trust board papers - isle of wight primary care trust september 2017.pdf · meeting in public on...

Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public (Part 1)

to be held on

Wednesday 6th September 2017

at

9.00am - Conference Room, School of Health

Sciences (South Hospital)

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

Staff and members of the public are welcome

to attend the meeting.

*Excellent patient care

Our vision and goals guide us; our values underpin everything we do

Quality care for everyone, every time

Our Values

*Work with others to keep improving

our services

*A positive experience for

patients, service users and staff

*Skilled and capable staff

*Cost effective, sustainable services

Improve mortality rate Prevent avoidable

harm *Improve care of: - older people - people with

dementia - children and

young people Implementation and monitoring the effectiveness of the sepsis care bundle

*Create and maintain partnerships with other organisations so that we can deliver excellent care *Develop an

integrated IT infrastructure *Develop 24/7 and 7

day services *Improve communication with patients and carers

*Improve what people think of their care *Improve how staff

feel about work *Provide Excellent

End of Life Care

*Improve the culture of the organisation to improve patient experience

All staff continue to develop All staff understand

how their contribution helps to achieve our Vision *Develop our

workforce to embrace integration and co-production

*Improve the Discharging Planning Process

* Design services to deliver best practice within our resources * Ensure value for

money for each service * Develop efficient

and effective processes with minimal waste

Reduce Incidence of Patient Harm

Goa

ls

Prio

ritie

s

QI QI QI QI QI

Working “Beyond Boundaries” to be the preferred choice for sustainable integrated care

*Starred items have direct links to

http://intranet/uploads/General/Graphics/Isle%20of%20Wight%20NHS%20TrustCOL.jpg

Emergency Generator

PondME

DIN

A W

AY

El Sub Sta

15.2m

Drain

Chy

8 to 11

34

Gas

Gate

45

1

6

Upper St Cross Farm

48a

27

Radio Station

36

23

2

4 to 8

22

Governor

Medina

El Sub Sta

Medical Gas Store

wall

Refuse

Medical Vacuum Plant Room

Refuse Store

El Sub Sta

Shelter

PCs

Pond

LB

Pond

13.1m

DODNOR LANE

DAISH

WAY

Sub Sta

El Sub Sta

El Sub Sta

El

Dodnor Park

12

3

29

48

25

12

16

Margham House

Almond

6

Cherry

1

31

5

32

2

52

50

46

Gate

4

15

60

13

14

9

14.9m

Solent

Sub Sta

El

Sevenacres

09

Sub-Station "A".

11

Bund

06

18

Electrical Main Intake

16

07

14

19

10

06 0604

40

35

23

20

04

43

49

44

31

39

33

2146

24

47

2625

52

01

28

3032

37

32

TENNISCOURT

5

NO

.

DI

AL

YS

IS

38

(UNDER SIZE)

(OVER SIZE)

22

10

20

29

09

12

20

20

02

08

10

17

53

35

15

1305

06

43

41

5150

36

20

3427

30

3248

DOCTORON CALL

CHEMO

WAITINGONLY AND

DR

OP

OFF

POIN

T

NO

EXI

T

DROP OFFONLY

PAREN

T & CH

ILD

KEEP

M/C

CLEAR

DROP OFF

KEEPCLEAR

15

18.37

S1

TARMACPAVINGSLABS

PAVINGSLABS

SMALL TREES & BUSHES IN THIS AREA

SMALL TREES & BUSHES IN THIS AREA

ramp

S4 18.954

GRASS

GRASS

GRASS

TREE STUMPS

GRASS

CAR PARK

GRASS

Sedum / Grass

FIRE

AP

PLIA

NC

E K

EE

P A

RE

A C

LEA

R

FIR

E A

PP

LIA

NC

E K

EE

P A

RE

A C

LEA

R

FIRE

AP

PLIA

NC

EK

EE

P A

RE

A C

LEA

R

GRASS

03 path

Block Numbers

01 AMBULANCE STATION02 SOCIAL CLUB03 HELI PAD04 AMBULANCE HQ, RESEARCH DEPT.

05 MAIN BOILERHOUSE06 MAIN SOUTH HOSPITAL BUILDING07 WHEELCHAIR SERVICES08 LAIDLAW DAY UNIT09 ALMONDGATE/CHERRYGATE10 PODIATRY/ORTHOTICS/SPEECH THERAPY11 ALLERGY RESEARCH CENTRE12 HOLLY HOUSE13 DIABETIC CENTRE14 BREAST SCREENING UNIT15 BREAST CARE UNIT16 SCHOOL OF NURSING17 THE COTTAGE18 VECTASEARCH UNIT19 SOUTH PUBLIC WC's/GENERATOR20 MAIN HOSPITAL21 HV ELECTRICAL INTAKE22 MOTTISTONE BLOCK23 B BLOCK24 PHYSIO/MANAGEMENT BLOCK25 A BLOCK26 MFU/ORTHODONTICS27 DAY PROCEDURES UNIT28 MATERNITY29 LINEN SERVICES/MORTUARY30 SEXUAL HEALTH SERVICE

31 MED. RECS./TEL. EXCH./PRINTROOM32 NEWCROFT BLOCK33 FINANCE AND INFORMATION34 MARGHAM HOUSE35 EDUCATION CENTRE36 WESTERN HOUSE37 NORTH BLOCK GENERATOR38 ESTATES BLOCK39 SEVENACRES40 PORTACABIN41 PRE-OPP ASSESSMENT42 LINK CORRIDORS NORTH43 ENT/AUDIOLOGY BLOCK44 NORTH X-RAY45 NORTH BLOCK OUTBUILDINGS46 STORES GENERATOR47 C BLOCK48 YMCA DAY NURSERY 49 RENAL DIALYSIS UNIT50 SOLENT51 MEDINA52 EBME DEPARTMENT53 H.S.D.U.

And Buildings List

& IT DEPARTMENT / SERVER ROOM

& TRANSPORT

ByItemDateRev

Revisions

Project Title

Drawing Title

Scale Date Drawn

Level.Site No. Block. Project No.

ESTATES MANAGEMENT DEPARTMENTSt Mary's Hospital NHS TrustNewport, Isle of Wight,PO30 5TGTel: (01983) 534256Fax:(01983)525157

ALL201

06/10/2014Not to Scale @A1

Site Plan

Isle of WightSt Mary's Hospital

? ? ? ?

Conference Room in the School of Health Science Building - Building No 16

Meeting in public on 6th

September 2017 Isle of Wight NHS Trust Board – Page 1

The next meeting in public of the Isle of Wight NHS Trust Board will be held on Wednesday 6

th September 2017

commencing at 9.00am in the Conference Room, School of Health Science, St Mary’s Hospital, Newport, IW PO30 5TG Staff and members of the public are welcome to attend the meeting. Staff and members of the public are asked to send their questions in advance to [email protected] to ensure that as comprehensive a reply as possible can be given.

AGENDA

Indicative Timing

No. Item Who Purpose Enc, Pres or Verbal

This meeting will be recorded for the purposes of assisting in preparing the minutes and actions from the meeting.

09:00 1 Apologies for Absence, Declarations of Interest and Confirmation that meeting is Quorate

1.1 Apologies for Absence: Frank Sims, Deputy Chief Executive Barbara Stuttle, Board Advisor - Nursing Jon Burwell, Executive Director of Strategy & Planning Chris Palmer, Executive Director of Financial & Human Resources

Chair Receive Verbal

1.2 Confirmation that meeting is Quorate No business shall be transacted at a meeting of the Board of Directors unless one-third of the whole number is present including: The Chairman; one Executive Director; and two Non-Executive Directors.

Chair Receive Verbal

1.3 Declarations of Interest Chair Receive Verbal

2 Staff Awards

2.1 Employee Recognition of Achievement Awards ICEO Receive Pres

3 Minutes of Previous Meetings

3.1 To approve the minutes from the meeting of the Isle of Wight NHS Trust Board held on 5th July 2017

Chair Approve Enc A

3.2 Review Schedule of Actions Chair Receive Enc B

4 Chairman’s Update

4.1 The Chairman will make a statement about recent activity Chair Receive Verbal

5 Chief Executive’s Update

5.1 The Interim Chief Executive will make a statement on recent local, regional and national activity.

ICEO Receive Enc C

6 PRINCIPAL RISK 674 – QUALITY and PRINCIPAL ISSUE 1085, CQC SECTION 31 WARNING NOTICE

6.1 Safer Staffing Monthly Review ADNQ Receive Enc D

6.2 Serious Incidents Requiring Investigation (SIRI) Report ADNQ Receive Enc E

6.3 Learning from Deaths; A framework for identifying, reporting, investigating and learning from deaths in care

EMD Receive Enc F

6.4 CQC Inspection Update ICEO Receive Enc G

6.5 Shackleton Ward & Older Peoples Health Improvements Update

DMH Approve Enc H

mailto:[email protected]



7 PRINCIPAL RISK 673 - STRATEGY

7.1 Integrated Improvement Framework Programme Board Report ICEO Receive Enc I

7.2 Quality Improvement Plan Highlight Report ADNQ Receive Enc J

7.3 Report on Progress of NHSI Undertakings ICEO Receive Enc K

8 PRINCIPAL RISK 712 - FINANCE & PRINCIPAL RISK 671 - WORKFORCE

8.1 Performance Report COO Receive Enc L

8.2 Chief Operating Officers Report COO Receive Enc M

8.3 Financial Plan 2017/18 ITCFO Approve Enc N

9 Top Key Issues & Risks arising from Sub Committees for raising at Trust Board. Minutes Included: Quality Governance Committee - 25 July 17 Finance, Investment, Information & Workforce Committee - 25 July 17 ICT Assurance Committee - 21 July 17

Receive Enc O

10 Issues to be covered in private. Chair Receive

11 Questions from the Public Chair Receive

12 Issues to be covered in private.

The meeting may need to move into private session to discuss issues which are considered to be ‘commercial in confidence’ or business relating to issues concerning individual people (staff or patients). On this occasion the Chairman will ask the Board to resolve: 'That representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', Section 1(2), Public Bodies (Admission to Meetings) Act l960.

The items which will be discussed and considered for approval in private due to their confidential nature are:

Carnall Farrar Leadership Review Outcome

Integrated Dermatology Sub Contract - Commercial in Confidence

Business Case - Phase 1 - Sevenacres Ligature Work - Commercial in Confidence

13:00 13 Date of Next Meeting

The next meeting of the Isle of Wight NHS Trust Board to be held in public is on Wednesday 4th October 2017 in the Conference Room - School of Health Science Building, St Mary's Hospital, Newport, IW PO30 5TG



PRINCIPAL RISKS & ISSUES Risk 671, Human Resources: If the Trust is unable to attract, recruit and retain sufficient staff of the right quality and skillset then it will be unable to meet demand

Risk 676, ICT Strategy: If the Trust is unable to deliver against the ICT Strategy, then there will be a negative impact on quality, Income, Performance, Information Governance Compliance and Staff morale

Risk 673, Strategy and Planning: If our Trust Strategy is not robust and embedded then staff will be unable to create effective service plans.

Risk 677, Local Health and Social Care Economy Resilience: If there is insufficient resilience in the local health and social care economy then we will be unable to deliver safe effective and financially viable care.

Risk 674, Quality Governance: If the Trusts quality governance processes are not robust and embedded then the Trust may not be able to maintain adequate patient safety, patient experience and clinical effectiveness.

Risk 705, Board Capacity and Capability: If there is not sufficient capacity and capability within the Executive and Non Executive Team, then the Trust will not be able to achieve its strategic ambitions.

Risk 675, Culture: If the Trusts culture does not reflect our core values then we will be unable to deliver our vision, goals and priorities.

Risk 712, Financial Resources: If the Trust is unable to manage within the revenue and capital financial resources it receives then it may become financially unsustainable in 16/17 and in future years.

Issue 1085, CQC Section 31 Warning Notice: The CQC have served the Trust with an warning notice of decision to impose conditions on our registration as a service provider in respect of a regulated activity in relation to the Mental Health and Learning Disabilities CBU, under Section 31 of the Health and Social Care Act 2008. They have also issues the Trust with a regulation 17.

IOW NHS Trust Board Meeting Pt 1 5th July 2017 1

Minutes of the meeting in Public of the Isle of Wight NHS Trust Board held at 9.00am on Wednesday 5th July 2017 in the Conference Room, School of Health Science, St Mary’s Hospital, Newport, IW PO30 5TG

PRESENT: Eve Richardson Chair Jessamy Baird Non-Executive Director David King Non-Executive Director Charles Rogers Non-Executive Director Vaughan Thomas Non-Executive Director Maggie Oldham Interim Chief Executive Gary Edgson Deputy Director of Finance (deputising for Executive

Director of Financial &Human Resources) Sarah Johnston Deputy Director of Nursing (deputising for Executive

Director of Nursing & Quality) Mark Pugh Executive Medical Director Shaun Stacey Chief Operating Officer In Attendance: Jon Burwell Executive Director of Strategy & Planning Kevin Bond Interim Director of Mental Health Dr Barbara Stuttle CBE Board Advisor – Nursing Julie Pennycook Board Advisor – HR & OD Andy Hollebon Head of Communication & Engagement Observers: Chris Orchin Chair of Healthwatch Mike Carr Patient Council Representative Hannah Farrar Carnall Farrar Melissa Egle Carnall Farrar Minuted by: Lynn Cave Board Governance Officer

Members of Staff and Public in attendance:

There were nine staff members and sponsors attending for the Employee Awards. There was two member of the public present. A representative from the IW County Press also attended

Minute No. 17/T/093 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND

CONFIRMATION THAT THE MEETING IS QUORATE Apologies for absence were received from Alan Sheward, Executive Director of

Nursing & Quality; Nina Moorman. Non-Executive Director and Chris Palmer. Executive Director of Financial & Human Resources. The Chair announced that the meeting was quorate. Declarations of Interest were received from Charles Rogers, Non-Executive Director as a Director of Wightlife Partnership The Chair welcomed Kevin Bond who is joining the Trust as Interim Director of Mental Health. She also welcomed the representatives from Healthwatch and the Patient Council. The Chair advised that Hannah Farrar and Melissa Egle from Carnall Farrar would also be observing the meeting and welcomed them also.

Staff Awards 17/T/094 EMPLOYEE RECOGNITION OF ACHIEVEMENT AWARDS The Interim Chief Executive presented the Employee Recognition of Achievement

Awards. This month the nominations were as follows: Category 1 – Quality Care & Innovation

• Lynn Salmon – Advanced Care Practitioner • Anne-Marie Phillips – Practice Educator

The Interim Chief Executive congratulated them both on their achievements.

Enc A


17/T/095 EMPLOYEE OF THE MONTH AWARD Employee of the Month – April 2017

• Helen Taylor, Staff Nurse, Coronary Care Unit Employee of the Month – June 2017

• Felicity Young, Consultant Nurse, Sexual Health Service

The Interim Chief Executive congratulated them both on receiving their awards.

17/T/096 MINUTES OF PREVIOUS MEETING Minutes of the meetings of the Isle of Wight NHS Trust Board held on 7th June 2017

were reviewed and approved. The Isle of Wight NHS Trust Board approved the minutes of the 7th June 2017.

17/T/097 REVIEW OF SCHEDULE OF ACTIONS The Board received the schedule of actions with the following updates:

a) TB/232 – Discharge Arrangements: It was confirmed that this would be

included in the Board Seminar in July as part of the wider Patient Flow Update. This action is now closed.

b) TB-246 – Revised Board Committee Structure: It was confirmed that this would be discussed at the Remuneration & Nominations Committee later in the day.

17/T/098 CHAIR’S UPDATE The Chair presented her update. Following the elections there have been changes

within the Local Authority and she confirmed that together with the Interim Chief Executive, she would be discussing how the organisations will work closely together to bring about agreed improvements. She also confirmed that a meeting was being arranged for the Interim Chief Executive and herself to meet with the new MP, Bob Seely to foster a close working relationship. The Chair advised that she had pleasure in formally opening the new Trust Print Room building which is situated on Dodnor Lane. She highlighted that the team, in addition to the Trust work, undertook a wide range of printing services for other organisations on the Isle of Wight. She advised that this was an excellent income generation activity and advised that Board should visit the unit to view the state of the art equipment and view the wide range of work the team can produce. The Isle of Wight NHS Trust Board received the Chair’s Update

17/T/099 INTERIM CHIEF EXECUTIVE’S UPDATE The Interim Chief Executive presented the report and highlighted the following:

a) Grenfell Tower Fire and cladding on NHS buildings: Following the tragic

events at Grenfell Tower and the instruction to the NHS to review fire safety, the Trust is working with the IW Fire & Rescue Service to review property owned by Isle of Wight NHS Trust including St. Mary’s Hospital. She reported that currently there are no alerts raised and further reviews will take place as part of an ongoing process. The Executive Director of Strategy & Planning highlighted that the Trust has a long standing relationship with the IW Fire & Rescue Service and that following a meeting last week they have confirmed that the Trust has robust fire practices in place and that there are no further plans for testing at this time.

b) Urgent Care Service: The Interim Chief Executive confirmed following consultation and a decision by the Clinical Commissioning Group with effect from 3rd July there will be no GP presence in the Urgent Care Service on


weekdays between 8:00am and 6:30p.m. This means that patients wishing to see a GP during those times need to visit their local GP surgery. The Trust will be monitoring the effects of this decision on our services as an increase in attendance is anticipated as the summer progresses.

c) Heatwave: The Trust has implemented the Heatwave policy during the last heatwave period and with the predicted heatwave due to return is promoting the public health message to encourage people to take precautions, stay hydrated and avoid midday sun.

d) Patient Safety Awards 2017: The Interim Chief Executive confirmed that both the Serenity Integrated Mentoring (SIM) service (a partnership between Hampshire Constabulary, Isle of Wight NHS Trust and Wessex Academic Health Science Network),and our work with Bruin Biometrics (BBI) using their SEM Scanner for the early detection of pressure ulcers have won awards in the Patient Safety Awards held on 4 July 2017.

e) NHS 69: The Interim Chief Executive advised that an anniversary event had taken place at the Quay Arts Centre on Tuesday 4 July 2017 which had been well attended.

f) Appointments: The Interim Chief Executive advised that Mark Price, Company Secretary had left the Trust after 20 years service. She thanked him for all his work over the years and wished him well for his future endeavours.

The Isle of Wight NHS Trust Board received the Interim Chief Executive’s Update

Principal Risk 674 - Quality 17/T/100 QUALITY GOVERNANCE COMMITTEE UPDATE The Executive Medical Director presented a verbal update from the Quality

Governance Committee in the absence of the Chair. He advised that this was the first time the Quality Improvement Plan had been presented and that following discussion a number of aspects of the report had been highlighted for further work which is currently being undertaken, and will be presented to the next Board meeting. The Executive Medical Director highlighted the top issues raised by the Committee: a) Speech & Language Therapy Building: The Executive Director of Strategy &

Planning is maturing a plan for the relocation of clinical services from this area and would be bringing the plan to the Committee once completed.

b) Quality Improvement Plan: A number of issues had been highlighted and the Committee had not felt assured and had requested more detail be provided.

c) Infection Prevention Control Annual Report 2016/17: The Committee did not feel that enough detail was provided and had requested that this report be brought back to the next meeting.

d) Annual Nutrition Report 2016/17: The Committee was pleased to see the excellent work taking place and that more work would be undertaken with the CBU’s in the coming year to ensure a robust provision of the service.

e) Internal Audit reports – End of Life Care and Medicine Management: These were reviewed and the Committee was updated on the positive work being undertaken with the Earl Mountbatten Hospice in relation to end of life care and it received positive assurance that all actions in relation to medicine management were completed.

f) Jessamy Baird advised that she would be linking with Nina Moorman and they would discuss future reporting with the Chair and Interim Chief Executive.

Action: Amended QGC Report inc Quality Improvement Plan update would be presented to the September Board.


Action by: EMD/JB The Isle of Wight NHS Trust Board received the Quality Governance Committee Update

17/T/101 SAFER STAFFING MONTHLY REPORT The Deputy Director of Nursing presented the report and advised that although data

for last month had improved there were still some areas which were showing as red. She reported that agency and bank requests had been filled but levels of short term sickness and substantive post vacancies continued to put pressure on usage. She outlined that many wards were using 12 hour shifts instead of two 7.5 hour shifts a day and although this did not affect patient care it did reflect in the data as a shortfall of 3 hours per shift which contributed to the overall picture. It also restricted staff from being able to be released for mandatory training and this was being reviewed with the education team to develop a more resilient approach. The Deputy Director of Nursing also advised that teams are being supported to enable mandatory training to be completed as well as ensuring competencies are up to date. She confirmed that meetings were taking place with ward managers on Appley Ward and MAU to ensure that they have support to manage their areas effectively, and in addition any hot spots identified for pressure ulcers were being supported and would be part of a cluster review. The Deputy Director of Nursing confirmed that the acuity and dependency review had been completed and the report would be seen at Board in September where areas which have remaining issues will be highlighted. She confirmed that the Safe Care ‘cloud’ would be in place by 11 July and project management support for the roll out and training was being finalised. The Board Advisor – Nursing advised that she would be meeting with each ward to review their templates to ensure that reporting was robust and this would include a review of the use of 12 hour shifts to ensure that training is rostered in. She confirmed she would be looking at how training is provided and delivered. Vaughan Thomas advised that he was aware of all the work being done but highlighted the difference between reassurance and assurance and stated that he felt that the report did not provide positive assurance. He noted that a number of areas showed reassurance and asked that the report be reviewed and that evidence based assurance be provided. David King accepted that work was taking place to increase mandatory training levels but questioned why the levels were not showing an increase in the report. The Board Advisor – Nursing advised that nursing staff are reporting that they under high pressure and she has met with the Chief Operating Officer to address this. She stated that there needs to be clear lines of accountability and responsibility to undertake this training as they are unable to professionally revalidate unless they are fully compliant, and that her work with the education team aimed to address this. The Interim Chief Executive advised that Mandatory Training was included within the IIF1 and that progress against trajectory would be shown over the coming months as the projects progress. Charles Rogers queried why the establishment levels had reduced over the previous months despite recruitment and questioned what the forward plan was for this. The Deputy Director of Finance advised that the numbers related to a number of staff who had been TUPE’d over to the Earl Mountbatten Hospice. Jessamy Baird queried if safe staffing was being operated how did this link to wider clinical issues. She highlighted that she was not seeing links to recent SIRIs and

1 Integrated Improvement Framework


what actions were being taken and by when. The Deputy Director of Nursing advised that the report was being reviewed and that incidents including those raised due to low staffing were being reviewed by the Associate Medical Director for Quality Governance. She also confirmed that links would be included as well as defined actions with due dates in the revised report. David King questioned what was being done in relation to retention and recruitment of nurses. The Board Advisor – Nursing advised that nursing faced national issues and disillusionment with the profession and work needed to take place to make it more attractive. Ways of using volunteers, housekeepers and healthcare assistants in more creative ways, understanding what the ward needs in terms of support, Also providing positive work experience for apprentices and using staff coming up for retirement as their mentors would be a positive way of encouraging them to go into nursing. She also stated that the authority of the ward managers needed to increase so that they are able to manage their wards effectively. The Executive Medical Director highlighted that it was not just a national nursing shortage but that this affected medical, allied health professionals, community services and mental health staff also, and therefore a wider scope was needed to resolve this issue. The Board Advisor for HR&OD advised that a review was taking place for the workforce strategy as there was a need for improved workforce planning, and that retention and recruitment planning was included within the IIF with PIDs2 working on the report matrix so that this will be clearly reported. The Interim Chief Executive advised that papers needed greater correlation with the IIF and requested that this be included within future reports. She also asked that an update on the pressure ulcer situation be reported at the next Seminar. Action: The Deputy Director of Nursing to undertake a review of the report and present the revised report to the next FIIWC and Board. Report to include links to incidents, defined actions and due dates and that it clearly correlates with the IIF.

Action by: DDN Action: The Deputy Director of Nursing to provide an update on the pressure ulcer situation at Seminar in July.

Action by: DDN The Isle of Wight NHS Trust Board received the Safer Staffing Monthly Report

17/T/102 REPORTS FROM SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRIS) The Deputy Director of Nursing presented the report and advised that there were 10

SIRI’s reported to the Isle of Wight Clinical Commissioning Group (CCG) during May. She advised that this was an unusually high number of SIRI’s and reflects the attention to scrutiny of incidents at this time. Ambulance Urgent Care and Community have instigated 7 of the SIRI’s and these are spread over the 3 speciality areas. She confirmed that there were 33 investigations open and that the IW CCG had closed 7 SIRI cases. The Deputy Director of Nursing confirmed that recruitment for more investigating officers is underway to support the process and to conclude investigation on track. David King queried if there was a diabetic foot ulcer policy. The Deputy Director of Nursing advised that measures were in place and that competencies are being done. The Board Advisor – Nursing stressed that staff needed to be aware that actions have consequences and that professional standards need to be maintained. The Chair reminded the Board that the Trust has an award winning Diabetic service and suggested that they provide assistance with training. The Interim Chief Executive questioned if there was a correlation between temporary staff and incidents. The Deputy Director of Nursing advised that this was a factor but that although they have access to processes these may differ from Trust to Trust and it was important that they are made aware of our processes.

2 Performance Information & Decision Support


Vaughan Thomas expressed concern that the increase in numbers was down to staff looking harder at incidents and questioned if the same criteria was being applied. The Deputy Director of Nursing confirmed that there were national criteria and that this was agreed with CCG. She advised that there were cases which are not clinical which are included within the numbers and that following discussions with the CCG and NHSI it was concluded that they should be included for good learning. Vaughan Thomas queried if there was anything the Board needed to know in relation to the unexpected deaths shown in the report. Jessamy Baird advised that the Quality Governance Committee is responsible for reviewing these cases and providing assurance to the Board and that the report should not be a stand-alone document; it needed to be linked to the IIF. She stressed the need for lessons learnt to be embedded and that this needed to be audited and evidence based assurance provided. The Interim Chief Executive acknowledged that the SIRIs are measured by national criteria but that this was not open to local interpretation – a SIRI is a SIRI. She confirmed that as part of the governance review this would be clarified. The Isle of Wight NHS Trust Board received the Serious Incidents Requiring Investigation (SIRIs) Report.

17/T/103 REPORT ON PROGRESS OF NHSI UNDERTAKINGS The Interim Chief Executive presented the report and advised that she would be

asking at the next oversight meeting how we report on the undertakings. However, in this Trust as we know from the CQC, we have introduced our own way of reporting issues and risks. The Chief Operating Officer advised that it had been agreed that the CQC report submission date had been changed from 1st of month to 10th of month to allow the report to be seen by the Board before submission. The Isle of Wight NHS Trust Board received the report on the Progress of NHSI Undertakings

Principal Issue – Section 31 CQC Letter 17/T/104 WOODLANDS LEASE The Executive Director of Strategy & Planning presented the report and advised that

the current lease for the Woodlands building was due to expire in February 2018 and confirmed that the paper recommends that the Board approve the renewal of the lease for a further 3 years with an annual break clause in August. He confirmed that the Trust Leadership Committee had approved this paper but under its Scheme of Delegation the Board is requested to “ratify proposals for the acquisition, disposal or change of use of land and/or buildings”. The Executive Director of Strategy & Planning outlined that the rehabilitation facility at Woodlands and its future is currently under review by the Mental Health Reconfiguration Planning meeting led by the Clinical Commissioning Group. He advised that there had been no clear agreement as to the next steps but the general consensus of the group is to recommission a non-medical model reablement facility. He confirmed that the CCG had yet to develop the model fully and the new provision will not be ready for patients before the current lease expires at Woodlands and if the lease is not extended, there is a high risk that patients will need to be relocated to the mainland for appropriate rehabilitation and this would have a negative impact on both patients and their families. Vaughan Thomas questioned if there was any provision for dilapidation costs included within the accounts. Action: The Deputy Director of Finance to review the provision for dilapidation costs in relation to leasehold buildings and in particular Woodlands.

Action by: DDF


Jessamy Baird stressed the need to get the staffing level issues resolved and the associated risk it entailed. The Chief Operating Officer provided an update on the staffing at Woodlands and confirmed that measures were in place to ensure appropriate staffing and that this was being monitored by the matron. He also stressed that the paper today was only in relation to the building and in no way affected the service or staff. The Isle of Wight NHS Trust Board approved the renewal of the Woodlands Lease

Principal Risk 673 - Strategy 17/T/105 INTEGRATED IMPROVEMENT FRAMEWORK (IIF) PROGRAMME REPORT Vaughan Thomas as Chair of the Integrated Improvement Framework Programme

Board advised that progress was being achieved with a large percentage of the actions being Amber and on plan. He confirmed that some further discussion would be needed in some cases to ensure that the forward dates are correct. He advised that 100s of people are working on producing the evidence and monitoring progress and this is reflected in the report. Vaughan Thomas stressed the importance of the Critical Path and how important the dates are to ensure things happen. He advised that work was being undertaken to ensure that this is not affected. The Interim Chief Executive confirmed that lots of meetings were taking place behind the report and as progress is made stress testing will take place by auditors. The Chair stressed the important role communications and engagement play as the staff need to own the IIF to make it real and they need to know how their role links into the wider plan. The Chief Operating Officer confirmed that the CQC actions had been grouped in detail to ensure actions are met and this is also included within the report. The Isle of Wight NHS Trust Board received the Integrated Improvement Framework Programme Report

Principal Risk 712 – Finance & Principal Risk 671 – Workforce 17/T/106 FINANCE, INVESTMENT, INFORMATION & WORKFORCE COMMITTEE CHAIR

REPORT Vaughan Thomas presented the report and advised that overall the Committee had

negative assurance and highlighted the following: Finance: • Financial position: This is running ahead of budget which appears good, but

the reality of a £2m per month deficit is that there will need to be a material improvement in later months in order to achieve the £18.8m target deficit for the year. The £18.8m relies on an underlying cost improvement programme of £8m. There are now plans that the executive believes are deliverable for £5m of Cost improvements but over £3m of improvements still need to be identified. Because these costs have not yet been completely identified, and agreed with CBU leads, the budget has not yet been cascaded into the CBU’s. The net of this is that CBU leads are operating without a budget that matches the Board approved deficit that has been submitted to NHSI.

• Cash position: At the last Board meeting authority was delegated to the Executive Director Financial & Human Resources to agree revenue support loans with NHSI. During 2016/17 £14m was approved by NHSI. This was at a rate of roughly £1.2m per month. So far in the financial year 2017/18 (3 months) the loan has already been drawn to £4.4m running at £1.4m per month. Looking forward however, the Trust is also using cash in other ways. Debtors (money


owed to the Trust) have increased by £1.8m in month, and Creditors (money owed by the Trust to suppliers) have reduced by £1.1m in month. The impact of this is that the Trust has increased its need for borrowings by £2.9m in month because of the way basic working capital is being managed.

• This has been partly offset by the Trust not yet having to pay for capital programmes that have been approved.

• Contractual Arrangements: The main contract with the CCG includes a need to deliver QIPP3 savings of £6.4m in year. The CCG has informed the Trust that it does not yet have in place identified programmes that will result in these quality Improvement initiatives. However, the revenues have already been withdrawn from the contract. The FIIWC was clear that the implied £533k per month revenue reduction could not be accepted by the Trust until agreed programmes were in place. The implication of this is that even if fortuitously the activity anticipated had reduced, there was no basis on which this could be attributed to CCG/Trust agreed QIPP programmes. As such the CCG would need to re-imburse the Trust for the 3 months so far i.e. £1.599m. Executive Director Financial & Human Resources & Interim Chief Executive agreed to formally notify the CCG of the position on behalf of the Board.

Workforce:

• Sickness rates have deteriorated. The overall cost of sickness in the 12 months to May17 was £3.7m, and was £311k in month. Stress and anxiety is the biggest contributor, and the deep dive identified that much of this is non work related. Musculo-skeletal (back) problems have reduced but are still a significant driver. Colds, coughs, influenza and flu were also a factor having risen significantly in May.

• Recruits: A number of overseas recruits continue to repeatedly fail the OSCE4 examinations

• Mandatory training: Key areas continue to be significantly below target levels. The Board Advisor – HR&OD reported that assurance could not be given that in line with Board policy bank staff would not be used unless they had undertaken mandatory training. This is because basic processes are not yet in place to ensure compliance.

• Appraisal rates have fallen.

• E-Rostering: 94 departments failed to meet the roster approval.

• HR overpayments have been significantly reduced with a single incidence in May. This follows meetings with SBS5.

Workforce matters continue to show limited improvements, and some deterioration. Overall many of these issues (appraisals, mandatory training, sickness) are occurring in the same segments of the workforce i.e. ambulance, mental health, clinical support cancer diagnostic service, surgical women & child health and bank staff.

Estates: • Estate Annual Fire Safety report. A number of matters were raised, and

3 Quality, Innovation, Productivity and Prevention (QIPP) Commissioning 4 Objective Structured Clinical Examinations (OSCEs) 5 NHS Shared Business Services


Estates have already engaged the services of an independent estates advisor to comment on the report. Following the events at Grenfell tower the Committee enquired about St Mary’s external cladding and were re-assured it is not of the aluminium bonded materials, used in other buildings. In addition enquires about insulation, voids, were raised. These were all agreed to be included in the independent review and the visit by fire safety officers within the week. The report also highlighted the need for additional fire wardens, and improvements in mandatory training levels.

Jessamy Baird challenged the point that the QIPP & CQUIN6 measures had not been agreed and requested that this be verified. Action: The Deputy Director of Nursing to review when the QIPP agreements had been made for this financial year.

Action by: DDN Jessamy Baird also asked that for future reporting would it be possible for e-rostering data to be split into corporate and clinical care as they had very different impacts on the Trust and patient safety. Action: The Board Advisor – HR & OD to arrange for future e-rostering reporting to be split into corporate and clinical care areas.

Action by: BA-HR&OD The Isle of Wight NHS Trust Board received the report from the Finance, Investment, Information & Workforce Committee

17/T/107 PERFORMANCE REPORT The Chief Operating Officer presented the report and highlighted the following:

Highlights:

• Referral to Treatment Time (RTT) has continued above plan ending the month of May at 91.2% validated against a trajectory of 87.1%. RTT For June the Trust finished on target at 92.% un-validated

• No patients have waited over 12 hours in Accident & Emergency from decision to admit to admission in May.

• Mental Health - All patients have been placed on an Early Intervention in Psychosis (EIP) pathway within 2 weeks and above the national standard patients have completed their IAPT treatment and moved to recovery. 70% of patients who are known to community mental health services have had a risk assessment completed in the last 12 months which is an increase of 19% in the last 12 months.

• No new cases of Methicillin-resistant Staphylococcus Aureus (MRSA) within the Trust during May.

• No cancellations on the day of admission since April 2017. • No Grade 4 Pressure Ulcers since April 2017and overall performance on

Pressure Ulcers has a trend of reducing • No clinical incidents resulting in Major or Catastrophic harm and there has

been no significant injuries reported from Falls. • Sickness Absence for Medicine CBU is below the 3.5% target currently at

2.94% • Sickness absenteeism continues to be monitored and discussed at the

monthly leadership meeting despite the fact that the rate dropped below the 3.5% target in May.

• Paediatric nurse cover for ED has been 100% in May. However in June we have seen a challenge in providing cover with our default plan using Emergency Department nurses with Paediatric Immediate Life Support

6 Commissioning for Quality and Innovation (CQUIN)


(PILS) training being introduced • Stroke patients improved length of stay during May on the stroke ward

achieving 88% against 80% target • There were 19 formal complaints received in the Trust in May against 23 in

the previous months and 64 concerns against 78 in the previous month. All against 221 compliments that were received by the organisation. The Datixweb complaints module has commenced roll out and the Clinical Business Units in conjunction with the Complaints Team continue to work to improving timeliness and quality of complaint responses

• Theatre utilisation has increased from 77.7% to 83.8%, just above the local target of 83%.

