pledged its support to the ‘Sign up to Safety Campaign’ which is a new NHS campaign to improve patient safety.

The campaign asks that all Trusts halve avoidable harm over the next three years.

In the last three months the number of incidents where harm has began to decrease, it is hoped that this trajectory will continue, however we need to ensure that the levels of incident reporting increase whilst this figure decreases. All teams are requested to encourage proactive reporting of near miss incidents with a view to taking steps to prevent actual harm as soon as possible.

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Chart 5- Number of incidents per month where a level of harm has occurred

0

50

100

150

200

April

May

June

July

Aug

Sept

.

THEMES FROM INCIDENTS AND SERIOUS INCIDENTS

Documentation and poor standards of records keeping has been identified in incidents, complaints, inquests and legal claims. A task and finish group has been set up as a sub-group of the Patient Care and Clinical Governance Work stream of the Trust Improvement Plan. Monthly audits are in place for nursing documentation standards reporting to the

ssionals Steering Group, Patient Care and Clinical Nursing, Midwifery and Allied Health ProfeGovernance Work Stream Group and fed in to the Performance Review meetings.

3.2. Serious Incident Key Performance Indicators

Chart 6- SI Reporting KPI’s

Under the terms of the Contract for 2014/15 the Trust is required to monitor its performance around the reporting of SI’s. There is a requirement to ensure that all incidents graded as “SI” are escalated to CCG’s within a 48 (working) hour timescale via the STEIS system; this is a national target. Although an improvement target is yet to be formally agreed, the Trus

onale for this being that some or

iate elf-

e

he Trust cident reporting system must be discussed with the patient or the next of kin. This is now a

porter before the incident can be s one of the Trust key performance indicators that has been 014/15. Of the 572 patient safety incidents that have been

reported via the incident reporting system all patients or relatives have been informed that an incident has occurred or if this is not possible there has been the reasoning behind this registered on the system. When a serious incident is reported the patient and/or next of kin is sent a letter to confirm that the Trust is undertaking a serious incident investigation and inviting the patient and/or the relative to contribute and receive a copy of the report. Work is currently on going to ensure that these letters can be sent directly from the database system.

t proposed performance target against this is 75%, the ratiincidents can be complex and take a number of days to correctly evaluate the severity degree of harm that will result in an SI being declared. A level 0 grade may be approprfor some but not all of those cases. For the month of September the Trust achieved this sset target, with 75% of serious incidents notified within 48 hours or two working days. ThTrust incident reporting policy is under review; this review will consider how processes for escalating may be improved the aim is to achieve 100%.

o ensure compliance with the duty of candour, all incidents that are reported on tTinmandatory field and so must be completed by the resubmitted. Duty of candour iagreed with the CCG’s for 2

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Chart 7- SI Timescale KPI's

Under the terms of the Contract for 2014/15 the Trust is required to monitor its performance around the timescale for submission of SI reports. There is a requirement to ensure that none are overdue their target date for submission (45 or 60 days) by more than 3 months. Historically, performance has been weak in relation to submission timescales and the Trust is on an extended improvement trajectory. It is anticipated that in 2015/16 the 3 month waiver will be removed. Reasons for delays include late identification of the SI, difficulty in identifying the most appropriate investigator, Directorates being unable to manage the timescales when investigators are outside of their team and delays in being able to access/ interview key staff. The review of the incident reporting policy and procedures will consider how the investigation process can be expedited.

During the month of September the Trust submitted 21 completed serious incident reports for closure.

All reports are now under greater scrutiny which has contributed to the delay in getting a number of the reports closed within the time frame, which has led to the Trust breaching the contract for 2014/15. An action plan has been developed and has been sent to the Commissioners for consideration. It should be noted however that the increase scrutiny related to the sign off of the reports has led to less additional information being requested.

Chart 8 – Status of SI Action Plans

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Chart 9- SI action plans with overdue actions by area

Under the terms of the Contract for 2014/15 the Trust is required to monitor its performance in completing actions from SI’s from recommendations by their due date. Timely closure of action plans demonstrates a drive from the Trust to make changes in practice, procedure or behaviour as a result of learning from SI’s. Management teams should ensure that action plans are monitored locally to track progress and timely completion having identified realistic and achievable actions.

From the data it can be seen that the Trust has work to do in relation to firstly setting realistic and achievable timescales for SI actions but also in tracking progress against these to ensure timely closure. Improved data monitoring and tracking (as above) will be the first step toward achieving this. The SI Panel Meeting will oversee this in the future.

3.3. Serious Incident Review Panel

ll completed SI reports are reviewed at the monthly Serious Incident Review Panel eeting. Directorates are asked to identify a nominated representative to attend these eetings to discuss their serious incident reports and associated action plans.

he sign off process for Serious Incidents has been revised to provide greater scrutiny on completeness and appropriateness of actions; this is in response to both internal

nd external feedback (CCG’s) and also feedback received from some service users/

horough investigation and adequate learning from incidents and as such submission to timescales may temporarily dip whilst the quality of reports is more rigorously assured.

A meeting of the Panel was held on the 12th September 2014. The aim is for the dates to be streamlined in future so that feedback can be incorporated into this report.

At the meeting held in September the Panel heard an update relating to the two previous cases that had been presented by the Children’s Directorate.

Actions that the Panel had requested following review of these investigation reports were:

Establish an alert system on Symphony 2 to immediately identify children with complex medical needs. – This has been undertaken and is now available

Complete a gap analysis on competencies and capabilities on Inra-Osseous cannula usage. This has been completed and the education lead has confirmed that thisforms part of the BLS and PLS training package

Amm

Treports for afamilies.

The SI panel has considered that the focus should be on ensuring a t

2 Emergency Department Patient Information System

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ompetencies of locum doctors covering shifts within the Trust

has been disseminated to staff via email, Intranet and new message board that has

Panel suggested that staff should confirm to

Produce a flow chart that demonstrates the level of care escalation process within Paediatrics. This has been incorporated within the escalation document.

Examine the level of cand how this is assured. The Clinical Director informed the Panel who she is assured relating to locum doctors

To produce a level of care escalation document for sick babies in SCBU at King George Hospital. The Clinical Director confirmed that this has been produced and

been erected in the staff room. The ensure that they have read the document, the Clinical Director confirmed that she will undertake this further action

A contingency plan to be put in place when there is a lack of bed capacity to transfer the sick baby out of SCBU to a higher level of care. This is contained within the escalation document.

4. INQUESTS

There are two forthcoming inquests that the Trust has been notified of:

Reference Number: 3523

Acute Medicine – Patient SP

This patient was admitted to hospital with an upper GI bleed. Whilst on the ward this patient had a fall and sustained an injury, extra-dural haematoma resulting from a fractured skull.

ter. The cause of death after post mortem was recorded as

with injury” and a copy of the

seeable tragic

He was transferred to Neuro ITU; however he developed pneumonia and passed away 7 days la

1a) Septicaemia

1b) Bronchopneumonia

1c) Extra dural haematoma with fractured skull and brain contusion (operation for).

An inquest date is awaited

This case was subject to serious incident review as a “fall serious incident report has been forwarded to HM Coroner.

The serious incident review of this incident concluded that this was an unforeaccident. The patient was startled when an emergency alarm sounded on the ward, he stated that this made him jump and he attempted to get out of bed too quickly and fell.

Reference Number: 3091

General Surgery – Patient BF

The cause of death after post mortem was recorded as

1a) Multi Organ failure and generalised peritonitis

1b) Caecal Carcinoma (operations)

An inquest date is awaited

This case is subject to a complaint

Reference Number: 3248

e – Patient BK

been identified with regards to the Care Home that this patient

Geriatric Medicin

The cause of death after post mortem was recorded as:

a) Large left-side subdural haematoma 1

There are issues that havewas admitted from

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Reference Number: 3557

Emergency – Patient EC

This patient was admitted to Queen’s Hospital after she was found collapsed in her garden same day. at her home address. She died the

The cause of death after post mortem was recorded as:

1a) Pulmonary Oedema

1b) Cardiorespiratory failure

1c) Hypothermia

2) Chronic bronchitis and emphysema

Reference Number: 3088

Specialist Surgery – Patient PP

Queen’s Hospital with periprosthetic femur fracture and rgan failure secondary to his sepsis. He also suffered with

suscitative attempts and multiple sed away

was recorded as:

ypertension

) Pneumonia, right above knee amputation for fracture distal femur

This man was admitted to subsequently developed multi oacute coronary syndrome and heart failure. Despite all reantibiotics his condition did not improve and he pas

The cause of death after post mortem

1a) Left Ventricular failure

1b) Coronary artery atheroma and h

2

Reference Number: 3482

Emergency – Patient TH

This gentleman was admitted to hospital after a choking incident whilst out at lunch

iration

) Previous cerebral infarction, hypertensive and ischaemic heart disease

he family have raised some issues regarding the care that this patient was given in relation the manner and the attitude of the doctors and nurses and end of life care

The cause of death after post mortem was recorded as:

1a) Choking and asp

2

Tto

Reference Number: 3310

Specialist Surgery– Patient IB

ma, peripheral vascular disease

ns related to the hospital

The cause of death after post mortem was recorded as:

1a) Acute and Chronic heart failure

1b) Recent operation for knee prosthesis

2) Coronary Artery Athero

The family have some concer

Reference Number: 3343

Geriatric Medicine – Patient RF

ion, COPD and old brain stroke and high ft sided chest pain and nausea and retching. Based on

mitted

Past medical history of acute myocardial infarctblood pressure. Admitted with leresponse to treatment patient discharged home with outpatient appointment. Readtwo weeks later with a diagnosis of hospital acquired pneumonia and sadly passed away The cause of death after post mortem was recorded as:

1a) Emphysema with bronchopneumonia

This is subject to a complaint

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Incident_data_report_October 2014 Final 14

5. SUMMARY

The top categories for incmedication incidents, staf

ident reporting in month were once again Slips trips and falls, fing and transfer/discharge of patients. These themes remain s month.

ing with

and procedures are under review; this will include processes for changes are now

that has

’s for 2014/15. The Trust has made positive progress against this work on improvements.

‘Sign Up for Safety’ campaign which was launched in July. over the next three years.

support to help reduce the number of open SI cases.

consistent with the previou

The numbers of medication incidents and slips, trips and falls incidents are in keepother large acute trusts according to NRLS data.

The incident reporting policyescalation, investigation and monitoring of actions. Some corporate level embedded but the Trust has improvements to make in these areas overall.

Duty of Candour is now a mandatory field and so must be completed by the reporter beforee incident can be submitted. This is one of the Trust key performance indicators th

been agreed with the CCGindicator and continues to

The Trust has signed up to theThe campaign asks that all Trusts halve avoidable harm

It has been agreed to get additional

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Incident_data_report_October 2014 Final 15

APPENDIX 1

Some examples of Lessons Learned from Incidents

Incident: Drug Error

Root cause:

Failure to administer insulin

Actions to be taken:

An insulin working group has been set up to ensure that the Trust proactively address the issue related to insulin compliance. The Incident concerned did not cause harm to the patient however it did raise issues relating to the education and understanding of insulin management with staff. Actions to be taken following the initial meetings of the group are:

1. Highlight insulin management through the use of a screensaver and ensure the information is reiterated in the LINK the internal newsletter.

2. The pharmacist and Specialist Diabetic Nurses are receiving all incidents relating to insulin so that practice and themes can be identified.

3. Item for discussion at the Senior Nurses meeting in October regarding the implementation of education cards on the drug trolley.

4. Highlighting of the criteria for Never Events in relation to the maladministration of insulin and how improvement in knowledge exchange and education, can be conveyed using preferred methods of training for senior nurses to agree a way forward.

5. Wards received envelopes to provide suggestions for improving engagement with diabetic specialist nurses and education this is currently being analysed.

6. Issues regarding sliding scales and consistency across the organisation in relation to insulin have been identified these are to be addressed by the Medical Director and specialist consultant for agreement on standardised procedures across the Trust.

7. Diabetic specialist nurses provide face-face education and support on the wards and will continue to identify areas for support and additional advice.

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Date of Trust Board meeting: 5 November 2014

Title of Paper: IP&C Annual Report 2013-14 and Strategy & Action Plan 2014-15

Introduction/Summary:

The Annual Report highlights our achievements over the last 12 months and any areas for improvement.

The Strategy and Action Plan addresses areas for improvement noted in the Annual Report and other emerging national and international issues facing the Trust.

Patient Safety implications: The Trust has performed well and introduced various methods to prevent and control infections. The Strategy & Action Plan outlines how this performance should be reinforced so that good Infection Prevention & Control practice is embedded as per the CQC report throughout the organisation. It also includes how we will address emerging threats such as from multi-resistant gram-negative bacteria which the UK government has indicated is a national and internal emergency.

Risks:

1. The increasing threat posed by high-level antibiotic resistant gram-negative bacteria which may lead to untreatable infections.

2. Emerging (new) threats such as from the Middle East Respiratory Syndrome Virus and the Ebola virus outbreak in West Africa since international travel could lead to such infections appearing here.

3. Vascular-line-associated infections of the blood stream from a failure to apply good line insertion and care techniques.

4. Contamination of blood cultures drawn from vascular lines or contamination from skin bacteria from poor blood culture technique leading to a breach of the MRSA zero tolerance target ( see 5 as well).

5. Insufficient compliance with Aseptic Non-touch Technique (ANTT) training and its application leading to blood culture contamination and breach of the MRSA target.

Financial implications: Financial penalties to the Trust are imposed if NHS England targets set for BHRUT for MRSA bacteraemia (“zero tolerance”) and C. difficile (less than 37 cases) are breached.

Legal advice and implications: N/A

Consultation (including patient and public involvement): Approved by the Infection Prevention and Control Committee (including patient advocates), the CCG led Clinical Quality Review Meeting (CQRM) and the Trust Executive Committee.

Communications: Papers were submitted to and approved by Infection Prevention & Control Committee before presentation to CQRM on 14th July 2014.

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Equality Impact implications: N/A

Reviewed by/action taken? N/A

Recommendations:

The Trust Board is asked to consider and note the assurances provided in the

a. IP&C Annual Report (2013-2014)

b. IP&C Strategy & Action Plan (2014-2015)

Author and Lead Officer (if different):

Author: Rosie Madeloso, Sacha Coodye, Ian Hosein

Lead Officer: Mr Stephen Burgess, Interim DIPC

Date(s) for further review. Strategy & Action Plan will be updated throughout the coming year.

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Infection Prevention and Control

Annual Report

April 2013 – March 2014

Authors: Sacha Coodye, Matron for IPC Rosie Madeloso, Clinical Support and Data Analyst, IPC Dr Ian Hosein, Director of IPC

Date: 23rd May 2014

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CONTENTS

Page

1.0 EXECUTIVE SUMMARY 5

2.0 BACKGROUND TO INFECTION PREVENTION AND CONTROL ARRANGEMENTS 5

2.1 What are the structures in place? 5

2.2 How have the arrangements worked in 2013-14? 6

3.0 HEALTH CARE ASSOCIATED INFECTION RATES & OTHER IPC SURVEILLANCE 6

3.1 Meticillin-resistant S. aureus (MRSA) Bacteraemia 6

3.1.1 Blood Culture Contamination 7

3.1.2 MRSA Screening 7

3.2 Clostridium difficile 8

3.3 Other Healthcare-Associated Infections 10

3.3.1 E. coli Blood Stream Infections (E. coli BSI) 10

3.3.2 Meticillin-sensitive S. aureus Blood Stream Infection (MSSA BSI) 11

3.4 Outbreaks and Incidents 12

3.4.1 Outbreaks of Norovirus (or syndromic viral diarrhoea and vomiting) infection leading to closure of bays and wards.

12

4.0 HAND HYGIENE 13

5.0 ESTATES 13

5.1 Water incident at KGH October 2013 13

5.2 Water Quality Assurance for Legionella Control 14

5.3 Theatre Ventilation 14

5.4 Cleaning Services 14

6.0 AUDIT PROGRAMME 14

7.0 REPORT FROM ANTIMICROBIAL PHARMACISTS/CONSULTANT MICROBIOLOGISTS 14

7.1 Guideline development and implementation 14

7.2 Audits completed 15

7.3 Antimicrobial Stewardship Committee 15

7.4 Education & Training 15

7.5 E Learning Module 15

7.6 Conclusion 15

8.0 HEALTH & SAFETY – NEEDLE SAFETY 16

9.0 INTERNAL AUDIT REVIEW 16

10.0 CQC INSPECTION 16

11.0 CONCLUSION 16

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1.0 EXECUTIVE SUMMARY

This report covers the period from April 2013 to March 2014 and informs the Infection Prevention and Control (IPC) Committee of performance towards prevention and control of Healthcare Associated Infections (HCAI) within the framework of the Hygiene Code (The Health Act, 2008) and the revised code introduced in December 2010. The zero tolerance target for “MRSA bacteraemia” was breached by 2 cases of blood culture contamination but these are still counted nationally as blood stream infections. MRSA screening increased from 76% in May 2012 to 95% in November 2013. Problems in the migration to Medway resulted in non-collection of this data by the Information Department from Nov 2013 to March 2014. There were 24 cases of C. difficile infections against a ceiling of 40. Confirmed or suspected Norovirus infection with diarrhoea and vomiting continues to be successfully managed. The data showed that there was a 74% reduction in bed-days lost in winter 2012-13 compared to the previous year, with a significant reduction in patients and staff affected. This performance continued in winter 2013-14. The CQC report on the Trust (Dec 2013) indicated that whilst we had made significant improvements in Infection Prevention & Control, there was still too much variation in staff compliance with hygiene and in the fitness of the hospital environment for optimal Infection Prevention & Control. The report stated that: “Infection control procedures must be implemented consistently in every ward and theatres across the trust”. Both of these issues are specifically addressed in the Trust’s CQC Improvement Plan and have been incorporated into the IP&C Strategy and Action Plan for 2014-15. The internal audit undertaken by Baker Tilley on IPC functions over this last year has emphasised the need for ownership of IPC at directorate level. This Annual Report should be read with the IP&C Strategy and Action Plan for 2014-2015 since together these documents give a full picture of the past year and future plans. 2.0 BACKGROUND TO INFECTION PREVENTION AND CONTROL ARRANGEMENTS

2.1 What are the structures in place? There is duly constituted Infection Prevention and Control Committee (IPCC) which meets bi-monthly and which reports to the Quality and Safety Committee. The Quality & Safety Committee in turn reports to the Trust Board. Clinical Directorates are charged with the safe delivery of care and IP&C is considered within their governance arrangements. Furthermore, directorates are represented on the IPCC. There is an Infection Prevention & Control Team of nurses, doctors, administrative staff and a data analyst which supports both the corporate function for Trust wide issues in IP&C and also supports Clinical Directorates in policy implementation, monitoring, and data analysis. 2.2. How have the arrangements worked in 2013-14?

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Reporting from the IP&C Committee to the Quality & Safety Committee

This occurred regularly though the agenda of the Quality & Safety Committee meetings and ensuing discussions are such that there is insufficient time given to IP&C.

Reporting from the Quality & Safety Committee to the Trust Board. There has been no feedback as to what has or has not been reported to the Trust Board as regards IP&C so this is an uncertain issue.

IP&C at Clinical Directorate Level: Improvements have been made in the way IP&C is delivered by Clinical Directorates. However, the significant progress we have made as a Trust in preventing and controlling MRSA Blood Stream Infection and infections from C. difficile and Norovirus appear to have diminished the time given to IP&C in Directorate Governance meetings since we have fewer crises.

3.0 HEALTH CARE ASSOCIATED INFECTION RATES & OTHER IPC SURVEILLANCE This section gives more details of infections for which we have set national targets and those which must be reported as well but for which there are no set targets.

3.1. Meticillin-resistant S. aureus (MRSA) Bacteraemia

The Trust breached the zero target by two cases. These were contaminants in the blood culture bottles, not true infections. Only two London Trusts met the target of zero and BHRUT was one of 13 Trusts with two cases or less. See Graph A. Graph A. MRSA Blood Stream Infections by month from April 2012 to end March 2014

3.1.1 Blood Culture Contamination: We have taken steps to reduce blood culture contamination including the launch of new blood collection packs in July 2013 with skin decontaminating agents included in

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the same packs to encourage usage. Training in aseptic technique to be used in the taking of blood for culture is also included in the overall training as Aseptic Non- Touch Technique (ANTT), however the delivery of this has been challenging. Since both cases of MRSA bacteraemia reported were contaminants, ANTT practises on both wards concerned were consolidated through refresher training sessions. This was further facilitated through the designation of an IPC Nurse as a dedicated ANTT trainer. The inclusion of ANTT in the Training Needs Analysis (TNA) ensured clinicians understood the importance of compliance with the assessment aspect of the training. A similar approach will be adopted in 2014-15 to ensure flexible availability for training and assessments to take place, including the reinstatement of Train-The-Trainers (TTTs) on every ward. 3.1.2. MRSA screening MRSA screening is essential in documenting patients with this organism so that appropriate isolation and decolonisation protocols can be implemented. Additionally, if a patient is known to be MRSA positive, the correct antibiotic agent will be used and this could prevent blood stream invasion. Required MRSA screening increased from 76% in May 2012 to 95% in November 2013. After this time, no information was provided until end March 2014 by the Information Department because of problems following the migration to Medway. The retrospective data which has now been provided is shown in the graphs (B & C) but have not been properly validated – the Information Department has indicated that validation will recommence from June 2014 but this will only be for data from that point onwards.

Graph B. Monthly Trust compliance with elective MRSA screening from May 2012 to

April 2014

Graph C. Monthly Trust compliance with non-elective (emergency) MRSA screening

from May 2012 to April 2014

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3.2. Clostridium difficile

There were 24 cases of Clostridium difficile infections (CDI) against a ceiling of 40 for the year 2013-14, as shown in Graph D. Of the 24 cases, only two were at King George Hospital. The target set by NHS England for our Trust for 2014-15 is 37. Graph D. BHRUT cumulative cases of C. difficile cases in 2013-14 compared to 2012-

13 and the external target trajectory of 40 set by NHS England.