• Day Surgery Unit (DSU) utilisation has increased slightly from 78.4% to 79.3%. DSU– below the target of 83%

• 5 new starters joined the trust in May, with a recruitment specialist joining the trust on 5th June

• 13 volunteers have been selected for the community first responder service. Positive reception to volunteers during volunteer week 1st to 7th June 2017 with 742 likes on Facebook

Lowlights:

• Ambulance: The Trust under-performed in May against the 3 national ambulance targets and the system-wide agreed trajectories;

o Red 1 slightly under-performed at 64.3% against trajectory of 67.4% (and 75% national target);

o Red 2 also slightly under-performed at 71.4% against trajectory of 74.7% (and 75% national target);

o 19 mins under performed at 91.8% against target of 95% and trajectory of 95.2%. This is also an IIF milestone. The team are also reviewing how the service can cope with high demands as reviewing the data the challenge in May was periods of peak demand on the service with resources delayed in the transfer of care and complicated by the high number of staff absence across the Trust (9.73%) against a 5.50% Standard.

o Emergency Care 4 Hour Standard - In May the Trust under-performed at 80.1% against the incomplete trajectory of 89.2% due to ongoing system wide pressures impacting upon patient flow and appropriate bed capacity.

o Ambulatory Care continues to be challenging due to ongoing bed pressures. Review recommendations have now been placed within the IIF with interdependencies to delivery of ECS7 target being recognised. The in patients service are working proactively to introduce senior review and multiagency review of all patients including those at the front door. Staff are escalating delays and there had been positive recruitment to the nursing establishment. Rick Strang Emergency Care Improvement Lead started 25th June supporting patient flow, the urgent and emergency care standard performance improvement.

• Cancer diagnosis to treatment <31 day and Cancer urgent referral to treatment <62 day targets were not achieved in May against the trajectory nor the target. All concerned complex pathways with multiple speciality involvement.

• Clostridium Difficile (C.diff): There have been three new cases of Healthcare Acquired Clostridium Difficile identified in the Trust during May. This has increased the Year to date figure to 4 against a total of the year of 7. Actions to drive C.Diff reduction include education regarding management of loose stools and utilisation of hydrogen peroxide vapour (HPV) for terminal environmental decontamination post discharge/transfer of patients with active Clostridium difficile infection or colonisation.

• A team from IW NHS Trust participated in a national NHS improvement

7 Emergency Care Standard


programme in the year 16/17 and focused on improved bed space cleaning methodology with the aim of introducing a standardised approach to bed space cleaning following patient discharge/transfer within the organisation. A training video has been developed to support staff

• MH&LD8 Nurse led clinics – drop in clinic numbers that is related to workforce and recruitment of substantive and temporary workers and also relates to the challenge to getting patients to attend the clinics.

• There were 3 mixed sex breach events involving an end of an ITU stay. Following 14 reportable incidents for year to date an options paper has gone out for comments from clinicians to discuss surgery and DSU mixed sex accommodation going forward.

• Estates have been tasked with producing a feasibility plan following theatre/DSU meeting to discuss requirements. Business plan will be worked up for the capital meeting.

• Appraisal position has decreased to 68.11% in month from 79.12 %. • Mandatory training trust wide has decreased by 2% in month at 65% against

a target of 80% • Sickness absence has increased marginally in May 17 within Acute and

Ambulance the theme are anxiety/stress followed by musculoskeletal issues. The Chief Operating Officer confirmed that in order to address the issues around stress/anxiety related sickness, the Trust is undertaking a number of initiatives including those recommended for employers through NICE guidance, to improvement managers ability to support employees with stress related illness and these include access to physiotherapy and continued access to health and wellbeing reviews. A training session was held for all senior leaders on 22 June 2017. The Chief Operating Officer advised that there were also added drop in sessions for staff around mindfulness techniques. The Chief Operating Officer confirmed that these resources to support improvement initiatives were being supported by the Interim Director of Mental Health and Rick Strang, an Urgent & Emergency Care Specialist.

• 17 people left the organisation in May • The number of vacancies has increased by 26 in month • Finance:

o Deficit: The Trust has a cumulative deficit of £3.717m as at 31 May 2017. This is a positive variance of £0.737m ahead of the Board approved deficit plan. The current forecast deficit position of £18.8m remains likely although there is a risk of a further £2.4m of additional quality improvement plan costs which are over the planned deficit position, as approved by the Trust Board in May 2017. As at 31 May £0.189m of capital allocation has been spent.

o Outstanding Overpayments has reduced by £5k in May (104K to 99K) this still remains very high but is a improvement on the previous position.

o CIPS9: The positive variance to date against the Board approved plan is due to the phasing of CIP targets increasing from Month 3. Year to date, CIP savings of £0.697m have been achieved, which is ahead of plan by £0.180m. Under a Worst Case scenario the Trust will deliver a £28.5m deficit. This assumes a shortfall in CIP achievement of £3.0m and further QIPP10 assigned from the CCG, without equivalent cost reduction, of £4.3m.

The Chief Operating Officer also advised that to drive our improvement in the areas which continue to see poor performance the Integrated Improvement Framework (IIF) will be used. Likewise to ensure that the Trust continues to meet the Section 31 and

8 Mental Health & Learning Disabilities 9 Cost Improvement Programmes 10 Quality, Innovation, Productivity and Prevention (QIPP) Commissioning


Regulation 17 Care Quality Commission (CQC) improvements the Quality Improvement Programme (QIP) will be used (which is also included within the IIF). The Chief Operating Officer confirmed that the use of both these documents will drive improvements forward for the Trust. Charles Rogers expressed concern that the ambulance and emergency department continued to breach targets and asked what was being done to rectify this. The Chief Operating Officer advised that a combination of sickness absence and increased call volumes had contributed to the team not being able to sustain their levels of achievement. He confirmed that in addition to the IIF programme, a new Operations Manager was being brought in from London to provide expert experience to the team. The Interim Chief Executive also advised that bringing the Interim Director of Mental Health to the team would also provide support for the Chief Operating Officer. The Board Advisor – Nursing stressed that whilst there were no 12 hour trolley breaches reported it was important that the revitalised de-escalation process was reintroduced and applied consistently. She also highlighted that it was important for both patients and staff that there is a safe area within the emergency department where patients suffering from mental health issues can be taken on arrival. The Chief Operating Officer confirmed that this had been raised by the CQC and confirmed that a designated safe area was now in place. Jessamy Baird questioned if the cases of C.Diff related to patient moves within the hospital. The Chief Operating Officer advised that there had been no clinical moves and that an analysis of antibiotic use had taken place. David King and Jessamy Baird asked if more information could be provided within the Performance report in relation to unexpected deaths/birth defects, increased focus on community services and trend lines as some numbers are very small and a trend would demonstrate clearly any changes. The Executive Director of Strategy & Planning confirmed that the report was undergoing a full review and would be revised to include CBU matrix as well as actions previously mentioned. Jessamy Baird requested that some of these actions could be actioned quickly and it was agreed that this would be taken forward. Action: The Executive Director of Strategy & Planning to discuss including data on unexpected deaths/birth defects, reviewing the focus on community services within the report and introducing trend lines into the reports for the next Performance Report and that any future amendments to the report will be flagged in the coversheet for reference as they are introduced.

Action: EDSP. The Isle of Wight NHS Trust Board received the Performance Report

17/T/108 CHIEF OPERATING OFFICER’S REPORT The Chief Operating Officer presented his report which provides an overview of

current service issues and challenges, mitigating actions and good news, affecting the five clinical business units for the period 20th May to 23rd June 2017. Vaughan Thomas queried if due dates would be included in future reports. The Chief Operating Officer confirmed that this was being undertaken and would appear in the next report. Jessamy Baird queried if core assessment and care plans were being monitored. The Chief Operating Officer confirmed that this was being undertaken within the IIF and further detailed update would be presented later in part 2. The Isle of Wight NHS Trust Board received the Chief Operating Officer’s Report.

17/T/109 REFERENCE COSTS SUBMISSION 2017 The Deputy Director of Finance presented the report and confirmed that it is a

national mandatory requirement that these are submitted by the end of July. He confirmed that it had been discussed at FIIWC where some amendments had been


requested and these were included within the paper. Vaughan Thomas reported that the FIIWC felt there was a reasonable level of assurance provided and that there was a need to certify and validate the process and this would be undertaken by the internal auditors. The Isle of Wight NHS Trust Board approved the Reference Costs Submission 2017

17/T/110 HUMAN & FINANCIAL RESOURCES APPROVAL PROCESS The Deputy Director of Finance presented the report which had previously being

discussed at FIIWC and TLC and recommended for approval by the Board. He outlined the proposed processes for both the human and financial resources highlighting key elements. He confirmed that following the FIIWC meeting a number of amendments had been requested and these were included within the paper. Vaughan Thomas confirmed that this met the requirements of the FIIWC and suggested that the Board defer the decision on the Financial Resources until after the Independent Financial Review presentation in Part 2. Post meeting note: Following further discussion in Part 2 the Board approved the financial resources proposal. . The Isle of Wight NHS Trust Board approved the Human & Financial Resources Approval Process

17/T/111 TRUST SELF CERTIFICATION 2016/17 The Interim Chief Executive advised that this had been previously discussed and

approved and was coming today to have this approval ratified. She outlined that NSHI had introduced self certification to all Trust (not just FT Trusts as had previously been the case) and confirmed that the Trust would be submitting a declaration of Non Compliance – FT4 due to being in Special Measures. The Isle of Wight NHS Trust Board ratified approval of the Trust Self Certification 2016/17

Principal Risk 675 - Culture 17/T/112 ANNUAL FIRE SAFETY REPORT 2016/17 The Executive Medical Director presented the report which covered the period April

2016 – March 2017. He advised that it included oversight into the number of incidents, call outs, mandatory training, provision and training of fire wardens as well as the evacuations processes and legislative aspects of fire safety management. He confirmed that an audit and risk assessment for all Trust properties would be undertaken over the next 6 month and that to assist and support the team an external specialist would be involved. The Interim Chief Executive advised that the external specialist would be available on an adhoc basis and that the date to commence the review would be dependent on the availability of the IW Fire & Rescue Service. She also confirmed that in future a more contemporary report would be provided which will be produced working with external partners. Action: The Executive Medical Director to provide a report on the outcome of the audit and risk assessment for all Trust properties is submitted to the Board.

Action by: EMD The Isle of Wight NHS Trust Board received the Annual Fire Safety Report 2016/17


17/T/113 TOP KEY ISSUES & RISKS ARISING FROM SUB COMMITTEES The Chair presented the Top Key Issues and Risks arising from Sub-Committees.

a) Serenity Project: Jessamy Baird highlighted that in addition to their recent

award (2nd major award) the Serenity Project had also won a number of other awards and highlighted that as a result of this project fewer people had been placed into unsuitable situations and that it was having a positive effect. The Interim Director of Mental Health stated that this is a state of the art practice which has been instrumental in preventing vulnerable people from being placed in unsuitable areas and allowing them to be seen in a place of safety. It was also highlighted that this project which is run in partnership with the University of Southampton, has been introduced internationally in New Zealand, Australia and will soon be introduced in the USA.

The Isle of Wight NHS Trust Board received the Top Key Issues & Risks Arising From Sub Committees

17/T/114 ANY OTHER BUSINESS None

17/T/115 QUESTIONS FROM THE PUBLIC The Board received the response to the question posed to the Board by a member of

the public. The Isle of Wight NHS Trust Board received the response to the question from the public

DATE OF NEXT MEETINGS The Chair confirmed that the next meeting of the Isle of Wight NHS Trust Board to be

held in public is on Wednesday 6th September 2017 to be held in the Conference Room, School of Health Science Building, St Mary’s Hospital, Newport, IW PO30 5TG

The meeting closed at 11.35am Signed………………………………….Chair Date:…………………………………….

Enc B

31/08/20171 of 4

ISLE OF WIGHT TRUST BOARD Pt 1 (Public) from April 17 - March 18ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update Report Author

Further Action by Other

Committee

Due Date Forecast Date

Progress RAG

Date Closed

05-Oct-16 16/T/192 TB/226 Annual report of compliance against the Code of Accountability (Code of Conduct)

An annual report of compliance against theCode of Accountability (Code of Conduct)would be presented at the end of the financialyear.

DCEO 17/05/17 - This report will be presented to the next meeting of the Audit &Corporate Risk Committee on 8th August 201708/08/17 - Report has been deferred to November meeting due to changeswithin the Board

ACRC 30-Apr-17 14-Nov-17 Progressing

07-Dec-16 16/T/212 TB/231 Review of Performance Report The Deputy Director of Information to include information on ‘I want great care’ as well as reviewing the Performance Report in line with the other suggestions made by NEDs.

EDSPDDI

01/02/17 - Review of KPIs with CBUs underway to ensure KPIs being monitored give a more comprehensive assessment of their performance, including Community and Mental Health Services. Following this review the performance report will be revised to include feedback from 'I Want Great Care'.02/03/17 - This is now included as a page within the Performance Report.08/03/17 - The Executive Director of Financial & Human Resources advised that ‘I want great care’ has been included within this months report. She confirmed that the PIDs team were meeting with the CBUs to agree their KPIs for 2017/18 and in particular those relating to Mental Health which would be included in the April report.05/04/17 - Review of KPIs in progress with CBUs; April data will be reported at the June meeting. Dashboard under development. I want great care discussed at QGC – business case and funding availability being prepared. 31/05/17 - Quality Improvement Plan KPIs have been developed and report produced and shared at Programme Board. PIDS are now working on individual programme reports. A draft report to the board is due to be prepared for the July Board Meeting. 25/07/17 - QIP report revised and submitted to QGC. Action now closed

05-Apr-17 05-Jul-17 Closed 25-Jul-17

07-Dec-16 16/T/212 TB/232 Discharge Arrangements The Company Secretary to arrange for a Board Seminar item on discharge arrangements.

CS 03/01/17 - Discharge Arrangements added to the Board Seminar Forward planner08/02/17 - This is being progressed for a later date.08/03/17 - This would be discussed as part of a Board Seminar.17/05/17 - Not prioritised for April or May Seminars07/06/17 - The Company Secretary confirmed that this would be included within the July seminar programme as part of a wider topic of Patient Flow.05/07/17 - It was confirmed that this would be included in the Board Seminar in July as part of the wider Patient Flow Update. This action is now closed.

Seminar 13-Jun-17 18-Jul-17 Closed 18-Jul-17

Non Executive Directors: Eve Richardson (ER) Charles Rogers (CR) David King (DK) Jessamy Baird (JB) Vaughan Thomas (VT)

Key to LEAD: Interim Chief Executive (ICE) Deputy Chief Executive Officer (DCEO) Interim Turnaround Chief Financial Officer (ITCFO) Executive Director of Strategy & Planning (EDSP)

Director of HR &OD (DHROD) Board Governance Officer (BGO) Head of Communications (HC) Head of Corporate Governance (HoCG)

Chief Operating Officer (COO) Deputy Director for Allied Health Professionals (DDAHP)

Executive Medical Director (EMD) Acting Director of Nursing & Quality (ADNQ) Deputy Director of Nursing (DDN) Director of Mental Health (DMH)

Enc B

31/08/20172 of 4

Date of Meeting




Committee


Progress RAG

Date Closed

08-Mar-17 17/T/030 TB/237 Patient Story Action Plan The Deputy Director of Nursing to provide theaction plan on the Patient Story to QGC

DDN 29/03/17 – The Out Patient team own the action plan for this patient story and will present to QGC in April05/04/17 - This will now be presented at the next QGC as April meeting has been cancelled and May meeting is due to be a planning workshop.22/06/17 - QGC continue to monitor this and a review will be provided to the July meeting25/06/17 - Update on progress planned for QGC on 27th June with summary update at the September meeting

QGC 05-Apr-17 26-Sep-17 Progressing

08-Mar-17 17/T/033 TB/239 Mental Health Future Service Plan

The Chief Operating Officer to update theBoard at Seminar on the future service plan.

COO 05/04/17 - This was due to be discussed at the Seminar on 5 April following the Board meeting.15/05/17 - Updates on plans for Shackleton Ward and Woodlands provided at April & May Seminars. Full plan including options and costings to be presented to Board for review and comment31/05/17 – An update on this will be given at the June Board meeting. 26/06/17 - Review undertaken by Berkshire Healthcare NHS Foundation Trust and and External Estates Advisor awaiting report on outcomes to formulate plan with detailed costs and accurate time line. Due to be submitted to Board Seminar.15/08/17 - Item was discussed at Seminar. Action now closed

Seminar 18-Apr-17 18-Jul-17 Closed 18-Jul-17

08-Mar-17 17/T/042 TB/243 Local Area Co-ordinator Pilot Scheme

The Chief Operating Officer to bring a report tothe Board on the outcome of the Local Area Co-ordinator Pilot Scheme.

COO 31/05/17 - The Trust continues to wait for the decision to be made on thefuture of the ownership and direction of travel for this pilot. Currently the JointCommissioning Board is looking to make a decision on the future of this inJune. The Trust will be in a position at the end of June to report on the future ofthese services26/06/17 - The development has been discussed with the health and socialcare economy on 27th June. Further discussion on progress will be takenforward through the Joint Commissioning Board at the next meeting

07-Jun-17 19-Sep-17 Progressing

05-Apr-17 17/T/053 TB/244 Solent Cancer Alliance roadmap

The Chief Operating Officer to ensure that the Solent Cancer Alliance roadmap is presented to QGC by the Clinical Support, Cancer & Diagnostic CBU..

COO 31/05/17 – This will be picked up by Head of Operations, Clinical Support,Cancer & Diagnostics CBU22/06/17 - QGC will be receiving an update at their July meeting25/07/17 - Seen at QGC - Action now closed

QGC 27-Jun-17 25-Jul-17 Closed 25-Jul-17

05-Apr-17 17/T/054 TB/245 Revised Assurance reporting on Safer Staffing

The Deputy Director of Nursing and the Chair of FIIWC to meet to agree reporting for safer staffing to FIIWC.

DDN 31/05/17 - Revised report will go to FIIWC in June25/06/17 - Date for discussion being set25/07/17 - Report submitted to FIIWC. Action now closed

FIIWC 27-Jun-17 25-Jul-17 Closed 25-Jul-17

05-Apr-17 17/T/057 TB/246 Revised Board Committee Structure

The Company Secretary to prepare the Termsof Reference for the new Committees togetherwith a timeline for the implementation of thenew Board Committee Structure.

CS 17/05/17 - Chair emailed NEDs to confirm implementation of Board Sub Committee structure postponed until Associate NEDs are recruited.07/06/17 - The Company Secretary confirmed that terms of reference for the committees was being covered within the Corporate Governance Framework report later in the meeting. 05/07/17 - It was confirmed that this would be discussed at the Remuneration & Nominations Committee later in the day.29/08/17 - Structure to be agreed following outcome of Extermal Governance Review

07-Jun-17 06-Dec-17 Progressing

Enc B

31/08/20173 of 4

Date of Meeting




Committee


Progress RAG

Date Closed

16-May-17 17/T/069 TB/249 Change to Organisational Culture

Chair to include a discussion of how to change culture from a top down structure at a future seminar

CS 31/05/17 - Company Secretary to include within the programme for future seminars07/06/17 - The Chair advised that this would be discussed at Board Seminar and stated that she was keen to reflect the various cultures within the organisation and to explore a variety of approaches. 23/06/17 - Included on seminar forward plan but to be agreed when to schedule05/07/17 - On Seminar forward planner. Action now closed

18-Jul-17 19-Sep-17 Closed 05-Jul-17

07-Jun-17 17/T/080 TB/250 Safer Staffing Report amendments

The Deputy Director of Nursing to includenumber of beds occupied at any one timewithin the revised 6 monthly report.

DDN 25/06/17 - Report amendments in progress29/08/17 - Amended report will be submitted to October Board. Action nowclosed

05-Sep-17 06-Sep-17 Closed 29-Aug-17

07-Jun-17 17/T/080 TB/251 ‘Safe Care’ software package The Deputy Director of Nursing to provide anupdate on implementation of the 'Safe Care'software package to the Board Seminar and averbal update at FIIWC and QGC at theirmeetings.

DDN 25/06/17 - Set up processes are underway: the ‘cloud will go live on 11th Julywhich is a requirement for the use of Safe Care, a clinical lead for safe care isbeing appointed, a project lead from Allocate has been designated to the Trust.15/08/17 - Update on progress presented to Board Seminar. On forward plamfor for QGC & FIIWC. Action now closed

QGCFIIWCSeminar

18-Jul-17 25-Jul-17 Closed 15-Aug-17

07-Jun-17 17/T/081 TB/252 Review of SIRI report The Deputy Director of Nursing to review theSIRI report in relation to the presentation of thecases in order of seriousness.

DDN 25/06/17 - List of items considered under SIRI report reported in graph 6 isautomatic from Datix - team are reviewing report for presentation of June datain September29/08/17 - Revised report submitted. Action now closed

05-Jul-17 05-Sep-17 Closed 29-Aug-17

07-Jun-17 17/T/082 TB/253 Performance Report amendment - Performance Trajectories

The Chief Operating Officer to ensure that an additional page be added to the performance report for performance trajectories to present predicted against actual performance.

COODDI

26/06/17 - PIDs team are working on revising the Performance Report to include this in future reports.29/08/17 - Revised report submitted. Action now closed


07-Jun-17 17/T/084b) TB/255 Chief Operating Officer report amendment - Walk In Service

The Chief Operating Officer to provide data on attendance ‘in hours’ and ‘out of hours’ for the walk in service and include within his monthly report to the Board.

COO 26/06/17 - The team are reviewing the available data and this will be included from the September report.29/08/17 - Included as appendix to report. Action now closed


07-Jun-17 17/T/085 TB/256 CQC Section 31 - Review of Data for CPA's

The Chief Operating Officer to review data on service user agreement to their care plan

COO 26/06/17 - The team are reviewing the available data and this will be included from the September report 29/08/17 - Revised report submitted. Action now closed


07-Jun-17 17/T/088 TB/258 Performance Report - Review of Highlight & Lowlight pages

The Executive Director of Financial & HumanResource to include a review of the highlightand lowlights section within the wider reportredesign.

EDFHRDDI

26/06/17 - The team are reviewing this as part of the wider review into thePerformance Report 05/07/17 - Highlights and Lowlights removed from report. Review of report inprogress by EDSP. Action now closed

05-Jul-17 06-Sep-17 Closed 05-Jul-17

05-Jul-17 17/T/100f) TB/260 QIP Report Amended QGC Report inc QualityImprovement Plan update would be presentedto the September Board.

EMD/JB 29/08/17 - Amended report submitted. Action is now closed 06-Sep-17 06-Sep-17 Closed 29-Aug-17

Enc B

31/08/20174 of 4

Date of Meeting




Committee


Progress RAG

Date Closed

05-Jul-17 17/T/101 TB/261 Safer Staffing Report The Deputy Director of Nursing to undertake areview of the report and present the revisedreport to the next FIIWC and Board. Report toinclude links to incidents, defined actions anddue dates and that it clearly correlates with theIIF.

DDN 29/08/17 - Revised report submitted. Action now closed 06-Sep-17 06-Sep-17 Closed 29-Aug-17

05-Jul-17 17/T/101 TB/262 Pressure Uicers The Deputy Director of Nursing to provide anupdate on the pressure ulcer situation atSeminar in July.

DDN 18/07/17 - Seminar Programme amended. This item was deferred to later Seminar.

18-Jul-17 19-Sep-17 Progressing

05-Jul-17 17/T/104 TB/263 Woodlands Estate The Deputy Director of Finance to review theprovision for dilapidation costs in relation toleasehold buildings and in particularWoodlands.

DDF 04-Oct-17 04-Oct-17 Progressing

05-Jul-17 17/T/106 TB/264 QIPP Agreements for 2017 The Deputy Director of Nursing to review whenthe QIPP agreements had been made for thisfinancial year.

DDN 04-Oct-17 04-Oct-17 Progressing

05-Jul-17 17/T/106 TB/265 E-Rostering Reporting The Board Advisor – HR & OD to arrange forfuture e-rostering reporting to be split intocorporate and clinical care areas.

IDHR&OD 04-Oct-17 04-Oct-17 Progressing

05-Jul-17 17/T/107 TB/266 Performance Report additional data

The Executive Director of Strategy & Planningto discuss including data on unexpecteddeaths/birth defects, reviewing the focus oncommunity services within the report andintroducing trend lines into the reports for thenext Performance Report and that any futureamendments to the report will be flagged in thecoversheet for reference as they areintroduced.

EDSP 04/10/2017 04-Oct-17 Progressing

05-Jul-17 17/T/112 TB/267 Fire Risk Assessment Report The Executive Medical Director to provide areport on the outcome of the audit and riskassessment for all Trust properties issubmitted to the Board.

EMD 04-Oct-17 04-Oct-17 Progressing

REPORT TO THE TRUST BOARD (Part 1 – Public) Enc C - 1

REPORT TO THE TRUST BOARD (Part 1 - Public)

ON 6th

SEPTEMBER 2017

Title Chief Executive Officer’s Report

Sponsoring Executive Director

Maggie Oldham, Interim Chief Executive Officer

Author(s) Andy Hollebon, Head of Communications and Engagement

Purpose For information

Action required by the Board:

Receive X Approve

Previously considered by (state date):

Sub-Committee Dates Discussed

Key Issues, Concerns and Recommendations from Sub Committee

Trust Leadership Committee

Audit & Corporate Risk Committee

Charitable Funds Committee

Finance, Investment, Information & Workforce Committee

Mental Health Act Scrutiny Committee

Remuneration & Nominations Committee

Quality Governance Committee

Information & Communications Technology Assurance Committee

Integrated Improvement Framework Programme Board

Please add any other committees below as needed

Board Seminar

Other (please state)

Integrated Improvement Framework:

IIF Workstream Section/Clause Current Status/ RAG Section/Clause Current Status RAG Section/Clause

Current Status RAG

Staff, stakeholder, patient and public engagement:

This report has been prepared by the Head of Communications & Engagement on my behalf. The report covers the period 29th June to 30

th August 2017. The report is intended to provide information

on activities and events and cover issues of national, regional and local importance that would not normally be covered by the other reports and agenda items. Detailed information about the five Clinical Business Units appears in the separate Chief Operating Officers report.

Enc C


Executive Summary & Analysis:

This report provides a summary of key successes and issues which have come to the attention of the Chief Executive. The report covers the following issues:

National

• Seven Day Services

• Allergy and Asthma Research feature on BBC Country File ‘Summer Diaries’

Regional

• Portsmouth Hospitals NHS Trust

• Award Winning work on Pressure Ulcers features on BBC South Today

Local

• Board Membership

• Annual General Meeting and Medicine for Members Meeting

• Car Parking and Security at St. Mary’s Hospital

• Cowes Week 2017 and National Ambulance Resilience Unit (NARU) support

• Ambulance Staff Recognised for over 600 Years Long Service and Good Conduct

• Payslip change for staff

• Patient Safety Campaigns

• Patient-led Assessment of the Care Environment (PLACE) Survey

• ‘Getting to Good’ Staff Engagement Programme

• Maternity Services Survey

• Award Winning work on Pressure Ulcers features on BBC South Today

• Supporting our community

• Fundraising, Charitable Funds and community support for the NHS

Recommendation to the Board:

The Board is recommended to note the contents and receive the report.

Attached Appendices & Background papers

For following sections – please indicate as appropriate:

Trust Goals & Priorities All

Principal Risks (BAF) None

Legal implications, regulatory and consultation requirements

None

Date: 30th August 2017 Completed by: Andy Hollebon, Head of Communications and

Engagement


Chief Executive’s Report covering the period 29th June to 30th August 2017

It is now four months since I took up post (2nd May 2017). It has been a very busy period during

which we have made progress across a number of areas including:

• Development of the Integrated Improvement Framework (IIF) including the Quality

Improvement Plan (QIP) - available on our website at

http://www.iow.nhs.uk/Publications/quality-improvement-plan.htm.

• Approval of the Trust’s £8.3m capital programme including spend of £1m on mental health

buildings (£300k additional spend was included in 2016/17).

• Development of the Trust’s Financial Recovery Plan.

• Recruitment of additional staff into services such as mental health

• Appointments to the Trust Board made and posts, such as the Chairman and Chief Executive,

advertised.

• Commencement of our new staff engagement programme ‘Getting to Good’

• Substantial improvements to the flow of patients through the hospital with the 4 hour

emergency care standard being met on many days, despite August being one of the Trust’s

busiest months.

Further substantial change is underway but there are no quick fixes to some of the issues facing the

Trust. National shortages in qualified nurses, doctors and other staff mean that we remain heavily

reliant locum or agency staff. We’re getting to understand the causes of the financial deficit and

some of the changes we can put in place to be more efficient, save money and make the organisation

more sustainable.

These things take time to implement but I am pleased that staff are showing incredible support for the

change programme. There is an enthusiasm to get things done and make changes, the right

changes. I am confident that we have made a good start but we will need to sustain the effort over the

next two years and possibly beyond to make a real difference.

My report this month covers a range of issues between 29th June and 30th August including items of

national and regional importance, and local issues. More detailed information relating to the five

Clinical Business Units appears in the separate Chief Operating Officers report.

National

Seven Day Services

Under the leadership of Deputy Medical Director Dr Oliver Cramer the Trust has started a period of

engagement about the implementation of seven day services. Ten clinical standards have been set

nationally to improve the quality of care and which define what seven day services should achieve for

patients admitted to hospital in an emergency. These clinical standards are supported by the

Academy of Medical Royal Colleges – four have been prioritised as a ‘must do’ for all hospitals by

2020 – just two years away - and will ensure:

• Patients wait no longer than 14 hours to initial consultant review;

• Patients get access to diagnostic tests with a 24 hour turnaround time. For urgent requests,

this drops to 12 hours and for critical patients, one hour;


• Patients get access to specialist, consultant-directed interventions; and

• Patients with high-dependency care needs receive twice-daily specialist consultant review and

those patients admitted to hospital in an emergency will experience daily consultant-directed

ward rounds.

Dr Cramer has already discussed this with the Trust’s Patient Council and in September will be

promoting discussion at the next Medicine for Members event.

Allergy and Asthma Research feature on BBC Country File Summer Diaries

Allergy and asthma research undertaken by Professor Arshad in the David Hide Asthma and Allergy

Research Centre on the St. Mary’s hospital site featured in BBC Country Files ‘Summer Diaries’

broadcast on BBC 1 on 29th August. The programme can be viewed on the BBC iPlayer website at

http://www.bbc.co.uk/iplayer/episode/b093pc2p/countryfile-summer-diaries-2017-episode-2 until 28th

September.

Regional

Portsmouth Hospitals NHS Trust (PHT)

On 24th August the Care Quality Commission published their report on Portsmouth Hospitals NHS

Trust. Inspectors visited Queen Alexandra Hospital in both February and May, paying particular

attention to the emergency medical pathway, the emergency pathway for mental health patients, and

the Trust leadership. Like our own CQC inspection report many – although by no means all – of their

findings make for uncomfortable reading.

Mark Cubbon has recently taken over as the new PHT Chief Executive and Dr John Knighton as their

new medical director. Mark is assembling a new leadership team and I will be meeting him to discuss

how Portsmouth and the Isle of Wight can work together more closely for the benefit of patients on

both sides of the Solent. It is in the interests of our patients who we refer to Portsmouth and to the

Portsmouth staff who work closely with us both here on the Island and in Portsmouth that we address

the challenges faced by the Hampshire and Isle of Wight health system and improve the quality of

services for all patients.

Award Winning work on Pressure Ulcers features on BBC South Today

At the last Board meeting I was able to report that our work with hand held

scanners used to identify patients with pressure ulcers had won a national

patient safety award. This work has now featured on BBC South Today,

broadcast on 28th August, with interviews with patient safety lead and

Tissue Viability Nurse Glenn Smith and the CEO of Bruin Biometrics. You

can view the story at http://www.bbc.co.uk/news/av/uk-england-hampshire-

41065539/the-bedsore-scanner-which-could-save-thousands-of-lives

Local

Board Membership

Our Trust Board membership is changing to meet the challenges faced by the Trust as we address

the issues raised by the Care Quality Commission (CQC) reports.

At the last Board meeting on 5th July we welcomed Kevin Bond as Director of Mental Health. Since

then we have been joined by Darren Cattell as Interim Turnaround Chief Financial Officer and Frank

Sims as Deputy Chief Executive. Alan Sheward has left the Trust and pending the appointment of a

permanent Director of Nursing and Quality, Barbara Stuttle CBE is the acting Director.


We have also been joined by Dr Charles Godden as an Associate Non-Executive Director following

the expiry of Dr Nina Moorman’s appointment. The roles of Chairman and Chief Executive have been

advertised and interviews take place in September.

Annual General Meeting and Medicine for Members Meeting

We held our Annual General Meeting combined with a Medicine for Members Meeting on Tuesday

18th July. The meeting was well attended and the Trust published the Annual Report and Accounts

and the Quality Account. Both can be found on the Trust’s website at

http://www.iow.nhs.uk/Publications/publications.htm.

Car Parking and Security at St. Mary’s Hospital

Earlier this year the Trust went into partnership with a new contractor for car parking and security

services at St Mary’s Hospital. The partnership is set to make parking at St Mary’s easier with

upgrades and refurbishments to parking equipment, including a virtual permit system and pay on exit

for patients. These improvements will streamline the processes on site and enhance the parking

experience for visitors, staff and patients. The five year contract, which has the option to be extended

by an additional two years, will see APCOA Parking, the leading provider of parking solutions in the

UK, manage services across a total of 1,297 spaces, 24 hours a day, 7 days a week as well as

supporting clinical and corporate staff with security issues across the St. Mary’s Hospital site.

Cowes Week 2017 and National Ambulance Resilience Unit (NARU) support

The National Ambulance Resilience Unit (NARU) visited the

Island for a second time this year (the first was for the Isle of

Wight Festival in June) to support the Trust’s resilience

arrangements for Cowes Week 2017. Whilst the NARU

personnel, vehicles and equipment were on the Island we took

the opportunity to invite Island MP Bob Seely to visit. The

Trust’s staff involved in emergency planning and resilience and

NARU staff explained how the ambulance service and the

Trust plan for large events and some of the potential

complexities of responding to incidents at major events on the

Island.

Ambulance Staff Recognised for over 600 Years Long Service and Good Conduct

On 20th July I was pleased to be able to present alongside the

Lord Lieutenant sixteen (16) current and former ambulance

staff with their Long Service and Good Conduct medal. The

medal is a long service medal of the United Kingdom

established in 1995 and is awarded to members serving on

emergency duty for 20 years or more. It is only awarded to

ambulance technicians, paramedics and ambulance officers.

Ambulance service officers must have served at least seven

years on emergency duty. We also presented two other staff

(call handlers/dispatchers) within the ambulance service with a

glass plaque engraved with the Isle of Wight Ambulance Service crest to honour their long service.

Pay slip change for staff


From October 2017 pay slips will only be available to Trust staff online – either via a personal

computer at work or home or via an ‘app’ which can be downloaded onto smart phones. This is part of

the Trust’s commitment to become paper-free - providing ‘greener care’. The Trust’s ESR Employee

Self Service offers easy access to online pay slips along with Total Rewards Statements (pension

information), personal information and more. This change is being widely advertised across the Trust

during August and September.

Patient Safety Campaigns

As part of the Quality Improvement Plan we are running a series of campaigns focused

on patient safety. During August we have been looking at the issue of ‘Never Events’

and the importance of learning from Serious Incidents Requiring Investigation (SIRIs).

Over the following months we are focusing on a range of subjects including Infection

Prevention & Control, Safeguarding, Falls, Pressure Ulcers, VTE, Medicines

Management, the deteriorating patient, Sepsis and Nutrition.

Staff at St. Mary’s Hospital have also been supporting the national

‘End PJ paralysis’ campaign which is raising awareness of the

impact of patients staying in pyjamas or hospital gowns for longer

than they need to and the benefits of getting dressed and being more

active. Patients that stay in their pyjamas or gowns can have a

higher risk of infection, loss of mobility, fitness and strength which

results in them staying in hospital longer. Many patients lose the

ability to carry out routine daily functions like bathing, dressing,

getting out of bed and walking, due to unnecessary bed rest.

Patient-led Assessment of the Care Environment (PLACE) Survey

On 15th August NHS Digital published the results of the Patient-led Assessment of the Care

Environment (PLACE) survey which took place across the Trust’s services on 6th March 2017. The

purpose of the PLACE assessments is to assess organisations across a range of environmental

aspects against common guidelines. It is recognised that sites/organisations vary in age and design;

sometimes this will limit their ability to meet the higher criteria. Whilst there may be nothing that the

organisation can do about some of these things, it is important that the assessment be based on

standard criteria and no allowances should be made for such factors. The scores awarded must

reflect what was seen on the day.