The distribution of the 24 cases is shown in Graph E.

Graph E. Distribution of 24 cases of C. difficile in 2013-14 by ward.

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Attempts have been made to prioritise the training provided by IP&C members to the most affected wards, highlighted in red in the Graph E, and this will continue in 2014-15. BHRUT CDI rate is compared to the London CDI rate per 100,000 bed days below (Graph F). Graph F. BHRUT performance (green line with black ∆) against National performance

(dashed purple line) and performance in the London region (dashed black line), as rate per 100,000 bed days

3.3 Other Healthcare-Associated Infections

3.3.1 E. coli Blood Stream Infection (BSI) There is no target for E. coli BSI; however, we are still required to report our numbers as part of mandatory reporting to Public Health England. Graph G shows that the trend

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for the last year has been downwards as compared to 2012-13. A major cause of E coli BSI is infection associated with urinary catheters and resulting blood stream invasion (bacteraemia). In 2014-15 we will have a plan to address the whole area of urinary catheters in terms of type, insertion, care, diagnosis, and management of infections. Graph H shows that the numbers of E. coli BSI that are associated with urinary catheters has plateaued.

Graph G. Comparison of cumulative cases of E. coli bacteraemia by financial year, from April 2011 to March 2014.

Graph H. Comparison of cumulative cases of CAUTI-related E. coli bacteraemia by financial year, from April 2011 to March 2014.

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3.3.2 Meticilin-sensitive S. aureus Blood Stream Infection (MSSA BSI)

In 2013-14, the Trust had 31 cases of MSSA blood-stream infections compared to 25 the previous year (Graph I). A major cause of MSSA BSI is invasion via vascular lines. Vascular line-related MSSA BSI cases have also increased from eight the previous year to 13 in 2013-14 (Graph J). A vascular-line insertion and care audit was completed via the IP&C Committee in 2013-14. Findings showed that a much clearer protocol to address this area was needed. This will be addressed in the 2014-15 plan.

Graph I. Comparison of cumulative cases of MSSA bacteraemia by financial year,

from April 2011 to March 2014.

Graph J. Comparison of cumulative cases of vascular line-related MSSA bacteraemia by financial year, from April 2011 to March 2014.

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3.4 Outbreaks and Incidents

3.4.1 Outbreaks of Norovirus (or syndromic viral diarrhoea and vomiting) infection leading to closure of bays and wards. Figure 1 shows the improvement in Norovirus control in 2012-13 compared to the previous year. This good performance continued in 2013-14.

Figure 1. Improvement in Norovirus control by number of patients affected, number of staff reported illness on affected wards, and the number of bed days

lost due to bed closures

Time Period

No. of patients affected

No. of staff reported illness

No. of bed days lost

April 2011 – March 2012 626 109 1432 April 2012 – March 2013 316 44 378

April 2013 – March 2014 108 15 83

The number of bed days lost in April 2013 – March 2014 compared to April 2012 – March 2013 has shown a reduction of 78%. Analysis of the Norovirus clusters and impact on BHRUT wards is also depicted graphically below (Graph K). Graph K Number of bed days lost due to bay or ward closures as a result

of suspected Norovirus from April 2010 to March 2014.

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4.0 HAND HYGIENE Wards complete weekly hand hygiene observational audits. These audits are received by the IP&C Team for analysis. Feedback of overall compliance and compliance by staff group is sent out as part of regular monthly reports to Clinical Directorates by the IP&C Team. The IP&C Team also completed validation audits throughout the year and concordance with ward audits was shown. Hand hygiene compliance increased from 69% to 91% week beginning 17th March 2014 since the roll-out of weekly hand hygiene submissions in March 2013, also indicating an underlying upward average trend (Graph L).

Graph L. Average hand hygiene compliance by week from week beginning 18th March 2013 to 17th March 2014.

5.0 ESTATES

5.1 Water incident at KGH October 2013.

The water supply at KGH was from a bore hole and in October 2013 E. coli was found in surveillance water samples from selected tap outlets. Since E. coli is a marker organism of possible faecal contamination, an incident was immediately declared and water use from this source stopped.

Incident meetings involving Public Health England and other stakeholders were chaired by the Director of Estates and though no clear cause could be identified, the bore hole was taken out of service and remains so. Water at KGH is from the mains and this will remain the situation with the bore hole now decommissioned. There was no evidence of harm to patients or staff as a result of this incident however isolates for typing were not kept by the microbiology laboratories at BHRUT or the laboratories utilised by the external water management company. The BHRUT DIPC has expressed concerns about these failures and arrangements have now been made in the Microbiology Department to keep any future isolates from patients or the environment of IP&C importance. The situation with the external water monitoring company has not been resolved.

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5.2 Water Quality Assurance for Legionella Control Water quality has been monitored by Sodexo staff and the assurance systems indicate that we are in control. 5.3 Theatre Ventilation Theatre ventilation systems are subject to regular checks by Sodexo staff and these indicate that the systems are assured.

5.4 Cleaning Services

Cleaning validation is managed and audited by Sodexo, the providers of cleaning functions at BHRUT, through various multidisciplinary audits, including a weekly environmental audit involving the Trust, Catalyst and Sodexo. Recommendations agreed during each weekly environmental walkabout, including those from the IP&C Team, are circulated to the Estates Team, Sodexo and the Matron and Senior Sister of the area audited to ensure appropriate repairs are undertaken and that specific equipment is visibly clean upon inspection, for example commodes, or assembled correctly, for example sharps bins. Actions plans are formulated to address any outstanding issues related to cleaning assurance and the hospital environment.

6.0 AUDIT PROGRAMME Corporate-led audits including PLACE (Patient-led audit of the care environment) and Quality Road Map were part of the Trust annual audit programme, arranged by the Deputy Directors of Nursing as part of their remit. The IPC Team provides further validation through the undertaking of core IPC audits using the ICNA audit tool, including hand hygiene, isolation practises and the use of PPE, the results of which are disseminated in monthly reports by the IP&C Team. Feedback of results of audits by the IP&C Team was given to ward staff immediately in the clinical area so that any inappropriate practise was corrected and any educational sessions on specific wards were arranged as necessary. 7.0 REPORT FROM ANTIMICROBIAL PHARMACISTS/CONSULTANT MICROBIOLOGISTS This section details the key areas of work that have been carried by the antimicrobial pharmacist and microbiology department throughout BHRH in 2013/14.

7.1 Guideline development and implementation The following guidelines have been written in conjunction with consultant microbiologists with the involvement of senior medical staff and approved by Drugs and Therapeutics Group::

Clostridium Difficile pathway,including introducing Fidaxomicin to the formulary.

Ear, Nose and Oropharynx

Influenzae Opportunistic Infections Sepsis of Unknown Origin

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Bone and Joint Infections Teicoplanin monitoring guidelines

7.2 Audits completed a) Point Prevalence study The 4th Annual Trust wide largest Point Prevalence study was carried out in July 2012. This was a snapshot of antimicrobial use across the trust, Table 1 list the comparisons in previous years

2010 2011 2012 2013 No of charts seen 649 868 660 803 No of antimicrobials prescribed 378 409 326 315 % of pts with antimicrobials prescribed 34% 33% 37% 39.2% Allergy Documented 99.5% 99.7% 99.2% 97.8% Nature of Allergy documented 21% 33% 33% Indication documented in Drug Chart 7% 53.3% 73% 73% Documentation of duration/course length on drug chart

32% 51% 64% 67%

b) Monthly audit on Antimicrobial Management Code On a monthly basis the antimicrobial management code is being audited across the Trust. This is a rolling audit where 5 wards, one from each directorate are audited each month.

There is an overall improvement from 2012-2013 to 2013-2014. However much improvement is required to ensure higher results are seen in achieving >95%.

7.3 Antimicrobial Stewardship Committee The committee met three times in this financial year. Representation from different directorates is still being sought.

7.4 Education and Training The antimicrobial pharmacists and the consultant microbiologists were actively involved in clinical education. A mandatory antimicrobial stewardship training competency was delivered to all FY1s. We have delivered over 40 sessions of teaching to medical staff, nurses and pharmacists trust wide at King George and Queen’s Site.

7.5 E Learning Module The first e-learning module on antibiotic prescribing is mandatory for all new doctors. For 2013/2014 54% of FY1s and 53% of consultants completed the e-learning module, 7.6 Conclusion The action plan report of 2012/2013 identified 5 areas which needed attention in 2013-14. Most of these actions were achieved. We failed to deliver in the area of Trust wide antimicrobial usage; one of our key actions for this coming year should be to achieve this. We have now started to implement an App for antibiotic guideline access and this needs Trust-wide implementation. We will continue to build on the most successful aspects of previous years and extend our action plans for 2014/2015.

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8.0 HEALTH & SAFETY – NEEDLE SAFETY The EU Commission issued Legislation regarding safety devices for use with venipuncture and other cannulation activities in order to protect staff. This legislation is mandatory in all EU countries and the matter was raised at the Health & Safety Committee. Following an analysis of requirements to implement the legislation, the Health & Safety Committee has now advised that such implementation will begin in 2014-15. 9.0 INTERNAL AUDIT REVIEW An internal audit of IPC department’s function was undertaken by Baker Tilley during October 2013. The thrust of the recommendations produced in January 2014 indicated the need for ownership and embedding of infection prevention and control at Directorate level across the organisation. 10.0 CQC INSPECTION The CQC report on the Trust (Dec 2013) indicated that whilst we had made significant improvements in Infection Prevention & Control, there was still too much variation in staff compliance with hygiene and in the fitness of the hospital environment for optimal Infection Prevention & Control. The report stated that: “Infection control procedures must be implemented consistently in every ward and theatres across the trust”. The rest of the recommendations have been incorporated into the Annual Plan for 2014-15. 11.0 CONCLUSION BHRUT has demonstrated significant improvements in infection prevention and control practises and outcomes in 2013-14, including continued improvement in Noroviral control and finishing the year below the target of 40 for C. difficile infections by 16 cases. However, CQC indicated the need to embed infection prevention and control practises across all areas of the Trust and provide assurance of cleaning in theatres at King George. These will be addressed in the Infection Prevention and Control Strategy and Action Plan.

--END--

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Infection Prevention and Control

Strategy and Action Plan

1st April 2014 to 31st March 2015

Authors: Rosie Madeloso – Clinical Support Officer & Information Analyst Sacha Coodye – Matron, Infection Prevention & Control Dr Ian Hosein – Director of Infection Prevention & Control Document Date:

23rd May 2014 Executive Summary: This Strategy and Action Plan should be read together with the Annual Report for 2013-2014 since both give a full picture of how we have been performing and the reasons for our future plans. The Trust has made significant improvements in the prevention and control of hospital acquired infection but the CQC inspection in October 2013 highlighted that we needed to have better assurance systems for cleaning in theatres and for staff compliance with front line IP&C procedures such as hand hygiene. This Strategy and Action plan therefore builds on what we have been doing well, addresses the gaps in assurance noted by the CQC, and also addresses recent national guidance on IP&C related matters.

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2

List of Contents

A. Introduction…………………………………………………………….2 B. How have we been performing?....................................................4 C. What are the strategic drivers for optimal IP&C in 2014-2015?

i. External…………………………………………………………5 ii. Internal………………………………………………………….6

D. BHRUT Action Plan for Infection Prevention & Control……………7

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A. Introduction Infection Prevention & Control (IP&C) is a BHRUT priority and effective implementation of all necessary standards is a core objective of the Trust. This document considers what we have been doing to improve IP&C from October 2012, including our performance, current external and internal strategic drivers affecting Infection Prevention & Control, and then shows how these aspects have informed the development of our Action Plan for 1st April 2014 to 31st March 2015. Why is October 2012 being taken as a period start and what have we been doing to improve Infection Prevention & Control from then to date (March 2014)? A new strategy and action plan was launched in October 2012 to cover from then to end March 2014.Some aspects in that plan are noted below:

I. Stakeholder Engagement: A patient representative was invited to the IP&C Committee and we established better working relationships with our commissioners and Public Health England. A better working relationship was established with our partners in Facilities Management who share responsibility for food safety and environmental cleaning

(see below part VI on the environment).

II. Enabling Leadership: The Trust appointed a highly experienced Director of Infection Prevention & Control in the UK in October 2012 to lead improvements in Infection Prevention & Control. The Infection Prevention & Control Team adopted new ways of working with a greater emphasis on engagement with ward staff. A new matron for Infection Prevention & Control was appointed in Feb 2013 to strengthen the Infection Prevention & Control Nursing Team. A new Infection Prevention & Control Doctor was appointed in March 2013. A Data Analyst and Development Lead was appointed permanently in July 2013.

III. Distributed Leadership: There was a drive to place more ownership

for the optimal delivery of Infection Prevention & Control with frontline staff in all directorates. Clinical Directorates have been provided with key performance data including hand hygiene, MRSA screening, MRSA Blood Stream Infection and C.difficile Infection for review and action at directorate governance meetings.

IV. Staff Understanding and Behaviour: Much training in hospital infection was done at the Trust prior to October 2012 and yet this was not being effective as seen by the high outcome figures for Norovirus impact, MRSA blood stream, and C. difficile infections. A new approach to training in Infection Prevention & Control for Trust staff has been in place since October-November 2012 with the emphases being on:

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better understanding of how pathogens are transmitted the role of staff members in protecting patients, themselves and

their families promotion of a “Can Do” culture to address the defeatism that

had been engendered by devastating outbreaks from Norovirus in prior years.

V. Promotion of Team Working: There has been a concerted effort to

promote the idea of better team-working for delivery of IP&C so that nurses, doctors and managers in local teams are jointly responsible.

VI. The Environment: The fitness of the Trust’s physical infrastructure for

effective delivery of Infection Prevention & Control by staff was audited between October – November 2012 and, as a result, mobile sinks were immediately deployed at the entrances to wards and restaurants. We have since placed permanent sinks at those locations to supplement other sinks already in place on all wards. There was a concerted effort to develop more clarity around roles and responsibilities for keeping the environment clean and maintaining equipment since the Trust has a contract with an external company for much of Facilities Management.

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B. How have we been performing?

I. MRSA bacteraemia:- The NHS England target of “zero tolerance” (interpreted as zero cases) for 2013-2014 was breached by two cases. Both were not true MRSA bacteraemia but determined to be blood culture contaminants following Root Cause Analyses (but contaminants are still checked as bacteraemia for NHS surveillance purposes).The improvement for 2013-2014 compared to the previous year was a 78% reduction (9 cases vs. 2 cases). Only 2/25 Trusts across London achieved the trajectory (i.e. zero cases of MRSA bacteraemia).

II. C. difficile infection:- There were 24 cases of Clostridium difficile

infections (CDI) against a ceiling of 40, that is, 16 cases below the annual trajectory for the year 2013-14. Of the 24 cases, 92% were at Queens (22/24 cases). This is an improvement compared to 2012-13 when the target of 59 was breached by 65 cases. The target set by NHS England for our Trust for 2014-15 is 37.

III. Improvements in Norovirus Control:- Norovirus control in winter

2012-13 compared to 2011-12 showed a reduction of 74% of bed days lost (378 vs. 1432). In that winter of 2012-2013, the UK as a whole experienced one of the worst years for Norovirus impact placing the Trust’s improvement in an even greater context. The good performance continued this winter 2013-2014 with a further reduction in bed days lost to 83.

IV. Hand Hygiene:- The introduction of weekly hand hygiene audits by

every ward has enabled the continuous monitoring of compliance. Since roll-out in March 2013, hand hygiene compliance has increased from 70% to 90% in March 2014. Feedback of compliance is circulated to Assistant Directors of Operations, Clinical Directors, General Managers and Matrons on a monthly basis.

V. MRSA Screening:- Overall MRSA screening compliance has

increased from 76% in May 2012 to 95% in November 2013. The circulation of failed screens to Matrons has allowed the investigation of reasons why patients have not been screened for improvement actions. Following the changeover from PAS to Medway, the MRSA screening dashboard is being re-established for circulation.

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C. What are the Strategic Drivers for Optimal IP&C in 2014-2015? :

External:

I. The increasing threat posed by high-level antibiotic resistant

gram-negative bacteria such as E. coli, Enterobacter spp. and Klebsiella spp. as given in the letter to CEOs 27th Feb. 2014 from Sir Bruce Keogh - NHS England and Dr Paul Cosford - Public Health England entitled:

“Addressing the infection risk from carbapenemase-producing Enterobacteriaceae and other carbapenem-resistant organisms”

II. The CQC Inspection Report for the Trust dated Dec 17th 2014

indicated that despite improvements in infection prevention & control, they found unacceptable variation in our levels of compliance with front line standards such as hand hygiene and environmental/equipment cleaning. The report stated:

“Infection control procedures must be implemented consistently in every ward and theatres across the Trust.”

III. The NICE Quality Standard Document (QS 49, Oct. 2013) on

Surgical Site Infection Prevention, Management and Surveillance gives seven quality standards to be met for assurance of optimal infection prevention & control in surgical practice.

IV. The Trust annual targets for C. difficile and MRSA infections for

the coming year are:

C. difficile infection <37 MRSA blood stream infections = 0

V. Norovirus and Influenza arise in the wider community and both present a continual threat to patients and staff each year with possible ward closures

VI. Emerging (new) threats: the recent emergence of the Middle East

Respiratory Syndrome (MERS) and the current Ebola outbreak in Guinea ( April 2014) means that we must be ready at all times for high level threats. In London Tuberculosis (TB) remains a threat, in particular multi-drug resistant TB.

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7

Internal: Whilst there have been key successes from the application of the last strategy and action plan (October 2012 to March 2014), the following areas were not fully addressed:

I. Directorates must take more ownership of Infection Prevention & Control –IP&C is discussed within directorate governance meetings but more needs to be done in assuring compliance with core standards in clinical areas e.g hand hygiene.

II. Infection Prevention & Control should be discussed as part of

staff appraisals.

III. Blood culture contamination rates must be reduced.

IV. Uptake of Aseptic Non-touch Technique (ANTT) training and assessment must be increased.

V. A clear guideline for the insertion and care of vascular access

devices must be produced and implemented.

VI. A clear guideline for the insertion and care of urinary catheters must be produced and implemented.

VII. The microbiology laboratory infrastructure to support Infection

Prevention & Control must be optimised with newer and rapid methods of pathogen and antibiotic-resistance detection e.g. molecular methods

VIII. There must be more evidence of rational antibiotic prescribing

across the Trust.

IX. There must be an increase in staff vaccination for influenza.

X. The Trust’s decontamination committee must be more functional and be able to provide assurances on decontamination/safety practices for :

Water quality Environmental and equipment cleaning Food safety Decontamination of reusable devices e.g. endoscopes Sterility of surgical instruments Theatre ventilation systems Negative pressure rooms for respiratory isolation e.g. multi-drug

resistant TB cases

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BHRUT Action Plan for Infection Prevention & Control ( April 1st 2014- March 31st 2015 ) Executive Lead: Mr Stephen Burgess, Medical Director Operational Lead: Dr Ian Hosein, Director of Infection Prevention & Control

ITEM Aim and Outcome Actions Required To be delivered by: Monitoring

Frequency/ Completion date

Evidence Update as at May 20th 2014.

1. Development of multi-drug resistant gram-negative organisms policy incorporating a CPE Management Plan

Infection Prevention & Control Team (IPCT)

Update to policy every 3 years or as required

Policy issued on Trust intranet

Policy currently drafted and circulated for comment

2. Communicate plan through:

a) inclusion of CPE in Infection Control Level 2 e-learning module

Matron, IPC

June 2014

WIRED records of staff compliance with training

IPC e-Learning package currently under review

b) communications from DIPC to Clinical Directors and Medical Doctors

DIPC

April 2014 and to continue throughout year

Emails sent to staff

First communication sent 18/04/2014

1. The increasing threat posed by high-level antibiotic resistant gram-negative bacteria - Prepare the Trust for emerging threat of Carbapenemase-producing Enterobacteriaceae (CPE), as per Public Health England toolkit (December 2013)

3. Establish a surveillance database for continuous monitoring of CPE cases

IPC Data Analyst May 2014

Database Database established and in use

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9

4. Ensure laboratory infrastructure to rapidly detect, confirm and report evidence of CPE cases

Clinical Lead for Microbiology

June 2014

Laboratory infrastructure exists to comply with PHE toolkit: 1. Laboratory policy 2. Appropriate

detection media

3. Reporting systems.

Initial meeting with Microbiology staff and DIPC held 19th May 2014

5. Introduce an alert on the Medway system for patients with CPE (ICA6)

IPCT Data Analyst

May 2014

Audit of Medway alerts

ICA6 alert added to Medway and in use

6. Respond to cases/clusters in line with PHE toolkit and CPE management plan

DIPC

As required

Liaison between IPCT, ward staff, Microbiology Consultants and PHE regarding cases

This process was followed when cases arose previously

7. Evaluate the use of a UV emitting device for possible decontamination of patient isolation rooms between occupants

DIPC/IPCT Information & Development Lead

Trial of device planned in May 2014

Trial has been completed

Protocol written with expected start date 2nd June 2014

2. The CQC Inspection Report (December, 2013) stated: “Infection control procedures must be implemented consistently in every ward and theatres

The following are taken from the Trust’s CQC Improvement Plan 1. Ensure that Infection Prevention & Control

metrics are included in the developing ward performance dashboards to include:

Hand hygiene Ward acquired MRSA Application of MRSA

DIPC/IPCNs

Monthly

Receipt of ward dashboards

Hand hygiene, MRSA BSI and C. difficile cases are included in Synbiotix at this

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10

decolonisation protocol Assurance of commode cleaning Appropriate and timely use of

single rooms

time

2. Ensure that compliance reports for Infection Prevention & Control are being addressed at Directorate Governance meetings through circulation of minutes to DIPC.

DIPC/IPCNs

As meetings occur

Minutes of meetings

Minutes requested for review by DIPC

3. Weekly calendared visits to wards

DIPC/IPCNs Weekly

Documentation in patients notes of IPC advice Audit trail in WinPath of follow-up of patient results.

In place

4. Theatres to update CQC Action plan which incorporates Infection Control improvements.

Theatre Matron/ General Manager of Theatres

Monthly

Action Plan

Refer to Theatres Action Plan

across the Trust.” “Cleanliness and infection control must be improved in operating theatres at King George Hospital.” The use of personal protective equipment such as gloves and aprons must be consistent throughout the Trust.

5. Infection Prevention & Control Link Practitioners (IPC LPs) to monitor use of PPE within ward/department areas daily and challenge poor practice.

IPC LPs Daily Feedback to IPCT if non-compliance observed

No reports triaged to IPC Department to date and no reports of non-compliance reported to IPC Matron at LP Study Day on 15th May

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11

6. Directorates to undertake PPE audits using the ICNA audit tool and results to be actioned at governance meetings

IPC LPs Monthly

Receipt of audits

Audits submitted for April currently being collated by IPC Data Analyst

7. Trend analysis of PPE audit results, with compliance being 85% and above, to be undertaken by ward with guidance from IP&CT

IPC Data Analyst

Monthly

Feedback of trends through monthly reports

Trend analysis to be circulated once data collated

8. All staff within the Trust have a responsibility for ensuring equipment is well maintained and cleaned using the Decontamination and Environment checklist based on the ICNA audit tool or the Theatre daily decontamination of equipment checklist.

Clinical Directors

Monthly

Feedback of audit results

9. At Queen’s hospital site, all dispensers containing Personal Protective Equipment (PPE) be re-located from inside isolation rooms to outside rooms.

Estates Department 2014-15 Work completed Trial done on Bluebell A. Environmental working Group established to plan a work programme.

Cross Reference to CQC Improvement Plan regarding Theatre Services as given above in Item 2 part 4. 1. Review of theatres and related procedures

for prevention of SSI

General Manager for Theatres

May 2015

Theatres CQC Improvement Plan (see Item No 2. CQC Inspection Report).

Theatres CQC Improvement Plan (see Item No 2. CQC Inspection Report).

3. The NICE Quality Standard Document (QS 49, Oct. 2013) on Surgical Site Infection (SSI)

2. Collation of orthopaedic SSI data submitted to Public Health England by the

IPC Data Analyst Quarterly Report Data to be collated once

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12

Community Orthopaedic Project in Essex (COPE) Team based in the Orthopaedics Department.

quarterly data is submitted

3. Introduction of neurosurgical SSI surveillance

Neurosciences Clinical Director

July 2014

Surveillance introduced with reports to IP&C Committee

Initial meetings held between IP&C Team Service. NICE guidelines on SSI circulated by IPCT.

4. Introduction of c-section SSI surveillance Clinical Director (Women)

July 2014 Surveillance introduced with reports to IP&C Committee

Initial meetings held between IP&C Team Service. DoH guidance circulated

1. All cases of C. difficile to have an in depth root cause analysis involving the clinical and nursing teams and recorded in multidisciplinary teams

IPCT/IPCD

As occurs

Feedback of RCA outcomes and lessons learnt to IPCC

IPCT using new PHE CDI RCA tool for all cases

2. Continued involvement and participation of senior clinicians for determination of clinical significance of cases and decision of appropriate treatment

IPCT/Clinical Directors

As occurs Minutes of RCA meetings

This process is being followed.

3. Improvements identified in RCAs to be taken forward and monitored via action plans and reported through IPCC

Clinical Directors

As occurs

IPCC minutes

Improvement actions included in IPC. Report to IPCC to facilitate discussion between IPCC members.

4. Meet C. difficile target trajectory set by NHS England of less than 37 cases for the year

4. Serious Incidents (SIs) to be raised for all cases with C. difficile cited on death certificate to Clinical Governance

IPCT/DIPC

As occurs

Records in Clinical Governance.

Clinical Governance to be contacted to

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13

Copies of death certificates held by IPCT when triaged from Bereavement

determine if Part 1 and Part 2 citations must be reported as an SI

5. Improvements identified in RCAs to be circulated on a monthly basis to Directorates

IPC Data Analyst Monthly Monthly reports

Process in place

6. Review of HAI and CAI cases of C. difficile with CCG for Barking, Havering and Redbridge, the CSU covering the CCG and NELFT, including sign off of action plans

DIPC/IPCT

Monthly

Minutes of meetings

Monthly meetings scheduled. Action plans signed off when necessary by all parties present.

Cross Reference to Item 14 for Antibiotic Strategy

1. All cases of MRSA BSI will involve a Root Cause Analysis or Post Infection Review to identify causes and learning for implementation

DIPC/IP&C Matron

As occurs

Feedback of RCA outcomes and lessons learnt to IPCC

No RCAs required currently.

2. All RCA’s and action plans to be presented to IPCC.

Clinical Directors/ DIPC

Bi-monthly

Minutes of IPCC

As above.

3. Clinical Directors to ensure full engagement with RCA /PIR processes and implementation of learning

Clinical Directors

As occurs

Minutes of RCA/PIR meetings

As above.

5. Zero tolerance approach to MRSA Blood Stream infections. This must include prevention of MRSA blood culture contamination.

4. Review of HAI and CAI cases of MRSA bacteraemia with CCG for Barking, Havering and Redbridge, the CSU covering the CCG and NELFT, including sign off of action plans

DIPC/IPCT Monthly Minutes of meetings

Monthly meetings scheduled. Action plans signed off when necessary by

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14

all parties present.

5. MRSA screen of all elective and non-elective admissions who meet the criteria

Clinical Directors

Monthly performance report

Circulation of MRSA screening dashboard

Problems faced by Information Team in running the report being addressed currently. Update will be given to Board in June regarding progress of this.

6. Yellow magnets placed on magnetic boards are to be used to flag MRSA colonised patients on wards

Ward Managers

As required

Auditing by IPCT on ward visits and feedback to Ward Managers

Established practise from last year

7. Patient is isolated and decolonisation protocol commenced

Ward Managers As required Auditing by IPCT on ward visits and feedback to Ward Managers

No issues have been identified currently

Achieve 95% or above monthly compliance with elective and emergency screening for MRSA. MRSA positive patients are isolated and commenced on decolonisation protocols a) immediately if previously known positive, b) once result is available on wards. Daily prevalence report of MRSA colonised patients sent to Ward Managers from IPCT.

8. Daily report IPC Data Analyst Daily Circulation of Report

Report is being evolved to give additional details to support ward staff, e.g. indicating patients who need to be

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15

screened within the next 5-7 days.

9. All patients to have weekly screens for MRSA

IPCT/Ward Managers

As occurs Report by IPCT if ward under special measures

No wards have been placed under special measures

10. Additional hand hygiene training to be held on the ward

IPCT As occurs Documentation of staff trained by IPCT

No wards have been placed under special measures

11. Review MRSA screening and decolonisation implementation on wards concerned

IPCT As occurs Report by IPCT if ward under special measures

No wards have been placed under special measures

12. Joint monitoring of ‘at risk’ patients by IPCT and Tissue Viability Nurses (TVNs)

IPCT/IPC Data Analyst/TVNs

Monthly Feedback of cases to IPCC

This will be implemented going forward

If two or more cases of ward acquired MRSA are identified, the ward in question will be placed under “special measures” including weekly screening of all patients Monitor MRSA invasion via chronic ulcers

Cross Reference to item 9 for prevention of blood culture contamination and item 10 for ANTT.

6. Prevent and control Norovirus spread in the Trust

Reinforce all measures learnt over previous year as regards to hand hygiene, food safety and rapid institution of isolation precautions. These items have been cited elsewhere in this Action Plan.

IPCT In response to clusters/outbreaks of D&V

Minutes of outbreak meetings, register of staff at educational sessions

Continuing good performance in Norovirus control (data on file)

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16

1. Raise staff awareness of emergence of MERS and Ebola through:

Grand Rounds Communications to Clinical

Directors Communications to all junior

Medical Staff

DIPC

April 2014 and to continue throughout the year

Emails

First communication sent 18/04/2014.

7. Emerging (new) threats including the recent emergence of the Middle East Respiratory Syndrome (MERS) and the Ebola outbreak in Guinea Tuberculosis 2. Develop a checklist for communications

regarding multi-drug resistant TB cases IPCT June 2014 Checklist in use

to respond to cases

Checklist currently being drafted

ItemIm

(IPCT

s are the submission in the Trust CQC provement Plan

1. Infection Prevention and Control Team ) to circulate a weekly status update of

performance and outcome measures for HCAIs:

MRSA BSI MSSA BSI E. coli BSI C. difficile infection

IPCT/ IPC Information Analyst

Weekly sign off by DIPC

Reports issued

Being done

8. Enable Clinical Directorate Ownership of Infection Prevention & Control

2. IPCT to circulate a monthly report for Directorate-specific performance update for HCAIs and other key metrics:

MRSA BSI MSSA BSI E. coli BSI C. difficile infection Hand hygiene compliance by ward

and staff group

IPC Data Analyst

Monthly sign off by DIPC

1. Reports issued by IPCT 2. Minutes of Directorate Governance meetings to include discussion and follow-up actions from reports in (1).

Being done

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17

Incidents/outbreaks/clusters MRSA screening performance

1. Continue Bundling of Chloraprep with blood culture sets

General Manager Pathology/IPCT

Finance sign-off April 2014

Use on wards/business case

Funding for blood culture kits agreed with General Manager for Pathology

9. Blood culture contamination rates must be reduced

2. Continue ANTT training to reduce blood culture contamination and central line related BSI

Details are discussed below in item 10.

IPCT

Ongoing throughout the year

Increase in ANTT compliance across the Trust

Monthly drop-in sessions for training scheduled

1. Re-establish the ANTT Train The Trainer (TTT) Study Days for directorate ownership of compliance

IPCT/Clinical Directors

As required IPCT record of ANTT TTTs on wards

2. ANTT training mandatory for all clinical staff undertaking invasive procedures – nursing, medical, phlebotomists

DoN/MD

May 2014 ANTT is included in Training Needs Analysis (TNA)

10. Uptake of Aseptic Non-Touch Technique (ANTT) training must be increased

3. ANTT incorporated into staff appraisals so staff must be assessed as competent pre-study leave

DoN/MD

May 2014 Requests for ANTT training prior to study leave sign-off

1. Health & Safety Committee to introduce needle safety devices

Chair Health & Safety Committee

May 2014

Approved. Granted for full implementation across the Trust

11. Comply with European Directive on introducing safer needle devices

2. Occupational Health to circulate needlestick injury data to all Directorates

Occupational Health Consultant

Monthly Evidence of reports

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18

1. Development of a line insertion protocol

IPCD

June 2014

Guideline available on intranet

12. A clear guideline for the insertion and care of vascular access devices must be produced and implemented

2. Monitoring of compliance with line insertion protocol

IPCD

Ongoing

Audit report to IPCC about compliance

1. Procurement to establish a review group for urinary catheters to discuss:

Types of catheter Training provision via contract

Procurement/Clinical lead Urology/IPCN

June 2014

13. A clear guideline for the insertion and care of urinary catheters must be produced and implemented 2. Surveillance system to monitor CAUTI to

be developed

IPC Data Analyst May 2014 Database Database under development using blood culture data

This reflects the submission to the TDA as part of the Trust Development Plan 1. Annual Point Prevalence Survey (PPS) of

appropriate antibiotic prescribing

Chief Pharmacist/ Lead Microbiologist

Planned for October 2014

Report of PPS circulated to IPC Committee once results have been analysed

Result expected at IPCC from January 2014 onwards following analysis of data

14. There must be more evidence of rational antibiotic prescribing across the Trust Develop a plan to implement the recommendations of the national 5-year strategy for antimicrobial resistance

2. Monthly audits and dissemination of reports of appropriate antibiotic prescribing

Chief Pharmacist/ Lead Microbiologist

Monthly

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19

3. Development and implementation of ‘Guidelines for Severe Sepsis of unknown origin’

Chief Pharmacist/ Lead Microbiologist

4. Development of a smart phone app for quick access to antibiotic guidelines

Chief Pharmacist/ Lead Microbiologist

August 2014 App in use and available for download

App has been purchased and being populated currently. App is predicted to be ready for the next intake of Junior Doctors in August.

5. Embedding of antibiotic management code in clinical dashboards

Chief Pharmacist/ Lead Microbiologist

Evidence of code within clinical dashboards

Mechanism being investigated currently

6. Mechanisms for tighter control of restricted antibiotics under development as per national 5-year strategy

Chief Pharmacist/ Lead Microbiologist

Ongoing process

7. Launch multi-disciplinary sepsis steering group and, once established, deliver key improvements in raising awareness of clinical staff about sepsis

DIPC/ Lead Microbiologist/ Chief Pharmacist

Grand Round held 30th May 2014 by DIPC/Lead Microbiologist/ CD for Emergency Care. Sepsis Campaign week arranged 2 – 6 June ‘14.

8. Report of antimicrobial usage trust wide – using new Define system

Chief Pharmacist/ Lead Microbiologist

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20

1. Occupational Health to host influenza vaccination clinics on wards

Occupational Health Consultant

15. There must be an increase in staff vaccination for influenza 2. Flu vaccination champions to be

designated on every ward Occupational Health Consultant

1. Head of Estates to re-establish Trust Decontamination Committee for assurances of :

Water Quality Policy Water Quality in augmented care units. Legionella control in hospital water

systems Ps. aeruginosa in hospital water Environmental and equipment cleaning Food Safety Decontamination of reusable devices

e.g. endoscopes Surgical instrument sterilization Ultra-clean Theatre ventilation system

Head of Estates

June 2014 Decontamination Committee meets regularly with minutes and action points

Director of Estates and DIPC agreeing Terms of Reference

2. Decontamination Committee to provide assurance to IPCC

Head of Estates

16. The Trust’s Decontamination Committee must be more functional

3. Invite external advisor to review decontamination in the Trust

DIPC

End of Strategy and Action Plan-------------------------------------------------------------------- Dr Ian K Hosein MD MA FCAP FRCPath MBA Director of Infection Prevention & Control, Barking, Havering & Redbridge Hospitals NHS Trust

141

AGENDA ITEM:4.1

Meeting: Trust Board Date: 5th November 2014

Title of Paper: Performance Report

Introduction/Summary: This report provides the Trust Board with an assessment of the Trust’s performance against the accountability framework. All indicators are reported for September 2014 unless otherwise indicated. This report relates to the following corporate objectives:

Objective 2: We will continuously improve the effectiveness, efficiency and accessibility of our services

Objective 3: We will retain, recruit, deploy and develop an engaged and motivated workforce

Patient Safety implications: Patients may be exposed to additional risk resulting from underperformance against the standards. Harm review processes are in place for those areas.

Risks: The Trust has underperformed against a number of the standards meaning that patients are not receiving services to the standard expected in the following areas:

Emergency treatment within 4 hours (performance deteriorating)

Diagnostic tests within 6 weeks (performance expected to recover)

Elective treatment within 18 weeks (marginal improvement)

Cancer treatment within 62 days (continued underperformance)

Financial implications: There are no direct financial implications of this report, although performance improvement in particular in the emergency care pathway will require transitional support. The underperformance against the key standards would allow CCGs to impose significant financial penalties on the Trust.

Legal advice and implications: Some of the NHS Constitution standards are no being met

Consultation (including patient and public involvement): N/A

Communications: The Trusts performance is reported publicly and forms part of the team brief.

Equality Impact implications: N/A

Reviewed by: Trust Executive Committee, 28th October 2014

Recommendations: That the Board note the performance against the accountability framework and agree actions to improve performance.

Author and Lead Officer (if different): Steve Russell, Deputy Chief Executive

Date(s) for further review. Trust Executive Committee, 25th November 2014

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AGENDA ITEM:4.1

143

AGENDA ITEM:4.1 Section 1 – Background 1. The Trust is accountable to the NHS Trust Development Authority (TDA) for the

delivery of safe, effective high quality services. The TDA has published the accountability framework for NHS Trusts which sets out the standards which NHS Trust Boards are expected to achieve for patients treated in their organisations.

2. This report presents the Trust Executive Committee with summary of the Trust’s

performance at September 2014 (unless otherwise stated) against the TDA Accountability Framework.

Section 2 – The Accountability Framework 3. The Trust’s performance for September 2014 was as follows against each of the

domains (in which 5 indicates the best possible performance)

Responsive 2/5 (deterioration) Effective 5/5 (consistent with previous) Safe 5/5 (improvement) Caring 3/5 (consistent with previous) Well led 3/5 (consistent with previous)

144

Section 3 – Key issues Area In month (September position) Actions and forecast Accountable

Clinical Directors

RTT The admitted backlog was 3,536 against a trajectory of 3,622. The number of patients admitted for treatment was lower than required at 2,014 against a plan of 2,850. 1,080 patients had been referred to the ISTC and 461 had been treated.

In order to maintain the backlog reduction the run rate is required to be sustained at a higher level month. Urology, Gynaecology and Neurosurgery have backlogs in excess of sustainable levels and each have plans in place to reduce this by end December. The Trust intends, subject to securing funding, treat additional patients in the independent sector between November 2014 and March 2015.

DM DO GS RO JP

Diagnostic waits

This standard was marginally failed in the month due to Audiology, where a large number of patients had not been given a date within 6 weeks.

A change has been made to the diagnostic PTL which will ensure all patients in audiology and cardiology are included in the PTL. The Trust expects to recover performance in the month of October.

GS

Cancer two week wait

The two week standard was achieved in August 2014 for the third consecutive month

The Trust expects to continue to meet the 2ww standard. The blood in pee campaign starts in October and additional capacity has been put in place to manage the expected increase in demand.

DM

Symptomatic breast

91% of patients were seen within 2 weeks, but 15 patients chose not to accept the appointments offered and chose to wait over 2 weeks. This resulted in the standard being failed with a total of 17 patients waiting over 2 weeks for their appointment

The Trust is working with the CCG to ensure that women referred to the service are given the appropriate information and to ensure they are able and willing to accept an appointment within a 2 week period.

DM

Cancer 62 days

There has been consistent underperformance against this standard in Lower GI, Upper GI,

The Trust forecast of recovering performance for November is at risk due to the number of patients who

DM SA

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AGENDA ITEM:4.1

Lung and Urology resulting from consistently slow pathways. There were 17 breaches of this standard in the month. There was an unplanned underperformance in Breast.

have not been treated within October.

Cancer 31 days

Provisional data indicates that there is a risk this standard will be failed in September, largely driven by Breast and Skin although validated performance against the standard is reported 1 month in arrears. Performance against the radiotherapy standard was not achieved with 13 patients waiting more than 31 days.

Improvements in the live update of the PTL are required to improve the ability of MDTs to identify risks and take appropriate action to ensure patients are treated within the required timescales

JS DM

Emergency Care

Performance in September deteriorated to 85.1%. from 87.7% in July. The 95th centile for non-admitted patients is 339. If the pathway for non-admitted patients is reduced by 99 minutes the standard would be met. The median wait for patients who are admitted to hospital is 4hours, meaning over half our patients wait over 4 hours.

Non elective length of stay in medicine rose in the month indicating an increased risk to access to beds, with a 2% rise at QH and a 12% rise at KGH. There has been a significant shift in the proportion of earlier discharges reflecting the work of clinical teams. This has not yet translated into an improvement in performance as it is not yet sufficiently consistent but also as it has identified a number of other elements of the pathway that require improvement (MAU and Bed Management) The Trust is implementing ‘majors-lite’ and improving the workforce capacity in the Urgent Care Centre in November and implementing changes to the assessment units at the end of November which are expected to improve performance.

DK (Non admitted) ALL (Admitted)

146

AGENDA ITEM:4.1 Section 4 – Reporting Risks 10. There are some areas of the TDA accountability framework that the Trust is not

yet able to report against, notably some of the Mortality Indicators. The Trust has now selected a new provider for informatics which will enable much more powerful reporting and analysis.

11. The VTE data is not considered to be reliable. As part of the Trust’s ongoing

review of data quality and data reporting, it was identified that Medway PAS does not capture the date of the assessment. The Trust has concluded a review of the system in place, and has developed a solution in clinical note, which is .

12. There are a number of areas where the reporting of data is undertaken locally

rather than by the information department. The Board has previously agreed that the information department should take responsibility for all reporting. This is being phased in as the capacity in the department is increased.

13. The Trust has requested internal audit review the processes of reporting for the

mandatory returns to provide assurance about the robustness of the processes and the accuracy of the data.

Section 5 – Recommendation 14. It is recommended that the Board:

Note the assessment of performance against the accountability framework Note the risks and actions being taken Agree any further action required of the Executive Team.