The results for Isle of Wight NHS Trust indicate:

• Cleanliness – Improved (as has national average)

• Food and hydration – Deteriorated (compared to national average which has improved)

• Privacy, dignity and wellbeing – Deteriorated (national average has also deteriorated)

• Condition, appearance and maintenance – Improved (as has national average)

• Dementia – Deteriorated (compared to national average which has improved)

• Disability – Improved (as has national average)

More information about the results can be found at http://www.digital.nhs.uk/catalogue/PUB30055. It

is disappointing that in some areas we have deteriorated. The improvements outlined in our

Integrated Improvement Framework (IIF) and the Quality Improvement Plan (QIP) will have an impact

on PLACE going forward and we will be analysing the results in more detail to see how we can

achieve improved results for 2018.


‘Getting to Good’ Staff Engagement Programme

The Care Quality Commission inspection reports identified that

the Trust needed to listen to and engage more with Trust staff.

During August we have started our new staff engagement

programme which is titled ‘Getting to Good’ – a reflection of the Trust Board’s commitment to

achieving a ‘Good’ CQC rating by 2020. The programme is being introduced to staff by their line

managers during the last week of August and first week of September with a video which can be found

on the Trust’s YouTube channel at https://youtu.be/r_Ja6doE3nI with an initial discussion about how

every member of staff can contribute to the Trust’s improvement programme. ‘Getting to Good’ will

include a dedicated staff website and ‘app’ for use on mobiles. There will be a new electronic

newsletter and the creation of over 100 case studies of how services have been improved with ideas

contributed by staff.

Maternity Services Survey

Feedback from our service users is very important and as the Care Quality Inspection report noted,

something we should take more notice of. We’re pleased to be supporting Healthwatch Isle of Wight’s

Maternity Services survey with hard copies of the survey available in Trust buildings and by promoting

it through our social media channels.

Supporting our community

During the period under review we have supported:

• Closer working with the Children’s Hospital in

Southampton will be essential to ensuring good quality

treatment for Island children and staff on the Children’s

Ward supported a father and son team running 10

marathons in 10 days to raise awareness of ‘Robbie’s

Rehab’ - the new service for children with brain tumours

at Southampton funded 100% by ‘robbiesrally’ charity.

The pair ran around all of Southampton’s shared-care hospitals between 19th and 28th

August without a day off! Please support them at www.justgiving.com/fundraising/mark-

keville3

• Staff from our Research Team completed the 5k #PrettyMuddy in

Portsmouth recently raising over £700 for charity. A great team effort

for a great cause that benefits our patients.

• The CoverUpMate campaign and improved awareness of skin

cancer. In collaboration with Lighthouse Medical Ltd our

specialist skin nurses offered advice on sun protection and

information on how to spot the early signs of skin cancer as well

as carrying out free mole checks at Boots in Newport. The

Trust has also been active in supporting the national ‘Be Clear

on Cancer Campaign’ via our social media channels.

• We had a presence at the inaugural IW Pride event where our

Sexual Health Service had a stand and we were also present at

the Chale Show where we shared a stand with Sunshine

Hospital Radio and the Friends of St. Mary’s.


• As we approach winter the ability of family and friends to support vulnerable relatives or

neighbours will be vitally important to those individuals and help ensure that health and care

services are sustainable. The Trust is helping to promote ‘Rally Round’, a free social

networking tool available on the Island to enable family, friends & carers to create a secure

support network for someone they care about. Anyone can set up a Rally Round network by

inviting people they know and trust to join their network. Members can add tasks that need

doing such as shopping, help with transport or organising a social outing to the ‘to do list’. To

use Rally Round visit www.rallyroundme.com/iow.

Fundraising, Charitable Funds and community support for the NHS

Funds raised for the NHS are overseen by the Trust Board as Corporate Trustee for the Isle of Wight

NHS Trust Charitable Funds and we welcome individuals and groups who wish to raise or donate

funds or leave legacies for the benefit of patient and staff in local NHS. Those wishing to donate to

the Trust’s Charitable Funds can do so via our JustGiving page at www.justgiving.com/iow-nhs.

A big thank you to Lake resident Anne Taylor who has raised £32,185 for St

Mary’s Hospital Cancer Care service following a 16-month long fundraising

campaign. The money which exceeded all targets will fund a new ultrasound

scanner and vein finder to help in the care of cancer patients. Around 1,200

people are diagnosed with cancer each year on the Island, many needing cancer

care and treatment.

For some who are expecting babies there is no opportunity to

pack a bag to bring into our Maternity Unit. Charmaine Reichmann with the

support of Morrisons and Isle Love Fluff, makers of soft flannels, has presented the

Maternity Unit with 40 packs of toiletries to be given to other mums who find

themselves in this situation. In the packs are the basics that every mum needs,

toothpaste, shampoo, deodorant, shower gel, toothbrushes and the soft flannels.

Governance - Trust Leadership Committee

The Trust Leadership Committee (TLC) comprises Executive Directors and Clinical Business Unit

representatives and meets monthly. The following key points were approved/discussed:

22nd

June 2017

• Annual Report and Governance Statement - Ratified

• IRIS (Drug and Alcohol Service) Contract Extension - Approved

• SWASH Consortium (Information Technology) Agreement - Approved

• Scrutiny Process for Staffing and Approval - Approved

• Woodlands Business Case – Approved

Maggie Oldham

Interim Chief Executive Officer

30th

August 2017


ON 6th September 2017

Title Safe Staffing Monthly Report


Sarah Johnston, Acting Director of Nursing & Quality

Author(s) Sarah Johnston, Acting Director of Nursing & Quality

Purpose To provide a monthly report on nurse staffing for inpatient areas


Receive X Approve





Audit and Corporate Risk Committee

Charitable Funds Committee Finance, Investment, Information & Workforce Committee

Mental Health Act Scrutiny Committee Remuneration & Nominations Committee

Quality Governance Committee No meeting in August Information & Communications Technology Assurance Committee

Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: None Executive Summary & Analysis:

Overall the staffing picture is improving: although there are red indictors where consistent issues are evidenced, there has been action taken and these are addressed or improving.

• The number of areas that are indicating below 90% of registered nurses in the day is static this

month.

• Osborne (MH), Rehab, Colwell and Appley (medical) are areas that have more than one red indicator and require support to rectify this position. Matrons and Heads of Nursing are aware of this; there has been difficulty obtaining temporary staff including agency staff this month due to holidays. The staffing review has incorporated issues needing action in relation to these areas.

• For Health Care Assistants we are below 90% for achieving our planned hours in the day for 6 areas however, there are no significant concerns raised from this position as the broader picture for these areas is good.

• Sickness remains red rated in 15 out of 20 areas.

Enc D

• Bank and agency have been difficult to source in some instances and the request to fill rate for

agency registered nurses has dropped which is unusual. This is likely to be due to the holiday period and will extend through August.

• Mandatory training is much improved with 15 areas now rated green

• Incidents have identified that shortfalls in staffing are related to short term sickness, high acuity

and dependency and skill mix for ITU. Limited assurance is indicated as daily data to manage staffing is not yet available.


The Board is asked to receive the report.

Attached Appendices & Background papers;


Trust Goals & Priorities Excellent patient care

Skilled and capable staff Principal Risks (BAF) Risk of inadequate staffing whilst recruitment plans come to

fruition. DNT will discuss issues and HoN&Q will ensure good forward planning for bank and agency requests to ensure maximum planning success.

Risk of not recruiting adequately to RN and Midwife positions to adequately increase workforce. As staff are leaving the current recruitment plan is inadequate to achieve full establishments. A full workforce plan for nursing, including where new planned for staff, and assumption around leavers, is still required.


The recommendations include items identified as required as part of the CQC inspection. The National Quality Board guidance sets out requirements of the Board in relation to safe staffing - the Board should receive a monthly report on nurse staffing

Date: 18th August 2017 Completed by: Sarah Johnston, Acting Director of Nursing &

Quality

Safe Staffing Monthly report

Wednesday 6th September 2017

1. Monthly data 1.1 Care Hours per Patient per Day (CHPPPD) is an automatic calculation provided by the input of

our data. The measure indicates, for each ward area, and by registered and non-registered staff, the number of care hours available for each person in a 24 hour period.

1.2 The measure is now being utilised as trend data to support Heads of Nursing and Quality to

review the number of care hours provided to patients, mapped against indicators identified in the monthly dashboard.

1.3 In July we have provided over 5 care hours per patient per day across all areas. In speciality areas that require higher input this is also evidenced

1.4 The ratio of Registered Nurse hours to non registered hours is nearer 50/50 in Mental Health areas. Acute areas are providing less HCA hours and more registered hours in proportion with speciality area and the 60/40 ratio benchmark. Luccombe ward (orthopaedic) is the only area where non registered hours are higher than registered hours. This has been discussed at the staffing reviews this month and the Ward Manager has assured the senior nurse team this is her professional opinion of how the ward works well.

1.5 In the ward measurements 6 areas had less than 90% of registered nurses covered in the

day. Of those 6 areas (Osbourne (MH acute), Mottistone and Whippingham (surgery) Rehabilitation and Colwell (medicine) and Coronary Care) all areas were above 85% with exception of CCU who measured 82% with all other measures over 90%

1.6 For non registered in the day 6 areas were below 90%. These included Shackleton however the data does not reflect the true picture due to the new model of working in place and the reduced requirement. There have been no issues or incidents raised from this area. Two surgical areas, rehab and MAU had low non registered staffing; MAU dropped to below 80%. NICU also had low numbers of nursery nurses at night. These nurses help with feeding support for babies in the unit.

1.7 For registered staff in the night Osborne, NICU, MAU and Appley dropped below 90%. The unit has 3 senior staff on sickness leave. The requirement for NICU is specialised and without the adequate staffing there is potential to close the unit and transfer babies to another unit to ensure safety.

1.8 For non registered staff at night two areas were below 90%; Appley and Osborne ward. Appley

dropped below 80% f at night however the Matron has reviewed this and identified a reporting anomaly that has been rectified and should be seen in the data by October. There are no significant concerns raised however both Appley and Colwell should have 3 registered Nurses at night but usually only have 2 due to staff being moved to cover other areas for sickness

1.9 Stroke and MAAU were indicated as having pressure ulcers last month and this month this is

still the case although the number is reducing. All stroke staffing indicators are green: the unit is linked into the patient safety group and has actions in place to improve. MAAU also has green staffing indicators which is excellent as this area has been consistently red for the past few months and work has been ongoing to improve management of rotas and staffing.

1.10 Colwell indicates red ratings for RN’s on both day and night and high incidence of pressure ulcers this month. The team are working to address this. This area is a ward that requires an additional RN at night. Agency is utilised however due to high sickness across areas this is often utilised elsewhere. Long lines of agency are booked however currently, this is not enough to cover the staffing gaps that appear on the actual day or night.

1.11 NICU is highlighted as a hotspot for sickness with 3 senior staff off sick currently. This unit will

not take babies over the staffing compliment available and the impact of this is potential

closure of the unit and transfer to mainland hospital if the unit becomes full. This did not occur in July.

1.12 Mandatory training is now starting to pick up with almost all acute areas with a green rating. Mental Health areas are all in the 70% and it is expected that this will move forward to 80% in the next month.

1.13 See Appendix 1 Table 1 - Unify average fill rate data for each ward and quality and safety indicators.

1.14 See Appendix 1 Table 2, - Safe Staffing average fill rates over time against our locally set

target of 90% fill rate. 2 Assessment of monthly position

2.1 Overall, the Trust achieved our local set fill rate for day or night with the percentage of actual v

planned hours being over 95% across all 4 metrics which is a green rating.

2.2 For Registered Nurses in the day this remains an improved position. Bank and agency are able to be booked and are expected to be booked although over summer months the availability of these groups is less.

2.3 In managing the rota’s the shift pattern of 2 shifts in the day is often converted to 1 x 12 hour

shift in the day when required, by the ward manager, so hours are lost but safety and care are not compromised. This flexibility is required to enable the ward managers to manage their staffing and with the commencement of safe care we will be able to provide more robust assurance that shortfalls in hours are managed well.

2.4 Overall the total of CHPPPD is achieving over 5 hours of care per day for all areas (with the

exception of the Rehabilitation unit) but this is low for our medical areas of Colwell and Appley where our elderly patients are cared for. The skill mix ratio is good with more RN than HCA hours achieved.

2.5 The Rehabilitation Unit has more HCA hours than registered hours, however we do not

currently capture hours of care input from the allied health professionals which are an integral part of the rehab care and are based in this unit.

2.6 Managing risk in these areas is through the ward managers and Matrons processes for assessing their ward areas daily and making judgements as to the need for staffing on that day. Assurance that this is right is currently through looking at outcomes as indicated on the dashboard.

2.7 Areas of concern/action:

This month we are able to evidence improvements on issues raised last month 2.7.1 Stroke Ward have significantly improved their position from last month however

pressure ulcers remains a focus for this unit.

2.7.2 For the Medical Assessment Unit a deep dive was requested by the team in order to ensure staffing was managed correctly and all required actions were taken. There is a much improved position this month with the care staff in the day being the one indicator that requires work.

2.7.3 Appley ward at night remains poor. This is in part a data issue highlighted by the Matron which will be rectified, however areas that require 3 RN’s at night are currently not able to achieve this or are having staff moved to other areas to ensure full cover.

2.8 Mental Health and Learning Disabilities CBU

Issue Mitigation/Actions Osborne Ward – 3 staffing indicators red rated, 4 incidents raised in relation to staff not having enough staff to manage acuity Staff reporting high stress

No harms identified – HoN to review whether daily staffing is being managed well

Sevenacres – no ECT clinic provision as no staff available – this treatment is supported by nurse from ward areas and when staffing is low ECT is not available, this is not sustainable in this way

As part of the 6 monthly review the additional staff requested will support ECT. There are also discussions underway with Southern Health to support this service

2.9 Medicine

Issue Mitigation/Actions Colwell – 3 incidents raised in relation to high acuity (blood transfusions) and dependency (confused patients requiring more input) and not enough staffing to manage safety or provide high quality care

There is no flex in the system currently to accommodate this other than movement of staff from different areas or to request bank at short notice. The proposed HCA pool will support this, alongside 6 monthly staffing recommendations for additions to this area, and rapid recruitment.

2.10 Clinical Support, Cancer and Diagnostics

Issue Mitigation/Actions ITU – 8 incidents raised to highlight band 5 RN in charge of the unit – this is out of kilter with national requirements either from inadequate number of band 6 staff available, and/or sickness

Band 5 staff take charge if required however this is not sustainable. This has been addressed in the 6 monthly safe staffing review

2.11 Surgery, Women and Childrens

Issue Mitigation/Actions NICU – 2 indicators below 80% - non registered in the day and RN at night which is the same as last month. High sickness is a challenge

This unit will closely manage its capacity. Head of Midwifery and the Paediatric lead for Nursing oversee this area, potential to close temporarily if required.

2.12 Ambulance Urgent Care and Community

Issue Mitigation/Actions No issues highlighted

3 Future actions 3.1 Software system ‘Safe Care’ has commenced. The IT cloud went live on 14th Aug and data is

being drawn from pilot areas: CCU, Alverstone and Luccombe and Colwell. This will be fed back to the organisation on 25th September when the project can start in earnest.

Sarah Johnston Sarah Johnston, Acting Director of Nursing & Quality Aug 2017

Appendix 1 Table 1. Site Summary of Nurse staffing Data as per Unify report – July 2017

Day NightRegistered midwives/nurses Care Staff Registered midwives/nurses Care Staff Day Night

Total monthly planned staff

hours

Total monthly actual staff

hours


hours


hours


hours


hours


hours


hours

Average fill rate -

registered nurses/midwiv

es (%)

Average fill rate - care staff (%)

Average fill rate -

registered nurses/midwi

ves (%)


Cumulative count over

the month of patients at 23:59 each

day

Registered

midwives/ nurses

Care Staff Overall

33489.716 31840.742 20107.25 19550.8 16869 16109.583 10568.25 10943.25 95.1% 97.2% 95.5% 103.5% 8601 5.6 3.5 9.1

Care Hours Per Patient Day (CHPPD)

Table 2. Percentage rate and KPI’s for each area, RAG rated – July 2017

Jul-17

SHACKLETON 127.7% 52.4% 104.2% 102.1% 104 13.3 13.9 27.3 6.0% 72% 0 0ALVERSTONE 95.3% 85.0% 100.0% 123.8% 331 4.7 2.4 7.2 4.0% 89% 1 1SEAGROVE 104.1% 111.0% 104.8% 123.4% 219 9.0 9.0 18.0 5.0% 76% 0 0OSBORNE 89.1% 117.4% 80.8% 83.4% 506 3.6 3.6 7.3 8.0% 73% 1 0

MOTTISTONE 87.6% 128.7% 97.3% - 248 6.0 2.0 7.9 5.0% 84% 0 0ST HELENS 101.6% 87.1% 96.8% 96.8% 400 4.0 2.6 6.6 6.0% 84% 1 1

STROKE 101.0% 112.7% 124.7% 150.0% 683 5.0 3.6 8.6 5.0% 81% 1 3REHAB 89.9% 86.1% 103.0% 89.3% 942 2.5 2.4 4.9 4.0% 81% 0 0

WHIPPINGHAM 86.7% 116.0% 98.4% 91.4% 749 3.5 3.0 6.4 2.0% 71% 1 1COLWELL 86.6% 93.1% 83.9% 111.3% 853 3.1 2.4 5.6 2.0% 90% 1 4

INTENSIVE CARE UNIT 95.0% 97.7% 95.6% 116.2% 161 30.4 3.2 33.6 3.0% 90% 7CORONARY CARE UNIT 82.8% 92.5% 91.1% 116.5% 503 6.8 2.0 8.8 6% 85% 3NEONATAL INTENSIVE

CARE UNIT 95.2% 76.7% 67.7% 99.3% 34 46.3 19.5 65.8 16.0% 84% 0 0MEDICAL ASSESSMENT

UNIT 103.6% 79.5% 105.6% 93.6% 583 5.7 3.4 9.1 4.0% 88% 0 2AFTON 113.2% 91.7% 98.0% 96.4% 268 7.5 6.2 13.7 1.0% 94% 0 0

PAEDIATRIC WARD 92.2% 93.3% 92.6% 96.8% 162 14.8 4.3 19.1 5.0% 82% 0 0MATERNITY 95.0% 109.9% 103.2% 97.9% 197 15.5 9.5 24.9 5.0% 85% 0 0

WOODLANDS 94.6% 95.5% 100.0% 99.8% 165 10.2 4.7 14.9 0.0% 73% 0 0LUCCOMBE 91.2% 141.5% 98.4% 151.4% 645 3.2 4.0 7.2 6.0% 84% 1 1

APPLEY 97.5% 97.3% 77.4% 76.4% 848 3.1 2.5 5.6 4.4% 88% 2 1

95% - 100% fill rate as per as per 0 090% - 94.9% fill rate quality quality 2 2<90% fill rate dashboard dashbaord >2 >2

Falls with any

harm

Pressure Ulcers (new

reported)

Day Night Care Hours Per Patient Day (CHPPD)

Average fill rate - registered

nurses/midwives (%)


Average fill rate - registered

nurses/midwives (%)


Cumulative count over

the month of patients at 23:59 each

day

Registered midwives/

nurses

*Ward template set to 16 beds only and 27 beds utilised

Care Staff Overall Sickness Mandatory TrainingWard name

Table 3. Safer staffing levels trend

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%110.0%120.0%130.0%

Average fill rate for Nurses and Midwives Inpatient areas Acute and Mental Health (local target 90%)

Average Fill rate - Registered nurses/midwives (Day) Average Fill rate - Care staff (Day)

Average Fill rate - Registered nurses/midwives (Night) Average Fill rate - Care staff (Night)

Table 4 Bank and Agency fill rates July 2017

REPORT TO THE TRUST BOARD (Part 1 – Public)


on 6 September 2017

Title Serious Incident Requiring Investigation (SIRI) Activity Report (July data)



Author(s) Karen Kitcher, Quality Assurance Lead Deborah Matthews, Deputy Director of Quality

Purpose To provide an overview of SIRI cases reported and in progress. Action required by the Board:

Receive X Approve








Quality Governance Committee The standard QGC meeting was not held during August



Please add any other committees below as needed Board Seminar Other (please state) Patient Safety, Experience and Clinical Effectiveness (SEE) Meeting

9 August 2017

Integrated Improvement Framework: IIF Workstream 9. Leadership, Governance & Quality Improvement (Well-led)

Milestone 9.8 - To improve the learning from national and local Never Events and serious incidents

Section/Clause Current Status/ RAG Section/Clause Current Status RAG Section/Clause

Current Status RAG

Staff, stakeholder, patient and public engagement: There was no attendance from the Patient’s Council to the August SEE meeting due to sickness

Enc E



This report provides an overview of Serious Incidents Requiring Investigation (SIRI) activity during July 2017. It also contains a description of what we are doing to improve the quality of the reports and the timely recognition and management of cases. There were 5 SIRI’s reported to the Isle of Wight Clinical Commissioning Group (CCG) during July At the time of writing this report there were: • 40 open investigations - 3 of these were with the CCG awaiting consideration for closure - 6 the CCG have declined to close with requests for further work/information - 2 were overdue within CBU’s; 1 Mental Health and Learning Disabilities; 1 Ambulance, Urgent Care & Community - 29 cases were open and still in-time that were under investigation. The case numbers by CBU are summarized within the report. During July 2017 and at the time of reporting the IW CCG had closed 4 SIRI case The details of these and the lessons learnt for those closed SIRI cases are detailed within the report.

Recommendation to the Board: The Board is recommended to receive the report.

Attached Appendices & Background papers SIRI Report (July 2017 data). For following sections – please indicate as appropriate:

Trust Goals & Priorities Excellent patient care; positive experience for patients, service users and staff

Principal Risks (BAF) Principal Risk 674 Quality and Harm


Adherence to NHS SIRI Framework (2015); completed reports submitted within national timeframe are monitored by IW Clinical Commissioning Group

Date: 29.8.17 Completed by: Karen Kitcher, Quality Assurance Lead Deborah Matthews, Deputy Director of Quality


Serious Incident Requiring Investigation (SIRI) Activity Report July 2017 data

(1) NEW INCIDENTS REPORTED AS SIRI’S During July 2017 there were 5 Serious Incidents the Trust reported to the Isle of Wight Clinical Commissioning Group (CCG).

Under whose care Summary

Mental Health Unexpected death

Mental Health Potential failure to admit vulnerable patient

Surgery Surgical error

Community Patient fall

Corporate Data breach

(2) TWICE WEEKLY INCIDENT/SIRI REVIEW MEETING The twice weekly SIRI & incident meetings continue to be held. The topics reviewed and discussed are:

• Each incident graded as moderate or above (early recognition and prompt for timely investigation)

• Formal decisions and declaration of SIRI reportable incidents • Incidents graded as minor (low) that may warrant an investigation & possible upgrade of risk

score • Status of all open and overdue SIRI cases • Progress on any outstanding queries waiting to be returned to the Clinical Commissioning

Group (CCG) (3) WEEKLY PATIENT SAFETY WORKING GROUP The Patient Safety Working Group continues to meet weekly and is well represented from areas across the Trust; individual incidents of moderate harm or above are discussed at the meetings, including any other patient safety related topics that staff want to raise, or that have arisen recently. The following topics were raised and discussed during July:

• Intravenous cannula and the guidance around how long they should remain in place • Photographs of patient wounds (problems with I.T. equipment and uploading photos) • Hot debriefs post cardiac arrest • Falls prevention competencies (to be mandatory in due course) • Falls training (25/27 July)


• Safety Thermometer (data collection) • Dementia data (data inputting challenges) • Bed sensors (equipment/resource) • Oxygen prescribing (training/JAC – electronic prescribing/policies) • National Patient Experience Survey (cancer research/3 areas marked for improvement) • Managing aggressive patients • Infection control issues (clostridium difficile, MRSA screening; CPE screening)

(4) CURRENT POSITION: The table below provides the current status of open SIRIs at time of submitting this report. SIRIs HOSPITAL &

AMBULANCECBU 1 Surgery, Women's &

Children's

CBU 2Medicine

CBU 3Clinical Support, Cancer & Diagnostics

CBU 4Ambulance, Urgent Care, Community

CBU 5Mental Health & Learning Disabil ities

CBU 6Corporate Services

OVERDUE CASES• With Coroner 0 0 0 0 0 0 0• With Clinical Business Unit 0 0 0 0 1 1 0• With Quality team 0 0 0 0 0 0 0• With Execs 0 0 0 0 0 0 0• With Commissioner 1 0 0 0 0 2 0• Returned from Commissioner - further work

0 1 0 1 1 3 0

TOTAL 1 1 0 1 2 6 0CURRENT CASES• With Coroner 0 0 0 0 0 0 0• With Clinical Business Unit 0 3 3 1 12 4 4• With Quality team 0 0 0 0 0 0 0• With Execs 0 0 0 0 0 0 0• With Commissioner 0 0 0 1 0 0 0• Returned from Commissioner - further work

0 1 0 0 0 0 0

TOTAL 0 4 3 2 12 4 4TOTAL NUMBER OF OPEN CASES 1 5 3 3 14 10 4

(5) REVIEW AND PLANNED IMPROVEMENTS TO OUR SIRI MANAGEMENT Due to the wide variation in the quality and timely delivery of SIRI reports, as an organisation to better improve our management and learning from such incidents we are recruiting the equivalent of two full time investigating officers. In addition to this the Trust has commissioned Quality Governance Solutions to review our current management of SIRI’s with the aim of developing and assisting in the implementation of new systems and processes to enable us to better meet the required standards. Meanwhile the Trust is working with the CCG to progress closure of a number of overdue SIRI.

(6) CLOSED SIRI CASES: During July 2017, and at the time of reporting, the IW Clinical Commissioning Group had advised on the closure of 4 cases. (6a) LESSONS LEARNT: Following closure of SIRI cases, the learning is shared across the Trust via various methods: Trust’s monthly Quality reports; organisational and local Quality Governance


meetings; audits; newsletters; clinical education, Morbidity & Mortality groups. Outcomes are also captured via quarterly collation of outcomes by subject, e.g. communication, clinical care, education etc., and are available for staff to access via the SIRI page of the Trust’s intranet site. Case 1: FINDINGS: GP capacity within the Urgent Care Service and poor escalation processes ACTION: management plan to:

• Prioritise advice calls above base visits • Closer management and scrutiny of GP capacity – ensuring guidance on how to effectively

cover gaps in roster • Improved communication when the GP roster is not covered to ensure calls are managed

safely • GP capacity within Urgent Care Service was raised as a risk on the risk register • All advice calls outsourced to an external provider

Case 2-4: Breaches of the 12 hour Emergency Department standard FINDINGS: These 3 cases were revalidated and subsequently downgraded, as they did not meet the criteria for breach. (7) OVERVIEW OF SIRI SUBJECTS: This shows a comparison of SIRI subjects over the last 3 years.

0 2 4 6 8 10 12 14 16 18

NEVER EVENTSlip, Trip, Fall

Confidential Information LeakUnexpected Death

SafeguardingOther

Delayed DiagnosisAmbulance IssueSurgical Incident

Sub-optimal care of deteriorating patientPressure ulcer grade 3Pressure ulcer grade 4

Screening IssueFailure to act upon test results

Maternity ServiceAllegation against HC professional

Hospital transfer concernsMedication issue

Hospital Equipment Failure12-hour breachesDelay in treament

2017 - 2018

2016 - 2017

2015 - 2016

Comparison of SIRI subjects over last 3 years (2015 - 2016; 2016 - 2017 and April 2017 - to date)

(8) ACTION PLANS: The Quality Team, together with the Clinical Business Units, continue to monitor and update all actions plans arising from previous/current SIRI cases. Upon completion, the action plans are then forwarded to the Patient Safety, Experience and Clinical Effectiveness meeting for review and final sign off.


(9) EXTERNAL REVIEW: As part of the external review by Quality Governance Solutions, a full SIRI process review will be undertaken against the National Framework. There will be a number of recommendations to be implemented by the Executive Team at pace. An update of the process with a comprehensive SIRI paper will be submitted in October. Sarah Johnston Acting Director of Nursing & Quality Paper produced and prepared by: Karen Kitcher, Quality Assurance Lead (August 2017) Updated by Deborah Matthews, Deputy Director of Quality



on 6th September 2017

Title Learning from Deaths; A framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care


Dr Mark Pugh, Executive Medical Director

Author(s) Anna Daish-Miller, Business & Projects Co-ordinator

Purpose For Board information and review


Receive x Approve








Quality Governance Committee Information & Communications Technology Assurance Committee


Please add any other committees below as needed Board Seminar Mortality Review Group 26/08/17 Other (please state) Staff, stakeholder, patient and public engagement: n/a Executive Summary & Analysis:

This report provides a brief summary the National Quality Board document Learning from deaths: A framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care. Learning from Deaths Framework:

• This should cover the total number of the provider’s in-patient deaths, the subset of these that the provider has subjected to case review and, following application of the Structured Judgement Review methodology, estimates of how many deaths were thought more likely than not to have been related to problems in care

• The data in the dashboard should be collected and published on a quarterly basis together with relevant qualitative information, interpretation of the data, and what learning and related actions your organisation has derived from it.

Enc F


Quarterly data will need to be published and discussed at public board meetings, submitted quarterly to NHSI and included in the Quality Account in 2018. The Trust, in line with the national timetable, is publishing by the end of Q2 our policy and approach, and commence reporting by the end of Q3. We will incorporate the national requirements into our quarterly review, and will start reporting by the end of Q3. As a minimum Trusts must review

• All deaths where family, carers or staff have raised a concern about the quality of care; • All deaths of those who are identified to be significantly disadvantaged, eg Learning

Disabilities and severe mental illness; • All deaths in a service specialty, particular diagnosis or treatment group, where an ‘alarm’ has

been raised with the Trust eg via a Hospital Standardised Mortality Ratio (HSMR), concerns raised by audit work or by a regulator like CQC;

• All deaths of patients subject to care interventions from which a patient’s death would be wholly unexpected, for example in relevant elective procedures;

• Deaths where learning will inform the organisation’s existing or planned improvement work, for example if work is planned on improving sepsis care,

• A further sample of other deaths should be selected that do not fit the identified categories, to ensure Trusts can take an overview of where learning and improvement is needed most overall. This does not have to be a random sample, and could use practical sampling strategies.

Q3 data will be presented to Trust Board after presentation to the Mortality Review Group in October and the Quality Governance Committee in November, with a target date of Trust Board in December.

Recommendation to the Board: The Trust Board is asked to receive and note the contents of the report.

Attached Appendices & Background papers For following sections – please indicate as appropriate:

Trust Goals & Priorities - Excellent Patient Care

- Work with others to keep improving our services

A positive experienced for patients, service users and staff

- Skilled and capable staff Principal Risks (BAF) Risk 674 – Quality Governance


Date: 18 August 2017 Completed by: Anna Daish-Miller, Business & Projects Co-ordinator




Title Care Quality Commission Section 31 & Regulation 17 Progress Report to the Trust Board for July 2017


Maggie Oldham – Interim Chief Executive

Author(s) (a) Shaun Stacey – Chief Operating Officer (b) Jo Ferguson – Executive Assistant to Chief Operating Officer (c) Cathy Frost – Project Manager for Mental Health and Learning Disabilities

Purpose To inform the Trust Board of the progress monthly to address the risks and issues in response to the Care Quality Commission inspection in November 2016 directly related to the Section 31 & Regulation 17 actions. This is an update since the last report received June 2017. July and August reports are due to be presented to the Board in October following presentation at the Quality Governance Committee in September in line with agreed governance processes


Receive X Approve








Quality Governance Committee 25.7.17 Received July’s report at the July QGC. Information & Communications Technology Assurance Committee


Please add any other committees below as needed Board Seminar Integrated Improvement Framework: IIF Workstream Contained within the IIF workstreams.

Actions from the November 2016 CQC report wider than the Section 31 & Regulation 17 will be found contained within the IIF Programme Board report.

Staff, stakeholder, patient and public engagement: The paper has been written to report the updated position on actions taken in response to the Section 31 & Regulation 17 applied to the Trust following the November 2016 inspection by the Care Quality Commission. As part of the response both staff and patients have formed part of local engagement and improvement teams

Enc G



Following an inspection of all elements of the Trust by the Care Quality Commission in November 2016, the Trust received a Section 31 and Regulation 17 notice requiring the Trust to take immediate actions to address concerns. Their concerns largely cover areas of Clinical Care, Governance, Workforce and Infrastructure. This report is to update the Board in the progress to the end of June 2017 completed against the actions required for the above regulatory notices.


The Trust Board is recommended to receive the enclosed update reports as an honest assessment of where we believe the Trust to be following receipt of the Section 31 and Regulation 17 notification. The July report is being submitted retrospectively to comply with our governance processes. The Board is asked to be aware of the limited assurance that exists across some improvements and to acknowledge the immediate actions that have been taken to address this.

Attached Appendices & Background papers CQC report update for July 2017 For following sections – please indicate as appropriate:

Trust Goals & Priorities Excellent Patient Care, A positive Experience for Patients, Service Users and Staff

Principal Risks (BAF) There are a number of principal risks covering the recent CQC inspection, Section 31, Regulation 17 and Integrated Improvement Framework.


Issue 1085; The Trust has a notice served under Section 31 of the 2008 Health and Social Care Act. In place for Mental Health Services.

Date: 31 August 2017 Completed by: Jo Ferguson – Executive Assistant to Chief Operating Officer / Cathy Frost – Project Manager for Mental Health and Learning Disabilities & Shaun Stacey – Chief Operating Officer

Update Assurance Report Care Quality Commission (CQC) Section 31 Received on 9th December 2016 Update July 2017

Contents Page Introduction

Assurance Progress Summary

Section 31 Requirements

A - Escalation Protocol

B - Patients Placed in Business Continuity

C - Care Planning and Documentation

D – Community Mental Health Services Redesign

G - Ligature Risks

H – Policies and Procedures

Regulation 17 Requirements

Person Centred Care: Community mental health care plans were not person centred or holistic - Training for staff

Dignity & Respect: The seating area at the end of the corridor on Afton ward not complying with privacy and dignity standards. Mixed sex accommodation and occurrences

Safe Care & Treatment: 1) Care and treatment in Osbourne ward not safe. 2) Improved core assessment, care plans & risk assessment required in CMHS. 3) Jack & Jill bathrooms inappropriate. 4)temperamental locks on Shackleton & Afton wards. 5) No maximum and minimum temperature monitoring of medicine fridge on Seagrove. 6) Woodlands garden environment was not safe for use.

Premises & Equipment: 1) Osbourne Ward not to exceed 19 patients. 2) Staff alarm system to be fixed on Seagrove & Osbourne Wards

Patient transfers [including EoLC} for non clinical reasons

24/7 RSCN cover to ED. Also ED nurses to be trained in PILS and safeguarding up to level 3

2

Contents Page Regulation 17

Overcrowding in ED and excessive waiting times

There were 3 medicine cupboards at Medina House School which were unlocked or keys kept very close

The Medicine Fridge storing vaccinations at the school nurse base was reporting high temperatures.

Adrenaline was stored in an unlocked staff fridge with no monitoring of the temperatures by the District Nurse (DN) team.