147

*Figures are validated (Month in arrears)

Our in‐month performance against the accountability framework

Responsiveness - 1

RTT Non-Admitted

(Sept)

RTT Incomplete

(Sept)

RTT Incomplete

>52 (Sept)

Diagnostic 1.07% (Sept)

RTT Admitted

(Sept)

Effectiveness

HSMR 101.6

(May'14)

Emergency Re-

admissions 6.2%(Aug)

SHMI 98.7

(Jan'13 - Dec'13)

Safe - 1

MRSA 1

(Sept YTD)

Harmful patient safety

incidents129

(Sept)Never Events

0 (Sept)

Serious Incidents

14 (Sept)

C.Diff 16

(Sept YTD)

Responsiveness - 3

2ww Breast Symptoms

89.9% (Aug)*

31 Day 98.8% (Aug)*

62 day Screening

100% (Aug)*

62 Day 83.9% (Aug)*

2ww 93.9% (Aug)*

Responsiveness - 2

A&E Trolley Waits

0(Sept)

Cancelled not treated within 28

days0

(Sept) Urgent

operations cancelled 2nd time

0(Sept)

Delayed Transfers of Care 1.5%

(Sept)

A&E (All types) 85.1%(Sept)

Caring

FFT A&E31

(Sept)

MSA breaches

12 (Sept)

FFT Inpatients

71(Sept)

Safe - 2

Harm Free Care

93.3%(Sept)

VTE 97.6%(Sept)

Medication Errors with

serious harm

0 (Sept)

Maternal deaths

0 (Sept)

Outstanding CAS alerts

0 (Sept)

Well Led

FFT A&E

Response Rate23%

(Sept)

Vacancy Rate

11.7%(Sept)

Turnover Rate

14.1% (Sept)

Sickness Rate 4.0%(Sept)

FFT Inpatient

Response Rate49%

(Sept)

Produced by Information Services Page 1148

Responsiveness Domain 73% Safe Domain 10%

Metric Weight Standard Period Perf Score Metric Weight Standard Period Perf Score

Referral to Treatment (Admitted) 10 90% Sep-14 73% 10 Clostridium Difficile - YTD 10 18 Sep-14 16 0

Referral to Treatment (Non Admitted) 5 95% Sep-14 82% 5 MRSA bactaraemias 10 0 Sep-14 0 0

Referral to Treatment (Incomplete) 5 92% Sep-14 43% 5 Never events 5 0 Sep-14 0 0

Referral to Treatment 52+ Week Waiters 5 0 Sep-14 3353300% 5 Serious Incidents 5 - Sep-14 14 0

Diagnostic waiting times 5 <1% Sep-14 1.1% 5 Harmful patient safety incidents 5 0 Sep-14 129 5

Urgent operations cancelled for 2nd time 2 0 Sep-14 0 0 Medication errors with serious harm 5 0 Sep-14 0 0

Outstanding CAS alerts 2 0 Sep-14 0 0

Maternal deaths 2 0 Sep-14 0 0

A&E (All Types) 10 95% Sep-14 85.1% 10 VTE Risk Assessment 2 95% Sep-14 97.6% 0

12 hour Trolley waits 10 0 Sep-14 0 0 Percentage of Harm Free Care 5 95% Sep-14 93.3% 5

Delayed transfers of care 5 3.5% Sep-14 1.5% 0 Weighted Total 51 5

2 week wait for suspected cancer 2 93% Sep-14 96.0% 0

2 week wait for symptomatic breast 2 93% Sep-14 91.1% 2 Caring Domain 58%

31 days from diagnosis to treatment* 2 96% Sep-14 90.0% 2 Metric Weight Standard Period Perf Score

31 days for subsequent drug treatment* 2 98% Sep-14 95.7% 2 FFT net promoter score(in-patients) 5 60 Sep-14 71 0

31 Day for subsequent radiotherapy* 2 94% Sep-14 81.4% 2 FFT net promoter score(A&E) 5 46 Sep-14 31 5

31 days for subsequent surgery* 2 94% Sep-14 75.0% 2 Complaints 5 - Sep-14 106

62 days from GP referral to treatment* 5 85% Sep-14 82.1% 5 Mixed Sex Accommodation Breaches 2 0 Sep-14 12 2

62 days from screening referral to treatment* 2 90% Sep-14 81.3% 2 Inpatient Survey - good experience 2 - Annual 76

Weighted Total 78 57 Weighted Total 12 7

Effectiveness Domain 0% Well Led Domain 16%

Metric Weight Standard Period Perf Score Metric Weight Standard Period Perf Score

HSMR* 5 - May-14 101.6 Inpatient FFT response rate 2 30 Sep-14 49 0

Deaths in low risk conditions 5 - A&E FFT response rate 2 20 Sep-14 23 0

Weekday HSMR* 5 - May-14 99.9Staff recommending the trust as a place of work

2 61 Annual 51 2

Weekend HSMR* 5 - May-14 106.3Staff recommending the trust as a place to receive treatment

2 67 Annual 54 2

Data Quality of Returns to HSCIC 2 - Annual

Trust turnover rate (annualised) 3 - Sep-14 14.1

Emergency re-admissions within 30 days 5 - Aug-14 6.16 Trust level total sickness rate 3 - Sep-14 4.0

Weighted Total 10 0 Trust vacancy rate 3 - Sep-14 11.7

Temp/overtime as % of total paybill 3 - Sep-14 16.8

Staff with annual appraisal 3 - Sep-14 79.6*Figures are provisional and subject to change with national deadlines Weighted Total 25 4

Jan 13 to Dec 13

98.7 0

Patients not treated within 28 days of last minute cancellation

2 0 Sep-14 0 0

SHMI (Jan 13-Dec 13) 5Expected

range

Our in‐month performance against the accountability framework by metric%'s by domain shows the weighted proportion of indicators failed

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Overall Quality Score 4 4 4 4 4 4

Responsiveness Standard Weighting Apr‐14 Score May Score Jun Score Jul Score Aug Score Sep Score Oct Score Nov Score Dec Score Jan Score Feb Score Mar Score

Referral to Treatment Admitted 90 10 10 72.8 10 72.8 10 10 10 10

Referral to Treatment Non Admitted 95 5 5 88.2 5 82.4 5 5 5 5

Referral to Treatment Incomplete 92 5 5 43.5 5 43.1 5 5 5 5

Referral to Treatment Incomplete 52+ Week Waiters 0 5 5 32,639 5 33,533 5 5 5 5

Diagnostic waiting times 1 5 2.2 5 1.6 5 0.7 0 0.1 0 0.2 0 1.07 5

A&E All Types Monthly Performance 95 10 88.4 10 84.7 10 84.7 10 87.7 10 85.5 10 85.1 10

12 hour Trolley waits 0 10 0 0 0 0 0 0 0 0 0 0 0 0

Two Week Wait Standard 93 2 76.1 2 76.6 2 85.5 2 93.8 0 93.9 0 96.0 0

Breast Symptom Two Week Wait Standard 93 2 38.4 2 50.6 2 83.6 2 88.4 2 89.9 2 91.1 2

31 Day Standard 96 2 97.5 0 96.2 0 95.98 2 97.6 0 98.8 0 90.0 2

31 Day Subsequent Drug Standard 98 2 100.0 0 100.0 0 100.0 0 100.0 0 100.0 0 95.7 2

31 Day Subsequent Radiotherapy Standard 94 2 100.0 0 95.7 0 96.6 0 98.7 0 100.0 0 81.4 2

31 Day Subsequent Surgery Standard 94 2 100.0 0 95.2 0 96.2 0 90.9 2 100.0 0 75.0 2

62 Day Standard 85 5 88.8 0 85.9 0 73.4 5 83.6 5 83.9 5 82.1 5

62 Day Screening Standard 90 2 93.8 0 94.4 0 94.7 0 100.0 0 100.0 0 81.3 2

Urgent Ops Cancelled for 2nd time (Number) 0 2 0 0 0 0 0 0 0 0 0 0 0 0

Proportion of patients not treated within 28 days of last 

minute cancellation0 2 5 2 2 2 2 2 0 0 0 0 0 0

Delayed Transfers of Care 3.5 5 1.9 0 1.8 0 1.6 0 1.2 0 1.5 0 1.5 0

Weighted Total 78 46 46 48 44 42 57

Responsiveness Domain Score 3 3 2 3 3 2

Effectiveness Standard Weighting Apr‐14 Score May Score Jun Score Jul Score Aug Score Sep Score Oct Score Nov Score Dec Score Jan Score Feb Score Mar Score

Hospital Standardised Mortality Ratio (DFI) ‐ 5 95.2 101.6

Deaths in Low Risk Conditions ‐ 5

Hospital Standardised Mortality Ratio ‐ Weekday ‐ 5 90.1 99.9

Hospital Standardised Mortality Ratio ‐ Weekend ‐ 5 112.3 106.3

Summary Hospital Mortality Indicator (HSCIC) Expected range 5 99.1 99.1 99.1 98.7 98.7 98.7

Emergency re‐admissions within 30 days following an elective 

or emergency spell at the Trust‐ 5 9.0 9.3 8.4 6.2 6.2 6.2

Weighted Total 10 0 0 0 0 0 0

Effectiveness Domain Score 5 5 5 5 5 5

Safe Standard Weighting Apr‐14 Score May Score Jun Score Jul Score Aug Score Sep Score Oct Score Nov Score Dec Score Jan Score Feb Score Mar Score

Clostridium Difficile ‐ YTD 18 10 2 0 4 0 4 0 7 0 13 0 16 0

MRSA bactaraemias 0 10 0 0 0 0 0 0 1 10 0 0 0 0

Never events 0 5 0 0 0 0 0 0 0 0 0 0 0 0

Serious Incidents rate ‐ 5 12 0 17 0 14 0 9 0 16 0 14 0

Patient safety incidents that are harmful 0 5 139 5 144 5 156 5 136 5 131 5 129 5

Medication errors causing serious harm 0 5 1 5 2 5 2 5 0 0 2 5 0 0

CAS alerts 0 2 0 0 0 0 0 0 0 0 0 0 0 0

Maternal deaths 1 2 0 0 0 0 0 0 0 0 0 0 0 0

VTE Risk Assessment 95 2 97.2 0 98.1 0 98.4 0 97.9 0 97.5 0 97.6 0

Percentage of Harm Free Care 95 5 92.0 5 92.1 5 93.8 5 94.4 5 93.3 5 93.3 5

Weighted Total 51 15 15 15 20 15 10

Safe Domain Score 4 4 4 4 4 5

Caring Standard Weighting Apr‐14 Score May Score Jun Score Jul Score Aug Score Sep Score Oct Score Nov Score Dec Score Jan Score Feb Score Mar Score

Inpatient Scores from Friends and Family Test 60 5 67 0 69 0 70 0 73 0 71 0 71 0

A&E Scores from Friends and Family Test 46 5 22 5 19 5 14 5 20 5 26 5 31 5

Complaints 5 83 73 89 85 73 106

Mixed Sex Accommodation Breaches 0 2 6 2 11 2 8 2 12 2 5 2 12 2

Inpatient Survey Q 68 ‐ Overall, I had a very poor/good 

experience‐ 2 76 76 76 76 76 76

Weighted Total 12 7 7 7 7 7 7

Caring Domain Score 3 3 3 3 3 3

Well Led Standard Weighting Apr‐14 Score May Score Jun Score Jul Score Aug Score Sep Score Oct Score Nov Score Dec Score Jan Score Feb Score Mar Score

Inpatients response rate from Friends and Family Test 30 2 54 0 44 0 43 0 45 0 50 0 49 0

A&E response rate from Friends and Family Test 20 2 22 0 18 2 18 2 22 0 21 0 23 0

NHS Staff Survey: Percentage of staff who would recommend 

the trust as a place of work61 2 51 2 51 2 51 2 51 2 51 2 51 2

NHS Staff Survey: Percentage of staff who would recommend 

the trust as a place to receive treatment 67 2 54 2 54 2 54 2 54 2 54 2 54 2

Data Quality of Returns to HSCIC ‐ 2

Trust turnover rate (annualised) ‐ 3 13.51 13.87 14.36 14.40 14.3 14.1

Trust level total sickness rate ‐ 3 3.81 3.67 3.72 4.00 4.1 4.0

Total Trust vacancy rate ‐ 3 11.14 11.27 11.81 12.73 12.6 11.7

Temporary costs and overtime as % of total paybill ‐ 3 15.98 16.31 15.74 16.01 17.05 16.83

Percentage of staff with annual appraisal ‐ 3 77.55 80.55 75.60 78.3 79.9 79.6

Weighted Total 8 4 6 6 4 4 4

Well Led Domain Score 3 2 2 3 3 3

Our month on month performance against  the accountability framework

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150

Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Diagnostic waiting times ‐ seen within 6 weeks 99% 97.9% 98.4% 99.3% 99.9% 99.8% 98.9%

Endoscopy 99% 84.9% 88.8% 98.7% 99.2% 98.2% 99.7%

Colonoscopy 99% 79.9% 94.0% 98.5% 100.0% 97.7% 99.6%

Cystoscopy 99% 97.9% 93.7% 100.0% 97.6% 96.3% 99.2%

Flexi sigmoidoscopy 99% 76.5% 81.4% 93.8% 100.0% 100.0% 100.0%

Gastroscopy 99% 84.0% 84.8% 99.3% 99.0% 98.9% 100.0%

Imaging 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Barium Enema 99% ‐ 100.0% ‐ 100.0% 100.0% ‐

Computed Tomography 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

DEXA Scan 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Magnetic Resonance Imaging 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Non‐obstetric ultrasound 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Physiological Measurement 99% 100.0% 99.6% 94.6% 98.99% 100.00% 88.54%

Audiology ‐ Audiology Assessments 99% 100.0% 99.1% 72.7% 95.9% 100.0% 69.5%

Cardiology ‐ echocardiography 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cardiology ‐ electrophysiology 99% ‐ ‐ ‐ ‐ ‐ ‐

Neurophysiology ‐ peripheral neurophysiology 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Respiratory physiology ‐ sleep studies 99% 100.0% 98.6% 98.7% 98.2% 100.0% 98.8%

Urodynamics ‐ pressures & flows 99% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Diagnostics

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15provisional

Two Week Wait Standard 93% 76.1% 76.6% 85.5% 93.8% 93.9% 96.0%

Total Seen 1,376 1,280 1,421 1582 1452 1365

Breaches 329 300 206 98 88 54

Breast Symptom Two Week Wait Standard 93% 38.4% 50.6% 83.6% 88.4% 89.9% 91.1%

Total Seen 263 330 207 232 179 190

Breaches 162 163 34 27 18 17

31 Day Standard 96% 97.5% 96.2% 95.98% 97.6% 98.8% 90.0%

Total Seen 162 183 174 166 161 130

Breaches 4 7 7 4 2 13

31 Day Standard ‐ by tumour group

Breast 96% 100.0% 95.5% 94.9% 95.0% 100.0% 80.0%

Lung 96% 100.0% 95.5% 92.9% 100.0% 100.0% 100.0%

Haem 96% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Upper GI 96% 85.7% 100.0% 100.0% 100.0% 91.7% 100.0%

Lower GI 96% 100.0% 100.0% 100.0% 95.7% 100.0% 95.0%

Skin 96% 86.7% 84.0% 81.0% 83.3% 100.0% 62.5%

Gynae 96% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Brain CNS 96% 100.0% 100.0% 100.0% 100.0% 100.0% 66.7%

Urology 96% 100.0% 100.0% 100.0% 100.0% 95.8% 93.3%

Rare 96% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Head & Neck 96% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Sarcoma 96% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Other 96% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

31 Day Subsequent Drug Standard 98% 100.0% 100.0% 100.0% 100.0% 100.0% 95.7%

Total Seen 16 32 22 25 19 23

Breaches 0 0 0 0 0 1

31 Day Subsequent Radiotherapy Standard 94% 100.0% 95.7% 96.6% 98.7% 100.0% 81.4%

Total Seen 46 47 58 75 41 70

Breaches 0 2 2 1 0 13

Cancer

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15provisional

Cancer

31 Day Subsequent Surgery Standard 94% 100.0% 95.2% 96.2% 90.9% 100.0% 75.0%

Total Seen 27 21 26 11 12 4

Breaches 0 1 1 1 0 1

62 Day Standard 85% 88.8% 85.9% 73.4% 83.6% 83.9% 82.1%

Total Seen 85 103 94 91.5 96 84

Breaches 10 15 25 15 15.5 15

62 Day Standard ‐ by tumour group

Breast 85% 95.1% 83.7% 65.0% 89.2% 81.8% 77.3%

Lung 85% 87.5% 83.3% 62.5% 66.7% 100.0% 66.7%

Haem 85% 66.7% 83.3% 90.0% 100.0% 100.0% 80.0%

Upper GI 85% 100.0% 63.6% 72.7% 55.6% 40.0% 71.4%

Lower GI 85% 80.0% 87.5% 68.0% 70.0% 81.0% 77.8%

Skin 85% 84.6% 96.8% 85.2% 92.6% 85.7% 87.5%

Gynae 85% 90.0% 92.9% 57.1% 100.0% 33.3% 100.0%

Brain CNS 85% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Urology 85% 88.9% 83.3% 75.0% 88.9% 50.0% 75.0%

Rare 85% 0.0% 50.0% 100.0% 100.0% 100.0% 100.0%

Head & Neck 85% 100.0% 100.0% 85.7% 75.0% 100.0% 81.8%

Sarcoma 85% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Other 85% 100.0% 0.0% 0.0% 0.0% 100.0% 100.0%

62 Day Screening Standard 90% 93.8% 94.4% 94.7% 92.3% 100.0% 81.3%

Total Seen 16 18 19 19.5 14.5 16

Breaches 1 1 1 1.5 0 3

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

All types A&E performance

QH 95% 84.5% 78.8% 78.2% 83.4% 80.5% 79.8%

KGH 95% 93.9% 93.1% 93.9% 94.1% 93.0% 92.5%

Trust 95% 88.4% 84.7% 84.7% 87.7% 85.5% 85.0%

Admitted performance

QH 95% 63.9% 53.7% 53.2% 63.3% 57.5% 55.2%

KGH 95% 74.2% 73.4% 73.0% 72.3% 68.4% 67.5%

Trust 95% 67.3% 60.1% 59.6% 66.3% 60.8% 59.0%

Non admitted performance

QH 95% 89.4% 85.1% 84.2% 87.4% 86.5% 86.0%

KGH 95% 95.8% 94.8% 95.8% 96.3% 96.0% 96.0%

Trust 95% 92.2% 89.3% 89.2% 91.2% 90.6% 90.4%

Total time in A&E (Admitted)

Median 237 239 239 238 238 236

95th Percentile 240 678 847 836 747 797 805

Total time in A&E (Non‐Admitted)

Median 170 172 178 175 169 166

95th Percentile 240 336 370 365 342 356 339

Time to Initial Assessment

Median 6 7 6 7 6 7

95th Percentile 20 43 42 39 43 38 41

Time to Treatment

Median 60 71 65 56 54 48 52

95th Percentile 214 221 212 200 186 176

Left without being seen 5% 4.0% 4.3% 4.2% 4.4% 5.2% 4.7%

Reattendance rate 1%‐5% 5.8% 5.9% 7.2% 6.3% 8.7% 7.7%

Emergency re‐admissions within 30 days following an elective or 

emergency spell at the Trust 9.4% 7.2% 7.8% 9.5% 8.4% 6.2% 6.2%

Emergency Pathways

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Emergency Pathways

% activity change against previous year

Non‐Elective (NEL) Spells 0.1% ‐4.7% ‐3.8% 2.4% ‐3.0% 7.1%

A&E Attendances 1.4% 2.7% 3.3% 1.4% ‐0.6% 7.0%

Non‐Elective LOS ‐ Mean

QH 5.4 5.6 5.9 5.6 5.6 5.8

KGH 6.5 6.2 6.2 6.2 6.2 6.8

Trust 5.8 5.7 5.7 5.9 5.8 5.7 6.1

Non‐Elective LOS ‐ Median

QH 2.3 2.6 2.5 2.4 2.5 2.6

KGH 2.0 2.0 2.1 2.0 2.2 2.4

Trust 2.4 2.2 2.3 2.3 2.2 2.4 2.5

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Outpatient first waits

< 9wks 70.6% 69.0% 69.8% 73.5% 71.3% 67.2%

9‐13wks 15.0% 14.8% 16.2% 14.0% 19.0% 22.5%

> 13wks 14.4% 16.1% 14.0% 12.6% 9.7% 10.3%

Outpatient first waits (Excl. Cancer)