Treatment Rooms on the general rehabilitation ward and stroke unit were unlocked and contained unlocked pharmacy return boxes containing medicines

There were no facilities for medicines storage in the discharge lounge

The Ambulance Station was not secure and there was no garage door

Inadequate segregation of clean and dirty equipment in the equipment cleaning area. There was a risk of contamination

The Emergency Department did not meet the minimum registered nursing levels for safe care

There is insufficient Consultant Medical Cover in the ED to cover 16 hours a day

There is not the appropriate levels of nursing staff in acute medicine- Coronary Care Unit (CCU)

Nurses on CCU were not appropriately trained and did not have competencies for some patient’s needs

ITU Staff were not appropriately trained to care for medical outliers

There was inadequate supervision of independent non-medical prescribers in community and adult services

Introduction This report sets out the steps the Trust has taken to address the conditions that have been imposed:- • The specific conditions imposed within the Section 31 letter; • Actions already taken to address the condition, their current status, evidence, and the level of assurance reached; • How risks are being mitigated in the interim, until all actions have been undertaken and there is sufficient assurance that the

actions have had the desired outcome; • Further actions planned to resolve the above. For the Trust to gain assurance that actions have been undertaken, the evidence is being reviewed internally by the relevant Clinical Business Unit (CBU). The Trust will use its governance framework to assure evidence on the actions being taken to address the CQC concerns contained within the section 31 letter. Given the serious nature of the Section 31, assurance and actions for Mental Health has been led and reviewed by the Trust Mental Health Improvement Group. This is a task and finish group with the responsibility of ensuring the progress of actions and mitigations around the mental health services provided by the Trust. This group is chaired by the Chief Operating Officer, meets fortnightly and directly reports into the integrated improvement framework [IIF] Programme Group for Mental Health, chaired by the Chief Operating Officer. To provide assurance that actions are consistently delivering the outcomes, planned audits have been and will continue to be undertaken. The key assurance committee is the Trust Quality Governance Committee, a sub-committee of the Board. Using the defined assurance definitions [Table 1 below] the Quality Governance Committee make recommendations to the Trust Board for sign off.

Table 1 – Assurance Definitions

3

Substantial Assurance

Based upon our findings there is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. This level of assurance is only reached when the Trust Quality Governance Committee has signed off the evidence and action.

Reasonable Assurance

Based upon our findings there is a series of controls in place, however there are potential risks that they may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Reasonable assurance for the Trust Board will always be the position until such time as the Quality Governance Committee have reviewed the actions and the evidence and confirmed that they are content for the position to move to substantial assurance.

Limited Assurance

Based upon our findings the controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls.

No Assurance Based upon our findings there is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls.

4

Assurance Progress – Summary of Section 31

Section 31 Definition Apr 17

May 17

Jun 17

Jul 17

Aug 17

A Escalation Policy

Addresses the condition

Organisation assured that risks associated with the condition have been mitigated

B BCP &

Risk Assessment



C Care Planning & Documentation



D CMHS Strategy



G Ligature Risks



H Policies &

Procedures



Substantial Assurance Reasonable Assurance Limited Assurance No Assurance

Assurance Key

5

Assurance Progress – Summary of Regulation 17 Substantial Assurance Reasonable Assurance Limited Assurance No Assurance

Assurance Key

Regulation 17 Definition Apr 17

May 17

Jun 17

Jul 17

Aug 17

Person Centred Care: Community mental health care plans were not person centred or holistic



Dignity & Respect: The seating area at the end of the corridor on Afton ward not complying with privacy and dignity standards. Mixed sex accommodation and occurrences.



Safe Care & Treatment: 1) Care and treatment in Osbourne ward not safe. 2) Improved core assessment, care plans & risk assessment required in CMHS. 3) Jack & Jill bathrooms inappropriate. 4)temperamental locks on Shackleton & Afton wards. 5) No maximum and minimum temperature monitoring of medicine fridge on Seagrove. 6) Woodlands garden environment was not safe for use.



Premises & Equipment: 1) Osbourne Ward not to exceed 19 patients. 2) Staff alarm system to be fixed on Seagrove & Osbourne Wards






24/7 RSCN cover to ED. Also ED nurses to be trained in PILS and safeguarding up to level 3.



Overcrowding in ED and excessive waiting times



There were 3 medicine cupboards at Medina House School which were unlocked or keys kept very close



The Medicine Fridge storing vaccinations at the school nurse base was reporting high temperatures.



6


Assurance Key


May 17

Jun 17

Jul 17

Aug 17

Adrenaline was stored in an unlocked staff fridge with no monitoring of the temperatures by the District Nurse (DN) team



Treatment Rooms on the general rehabilitation ward and stroke unit were unlocked and contained unlocked pharmacy return boxes containing medicines



There were no facilities for medicines storage in the discharge lounge



The Ambulance Station was not secure and there was no garage door



Inadequate segregation of clean and dirty equipment in the equipment cleaning area. There was a risk of contamination



The Emergency Department did not meet the minimum registered nursing levels for safe care



There is insufficient Consultant Medical Cover in the ED to cover 16 hours a day



There is not the appropriate levels of nursing staff in acute medicine- Coronary Care Unit (CCU)



Nurses on CCU were not appropriately trained and did not have competencies for some patient’s needs

7


Assurance Key


May 17

Jun 17

Jul 17

Aug 17

ITU Staff were not appropriately trained to care for medical outliers - Marcia



There was inadequate supervision of independent non-medical prescribers in community and adult services



The Registered Provider must operate an effective escalation protocol in community mental health services. This escalation protocol will need to ensure patients are prioritised appropriately in response to service demands and pressures. There should be appropriate governance and leadership arrangements, and appropriate resources and support to the service and staff. The use of the escalation protocol should be on the corporate risk register and there should be clear mitigation and monitoring arrangements. The trust should ensure the escalation procedures are adhered to.

Section 31 - Specific Undertakings

A Level of Assurance Addresses the condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Substantial Assurance

8

Evidence to Date: • The following evidence was reviewed by the Clinical Business Unit

and the Quality Governance Committee; • Community Mental Health Services Standard Operating Procedure; • Early intervention psychosis Standard Operating Procedure; • CMHS Business continuity plan; • CBU Quality meeting minutes of 25th January 2017 approving the 2

SOP’s and Business Continuity Plan. • Sign off sheets indicating staff have read and understood the above

documents • DATIX incident logs relating to when caseloads exceed the expected

levels

Caseload Tolerances = 40 maximum (CMHS)

Actions Taken in the Last 4 weeks The Caseload data continues to be reviewed formally through the Mental Health Improvement Group on a fortnightly basis, and caseload management continues monthly.

In month Update The number of staff who have a caseload exceeding the anticipated maximum reduced to 3 in May. However the acuity of these 3 practitioner caseloads have been reviewed and it has been determined that they are manageable due to the acuity of the patients. Are in residential homes and therefore the acuity reduced making the caseloads safe.

Actions Taken to Mitigate Caseload management monitoring has become part of the Mental Health CBU performance Key Performance Indicators’ (KPI) and is reviewed currently via bi-monthly executive lead monitoring. Caseload data confirms that there are still 3 practitioners whose caseload exceeds the expected parameters as outlined in the standard operating procedures. As indicated previously a DATIX incident form has been submitted in relation to each of these. However, it has not been deemed necessary to adjust their caseloads as there are mitigating circumstances as to why the caseloads are manageable and patients managed appropriately and safely cared for. Staff receiving monthly management support and supervision.

The Registered Provider must ensure that every patient who has received a letter, as part of the current action taken under the business continuity plan, is risk assessed and appropriately managed. Each patient must have a documented risk assessment and a clear date for review. B

Level of Assurance Addresses the condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Substantial Assurance

9


Evidence to Date: • A Database of all 159 patients including; confirmation of risk

assessment and care plans are in the right place on PARIS and confirmation that this has been quality assured by a named senior clinician;

• Evidence that all 159 have been assessed and either discharged or held on caseload for active management;

• Community Mental Health Services Standard Operating Procedure;

• Early intervention psychosis Standard Operating Procedure; • CMHS Business continuity plan; • One new Matrons in post • Caseload Management and Clinical Supervision now taking

place and levels are monitored via the CBU Improvement Group

• All patients were sent a letter of apology from the Trust

Any other Significant New Actions Taken in the Last 4 weeks • No further actions taken

Patients Reviewed = 159

In month Update No further update required as condition addressed.

Actions Taken to Mitigate No further update required as condition addressed. This action is complete

The Registered Provider must complete the review of the current caseload of each clinician. Each patient must be identified, have a full assessment of their needs and patients should be allocated for CPA according to the set criteria and guidelines. C

Level of Assurance Addresses the condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

10


Evidence to Date: • Initial consultant caseload review undertaken by lead consultant

psychiatrist • CPA audit of all patients with a risk assessment/care plan facilitated

by Quality lead and additional patients identified for CPA. • CPA audit tool in place and representative sample audit undertaken

monthly. • consultant and practitioner caseloads including % with a risk/core

assessment reviewed at the mental health improvement group fortnightly, and CBU improvement group weekly.

• Nurse led clinics operational to support reviews being undertaken.

Any actions taken to recover the position on the key indicators • An additional nurse has been appointed to increase capacity in the

nurse led clinics • Business Case submitted to increase practitioner capacity across the

CMHS by 4 wte in order to ensure that all patients have a named lead clinician who oversees their care.

• Assertive outreach approach being utilised with patients who fail to attend for their appointment.

• As reported previously in relation to the 110 patients who had been seen in the previous 8 weeks who did not have a risk assessment . This was investigated and by far the majority of these patients had been seen by a Locum Consultant who no longer works for the Trust.

Key Indicators in the Month

Please Note: Data is refreshed on varying times across the month

June 17 July 17

% of patients with a risk assessment and care plan on PARIS

As of w/e 18/06/17 73.31% (21.46% increase in the last 12 months) 404 outstanding

As at W/E 09/07/17 76.7% 360 outstanding

Total patients open to CMHS without core assessment and risk assessment

404 (as of 25-6-17) 360 as of W/E 09/07/17

Proportion of patients on CPA As of w/e 11-6-17 20.98%. Increased by 13.47% from w/e 12/06/2016 compared to w/e 11/06/2017

As of W/E 09/07/17 21.4%. 13.76 % increase from 10/07/16 to 09/07/17.

Revised Core and risk assessment tool installed on PARIS

Due 17-11-17 Due 17-11-17

Clinical risk assessment training compliance

CMHS 79% (as of the 2-6-17 Non CMHS 68% (as of the 2-6-17)

CMHS 75% Non CMHS 66% As at 13/07/17

Refocussing CPA training compliance 80% (as of the 2-6-17)

83% As at 13/07/17

The Registered Provider should agree a comprehensive community mental health services improvement plan. There should be the necessary external advice and agreement for this improvement plan. The plan should ensure demands on the service are appropriately escalated, assessed and managed. There should be structures that ensure national guidance and best practice is followed; that promote effective leadership, and review capacity and capability of staff; there should be sufficient resources and support to the service. Staff must be effectively supervised and supported to review their caseloads. The improvement plan should be adhered to and the necessary changes must be implemented at the appropriate pace and urgency.

D Level of Assurance Addresses the Condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

11


Evidence to Date: • Community MH service improvement

plan; • Minutes from MH Improvement group

where the plan was discussed on 27th March 2017;

• Emails to and from Clinical Director for Solent Community and Mental Health Trust;

• Appointment of a number of Senior Clinical Staff;

• Appointment of Director of MH to add further Board capability;

• MH plans part of the Trust’s overall integrated improvement framework focusing on operational and more strategic issues.

In month Update The following improvements were identified at the CMHS workshop held on the 16th June. (1) Make better use of resources available for the service (recognising lack of resources (7 mentions) (2) Reduce long delays in access to treatment (6 mentions) (3) Improve access to psychological therapies (5 mentions) (4) Reduce gaps between services, (5 mentions) (5) Improve engagement/integration with third sector services and joint working with the Local Authority (5 mentions) (6) Improve communication between and among services involved in mental health (5 mentions) (7) Improve access to services (4 mentions) (8) Improve service user engagement and listening to service users (4 mentions) (9) Develop and use collaborative care plans that reflect a whole pathway approach that are focused on outcomes (4 mentions) A Meeting booked to develop and link in with the original plan for the re design of CMHS Two workshops were held one with NHS staff (internal) and one held with third sector volunteers and patients (external). Feedback produced these 9 key things. Out of the internal and external workshops it’s identified how many times these themes were mentioned. Plan is being reviewed in light of the internal and external resources and STP. A further plan will be submitted November via the IIF.

The registered provider must carry out an urgent assessment of the physical environment on the inpatient mental health wards at St Mary’s Hospital. The trust must ensure there is a comprehensive ligature assessment and an action plan to mitigate the risks. The action plan must include a stated time for completion. The assessment must cover all inpatient mental health wards and environments. There should be effective leadership, and the necessary resources and support to ensure changes have appropriate governance, are appropriately supported and are implemented with the necessary pace and urgency.

G Level of Assurance Addresses the Condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

12


Evidence to Date: • Comprehensive risks and ligature action plan; • Broader environmental risk action plan; • Board Seminar Agenda from 8th March and the 5th

April; • Fortnightly ligature risk review meeting minutes; • Ligature Policy Approved at Corporate Governance

and Risk Sub-Committee held 10th January 2017; • Specialist Director level estate support engaged to

test and mature current plans; • Berkshire Healthcare NHS FT have been asked to

undertake a full audit and assessment of our work to date on 20th June for 3 days

Context

June July **

Ligature risk training compliance (new training)

100% 100%

Total Risks Identified 2582 2582

Manged through mitigation - See slide 13 848 848

Total to be managed 1734 1734

Outstanding as at end of reporting period 1178 1178

Sevenacres – Ligature Risks 84% complete External review complete. Final report received by the Improvement Director on the 14th July 2017. Proposal for estates work in relation to ligature’s and costings for the work to be completed is to be presented to Trust Board Seminar on the 18/07/17. Mitigation – Ligature cutters on ward and staff aware of location and process to follow.

Shackleton – Ligature Risks 7% complete Immediate ligature risks and associated improvements (interim solution) on plan to address by 31/10/2017. High level brief to be presented at Trust Board Seminar on the 18/07/17. Mitigation – Ligature cutters on ward and staff aware of location and process to follow.

Woodlands – Ligature Risks 10% complete New lease (with break clause) on track for completion by 04/08/2017. High level brief to be presented at Trust Board Seminar on the 18/07/17. Mitigation – Ligature cutters on ward and staff aware of location and process to follow.

**remains same as awaiting outcome of review

G Level of Assurance

Addresses the Condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

13


Current position for actions due by. This may change following the presentation at Trust Board Seminar on the 18th July of the proposal for estates work in relation to ligature’s, costings and timescale for the work to be completed. 2582 risk were identified 1297 of these risks are being managed by procedure and policies 724 litigations are fully mitigated and therefore complete 521 are being mitigated through observation, policy and procedure which will be fully completed by January 2018 through the estates project

1 Area in Full View of Staff 4 Controlled Access 6 Public Area on Ward2 Area Locked, No Patient Access 5 Minimum 1:1 Supervision 7 Risk Removed3 Area Locked, Supervised Use Only

The registered provider must immediately review its policy and procedures and governance arrangements to ensure there is appropriate assurance to identify, assess, manage, mitigate and monitor all environmental risks to patients’ care and safety across all inpatient mental health services. This includes where patient privacy and dignity may be compromised. The governance arrangements need to identify where additional resources and support are required and how staff will be supported to understand what actions need to occur to effectively manage all environmental risks.

H Level of Assurance

Addresses the Condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Reasonable Assurance

14


Evidence to Date: • Revised Risk Management Strategy and Policy ratified and

approved by the Trust Board on the 8-2-17 • Ligature risk assessment policy ratified and approved at

the Corporate Governance and Risk Subcommittee on the 10-1-17

• Email re policy draft for comment to senior leaders in the CBU

• CBU meeting minutes including feedback from CQC • Fortnightly CBU Ligature Risk meeting minutes 24

November 2016 & 7 February 2017 • Attendance list for CBU dedicated risk management

training session. • Risk Management Training slide pack • Evidence of regular CBU risk meetings recorded in new

notes field for each risk/issue. • Terms of Reference for the 3 senior CBU meeting relating

to management of risks and issues.

Any other Significant New Actions Taken in the Last 4 weeks Contact made with the Medical Director, who has responsibility for the environmental audit checklist to check on progress. MD indicated this would be resolved imminently – currently awaiting the outcome from this review.

External estates confirm and challenge External review carried out and final report received on the 14th July 2017. Proposal to address the Jack and Jill bathrooms to be presented to Trust Board Seminar on the 18/07/17. This has been informally agreed and forecast will be formally presented to the Board 6 September 2017. Works will commence 25 September subject to Board approval. If approved full works schedule will be developed and shared.

15

Regulation 17 - Specific Requirements Person Centred Care - Community mental health care plans were not person centred or holistic and lacked any detail to enable staff to understand individual needs and monitor progress. 1.1


Level of Assurance

Evidence to Date: • Monthly representative sample quality assurance

audits are being undertaken in relation to risk assessments and care plans.

• Audit outcomes are being presented to the CBU Quality Meeting to determine actions required.

• Audit outcomes also presented to the Mental Health Improvement Group by exception for further assurance.

• Clinical Risk Assessment in-patient competencies x 4 introduced.

• CPA audit undertaken, and higher proportion of patients now allocated to CPA

• Regular ward based audits undertaken by the Head of Nursing and Quality / Inpatient Matron to assess the quality of risk assessments and care plans


Any other Significant results and actions from audits and/or quarterly unannounced visit by CBU triumvirate External review complete by Berkshire NHS Trust. Initial draft report indicates that staff can clearly articulate risks and how they manage risk on a daily basis, however there were concerns raised around the inconsistency of documentation of risk and risk management. Sourcing an external resource to work with individual staff around care planning and risk assessment.

June 17 July 17

Clinical risk assessment training compliance (CMHS)

CMHS 79% (as of the 2-6-17

CMHS 75%** As at 13/07/17

Clinical risk assessment training compliance (non CMHS)

Non CMHS 68% (as of the 2-6-17)

Non CMHS ** 66% As at 13/07/17

Care planning for Mental Health CMHS (commenced 31-5-17)

52% as of the 2-6-17

90% as of the 12/07/17

Care planning for Mental Health (non CMHS) (commenced 31-5-17)

8% as of the 2-6-17

63% as of the 12/07/17

**Clinical risk assessment training compliance – decrease seen in July due to staff capacity however they are now booked on the session on the 21st August 2017. One staff member also had requirement removed and the number of eligible and staff trained have both reduced by 1 since last report

16

Regulation 17 - Specific Requirements Dignity & Respect: The seating area at the end of the corridor on Afton ward not complying with privacy and dignity standards. Mixed sex accommodation and occurrences. 2.1


Level of Assurance

Seating area Afton Ward Evidence to Date: • Due to patient wishes it was agreed that frosting would be

installed to left hand fire escape door only so as not to obscure the view, however, Anti ligature curtains have also been installed in May 2017, and can be drawn at the request of patients to prevent dignity breaches. Signs in bathrooms regarding use of bathrooms

Mixed Sex Evidence to Date: • All contingency areas were closed at the beginning of

February 2017 and have remained closed • A revised contingency bed escalation protocol is in place

which reduces the risk of utilising areas where a mixed sex breach was a risk

• The Trust practice around single sex compliance has been externally reviewed leading us to improve our policy and procedures to include the use of mixed sex accommodation. Staff have received training to include a comprehensive focus in reducing the risk of “Mixed Sex Occurrence”.

• Immediate solution to the mixed sex breach issue relating to the Jack and Jill bathrooms in MH.

Any other Significant New Actions Taken in the Last 4 weeks External review carried out and final report received on the 14th July 2017. Proposal to address the Jack and Jill bathrooms to be presented to Trust Board Seminar on the 18/07/17. This has been informally agreed and forecast will be formally presented to the Board 6 September 2017. Works will commence 25 September subject to Board approval. If approved full works schedule will be developed and shared.


Number of DATIX identified for single sex

0 reported from the 03/05/17 to 16/07/17

17

Regulation 17 - Specific Requirements Safe Care and Treatment: 1) Care and treatment in Osbourne ward not safe. 2) Improved core assessment, care plans & risk assessment required in CMHS. 3) Jack & Jill bathrooms inappropriate. 4)temperamental locks on Shackleton & Afton wards. 5) No maximum and minimum temperature monitoring of medicine fridge on Seagrove. 6) Woodlands garden environment was not safe for use.

3. 1/.4/.5/.6

/.9/.13


Level of Assurance

Evidence to Date: • Bank staff are being utilised to cover the out of hours

service, whilst substantive recruitment is underway. • Ward environmental checks are carried out daily. • Medicines fridge temperatures are being recorded daily in

line with the SOP and reported monthly to the CBU. This forms part of a Trust wide monitoring database.

• A Health and Safety inspection of the Woodlands garden was undertaken on the 20th December 2016, and actions were undertaken to address the identified risks. These actions have all now been completed.

• The smoking shelter within the Woodlands gardens has been removed.

• Repairs have been made to the greenhouse. Broken furniture etc. has been removed.

• The garden is checked daily as part of the environmental checks.


Afton Ward tender out to the market Red

Preferred supplier agreed Red

Works being completed according to plan Red

Manchester Audit Tool Training [ Total Staff Identified]

29

Total staff completed training to date 18

Any other Significant New Actions Taken in the Last 4 weeks Proposal to address the Jack and Jill bathrooms to be presented to Trust Board Seminar on the 18/07/17. This has been informally agreed and forecast will be formally presented to the Board on 6 September 2017. Works will commence 25 September 2017 subject to Board approval. If approved full works schedule will be developed and shared. Ligature Training - Additional training sessions are currently being arranged with capacity of 30 to cover outstanding 11 MHLD staff. The excess will allow access for Paeds/Rehab/ED/Appley/Colwell/Whippingham and Estates staff

18

Regulation 17 - Specific Requirements Premises & Equipment: 1) Osbourne Ward not to exceed 19 patients. 2) Staff alarm system to be fixed on Seagrove & Osbourne Wards

4.3/.4

Addresses the Condition Substantial Assurance



Level of Assurance

Evidence to Date: • Osborne has not exceeded the bed capacity of 19 since the

initial report was received from the CQC. • Revised alarm has now been installed (7-6-17) and functions

well. Draft Standard Operating Procedure produced and awaiting sign off at the CBU Quality meeting. During this intervening period staff have continued to carry an Ascom alarm. Personal alarms have been issued to staff and the Security nurse on the ward carries an additional radio which immediately communicates to the following areas:

• All Mental Health Wards • Security



2.2




Level of Assurance

Evidence to Date: • The Non clinical transfer SOP has been updated and approved at

Executive Led Operational Management Group Meeting (OMG) December 2016. This has subsequently been added to the Trust Patient Transfer Policy.

• A non-clinical transfer code has been added to the Trust DATIX system. Daily reports on non-clinical transfers, has been requested but yet to be fully developed, currently weekly reports are being provided.

• Reports from Datix on non-clinical transfer are reviewed by Clinical Capacity and Patient Pathway manager.


June July Aug

EoLC non clinical moves reported during the period

Zero

Zero

Root Cause and Action Taken Patient transfer form has now gone live w.e.f 17 July 2017. Communication plan and training of relevant staff now completed. PIDS on a monthly basis will provide reports on non-clinical transfers for monitoring to the Clinical Capacity and Pathway Manager.

June July

Osbourne admissions greater than 19 None None

Alarm test compliance Yes Yes

Number of Datix submitted for alarm failure

None None

Key Actions Taken to Improve Key Indicators Standard operating procedure completed and is on the Agenda for the Quality and Risk meeting for approval on the 19/07/17

19

Regulation 17 - Specific Requirements 24/7 RSCN cover to ED. Also ED nurses to be trained in PILS and safeguarding up to level 3 3.2

Addresses the Condition Limited Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

Level of Assurance

Evidence to Date: • Open advert for dual trained nursing staff with incentives. • Business case being developed and presented in June for the

development of a PAU. • Increased PILS training. • Increased safeguarding training,


Key Actions Taken to Improve Key Indicators • Agency and substantive posts out to recruitment struggling to fill via

agency • Band 5 ED Nurse (paediatric trained) appointed and due to commence

beginning of August • Agency paediatric staff and staff from the paediatric service are being used

to ensure cover within the ED • ED/Paediatric team from UHS visited at the end of June &

recommendations are currently being reviewed around training nurses differently to meet the demands. Final full report awaited from UHS.

• PILS and safeguarding for all staff has been undertaken and completed. 24/7 RSCN cover and financial allocation has been roster for currently we are using Bank and Agency whilst we appoint to comply with this.

Overcrowding in ED and excessive waiting times 3.3

Level of Assurance Addresses the Condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Reasonable Assurance

Evidence to Date: • A draft Standard Operating Procedure has been written to

support the escalation. • Review of breaches to identify specialty review and late

discharges as the key challenges • Two new locum Consultants appointed. Another 2 out to advert.


Key Actions Taken to Improve Key Indicators • ED full capacity SOP out to consultation within CBU. To be

ratified at July CBU Governance Meeting. • Ambulance draft escalation / handover protocol in development. • Draft RAT’ing procedure developed by clinical lead. To be agreed

at July Consultants Meeting. • Identification of designated Ambulance handover bay. • Key performance data requested to analysis internal and

external departmental timeliness and efficiencies. • 88-90% compliance for July which has reduced the over

crowding there is a SOP in place which has been reviewed in light of breaches having been reduced. We are currently working to 8 consultants in ED which has i9mporved capacity.

• Daily Ward reviews has had a significant impact on flow.

25.5.17 – 24.617 25.06.17 - 16.07.17

Staff in ED who are PILS trained 21 of 27 21 of 27

Level 1 safeguarding training in ED 89% 89%



% of Shift/Fill availability of paediatric nurses in period

n/a % data to be provided in next report

25.5.17 – 24.617

25.06.17 - 16.07.17

Number of hours ED has more than 33 patients

219 90

Number of days full capacity triggered

28 Awaiting data review outcome

Number of days Opel 4 triggered 3 0

Regulation 17 - Specific Requirements There were 3 medicine cupboards at Medina House School which were unlocked or keys kept very close 3.7 The Medicine Fridge storing vaccinations at the school

nurse base was reporting high temperatures. 3.8




Level of Assurance Addresses the Condition Substantial

Assurance Organisation assured that risks associated with the condition have been mitigated


Level of Assurance

Evidence to Date: • The Trust is helping the school to implement ‘Supporting Pupils at

School with Medical Conditions’ statutory guidance for state funded schools

• All cupboards now locked. • Audit results being reviewed by School Nurses with Teachers. • School has adopted Trust guidance. • To date 2 unannounced checks have taken place with full

compliance observed. • Part of medicines management routine annual audit.

Evidence to Date: • Daily Checks in place in line with the SOP for recording medicines

fridge temperatures, with a sign in temp sheet / log. • Instructions for resetting the maximum and minimum readings

have been provided. • The Head of Service is checking the logs on a daily basis these are

scanned and sent to the CBU Quality meeting monthly.


June July Aug

Audit undertaken this month

Yes Yes

Compliance Results 100% 100%

Key Actions from Audit As at 23.6.17 All recent audits have demonstrated 100% compliance. Action will be closed after evidence of assurance presented to the QGC Independent external review undertaken 20.7.17 and results to be reviewed


June July Aug

Daily Log max or min temperatures compliance

100% 100%

Audit undertaken this month Yes Yes


Key Actions from Audit As at 23.6.17 All recent audits have demonstrated 100% compliance. Action will be closed after evidence of assurance presented to the QGC. Independent external review undertaken 20.7.17 and results to be reviewed 20

21

Regulation 17 - Specific Requirements Adrenaline was stored in an unlocked staff fridge with no monitoring of the temperatures by the District Nurse (DN) team

3.10 Treatment Rooms on the general rehabilitation ward and stroke unit were unlocked and contained unlocked pharmacy return boxes containing medicines

3.11







Level of Assurance

Evidence to Date: • The DN’s have been educated about the correct storage of

adrenaline. • service has now been provided with a locked medicines cabinet. • Audit by Pharmacy Locality Leads monthly and is also now part of

medicines management ongoing annual audit.


June July

Daily medication check list compliance

90% for months of

May & June

90%

Audit undertaken this month by pharmacy

Yes Yes


Key Actions from Audit Medication locked cabinets in bases now attached to walls. Awaiting confirmation from pharmacy re interval timescale between audits and feedback from latest audit.

Evidence to Date: • functioning locks and are monitored daily for compliance with the

SOP. • Concerns with compliance are reported on DATIX • All medicines deliveries are in sealed tamper evident containers • A works request has been made to improve the locking systems

on the treatment room doors.


June July

Locking systems on treatment doors fixed

Yes Yes


Checks undertaken this month Yes Yes


Key Actions from Audit Awaiting confirmed quote from Estates team for swipe card locks for both treatment room doors which will improve ease of entry for staff when carrying equipment this does not impact on meeting the above condition Evidence to be provided to the Quality Governance Committee for 26 September meeting.

22

Regulation 17 - Specific Requirements There were no facilities for medicines storage in the discharge lounge 3.12 The Ambulance Station was not secure and there was no

garage door 4.1







Level of Assurance

Evidence to Date: • Mobile POD locker unit and stock storage units ready for

immediate access for contingency beds • Audit results have been presented to the CBU Quality Group at

the Monthly Meeting commencing January 2017 and is dependent on whether contingency beds are opened.


June July Aug

Contingency beds in discharge lounge used

No No

Medicines Trolley with individual locked drawers available

Yes Yes

Key Actions No further action required and will be presented for closure to the QGC at the August meeting as evidence is currently being collated

Evidence to Date: • A new garage door was ordered on 23rd December 2017 and

delivered to the island during week commencing 27th February 2017.

• The New door was installed during the last week of February 2017 and is now in place and fully operational.

• Any future issues identified will be immediately raised to the duty officer or on-call officer out of hours.

• An issue log will be maintained and any problems that arise in the future will be reviewed in the CBU Quality Meeting from April 2017.

Key Actions No further action as door now installed and fully operational will be closed after evidence presented to the QGC at September meeting as evidence is being collated currently and is to be presented to the CBU

23

Regulation 17 - Specific Requirements Inadequate segregation of clean and dirty equipment in the equipment cleaning area. There was a risk of contamination 4.2 The Emergency Department did not meet the minimum

registered nursing levels for safe care 5.1







Level of Assurance

Evidence to Date: • Consultant Nurse for IPC has contacted department and reviewed

and inspected the premises on Thursday 22nd December 2016. • The department has purchased plastic curtains to assist in

segregation of clean and dirty equipment; these have been in place since 20th February 2017.

• IP&C Consultant Nurse continues to monitor the risk with surveillance reports presented at The Infection Prevention and Control Group and reported through to the Trust Quality Governance Committee monthly.

• service is owned and managed by the Local Authority, who also own the building.

• Curtained structure in place. • Hazard tape in situ on floor marking designated area of curtained

space. • Signage in place identifying purpose of area. • Local Authority have taken over management of store. Request

submitted to CQC liaison officer to close this action for the Trust.

Service no longer run by the Trust and will be closed after evidence presented to the QGC

Evidence to Date: • A trajectory showing the new staff arriving. • ED staffing monitored by Matron and ED Sister daily. • 145% registered nursing shifts covered from 1st May (143% in

April). An additional nurse has been placed on night shift which is above the current agreed establishment.

• 66% Unregistered nursing shifts covered from 1st May (68% in April)


June July

Workforce plan agreed No No

Agency Request and fill rates 100% 100%

Substantive Posts Commenced Against Workforce Plan

1 wte B6 1 wte B5

1 wte B6 1 wte B5

Key Actions • ED Reception vacant posts recruited (91.5 hrs) Due to

commence post within 4 weeks – end of July 17 • Identification of Band 4 post to assist with ED and Ambulance

handovers. Advert will be placed with two weeks of agreement to recruit.

• There has been an increase in staffing shifts being covered in ED.

Regulation 17 - Specific Requirements There is insufficient Consultant Medical Cover in the ED to cover 16 hours a day 5.2 There is not the appropriate levels of nursing staff in acute

medicine- Coronary Care Unit (CCU) 5.3







Level of Assurance

Evidence to Date: • 2 Additional Locum Consultants commenced 11th May and 1st

June 2017. • consultant staff providing cover for the period 8am – 8pm [12hrs]

Monday to Friday and 8am – 4pm at weekends [8hrs]. • A further 2 Locums out to advert to accommodate 16 hours ED

cover. • 100% of agency requests fill rates reviewed by CBU. • Daily Staffing monitored/reviewed by CBU. • Electronic job plan portal. • Incident reporting mapped to Consultant presence using DATIX

for review by CBU.


June July

Compliance of 12 hour weekday and 8 hours weekend Consultant cover with 6 Consultants

100% 100%

Locum Interest Received No No

Interview Dates Agreed No No

Appointment(s) Made and Start Dates Agreed No No

Key Actions Draft rota being developed to evidence how 16hrs would be covered.

Evidence to Date: • The Trust has recognised that ‘Safer Staffing’ levels cannot

currently be achieved on CCU without the use of agency and bank staff. 1.64wte have now been recruited and have commenced in post in February and March 2017.

• 100% of agency requests fill rates reviewed by CBU • Daily Staffing monitored reviewed by CBU • Evidence of report. Skill mix and staff deployment reviewed when

short staffed. • Twice daily staffing covering all in-patient beds has commenced. • Additional recruitment of 1.0 WTE substantive appointment. Start

date May 2017.


June July

Safer Staffing Level Compliance Average fill rates for RN’s

87.5%

Average fill rates for RN’s

84.7 %

Key Actions • Tight management of all sickness utilising Bradford scores in

conjunction with HR • Twice daily ICU/CCU staffing reviewed to assess how the units can

assist with shift cover for short term sickness as required • All bank shifts escalated to HR three weeks in advance • Average fill rates for RN’s 84.7 % • Further recruitment over establishment now agreed 24

Regulation 17 - Specific Requirements Nurses on CCU were not appropriately trained and did not have competencies for some patient’s needs 5.4




Level of Assurance

Evidence to Date:. • BIPAP training has taken place and competence assessment for all

staff has been completed as at 31st March 2017 • Training records uploaded to the DATIX system • CBU leading a collaborative on the recording of competence on

medical devices to reduce the risk • Mandatory Training reviewed at CBU Quality and Patient Safety

Group • All staff have completed competency assessment for BiPAP records

available for review • CCU identified as a pilot project area for Medical Devices QC May till

October 2017


ITU Staff were not appropriately trained to care for medical outliers 5.5




Evidence to Date: • ITU staff were not trained to use the Electronic Patient Prescribing

and Medicines Administration system (EPMA). • When supporting contingency beds they were unable to

administer medicines unaided and patients may have sustained delays in receiving medication.

• Training records uploaded to the DATIX system including a copy of competence.

• All Mandatory Training reviewed at Clinical Business Unit Quality and Patient Safety Group.


June July Aug

Compliance of EPMA Training for ICU Staff

100% 100%

Hardware for ICU utilisation of JAC sourced

Yes Yes

JAC system implemented No No

Key Actions • Substantial assurance will be achieved once ICU fully

transfers to the JAC system which will be implemented following a trust wide JAC upgrade date to be confirmed. Retraining will occur annually in the period that the staff are not using the system regularly if upgrade is delayed

July Aug

Staff signed for as competent in BiPAP NIV therapy

100%

Reviewed at Quality and Patient Safety Group Yes

Competencies developed for all medical devices in CCU

100%

Key Actions • Staff sign off for all medical devices aiming for 50 % compliance end

of August , 75% by end of September and 100% by end of October • A renewed focus to get mandatory training to 100% has been

launched within the CBU 25

Regulation 17 - Specific Requirements There was inadequate supervision of independent non-medical prescribers in community and adult services 5.5




Level of Assurance

Evidence to Date: • There has been a robust clinical supervision process

implemented in Community Nursing. • work is underway to review the work of advanced practitioners

in the Community through the Consultant in MAU. • Advanced Nurse Practitioners in Community are being

supervised by MAU Consultant and supported in their prescribing.

• Community Matrons are sourcing supervision from Locality GP’s in practice.

• One GP practice has expressed an interest in supporting the Supervisor/Prescribing Mentor role.


June July

Non-Medical Prescribers in Community & Adult

Services on a single list

Yes – Community Nursing

Yes – Community Nursing

Staff receiving supervision Community Matrons – peer supervision & %

Community Matrons – peer supervision & %

Annual audit compliance

Key Actions Email received from GP at Esplanade Surgery to offer to undertake supervision to NMP. GP unavailable at present to plan dates as on annual leave. This will be chased up on return mid-July to clarify dates 26



On 6th September 2017

Title Shackleton Ward and Older Peoples Mental Health


Kevin Bond, Director of Mental Health

Author(s) Kevin Bond, Director of Mental Health and Joanne Ferguson, Executive Assistant to Chief Operating Officer

Purpose Decision to progress on temporary provision for older peoples mental health which meets CQC requirements and meets conditions of Sec 31/Regulation 17


Receive Approve X










Please add any other committees below as needed Board Seminar June/August To develop an acceptable solution to meet

CQC conditions relating to Shackleton meeting Sec31/Regulation17 requirements and continued registration in a timely and thorough enough manner, to ensure continued service before full dementia strategy

Other (please state) Previous trust board discussions relating to full CQC

requirements Integrated Improvement Framework: IIF Workstream 2.9

Section/Clause 2.9.1 - 2.9.16 Section/Clause Section/Clause

Staff, stakeholder, patient and public engagement: Staff and CCG discussions throughout. CCG developing options for future older peoples care as part of 4 priorities for local care board

Enc H



The CQC have issued notices under Sec 31 and regulation 17, with many particular references to Shackleton ward. In addition, the Trust has discussed the service provision on Shackleton, separately to CQC, and it is felt that the facility is not fit for modern purpose. Several mitigations have taken place to ensure safety and the end strategy being developed by commissioners is one that will require bespoke, up to date and fully appropriate facilities linked with the community, these will likely take over 2 years to facilitate. It is felt that maintaining Shackleton in its mitigated state, is not acceptable for such a lengthy period and a solution is being proposed that will help services develop towards the anticipated commissioning goals, including partnering with step down beds. As such, a business case has been developed that will go to capital investment committee in September and back to Trust Board for approval in October. The preferred option is to adapt the most appropriate area for the purpose of maintaining 4 assessment beds for dementia, linked to step down, supported by our staff on an outreach basis. The option also takes into account views of staff, suitability for purpose, disruption and relocation of other services and reuse of Shackleton for wider need should the board agree. The business case will need to be developed and implemented at speed and will therefore take account of the phasing both in terms of the capital programmes for 2017/8 and 2018/19 and any enabling work and other service moves.

Recommendation to the Board: The Board is recommended to approve the progress of a business case that confirms any impact on the phasing of expenditure in 2017/18 and 2018/19.

The board is recommended to


A For following sections – please indicate as appropriate:

Trust Goals & Priorities All goals enhanced Principal Risks (BAF) Issue 1085


Requirement for CQC registration of overall services

Date: 28 August 2017 Completed by: Kevin Bond, Director of Mental Health and Joanne Ferguson, Executive Assistant to Chief Operating Officer



ON 6 SEPTEMBER 2017

Title Integrated Improvement Framework Programme Report Sponsoring Executive Director

Maggie Oldham, Interim Chief Executive Vaughan Thomas, Non-Executive Director (Chair of IIF Programme Board)

Author(s) Jo Case, Head of Service Improvement Purpose For review and discussion Action required by the Board:

Receive X Approve





Audit and Corporate Risk Committee




Please add any other committees below as needed Board Seminar Integrated Improvement Framework Programme Board

30/08/17 Progress on mobilisation of the IIF


Executive Teams, Non- Executive Directors, Operational Leads, Clinicians


The Integrated Improvement Framework Programme Board took place on 30th August 2017. Key Themes emerging across the Programmes were discussed:

• There are several examples of where working with partners is causing delays and placing extra demands on the work of the IIF.

• Annual leave and completing the ‘day job’ is causing delays to delivery of the IIF. As the IIF is the single most important agenda for the Trust this level of distraction is surprising.

• Interdependencies are not being managed to avoid delays and are impacting on key deliverables within the IIF. For example to support the Clinical Services; Human Resources – (Recruitment Strategy, Rostering and Safe Staffing levels) IM&T, & Estates.

Concerns and slippage in the following areas for Trust Board to be aware of:

• Mental Health Programme has been turned RED • Community Programme has been turned RED • Ambulance Programme has raised several concerns and the Exec Lead has taken the action to

really understand the issues and support the teams.

Enc I


Actions have been taken at Programme Board to address all areas detailed above and are for Trust Board awareness at this point. Items Agreed at Programme Board:

• Critical Path – agreed for Programme use only to focus key discussions at senior level. • Quality Impact Assessment (QIA) Identification – 24 QIAs have been identified for completion by

Medical Director • Programme Changes – with the lack of traction and slippage all programme changes have been

agreed with reluctance.

Recommendation to the Board: • To Note: Trust Board to note the areas of concern detailed in this front cover.

Attached Appendices & Background papers Report attached. For following sections – please indicate as appropriate:

Trust Goals & Priorities Excellent Patient Care Work with Others to keep improving our services A positive experience for patients, service users and staff Skilled and capable staff Cost effective, sustainable services

Principal Risks (BAF) Risk 671, Human Resources, Risk 676, ICT Strategy, Risk 673, Strategy and Planning, Risk 677, Local Health and Social Care Economy Resilience, Risk 674, Quality Governance, Risk 705, Board Capacity and Capability, Risk 675, Culture, Risk 712, Financial Resources


Date: 30th August 2017 Completed by: Jo Case, Head of Service Improvement

IIF Programme Board

Integrated Improvement Framework Highlight Report

Date: July 2017

To Note: Report is based on Master IIF Version 36

Key Messages Current Status

• Challenge to be given to at Programme Board of Programme status • Critical Path drafted for all Programmes to identify key work areas to give focussed discussions at Programme Board • There are a number of changes for this Programme Board to agree • Key Performance Indicators have been developed for Programme Board there are still a number of definitions to be identified

– explained throughout report • Communications Launch to Organisation of ‘Getting to Good’ • The Programme Board should now note the importance of getting a senior resource in to support the Governance, Leadership

and QI work stream and be responsible for administering some of the tasks and taking responsibility for preparing the work stream summary reports.

• A number of milestones are starting to be complete and evidence logs are in place now for all programmes. Evidence logs will

be approved via each Programme Group for assurance of completed Milestones.

Status Criteria: Red: Significant Issues to delivering agreed outcomes Amber: Progressing to Plan Green: Completed / Signed Off N/S: Not due to start

A

Integrated Improvement Framework Report

Delivery of Programmes is detailed within the following slides. Key milestones have been highlighted in red for information of the Board. There will be specific requirements of this Board, programme by programme that will need to be discussed and addressed. For each Programme some of the highlights and areas of concern will be brought to the attention of the Programme Board.

31st July 2017

1. Ambulance Programme To provide an clinically led 111 service that dispatches the right level of resource and directs potential patients to the most appropriate level of service for their needs. When an ambulance needs to be despatched it will arrive with the patient within target response times as often as is possible

Overall Rating A

Work Streams Milestones R A G N/S

1.1 To make the hospital handover process as timely and safe as possible so that ambulances can get back onto the road and respond to further life threatening calls A 0 0 6 0

1.2 To increase the coverage of the volunteer community first responder provision across the island using well trained staff who have access to the right equipment ensuring a safe and sustainable service

A 0 3 11 5

1.3 The deployment of our workforce to meet the known demands of the service through the implementation of new rota's

A 0 2 1 14

1.4 To ensure known vacancies are filled with well trained staff achieving full staffing with no vacancies and improved staff retention, so there are sufficient numbers of suitably qualified and competent staff and managers, to provide a safe, effective and responsive ambulance service

A 0 3 10 13

1.5 Embed the national directives of Nature of Call & Dispatch on Disposition to assess situations correctly and despatch the right level of resource to our patients

A 1 2 3 0

1.6 To assess the accuracy of data provided during the last two years to ensure Trust has correctly reported its ambulance performance

A 2 1 6 11

1.7 The Trust is compliant in the requirements of EPPR, CBRN and MTFA capability in the Ambulance Service as agreed by the Board A 0 5 3 3

1.8 To have visibility of the service's response to patient needs and demonstrate improvements in it's performance A 4 1 0 3

1.9 To ensure equipment is available to for use by our ambulance crews to respond quickly to all patient needs G 0 0 10 0

1.10 Ambulance Services - CQC Specific actions which require resolution A 5 3 9 0

1.11 CCG Responsibilities A 0 7 0 0

1.5 - KPIs and reports developed with Valentia. PIDs are analysing the test data for accuracy currently and as soon as cleared will begin reporting.

1.6 - On hold due to changes to Ambulance Quality Indicators and ARP 1.8 - High level audit completed, results not conclusive, another audit

requested based on weekly heatmap from PIDS to be completed by CSO CSD, 31.08.17.

1.10 - KPIs developed with PIDs and produced for CCG. Existing KPIs go to Ambulance service but CCG asked for enhanced set of KPIs which is being finalised with them. Potential cost implication if software alterations required.

Changing codes. Service now looking at swipe card system that gives authorised access as required by job role. So Ambulance driver swipe card will access Ambulance station and medicines cupboard on ambulance

Areas of Concern on plans that should be delivered by 31st July

1.1 – Awaiting finalisation of evidence then workstream to be signed off. 1.2 - Training of new CFRs starts in September 2017 1.5 - NOC and DOD showing significant improvement at 2.8.17, despite

slow start. Nationally the IOW service compares well in relation to see and treat

and hear and treat. 1.9 - Equipment is available to for use by our ambulance crews to respond

quickly to all patient needs – assessing impact of change before coming to Programme Board for Sign off.

Areas achieved on plans that were delivered by 31st July

Programme Board should acknowledge this

Future Areas of Concern New Ambulance service standards were announced on 13 July 2017 by NHS England.

Programme Board should explore this

1. Ambulance Services (1)

4

P AMB 1 Description Aggregate Position

% R

ed 1

Cal

ls

Res

pond

ed W

ithin

8

Min

utes % Red 1 Calls Responded

Within 8 MinutesMonitor Trajectory

towards target


% R

ed 2

Cal

ls

Res

pond

ed W

ithin

8

Min

utes % Red 2 Calls Responded

Within 8 MinutesMonitor Trajectory

towards target


% R

ed 1

&2

Cal

ls

Res

pond

ed W

ithin

19

Min

utes % Red 1&2 Calls Responded Within 19

Minutes

Monitor Trajectory towards target

Variation

-

Variation

-

-

Variation

0.010.020.030.040.050.060.070.080.090.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% W

ithin

Tar

get

Baseline Trajectory Target

0.010.020.030.040.050.060.070.080.090.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% W

ithin

Tar

get


84.0

86.0

88.0

90.0

92.0

94.0

96.0

98.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% W

ithin

Tar

get


1. Ambulance Services (2)

5


NH

S 11

1 - %

Cal

ls

Clo

sed

With

Clin

cal

Adv

ice

Onl

y

% of (TRIAGED) calls transferred to OR

answered by a clinical advisor

Target 50%

Variation

-

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Apr-1

6M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6No

v-16

Dec-

16Ja

n-17

Feb-

17M

ar-1

7Ap

r-17

May

-17

Jun-

17Ju

l-17

Aug-

17Se

p-17

Oct

-17

Nov-

17De

c-17

Jan-

18Fe

b-18

Mar

-18

% C

alls

Clo

sed


Measure of Success Due Date Status Update RAG

5. Standardised access to urgent care centres through NHS 111 31/03/18 CCG discussion ongoing for definition of standard NHS 111 A

2. Mental Health Programme Overall Rating A

Work Streams Milestones

R A G N/S 2.1 To take the necessary focused action and ensure

the service is compliant against CQC Section 31 and Regulation 17.

A 8 4 38 0

2.2 To develop and implement a clinical business unit infrastructure with sufficient capacity and capability that enables the safe and effective delivery of MH&LD services.

A 2 7 10 0

2.3 Ensure the patient environment is physically safe and protects the privacy and dignity of patients across the CBU at all times

A 0 3 2 0

2.4 Ensure Patient and Carer Stakeholder Feedback is captured and acted upon as part of the daily business across the CBU

A 0 4 1 1

2.5 Ensure that robust and embedded Quality governance arrangements are in place across the CBU which include clear escalation routes to the wider Trust

A 3 7 5 0

2.6 Ensure that robust and appropriate KPI's are in place for all CBU services and that there is a direct line of sight in relation to these from front line through to the board

R 8 2 6 0

2.7 Ensure that appropriate documentation is in place, and that across the CBU there is robust document control. This will provide staff with sufficient instruction and guidance to operate safely and effectively, taking into account the redesign work streams and therefore the needs to update documents as changes in process are made. In addition robust document control will support efficiency and effectiveness across the CBU.

R 3 3 1 0

2.8 Ensure that the MH&LD CBU has in place an appropriate Electronic Paper Record that is fit for purpose and support the Trust to capture, submit and analyse relevant data as required in order to meet local and national requirements and support service improvement

A 1 1 2 0

2.1 – Consultant only caseload risk assessments recording will be complete by end of August. Woodlands deep-dive complete – approach discussed with CQC & NHSI – final audit indicates compliant with only 2 minor changes required – report to be resubmitted to QGC September 17. Manchester ligature audit tool – all staff trained by 30/09/17 Jack & Jill Bathroom - Ensuite door design solution being reviewed by Berkshire – this will not delay the planned ligature works – expected start date September 2017.

2.2 – IIF shared and appraisals will now be completed by 31/03/18. Confirmation of MH CBU Structure will be completed by 30/09/17. 2.5 – Risk Management Training – additional sessions to be run through

September to capture remaining staff. CQUIN Quality Advisor recruited and work plan to be agreed by

21/08/17 2.6 - Delays in developing the mechanisms to enable data capture for the

identified KPIs due to capacity within PIDS. Escalated to Exec Lead 2.7 – Business Continuity Plans : Programme group agreed the key policies

which would impact safety and these will be completed first. Extension to workstream timeframes required.

2.8 - TOR not agreed for Clinical Reference Group– Chair to approve ASAP



2.1 – Section A & H of the Section 31– all milestones complete, evidence signed off by QGC.

Section C of the Section 31 re Care Planning and Documentation – 5 of 7 milestones complete. Caseload reviews complete, audit of risk assessment and care plans in place

Section G of the Section 31 re Ligature Risks – Comprehensive ligature/environmental risk assessments complete

2.2 - OOH recruitment for SPA complete 2.4 - A “You Said, We Did” poster has been produced and cascaded to all

public Mental Health and Learning Disability areas. 2.5 - Quarterly report outlining trend analysis and lessons learnt from

complaints, incidents and SIRI’s is reported in the CBU leadership Group



2. Mental Health Programme [2] Overall Rating A


R A G N/S 2.9 Shackleton - To ensure that Shackleton can

provide an appropriate Dementia Care Pathway that is fit for purpose and meets the needs of the ageing population of the Isle of Wight, whilst ensuring compliance with the CQC specific items relating to this Ward

A 5 9 2 0

2.10 Woodlands - To work in partnership with the CCG to deliver a new non medical model re-ablement strategy and provision for the Isle of Wight whilst ensuring compliance with the CQC specific items relating to this Estate

A 3 5 5 1

2.11 Reconfigure Acute care pathways through Single Point of Access and into the Community to deliver a safe and effective service for patients A 5 12 12 6

2.12 Redesign the Community Mental Health Services to ensure they are safe, effective in line with best practice, financially viable and outcome focused as well as ensuring compliance with the CQC specific items relating to this Service

A 5 15 5 0

2.13 Learning Disabilities - 1.Undertake a comprehensive review of the Community Learning Disability Service to plan, re-design and implement integrated NICE compliant treatment pathways for those with learning disabilities and/or autistic spectrum disorders and co-morbidities such as Attention Deficit and Hyperactivity Disorder (ADHD), significant mental disorders and behaviours that challenge for the adult population. 2. Ensure compliance with the CQC specific items relating to this service

A 1 5 0 4

2.14 CAMHS - Undertake a comprehensive review of Child and Adolescent Mental Health Services and ensure compliance with the CQC specific items relating to this service

A 1 8 4 2

2.15 IRIS - Undertake a comprehensive review of Island Recovery Integrated Service to ensure it is deliverable within the financial envelope and ensure compliance with the CQC specific items relating to this service

A 4 4 4 1

2.16 To review and deliver clear protocols for inpatient and community staff to better manage CPA and achieve 7-day follow up ensuring this meets national best practice.

A 1 2 0 0

2.9 – Capacity issues with the Breakaway/PI trainer . Meeting to discuss 22/08/17.

2.10 - Berkshire report and audit outcomes have indicated the need for further support in relation to risk assessment & care planning. SBAR has been written for Nurse Consultant post . TLC 24/08/17 for approval.

2.11 - Nurse Led Standard Operating Procedure to be agreed at MHIG 04/09/17

Competency over the CPA Competency and all staff should have completed by the 31/08/17

2.12 - Meeting arranged with Human Resources 31/08/17 to batch adverts and incentivise vacancies.

2.13 – MCA & DOLS , more training sessions are planned to ensure that the team embed the training.

2.14 - CPD (continuing professional development) for adult psychiatrists to discuss learning points and questions raised from out of hours cases.

2.15 - CBU environmental risk assessment top be drafted 31/08/17



2.9 - Decommission the seclusion room on Shackleton Ward 2.10 – Extension on Woodlands lease has been agreed 2.11 - Increase awareness of safeguarding issues and how to report them Introduction of new seclusion paperwork 2.12 - Robust process is in place to record and monitor fridge

temperatures-complete 2.14 - Review of incidents has been added as a standing item on team

meeting agenda for lessons learnt feedback and discussion



Future Areas of Concern

No areas for concern

2. Mental Health Services (1)

8

P MeH 1 Description Aggregate Position

Patie

nts

with

a fu

ll as

sess

men

t/car

e pl

an

and

CPA

leve

l al

loca

ted Number of patients known

to the service with a Risk Assessment Completed

Target of 100%


Cas

eloa

d m

anag

emen

t su

perv

isio

n

Caseload management supervision

If monthly is the standard then at 90% target

P WKF 16a Description Aggregate Position

App

rais

als Proportion of staff with current appraisal

completed in 12 month rolling period

95% in rolling 12 month period

Variation

Target may need to be reviewed unlikely to be 100% due to timing.

Improvement trajectory needs to be agreed

Variation

-

Currently only includes Community MH team

Variation

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% P

atie

nts


0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

visi

on


0.010.020.030.040.050.060.070.080.090.0

100.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% A

ppra

isal

s Co

mpl

eted



9

P WKF 13a Description Aggregate Position

Clin

ical

Sup

ervi

sion

Proportion of relevant staff receiving clinical supervision in line with

policy

-

P QUA 22a Description Aggregate Position

Ris

k M

anag

emen

t Tr

aini

ng Compliance with risk management training

requirements-


Patie

nts

bein

g fo

llow

ed u

p w

ithin

7

days

of d

isch

arge The proportion of people

under adult mental illness specialties on CPA who were followed up within 7 days of discharge from

psychiatric in-patient care during the period

Target of 95%

Variation

Which key professional groups?Speak to Bev Fryer re MH

spreadsheet

Variation

-

Note, training needs analysis being undertaken and approach will

change significantly. Unable to currently say % untrained risk staff

in CBU

Variation

0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

vise

d


0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

vise

d


84.086.088.090.092.094.096.098.0

100.0102.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% C

ompl

eted



10

P MeH 17 Description Aggregate PositionIn

-pat

ient

and

car

ers

loca

l sur

vey

Local survey for in patient and carers increased

positive response

5% increase - Q210% increase - Q3 15% increase - Q4


Com

plai

nts,

SIR

I's a

nd

inci

dent

s co

mpl

eted

w

ithin

the

Trus

t re

quire

d tim

esca

les

Complaints, SIRI's and incidents are completed within the Trust required timescales by 31/03/17

1% Quarterly Increase

Variation

-

TBC

Variation

0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

-


0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

-


3. Community Programme Overall Rating A To Develop an Infrastructure alongside partner colleagues that delivers more care, that is safe, closer to home for the people of the Isle of Wight


R A G N/S 3.1 Adult Services - To have caseloads that are

consistent across all staff and ensure patients are managed safely

A 0 13 1 9

3.2 All Services - Developing a workforce that is resourced to provide safer care A 0 6 7 1

3.3 Adult Services - Ensure the right patients are accessing services with well written specifications

A 0 3 1 1

3.4 Adult Services - Improved record keeping for patients and staff have skills and competencies to use IT systems available to them.

A 0 10 4 7

3.5 Adult Services - To improve access to service provision and care for patients with frailty needs

A 0 12 0 2

3.6 Adult Services - More rehab patients cared for in a community setting closer to their own homes A 0 4 4 1

3.7 Adult - Other CQC Specific A 4 5 1 0

3.8 Community Services - CQC Specific: Children, Young People and Families A 0 1 10 0

3.9 Plus MLaFL [Care Home TEC, Integrated Locality Teams] and single change plan N/A N/A N/A N/A N/A

3.7 - SOPs awaiting ratification and visits to some community sites required to finalise their arrangements

Falls Strategy is now sitting with LA for sign off Options have been produced to resolve the situation at

Laidlaw and these are being costed. SBAR completed for option appraisal 15.8.17.


3.1 - Paper re: demand and escalation recommendations underway 3.2 - Clinical Supervision in Community Nursing/Physio/OT and 0-

19 is established. Mental Capacity Act 2005/ Deprivation of Liberty training has

been delivered bespoke in Localities. 3.3 - Wheelchairs Specification has now changed, and the service

has transferred to a new provider (Millbrook) 3.5 - Frailty pathway commence formally 28/08/17 3.6 - Rehab ward decommissioning in line with CCG intentions has

commenced and reduced inpatient rehab beds from 22 to 13 over past month.

3.8 - Service level KPI’s generated monthly with quarterly returns, this information is fed back to quality meetings. ‘I Want Great Care’ in use across 0-19 services and monthly report saved with feedback.





3. Community Services (1)

12

P Com 7 Description Aggregate PositionVa

canc

y Fi

ll ra

tes

% establishment currently not filled by permanent

staff.Monitor Trends

P Com 10 Description Aggregate Position

Reh

ab p

atie

nts

care

d fo

r in

a co

mm

unity

se

tting

100% rehab patients cared for in a community

setting and not on the hospital ward

-

P WKF 9c Description Aggregate Position

Vaca

ncy

rate

s

Vacancy ratesKey vacancy levels

reduced by 50% from Apr 17 baseline

Variation

-

Variation

-

-

Variation

0.02.04.06.08.0

10.012.014.016.018.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

Vaca

ncy

Rate


0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% P

atie

nts


0.02.04.06.08.0

10.012.014.016.018.020.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

Vaca

ncy

Rate


3. Community Services (2)

13

P WKF 1b Description Aggregate PositionM

anda

tory

trai

ning

Training compliance including DoLS, MHCA, Safeguarding, Duty of

Candour etc

Monitor Trend

P WKF 13b Description Aggregate Position

Clin

ical

Sup

ervi

sion

Proportion of relevant staff receiving clinical supervision in line with

policy

-

Variation

Does this need to include all mandatory training or specific

training only, currently includes all mandatory training?

Duty of Candour is not mandatory, should it be?

Which key professional groups?

Variation

76.0

78.0

80.0

82.0

84.0

86.0

88.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% C

ompl

eted


0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

vise

d



8. Quality and performance metrics in place at service level and evidence of them being used at team meetings 31/08/2018 KPI's under review with services A

9. Updated assessment of demand and capacity by end of Q3 31/12/2017 D&C plan being developed. CCG and Internal review of service specifications underway A

4. Acute Programme

To Develop an organisational infrastructure and approach that supports the treating of patients safely through the Unscheduled Care and Elective Care Pathways

Overall Rating A


R A G N/S 4.1 Unscheduled Care - To have the ability to

make decisions and manage at least 90% of patients through the ED within 4hrs by Oct 17 and 95% by 31st Mar 18

A 6 12 4 0

4.2 Unscheduled Care - To Have a focused approach to managing specific medical patients using an ambulatory care philosophy to reduce the proportion of medical admissions

A 6 6 1 3

4.3 Unscheduled Care - To drive a philosophy of care in MAU/SAU/PAU that assesses and discharges a greater number of patients within 24hrs and 72 hrs from the current baseline

A 3 10 7 5

4.4 Unscheduled Care - To focus on flow and a way of working on each ward that supports safe care and discharges that balance admissions 7 days per week.

A 4 36 5 6

4.5 Unscheduled Care - To show respect to patients, families and carers and be an advocate for their wishes throughout the end of life phase

A 0 16 1 0

4.6 Unscheduled Care - Other CQC Specific: Stroke and Rehab A 1 5 1 0

4.1 – ED Staffing paper going to TLC 28/09/17 CBU and PIDS working together to provide minor breach

information 06/09/17 4.2 - Report from Dr Feather received joint MAU, AEC options

appraisal paper will be produced by 18/08/17 4.3 - CBU and PIDS working together to provide LOS information

06/09/17 4.4 - Environmental self-audits of standards of cleanliness to be

discussed at Infection Control meeting on 15/09/17 4.6 - A day is planned to visit all wards to talk through the protocols

and audit each area for lockable notes trollies by 08/09/17


Programme Board should explore these

4.1 –ED and the Operations Centre a new on screen dashboard shows the current level of attendance and performance in ED

Mental Health Assessment Room in ED has been signed off as complete

4.2 - Review of current service and baseline has been completed by Dr Feathers

4.4 -Clinical team and structure to roll out SAFER patient flow bundle team are in place

4.5 - Monthly EoL Champions meetings 4.6 – Lockable notes trolley not in place on both wards



4. Acute Programme [2] To Develop an organisational infrastructure and approach that supports the treating of patients safely through the Unscheduled Care and Elective Care Pathways

Overall Rating A


4.7 Elective Care - To manage , as a minimum, 92% of patients safely from referral to treatment within an 18 week period. A 21 11 2 34

4.8 Elective Care - To make the correct decisions at MDT's that results in our cancer patients being treated safely within 62 days of referral

A 0 16 16 11

4.9 Elective Care - Develop the internal diagnostics provision so that it supports safe and efficient patient care and decision making 7 days per week

A 6 16 2 9

4.10 Elective Care - Manage outpatients in an efficient way to further improve access to a specialist opinion for our patients and GPs

A 1 12 13 7

4.11 Elective Care - To improve the process of pre-assessment so that hospital resources are maximised and patients are fit and healthy and better prepared for their elective procedure

A 0 2 3 4

4.12 Elective Care - Increased Day Surgery, Theatre & OPD Procedures efficiency to improve access for our patients

A 9 3 6 13

4.13 Elective Care - 7 Day Services - Delivery of NHS 7 Day Services Clinical Standards Self-Assessment Readiness Tool

A 1 0 1 8

4.14 Primary Care - GP out of hours and walk in service A 0 3 0 0

4.7 - Updated framework to be presented to OMG 12/09/17 MBI tool to be reviewed and tailored to Trust 29/09/17 Demand & Capacity Plans - quarterly monitoring not yet received,

escalated to COO by 29/09/17 4.9 -Sunquest System Tidy Up funding is waiting for Board approval

21/08/17 4.10 - Issues being discussed with CCG by 14/09/17 4.12 - CIG Group approval for confirmation of Estates Strategy on

21/08/17 Funding for Deloittes ‘Super Sight Touch’ benchmarking option to be

agreed 15/08/17 Meeting booked in between PIDS and Clinical Lead to review

benchmarking data 31/08/17 4.13 - Resource now acquired to be completed by 24/08/17



4.7 - Key Measure Of Success: Treat at least 92% of patients within 18 weeks of RTT by Sept 17 –Achieved for July 27 out of 31 days for the month and every date to date during August.

4.8 - Cancer Dashboard created by PIDS and operational via Intranet. Audits submitted for Cancer outcomes to ensure they meet COSD mandatory requirements and are evidenced within the National Database.

4.9 - A Paper in request of GP Order Comms, Sunquest ICE and Pathology IT refresh was presented to ICT & CIG. Paper agreed in principle but await Board approval to progress.

4.10 - Peer review of 10 hospitals completed (IW come in top efficiency 1-3 place in trusts of same size).

4.12 - Theatre Dashboard from PIDS sent and a weekly report produced. 4.13 - 100% Completion of audit against 7 Day working Standards



4. Acute Services (1)

16

P Acu 1 Description Aggregate Position

DTO

C's

Reduction in DTOC numbers Trajectory by Sept 17


Med

icin

e Pa

tient

s Lo

S

Reduction in overall LoS for medicine patients

10% reduction Oct 17 and 20% by April 18 from Apr 17 baseline


Emer

genc

y C

are

4 H

our S

tand

ard

Emergency Care 4 Hour Standard

Monitor Trajectory to achieve target by Mar'18

Variation

-

Variation

-

-

Variation

0.0

50.0

100.0

150.0

200.0

250.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

DTO

C Da

ys


0.0

2.0

4.0

6.0

8.0

10.0

12.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

LoS

Days


70.0

75.0

80.0

85.0

90.0

95.0

100.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb

-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18F

eb-1

8M

ar-1

8

% P

atie

nts <

4 H

rs



17


18


Bre

ast S

ympt

oms

2 w

k G

P re

ferr

al to

1st

O

P Breast Symptoms 2 wk GP referral to 1st OP Monitor Trend


31 d

ay s

econ

d or

su

bseq

uent

(sur

gery

)

31 day second or subsequent (surgery) Monitor Trend


31 d

ay s

econ

d or

su

bseq

uent

(dru

g)

31 day second or subsequent (drug) Monitor Trend

Variation

-

Variation

-

-

Variation

86.0

88.0

90.0

92.0

94.0

96.0

98.0

100.0

102.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et


84.086.088.090.092.094.096.098.0

100.0102.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et


96.5

97.0

97.5

98.0

98.5

99.0

99.5

100.0

100.5

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et



19


31 d

ay d

iagn

osis

to

treat

men

t for

all

canc

ers

31 day diagnosis to treatment for all cancers Monitor Trend


62 d

ay re

ferr

al to

tre

atm

ent f

rom

sc

reen

ing

62 day referral to treatment from

screeningMonitor Trend


62 d

ays

urge

nt

refe

rral

to tr

eatm

ent

of a

ll ca

ncer

s

62 days urgent referral to treatment of all

cancers

Monitor agreed recovery trajectory

Variation

-

Variation

-

-

Variation

93.0

94.0

95.0

96.0

97.0

98.0

99.0

100.0

101.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et


0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et


0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et



20


Dia

gnos

tic W

aitin

g Ti

mes 99% of diagnostics

seen within 6 weeks of referral

99% Seen within 6 Weeks

P WKF 1c Description Aggregate Position

Man

dato

ry tr

aini

ng


Candour etc

Monitor Trend

Variation

-


training only, currently includes all mandatory training?

Duty of Candour is not mandatory, should it be?

Variation

98.498.698.899.099.299.499.699.8

100.0100.2

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% w

ithin

targ

et


77.0

78.0

79.0

80.0

81.0

82.0

83.0

84.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

eted



9. Achievement of audit for 7 day services and paper to board 30/09/2017 A

10. Delivery of 4 Priority Standards by 2018 31/03/2019 A

5. Financial Programme Overall Rating R

To establish and effectively implement systems and/or processes for effective financial decision making, management, governance and control to achieve Financial Recovery and Financial Sustainability whilst improving Quality


R A G N/S 5.1 To develop a cost improvement programme

for 17/18 that is supported by operational plans

R 8 3 14 4

5.2 To develop a Capital Investment Programme for 17/18 and 18/19 that reflects the organisations strategic and operational priorities and meets the Capital Resource Limit

R 6 0 10 10

5.3 To develop and refine a Long Term Financial Plan that reflects a sustainable portfolio of services and service quality on the Island

A 3 0 6 2

5.4 To develop a finance training programme that supports operational managers to be better equipped for taking on the responsibility of financial management decisions within their CBU/Directorate

A 0 1 3 1

5.5 To ensure final 17/18 budgets and the financial plan is delivered thus providing value for money services

R 3 2 13 1

5.6 To ensure good systems and controls are in place and assure our stakeholders that financial governance is being adhered to A 0 1 3 2

5.7 To be prepared for future years and align the 18/19 cost improvement programme with the business planning cycle N/S 0 0 0 9

5.1 - Awaiting development of Local Delivery Service Plan. CIPs to be aligned once finalised

Full identification of £8.613m CIP only £4.542m identified Plans signed off for identified £4.542m but balance of

£4.071m require documentation & sign off 5.2 – Awaiting Board approval of capital priorities 15.08.17 5.3 - Approval of LTFP at FIIWC and Board – Due in July but delays

with D&C analysis have postponed signoff until Sept17 Board, via TLC/FIIWC/Board (no Board in Aug17)

5.5 – Budget Holder sign off to be completed by 31/08/17



5.2 - Board confirmation of proposed Capital Contingency Reserve of £350K identified on 19.05.17

5.3 - Current LTFP to be developed and circulated for review - base year 2017/18 – final draft circulated 26/07

5.4 - Agree training programme schedule and prioritised staff 5.5 – Sign of budgets at Business Unit level




Identification of remaining CIP Additional spend for resources to support QIP. Original ask 2.4m, committed 3.8m leave a 1.4m cost pressure

5. Finance (1)

22

P FIN 1 Description Aggregate Position17

/18

CIP

Achi

eved

£8.613M CIP achieved 100% Monitor Trend

P FIN 2 Description Aggregate Position

Capi

tal R

esou

rce

Lim

it fo

r 17/

18

achi

eved

at 3

1 M

arch

20

18 Capital Resource Limit achieved Monitor Trend

P FIN 3 Description Aggregate Position

Fina

ncia

l pla

n ac

hiev

ed a

t 31

Mar

ch

2018

100% achievement of 17/18 budgets and

agreed financial planMonitor Trend

Variation

Year to date, CIP savings of £0.697m have been achieved,

which is ahead of plan by £0.180m. However the full year

savings forecast is £5.481m, which is £3.132m less than the total of

£8.613m required.

Variation

Currently ahead of plan at M2 but with risks, opportunities and

mitigating actions the likely year end forecast scenarios are:

Best Case - £18.8mLikely Case - £21.2mWorst Case - £28.5m

Any risks to the revised forecast need to be mitigated by identification of further

opportunities.

As at 31 May £0.189m of capital allocation has been spent and

there are only £2.6m pf projects that are underway. There remains

£3.7m of the £8.3m allocation uncommitted against specific schemes. The Trust Board is holding a Capital Seminar to

decide priorities by the end of July.

Variation

0.01,000.02,000.03,000.04,000.05,000.06,000.07,000.08,000.09,000.0

10,000.0

Apr-

16M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7Ap

r-17

May

-17

Jun-

17Ju

l-17

Aug-

17Se

p-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% Co

mpl

eted


0.01,000.02,000.03,000.04,000.05,000.06,000.07,000.08,000.09,000.0

Apr-

16M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7Ap

r-17

May

-17

Jun-

17Ju

l-17

Aug-

17Se

p-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% Ab

senc

e


0.02,000.04,000.06,000.08,000.0

10,000.012,000.014,000.016,000.018,000.020,000.0

Apr-

16M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7Ap

r-17

May

-17

Jun-

17Ju

l-17

Aug-

17Se

p-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

£



3. LTFP prepared and understood Plan prepared and distributed. Awaiting Board sign-off. A

4. CIP operational plans for 18/19 developed by Dec 17 31/12/2017 Not due A

6. Workforce & OD Programme Overall Rating A

Deliver the HR & OD Strategic plans underpinning organisation vision & values


R A G N/S 6.1 HR & OD Strategy 2017-20 - create the 2017-20

HR & OD Strategy to underpin delivery of organisational vision and strategic objectives

A 1 1 0 1

6.2

Recruitment, Retention & Resourcing - develop the Trust Recruitment & Retention plan to position the Trust in a better place to be able to attract, recruit and retain people with the right skills and attitude

A 0 10 0 2

6.3 Employee Engagement & Cultural Development - Develop and deliver an Employee Engagement Strategy & delivery plan to ‘win hearts & minds and create a great place to work’

A 2 5 0 2

6.4 Develop and launch an integrated leadership competency & behavioural framework for IOW NHS Trust leaders with corresponding self -assessment audit and modular programme of training/coaching & mentoring interventions

A 0 3 0 1

6.5 Education & Development - Develop and implement Education & Training Plan 2017-18 A 0 8 3 4

6.6 Development and promotion of mechanisms to enable employee voice and make it easy for staff to raise concerns in confidence that the Trust will act

A 0 4 3 0

6.7

Health & Wellbeing - Health & Wellbeing - Maintain a focus on Health & Wellbeing to achieve a sustainable reduction in absence to <4% by March 2018

A 0 4 0 1

6.8 HR & OD Department Development - Develop and implement an OD & HR Department continuous development plan A 0 2 1 2

6.1 – OD strategy behind schedule due to be signed off 31/08/17 6.3 - New post in place to support Employee Engagement Delivery

Plan sign off by 29/09/17



6.2 - Additional resources approved to support recruitment. Testing for Allocate Cloud completed successfully. Plan to go

live with Allocate Cloud on 14/08/17 and go live with ESR by the end of August.