< 9wks 70.2% 68.7% 69.6% 73.3% 71.3% 66.8%

9‐13wks 14.9% 14.8% 16.3% 14.1% 19.0% 22.6%

> 13wks 14.9% 16.5% 14.1% 12.6% 9.7% 10.6%

FUP:FA Attendance Ratio 2.1 2.0 1.9 1.9 1.9 1.9 1.9

100 ‐ Surgical 1.6 1.5 1.7 1.6 1.5 1.5 1.5

101 ‐ Urology 2.2 2.3 2.6 3.1 2.4 2.1 2.4

103 ‐ Breast Surgery 1.3 0.6 0.4 0.5 0.6 0.5 0.6

107 ‐ Vascular Surgery 1.3 1.8 1.2 1.5 1.6 1.8 1.8

110 ‐ Orthopaedics 1.8 2.4 2.6 2.3 2.3 2.3 2.4

110 ‐ Trauma Outpatients 1.8 1.5 1.3 1.5 1.5 1.4 1.4

120 ‐ Ear Nose and Throat 1.4 1.6 1.4 1.4 1.5 1.5 1.5

130 ‐ Ophthalmology 3.0 2.4 2.5 2.4 2.7 3.0 2.6

143 ‐ Orthodontics 9.1 20.4 16.3 12.6 15.2 12.7 14.9

144 ‐ Maxillo‐Facial Surgery 1.4 1.6 1.2 1.5 1.5 1.4 1.7

150 ‐ Neurosurgery 1.6 1.2 1.3 1.1 1.1 1.0 1.2

180 ‐ Accident & Emergency 0.3 0.1 0.0 0.1 0.1 0.1 0.0

191 ‐ Pain Management 2.6 0.8 0.7 0.5 0.6 0.8 0.6

300 ‐ General Medicine 1.6 2.3 2.5 2.2 2.6 2.6 2.4

301 ‐ Gastroenterology 2.0 2.3 2.2 2.2 2.3 1.6 1.8

302 ‐ Endocrinology 3.3 2.8 2.6 2.8 2.7 3.1 3.5

303 ‐ Haematology (Clinical) 6.7 4.4 5.4 6.5 5.7 4.8 4.9

306 ‐ Hepatology 4.8 2.9 3.1 2.9 3.0 3.3 2.8

320 ‐ Cardiology 1.4 0.4 0.4 0.4 0.4 0.5 0.4

324 ‐ Anti‐Coagulation 17.9 10.2 7.0 8.6 8.6 8.8 8.3

327 ‐ Cardiac Rehabilitation  6.0 6.5 5.3 5.9 5.4 2.8 6.3

328 ‐ Stroke Cases 1.1 1.3 1.5 1.8 2.7 2.6 2.6

330 ‐ Dermatology 2.6 2.7 2.3 1.9 1.5 1.4 1.4

340 ‐ Chest Diseases 2.1 2.1 2.1 1.7 1.9 1.9 2.2

361 ‐ Nephrology 9.0 4.0 3.7 3.7 3.5 3.1 3.5

370 ‐ Medical Oncology 9.4 15.5 10.8 11.2 18.0 19.4 18.5

Outpatients

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Outpatients

400 ‐ Neurology 1.6 2.2 1.9 1.9 1.9 1.8 1.6

410 ‐ Rheumatology 4.2 6.0 4.9 5.0 4.8 4.6 4.3

420 ‐ Paediatrics 1.4 0.9 0.9 0.9 0.8 0.8 0.8

422 ‐ Neonatology 2.2 3.5 3.8 2.7 2.2 3.4 2.4

430 ‐ Healthcare O/A 1.5 2.4 2.5 2.3 2.2 2.2 2.5

502 ‐ Colposcopy 1.1 0.7 0.8 0.9 1.0 0.9 1.1

502 ‐ Gynaecology 1.1 1.4 1.8 1.9 1.9 1.5 1.7

503 ‐ Gynaecological Oncology 1.6 1.5 1.3 1.0 0.9 1.5 1.1

800 ‐ Clinical Oncology 8.1 5.0 6.0 5.3 5.2 5.1 4.8

DNA Rate 8.1% 11.9% 11.9% 12.5% 13.0% 12.8% 12.8%

100 ‐ Surgical 7.5% 11.5% 10.8% 10.8% 10.6% 10.5% 10.9%

101 ‐ Urology 8.2% 14.4% 15.2% 14.0% 15.1% 17.3% 16.2%

103 ‐ Breast Surgery 6.4% 7.5% 8.2% 7.8% 9.4% 7.9% 8.3%

107 ‐ Vascular Surgery 8.0% 13.1% 13.3% 15.8% 18.2% 15.3% 14.3%

110 ‐ Orthopaedics 8.2% 9.9% 12.3% 14.2% 13.6% 13.9% 14.7%

110 ‐ Trauma Outpatients 8.2% 15.3% 14.3% 15.0% 15.7% 16.3% 15.4%

120 ‐ Ear Nose and Throat 9.1% 15.1% 15.1% 14.7% 16.0% 16.5% 17.8%

130 ‐ Ophthalmology 8.2% 13.2% 13.5% 12.7% 14.3% 11.9% 12.5%

143 ‐ Orthodontics 8.3% 14.3% 14.2% 14.1% 15.7% 13.8% 13.8%

144 ‐ Maxillo‐Facial Surgery 10.1% 17.4% 17.0% 20.4% 16.2% 19.9% 18.8%

150 ‐ Neurosurgery 7.9% 10.4% 7.0% 6.5% 8.0% 11.7% 9.5%

180 ‐ Accident & Emergency 11.1% 29.5% 18.0% 31.6% 36.9% 35.3% 26.6%

191 ‐ Pain Management 9.8% 18.0% 13.7% 15.8% 15.5% 19.1% 15.2%

300 ‐ General Medicine 9.2% 15.4% 15.0% 11.4% 17.0% 18.6% 13.9%

301 ‐ Gastroenterology 11.1% 14.1% 12.8% 14.0% 14.8% 16.1% 14.5%

302 ‐ Endocrinology 11.2% 17.4% 12.7% 16.5% 14.5% 14.3% 14.5%

303 ‐ Haematology (Clinical) 6.5% 6.9% 8.3% 7.6% 9.1% 8.7% 7.5%

306 ‐ Hepatology 14.6% 28.5% 26.4% 32.7% 29.8% 23.7% 32.1%

320 ‐ Cardiology 7.8% 9.2% 9.9% 8.5% 9.8% 9.0% 8.7%

324 ‐ Anti‐Coagulation 6.7% 5.4% 5.4% 9.8% 8.6% 7.4% 6.8%

327 ‐ Cardiac Rehabilitation  10.1% 3.6% 11.1% 10.3% 11.9% 18.2% 16.3%

328 ‐ Stroke Cases 12.0% 17.4% 12.9% 11.8% 8.1% 11.9% 14.3%

330 ‐ Dermatology 8.0% 10.2% 10.3% 13.5% 12.9% 11.8% 13.8%

340 ‐ Chest Diseases 10.7% 11.9% 10.3% 13.3% 12.6% 12.3% 13.4%

361 ‐ Nephrology 7.6% 13.9% 16.5% 13.9% 15.0% 16.1% 16.1%

370 ‐ Medical Oncology 4.0% 7.7% 0.0% 6.0% 5.0% 5.6% 10.0%

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Outpatients

400 ‐ Neurology 9.8% 12.5% 13.8% 11.6% 11.8% 15.4% 14.5%

410 ‐ Rheumatology 8.5% 11.5% 9.6% 13.2% 9.6% 11.9% 11.1%

420 ‐ Paediatrics 11.6% 23.4% 25.0% 21.9% 24.4% 29.1% 26.6%

422 ‐ Neonatology 9.4% 13.3% 8.2% 9.7% 12.6% 8.9% 17.6%

430 ‐ Healthcare O/A 9.6% 19.3% 17.6% 18.9% 24.6% 17.9% 14.3%

502 ‐ Colposcopy 7.6% 18.6% 23.5% 18.7% 19.2% 25.3% 23.8%

502 ‐ Gynaecology 7.6% 11.4% 11.7% 13.2% 11.7% 12.6% 10.8%

503 ‐ Gynaecological Oncology 7.1% 7.9% 9.1% 6.1% 8.7% 9.7% 9.2%

800 ‐ Clinical Oncology 3.1% 3.8% 3.5% 3.9% 4.6% 5.2% 5.2%

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Diagnostic Group (CCS) Risk

Number of 

Discharges

Number of 

Observed 

Mortalities

Number of 

Expected 

Mortalities

Standardised 

Mortality Ratio 95%CI Lower 95%CI Upper

Crude Mortality 

Rate

111 ‐ Other and ill‐defined cerebrovascular disease Within Expected Range 62 7 3 206.24 82.63 424.96 11.3%

50 ‐ Diabetes mellitus with complications Within Expected Range 303 6 4 150.65 55.01 327.92 2.0%

229 ‐ Fracture of upper limb Within Expected Range 566 6 4 145.35 53.07 316.37 1.1%

100 ‐ Acute myocardial infarction Higher Than Expected 438 59 41 145.00 110.37 187.04 13.5%

148 ‐ Peritonitis and intestinal abscess Within Expected Range 30 8 6 142.34 61.29 280.49 26.7%

132 ‐ Lung disease due to external agents Within Expected Range 16 6 4 136.83 49.97 297.84 37.5%

2 ‐ Septicemia (except in labor) Higher Than Expected 318 75 57 132.52 104.23 166.11 23.6%

146 ‐ Diverticulosis and diverticulitis Within Expected Range 252 9 8 116.68 53.24 221.52 3.6%

149 ‐ Biliary tract disease Within Expected Range 693 13 11 115.32 61.35 197.22 1.9%

122 ‐ Pneumonia (except that caused by tuberculosis or sexually transmitted disease) Higher Than Expected 2,148 476 416 114.39 104.35 125.15 22.2%

226 ‐ Fracture of neck of femur (hip) Within Expected Range 613 47 42 111.71 82.07 148.55 7.7%

125 ‐ Acute bronchitis Within Expected Range 1,387 50 45 110.23 81.81 145.33 3.6%

131 ‐ Respiratory failure; insufficiency; arrest (adult) Within Expected Range 94 25 23 107.71 69.68 159.00 26.6%

117 ‐ Other circulatory disease Within Expected Range 235 6 6 106.64 38.94 232.13 2.6%

71 ‐ Other psychoses Within Expected Range 210 10 10 105.21 50.37 193.49 4.8%

233 ‐ Intracranial injury Within Expected Range 111 14 13 104.64 57.16 175.57 12.6%

109 ‐ Acute cerebrovascular disease Within Expected Range 1,043 180 172 104.47 89.76 120.89 17.3%

103 ‐ Pulmonary heart disease Within Expected Range 202 11 11 102.56 51.13 183.52 5.4%

68 ‐ Senility and organic mental disorders Within Expected Range 222 17 17 100.66 58.60 161.18 7.7%

95 ‐ Other nervous system disorders Within Expected Range 464 7 7 100.64 40.32 207.36 1.5%

134 ‐ Other upper respiratory disease Within Expected Range 597 12 12 100.00 51.61 174.69 2.0%

133 ‐ Other lower respiratory disease Within Expected Range 222 16 16 99.94 57.09 162.31 7.2%

115 ‐ Aortic; peripheral; and visceral artery aneurysms Within Expected Range 54 15 15 98.93 55.33 163.18 27.8%

145 ‐ Intestinal obstruction without hernia Within Expected Range 208 15 16 96.27 53.84 158.80 7.2%

107 ‐ Cardiac arrest and ventricular fibrillation Within Expected Range 40 23 24 95.02 60.22 142.59 57.5%

157 ‐ Acute and unspecified renal failure Within Expected Range 418 63 66 94.88 72.90 121.39 15.1%

127 ‐ Chronic obstructive pulmonary disease and bronchiectasis Within Expected Range 1,401 72 77 93.40 73.07 117.62 5.1%

106 ‐ Cardiac dysrhythmias Within Expected Range 919 11 12 93.33 46.53 167.01 1.2%

129 ‐ Aspiration pneumonitis; food/vomitus Within Expected Range 237 74 81 91.24 71.64 114.54 31.2%

152 ‐ Pancreatic disorders (not diabetes) Within Expected Range 282 7 8 91.16 36.52 187.83 2.5%

135 ‐ Intestinal infection Within Expected Range 1,370 30 33 89.78 60.56 128.17 2.2%

159 ‐ Urinary tract infections Within Expected Range 2,493 94 105 89.41 72.25 109.41 3.8%

108 ‐ Congestive heart failure; nonhypertensive Within Expected Range 655 74 84 88.27 69.31 110.82 11.3%

150 ‐ Liver disease; alcohol‐related Within Expected Range 108 16 18 86.89 49.63 141.11 14.8%

130 ‐ Pleurisy; pneumothorax; pulmonary collapse Within Expected Range 300 17 20 86.30 50.24 138.18 5.7%

197 ‐ Skin and subcutaneous tissue infections Within Expected Range 1,199 15 18 84.19 47.09 138.87 1.3%

114 ‐ Peripheral and visceral atherosclerosis Within Expected Range 66 12 14 83.41 43.05 145.72 18.2%

55 ‐ Fluid and electrolyte disorders Within Expected Range 391 16 19 82.15 46.93 133.42 4.1%

151 ‐ Other liver diseases Within Expected Range 202 12 16 75.32 38.87 131.58 5.9%

153 ‐ Gastrointestinal hemorrhage Within Expected Range 610 22 30 74.11 46.43 112.21 3.6%

199 ‐ Chronic ulcer of skin Within Expected Range 143 8 11 71.44 30.76 140.77 5.6%

231 ‐ Other fractures Within Expected Range 306 7 10 68.04 27.26 140.20 2.3%

155 ‐ Other gastrointestinal disorders Within Expected Range 708 18 28 64.60 38.27 102.10 2.5%

Grand total Within Expected Range 38,371 1,786 1,796 99.46 94.90 104.18 4.7%

Mar'13 to Feb'14

Mortality

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Infection Rates per 100,000 bed days ‐ YTD

C‐Diff Upper Quartile 6.45 6.45 4.30 6.45

MRSA Upper Quartile 0.00 0.00 0.00 0.00

E‐Coli Upper Quartile 106.38 99.93 66.62 49.97

MSSA Upper Quartile 9.67 9.67 9.67 7.25

Patient Safety Thermometer*

Performance 95% 95.3% 94.7% 93.8% 94.4% 93.3% 93.3%

Numbers audited 1,082 1,097 1,109 1,096 1,034 1081

Pressure Ulcers ‐ Community Acquired 29 40 32 31 36 33

Grade 2 18 16 7 12 11 9

Grade 3 10 15 19 13 21 21

Grade 4 1 9 6 6 4 3

Pressure Ulcers ‐ Hospital Acquired 2 4 4 4 4 3

Grade 2 2 1 2 2 3 1

Grade 3 0 3 2 2 1 2

Grade 4 0 0 0 0 0 0

Fall in the community 14 16 27 15 18 22

No Harm 5 9 5 4 5 0

Low Harm 6 3 12 7 7 12

Moderate Harm 1 4 5 4 4 9

Severe Harm 2 0 5 0 2 1

Fall in hospital 3 1 5 3 5 3

No Harm 3 0 1 2 2 2

Low Harm 0 1 4 1 2 1

Moderate Harm 0 0 0 0 1 0

Severe Harm 0 0 0 0 0 0

UTI

Community Acquired 34 22 31 30 17 22

Hospital Acquired 21 14 21 35 29 34

Catheter 149 167 157 167 139 150

VTE Incidence

Community Acquired 17 8 13 18 18 14

Hospital Acquired 1 0 4 1 5 4

Patient Safety

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Patient Safety

MRSA Screening 90% 85.4% 80.0% 84.8% 93.5% 87.7% 91.4%

Elective 90% 86.7% 84.5% 85.1% 92.0% 83.3% 89.3%

Non Elective  90% 84.8% 78.0% 84.7% 94.4% 93.8% 92.7%

Dementia ‐ latest month has provisional figures

% Asked dementia case finding question within 72 hours of 

admission90% 63.5% 66.9% 73.6% 70.5% 71.6% 71.3%

% Reported as having had a dementia diagnostic assessment 

including investigations.90% 46.3% 83.1% 80.6% 66.9% 62.6% 65.4%

% Diagnostic assessment made and referred for further diagnostic 

advice/follow up90% 44.8% 68.2% 67.5% 63.8% 73.2% 70.6%

SI's Reported Trust 12 17 15 9 16 14

Women 3 2 4 3 5 3

Acute Medicine 0 3 1 2 3 4

Anaesthetics 2 1 0 0 3 0

Children 1 0 1 0 0 0

Emergency Care 2 2 6 1 0 2

Geriatric Medicine 3 5 1 2 1 2

Neurosciences 0 0 0 0 1 0

Pathology 0 0 0 0 0 0

Radiology 0 0 0 0 0 1

Specialist Medicine 0 1 0 0 0 0

Specialist Surgery 0 1 0 0 0 1

Surgical 0 1 0 1 0 0

Other 1 1 2 0 3 1

Number of SI's Open Trust (as at) 43 49 58 49 57 42

Women 7 5 7 5 7 6

Acute Medicine 7 9 11 8 11 10

Anaesthetics 3 3 2 2 2 3

Children 3 2 2 2 1 1

Emergency Care 4 6 12 13 12 3

Geriatric Medicine 6 10 10 5 5 4

Neurosciences 1 1 1 1 2 2

Pathology 1 1 1 1 1 0

Radiology 7 6 5 5 5 5

Specialist Medicine 0 1 1 1 1 1

Specialist Surgery 0 1 1 0 0 1

Surgical 2 1 1 2 2 1

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Patient Safety

Other 2 3 4 4 8 5

Category of SIs 12 17 14 11 16 14

Attempted Suicide 1 0 0 0 0 0

C‐Diff Hospital Acquired Infection 1 0 0 0 0 0

Child Death 1 0 0 0 0 2

Communicable Disease and Infection Issue 0 1 0 0 0 0

Delay London Ambulance 0 1 3 0 0 1

Delayed Diagnosis 1 0 1 1 0 0

Drug Incident 1 2 1 0 2 0

Failure to Act on Test Results 0 1 0 0 0 0

Other 0 1 2 1 3 0

Patient Accident in Hospital 0 1 0 0 0 0

Pressure Ulcer Grade 3 1 6 1 4 3 2

Safeguarding Vulnerable Child 0 0 1 0 0 0

Slips, Trips & Falls 1 2 1 1 1 4

Sub‐Optimal Care of the deteriorating patient  1 0 0 0 0 0

Suspension of Maternity Services 1 0 0 0 0 0

Transfer to NICU 2 2 2 2 3 3

Transfusion Incident 0 0 1 0 0 0

Outpatient Appointment Delay 1 0 0 0 0 0

Screening 0 0 0 1 0 0

Unexpected Neonatal Death 0 0 0 0 1 0

Failure / Delay in Treatment 0 0 1 1 0 0

Confidential Information Leaks 0 0 0 0 3 0

Unexpected Death 0 0 0 0 0 1

Radiology / Scanning 0 0 0 0 0 1

Patient Safety Incidents by impact 585 687 655 683 621 596

0 Near Miss (Blue) 13 10 4 8 7 8

1 Low   (Green) 406 502 470 518 467 451

2 Moderate (Yellow) 125 120 129 120 108 105

3 High (Orange) 16 26 25 20 20 14

4 Major (Red) 1 4 2 2 2 7

4a Major / Catastrophic (Red) 24 25 25 15 17 11

Total Number of Current Risks  141 149 152 162 158 163

Current Extreme Risks (Red) 22 24 24 28 26 28

Current High Risk (Orange) 49 52 52 55 54 54

Current Moderate Risks (Yellow) 47 51 54 55 57 59

Current Low Risk (Green) 23 22 22 24 21 22

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Patient Safety

Number of Risks where Review is Outstanding 47 39 64 65 49 63

Women 3 5 11 10 10 22

Acute Medicine 2 2 3 4 4 6

Anaesthetics 13 8 11 9 1 0

Children 12 9 12 0 2 0

Emergency Care 1 1 3 6 9 9

Geriatric Medicine 0 0 0 0 0 2

Neurosciences 0 0 0 2 2 2

Pathology 7 4 5 7 3 0

Radiology 3 2 3 6 7 0

Specialist Medicine 2 1 6 7 5 5

Specialist Surgery 2 2 6 2 4 16

Surgical 2 5 4 12 2 1

Complaints Received (in month) 83 73 89 85 73 106

Women 10 13 5 8 9 13

Acute Medicine 10 13 10 16 7 18

Anaesthetics 4 4 3 3 0 8

Children 1 2 4 1 2 1

Emergency Care 12 7 17 10 11 19

Geriatric Medicine 11 6 5 10 6 11

Neurosciences 3 4 7 6 4 7

Pathology 3 0 1 2 3 0

Radiology 1 1 2 3 3 3

Specialist Medicine 3 6 5 9 7 4

Specialist Surgery 8 10 16 8 12 11

Surgical 16 2 9 5 7 7

Other 1 5 5 4 2 4

Complaints Response rate (due in month) 41.8% 52.9% 70.5% 71.0% 37.2% 59.1%

Women 70.0% 91.7% 91.7% 85.7% 87.5% 90.0%

Acute Medicine 22.2% 21.7% 44.4% 80.0% 21.4% 41.7%

Anaesthetics 0.0% 100.0% 75.0% 75.0% 50.0% 25.0%

Children 66.7% 100.0% 100.0% 100.0% 0.0% 0.0%

Emergency Care 64.3% 82.4% 84.6% 93.3% 100.0% 100.0%

Geriatric Medicine 0.0% 12.5% 25.0% 25.0% 33.3% 28.6%

Neurosciences 66.7% 50.0% 66.7% 57.1% 16.7% 25.0%

Pathology 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Radiology 0.0% 60.0% 66.7% 100.0% 66.7% 100.0%

Specialist Medicine 50.0% 50.0% 100.0% 60.0% 12.5% 40.0%

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Patient Safety

Specialist Surgery 35.7% 43.8% 83.3% 61.5% 11.1% 62.5%

Surgical 36.8% 38.9% 44.4% 40.0% 33.3% 62.5%

Number of Open Complaints 214 196 191 198 210 229

Women 19 20 14 14 13 17

Acute Medicine 53 53 41 45 46 54

Anaesthetics 6 6 5 5 5 11

Children 4 3 5 4 4 4

Emergency Care 20 22 27 20 23 23

Geriatric Medicine 13 15 14 17 20 25

Neurosciences 11 10 16 14 14 17

Pathology 5 1 1 4 2 0

Radiology 6 1 1 4 3 3

Specialist Medicine 9 13 9 14 15 16

Specialist Surgery 28 23 29 27 34 34

Surgical 40 29 29 30 31 25

NICE Guidance Compliance Rate  66.3% 63.1% 63.1% 66.5% 72.1% 73.5%

Women 35.4% 34.3% 35.3% 39.7% 46.6% 50.0%

Acute Medicine 62.0% 60.4% 58.8% 63.9% 71.6% 71.6%

Anaesthetics 50.0% 50.0% 50.0% 70.0% 77.8% 77.8%

Children 58.6% 56.7% 56.7% 53.1% 51.5% 51.5%

Emergency Care 80.0% 63.2% 85.7% 76.5% 81.3% 81.3%

Geriatric Medicine 40.0% 22.2% 28.6% 28.6% 71.4% 85.7%

Neurosciences 89.5% 89.7% 94.9% 90.0% 97.4% 94.9%

Pathology 58.3% 58.3% 63.6% 100.0% 100.0% 100.0%

Radiology 60.0% 66.7% 66.7% 66.7% 66.7% 57.1%

Specialist Medicine 86.2% 81.3% 76.9% 80.9% 84.8% 86.3%

Specialist Surgery 54.8% 52.2% 48.9% 52.1% 54.3% 56.3%

Surgical 72.2% 68.4% 70.3% 70.3% 69.8% 76.3%

* Data reported is based on a snapshot audit

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Inpatient FFT Score

Trust 60 67 69 69 73 71 71

KGH 60 73 71 70 76 73 70

QH 60 65 67 69 71 71 71

Inpatient FFT National (Overall) Benchmark Scores

95th Percentile 86 86 85 85 87

90th Percentile 83 82 81 82 82

75th Percentile 76 76 77 77 77

50th Percentile 71 72 71 72 71

Inpatient FFT (Medical) Score

Trust Upper Quartile 72 72 73 75 75

KGH Upper Quartile 67 62 69 67 69

QH Upper Quartile 73 75 74 79 78

Inpatient FFT National (Medical) Benchmark Scores

95th Percentile 82 84 83 84 84

90th Percentile 79 83 80 82 82

75th Percentile 74 75 76 77 76

50th Percentile 69 70 69 70 70

Inpatient FFT (Surgical) Score

Trust Upper Quartile 68 73 73 79 75

KGH Upper Quartile 77 74 67 81 77

QH Upper Quartile 52 70 78 76 71

Inpatient FFT National (Surgical) Benchmark Scores

95th Percentile 87 84 83 85 86

90th Percentile 84 83 81 82 83

75th Percentile 78 77 78 79 78

50th Percentile 72 73 73 73 72

Inpatient FFT Response Rate

Trust 30% 54.3% 43.7% 42.2% 45.2% 49.8% 49.0%

KGH 30% 61.2% 55.0% 36.4% 54.0% 52.3% 59.7%

QH 30% 51.7% 39.4% 44.7% 41.1% 48.8% 44.1%

Friends and Family Test

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Friends and Family Test

A&E FFT Score

Trust 46 22 19 14 20 26 31

KGH 46 50 43 35 45 51 47

QH 46 18 15 11 17 23 28

A&E FFT Response Rate

Trust 20% 22.1% 18.3% 18.4% 21.6% 20.9% 23.4%

KGH 20% 9.1% 8.3% 8.2% 7.7% 7.4% 12.5%

QH 20% 27.7% 23.0% 23.6% 28.1% 27.5% 28.8%

Maternity FFT Score

Ante‐natal Care 61 72 60 71 74 78

Birth 54 61 52 55 65 74

Postnatal Community 84 74 71 80 85 80

Postnatal Ward 42 42 44 45 53 57

Maternity FFT Response Rate

Ante‐natal Care 15% 26.1% 32.2% 32.9% 29.0% 36.2% 37.7%

Birth 40% 43.8% 31.0% 63.3% 44.1% 29.9% 22.2%

Postnatal Community 15% 26.6% 37.6% 46.5% 29.6% 37.5% 39.8%

Postnatal Ward 40% 42.7% 28.7% 63.3% 47.1% 38.3% 35.6%

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Key Performance Indicator Threshold Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15