Implementation of Junior Doctor contract 95% complete 6.3 - Staff Partnership agreement drafted 6.4 - Appraisal behavioural competencies included and align with

appraisal paperwork. Plan to advertise coaching availability by the 31/08/17 6.5 - Mandatory Training Policy out for consultation 6.6 - Anti Bullying Advisors, 13 applications from a cross section of

staff Bullying and Harassment policy consultation completed 6.7 - Manager training sessions commenced, focusing on improving

H&WB of staff 6.8 - Initial review of structure undertaken, SBAR raised and

resources agreed.





6. HR & OD

24

P WKF 1 Description Aggregate Position

Man

dato

ry tr

aini

ng


Candour etc

Monitor Trend

P WKF 15 Description Aggregate Position

Staf

f rec

omm

endi

ng

the

Trus

t as

a pl

ace

to

wor

k or

rece

ive

treat

men

t > National sector average score - Acute

3.77, Ambulance 3.46 & Mental Health 3.63

-

Variation


training only?Duty of Candour is not mandatory,

should it be?

-

Variation

0.8

0.8

0.8

0.8

0.8

0.8

0.8

0.8

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

eted


0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ianc

e


7. IM&T Programme Overall Rating A

The Trust will have an Informatics service that supports the clinical services to deliver safe and effective patient care, working in a paper light environment using information to drive decision making.


R A G N/S 7.1 The Trust will have an approved informatics strategy that

will achieve paperless at the point of care (P@POC) with a robust implementation plan

A 4 5 3 2

7.2 The Trust will have in place robust IT Infrastructure and Hardware to enable staff to provide high quality and effective patient care and clinical services A 6 6 7 7

7.3 The Trust will have a professional and responsive service desk which supports the organisation A 2 1 1 1

7.4 The IOW Care System is working towards an integrated Care Record being developed to support the future strategy of integrated health and social care alongside self-care

A 2 0 1 6

7.5 The Mental Health and Community services that use Paris will have a system fit for purpose supporting effective management of patient care, paperless working and reporting

A 1 3 7 9

7.6 The Trust has an effective process of monitoring the quality of services through key performance indicators and benchmarking, undertaking deep dives to understand actions to be taken in outlying areas. The Trust is able to effectively and proactively operationally manage the organisation and make decisions through the use of business intelligence and management information. The organisation will have an evidence based performance management data set to ensure that it can monitor the performance of its services against national benchmarks

A 9 6 4 5

7.7 Develop the internal diagnostics provision so that it supports safe and efficient patient care and decision making 7 days per week.

R 1 1 0 6

7.8 The Trust will be compliant with Information Governance (IG) requirements including information sharing. The Trust will maintain a level 2 IG toolkit rating and seek to improve upon this.

A 3 17 0 20

7.9 The Trust will have fit for purpose standard operating procedures and focused KPIs in place to monitor, improve and maintain an excellent level of data quality across all users and reports.

A 1 2 2 4

7.10 Information Security - working towards a ISO27001 ISMS A 0 4 2 2

Programme Board asked to Note: Increased risk to the programme of PIDS & ICT Capacity. Trust out ot agency but with limited success to date. Trust will need to prioritise work noting impact. 7.1 - Strategy finalisation impacted by senior capacity. IT Service Desk and IT Dept reviews completed, further work impacted by

senior/team capacity , proposal for milestone end date to be rebased to 31 Dec 2017

7.2 - Report to be reviewed at Sept IM&T programme group then finalised by 15 Sept 2017

Options paper planned for submission to ICT Programme group end of Sept 2017.

7.3 - Service Desk workshop date set for 22 Aug 2017, delayed due to limited venue options – dates to be rebased to 01/09/17

7.4 - LCB now established with 10 priorities identified, expect to receive understanding of system integration ask by Sept 2017

7.5 - Civica has commenced work setting up the MHSDS; task not yet completed however 6.1 upgrade currently in test, will not affect overall delivery of Civica improvements

7.6 - Definitions to be completed for clinical/corporate KPIs by 4th & 18th August 2017 respectively, RAG ratings for all to be finalised by 18th August

Agreement that incremental changes will take place, proposal for MH indicators to be sent to TLC in Sept 2017.

7.7 - Procurement to be agreed by 8 Sept 2017, agreed between Trust and CCG. 7.8 - Executive Lead for IG in place and reviewing IG plan. SBAR to be written by 8

Sept 2017 for additional contracts resource. 7.9 - Finalised list of KPIs has now been agreed for all of programmes - baselines to

be established by 30/09/17


7.1 - Stakeholder feedback incorporated into informatics strategy Capital priorities approved 7.2 - Redistribution of IT assets; all new assets tagged Bring Your Own Device (BYOD) and Mobile Device Management (MDM)

approach agreed 7.4 - TEC Strategy completed and handed over to IWC for integration into wider

plans 7.5 - Confirmation and procurement of upgrade complete 7.6 - Draft plan for potential dashboards has been developed following meetings

with stakeholders and plan circulated to CBUs for comment. 7.8 - Confirmed that all new contracts will include IG statement



7. IM&T (1)

26

` Description Aggregate Position10

0% o

f sta

ff ha

ve

acce

ss to

Tru

st W

iFi

for T

rust

dev

ices

by

31/1

2/17 Staff have access to

Trust WiFi 100% Compliance

P IMT 2 Description Aggregate Position

50%

of P

aris

use

rs

retra

ined

by

31/1

2/17

, 10

0% re

train

ed b

y 31

/03/

18 Paris users identified as requiring retraining have

been retrainedMonitor Trend

Variation

-

Currently 63 staff have been identified from each of the services

for retraining.

Variation

0.0

0.2

0.4

0.6

0.8

1.0

1.2

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% S

taff


0.0

0.2

0.4

0.6

0.8

1.0

1.2

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

eted



Trust Informatics Strategy signed off by Board on 06/9/17 06/09/2017 Not Yet Due A

MH Paris system issues resolved by 17/11/17 17/11/2001 Not Yet Due A

Community Paris system issues resolved by 28/02/17 28/02/2017 Not Yet Due A

8. Estates & Facilities Programme Overall Rating A

To ensure the Trust has a fit for purpose Estates and Facilities function with a clear Strategy and programme of work supporting the improvement in Estate for high quality and safe clinical service provision.


8.1 The Trust will have a clear Estates Strategy and associated plan to develop and improve the Estate supporting effective and high quality clinical services. The Trust will have robust Estates governance arrangements in line the Assurance Framework

A 2 5 1 9

8.2 Wherever possible, Ligature risks within Sevenacres will be removed/made safe and wider Estates issues within Sevenacres will be resolved

A 2 1 6 0

8.3 The Trust has addressed / mitigated immediate ligature risks with the current Shackleton. The Trust will have fit for purpose estate solution for patients currently residing in Shackleton

A 5 0 6 9

8.4 The Trust will have fit for purpose estate for patients currently residing in Woodlands A 2 0 5 2

8.5 The Soft FM department provides an safe, timely and high quality service with robust monitoring in place to provide assurance of this delivery

A 1 2 1 9

8.6 The Trust has in place effective oversight and management processes for environmental risks and wider legislation/alerts relating to Estates and Facilities

A 2 0 1 2

8.7 The Trust enters into the Carbon Energy Fund Contract in order to un-lock the associated benefits; carbon reduction, financial savings and cost avoidance, investment and reduced risk

R 1 0 2 3

8.8 The Trust pro-actively manages Backlog Maintenance and Statutory Compliance through a planned and prioritised process, ensuring alignment with the Estate Strategy. The Trust understands the Quality and Functional Suitability of the estate.

A 1 0 0 7

8.9 The Trust is engaged in the HIOW STP Estates and Facilities work-streams to ensure alignment of strategies and to identify opportunities.

A 0 2 1 0

8.10 The Trust as a 'key stakeholder' is engaged in the IOW One Public Estate (OPE) Programme in order to work with public sector partners to un-lock and enable opportunities.

R 3 0 0 0

8.1 - Review of governance for Estates & Facilities portfolio has yet to be agreed for approval at TLC 24/08/17

8.2 - Workstream timetable adjusted to reflect revised timetable approved as a part of the business case with completion moving from 24/11/2017 to 05/01/2018.

8.3 - Solutions for the re-provision of Shackleton Ward still being considered and will be discussed at 15/08/2017 Trust Board Seminar

8.4 - Implementation of physical improvement works are no longer required, subject to evidence of formal approval from CQC via MHIG.

8.5 - Trust Lead working with SOEPS to ensure partner is appointed by 18/08/2017

8.6 - Procedure being developed to enable CBU’s to work with Estates to routinely review environments to establish risks

8.7 - CEF team has been re-mobilised so expect resolution quickly. May impact on timeframe of Trust Board approval of contract (Business Case already approved) that is planned for 06/09/2017

8.8 - 6 facet surveys included in capital plans for 2017/18, Backlog Maintenance / Statutory capital investment will be prioritised against known high risk issues that have already been identified.

8.10 - Work with OPE team to identify resource. Planned completion date of 31/08/2017 will not be met due to lack of resource


Programme Board to explore

8.1 - ERIC information ratified at FIIWC (25/07/2017) and final version submitted

8.2 - Trust Board approved business case for estate related solution, workstream timetable adjusted accordingly

8.4 – New 3 year lease in place for Woodlands 8.6 - MiCAD report sent to all relevant areas on a monthly basis 8.7 - DoH approval to ‘lease land’ has been achieved 8.9 - Submission of estates related STP Capital Bids for Newport and

Sandown ILS, outcome awaited.



8. Estates & Facilities

28


Sign off of Estates Strategy by 04/10/17 04/10/2017 Not Yet Due A

Revised governance in place by 01/07/17 01/07/2017 Awaiting confirmation of Governance structure R

Catering service tendered out by TBC TBC Procurement of specialist partner to be completed by 18/08/17 R

Effective monitoring Estates and Facilities legilation and alerts with effective oversight of recommended actions in place by 28/07/17 28/07/2017 Developing procedures with CBUs R

9. Leadership, Governance & QI Programme Overall Rating A

To develop a Trust that is well led with clear visibility of key operational, quality and financial performance at all levels of the organisation within an accountability framework


R A G N/S 9.1 To develop a Trust that is well led A 0 1 0 4 9.2 The Leadership of the organisation is robust and "fit

for purpose" A 3 3 0 4

9.3 The organisation will have a comprehensive clinical and corporate governance structure that ensures the flow of timely information from all services to Board to ensure that there is an effective Assurance Framework

A 5 1 0 2

9.4 To develop a Trust wide culture of improvement by skilling up key staff in recognised techniques and methodology

A 0 5 0 0

9.5 To increase the use of patient safety measures to drive improvement A 0 3 0 3

9.6 To improve compliance with NICE Guidance A 0 1 0 0

9.7 To improve the Learning from National and Local Never Events and Serious Incidents

A 0 4 0 6

9.8 To embed and improve the Trust's awareness and safer deliver of medicines management A 0 7 0 3

9.9 To improve the content of key patient records across the Trust R 7 0 0 0

9.10 To ensure our systems, processes and training of our people is sufficiently in place to better safeguard both children and adults of the IoW

A 0 6 1 0

9.11 To provide our patients with a much better patient experience when they come into contact with our people and our services

A 0 2 0 3

9.2 – Meeting with Kings Fund 02/10/17 to discuss Leadership Development Centres

9.3 – Capacity in Corporate Risk to provide training due to sick leave

9.9 – Improve content of Key Patient Records has not started. Capacity been requested to specifically support this piece of work via TLC but not agreed. Review of staffing taking place.


9.4 – NHS Elec currently undertaking review and providing options by Mid September. Decision on approach will be required at this point.

9.8 – Drugs advisory Group TOR updated and agreed. 9.10 – Executive Lead for Safeguard attends both Adult and

Children’s Safeguarding Boards




No current areas of concern

9. Leadership, Governance & Quality (1)

30

P QUA 22 Description Aggregate PositionTr

aini

ng in

Ris

k M

anag

emen

t

How many have been trained so far and what

groups?1

P QUA 23 Description Aggregate Position

At l

east

50

staf

f tra

ined

in

impr

ovem

ent

met

hodo

logy

by

- -

P QUA 24 Description Aggregate Position

100%

com

plia

nce

with

m

edic

ines

lock

ed

door

s an

d m

onito

ring

of te

mpe

ratu

re

- -

Variation

Note, training needs analysis being undertaken and approach will

change significantly. Unable to currently say % untrained risk staff

in CBU

Variation

-

-

Variation

0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

??


0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ete


0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ete


10. Communications & Engagement Programme Overall Rating A


R A G N/S 10.1 To enhance the capability and capacity of the

Trust's communication team and ensure the key messages and engagement with staff, patients and the public around the improvement programme are maximised

A 0 0 4 2

10.2 To promote more Community Engagement and promote a culture whereby the public are more involved with the Trust and feel more connected

A 0 14 4 6

10.3 To maximise social media and other key communication channels as part of the focused approach to ongoing recruitment of key staff

A 0 0 0 5

10.4 Visibility of the Executive Team A 0 0 0 3

10.5 To develop one message and clarity of message internally and externally about the IIF and QI

A 0 3 0 4

10.6 To promote a sharing and learning organisation A 0 6 0 3






No current areas of concern

Programme Plan has been updated to align with Freshwater work – changes within ratification section on agenda.

10.1 - Communications specialist , Freshwater commenced on 29/06/17

Launch of IIF Engagement video in organisation Branding agreed for IIF ‘Getting to Good’ 10.2 - Members Stall was in place at IOW Festival and 156

members recruited (complete) 10.4 – Meet the Chief Executive sessions continue



ON [6th September 2017]

Title Quality Improvement Plan Highlight Report – July 2017



Author(s) Andrew Irvine- MBI Health Group

Purpose To provide a report on the key progress and challenges relating to the delivery of the Trust’s Quality improvement plan that, if delivered, should move the Trust out of inadequate to requires improvement within 12-15 months


Receive X Approve








Quality Governance Committee No August QGC so not considered elsewhere before being presented to Trust Board.



Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream Update by exception on progress of the Trust’s QIP. Normally to be

considered by QGC then Trust Board.

Staff, stakeholder, patient and public engagement: • Information taken from the IIF work stream updates and the highlight report from the relevant

work groups. Executive Summary & Analysis:

It is important that the Quality Improvement Plan [QIP] is driven by the Trust through the infrastructure and governance that has been developed as part of the overall Integrated Improvement Framework [IIF]. It is important that the Quality Governance Committee [QGC] adds real value to the overall process and does not duplicate the role and function of the IIF Programme Board. Going forward the QGC should have the following role with respect to driving forward the changes required to deliver the Trust’s QIP:

Enc J


1. Understanding progress and impact against the 9 QIP goals that have been set and agreed;

2. Discuss, challenge and debate the impact the milestones are having on the relevant key theme(s);

3. Deep dives as per the IIF Programme Board against the relevant key theme(s); 4. Assurance of evidence against the relevant key theme(s)

QGC did not have a scheduled meeting in August to discuss new agenda items. Due to the importance of the QIP for the organisation is was agreed that an updated highlight report for July be brought directly to the Trust Board so that another month did not pass without the Board being cited on progress and challenges. Some of the key areas in the current highlight report for consideration by the Trust Board are: • Metrics that the QGC need to focus, and contained within the attached report, have still not been

finalised; • Visibility of the recruitment plan and progress for at least “hard to recruit posts” should be explored in

detail; • Actual progress against the Community Workforce vacancies should be discussed in detail; • Assurance of the content and impact of the mandatory training plan • A complete End of Life Care plan to come to a future Board Seminar outlining workforce, training,

partnership arrangements, reduction in moves, increase in numbers dying in a non hospital setting etc. • Progress and plans to achieve the Cancer 62 day treatment target; • Understanding of key initial findings from the Quality Governance Solutions commissioned work.

Recommendation to the Board: The Trust Board is asked to discuss, challenge and consider this highlight report and recommend to the Quality Governance Committee key pieces of deep dive and assurance work it should have scheduled for the remaining part of 17/18.

Attached Appendices & Background papers Quality Improvement plan Highlight Report – July 2017 For following sections – please indicate as appropriate:

Trust Goals & Priorities 1. Excellent patient care

2. Work with others to keep improving services

3. Positive experience for patients, service users and staff

4. Skilled and capable staff

5. Cost effective and sustainable services Principal Risks (BAF) Issue 1085, CQC Section 31 Warning Notice; Risk 674,

Quality Governance and Risk 675, Culture Legal implications, regulatory and consultation requirements

This report will be shared with the regulator through the monthly Quality Improvement Plan Oversight Group.

Date: 29th August 2017 Completed by: Andrew Irvine, MBI Health Group

July Position 2017

1

Isle of Wight NHS Trust Trust Board

QIP Highlight Report

29th August 2016

Introduction

2

It is important that the Quality Improvement Plan [QIP] is driven by the Trust through the infrastructure and governance that has been developed as part of the overall Integrated Improvement Framework [IIF]. It is important that the Quality Governance Committee [QGC] adds real value to the overall process and does not duplicate the role and function of the IIF Programme Board. Going forward the QGC should have the following role with respect to driving forward the changes required to deliver the Trust’s QIP:

1. Understanding progress and impact against the 9 QIP goals that have been set and agreed; 2. Discuss, challenge and debate the impact the milestones are having on the relevant key theme(s); 3. Deep dives as per the IIF Programme Board against the relevant key theme(s); 4. Assurance of evidence against the relevant key theme(s)

The priority measures have been assessed by the Quality Governance Team and the 250 metrics have been prioritised down to 84. Fifty two of the eighty four have been identified as output measures and these are the measures that the QGC will focus on to understand impact as part of its assurance role within the overall governance of delivering a sustainable organisation that aspires to get itself out of special measures within 12 months. Quality Metrics for the QGC to Focus on

• Patient safety – 24 [8 process and 16 outputs]; • Patient/User experience – 11 [5 process and 6 outputs] ; • Staff engagement and Leadership – 19 [11 process and 8 outputs]; • Operational performance – 22 [4 process and 18 outputs]; • Clinical and corporate governance – 6 [2 process and 4 outputs].

The following report identifies each of the five key themes within the QIP and by exception will highlight the key areas for discussion required of the QGC.

OVERALL GOALS

HIGH LEVEL GOALS

KEY THEMES

Avoidable Harm

Demand & Capacity

Staff Engagement 3.41 – 3.80

Improvement Methodology

Bulling & Harassment

survey results

Reduced vacancy and agency rates

Mandatory Training

85% Compliance

Operational Access Times

Increased Patient

Satisfaction from 16/17

Patient Safety

User Experience

Staff Engagement

Ops Performance

Clinical & Corporate Governance

REMEMBER THIS IS THE MINIMUM WE MUST DO TO IMPROVE FROM INADEQUATE TO NEEDS IMPROVEMENT BY APRIL 2018 3

Summary - Impact Overview

1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management. 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved

access to all services and access target achievement and short wait times for assessment in all services. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80, ambulance

3.41 & mental health 3.80. 4. The development of a continuous improvement culture through Board and leadership development and specific training in

improvement methodology. 5. Improve % of staff/colleagues reporting most recent experience of harassment, bullying or abuse > national sector score:

acute 45%, ambulance 48% and mental health 60%. 6. Reduce variance from budgeted establishment verses staff in post by 10%. 7. 85% compliance with all Mandatory training 8. All operational national performance targets being met 9. An increase in patient satisfaction.

High Level Goals/Impact: 1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80. 6. Reduce variance from budgeted establishment verses staff in post by 10%.

7. 85% compliance with all Mandatory training 8. All operational national performance targets being met 9. An increase in patient satisfaction

Patient Safety

Output Measures of Success

PS1 - Achievement of ambulance performance targets against trajectory - Red 1 – Mar 18, Red 2 Jun 17 and 19 min response by May 17

PS 2 - Revised job plans that address the availability of current Consultants in ED - 30/06/2017

PS3 - Paediatric nursing skills available to the ED on 100% of shifts – 15/05/2017

PS4 - Increased 2wte Acute Physicians in establishment from Apr 17 baseline - 30/09/2017

PS5 - National guidance targets for medical staffing in EoLC achieved 100% by Q3

PS6 - Key vacancy levels in the Community reduced by 50% from Apr 17 baseline by 31st Dec 2017.

PS9 - New Lessons Learnt Framework launched for SI’s – 30/09/2017

PS10 - Improved overall position of Carter Metrics in medicines management by Q4, compared to the Peer group benchmarked using Apr 17 baseline

PS11 - 10% reduction on prescribing errors from Apr 17 baseline - 31/11/2017

PS12 - At least 85% NMP have had supervision within the previous 4 months - 30/10/2017

Key Analysis of Impact This Month

Key Patient Safety Risks Mitigation Nurse Medical Prescribers (NMP) in the community delivering a generic model of care which means their range of prescribing will be extensive.

Develop the model of care and roll out around competencies and availability. GP supervision.

Substantive paediatric nurses to cover ED are proving difficult to appoint. Shifts currently covered by agency staff and 100% shift fill rate reported this month.

PS1 PS4 PS6

General Update

4

Red 1 response times for July did not improve with less than 50% achievement. The pilot results relating to new Quality Indicators would suggest they are more meaningful for patients but more challenging to meet within current resources. A workshop involving the wider team is scheduled for w/c 28th August to map these through. Numbers remain relatively small and performance against the two other targets are below the revised trajectory.

A rolling advert is out with incentives but it is unlikely a further 2 WTE acute physician will be employed over the next few months. Interviews in June did not appoint as candidates not suitable. The Trust Board to request a detailed, specific recruitment plan for these posts that describe the approach to ensuring they can be filled sustainably.

Key vacancy reductions in the Community Workforce are identified as being on plan to meet December 31st deadline. However, the workforce plans and improvements against plans are so important the Trust Board should explore progress and seek assurance and more detail of managing the risks.

• Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Sept]. • Job plans in ED have been significantly revised to support different working patterns and extend

coverage in the department to 8am-8pm weekdays and 8am-4pm weekends and bank holidays. Performance during the August Bank Holiday should be reviewed as a proxy for impact of revised job plans and having more ED Consultant coverage

High Level Goals/Impact: 1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80. 6. Reduce variance from budgeted establishment verses staff in post by 10%. 7. 85% compliance with all Mandatory training 8. All operational national performance targets being met 9. An increase in patient satisfaction

Patient Safety


PS13 - Reduced ambulance handover delays by 50% from Apr 17 baseline - 31/07/2017

PS14 - 30% increase in end of life care plans from April 17 baseline - 30/09/2017

PS16 - 50% reduction in reported incidents relating to lone Working in the Community- 30/09/2017

PS18 - In MH 100% of patients have a risk assessment and care plan in place within PARIS and % of patients on CPA - 30/06/2017

PS19 - All identified ligature risks in MH mitigated - 30/09/2017

PS20 - Mandatory training compliance at a minimum of 85% - 31/01/2018

Key Patient Safety Risks Mitigation Ambulance handover baseline figures yet to be agreed New ED [more real time] dashboard to go live in July to

include handover information which will create more focus

Lone working in the Community not seen as a priority. Part of the IIF and therefore escalation options for staff.

Consultant caseloads in MH still have not been thoroughly risk assessed and CPA status allocated.

Extra focus on these patients and the plan is to complete this action by end of August.

PS13 PS19 PS20

General Update

5


Action plan to address ED handover complete. Bay 4 ring fenced for ambulance handover; ED live dashboard to include ambulance handover delays. Baseline handover figures and progress of improvement should be presented to the September QGC for discussion.

• The September QGC needs to have visibility of the baseline and current performance relating to the agreed measures of success. • As a result of the revised plan for dealing with the ligature risks long term, the dates for completion will likely be sometime in Q3 and the revised plan

needs to inform and update the IIF and QIP.

Original timeline to mange the risks was not met. However, the external review by Berkshire Healthcare FT NHS Trust carried out in July demonstrated that all outstanding risks are being managed and mitigations are in place. A revised estates programme and revised timeline [with full costings] was presented at the Board Seminar on 18th July 2017.

Mandatory training rates for the Trust are slightly below 83% Mandatory Training Policy out for consultation 11/08/17. Statutory and mandatory training plan in place and along with the workforce plans the content of these should be explored by the Trust Board to assure themselves they are fit for purpose.

Patient/Service User Experience


PE3 - Achieve “about the same” rating for waiting lists and admissions “better” rating for at least 10% of the other questions in the CQC questionnaire - 28/02/2018

PE4 - Reduction in complaints for all services – 30/09/2017

PE6 - Children’s facilities in ED all meet Standards for Children and Young People in Emergency Care Settings - by the Royal College of Paediatrics. Where this is not possible evidence of mitigation to improve the situation from Apr 17 Baseline - 30/08/2017

PE7 - Reduced single sex accommodation breaches by 75% from Apr 17 baseline - 15/10/2017

PE8 - As a minimum 85% of all staff in the priority areas dealing with dementia identified and trained - 15/03/2018

PE9 - 50% increase in end of life patients dying in their preferred place of care from Apr 17 baseline - 15/09/2017

Key Patient/Service User Experience Risks Mitigation

Reliance on agency staff to fill the paediatric shifts in ED Advert out for substantive staff and the use of longer term agency staff means they are more familiar.

Patient flow challenges out of ICU mean mixed sex breaches are a possibility

Definition of the acceptable standard and visibility of adherence to it. More prioritisation of ICU patients into general beds

PE4 PE7 PE9

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Sept]. • End of Life Care joint venture with the Hospice is being considered to further improve this overall

patient experience.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80. 8. All operational national performance targets being met.

9. An increase in patient satisfaction.

6


The trend in complaints numbers is not on the decrease. More detailed analysis needs to be presented back to the Trust Board via the QGC. It is important that services understand exactly why their patients, carers and service users have not be fully satisfied with their service offer.

It will be a challenge to start and complete the DSU refurbishment by the end of December as the business case going to capital investment group in August and unscheduled care challenges are recognised in Q3. Agreements on the ICU definition of when there is a mixed sex breach needs to be agreed. Trust Board should request that it receives the baseline data and August performance at its next meeting

Trust Board should agree when is should see the outputs from a deep dive of EoLC provision. QGC should manage this process. Regular month on month figures are still not fully visible as a matter of routine and as part of business as usual.

Staff Engagement and Leadership


SE1 - The Trust will aim for, in the 2017-18 annual staff survey, to increase its EE score: acute 3.80, ambulance 3.41 & mental health 3.80 - 31/03/2018

SE2 - Improved score of staff recommending the Trust as a place to work or receive treatment: Acute 3.77; ambulance 3.46 & mental health 3.63 - 30/06/2017

SE13 - 60% of staff trained have completed at least 2 improvement projects - 31/03/2018

SE14 - Impact survey shows that at least 25% of the staff within each service (Ambulance, Mental Health, Acute, Community, Support Services) can articulate the top 3 quality improvements for patients and or staff that are being worked on in their area. By week 15 of the project increasing to 40% by week 20, 60% by week 25 and 85% by week 30

SE15 - Recruitment campaign schedule approved and delivered to achieve a reduction in variance from budgeted establishment verses staff in post by 10%. - 31/12/2017

SE16 - Increase Apprenticeships from 50 to 70 by Q4 - 31/03/2018

SE17 - Facilitate implementation of Healthroster Optima, including Safe Care to maximise effective use of available resources and achieve 100% compliance with rostering targets - 31/12/2017

Key Staff Engagement and Leadership Risks Mitigation Inadequate resource to deliver IIP ED/Rostering posts agreed, moving to recruitment.

Business case completed.

Recruitment into key posts not successful .A multi pronged approach to recruitment and stronger marketing material and advertising channels

The ability to train and supervise the level of Apprentices identified

Phased approach covering a number of CBU’s and support areas

SE1 SE13 SE15

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Sept]. • Improvement movement has just started to mobilise through NHS Elect. • Multi channel approach to recruitment.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80.. 4. The development of a continuous improvement culture through Board and leadership development and specific

training in improvement methodology. 5. Improve % of staff/colleagues reporting most recent experience of harassment, bullying or abuse > national sector

score: acute 45%, ambulance 48% and mental health 60%. 6. Reduce variance from budgeted establishment verses staff in post by 10%. 8. All operational national performance targets being met.

7


Equalities Lead appointed, commence role 07/08/17. Workplace Race Equality Standard (WRES) return completed for 01/08/17. Staff Partnership agreement drafted and presentation at Partnership Forum and JLNC in July explained the new ESR developments. Promotional material being developed to support training/awareness programmes. Successful training session in the Catering Department complete.

NHS Elect have mobilised their resources and are gathering intelligence on the current position of the Trust. They will link closely with the communicants work being developed by Freshwater Consultancy.

Recruitment advertisements on IW ferries gone live. Overseas recruitment – 5 further nurses will arrive on 25/08/ 17. LinkedIn has been used to advertise hard to fill posts within Gastro, Anaesthetics, Urology and Paediatrics and Psychiatry. This is such a significant area and the Trust Board should focus on the detail at a future Board Seminar.


OP1 - Achievement of 4 hr national target trajectory of 90% by Oct 17 and 95% - 31/03/2018

OP2 - Achievement of RTT target trajectory by – 31/03/2018

OP3 - Achievement of ambulance service target trajectory: Red 1 by Mar 18; Red 2 by June 17; 19 mins – 30/05/2017

OP4 -Achievement of Cancer Service target trajectory [Cancer 62 days] – 31/11/2017

OP5 - Reduction in DTOC numbers against agreed trajectory – 30/09/2017

OP6 - 10% reduction in overall LoS for medicine patients Oct 17 and 20% by April 18 from Apr 17 baseline – 31/03/2017

OP7 - 99% of diagnostics seen within 6 weeks of referral – 30/06/2017

OP8 - Theatre utilisation of at least 85% for all specialties – 28/02/2018

OP9 - Ambulance handover times achieving 15 mins 95% compliance – 30/10/2017

Key Operational performance Risks Mitigation Achievement of cancer 62 day standard Daily focus on all patients waiting over 62 days.

ED 4hr performance and overall patient flow Significant change programme in the IIF and experienced senior leadership recruited

Reduction in DTOC days reduces the focus on internal waits Visibility required for all waits against internal professional standards

OP1 OP4 OP8

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Sept]. • The Trust are now part of the national theatre utilisation programme using Four Eyes

methodology and experiences. It will be a light touch approach giving support to drive forward change with Consultants.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services.

4. The development of a continuous improvement culture through Board and leadership development and specific training in improvement methodology.

8. All operational national performance targets being met. 9. An increase in patient satisfaction.

Operational Performance

8


Theatre utilisation nearing 85% for many specialties however, much work still to be done. Meeting booked between PIDS and Clinical Lead to review theatre benchmarking data which highlights significant progress on efficiency.

The backlog position for 62 day treatment is reducing but slowly. Significant changes with mainland diagnostic provision and treatment which will continue to be challenged through the CCG and the Cancer Alliance. A critical friend review is taking place by NHSI on 7th September. The Cancer PTL, using Somerset as the source data continues to be validated.

Progress made in July compared to the June position for the 4hr performance target. Un-validated August position suggests further significant progress being made in August. ED and the Operations Centre have a new on screen dashboard which shows the current level of attendance and performance. The new Mental Health Assessment Room in ED has been signed off as complete.


OP10 - Zero breaches in non admitted stream – 30/06/2017

OP11 - As a minimum 15% increase in numbers with a LoS less than 24hrs from Apr 17 baseline – 31/01/2018

OP12 - As a minimum 15% increase in numbers with a LoS greater than 24hrs and less than 72 hrs from Apr 17 baseline – 31/03/2018

OP13 - Reduced breaches for specialty review by 50% from Apr 17 baseline – 30/06/2017

OP14 - As a minimum 30% increase in ambulatory care activity as a proportion of the medical take from Apr 17 baseline - 31/03/2018

OP15 - 10% of overall MAU daily discharges before 10am - 31/07/2017

OP20 - 25% increase in numbers of CPA’s from Apr baseline in MH - 31/01/2018

OP21 - 95% of service users on a CPA and followed up by MH within 7 days - 31/01/2018

OP22 - DTOC numbers in MH less than 7.5% for at least 3 months in 17/18 - 31/03/2018

Key Operational Performance Risks Mitigation The ability of the organisation to protect ambulatory care when flow is challenged.

Revised Trust escalation policy that protects ambulatory care. Consider making it a never event if used for inpatients.

The ability if the organisation to develop the assessment units as a chance to assess patients and not admit them.

Promotion and education by the Clinical Lead. Visibility of performance against short stay LoS.

Internal professional Standards [IPS] not being adopted by all CBUs.

Agreements by all CBU CDs. Individual conversations by the Medical Director with individual Consultants to understand barriers

OP11 OP13 OP14

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Sept]. • Whilst LoS is an indicator time of day for the available resource is as important and multiple

measures of success should be used to understand the story.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services.

4. The development of a continuous improvement culture through Board and leadership development and specific training in improvement methodology.

8. All operational national performance targets being met. 9. An increase in patient satisfaction.

Operational Performance

9


Whilst performance in this area has shown improvement the trend analysis from the baseline position have still not been developed. The development of these metrics and agreeing the overall process for recording and having visibility is a key priority.

Overall performance in July has improved from the June position. The August unvalidated position also looks to be in the right upward direction. However, the Trust Board should expect QGC to ensure there is evidence that correlates to changes in practice and assure themselves of the sustainable position.

Pathway developed that links with frailty service/ access to Comprehensive Geriatric Assessment if clinically appropriate has been achieved. Review of current service and baseline has been completed by Dr Feathers. The report received and circulated 14/08/2017


G1 - The Trust will develop a Board Assurance Framework - 01/08/2017

G4 - 80% staff in leadership roles to be trained in Risk Management - 01/02/2018

G5 - 85% staff trained in the Risk Management Policy and how to report risks, issues and raise concerns - 01/04/2018

G6 - A Board approved Audit plan to inform the BAF - 01/09/2018

Key Clinical and Corporate Governance Risks Mitigation The key external and specialised support does not leave a legacy with the organisation. Key output from the individual specifications and key responsibility for the Executive sponsor.

G1 G4 G6

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Sept]. • Longer term measures of success under this theme but its important that the QGC tests the impact as they penetrate the organisation.

Clinical and Corporate Governance

High Level Goals/Impact: 1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management.

10


Quality Governance Solutions commenced in August and an interim update presented to the CEO. Assurance on when the revised BAF will be developed should be sought by the Trust Board

Quality Governance Solutions partner procured and are due to complete work in September. QGC was presented with the TIAA and Trust audit plan at June meeting.

Risk management approach to date has been limited and not systematic.. Position on the risk management training numbers needs to be made clearer.




Title Report on Progress of NHSI Undertakings


Maggie Oldham – Interim Chief Executive

Author(s) Philippa Slinger – Improvement Director

Purpose For Board information and discussion as required


Receive x Approve




Trust Leadership Committee Audit and Corporate Risk Committee Charitable Funds Committee Finance, Investment, Information & Workforce Committee



Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: Report specifically for Board Members Executive Summary & Analysis: Following the NHSI investigation into the Leadership and Governance of the Trust in November 2016 and the NHSI letter informing the Trust that it was being placed in Special Measures, NHSI issued a set of Undertakings the Trust must comply with. This report provides the detail of those Undertakings and highlights actions taken toward their achievement. Going forward, this report will be led by the deputy chief executive and will be incorporated in future by, the Integrated Improvement Framework (IIF) given the importance this has in driving successful improvement. In particular, delivery of undertakings will be clearly mapped into the IIF to avoid duplication and to improve consolidation of reporting at Board. Recommendation to the Board: The Board is being asked to consider and note the report and progress to ensure it is satisfied that work to address the Undertakings is underway and will be effective. Attached Appendices & Background papers Board report on NHSI Undertakings For following sections – please indicate as appropriate:

Trust Goals & Priorities All 5 of the Trusts goals and priorities are relevant Principal Risks (BAF) 671. 673, 674, 705, 712, and Issue 1085


Date: 29 August 2017 Completed by: Philippa Slinger – Improvement Director

Enc K

Isle of Wight NHS Trust – Board Report on NHSI Undertakings

- 1 | P a g e

November 2016 Undertakings Governance and Leadership 1.1. The Trust will take all reasonable steps to put in place governance

structures and processes which would reasonably be regarded as appropriate for a supplier of healthcare services to the NHS, including but not limited to those set out in paragraphs 1.2 to 1.4, below.