Turnover % 11% 14.0% 14.3% 14.4% 14.5% 14.3% 14.2%

Admin, Clerical & Maintenance 11% 11.8% 11.9% 12.4% 12.1% 12.0% 12.0%

Medical & Dental 11% 27.7% 27.1% 25.5% 26.2% 25.2% 24.0%

Midwives 11% 10.7% 12.1% 12.9% 12.6% 12.9% 13.0%

Other Qualified Nurses 11% 14.0% 14.1% 14.5% 14.7% 14.7% 14.7%

HCAs & Patient‐care SWkrs 11% 13.5% 13.9% 13.7% 13.5% 13.1% 12.9%

Allied Health Professionals (PAMs) 11% 12.7% 12.9% 12.1% 12.9% 13.3% 11.9%

Professional, Technical & Scientific 11% 10.1% 10.9% 11.1% 11.3% 11.7% 12.1%

Ancillary & Non‐patient‐care SWkrs 11% 4.4% 4.4% 4.4% 4.4% 4.4% 4.4%

Sickness % (lost for month) 4% 3.7% 3.6% 3.7% 3.9% 4.1% 4.0%

Admin, Clerical & Maintenance 4% 4.1% 3.4% 4.0% 5.0% 4.0% 4.1%

Medical & Dental 4% 1.1% 1.1% 1.0% 1.0% 1.0% 1.2%

Midwives 4% 4.1% 4.6% 3.4% 3.5% 5.4% 4.0%

Other Qualified Nurses 4% 4.2% 3.7% 3.9% 3.8% 3.9% 4.0%

HCAs & Patient‐care SWkrs 4% 4.3% 6.1% 5.8% 6.0% 7.4% 6.4%

Allied Health Professionals (PAMs) 4% 3.7% 3.2% 3.5% 4.2% 3.8% 3.2%

Professional, Technical & Scientific 4% 4.8% 4.3% 4.7% 4.7% 5.1% 5.1%

Ancillary & Non‐patient‐care SWkrs 4% 5.6% 9.5% 10.0% 10.7% 8.9% 8.3%

Vacancy % 8% 11.1% 11.3% 11.8% 12.7% 12.6% 11.7%

Admin, Clerical & Maintenance 8% 13.2% 12.4% 13.0% 13.8% 13.7% 13.5%

Medical & Dental 8% 10.7% 11.5% 12.0% 12.6% 11.7% 11.9%

Midwives 8% 10.8% 13.3% 14.5% 15.0% 15.1% 13.8%

Other Qualified Nurses 8% 11.4% 11.0% 11.7% 12.9% 13.5% 14.0%

HCAs & Patient‐care SWkrs 8% 8.9% 10.4% 11.1% 13.0% 11.3% 6.3%

Allied Health Professionals (PAMs) 8% 13.9% 12.6% 11.5% 10.2% 11.2% 8.4%

Professional, Technical & Scientific 8% 7.9% 8.1% 8.6% 10.2% 10.6% 9.1%

Ancillary & Non‐patient‐care SWkrs 8% 18.5% 18.5% 18.5% 18.5% 18.5% 18.5%

Mandatory Training

Conflict Resolution 80% 40.1% 44.9% 48.1% 54.8% 55.5% 56.6%

Equality, Diversity & Human Rights 80% 63.7% 67.5% 70.7% 74.2% 74.0% 75.8%

Fire Safety 80% 61.7% 65.9% 65.9% 68.7% 72.3% 75.1%

Health, Safety & Welfare 80% 78.3% 83.6% 84.1% 85.3% 84.1% 84.9%

Infection Prevention and Control Level 1 80% 65.5% 67.2% 68.6% 70.7% 72.0% 72.1%

Infection Prevention and Control Level 2 80% 53.1% 59.4% 62.4% 67.0% 70.5% 73.1%

Workforce

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Workforce

Information Governance 95% 72.9% 76.8% 82.4% 84.0% 83.5% 85.6%

Moving and Handling Level 1 (Loads) 80% 74.7% 75.9% 76.7% 77.8% 75.5% 77.6%

Moving and Handling Level 2 (People) 80% 92.2% 93.1% 93.8% 94.1% 93.9% 94.2%

Resuscitation Level 2 Adult Basic Life Support 80% 72.6% 72.7% 73.4% 80.5% 82.4% 84.7%

Resuscitation Level 2 Paediatric Basic Life Support 80% 52.4% 55.7% 58.5% 65.4% 69.7% 74.4%

Resuscitation Level 3 Adult Immediate Life Support 80% 24.6% 31.6% 33.6% 50.0% 52.5% 54.5%

Resuscitation Level 3 Newborn Basic Life Support 80% 64.8% 65.6% 68.6% 77.4% 77.9% 84.6%

Resuscitation Level 3 Paediatric Immediate Life Support 80% 50.0% 83.3% 85.7% 85.7% 85.7% 100.0%

Safeguarding Vulnerable Adults 85% 82.4% 78.2% 77.4% 76.9% 74.4% 75.1%

Safeguarding Children Level 1 85% 74.5% 75.9% 77.4% 78.4% 79.3% 79.7%

Safeguarding Children Level 2 85% 82.9% 83.1% 84.6% 84.9% 85.4% 85.2%

Safeguarding Children Level 3 85% 75.4% 75.1% 80.3% 80.5% 79.7% 80.1%

Sepsis 80% 68.9% 84.8%

Produced by Information Services Page 31168

AGENDA ITEM 4.2

Meeting: Trust Board Date: 5th November 2014

Title of Paper: Self certification to the NHS Trust Development Authority

Introduction/Summary: This paper presents the Trusts self-certification for September for approval by the Board of Directors. This paper relates to the following corporate objectives:

Objective 1: We will provide excellent quality care, outcomes and safety

Objective 3: We will continuously improve the effectiveness, efficiency and accessibility of our services

Objective 4: We will make strong progress in delivering clinical and financial stability

Objective 5: We will ensure our Trust is well-led.

The Trust is reporting a risk to compliance against the domains of the self-certification in the following areas:

The trust has effective arrangements in place for the purpose of monitoring and improving the quality of healthcare

Compliance with the CQC registration requirements That the trust will remain at all times a going concern Compliance with the NHS constitution standards and TDA accountability

framework Compliance with Information Governance Level 2 A full substantive executive team Capacity of the management team to deliver the annual plan

Actions required in respect of these are as follows:

Improved information for monitoring services by December 2014 Continued oversight of the QCIP programme and delivery of the control total

by 31st March 2015 Delivery of the improvement plan and additionally development and delivery

of improvement actions in RTT and Cancer and confirmation of transitional support

Refresh of the Board Assurance Framework Recruitment to the executive team and a strengthening of the capacity and

capability within the Trusts wider clinical management and management structure.

Patient Safety implications: NA

Risks: The self certification sets out the risks to the requirements

Financial implications: NA

Legal advice and implications: The Trust is not able to certify that it is meeting all NHS Constitution standards.

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Consultation (including patient and public involvement): NA

Communications: The issues on which the self certification is based form part of the team brief within the Trust.

Equality Impact implications: NA

Reviewed by/action taken? Trust Executive Committee

Recommendations: That the board consider and approve the self certification or agree changes that are required.

Author and Lead Officer (if different):Steve Russell, Deputy Chief Executive

Date(s) for further review. Trust Executive Committee, 25th November 2014

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AGENDA ITEM 4.2

Trust Development Authority (TDA) Monthly Self-Certification Requirements

Board Statements September 2014

CLINICAL QUALITY, FINANCE, GOVERNANCE In line with the recommendations of the Mid Staffordshire Public Inquiry, the achievement of FT status will only be possible for NHS Trusts that are delivering the key fundamentals of clinical quality, good patient experience, and national and local standards and targets, within the available financial envelope. For CLINICAL QUALITY, that 1. The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. BHRUT compliance: RISK

Timescale for compliance: 31st December 2014 RESPONSE: Following a CQC review in October and publication of the report in December 2013 the Trust was found non-compliant with Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010: Assessing and monitoring the quality of service provision. The CQC found the Trust did not have effective systems in place to monitor the quality of the services provided. The Trust’s improvement plan includes actions to address this risk, the key ones which are expected to be in place by December 2014, although there will be further improvement work in Q4. The Trust has started to report performance against the TDA oversight model from this month.

2. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements. BHRUT compliance: RISK

Timescale for compliance: 31 March 2015 RESPONSE: Following a CQC review in October and publication of the report in December 2013 the Trust was found non-compliant with 5 Regulations at Queen’s Hospital and 5 regulations at King George Hospital. A response to the compliance actions required by the CQC was submitted by 31 January 2014, and the Trust’s full improvement plan includes the actions being taken to address these issues.

3. The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements. BHRUT compliance. YES

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For FINANCE, that 4. The board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from time to time. BHRUT compliance. RISK

Timescale for compliance: 31 March 2015 RESPONSE: The Trust has developed £10m of QCIP schemes for 2014/15 and is forecasting compliance with its control total of £39m. The governance arrangements to ensure effective delivery have been strengthened and equal focus is being given to budgetary control. The Trust has identified further controls are necessary to reduce the risk to the delivery of the control total.

For GOVERNANCE, that 5. The board will ensure that the Trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS Constitution at all times. BHRUT compliance. RISK

Timescale for compliance: 31 March 2015 RESPONSE: The Trust is not meeting a number of the standards in the accountability framework (cancer, RTT, and A&E) not fully meeting the NHS Constitution Standards for 18 weeks for RTT or 4 hours for A&E waits. The focus for emergency care is delivery of the improvement plan whilst additional recovery plans have been developed for RTT and Cancer.

6. All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner. BHRUT compliance. Risk Timescale for compliance: 31 December 2014

RESPONSE: A full risk assessment of the requirements of the accountability framework will be completed by end November 2014.

7. The board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance. BHRUT compliance. Risk Timescale for compliance: 31 October 2014

RESPONSE: The current Board Assurance Framework requires reframing and refreshing. At the current time it does not adequately reflect the risks for the organisation.

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AGENDA ITEM 4.2

8. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily. BHRUT compliance. YES 9. An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury BHRUT compliance. YES 10. The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets as set out in the NTDA oversight model; and a commitment to comply with all known targets going forward. BHRUT compliance. No

Timescale for compliance: 31 March 2015 RESPONSE: The Trust is not meeting a number of the standards in the accountability framework (cancer, RTT, diagnostics and A&E) not fully meeting the NHS Constitution Standards for 18 weeks for RTT or 4 hours for A&E waits. The focus for emergency care is delivery of the improvement plan whilst additional recovery plans have been developed for RTT and Cancer.

11. The Trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit. BHRUT compliance. No

Timescale for compliance: 31/10/2014 RESPONSE: The Trust has not achieved a minimum of level 2 performance. Despite significant progress it is likely that the Trust will not be compliant in all areas; it is anticipated that this will now be achieved by October 2014, with particular focus on IG training.

12. The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies. BHRUT compliance. RISK

Timescale for compliance: 31 March 2015

RESPONSE: There are a number of gaps in the substantive executive structure. Substantive appointments have been made to the Director of Finance & Investment and Chief Operating Officer posts.

13. The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

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BHRUT compliance. YES 5 14. The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan. BHRUT compliance. RISK

Timescale for compliance: 31 March 2015 RESPONSE: The Trust considers that there is not sufficient capacity and capability to deliver the operating plan and improvement plan. The executive team and non executive team is being strengthened and a subsequent review of the clinical and management structure in place will be undertaken. The transitional support requirements include strengthening the capacity and capability within the Trust.

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AGENDA ITEM 4.2

Trust Development Authority (TDA) Monthly Self-Certification Requirements Compliance Monitor Condition G4: Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions) BHRUT compliance. YES Condition G5: Having regard to monitor guidance BHRUT compliance. YES Condition G6: Registration with the Care Quality Commission BHRUT compliance. YES Condition G8: Patient eligibility and selection criteria BHRUT compliance. YES Condition P1: Recording of information BHRUT compliance. YES Condition P2: Provision of information BHRUT compliance. YES Condition P3: Assurance report on submissions to Monitor BHRUT compliance. YES Condition P4: Compliance with the National Tariff BHRUT compliance. YES Condition P5: Construction engagement concerning local tariff modifications BHRUT compliance. YES Condition C1: The right of patients to make choices BHRUT compliance. YES Condition C2: Competition oversight BHRUT compliance. YES Condition IC1: Provision of integrated care BHRUT compliance. YES

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AGENDA ITEM 6.1

Date of Trust Board meeting: 5 November 2014

Title of Paper: Reports of Meetings of the Committees of the Board

Introduction/Summary:

The purpose of the report is to inform the Board of significant issues arising from meetings of Committees of the Board and any decisions made, to highlight risks identified from those meetings and to advise on assurances received and discussed. This report includes summaries from the following meetings: Finance and Investment Committee held on 23.10.2014 Audit Committee held on 21.10.2014 Trust Executive Committee held on 28.10.2014

Patient Safety implications: NA

Risks: The Trust's sub-committee structure does not support effective governance

Financial implications: NA

Legal advice and implications: NA

Consultation (including patient and public involvement): NA

Communications: NA

Equality Impact implications: NA

Reviewed by/action taken? NA

Recommendations:

The Board is asked to receive and consider the report in accordance with Standing Orders.

Author and Lead Officer (if different):

Author: Committee Chairs supported by the Trust Secretary

Lead Officers: Committee Chairs

Date(s) for further review. 30 October 2014

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AGENDA ITEM 6.1

BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST

REPORT FROM THE FINANCE AND INVESTMENT COMMITTEE

TRUST BOARD MEETING: 5 NOVEMBER 2014

1. MATTERS FOR THE BOARD TO NOTE The Finance and Investment Committee meeting was held on 23 October 2014. 1.1 The Committee discussed at length the Month 6 Finance report focussing on 3 main

elements; Month 6 Finance analysis Expenditure on temporary staffing, in particular Agency Staff Funding for the delivery of the Improvement Plan

1.2 The September in-month position showed a deteriorating financial position, due to

increasing Agency expenditure and the failure of some QCIP schemes. 1.3 There had been a significant increase in retrospective temporary staff bookings

across the Trust in Month 6 indicating uncontrolled and escalating pay costs. Rising Agency usage was considered against the control processes put in to deliver a £3.0m reduction. Weekly meetings with Directorates were continuing to take place, however, Agency costs continued to rise.

1.4 Improvement Plan Funding from CCGs and the TDA/NHSE had still not been

confirmed in writing. The costs already incurred against delivery of the Improvement Plan totalled £875k. The full year forecast cost for 2014/15 was £4m. The Committee agreed that recurrent expenditure on IP schemes should be capped at £2.25m and the non recurrent IP expenditure should be capped at £1.3m.

1.5 The majority of recurrent IP expenditure, both that already being incurred at Month 6,

and any additional IP expenditure yet to be authorised will come principally in the form of temporary staffing i.e agency/locums. Due to the current lack of control of agency spend; this poses a high financial risk to the Trust.

1.6 The Committee also considered the financial consequences of the RTT Backlog

which was currently estimated at £11.3m. 1.7 The Trust Board should note that there is a significant risk on the cash shortfall, and

we need to deliver the more CIPs. 2. ESCALATION TO THE BOARD 2.1 The Finance and Investment Committee is escalating to the Trust Board through this

report, its concerns about the Trust’s Financial Position which has significantly deteriorated in September, principally due to the lack of control of temporary staffing usage and declining QCIP delivery, and that without immediate and effective management action to reduce expenditure, and a halt on any additional investments, the Trust will at best be left with a significant cash shortfall of £3.8m, and will also fail to meet the 2014-15 Financial Control total.

Eric Sorenson Chair, Finance and Investment Committee

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AGENDA ITEM 6.1

BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST

REPORT FROM THE AUDIT COMMITTEE

TRUST BOARD MEETING: 5 NOVEMBER 2014

1. MATTERS FOR THE BOARD TO NOTE The Audit Committee meeting was held on 21 October 2014. 1.1 Committee members received a detailed presentation on data quality from the Deputy

Chief Executive. He provided background and context detailing where the Trust had been in relation to data quality and proceeded to describe the drivers of the current quality of the data used by the Trust. Mr Russell itemised the current risks as follows: Limited income risk as coding generally good Data is incomplete as opposed to inaccurate There was a general lack of confidence in the data There was a lack of ownership and appreciation of the root cause of data quality

which is data entry A lack of understanding by clinical and operational parts of the organisation and a

lack of understanding of the clinical and business needs of the organisation. He outlined proposals for improvement which were accepted by the Committee.

1.2 The Committee received an update, as requested in July 2014, on the Siemens managed service agreement. Committee Members particularly sought assurance that the matters raised in the Internal Audit report had been addressed. The report provided a status report on the recommendations made by Internal Audit and presented an overview of the delivery of the managed service agreement for network and voice technologies, and set out the current position, the drivers of the delays to the project and recommended that the Trust take further legal advice given the lack of benefit realised due to the delays. This was agreed.

1.3 Members scrutinised the following:

Recorded losses and compensation Waivers of standing orders not to tender

2. ASSURANCES TO THE BOARD

2.1 Internal Audit confirmed that since the last meeting of the Audit Committee, final

reports had been provided for: Governance Improvement Plan (1.14/15) Serious Incidents (2.14/15) Mandatory Training (4.14/15) Asset Register (5.14/15) Infection Control – Governance Arrangements (19.13/14)

In addition Internal Audit advised members that responses and updates to 2013/14 audit reports were being received.

2.2 The final Comprehensive Fraud Risk Assessment had been issued and members received assurance that recommendations were being implemented.

Rob Whiteman Chair, Audit Committee

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AGENDA ITEM 6.1

BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST

REPORT FROM THE TRUST EXECUTIVE COMMITTEE

TRUST BOARD MEETING: 5 NOVEMBER 2014

1. MATTERS FOR THE BOARD TO NOTE The Trust Executive Committee meeting was held on 28 October 2014. In addition to the reports considered by the TEC prior to presentation to the Board the following reports were received or reviewed:

Feedback from the Board - The Chief Executive maintains communication between the Board and the TEC by presenting feedback from the Board to TEC and reporting to the Board on the items considered by TEC. ED Staffing Strategy – A detailed review of the medical workforce issues experienced in recent years, actions taken in the last twelve months together with proposals for further actions and developments was considered. TEC agreed that the right actions were being taken and emphasised the importance of the support provided by the other Directorates. Corporate Risk Register – The Committee reviewed the draft corporate risk register and agreed that progress had been made but each Directorate should meet with the new Risk Manager to ensure the risks are aligned to the Improvement Plan and the wider risks discussed in other reports. Department of Health Connecting Programme – This programme was set up following the Francis Inquiry report. Sir Robert Francis QC found that the Department often appeared remote from the realities of the experiences of patients and service users and recommended they spend time with staff in NHS and care organisations. This is being achieved through the Connecting Programme and the paper outlined the plans for DH staff to ‘connect’ at our Trust. Internal Audit Report – This report highlighted outstanding internal audit recommendations and required updates. Lead officers are updating the report prior to the Audit Committee scheduled for 4 December 2014. Replacement LINAC capacity for Radiotherapy provision commencing April 2016 - The purpose of this paper was to highlight the need to replace in 2016 the 4 Linear Accelerators which have been in use at Queen’s Hospital since 2006. A business case is being developed to secure capital funding in the region of £6.2million Terrific Tickets – The TEC fully supported the launch of Terrific Tickets which was Phase III of the PRIDE rollout. Each Clinical Director received a book of 25 tickets which will be replenished each quarter. These tickets are to be given out by the CD or a member of their team, to individual members of staff observed demonstrating PRIDE behaviours. The importance of this initiative is to say thank you at the time of handing out the ticket. Each ticket can then be redeemed at Costa for a tea or coffee.

All other reports are on the Board agenda for this meeting. Matthew Hopkins Chief Executive

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Trust Board meeting 5th November 20145

Title of Paper: Winter Resilience Plan

Introduction/Summary:

This is to inform the Trust Board that there are 3 plans in place to manage system pressures throughout the winter period:

1. Winter Resilience Plan

2. Surge Management Plan

3. Ward opening and decommissioning procedure.

The purpose of these plans are to:

Respond to extreme weather conditions

Respond to seasonal increase in infectious diseases

Act as triggers for the activation of out-of-hospital plans

Create additional capacity for surges in demand

Manage patient flow into, through and out of the hospital sites

These plans have been reviewed and updated by the Emergency Planning Steering Group (October 2014), discussed at the Trust Executive Committee and will be considered again in November by the Operational Management Group chaired by the Chief Operating Officer.