1.2. The Licensee will develop and agree with NHS Improvement a plan to meet the requirements of paragraph 1.1 above (“the governance plan”) by a date to be agreed by NHS Improvement and demonstrate that it can deliver that plan. 1.3 The governance plan will, in particular:

1.3.1. include the actions required to meet the requirements of paragraph 1.1, with appropriate timescales and resourcing, including:

(a) any outstanding actions required to implement the recommendations from the governance review, insofar as they are relevant to the Trust’s current situation; and (b) actions required to address gaps in the capacity and capability of the clinical business units, particularly in relation to finance;

1.3.2. describe the key risks to meeting the requirements of paragraph 1.1 and mitigating actions being taken; 1.3.3. be based on realistic assumptions; 1.3.4. reflect collaborative working with key system partners and other stakeholders;

Action to Achieve Requirements: The Trust has developed an Integrated Improvement Framework that encompasses all areas that require improvement across the Trust. A sub-set of that Framework makes up the Quality Improvement Plan that specifically addresses the concerns and issues raised by the Care Quality Commission from an inspection that took place in November 2016. An element of the IIF and the QIP is a set of actions to address the undertakings above. All measures within this paper relate back to the measures within the II and QIP In particular actions described within the Clinical and Corporate Governance section and the Staff Engagement and Leadership Section of that plan. Action Outcome Completion

Key Objective: The organisation will have a comprehensive clinical and corporate governance structure that ensures the flow of timely information from all services to Board delivered within an effective Board Assurance Framework. Overall completion date: 1/4/18 July Status within the IIF: Off plan in July – full completion date still achievable


- 2 | P a g e

1.3.5. set out the key performance indicators which the Trust will use to measure progress; and 1.3.6. be consistent with the Trust’s other key plans, including but not limited to those plans described elsewhere in these undertakings.

1.4. The Trust will keep the governance plan and its delivery under review and provide appropriate assurance to its Board regarding progress towards meeting the requirements of paragraph 1.1, such assurance to be provided to NHS Improvement on request. Where matters are identified which materially affect the Trust’s ability to meet the requirements of paragraph 1.1, whether identified by the Trust or another party, the Trust will notify NHS Improvement as soon as practicable and update and resubmit the governance plan within a timeframe to be agreed with NHS. tion Outcome Completion Operational performance 2.1. The Trust will take all reasonable steps to recover operational performance to meet national standards in a sustainable manner, including but not limited to those set out in paragraphs 2.2 to 2.4, below. 2.2. The Trust will revisit its operational performance plans and agree with NHS Improvement revised recovery plans to meet the requirements of paragraph 2.1 above (“the performance plan”) by a date to be agreed by NHS Improvement and demonstrate that it can deliver that plan. 2.3. The performance plan will, in particular:

2.3.1. include the actions required to meet the requirements of paragraph 2.1, with appropriate timescales and resourcing; 2.3.2. describe the key risks to meeting the requirements of

Action to Achieve Requirement The Operational Performance section of the QIP addresses all the actions required to meet this undertaking. Key Objectives: Achievement of A&E access target of 90% by October 2017 and 95% by

31 March 2018 Achieve RTT Trajectory by March 2018

Achievement of cancer target trajectories by November 2017


- 3 | P a g e

paragraph 2.1 and mitigating actions being taken; 2.3.3. be based on realistic assumptions; 2.3.4. reflect collaborative working with key system partners and other stakeholders; 2.3.5. set out the key performance indicators which the Trust will use to measure progress; 2.3.6. be consistent with the Trust’s other key plans, including but not limited to those plans described elsewhere in these undertakings and the Sustainability and Transformation Plan; and 2.3.7. support the Trust in delivering the control totals set by NHS Improvement.

2.4. The Trust will keep the performance plan and its delivery under review and provide appropriate assurance to its Board regarding progress towards meeting the requirements of paragraph 2.1, such assurance to be provided to NHS Improvement on request. Where matters are identified which materially affect the Trust’s ability to meet the requirements of paragraph 2.1, whether identified by the Trust or another party, the Trust will notify NHS Improvement as soon as practicable and update and resubmit the performance plan within a timeframe to be agreed with NHS Improvement.

95% of those with cancer requiring referral to a Tertiary centre to have that referral made by day 38 – daily expectation

75% of Red 1 calls on scene within 8 minutes - 30/10/17

75% of Red 2 calls on scene within 8 minutes – 30/10/17

95% of category C calls on scene within 19 minutes – 30/10/17

Ambulance handover time from A&E 15 and 30 mins – 30/10/17

July Status within the IIF: On plan Overall the recovery plan actions are being taken forward, with operational performance improving although not all standards are yet being met. Further work is also being undertaken in relation to changes in ambulance indicators that come into effect from 1/4/18.

Sustainability 3.1 The Trust will take all reasonable steps to deliver services in a manner that is clinically and financially sustainable, including but not limited to those set out in paragraphs 3.2 to 3.4, below.

Action to Achieve Outcome The Leadership work stream of the IIF and QIP addresses this requirement.


- 4 | P a g e

3.2 The Trust will, by a date to be agreed by NHS Improvement, develop a revised strategy to meet the requirements of paragraph 3.1 (“the strategic plan”), that aligns with relevant system plans and other initiatives with partners to further financial and clinical sustainability.

3.3 The strategic plan will, in particular:

3.3.1 include the actions required to meet the requirements of paragraph 3.1, with appropriate timescales and resourcing; 3.3.2 describe the key risks to meeting the requirements of paragraph 3.1 and mitigating actions being taken; 3.3.3 be based on realistic assumptions; 3.3.4 reflect collaborative working with key system partners and other stakeholders; 3.3.5 set out the key performance indicators which the Trust will use to measure progress; 3.3.6 be consistent with the Trust’s other key plans, including but not limited to those plans described elsewhere in these undertakings and the Sustainability and Transformation Plan; 3.3.7 support the Trust in delivering the control totals set by NHS Improvement.

3.4 The Trust will keep the strategic plan and its delivery under review and provide appropriate assurance to its Board regarding progress towards meeting the requirements of paragraph 3.1, such assurance to be provided to NHS Improvement on request. Where matters are identified which materially affect the Trust’s ability to meet the requirements of paragraph 3.1, whether

Key Objective The Board will develop and consider its future strategy as part of the wider STP and MLaFL plans aligned with the output of the financial review to ensure clinically and financially sustainable services on the Island. Board approved strategy by 1/4/2018 July Status within the IIF: On Plan:


- 5 | P a g e

identified by the Trust or another party, the Trust will notify NHS improvement as soon as practicable and update and resubmit the sustainability plan within a timeframe to be agreed with NHS Improvement. Turnaround Director

The Trust will co-operate fully with any Turnaround Director or other individual(s) appointed by NHS Improvement or the Trust’s Commissioners, including any jointly appointed by the Trust and its commissioners, to work with or support the Trust.

At present there is no System Turnaround Director, although the Trust has been working with an NHSI appointed Improvement Director.

Programme management 5.1. The Trust will implement sufficient programme management and governance arrangements to enable delivery of these undertakings. 5.2. Such programme management and governance arrangements must enable the board to:

5.1.1. obtain clear oversight over the process in delivering these undertakings; 5.1.2. obtain an understanding of the risks to the successful achievement of the undertakings and ensure appropriate mitigation; and 5.1.3. hold individuals to account for the delivery of the undertakings

There is a Programme Team in place. The Deputy CEO now is accountable for the oversight and management of the IIF and the Acting Director of Nursing has the same accountability for the QIP.

Meetings and reports 6.1. The Trust will:

6.1.1. attend meetings or, if NHS Improvement stipulates, conference

The Trust is attending all meetings as required.


- 6 | P a g e

calls, at such times and places, and with such attendees, as may be required by NHS Improvement; and 6.1.2. provide such reports in relation to the matters covered by these undertakings as NHS Improvement may require.

Special Measures Undertakings – April 2017

1. CQC report 1.1. The Trust will, in a timely manner, take all action necessary to address the quality and governance concerns identified by CQC in the Section 31 notice of decision dated 9 December 2016 and inspection reports dated X April 2017, such that the Section 31 notice can be lifted and the Trust can exit quality special measures, with no services rated Inadequate. This includes, but is not limited to, taking the action outlined in paragraph 1.2 below. 1.2. The Licensee will develop and agree with NHS Improvement a plan to meet the requirement of paragraph 1.1 above (“the CQC action plan”) by a date to be agreed by NHS Improvement and demonstrate that it can deliver that plan. 1.3. The Trust will keep the CQC action plan and its delivery under review and provide appropriate assurance to its Board regarding progress towards meeting the requirements of paragraph 1.1, such assurance to be provided to NHS Improvement on request.

Action to Achieve Outcome The Section 31 requirements are within the Mental Health plan of the IIF and the QIP. Key Objectives: All requirements within the Section 31 notice have been addressed by 31/12/2017 July Status within IIF: Off plan due to time delay in building works – anticipated completion now February 2018. However, Trust board has approved a capital investment plan that ensures resources have been allocated.

2. Board and leadership capacity and capability

2.1. The Trust will take all reasonable steps to ensure that it has sufficient and effective board, management and clinical leadership capacity and capability to enable it to address:

Action to Achieve Outcome The actions to address these undertakings are within the Leadership work stratum of the IIF and the QIP


- 7 | P a g e

2.1.1. the failures that have led to these undertakings and the undertakings agreed with NHS Improvement on 13 February, and 2.1.2. any other failures relating to quality, governance or operations that have caused or contributed to, or are causing or contributing to, or will cause or contribute to, a breach of the conditions equivalent to the provider licence that apply to NHS trusts. This includes, but is not limited to, taking the actions outlined in paragraphs 2.2 to 2.3 below if required.

2.2. The Trust will, if required, cooperate with an external review of board capacity and capability, to be commissioned either by the Trust or by NHS Improvement. 2.3. The Trust will take all actions necessary, within timescales to be agreed with NHS Improvement, to implement any recommendations addressed to the Trust, or within the Trust’s control, from the review of board capacity and capability.

Key Objectives: The Trust will have a Board approved Performance Management Framework in place by 1/10/17 The Board will have agreed a Board Development Plan by 1/8/17 The Board will have an internal management structure that reflects the services provided by the Trust and supports increasing devolution of corporate services into the day to day delivery of care. – Board approved structures by 1/11/17 July Status within the IIF: . Board Development Off plan The Board review is still underway and there remain key Non Executive and Executive posts to be filled. Performance Framework on plan but the data flows to support it cannot be completed before the governance and managerial structures are completed. Therefore a functional framework that is operational within the Trust is unlikely to be achieved before February 2018. In the meantime a broad accountability framework will be developed for November 2017 and will be led by the deputy CEO.

3. Comprehensive improvement plan

3.1. The Trust will, in accordance with timescales to be agreed with NHS Improvement, prepare and submit to NHS Improvement for approval, a comprehensive improvement plan incorporating all of the actions and action plans required to meet:

3.1.1. the undertakings set out in paragraphs 1.1 to 2.3 above; and

The Trust has the IIF and the QIP.


- 8 | P a g e

3.1.2. the undertakings accepted by NHS Improvement from the Trust dated 13 February 2017. 3.1.3. Any other actions needed to comply with conditions equivalent to the provider licence.

3.2. The Trust will keep the comprehensive improvement plan and its delivery under review and provide appropriate assurance to its Board regarding progress towards meeting the requirements of paragraph 3.1, such assurance to be provided to NHS Improvement on request. 3.3. The Trust will ensure that the delivery of comprehensive improvement plan and other measures to improve quality and operational performance do not compromise its overall financial position. The Trust will keep the financial cost of its quality and operational improvements under close review and will notify NHS Improvement as soon as practicable of any matters which are identified as potentially having a material impact the Trust’s overall financial position.

4 & 5 are repeats of the Programme Management and Attendance at Meetings Undertakings as set out in the 2016 Letter above.

As previously stated.

Isle of Wight NHS Trust Board Performance Report 2017/18July 17

Title


Author(s)

Purpose

Action required by the Board: XPreviously considered by (state date):

Trust Leadership Committee Mental Health Act Scrutiny Committee

Isle of Wight NHS Trust Board Performance Report 2017/18

Jon Burwell - Executive Director of Strategy & Planning

Iain Hendey - Deputy Director of Information

To update the Trust Board regarding progress against key performance measures and highlight risks and the management of these risks.

Receive Approve

Please add any other committees below as needed

Audit and Corporate Risk Committee Remuneration and Nominations Committee

Charitable Funds Committee Quality Governance Committee

Finance, Information, Investment & Workforce Committee Information & Communications Technology Assurance Committee


Legal implications, regulatory and consultation requirements Issue 1085, CQC Section 31 Warning Notice:The CQC have served the Trust with a warning notice of decision to impose conditions on our registration as a service provider in respect of a regulated activity in relation to the Mental Health and Learning Disabilities CBU, under Section 31 of the Health and Social Care Act 2008. They have also issued the Trust with a regulation 17.

Date: Tuesday 29th August 2017 Completed by: Iain Hendey, Deputy Director of Information

Principal Risks (BAF)Risk 671 - Human Resources, Risk 676 - ICT Strategy, Risk 673 - Strategy and Planning, Risk 677 - Local Health and Social Care Economy Resilience, Risk 674 - Quality Governance, Risk 705 - Board Capacity and Capability, Risk 675 - Culture, Risk 712 - Financial Resources

Assurance Level (shown on BAF) �� Red �� Amber �� Green

Other (please state)


Trust Vision: Quality care for everyone, everytime

Executive Summary:

This paper sets out the key performance indicators by which the Trust is measuring its performance in 2017/18. A more detailed executive summary of this report is set out on page 4 providing breakdowns of Excellent Patient Care, A positive experience for patients, service users and staff, Skilled and capable staff and Cost effective, sustainable services.

x

Page 1

Enc L


Index

34

5-9567

Ambulance, Urgent Care and Community…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………8Mental Health and Learning Disabilities…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………9

10-1710111213

Cancer…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………1415

Theatre Utilisation……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..161718

19-221920212223

24-34Front Sheet………………………………………………………………………………………………………………………………………………………………………………………………. 24

2526272829303132

Occupational Health & Wellbeing……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..3334

35-46Front Sheet………………………………………………………………………………………………………………………………………………………………………………………………. 35

3637-38

3940414243444546474849

Mandatory Training……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Appraisal Information ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Staff Turnaround……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Agency…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Cash…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….CIP Performance………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Plan Phasing and Forecast Outturn…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Income…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Single Oversight Framework…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Glossary of Terms…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Use of Resources Rating………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Capital Programme…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Pressure Ulcers……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Patient Safety…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Customer Complaints…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..A&E Performance - Emergency Care 4 hours Standard……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Benchmarking of Key National Performance Indicators……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Summary Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other 'Small Acute Trusts'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other Trusts in the 'Wessex Area'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Ambulance Performance……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Data Quality……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Ambulance………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Mixed Sex Accomodation……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..I Want Great Care……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

July 17

Balanced Scorecard - Aligned to 'Key Line of Enquiry' (KLOEs)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Executive Summary…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Performance Summary Pages…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Surgery, Women's and Children's Health…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Exception Reports…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Medicine……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Clinical Support, Cancer and Diagnostics……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Agency Information……………………………………………………………………………………………………………………………………………………………………………………………………Agency………………………………………………………………………………………………………………………………………………………………………………………………………………….

Clinical Business Unit Financial Performance…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Corporate Directorate Financial Performance…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Workforce Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Workforce Information………………………………………………………………………………………………………………………………………………………………………………………………..

Sickness Information………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

OD & Overpayments………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

E - Rostering……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Income & Expenditure…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Finance Report………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Executive Summary & Key Financial Risks……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Page 2


Balanced Scorecard - Aligned to Our Goals

Excellent Patient Care AreaAnnual Target

YTD Month TrendA positive experience for patients, service users and staff

AreaAnnual Target

YTD Month TrendCost effective, sustainable services

AreaIn month

planAnnual Target

YTDMonth Trend

Patients that develop a grade 4 pressure ulcer TW3 (80%

reduction on 15/16)

0 Jul-17 0 � Emergency Care 4 hour Standards AUC 95% 88% Jul-17 84% � RTT % of incomplete pathways within 18 weeks - IoW CCG TW 89.6% 92% Jul-17 �

Patients that develop an ungraded pressure ulcer TW 1 Jul-17 5 �Number of patients who have waited over 12 hours in A&E from decision to admit to admission

AUC 0 0 Jul-17 0 �� RTT % of incomplete pathways within 18 weeks - NHS England TW 92% 97% Jul-17 ��

VTE (Assessment for risk of) TW >95% 99.4% Jul-17 99.3% � Ambulance Category A Calls % < 8 minutes AUC 75% 64% Jul-17 70.9% � Zero tolerance RTT waits over 52 weeks (Incomplete Return) TW 0 2 Jul-17 0 8 ��

MRSA (confirmed MRSA bacteraemia) TW 0 0 Jul-17 0 �� Ambulance Category A Calls % < 19 minutes AUC 95% 91% Jul-17 93% � No. Patients waiting > 6 weeks for diagnostics TW <8 10 Jul-17 <100 24 �

C.Diff(confirmed Clostridium Difficile infection - stretched target)

TW 7 1 Jul-17 8 � Number of Ambulance Handover Delays over 1 hours AUC N/A 15 Jul-17 97 � % Patients waiting > 6 weeks for diagnostics TW <1% 0.8% Jul-17 <1% 0.5% �

Clinical Incidents (Major) resulting in harm(all reported, actual & potential, includes falls & PU G4)

TW 6 1 Jul-17 5 � % of CPA patients receiving FU contact within 7 days of discharge MH 95% 88.2% Jul-17 95.2% � Theatre utilisation SWC / CCD 83% 79% Jul-17 83% 80% �

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by investigation)

TW 0 Jul-17 2 � % of CPA patients having formal review within last 12 months MH 95% 99.0% Jul-17 98.0% � Total pay costs (inc flexible working) (£000) TW £10,092 £10,913 Jul-17 £41,982 £42,474

Falls - resulting in significant injury TW 5 0 Jul-17 1 �% of MH admissions that had access to Crisis Resolution / Home Treatment Teams (HTTs)

MH 95% 100.0% Jul-17 96.8% �� Staff in Post (£000) TW £10,060 £9,474 Jul-17 £41,756 £37,837

Symptomatic Breast Referrals Seen <2 weeks* CCD 93% 94.0% Jul-17 98.0% � All Cancelled Operations on/after day of admission SWC / CCD

10 Jul-17 54 � Variable Hours (£000) TW £31 £1,438 Jul-17 £226 £4,637

Cancer patients seen <14 days after urgent GP referral* CCD 93% 98.5% Jul-17 97.8% �

Cancelled operations on/after day of admission (not rebooked within 28 days) - including those not rebooked at the time of reporting

SWC / CCD

0 4 Jul-17 5 � Staff absences - Acute Acute 3.5% 3.61% Jul-17

Cancer Patients receiving subsequent Chemo/Drug <31 days* CCD 98% 100.0% Jul-17 100.0% �� Patient Satisfaction (Friends & Family test - Total response rate) TW 29% Jul-17 29% � Staff absences - Ambulance Ambulance 5.5% 8.61% Jul-17

Cancer Patients receiving subsequent surgery <31 days* CCD 94% 100.0% Jul-17 100.0% �� Patient Satisfaction (Friends & Family test - A&E response rate) TW 2% Jul-17 4% � Staff absences - MHLD MHLD 4.5% 5.49% Jul-17

Cancer diagnosis to treatment <31 days* CCD 96% 98.6% Jul-17 98.6% � Mixed Sex Accommodation Breaches TW 0 5 Jul-17 35 � Staff Turnover TW 5% 0.61% Jul-17 5% 0.59%

Cancer Patients treated after screening referral <62 days* CCD 90% 100.0% Jul-17 100.0% �� Formal Complaints TW 36 Jul-17 104 � Mandatory Training* TW 80% 80.0% Jul-17 80.0%

Cancer Patients treated after consultant upgrade <62 days* CCDNo measured

operational standard

No Pts Jul-17 50% �� Compliments received TW N/A 175 Jul-17 758 � Appraisal Monitoring TW 100% 50.0% Jul-17 50.0%

Cancer urgent referral to treatment <62 days* CCD 85% 76.7% Jul-17 79.9% � Achievement of adjusted financial performance TW (£2.329) Jul-17 (£18.8m) (£8.226)

Summary Hospital-level Mortality Indicator (SHMI)July-15 - June-16

TW 1 1.015Published Jan 2017 N/A � Variance against adjusted financial performance TW (£0.76) Jul-17 £0 (£0.49)

Never events TW 0 0 Jul-17 0 �� Liquidity ratio days metric TW Jul-17 4.0 4.0

Stroke patients (90% of stay on Stroke Unit) M 80% 84% Jul-17 86% � Capital Servicing Capacity (times) TW Jul-17 4.0 4.0

High risk TIA fully investigated & treated within 24 hours (National 60%) M 60% 100% Jul-17 100% �� Agency spend variance against plan (£000's) TW £0 (£554) Jul-17 £0 (£1.231)

*Cancer figures for September are provisional. Capital Expenditure as a % of YTD plan TW 7% Jul-17 =>75% 11%

Working with others to keep improving our services

AreaAnnual Target

YTD Month Trend Skilled and capable staff AreaIn month

planYear to

date planYTD I&E Margin Rating TW Jul-17 4.0 4.0

I&E Margin Variance from Plan TW Jul-17 1.0 2.0

Delayed Transfer of Care (lost bed days) - (MH) TW N/A 0 Jul-17 30 �� Total Workforce (inc flexible working) (FTE's) TW 2,964.06 2,902.0 Jul-17 N/A N/A Single Oversight Framework - Use of Resources TW Jul-17 2.8 3.6

Delayed Transfer of Care (lost bed days) - (Acute) TW N/A 110 Jul-17 413 � Total workforce SIP (FTEs) TW 2,750.76 2,681.0 Jul-17 N/A N/A Debtors over 90 days as a % of total debtor balance TW Jul-17 =<5% 25.0%

Delayed Transfer of Care (lost bed days) - (Community) TW N/A 269 Jul-17 734 � Variable Hours (FTE) TW 213.3 221.0 Jul-17 853.2 851.0 Creditors over 90 days as a % of total creditor balance TW Jul-17 =<5% 5.0%

Notes Agency Spend above Ceiling TW Jul-17 1.0 4.0

Delivering or exceeding Target � Key to Area Code Total CIP savings achieved TW 100% 93% Jul-17 100% 113%

Underachieving Target �� TW = Trust Wide Recurring CIP savings achieved TW 100% 89% Jul-17 100% 109%

Failing Target � SWC = Surgery, Women's and Children's Health Contract Penalties TW £5,750 Jul-17 £0.0 £7,500

M = Medicine Employee Relations Cases TW 0 29 Jul-17 113

CCD = Clinical Suppprt, Cancer and Diagnostics * Rolling year

AUC = Ambulance, Urgent Care and Community

MH = Mental Health and Learning Disabilities

Deterioration on previous month

Actual Performance

Actual Performance

No change to previous month

Actual Performance

Actual Performance

Improvement on previous month

Sparkline graphs wil be included in M1

Report to present the trends over time for

Key Performance Indicators

Actual Performance

Page 3


Executive SummaryJuly 17

Excellent Patient Care:Pressure ulcers: There are a number of ungradable pressure ulcers that are still under review, the numbers will continue to change following investigation and validation of all lesions as attribution is more accurately assessed and learning shared with the appropriate teams. A recent trial with hand held Tissue Scanners has demonstrated early detection of tissue damage up to 10 days prior to development of a visual lesion. This has indicated that the majority of ulcers developed within 10 days of admission have already passed the preventable stage prior to arrival on the wards and has proved a more reliable indicator than the current system scoring of risk.

C.diff: There has been one new case of Healthcare Acquired Clostridium Difficile identified in the Trust during July. The objective for 2017/18 remains at no more than 7 cases across the year and this has now been exceeded.

There have been no new cases of MRSA within the Trust during July.

Cancer urgent referral to treatment <62 days target was not achieved in July.

A positive experience for patients, service users and staff:

The Ambulance service targets were not achieved in July. Recruitment to paramedic posts is ongoing - shortlisting complete and interviews scheduled for 25th August. 2 staff commence training for CertHe paramedic course in September. This will have a positive impact on the workforce going forward. The substantive structure has now been drafted and shared with staff. This will be shared via the Trust Operational Management group being implemented and the service has planned a workforce workshop to be held on the 29th August to review the future requirements in order to meet the new Ambulance Responce Programme (ARP) standards which are being introduced nationally from 1st September. The service in the meantime has started a deep dive (August) in order to make internal improvements of the 'green up' time by improving the visibility of the Performance Support Officers (PSO) in ED to make sure ambulance staff are completing their ‘green up’ in a timely manner; looking at ways of being more efficient in replenishing stock on the vehicles; ensuring all dispatchers are prompting frontline staff when timeliness looks to be a concern and escalating to PSO's as appropriate to provide support.

Emergency Care 4 Hour Standard - Emergency Care Standard - The 95% National target was not achieved in July and the local trajectory of 88% was not achieved although there was a significant improvement of 7.2% from June's performance. In order to further improve performance the service is working to ensure compliance against actions embedded within the IIF and embed changes in working practice and culture in order to sustain and further improve performance.

Mixed Sex Accommodation - There were three mixed sex accommodation breaches during July that involved ward sleeping accommodation. However, there were 2 additional incidents within the Intensive Care Unit (ICU) of Acute Care Pathway's (ACP) ending - patients no longer requiring high dependency or intensive care treatment within ICU - where the patient was unable to be returned to ward care and the personal care facilities within ICU did not meet the single-sex accomodation standard. All of the MSA breaches involved extended ACP ends.

We have received 36 formal complaints during July (26 in June).We have received 195 compliments during July (141 in June).

% of Care Programme Approach patients having formal review within last 12 months is achieving YTD and % of Care Programme Approach patients receiving Follow Up contact within 7 days of discharge did not achieve in month however is achieving the YTD target.

0 patients have waited over 12 hours in A&E from decision to admit to admission in July.

Skilled and capable staff:

• Sickness absence has increased in July 17 within Acute, MHLD and Ambulance. Trustwide 4.17%• Anxiety, stress and other psychiatric illnesses remains the highest cause of absence although there has been a decrease of 2.48 % inJuly 2017. • Agency usage has exceeded the national ceiling, with Medics providing cover for vacancies and additional activity cover.• During July, agency nurses were used to cover vacancies within MH and to staff additional beds/capacity in Acute areas. • The Trust appraisal position has increased to 50.03% in month from 48.49%, and now represents the full rolling year figure since theappraisal “reset”. Information is being provided to identify those outstanding so that this position can be improved upon.• Turnover is stable at 0.61% in month 4• Mandatory training is at 80% Trustwide• Update to Occupational Health and Wellbeing CQUIN

Cost effective, sustainable services:

Referral to treatment times - In July the Trust over-performed against the system-wide trajectory of 88.8% by achieving 92.2%; this is also slightly over-performing against the national target of 92% which the Trust had forecast it would not be achieving until March 2018. This over-performance against the trajectory is a continued improvement upon the performance achieved in June of 91.2%.

Overall theatre utilisation has decreased very slightly over the last month from 79.7% to 79.4%. The percentage utilisation of Main Theatre facilities has increased from the previous month from 78.8% to 80.1% against the local target of 83%. Day Surgery Unit utilisation has decreased slightly from 81.0%, to 78.6% A daily review of individual list utilisation is in place with processes being further developed and monitored to embed consistency in clinician sign off of lists and agreed utilisation levels; this is alongside regular monitoring of reasons for late starts and early finishes as well as on the day cancellations and the identification of appropriate actions to reduce, such as reviewing the informed booking data and reviewing the Access Policy around patient choice .

The Trust has a cumulative deficit of £8.226m as at 31 July 2017. This is an adverse variance of £0.485m behind the Board approved deficit plan.The adverse variance to date against the Board approved plan is due to the increased additional expenditure on both agency and the Quality Improvement Plan.The control total for 2017/18 is a deficit of £0.366m.The current cumulative deficit is £6.6915m behind this control total.The most likely forecast outturn is £18.8m. This assumes a further £2.4m of additional quality improvement plan costs over the plan deficit, as approved by the Trust Board in May 2017. However, this will be offset by uncommitted centrally held investment funding.Any best case scenario will be in the region of £11m, assuming full delivery of CCG QIPP plans.Under a Worst Case scenario the Trust will deliver a £30.4m deficit. This includes a shortfall in CIP achievement of £3.5m and further QIPP assigned from the CCG, without equivalent cost reduction, of £4.3m.Year to date, CIP savings of £1.780m have been achieved, which is ahead of plan by £0.201m. As at 31 July £0.406m of capital allocation has been spent. The Trust board is meeting on 15th August to prioritise schemes for 2017/18 to the value of the approved Capital Resource Limit of £8.3m.The cash position for the Trust remains a key risk, with monthly approvals of uncommitted loan funding required.The Trust’s Use of Resources Rating is a score of 4 (1 being best and 4 being worst). This is based on the control total of £0.366m deficit, which the Trust is monitored against with NHSI.

Page 4


Performance Summary - Surgery, Women's and Children's Health

Target Actual Target Actual Target Actual Target Actual

MRSA (confirmed MRSA bacteraemia) Jul-17 0 0 0 0 Mixed Sex Accommodation Breaches Jul-17 0 0 0 0

C.Diff (confirmed Clostridium Difficile infection) Jul-17 1 3 No. of Complaints Jul-17 12 31

Clinical Incidents (Major) resulting in harm

(all reported, actual & potential, includes falls & PU G4)Jul-17 1 0 3 1 No. of Concerns Jul-17 12 57

Clinical Incidents (Catastrophic) resulting in harm

(actual only - as confirmed by investigation)Jul-17 0 1 No. of Compliments Jul-17 61 286

Falls - resulting in significant injury Jul-17 0 0

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at

the time of reporting

Jul-17 0 4 0 5

Emergency 30 day Readmissions Jul-17 4.1% 3.5% All Cancelled Operations on/after day of admission Jul-17 10 54

Never Events Jul-17 0 0 0 0 No. of Reported SIRIs * Jul-17 1 3

Pressure Ulcers - Grade 1 Jul-17 3 7 Physical Assaults against staff Jul-17 3 11

Pressure Ulcers - Grade 2 Jul-17 2 7 Verbal abuse/threats against staff Jul-17 1 6

Pressure Ulcers - Grade 3 Jul-17 0 0


Pressure Ulcers - Ungradable Jul-17 0 1


Appraisals Jul-17 58.3%

Plan Actual Plan Actual Target Actual Target Actual

Total SLA Value Jun-17 3,444,238£ 3,457,064£ 10,005,982£ 10,161,655£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS

England)Jul-17 92% 91.1%

Zero tolerance RTT waits over 52 weeks (Incomplete Return) Jul-17 0 2 0 8

% Sickness Absenteeism Jul-17 3.5% 3.94% 4.05%

*12 hour breaches are now included in Siri figures

**The Acute Service Level Agreement performance reports a month behind, therefore figures are from June 2017.

Income**Latest

data

In Month YTD YTD

YTD

Cost effective, sustainable services

Latest

data

In Month

YTD Skilled and capable staff Latest

data

In Month

July 17

Balanced Scorecard - Surgery, Women's and Children's Health

Excellent Patient CareLatest

data

In Month YTD A positive experience for patients, service users and staff

Latest

data

In Month YTD


Latest

data

In Month

Key Headlines:

• RTT 18 week trajectory continues above plan, those specialties slightly under have plans in place to improve position. 92% has been achieved, however, this is subject to very close monitoring and concerns it can be sustained due to Day Case capacity

• Vacant lists continue to be targetted to Urology and Gynaecology to reduce the backlog of 18 week patients as little support from subcontracting capacity however due to surgeon and anaesthetist capacity, the gains from this are constrained

• Subcontracting continues in Orthopaedics and recently Ophthalmology and the contract is around 75% complete.

• Recruitment continues to fill nursing and consultant/middle grade posts to reduce levels of agency staffing currently being used, following performance review, a business case is in development for the recruitment of a consultant urologist

• The CBU is working closely with HR to target hot spots of sickness and to audit compliance with the management of ill health policy

Page 5


Performance Summary - Medicine








Falls - resulting in significant injury Jul-17 0 0 No. of Reported SIRIs * Jul-17 0 3

Emergency 30 day Readmissions Jul-17 10.4% 9.7% Physical Assaults against staff Jul-17 4 11

Stroke patients (90% of stay on Stroke Unit) Jul-17 80% 84.2% 80% 86.2% Verbal abuse/threats against staff Jul-17 4 10

High risk TIA fully investigated & treated within 24 hours (National

60%)Jul-17 60% 100.0% 60% 100.0%

Never Events Jul-17 0 0 0 0















Income**Latest

data

In Month YTD

Skilled and capable staff Latest

data

In Month

YTD

YTD


Latest

data

In Month


Latest

data

In Month YTD

July 17

Balanced Scorecard - Medicine


data


Latest

data

In Month YTD

Key Headlines:• Sickness absenteeism continues to be monitored and discussed at the monthly leadership meetings. Medicine CBU have met the 3.5% target in May, June and July 2017

• Weekely Specialty RTT meetings commenced in June 2017.

• A plan to improve the % of completed appraisals is being developed

• Additional Gastroenterology outpatient clinics are being put on to reduce the RTT deficit

• The information regarding pressure ulcers is being validated and an action plan will be developed if required.

Page 6


Performance Summary - Clinical Support, Cancer and Diagnostics








Falls - resulting in significant injury Jul-17 0 0

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at the time of

reporting

Jul-17 0 4 0 5

Emergency 30 day Readmissions Jul-17 0.0% 0.0% All Cancelled Operations on/after day of admission Jul-17 10 54

Symptomatic Breast Referrals Seen <2 weeks* Jul-17 93% 94.0% 93% 98.0% Theatre utilisation Jul-17 83% 79.4% 83% 80.0%

Cancer patients seen <14 days after urgent GP referral* Jul-17 93% 98.5% 93% 97.8% No. of Reported SIRIs *** Jul-17 0 0

Cancer Patients receiving subsequent Chemo/Drug <31 days* Jul-17 98% 100.0% 98% 100.0% Physical Assaults against staff Jul-17 0 2

Cancer Patients receiving subsequent surgery <31 days* Jul-17 94% 100.0% 94% 100.0% Verbal abuse/threats against staff Jul-17 0 8

Cancer diagnosis to treatment <31 days* Jul-17 96% 98.6% 96% 98.6%

Cancer Patients treated after screening referral <62 days* Jul-17 90% 100.0% 90% 100.0%

Cancer urgent referral to treatment <62 days* Jul-17 85% 76.7% 85% 79.9%

Never Events Jul-17 0 0 0 0









Total SLA Value Jun-17 1,215,176£ 1,241,476£ 3,542,895£ 3,518,072£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS England) Jul-17 92% 96.6%


No. Patients waiting > 6 weeks for diagnostics Jul-17 <8 10 <100 24

% Patients waiting > 6 weeks for diagnostics Jul-17 <1% 0.8% <1% 0.5%


*Cancer figures for April are provisional. These are subject to further validation and may change.


***12 hour breaches are now included in Siri figures

Income**Latest

data

In Month YTD


data

In Month

YTD

YTD


Latest

data

In Month


Latest

data

In Month YTD

July 17

Balanced Scorecard - Clinical Support, Cancer and Diagnostics

Excellent Patient Care Latest

data


Latest

data

In Month YTD

Key Headlines:

• Cancer Performance - The Trust is provisionally not achieving the 62 Day standard for July with 44 Treatments and 10 Local Breaches (3 x Haematology, 1 x LGI, 1 x Lung, 5 x Urology)Breach reports have been prepared and shared appropriately. Root Cause Analysis undertaken to identify reasons for

delays & improve management of complex pathways. Patient Access Meeting is focusing on resolution for patients passed 62 day target. Additional PTL meetings have been arranged.

• NHSI/IST visit 7th September to review service pressure areas & offer assistance.

• Short term funding secured to address backlog and improve timely access to MRI.