Patient Safety implications:

To ensure our patient care and safety is not adversely affected by winter pressures

Risks:

Key risks to the plan: • Financial risk of opening and closing a ward • Reliance on high levels of temporary staff for contingency areas and risk of

insufficient staff numbers • Delivery of partners’ winter resilience plans

Financial implications: Budget will be sourced through winter resilience funding and allocation will be agreed by the Executive team. Expenditure will be monitored by the Finance team and at the weekly pay review meetings chaired by the Executive Team.

Legal advice and implications: A concern has been raised about one statement recorded in the Winter Resilience plan relating to the following statement:

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AGENDA ITEM 7.1

‘Offer to clear your neighbours’ paths’

‘If your neighbour will have difficulty getting in and out of their home, offer to clear snow and ice around their property as well. Check that any elderly or disabled neighbours are alright in the cold weather. If you’re worried about them, contact your local council.’

The concern has been raised that under current “English Law” should a member of the public sustain an injury on an area of cleared snow/ice; the person that cleared the snow/ice is liable?

Legal advice has been requested.

Consultation (including patient and public involvement): N/A

Communications: In conjunction with BHRUT winter communications plan. This will also link with commissioning groups/LAS and Surge Management team and their supporting communication teams.

Equality Impact implications: N/A

Reviewed by/action taken? Emergency Planning Steering Group

Recommendations:

Paper for information

Author and Lead Officer (if different):

Author: Eileen Moore Acting COO

Date(s) for further review. Operational Management Group November 2014

 

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AGENDA ITEM 7.2

Date of Trust Board meeting: 5 November 2014

Title of Paper: 2014 Revised Standing Orders (SOs) and Standing Financial Instructions (“SFIs”)

Introduction/Summary: The current version of the Trust’s SOs is dated December 2013 and the last version of the SFIs is dated February 2010. Both required revision.

SOs and SFIs of all NHS bodies are heavily based on the last published version of the DH model (March 2006) and BH&R are no different in this respect. However, many Trusts and FTs are now seen to be moving away from the standard wording. This is particularly relevant to the SFIs in areas where electronic systems with embedded audit trails and controls make the paper based view of necessary controls irrelevant. The Trust’s contract with NHS Shared Business Services and the use of e-procurement through the NHS London Procurement Partnership are two such examples.

This revision of the SOs and SFIs covers changes in recent legislation and changes in job titles at senior levels in the Trust. The detailed changes are extensive and so a tracked changes version would be difficult to assess. The Governance Manual is detailed and complex and rather than reproduce a tracked document a simplified list of changes has been used to highlight material changes to both documents.

Patient Safety / Risks / Equality Impact : n/a

Financial implications: n/a

Legal advice and implications: n/a (not constitutionally and legally binding for a non FT)

Consultation (including patient and public involvement): For SFIs - extensive across senior and middle management especially finance/ HR/ procurement/ information/ incoming DoF Jeff Buggle. SOs have been reformatted and incorporates the provisions of the Health and Social Care Act 2012.

Communications: to be published on website and on intranet and other comms

Reviewed by/action taken? SOs and SFIs have been considered by the Audit Committee and approved by the Trust Executive Committee.

Recommendations: Approval of Standing Orders including Standing Financial Instructions is a matter reserved to the Board. The Trust Board is asked to approve the revised SOs and SFIs.

Author and Lead Officer (if different): Author SFIs: Richard Sharp – Interim Financial Controller. SOs Andrea Saville, Trust Secretary

Lead Officer: Alan Davies - Acting Director of Finance

Date(s) for further review. 2 years on from approval - 2016

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Revised Trust Standing Orders incorporating Standing Financial Instructions

Record of material changes made

Note: Scheme of Delegation to be revised when Chair of FIC appointed and new executive team fully in place in late 2014

RECORD OF AMENDMENTS SECTION (old references, subject to change in new version)

AMENDMENT (to the November 2012 version of the Trust’s S0s)

COMPLETION DATE

General The Standing Orders have been revised to include the relevant provisions of the Health and Social Care Act 2012. This is referenced throughout the document. New organisations are included e.g. NHS Trust Development Authority (TDA) and redundant ones removed e.g. Appointments Commission and Patient and Public Involvement Forum; PCGs have been replaced by CCGs. Advice on the Standing Orders from the Local Counter Fraud Specialist has been incorporated. The document has been reformatted and cross references to the SFIs have been updated throughout.

1.2 Accounting Officer changed to Accountable Officer (BHRUT is not an FT)

2.1 Included reference to Amendment Order 2009 No 43

2.3 Strengthening of sanctions for failure to comply to include criminal sanctions as well as dismissal

3.1.1.3 and 3.3.1 Reference the legislation relevant to PCTs has been removed and legislation relevant to NHS Trusts included

4.2.4 Number of days’ notice to request an agenda item to be considered by the Trust Board set at 10

7.2 Standing orders to be read in conjuction with - Standards of Business Conduct Policy, Gifts and Hospitality Policy, Speak up for a Healthy Trust Policy (Whistleblowing), Anti Fraud and Bribery Policy

5.8.4 Clinical Governance Committee omitted (Quality and Safety Committee included) Finance Committee changed to Finance and Investment Committee

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Revised version of the SFIs (currently page 30 onwards of Governance Manual)

Author: Richard Sharp (August/September 2014) – RECORD OF CHANGES MADE (detailed tracked changes reviewed by Acting DoF 5/9/14 and 16/9/14)

Note: Scheme of Delegation to be revised when Chair of FIC appointed and new executive team fully in place in late 2014

RECORD OF AMENDMENTS SECTION (old references, subject to change in new version)

AMENDMENT (to the February 2010 version of the Trust’s SFIs)

COMPLETION DATE

11.10 Clarify CEO role as “Accountable Officer” as distinct from DoF role to avoid possible confusion

August 2014

11.12 Better explanation included that SFIs are not detailed procedures and not a substitute for these

August 2014

11.12 Although DoF is ultimately responsible, such is the level of delegation to NHS SBS that this needs to be made clear, especially draft maintenance of ledgers, cash books, etc

September 2014

11.16 and 11.17 Rewrite the Audit Committee section according to the new HFMA Audit Committee Handbook published 2014

September 2014

11.21 Improvement of the explanation of the role of internal audit, especially the two key areas as a new preamble to Internal Audit section

August 2014

11.23, 11.24, 11.25 Change Chief Internal Auditor to Head of Internal Audit, the terminology used by the DH in FinMan and other guidance.

August 2014

11.25 Include the Local Audit and Accountability Act 2014 as the current legislation to appoint the external auditor in an NHS Trust (no longer down to Sec of State or the former Audit Commission)

September 2014

11.27 Show Director of Finance as the executive responsible as “Counter-Fraud Director” to the Board

September 2014

11.28 and others Remove references to Counter Fraud and Security Management Services Division of BSA and replace with NHS Protect under the BSA

August 2014

11.32 Include role of the Security Management Director (Director of Estates & Facilities)

August 2014

11.34 Security Management to report to Health & Safety Steering Group in the first place and then to Quality & Safety Committee (Board Committee responsible)

September 2014

11.35 Include the requirement for an annual plan and an annual report of Security Management to H&SSG and to Q&SC

September 2014

12.1 and 17.2 Replace Local Delivery Plan with Integrated Business Plan (IBP) and explain the composition of the IBP and LTFM as far as finance is concerned

August 2014

12.4 and others Include the role of FIC in many finance approvals rather than Board alone (but with FIC reporting to Board)

August 2014

12.3 Amend the fact that budgets must be within available funds to, add the words “or within planned deficits

September 2014

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agreed with the NTDA” 12.5 Use the term “senior budget holders” and define

(these persons sign-off all budgets). August 2014

12.6 Insert HfMA e-learning for budget holders.. August 2014 12.11 Insert modern/correct names for I&E and B/S. September 201412.15 Financial monitoring returns/TRUs to the NTDA now August 2014 13.1 Re-explain the AR&A production process as out of

date September 2014

13.2 Amend wording to explain the role of Audit Committee in reviewing Annual Report & Accounts (AR&A) and recommending to Board for Board approval.

August 2014

Old 15.6 now 14.1 Delete as the Trust has no choice but to use GBS and cannot tender for bank accounts!

August 2014

14 Replacement of OPG (Office of Paymaster General) by GBS (Government Banking Service) and electronic banking services

August 2014

14.1 Banking arrangements to be approved by FIC with reporting to Audit Committee

September 2014

14.3 Temporary loans from NTDA not commercial banks September 201414.6 Remove the clauses about tendering for commercial

bank accounts as obsolete (we must use Government Banking Services (GBS), no choice)

August 2014

15.2 15.3 15.4 Minor changes to setting prices and fees not set centrally by NTDA

September 2014

15.6 15.7 Changes to debt recovery to reflect NHS SBS responsibilities. Write-offs approved by DoF with reporting to Audit Committee

September 2014

15.9 Changes to security of cash and cashbooks to reflect NHS SBS and G4S contracts

September 2014

15.11 Gross accounting for receipts, no netting off. September 201415.12 Losses reported to LSMS (as well as Director of

Finance) September 2014

16 Revised for introduction of electronic tendering (using LPP’s Due North software) for 100% of non-EU tenders

September 2014

16.3 New overview of procurement at the Trust explained in simple terms. Distinction between long term e-tendering and transactional purchasing (i.e., Supply Chain, Office Depot, Squadron Medical)

September 2014

16.4 Minimum expenditure for a tender is £30k not £25k (has been the practice for some time)

September 2014

Various including 16 and 22

Replace references to Capital Accounting Manual with DH Manual For Accounts and or other guidance from NTDA/DH

September 2014

16.5 (was 17.8) Modify CE waiver condition (some unnecessary words) as agreed with Director of Procurement and Acting DoF. Delete waiver reasons 2 and 3 as obsolete/unnecessary as agreed with Director of Procurement and Acting Director of Finance

September 2014

16.6 Remove references to PASA which no longer exists. Reword as its roles split between Crown Commercial Service (was Government Procurement Service) and NHS Supply Chain

August 2014

16.13 16.14 Insert new clause on e-tendering and explain internal control and audit trail issues in the new computerised

September 2014

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system 16.36 Change “lowest cost tender” to “most economically

advantageous tender” September 2014

16.42 All tenders to be reviewed by FIC and, approved as appropriate if under £1 million and, if over £1 million a recommendation for Board approval is minuted

September 2014

16.45 Remove all the separate references to all the equal ops legislation and simply say “all equal ops and antidiscrimination legislation

September 2014

16.51 Insert that the Trust uses the Multiquote electronic system for all quotes required in Procurement Department and delete all the manual quotations wording

September 2014

16.56 Tender approvals updated to: any 2 from CE/DCE/DoF/DDoF up to £30,000, FIC decision £30k to £1m, Board decision over £1m

September 2014

16.62 Temporary staff contracts over £220 per day and over 6 months must now comply with DH/NTDA off-payroll directives

September 2014

16.62 and 18.8 Include the mid 2014 tighter controls over agency staff September 201417.1 17.2 Revise wording for the NHS reorganisation of

commissioners (CCGs, NHS England and LAs are now the main commissioners) and other wording (CQUIN and performance metrics)

September 2014

17.3 was 18.4 Delete the 2005 verbose insertion wording about the new “Patient Led NHS & PCT Commissioning” as not only out of date but also not strictly a matter for the SFIs

August 2014

16.59 25.8 Change name of NHS Logistics to NHS Supply Chain August 2014 18.14 Include salary sacrifice schemes in the clause

regarding variations to contracts of employment September 2014

19.1 19.2 19.3 Include the NHS SBS hierarchy of approvals August 2014 Insert appropriate references and compliance with the

Bribery Act 2010 August 2014

19.7 Official orders are also called POs under the SBS Oracle system

September 2014

20 External Borrowing - Lots of changes to reflect the fact that loan finance can only come from the NTDA and the necessary hoops to achieve this (for instance an IBP and LTFM for permanent PDC)

September 2014

21.1 Delete Financial Framework (obsolete) and replace with the NTDA’s Accountability Framework

September 2014

24.14 Losses & Special Payments reported annually to the Audit Committee in summary form. Those over £250,000 must be reported to the next Audit Committee as a separate agenda item

September 2014

25 Chief Information Officer responsible for FOIs (the executive director being the DCE).

September 2014

25.7 Insert the need for assurance about NHS SBS systems (technically called an ISAE 3402 report)

September 2014

25.8 Show that the Chief Information Officer is the Trust’s SIRO (Senior Information Risk Officer)(in his absence the DCE)

September 2014

27.1 27.5 Change all references to charitable and trust funds to charitable funds, as all such funds must be charitable since dual accountability ended in 2005 (to both DH

September 2014

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4  

and CC). Now only CC BUT there remains dual accounting to DH and CC (explain this subtlety)!

30.3 CEO to sign Annual Governance Statement September 201431 Insert new section Bribery and Corruption – include

appropriate references and compliance with the Bribery Act 2010

September 2014

All sections Update Director job titles to those of the July 2014 CEO review and subsequent changes

August 2014

All sections General review and updating re: legislative updates (e.g. Health & Social Care Act 2012, Conditions Relating to Payments by the NHS to LAs) Directions 2013)

August 2014

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Agenda item 7.3

Date of Trust Board meeting: 5 November 2014

Title of Paper: Business Conduct Standards Policy

Introduction/Summary: The previous version of this document combined the Trust’s approach to declaring and registering Gifts, Hospitality and sponsorship as well as other relevant and material interests. There are now two documents. The Gifts, Hospitality, Sponsorship, Inducements and Rewards Policy was agreed in 2013. The Business Conduct Policy now focuses on expected behaviour, provides guidance on undertaking private practice, working for or with other NHS providers and declaration and registering of interests including competition with the Trust. It has been updated in accordance with the Bribery Act 2010.

Decision required: This Policy forms part of the Governance Manual, approval of which is a matter reserved to the Board. The Trust Board is asked to approve the Business Conduct Standards Policy.

Reviewed by: Approved by the Trust Executive Committee on 28 October 2014 subject to development of an implementation plan and handling of any issues arising from the declarations.

Patient Safety implications: N/A

Risks: Staff do not adhere to expected behaviours and declare relevant interests.

Financial implications: N/A

Legal advice and implications: N/A

Consultation (including patient and public involvement): N/A

Communications: N/A

Equality Impact implications: None

Author and Lead Officer (if different):

Author: Andrea Saville, Trust Secretary

Lead Officer: Deborah Tarrant, Director of People and Organisational Development

Date(s) for further review: Joint Staff Committee

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BUSINESS CONDUCT STANDARDS POLICY

Barking Havering & Redbridge University Hospitals NHS Trust aims to design and implement services, policies and measures that meet the diverse needs of our

service, population and workforce, ensuring that none are placed at a disadvantage over others.

Policy No: 2006/HR/42 Version 2.0 (December 2010) Version 3 (July 2014)

Approved by: Trust Board Date: May 2008 Reviewed: December 2010 (NoChanges required – trust name amended) Approved by: Date:

Reviewed: Gifts and Hospitality and Declaration of Interest split into two policies. Updated in accordance with the Bribery Act 2010

Review Frequency: 3 yearly Review Due: December 2017

Responsible Officer: Chief Executive Author:

Advice: Director of People and Organisational Development and Trust Secretary

Core Human Resource Policy: Yes Applicable to Clinical and Non-Clinical Areas: Yes

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CONTENTS

Page

1.0 EXECUTIVE SUMMARY ................................................................ 4

2.0 SCOPE OF POLICY ....................................................................... 4

3.0 BACKGROUND ……………………………………………………… 4

4.0 BEHAVIOUR ................................................................................ 5

5.0 OBLIGATIONS TO THE TRUST AS EMPLOYER......................... 6

6.0 DECLARATION OF INTERESTS................................................... 6

7.0 CONFLICTS OF INTEREST AND COMPETITION WITH THE 6 TRUST........................................................................... ..

7.1 Trust Core Business ........................................................ 7

7.2 Duty of Confidentiality & Fidelity ...................................... 7

7.3 Undertaking Private Practice ........................................... 7

7.4 Not competing with the Trust as an individual, as part 8 of a consortium or with another provider......................

7.5 Trust collaboration with other providers and 8 competition for services .........................................

7.6 Working for or with other NHS service providers and 9 other possible conflicts of interest ........................... ................................................................................

7.7 Fraud and Bribery

7.8 Queries and Questions .................................................... 10

8.0 METHOD OF DECLARATION & REGISTER OF INTERESTS .... 10

9.0 PREFERENTIAL TREATMENT IN PRIVATE TRANSACTIONS .10

10.0 FAVOURITISM IN AWARDING CONTRACTS..................... …. 11

11.0 WARNINGS TO POTENTIAL CONTRACTORS............................ 11

12.0 REWARDS FOR INITIATIVE ......................................................... 11

13.0 COMMERCIAL ‘IN CONFIDENCE’................................................ 11

14.0 OBLIGATIONS TO THE PATIENT ………………………………… 12

15.0 OBLIGATIONS TO OTHER TRUST STAFF AND VISITORS ...... 12

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16.0 POLICY DEVELOPMENT............................................................... 13

17.0 DISTRIBUTION ............................................................................... 13

18.0 AUDIT AND REVIEW...................................................................... 13

19.0 ASSOCIATED TRUST POLICIES / DOCUMENTS ........................ 14

21.0 REFERENCES ................................................................................ 14

APPENDIX A DECLARATION OF INTERESTS FORM.......................... 15

APPENDIX B DECLARATION OF INTERESTS FLOW CHART ........... . 19

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1.0 EXECUTIVE SUMMARY Trusts are required to have in place a Policy on Declaration of Interests and Standards of Business Conduct. This policy fulfils the dual role of protecting the Trust’s interests and protecting Board members and staff from any possible accusation that they have acted less than properly in their relationship with the Trust. This policy exists to assist staff in maintaining strict ethical standards in the conduct of Trust business. 2.0 SCOPE OF POLICY The following information and guidance must be noted and adhered to by all employees, which includes full and part-time permanent and temporary members of staff, as well as consultants and those managers not employed by the Trust but who manage the Trust’s staff. If staff are uncertain about the correctness or propriety of any proposed business transactions declaration of interests then they must seek guidance from the member of the Conflict of Interest Review Panel through their line manager or the Trust Secretary. 3.0 INTRODUCTION

High standards of corporate and personal conduct are an essential component of public service. The purpose of this policy is to provide clear guidance on the standards of conduct and behaviour expected of Directors, Senior Managers and Senior Clinical Staff although all staff are expected to adopt the principles. This policy, together with the Gifts, Hospitality, Sponsorship, Inducements and Rewards Policy forms part of the framework to promote the highest possible standards of conduct and behaviour within the Trust. The policy is intended to operate within any future Trust Constitution, the Trust Standing Orders and Monitor’s Code of Governance. The policy applies at all times when Directors, Senior Managers and Senior Clinicians are carrying out the business of the Trust or representing the Trust in any capacity PRINCIPLES OF PUBLIC LIFE All Directors, Senior Managers and Senior Clinicians are expected to abide by the Nolan principles of public life:

Selflessness

Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

Integrity

Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

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Objectivity

In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

Accountability

Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

Openness

Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

Honesty

Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

Leadership

Holders of public office should promote and support these principles by leadership and example.

4.0 BEHAVIOUR – PRINCIPLES OF CONDUCT IN THE NHS

Trust Board members have a duty to conduct business with probity, to respond to staff, patients and suppliers impartially, to achieve value for money from public funds with which they are entrusted and to demonstrate high ethical standards of personal conduct. The general duty of the Trust Board and of each Director individually, is to act with a view to promoting the success of the organisation so as to maximise the benefits for the public. The Trust Board therefore undertakes to set an example in the conduct of its business and to promote the highest standards of conduct. The Trust Board will lead in ensuring the standing orders, standing financial instructions and accompanying scheme of delegation conform to best practice and serve to enhance standards of conduct. The Trust Board expects that this policy will inform and govern the decisions and conduct of all directors, senior managers and senior clinicians.

Indeed all staff are expected to adopt these principles when conducting official business for and on behalf of the trust so that appropriate ethical standards can be demonstrated at all times.

NHS staff are expected to:-

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Ensure that the interest of patients remains paramount at all times Be impartial and honest in the conduct of their official business

Use the public funds entrusted to them to the best advantage of the Service, ensuring value for money at all times.

It is also the responsibility of staff to ensure that they do not:-

Abuse their official position for personal gain or to benefit their family, friends or associates.

Seek to advantage or further private business or other interests, in the course of their official duties.

5.0 OBLIGATION TO THE TRUST AS EMPLOYER

All staff behaviour contributes to the public perceptions of the quality of services provide by the Trust, and all staff must therefore be fully aware that whether they are at work, or away from work, but identifiable as a member of NHS staff, they are acting as an ambassador of the Trust and are required to adhere to all relevant legal and civil legislation and bye-laws and to NHS Trust policies and the standards contained within them.

Failure to adhere to the relevant standards could leave the individual open to civil or criminal penalties, as well as the possibility of facing disciplinary action within their employment with the NHS Trust.

6.0 DECLARATION OF INTERESTS

It is a requirement that the Trust Board, members of the Trust Executive Committee, all Directors, Associate and Deputy Directors and Clinical Consultants should declare any conflict of interest that arises in the course of conducting NHS business on starting with the Trust and annually thereafter. All Board members, members of the Trust Executive Committee, all Directors, Associate and Deputy Directors and Clinical Consultants are therefore expected to declare any personal or business interests which may influence or may be perceived to influence their judgement. This should include as a minimum, personal direct and indirect financial interests, and should include such interests of close family members. Indirect financial interests arise from connections with bodies which have a direct financial interest, or from being a business partner, or being employed by, a person with such an interest.

All other staff will be informed upon joining the Trust they must advise the Trust of any conflict of interest including working with or for external agencies.

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All staff should be aware that disciplinary or criminal action can be taken in cases where an employee fails to declare a relevant interest, or is found to have abused his or her official position, or knowledge, for the purposes of self benefit, or that of family and/or friends. Disciplinary action may lead to dismissal.

7.0 CONFLICTS OF INTEREST AND COMPETITION WITH THE TRUST

The recent NHS reforms, in particular ‘Commissioning a Patient Led NHS’, has encouraged the introduction of a range of alternative providers of care for patients requiring or receiving NHS treatment. Clinical Commissioning Groups (CCGs) and other commissioners may now enter into agreements with a range of providers including NHS Trusts, Independent Sector Treatment Centres (ISTCs), private companies and Community Interest Companies (CICs) to pay for the provision of NHS treatment required by NHS patients. Patients may also exercise choice about the provider from whom they receive their NHS treatment. The purpose of this policy is to set out the arrangements and controls where the Trust’s own staff are asked to, or seek to work with, or for, such alternative providers of care and a conflict of interest may arise and seeks to encompass dealing with patients, the public, the media and other bodies external to the Trust . This element of the policy covers all Trust staff and is intended to protect the Trust’s future business.

7.1 Trust Core Business

The Trust’s core business is the provision of NHS acute care to NHS patients in Barking, Havering and Redbridge and the surrounding area. The Trust needs to ensure that it is attracting sufficient patients and treating them quickly, safely and effectively in order to sustain its income and future viability. This means that the Trust needs to compete with other organisations (NHS and alternative providers) to attract patients to use the services it provides. This situation can be contrasted with patients seeking private treatment (for example from a Consultant or other practitioner who undertakes private practice outside their NHS work) where the Trust does not, at present, compete directly to provide the service and which is agreed as a private arrangement between practitioner and patient that is not paid for by the NHS.

7.2 Duty of Confidentiality and Fidelity

All staff owe a duty of good faith and fidelity to their employer, in this case the Trust. This duty of good faith and fidelity arises at common law and is implied into every relationship between an employer and employee. Trust staff are also subject to some express terms governing their duty of confidentiality and fidelity to the organisation, as set out in their Terms and Conditions of employment. They are also bound by the duty of confidentiality regarding information obtained in the course of their employment, including information that might be useful to competitors.

Breaches of the duties of fidelity or confidentiality, such as (but not restricted to) failing to declare outside interests or seeking to set up in competition to the Trust or (Version 2.0-December 2010)

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working with another provider to compete with the Trust or divulging confidential data, would be a serious disciplinary matter, usually leading to dismissal.

7.3 Undertaking Private Practice

Private practice is work undertaken by a practitioner (usually a Consultant) by private arrangement with an individual patient. The patient, or their health insurer, will meet the costs of treatment, not the NHS. Staff who undertake private practice are required to notify the Trust, via the declaration of interest form (Appendix A) and the Medical Director. If they do so, they must ensure that this work does not interfere or take place during their NHS duties, require the use of Trust resource such as Medical Secretaries and will require the relevant insurance so the Trust is not accountable to any malpractice claims. If Trust facilities are used this must be with the express agreement of the Trust (which may levy an appropriate charge for such facilities and/or support). Agreement should be sought through the appropriate member of the Conflict of Interest Panel.

Practitioners are not expected to advertise or promote their private services to their NHS patients within the Trust, or to use their position of influence when providing NHS care to patients to encourage or unduly influence them to exercise their right to see the practitioner privately. For Consultants, their regular private commitments should be declared in their annual job plan. Provision of private treatment by any practitioner must not prejudice or disrupt the Trust’s services to NHS patients.

7.4 Not competing with the Trust as an individual, as part of a consortium or with another provider

Staff must not compete, or plan to compete, with the Trust on their own as an individual, or in a consortium or with other providers to win contracts for services. This is regardless whether the work being bid for will be conducted in the staffs’ own time or by other individuals. The only circumstances where staff may be allowed to bid for work is where the service is one which the Trust has no interest in providing or competing for and the Trust has expressly agreed that no conflict of interest arises and that the member of staff has permission to proceed.

In all such cases, permission should be sought from the Chief Executive before any bid is contemplated.

Competing with the Trust without permission whilst employed, or planning without permission, to compete with the Trust once the employment contract is ended, would be a breach of the duty of good faith and fidelity and be subject to disciplinary proceedings.

Confidential information that may assist a competing provider must not be shared with other providers without the express permission of the Clinical Director responsible for the service concerned.

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7.5 Trust collaboration with other providers and competition for services

From time to time the Trust may wish to bid for contracts, or work with other providers, to compete for and deliver services to patients. Staff will be expected to collaborate with such ventures, within the terms of their employment contracts and subject to Trust policies and procedures regarding staff involvement, consultation and, if appropriate, staff affected by change. Competition for business and patient services will help the trust secure its future and maintain or develop employment opportunities for staff. The Trust’s policies serve to protect staff interests and terms and conditions of employment where these may be affected by a bid to provide services or work jointly with another provider.

7.6 Working for or with other NHS service providers and other possible conflicts of interest

Unless stated in their contract of employment, Trust staff are not precluded from working for other organisations outside their hours of employment with the Trust - but they must only work for or with other providers of services to patients where there is no conflict of interest arising with the Trust’s own business and interests (whether the work is with or for other NHS trusts, Community Interest Companies, ISTCs or private companies).

Working for a secondary employer whilst absent from work due to sickness is not permitted,. Where an employee is suspected of secondary employment whilst absent due to sickness these matters will be investigated in accordance with the Trust Anti Fraud and Bribery Policy and the Disciplinary Policy & Procedure.

For some staff, who already have joint contract arrangements or work part-time for this Trust and another NHS or other organisation it is implied that the current arrangement is agreed. Similarly nursing staff undertaking additional hours of work for external Agencies/ other In-House Banks (whether at Queen’s, King George or elsewhere) are not expected to have to separately declare this – provided they are not working excessive hours and their contractual commitment is being met.

All employees of the Trust who hold a self-beneficial interest in private care homes or hostels must declare this interest. The General Medical Council advises that when a doctor refers a patient to a private care home or hostel in which he or she has a private interest, the patient must be informed of that interest before the referral is made. In light of a completed declaration, the Trust reserves the right to explore the details of the declaration further, discuss it with the employee and if the Trust concludes that a conflict does exist, ask the individual to restrict their non-Trust work if appropriate. If it is not possible to address the conflict this may result in the termination of the contract of employment with the Trust. However, all staff must declare if there is any apparent conflict of interest arising from their work with or for another NHS or other organisation. For example if the other NHS provider they work with or for seeks to compete for patients or ‘take over’ a service provided by the Trust this must be brought to the attention of the Trust, through the appropriate member of the Conflict of Interest Panel, and advice sought on managing that conflict of interest as soon as it arises. They must similarly alert the Trust, through completion of a declaration of interest form, where a spouse, partner or close relative may be in a position that creates a potential conflict of interest.

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7.7 Fraud and Bribery

The Trust has procedures in place that reduce the likelihood of fraud and bribery occurring and this policy should be read in conjunction with the following policies/procedures. These include Standing Financial Instructions, Standing Orders Gifts and Hospitality Policy, Declaration of Interest Policy, a system of internal control (including Internal and External Audit) and a system of risk assessment. In addition, the Trust seeks to ensure that a comprehensive anti-fraud and bribery culture exists throughout the Trust via the appointment of a dedicated Local Counter Fraud Specialist, in accordance with the NHS Standards for Providers 2014.

It is expected that Non-Executive Directors and staff at all levels will lead by example in acting with the utmost integrity and ensuring adherence to all relevant regulations, policies and procedures.

The Trust encourages anyone having reasonable suspicions of fraud or bribery to report them (see below). The Trust’s policy, which will be rigorously enforced, is that no individual will suffer any detrimental treatment as a result of reporting reasonably held suspicions. The Trust’s Policy for Raising Concerns in the Public Interest (whistleblowing Policy) and the Public Interest Disclosure Act 1998 gives statutory protection, within defined parameters, to staff who make disclosures about a range of subjects, including fraud and bribery, which they believe to be happening within the Trust employing them. Within this context, ‘reasonably held’ means suspicions other than those which are raised maliciously and are subsequently found to be groundless.

Any unfounded or malicious allegations will be subject to a full investigation and appropriate disciplinary action.

The Trust expects anyone having reasonable suspicions of fraud to report them. It recognises that, while cases of theft are usually obvious, there may initially only be a suspicion regarding potential fraud and, thus, staff should report the matter to their Local Counter Fraud Specialist who will then ensure that procedures are followed or via the NHS National Fraud Reporting Line: 0800 028 40 60..

7.8 Queries and Questions

Staff in any doubt about their personal position or possible conflict of interest between their own or a spouse, partner or close relatives’ position should discuss the matter initially with their manager. Individual queries and circumstances must be examined on a case by case basis in light of the contract of employment and duty of good faith and fidelity as outlined in this policy. In the case of any uncertainty about possible conflict of interest, the matter should be escalated to ta member of the Conflict of Interest Panel.

8.0 METHOD OF DECLARATION & REGISTER OF INTERESTS

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For the reasons above all Board members, members of the Trust Executive Committee, all Directors, Associate and Deputy Directors and Clinical Consultants will be required to complete the attached Declaration (Appendix A) upon joining the Trust and on an annual basis or on the acquisition of the interest (see Appendix B).

All other staff will be informed upon joining the Trust they must advise the Trust of any conflict of interest including working with or for external agencies.

We retain the right to undertake intermittent audits and requests to update employee information which will include a declaration of interests.

If any declared interest could be considered to be a conflict of interests, the Conflict of Interest Review Panel will convene to decide whether any action is necessary. Should the panel decide that there is a conflict of interests, the individual who declared the interest will be requested to take appropriate action. If the individual disagrees that there is a conflict, they may appeal to the Chief Executive who will convene an appeal panel. The decision of the appeal panel will be final. Refusal by an individual to take appropriate action following a panel hearing will constitute a disciplinary matter (see Appendix B).

The completed forms will entered on the Register of Interests.

The register of interest will be held and maintained by the Trust Secretary on behalf of the Chief Executive and will be subject to periodic review by the Trust Board.

9.0 PREFERENTIAL TREATMENT IN PRIVATE TRANSACTIONS

Individual staff must not seek or accept preferential rates or benefits in kind for private transactions carried out with companies with which they have had, or may have, official dealings on behalf of the Trust. (This does not apply to concessionary agreements negotiated with Companies, or by recognised staff interests, on behalf of all staff, for example staff benefits schemes).

All staff who are in contact with suppliers and contractors, including external consultants, and in particular those who are authorised to sign purchase orders, or place contracts for goods, materials or services, are expected to apply the principles outlined in sections 3 and 6 of this policy. Guidance relating to levels of authorisation is set out in the Trusts’ Scheme of Delegation.

10.0 FAVOURITISM IN AWARDING CONTRACTS

Fair and open competition between prospective contractors or suppliers for NHS contracts is a requirement of the NHS Standing Orders and of EC Directives on Public Purchasing for Works and Supplies. This means that:

No private, public or voluntary organisation which may bid for NHS business should be given an advantage over its competitors.

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Each new contract should be awarded solely on merit, taking into account the requirements of the NHS and the ability of the contractors to fulfil them.

Staff must ensure that no special favour is shown to current or former employees or their close relatives or associates in awarding contracts. Relationships and associations can be checked via the Declaration of Interests Register maintained by the Trust Secretary (ext 3674).

Contracts awarded to such businesses must be won in fair competition and the selection process must be conducted impartially.

11.0 WARNINGS TO POTENTIAL CONTRACTORS

All invitations to potential contractors to tender for NHS business should include a notice warning with regard to the consequences of engaging in any corrupt activity involving employees of the Trust. All contractors should be made aware of the Trust’s “Speak Up for a Healthy Trust, Whistle-blowing policy”.

12.0 REWARDS FOR INITIATIVE

Managers should ensure that they are in a position to identify intellectual property rights (IPR) as and when they arise so that they can exploit them properly. This will ensure that the Trust receives any reward or benefit (such as royalties), both in respect of work carried out by third parties, or work carried out by employees of the Trust. To ensure this is achieved managers should build appropriate specifications and provisions into the contractual arrangements before work is commissioned or begins, and seek legal advice in relation to specific cases.

13.0 COMMERCIAL IN CONFIDENCE

Staff should ensure they are aware of information relating to business conducted by the Trust which is ‘commercial in confidence’. All such information should be restricted with regard to disclosure particularly if its disclosure would prejudice the principle of a purchasing system based on fair competition. This refers to both private and public providers of services.

Employees should be careful not to adopt a too restrictive view on this matter.

The term ‘commercial in confidence’ should not be taken to include information about service delivery and activity levels, which should be publicly available, under the Freedom of Information Act. Employees should seek advice in relation to the exemptions which may or may not apply under this act. Also the exchange of data for medical audit purposes, subject to the rules governing patient confidentiality and data protection. 14.0 OBLIGATIONS TO THE PATIENT

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The Trust is committed to ensuring that patient care is provided in partnership with patients, their carers and relatives, and other organisations whose services impact on the patient’s well-being; respecting at all times, their diverse needs, preferences and choices.

Patients should receive services at BHRT as promptly as possible, have a choice in access to services and treatments, and not experience unnecessary delays at any stage of service delivery or during their care pathway.

All patients, their relatives or representatives, should be treated with politeness and consideration at all times. All employees have a responsibility to treat patients, as they would wish members of their own family to be treated. Patient safety is of paramount importance and staff have an obligation to ensure that their working practices are safe and follows Trust guidance. Staff must ensure they are competent and capable of delivering a safe service to the Trust’s patients and are appropriately qualified and skilled; attending internal and/or external training as required to ensure their skills are kept up-to-date, and all clinicians must maintain their registration with their professional bodies.

Staff must observe the patient’s right to have their individual concerns listened to; for their care to be given with all due regard to ensuring their privacy and dignity is not compromised; for their personal possessions to be safeguarded and not lost or damaged through carelessness; and to have the opportunity to contribute to the decision-making about their own care. Staff are expected to ensure that all dealings with patients, their families or representatives, is carried out in a professional, open and honest manner.

Where the patient may be deemed ‘vulnerable’, particular care must be given to ensure they are protected, as far as is practicable, in accordance with relevant Trust policies.

The Trust expects that where opportunities present to provide patients with information or services designed to protect their health, such preventative education, this should be included as a routine part of their care or treatment.

15.0 OBLIGATIONS TO OTHER TRUST STAFF AND VISITORS

Whilst the services of the Trust may be delivered from different sites and from within various specialties and departments, all the staff employed by BHRT work for the same organisation and have an obligation to reflect the Trust’s core values; working cohesively to achieving the Trust’s aims and objectives.

All Trust policies and procedures must be followed to enable the Trust to deliver a coherent and safe service. Following Trust guidance will reduce the number of mistakes made protecting both patients and staff from potential harm.

Staff should respect each other, valuing the different contributions made by other employees remembering that ‘none of us is as smart as all of us’.

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No staff member should use language or behaviour that can be deemed offensive to others and, where there may be differences of opinion; these should be settled equitably away from patients and relatives.

Senior staff across the organisation are expected to provide good role models to their colleagues and junior staff, ensuring that probity, quality assurance, reflection and improvement, and patient safety are central components of their activities.

All visitors to the organisation i.e., partner organisations, suppliers, contractors, and external bodies also have the right to be treated courteously and respectfully at all times. The impact of a negative interaction with a member of Trust staff may be felt in a loss of the Trust’s reputation, the loss of business or adverse media coverage.

16.0 POLICY DEVELOPMENT

This Policy was developed in consultation with the Trust’s Internal Auditors and Local Counter Fraud Specialist Baker Tilly Risk Advisory Services LLP,, the Policy Sub-Group of the Joint Staff Committee and with the involvement of the Audit Committee members. Drafts have been circulated to the Trust Executive Committee for comment prior to presentation to the Trust Board for approval.

17.0 DISTRIBUTION

A copy of the Policy will be put on the Trust’s intranet for staff to view and awareness will be raised by highlighting the document at Team briefing, in the Trust’s on-line electronic newsletter, Vital Link, and as an article in the in-house magazine, Vital Signs.

All new members of staff will be made aware of their responsibilities to this document as part of the recruitment policy.

18.0 AUDIT AND REVIEW PLAN

Declarations of interest of Committee members are to be included on the Agenda of each meeting – TB, AC, FIC, Q&SC, TEC and Workforce. In addition the opportunity to declare an interest relating to any specific agenda item is provided at the beginning of each meeting. In addition the full register of Interests will be submitted to the Audit Committee for scrutiny at least annually. Internal Auditors will be requested to review the policy within 2 years of it implementation. Any breaches or issues of concern regarding implementation will be monitored by the Conflict of Interest Panel and referred to Internal Audit or Counter Fraud as necessary.

19.0 ASSOCIATED TRUST POLICIES/DOCUMENTS

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Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions

Anti-Fraud & Bribery Policy Gifts, Hospitality, Sponsorship, Inducements and Rewards Policy Disciplinary Policy & Procedure Speaking Up for a Healthy Trust (Whistle-blowing Policy) Confidentiality & Disclosure Policy Equal Opportunities and Diversity Policy

All of the above are available on the Trust’s Intr@net or on request from the Human Resources Department

20.0 REFERENCES

Seven Principles of Public Life, Nolan Committee First Report on Standards in Public Life, (May 1995).

Commissioning a Patient Led NHS, Department of Health (July 2006) Freedom of Information Act (2000) Code of Conduct for NHS Managers (2002) Bribery Act 2010

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APPENDIX A

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DECLARATION OF INTERESTS I would like to declare the following outside interests and/or material financial transactions (give value of transaction where appropriate):

Directorships or significant

shareholdings Other Interests declared

Value of Transactions

(£ per annum)

Date interest commenced or ceased if during year ended 31 March 2014

1.

2.

3.

4.

Please continue overleaf I have no interests to declare I have no transactions to declare (tick box if this applies) (tick box if this applies) Signed: .............................................. Print Name: ……………………………….. Job Title: ……………………………… Date completed: …………………………….. I declare to the best of my knowledge, I am unaware of any circumstances in which any of the transactions, relationships or roles above could be construed as a conflict of interest or breach of fidelity as set out in the Policy and that any such situation will be brought to the immediate prior attention of the Trust in future transactions relationships or roles in which I am involved or otherwise aware.

I can also confirm that none of the transactions, relationships or roles above involve my disclosure of any information of a confidential nature concerning patients, employees, contractors or the confidential business of the Trust.

I understand that I am responsible for ensuring that the provision of any Private Professional Services and Fee Paying Services for other organisations does not result in detriment of NHS patients or services or diminish the public resources that are available for the NHS.

I further declare that I will immediately inform the Trust of any changes in my circumstances which may affect this declaration. I confirm that the information contained within this declaration is correct to the best of my knowledge. I understand that providing false or incomplete information may result in disciplinary or criminal investigation being taken against me.

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APPENDIX A

Barking, Havering & Redbridge University Hospitals NHS Trust Page 17 of 20 Business Conduct Standards Policy 2008/HR/42 (Version 3.0-September 2014)

DECLARATION OF INTERESTS continued I would like to declare the following outside interests and/or material financial transactions (give value of transaction where appropriate):

5.

6.

7.

8.

9.

10.

I confirm that the information contained within this declaration is correct to the best of my knowledge. I understand that providing false or incomplete information may result in disciplinary or criminal investigation being taken against me.

Signed: .............................................. Print Name: ……………………………….. Job Title: ……………………………… Date completed: ……………………………..

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APPENDIX A

Barking, Havering & Redbridge University Hospitals NHS Trust Page 18 of 20 Business Conduct Standards Policy 2008/HR/42 (Version 3.0-September 2014)

Extract from Trust Standing Orders detailing interests that should be declared. 8.1.2 Interests which are relevant and material

(i) Interests which should be regarded as "relevant and material" are:

a) Directorships, including Non-Executive Directorships held in

private companies or PLCs (with the exception of those of dormant companies);

b) Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS;

c) Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS;

d) A position of Authority in a charity or voluntary organisation in the field of health and social care;

e) Any connection with a voluntary or other organisation contracting for NHS services;

f) Research funding/grants that may be received by an individuals or their department;

g) Interests in pooled funds that are under separate management.

(ii) Any member of the Trust Board who comes to know that the Trust has entered

into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in Standing Order 8.3 …) has any pecuniary interest, direct or indirect, the Board member shall declare his/her interest by giving notice in writing of such fact to the Trust as soon as practicable.

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HOW A MEMBER OF STAFF SHOULD REGISTER AN INTEREST

Barking, Havering & Redbridge University Hospitals NHS Trust Page 19 of 20 Business Conduct Standards Policy 2008/HR/42 (Version 3.0-September 2014)

See over for Panel membership and definitions

Individual Joins the Trust

Individual acquires an interest.

Individual Annual Declaration

Declaration form is completed by the

individual and passed to Trust

Secretary for inclusion on Register.

Trust Secretary decides there

could be a conflict.

Trust Secretary decides there is no conflict of interest and there is no relevance to the Trust.

Trust Secretary liaises with a member

of the Conflict of Interest Panel

and they decide there could be a conflict of interest.

Trust Secretary liaises with a member of the Conflict of Interest Panel and there is no conflict of interest.

Conflict of Interest Review Panel meets to agree

Action agreed and acted upon.

Individual informed.Individual appeals

against Panel decision.

Interest Registered and a copy is sent to Line Manager and Human Resources for

Personal File. Action agreed and acted upon.

Individual informed.

Appeal Panel meets to consider appeal

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Panel Membership and DefinitionsPanel Membership and Definitions

Conflict of Interest Review Panel Membership: Director of People and Organisational Development Director of Planning and Governance Director of Finance & Investment

Chief Operating Officer

Appeal Panel Membership:

Chief Executive or Deputy Chief Executive Non Executive Director Medical Director or Chief Nurse

Attendance: Individual Friend/ representative Manager of Relevant Area

“Line Manager” is the individual who is responsible for managing the individual’s work – usually the appropriate General Manager, Clinical Director, Senior Nurse or Directorate Manager.

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eptember 2014)

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