• Theatre Utilisation - Performance has dropped slightly from 79.7% to 79.4% against a local target of 83%. Close monitoring of underutilisation plus daily meeting with the other CBU's expedite actions and challenge to improve these figures lists .

• Actions to improve overall utilisation includes review of reasons for late starts to theatre lists, early finishes and reasons for on day cancellations. Qlik view dashboard has been developed by PIDS to ensure we are reporting one % figure and this is still work in progress .

• Diagnostic breaches are due to Nurse Endoscopist vacancy, cancer and urgent patients are being prioritised. CBU exploring outsourcing routine cases on monthly basis until vacancy recruited to. Additional OOH sessions scheduled to address backlog

• Mixed Sex Breaches - Options paper drafted to refurbish DSU & address mixed sex accommodation going forward. Work will not commence until 2018. Risk being mitigated in interim.

• Sickness Absence Monitoring Analysis - Significant reduction in sickness in July. Management is addressing long term absences and supporting their return to work.

Page 7


Performance Summary - Ambulance, Urgent Care and Community



C.Diff (confirmed Clostridium Difficile infection - stretched target) Jul-17 0 0 No. of Complaints Jul-17 10 34

Clinical Incidents (Major) resulting in harm (all reported, actual & potential,

includes falls & PU G4)Jul-17 1 0 3 2 No. of Concerns Jul-17 12 58

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by

investigation)Jul-17 0 0 No. of Compliments Jul-17 0 79

Falls - resulting in significant injury Jul-17 0 1 Emergency Care 4 hour Standards Jul-17 95% 88.0% 95% 84.0%

Never Events Jul-17 0 0 0 0Number of patients who have waited over 12 hours in A&E from decision to admit

to admissionJul-17 0 0 0 0

Pressure Ulcers - Grade 1 Jul-17 2 3 Category A 8 Minute Response Time (Red 1) Jul-17 75% 50.0% 75% 66.4%

Pressure Ulcers - Grade 2 Jul-17 0 3 Category A 8 Minute Response Time (Red 2) Jul-17 75% 64.5% 75% 72.4%

Pressure Ulcers - Grade 3 Jul-17 0 0 Category A 19 Minute Response Time Jul-17 95% 91.2% 95% 93.3%

Pressure Ulcers - Grade 4 Jul-17 0 0 Number of Ambulance Handover Delays over 1 hours Jul-17 15 97

Pressure Ulcers - Ungradable Jul-17 0 0 No. of Reported SIRIs * Jul-17 1 12

Physical Assaults against staff Jul-17 3 8

Verbal abuse/threats against staff Jul-17 3 15




Total SLA Value Jun-17 2,382,403£ 2,293,007£ 7,049,563£ 6,734,613£ % Sickness Absenteeism Jul-17 5.5% 5.36% 4.74%

Ambulance re-contact rate following discharge from care by telephone Jul-17 3% 9.2% 3% 13.3%

Ambulance re-contact rate following discharge from care at scene Jul-17 2% 7.9% 2% 6.5%

Ambulance time to answer call (in seconds) - median Jul-17 1 1 N/A N/A

Ambulance time to answer call (in seconds) - 95th percentile Jul-17 5 4 N/A N/A

Ambulance time to answer call (in seconds) - 99th percentile Jul-17 14 15 N/A N/A

NHS 111 Call abandoned rate Jul-17 5% 3.5% 5% 3.5%

NHS 111 All calls to be answered within 60 seconds of the end of the introductory

message Jul-17 95% 90.2% 95% 88.4%

NHS 111 Where disposition indicates need to pass call to Clinical Advisor this should

be achieved by ‘Warm Transfer’ Jul-17 95% 93.8% 95% 94.6%

NHS 111 Where the above is not achieved callers should be called back within 10

mins Jul-17 100% 43.0% 100% 35.5%



Income**Latest

data

In Month YTD


data

In Month

YTD

YTD

Cost effective, sustainable services Latest

data

In Month


Latest

data

In Month YTD

July 17

Balanced Scorecard - Ambulance, Urgent Care and Community


data


Latest

data

In Month YTD

Key Headlines:• Recruitment to vacant posts continues to fill in order to reduce levels of agency staffing currently being used,

• The CBU is working closely with HR to target hot spots of sickness and to audit compliance with the management of ill health policy

• Appraisal information is now being received weekly and being used to target areas which are significantly behind, in particular ward areas.

• Emergency Care Standard - The 95% National target was not achieved in July but performance improved y 7.2% on June's data. Work continues to further improve and embed processes within the ED and the service is working closely with a newly appointed urgent care service improvement lead who is facilitating and guiding the change process

• Ambulance - The Ambulance service targets were not achieved in July and the service is undertaking a deep dive into all missed Red 1 calls in July.

• The ambulance service will also be undertaking a workforce workshop on the 19th August to guide changes required to meet new ARP guidelines and are also working to replace the current Computer Added Dispatch (CAD) system

• Community - There is continued pressure within the community nursing service ,and AUCC HONQ has been released to concentrate entirely on community nursing

• Frailty pathway has been mapped out and agreed system wide and have commenced Task &Finish group for Frailty Programme. A consultant is now confirmed to release consultant of Elderly care to support roll out.

• Community Services commenced Discharge to assess roll out.

• Commenced RRR T&F group for Rehabilitation redesign

• Commenced reduction of inpatient Rehab beds in order to deliver Rehab closer to home in line with CCG commissioning intentions.Page 8


Performance Summary - Mental Health and Learning Disabilities


MRSA (confirmed MRSA bacteraemia) Jul-17 0 0 0 0 FFT - % Response Rate Jul-17 2.0% 1.8%

C.Diff (confirmed Clostridium Difficile infection) Jul-17 0 0 FFT - % Recommending Jul-17 90% 99% 90% 96%


(all reported, actual & potential, includes falls & PU G4)Jul-17 1 0 3 0 No. of Complaints Jul-17 3 8


(actual only - as confirmed by investigation)Jul-17 0 0 No. of Concerns Jul-17 7 23

Falls - resulting in significant injury Jul-17 0 0 No. of Compliments Jul-17 0 11

Never Events Jul-17 0 0 0 0 No. of Reported SIRIs * Jul-17 2 2

% of EIP pathways completed within two weeks Jul-17 50% 66.7% 50% 80.0% Physical Assaults against staff Jul-17 12 57

IAPT – Proportion of people who have completed treatment and

moving to recoveryJul-17 50% 55.4% 50% 54.2% Verbal abuse/threats against staff Jul-17 22 63

% of Users known to CMHS with a risk assessment completed

within the last 12 monthsJul-17 100% 81.0% 81.0% % of CPA patients receiving FU contact within 7 days of discharge Jul-17 95% 88.2% 95% 95.2%

% of CPA patients having formal review within last 12 months Jul-17 95% 99.0% 95% 98.0%

% of MH admissions that had access to Crisis Resolution / Home

Treatment Teams (HTTs)Jul-17 95% 100.0% 95% 96.80%


Delayed Transfer of Care (lost bed days) - (MH) Jul-17 0 30 Appraisals Jul-17 39.7%




3 19685000 Zero tolerance RTT waits over 52 weeks (Incomplete Return) Jul-17 0 0 0 0


Caseload management supervision Jul-17 90% 93% 78%

Bed occupancy Jul-17 79.5% 81.8%



Income**Latest

data

In Month YTD

Skilled and capable staffLatest

data

In Month

YTD

YTD


Latest

data

In Month


Latest

data

In Month YTD

July 17

Balanced Scorecard - Mental Health and Learning Disabilities


data


Latest

data

In Month YTD

Key Headlines:• Sickness levels continue to be high and this will be monitored and actioned by the Head of Operations through the Operational Management Performance Meetings.

• The CBU has been working to address the issues in relation to RTT 18 week waits. Validation has identified an administrative issue in the Single Point of Access Clinics which was impacting on Performance in Adult MH. Poor performance in Learning Disabilities has been due to a number of patients waiting for specialist ADHD assessment. A secondment has been agreed for six

months to enable Nurse Prescriber clinics to undertake the assessments and these will commence by the beginning of September.

• Caseload management continues to be improved.

• It has been noted that there is not sustained performance against the 7-day follow-up target. Review of the follow-up process is being undertaken to ensure that one specific team is responsible for 7-day follow-up.

Page 9


Pressure Ulcers

Analysis:Commentary:General: Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). The Clinical Directorates took full responsibility for the management of pressure ulcer incidents in June 2015 including approval status and checking for duplicates. This is a move away from overall final responsibility for pressure ulcers incidents sitting with the Nutrition and Tissue Viability Service. Increased awareness is continuing to lead to increased numbers being reported. Hospital: N.B. Figures for previous months will continue to change as validation occurs during the process of investigation and attribution. Pressure ulcers also form part of the National Safety Thermometer snapshot audit scheme which is reported nationally. Further details of the Safety Thermometer are available here. http://www.safetythermometer.nhs.ukThe Patient Safety Working Group and the Operational Safety Group review all pressure ulcers that occur in the IW NHS care on a weekly basis. This has focussed further attention on this issue and raised awareness in the Business Units. After an initial rise in the overall reporting, this has started to improve. There are a number of ungradable pressure ulcers that are still under review, the numbers will continue to change following investigation and validation of all lesions as attribution is more accurately assessed and learning shared with the appropriate teams. A recent trial with hand held Tissue Scanners has demonstrated early detection of tissue damage up to 10 days prior to development of a visual lesion. This has indicated that the majority of ulcers developed within 10 days of admission have already passed the preventable stage prior to arrival on the wards and has proved a more reliable indicator than the current system scoring of risk. The scanners are able to detect small changes in potential damage and whether interventions are making an effective change. Work is ongoing to fully evaluate the scanners and the benefit to patients so that a business case for investment in scanners for all wards can be taken forward and extended into the community. Community: The trend overall is encouraging, and the reviews are now focussing on the root cause analysis and cluster review of grade 2 pressure ulcers as the Trust has set itself the target of reducing the occurrence of this grade of pressure ulcers by 50% in the next year. The overall trend across 2016/17 was decreasing incidence across all grades and this is generally continuing. The report now separates out ungradable pressure ulcers as a distinct reporting line so that it is clear that these ulcers (which were previously counted as grade 4s) have not yet been assigned a grade and do not automatically mean that this is an incident that has resulted in patient harm. Numbers will continue to change over several months as investigation continues validation and correct attribution. Pressure Ulcers benchmark

Action Plan: Person Responsible: Date: Status:

The graph shows improving trend. In June the Trust has been above the national average.

Quality Account Priority 2 & National Safety Thermometer CQUIN schemes Prevention & Management of Pressure Ulcers

The Patient Safety Working Group continues to meet weekly. The overall trends are encouraging and the recent increases in numbers are more indicative of increased awareness and reporting of lower grades than of increasing incidence. The trend continues to decrease.

Clinical Business Unit Heads of Nursing & Quality

& Tissue Viability Nurse SpecialistJul-17 Ongoing

• Trust wide Pressure Ulcer Prevention Group continues to meet. .• Deep dives for each Business Unit going ahead to look at why expected reductions were not achieved last year.• Action plans for pressure ulcer reduction have been reviewed and are being amalgamated into a single master plan for coming year.• Local monthly Tissue Viability and MUST audits are being established by Tissue Viability Service.• Pressure Ulcer Reporting has been handed to Matrons and Locality leads to supervise to develop local ownership of reporting and understanding the scale of the issue.•Work is also ongoing to identify where patients are admitted from their home address who have been receiving non NHS care assistance.

Clinical Business Unit Heads of Nursing & Quality

& Tissue Viability Nurse SpecialistJul-17 Ongoing

Page 10


Patient Safety

Commentary: Analysis: Clostridium Difficile infections against national and local targets


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

Acute Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0

Continued use of HPV terminal environmental decontamination post discharge/transfer of patients with active Clostridium difficile infection or colonisation.

Hotel Services manager Jul-17 Continuing

July 17

Clostridium difficileThere was 1 case of Trust attributed Clostridium difficile infection (CDI) in July. The objective for 2017/18 remains at no more than 7 cases across the year and this has now been exceeded.

Root cause analysis is undertaken both for Trust attributed CDI cases and those cases attributed to the CCG where the patient had been admitted to IWNHS Trust within the 3 months before diagnosis. There is no agreement between the Trust and CCG as to what constitutes a lapse in care however and this needs to be agreed (discussion with CCG requested). As a result of recent investigations, the catheter care pathway is to be revised and further investigation into the use of antimicrobials undertaken.

Whenever there is an inpatient with CDI, the ward is expected to undertake CDI management audit, regardless of whether or not the bacteraemia is hospital or community acquired. The IPCT undertake regular CDI audit at such times for assurance that IPC management is effective. The IPC Nurse undertakes a weekly CDI and C Difficile colonised patient review weekly with the pharmacist taking a lead in antimicrobial therapy. Continued actions to drive CDI reduction include education regarding management of loose stools and utilisation of hydrogen peroxide vapour (HPV) for terminal environmental decontamination post discharge/transfer of patients with active Clostridium difficile infection or colonisation.

A team from IWNHS participated in a national NHS improvement programme in the year 16/17 and focused on improved bed space cleaning methodology with the aim of introducing a standardised approach to bed space cleaning following patient discharge/transfer within the organisation. A training video was developed to support staff.

Methicillin-resistant Staphylococcus Aureus (MRSA)There have been no cases identified as Healthcare acquired infections during July.

Action Plan: Status:Person Responsible: Date:

End of July 2017

Ongoing

Ward SistersContinued drive to improve and maintain stool sampling in accordance with policy

Organisational roll Participation in National 90 day improvement programme with results discussed at national meeting. This has now resulted in a tutorial bed space cleaning video shared across the trust.

Ongoing IPCT

CompletedOngoing

Continuing

DIPC as team lead. HONQ and Ward Sisters to drive at ward level with support from

IPCT

Jul-17

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

Total cases 1 4 7 8 8 8 8 8 8 8 8 8

National Target 1 1 2 2 3 3 4 4 5 6 6 7

0

2

4

6

8

10

Isle of Wight NHS Trust C. Difficile cases (Cumulative)

Page 11


Formal Complaints

Analysis: Complaints only

May-17 Jun-17 Jul-17 RAG rating

0 2 0 ��

4 2 3 �1 1 1 �3 6 6 �0 0 0 ��3 6 8 �0 0 0 ��0 1 0 ��0 0 1 �0 0 0 ��0 0 0 ��0 0 1 �

0 2 1 �1 1 1 �3 1 2 �0 0 0 ��0 0 1 �

1 1 1 �

1 0 0 ��

2 3 7 �

0 0 3 �

Commissioning

Transport (Ambulances)

July 17

Consent

End of Life Care

The Datixweb complaints module has commenced roll out and the Clinical Business Units in conjunction with the Complaints Team continue to work to improving timeliness and quality of complaint responses

Executive Director of Nursing / Patient Experience Lead

Oct-17

Commentary:

Action Plan:

Access to treatment or drugs

Admissions and discharges

Appointments

Clinical Treatment

Integrated Care

Facilities

Primary Subject

Values and Behaviours (Staff)

Communication

Waiting Times

There were 36 formal Trust complaints received in July 2017 (26 in the previous month) with 195 compliments received by letters and cards of thanks for the same period. In addition to the 36 formal complaints, a further 65 concerns (66 in the previous month) were raised.

Across all complaints and concerns in July 2017: Top subjects were:

- Communication (21) - Appointments (14) - - Clinical Treatment (14) Top areas of complaints and concerns were:

- Emergency Department (10) - OPARU (9) - Surgical Wards (5)

In Progress

Mortuary

Other (Use with Caution)

Privacy, Dignity and Wellbeing

Prescribing

Person Responsible: Date: Status:

Patient Care

Restraint

Staff numbers

Trust admin/Policies/Procedures

Page 12


Emergency Care 4 hours Standard (ECS)

Commentary: Analysis:

Analysis:

Ambulatory Care Service

Action scheduled care projects with clear milestones and success measures within the IIF's Acute Scheduled Care Programme

Heads of Operations for Ambulance, Urgent Care & Community and

Medicine Clinical Business UnitsJul-17 Commenced

July 17

Action Plan: Person Responsible:

Emergency Care 4 hours Standard

Date: Status:

Emergency Care Standard - The 95% National target was not achieved in July and the local trajectory of 88% was not achieved although there was a significant improvement of 7.2% from June's performance. In order to further improve performance the service is working to ensure compliance against actions embedded within the IIF and embed changes in working practice and culture in order to sustain and further improve performance. The service continues to work proactively to introduce senior review of all patients at the front door. There are two ED consultant locums now in post to deliver increased frontline consultant presence in the ED and the service has been reviewing all workforce and skill mix required to run a safe ED. An emergency care service improvement lead has been employed as an interim measure and is proactively working with the ED and wards to improve patient flow. Handover between the ED and ambulance service has started to improve and the MAU team are also working with the urgent care improvement lead to reduce LOS and improve flow and review the ambulatory care pathway to determine the most effective way to treat these patients.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Au

g 1

6

Se

p 1

6

Oct

16

No

v 1

6

De

c 1

6

Jan

17

Fe

b 1

7

Ma

r 1

7

Ap

r 1

7

Ma

y 1

7

Jun

17

Jul

17

Target not achieved Target achieved Target Trajectory

Number of Admissions to AEC Ward and Follow Up Outpatient Visits

Data as at 18/08/2017

Point of delivery Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

2016/17

Total Apr-17 May-17 Jun-17 Jul-17 Aug-17

2017/18

Total

Admissions to AEC Ward 24 47 45 29 42 187 9 9 10 20 9 57

Follow Up Outpatient Visit 1 1 1 2 1 6 0 0 0 0 0 0

AEC Admissions by demand stream (Admission source)

Data as at 18/08/2017

Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

2016/17

Total Apr-17 May-17 Jun-17 Jul-17 Aug-17

2017/18

Total

NO DATA! 2 1 3 1 1

OTHER NHS HOSPITAL - GENERAL PATIENTS WARD 1 2 3 2 8 1 1

USUAL PLACE OF RESIDENCE 21 44 42 29 40 176 8 9 10 19 9 55

Grand Total 24 47 45 29 42 187 9 9 10 20 9 57

Page 13



Analysis:

Review compliance by end of June of referral/request forms being hand delivered by outpatient staff to diagnostics to improve the timeliness against pathway stages

Jul-17Operational Manager (Outpatients) Commenced

The Trust achieved all Cancer Waiting Times standards for July with the exception of the <62 Day standard. 94% performance was achieved for 2ww Breast Symptomatic with 3 patient-led breaches. 98.5% was achieved for 2ww with 7 patient-led breaches recorded (standard 93%). 98.6% performance was achieved for the 31 Day DTT to Treatment standard with one breach (Skin patient - DTA form not marked CaFT).

With regards to the cancer urgent referral to treatment <62 days target of 85%, the Trust under performed at 70.6% under old breach allocation guidance; this position is currently unvalidated as it includes potential shared breaches and is subject to reporting by tertiary centres by mid-September. Local performance stands at 76.7% with 43 patients treated and 10 breaches identified. (3 x Haematology - Complex diagnostic pathway, 1 x LGI - Required anaesthetic/cardiology reviews, 1 x Lung - Delay to PET scan, 1 x Urology - Delay to tertiary centre investigation, 1 x Urology - Patient requested thinking time, 1 x Urology - Required repeat biopsies, 1 x Urology - Required investigation for other condition, 1 x Urology - Patient unfit for investigations).

Breach reports have been prepared and root cause analysis is taking place into each of these to identify the lessons learned and implement actions to mitigate such further delays; these will be shared with operational staff.

There is currently an increased focus on patient pathways >62 days. Specialty and CBU PTL meetings are taking place weekly. Trends are analysed and key issues explored at the Patient Access Meetings with regular PTL catch up sessions introduced. The Trust is aiming to reduce all diagnostic waiting times to less than 7 days (radiology, pathology and endoscopy). Bids to NHS England have been completed for additional funding to facilitate this. Urology Improvement Meetings have been reinstated. The NHS England 'Critical Friend' visit on 7 September 2017 will focus on performance against the 62 Day standard. Initial discussions have already commenced and a full agenda for the day agreed.

Status:

Agree tumour site data collection minimum data set for each MDT by the end of June to increase standardisation and available reporting

AchievedLead Cancer Nurse Jul-17

July 17

Action Plan: Person Responsible: Date:

Cancer urgent referral to treatment <62 days

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Cancer urgent referral to treatment <62 days

Target achieved Target not achieved Target Trajectory

Page 14


Ambulance Performance


Analysis:

Action scheduled care projects with clear milestones and success measures within the IIF's Ambulance ProgrammeHead of Operations for Ambulance, Urgent Care

& Community Clinical Business UnitJun-17 In progress

Status:

July 17

Action Plan: Person Responsible: Date:

The Ambulance service targets were not achieved in July. Recruitment to paramedic posts is ongoing - shortlisting complete and interviews scheduled for 25th August. 2 staff commence training for CertHe paramedic course in September. This will have a positive impact on the workforce going forward. The substantive structure has now been drafted and shared with staff. This will be shared via the Trust Operational Management group being implemented and the service has planned a workforce workshop to be held on the 29th August to review the future requirements in order to meet the new Ambulance Response Programme (ARP) standards which are being introduced nationally from 1st September. The service in the meantime has started a deep dive (August) in order to make internal improvements of the 'green up' time by improving the visibility of the Performance Support Officers (PSO) in ED to make sure ambulance staff are completing their ‘green up’ in a timely manner; looking at ways of being more efficient in replenishing stock on the vehicles; ensuring all dispatchers are prompting frontline staff when timeliness looks to be a concern and escalating to PSO's as appropriate to provide support. Recruitment to call handlers has been successful with a number of staff now completing their training and the 111 service has seen an improvement in performance compared to June as a direct result of this. Further recruitment is ongoing to additional call handler posts. The service is working towards compliance against actions in the IIF.

0.0%

25.0%

50.0%

75.0%

100.0%

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Cat A 8 minutes response time (Red 1)

Target achieved Target not achieved

Target Trajectory 0.0%

50.0%

100.0%

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Cat A 19 minutes response time

Target achieved Target not achieved

Target Trajectory

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Cat A 8 minutes response time (Red 2)

Target achieved Target not achieved Target Trajectory

Page 15


Theatre Utilisation

Analysis:

July 17

Commentary

Overall theatre utilisation has decreased very slightly over the last month from 79.7% to 79.4%. The percentage utilisation of Main Theatre facilities has increased from the previous month from 78.8% to 80.1% against the local target of 83%. Day Surgery Unit utilisation has decreased slightly from 81.0%, to 78.6% A daily review of individual list utilisation is in place with processes being further developed and monitored to embed consistency in clinician sign off of lists and agreed utilisation levels; this is alongside regular monitoring of reasons for late starts and early finishes as well as on the day cancellations and the identification of appropriate actions to reduce, such as reviewing the informed booking data and reviewing the Access Policy around patient choice . Focus will continue on actioning the milestones within the Integrated Improvement Framework's Acute Scheduled Care Programme, in particular, improving delivery against the pre-assessment processes so that hospital resources are maximised and patients are fit and healthy and better prepared for their elective procedure, as well as increasing Day Surgery, Theatre & OPD Procedures efficiency to improve access for our patients.

Action plan Person Responsible: Date: Status:

Action scheduled care projects with clear milestones and success measures within the IIF's Acute Scheduled Care Programme

Head of Operations for Clinical Support, Cancer & Diagnostic

Services Clinical Business Unit

Jun-17 Commenced

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

Main Theatres

Target failed Target met Target

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

DSU


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

Main & DSU


Page 16


Mixed Sex Accommodation


Analysis:

Daily review of situation with increased reviews as alert status escalates. Executive Director of

Nursing / Senior Clinical Capacity Manager

Jul-17 Ongoing

July 17

Mixed Sex Accommodation


There were three mixed sex accommodation breaches during July that involved ward sleeping accommodation. However, there were 2 additional incidents within the Intensive Care Unit (ICU) of Acute Care Pathway's (ACP) ending - patients no longer requiring high dependency or intensive care treatment within ICU - where the patient was unable to be returned to ward care and the personal care facilities within ICU did not meet of the single-sex accomodation standard. All of the MSA breaches involved extended ACP ends. Critical care areas such as Acute Coronary Care or Intensive (High Dependency) Care are exempt from the accommodation/bathroom requirements as highly specialised critical care needs take priority and patients are generally too unwell to manage their own personal care or mobility at this time, making facilities for self-care unnecessary. However, when the critical care period ends the patient should be returned to a stepdown/general ward with the appropriate facilities as privacy and dignity (of both those both recovering and still requiring critical care) could otherwise be compromised. This is now reported as an ACP end breach if there is no appropriate bed available and obviously has an added effect of blocking beds needed for critical care use such as acute cardiac events, sepsis, following major surgery or trauma. This converts to MSA breach after 4 hours without a suitable bed on another care area. There is a risk of recurrence during periods of high bed occupancy levels and delayed discharges despite the permanent increase in the number of available beds and the opening of further contigency beds in periods of high demand. Although every effort is made to avoid the situation, the changing patient mix remains challenging as isolation requirements and care of the dying has to take priority and may require movement of some patients to accommodate the greater needs of others. Work is underway to redesign the day surgery unit so that privacy and dignity standards can be updated to those currently applicable but this is a long term project and will involve rescheduling of future surgery for the period of rebuilding. More detailed auditing of patient moves now in place will give further data towards understanding the increased operational needs.

0

2

4

6

8

10

12

14

Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17

Page 17


I Want Great Care

Clinical Business Unit Reviews Average Score

% Likely to

Recommend Clinical Business Unit Cleanliness Staff

Dignity/R

espect Information

Surgery, Women's and Children's Health 204 4.84/5 96.1% Surgery, Women's and Children's Health 4.90/5 4.93/5 4.95/5 4.73/5

Medicine 129 4.66/5 91.5% Medicine 4.74/5 4.82/5 4.77/5 4.42/5

Clinical Support, Cancer and Diagnostic Services 846 4.87/5 97.0% Clinical Support, Cancer and Diagnostic Services 4.89/5 4.91/5 4.91/5 4.82/5

Ambulance, Urgent Care and Community Services 391 4.82/5 92.1% Ambulance, Urgent Care and Community Services 4.77/5 4.89/5 4.89/5 4.71/5

Mental Health & Learning Disabilities 23 4.61/5 95.7% Mental Health & Learning Disabilities 4.50/5 4.87/5 4.83/5 4.22/5

July 17

88.0%90.0%92.0%94.0%96.0%98.0%

Surgery,

Women's

and

Children's

Health

Medicine Clinical

Support,

Cancer and

Diagnostic

Services

Ambulance,

Urgent Care

and

Community

Services

Mental

Health &

Learning

Disabilities

% of Reviewers Likely to Recommend by CBU

% Likely to

Recommend

I Want Great Care reports split by Clinical Business Unit to show reviews received in July, the average score each Business Unit received and how many of those reviewers are likely to recommend. There are Business Unit breakdowns of best reviewed service and worst reviewed service within that business unit.

Ambulance, Urgent Care and Community ServicesTop three services (with 5 reviews or more)

Laidlaw Day Hospital 5.00/5

Paediatrics - Speech and Language 5.00/5

Physiotherapy 4.98/5

Bottom three services (with 5 reviews or more)

Medical Assessment Unit 4.75/5

Emergency Department 4.71/5

Continence Service 4.70/5

Clinical Support, Cancer and Diagnostic ServicesTop three services (with 5 reviews or more)

Chemotherapy 5.00/5

Pain Management Programme - PMP 5.00/5

Asthma and Allergy - Research - Adults 4.99/5


Main Outpatient Department 4.80/5

Fracture Clinic 4.74/5

Diagnostic Imaging 4.22/5

MedicineTop three services (with 5 reviews or more)

Community Stroke Rehabilitation Team 4.96/5

Appley Ward 4.73/5

Respiratory 4.71/5


TIA Clinic 4.62/5

Stroke Unit 4.62/5

General Rehabilitation 4.25/5

Surgery, Women's and Children's HealthTop three services (with 5 reviews or more)

Alverstone Ward 4.89/5

Asthma and Allergy - Children's 4.89/5

Gynae Outpatient Department 4.88/5


Children's Ward 4.78/5

Postnatal Ward 4.72/5

Colposcopy 4.71/5

Mental Health & Learning DisabilitiesTop two services (with 5 reviews or more)

Mental Health Reablement Service 4.88/5

Osborne Ward 4.33/5

Bottom two services (with 5 reviews or more)

Mental Health Reablement Service 4.88/5

Osborne Ward 4.33/5


Benchmarking of Key National Performance Indicators: Summary ReportJuly 17

Best Worst Eng

Emergency Care 4 hour Standards 95% 100% 77% 87.6% 82.5% 150 / 164 Red Qtr 1 17/18

RTT % of incomplete pathways within 18 weeks 92% 100% 76% 90.0% 91.9% 119 / 185 Amber Red Jun-17

%. Patients waiting > 6 weeks for diagnostic 1% 0% 15% 1.9% 0.0% 1 / 177 Green Jun-17

Ambulance Category A Calls % < 8 minutes - Red 1 75% 76% 64% 70.5% 64.3% 8 / 11 Amber Red Jun-17

Ambulance Category A Calls % < 8 minutes - Red 2 75% 72% 52% 63.5% 71.4% 3 / 11 Amber Green Jun-17

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 72% 0% 64.0% 71.8% 3 / 11 Amber Green Jun-17

Ambulance Category A Calls % < 19 minutes 95% 95% 85% 90.8% 91.8% 3 / 11 Amber Green Jun-17

Cancer patients seen <14 days after urgent GP referral 93% 100% 68% 94.4% 97.6% 19 / 150 Green Qtr 1 17/18

Cancer diagnosis to treatment <31 days 96% 100% 82% 96.8% 96.1% 119 / 153 Red Qtr 1 17/18

Cancer urgent referral to treatment <62 days 85% 100% 0% 80.5% 85.6% 57 / 153 Amber Green Qtr 1 17/18

Symptomatic Breast Referrals Seen <2 weeks 93% 100% 12% 90.7% 99.3% 5 / 129 Green Qtr 1 17/18

Cancer Patients receiving subsequent surgery <31 days 94% 100% 77% 96.0% 100.0% 1 / 150 Green Qtr 1 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 100% 87% 99.2% 100.0% 1 / 134 Green Qtr 1 17/18

Cancer Patients treated after screening referral <62 days 90% 100% 0% 92.6% 100.0% 1 / 137 Green Qtr 1 17/18

Key: Better than National Target = Green Top Quartile = Green

Worse than National Target = Red Median Range Better than Average = Amber Green

Median Range Worse than Average = Amber Red

Bottom Quartile Red

Data PeriodIW RankNational

Target

National Performance IW

PerformanceIW Status

Page 19


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other 'Small Acute Trusts'July 17

Other Small Acute Trusts

Emergency Care 4 hour Standards 95% 82.5%24

87.6%19

98.2%2

98.4%1

92.7%13

92.3%14

95.4%6

N/A 96.7%4

94.1%10

88.6%18

92.0%15

97.0%3

90.7%16

N/A 95.1%7

95.6%5

N/A 93.7%12

83.9%23

89.7%17

94.7%8

85.6%22

87.0%20

86.3%21

94.6%9

N/A 94.0%11

Qtr 1 17/18

RTT % of incomplete pathways within 18 weeks 92% 91.9%16

95.2%4

94.6%6

85.0%19

97.6%1

N/A 92.6%12

N/A 93.7%8

93.2%10

92.0%14

91.9%15

95.6%3

92.3%13

N/A 83.4%20

90.9%17

N/A 94.8%5

93.3%9

N/A 82.0%21

93.1%11

93.9%7

76.0%23

90.0%18

N/A 96.7%2

Jun-17

%. Patients waiting > 6 weeks for diagnostic 1% 0.0%1

0.1%5

1.9%18

5.6%24

0.2%9

3.2%22

0.5%14

N/A 0.4%12

2.0%19

0.3%11

1.0%17

0.0%1

0.4%13

N/A 0.1%7

0.6%16

N/A 0.2% 2.6%21

0.1%6

0.0%1

0.2%8

0.5%15

2.2%20

3.2%23

N/A 0.0%1

Jun-17

Cancer patients seen <14 days after urgent GP referral 93% 97.6%3

96.4%12

93.8%21

86.2%24

97.4%5

92.4%23

95.4%14

N/A 96.4%10

96.5%9

97.4%4

96.7%7

97.3%6

95.0%18

N/A 94.2%19

0.0%20

94.0%22

93.6%22

98.2%2

95.5%13

95.2%16

95.2%15

96.4%11

96.6%8

95.0%17

N/A 98.4%1

Qtr 1 17/18

Cancer diagnosis to treatment <31 days 96% 96.1%24

98.7%14

97.0%23

98.9%12

99.3%9

98.2%16

98.1%17

N/A 99.1%11

100.0%1

98.7%15

100.0%1

100.0%1

99.2%10

N/A 100.0%1

98.9%13

N/A 97.5%21

97.8%19

97.0%22

98.0%18

100.0%1

99.4%8

100.0%1

97.6%20

N/A 100.0%1

Qtr 1 17/18

Cancer urgent referral to treatment <62 days 85% 85.6%17

64.3%24

85.8%16

85.1%18

97.7%1

87.2%13

86.0%14

n/A 79.9%20

91.8%5

77.8%21

88.9%11

97.6%2

89.4%8

N/A 85.8%15

89.0%10

N/A 77.8%22

94.1%3

84.8%19

89.1%9

93.3%4

88.6%12

90.4%6

90.2%7

50.0%25

71.2%23

Qtr 1 17/18

Breast Cancer Referrals Seen <2 weeks 93% 99.3%2

97.5%6

93.8%16

68.6%22

93.4%18

77.8%21

97.3%7

N/A 95.7%10

99.1%3

97.1%8

96.5%9

N/A 94.3%14

N/A 94.2%15

94.7%13

N/A 42.2%23

92.5%19

89.8%20

95.0%12

99.6%1

98.1%5

93.8%17

95.4%11

N/A 98.8%4

Qtr 1 17/18

Cancer Patients receiving subsequent surgery <31 days 94% 100.0%1

87.5%23

93.2%21

100.0%1

100.0%1

100.0%1

100.0%1

N/A 97.6%19

100.0%1

95.9%20

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 92.9%22

100.0%1

85.7%24

100.0%1

100.0%1

100.0%1

100.0%1

98.4%18

N/A 100.0%1

Qtr 1 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% N/AN/A

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A N/A N/A 100.0%1

100.0%1

100.0%1

N/A N/A Qtr 1 17/18

Cancer Patients treated after screening referral <62 days 90% 100.0%1

50.0%23

100.0%1

100.0%1

98.6%13

66.7%22

100.0%1

N/A 87.5%19

100.0%1

100.0%1

100.0%1

100.0%1

91.8%17

N/A 97.6%15

87.9%18

N/A 78.3%20

100.0%1

100.0%1

100.0%1

N/A 97.8%14

94.0%16

71.4%21

N/A 100.0%1

Qtr 1 17/18

Key: Better than National Target = Green R1F ISLE OF WIGHT NHS TRUST RC3 EALING HOSPITAL NHS TRUST RFW WEST MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST RLT GEORGE ELIOT HOSPITAL NHS TRUST

Worse than National Target = Red RA3 WESTON AREA HEALTH NHS TRUST RCD HARROGATE AND DISTRICT NHS FOUNDATION TRUST RGR WEST SUFFOLK NHS FOUNDATION TRUST RMP TAMESIDE HOSPITAL NHS FOUNDATION TRUST

Target Not Applicable for Trust = N/A RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST RCF AIREDALE NHS FOUNDATION TRUST RJC SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST RN7 DARTFORD AND GRAVESHAM NHS TRUST

RBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST RCX THE QUEEN ELIZABETH HOSPITAL KING'S LYNN NHS TRUSTRJD MID STAFFORDSHIRE NHS FOUNDATION TRUST RNQ KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST

RBT MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST RD8 MILTON KEYNES HOSPITAL NHS FOUNDATION TRUST RJF BURTON HOSPITALS NHS FOUNDATION TRUST RNZ SALISBURY NHS FOUNDATION TRUST

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RBZ NORTHERN DEVON HEALTHCARE NHS TRUST RE9 SOUTH TYNESIDE NHS FOUNDATION TRUST RJN EAST CHESHIRE NHS TRUST RQQ HINCHINGBROOKE HEALTH CARE NHS TRUST

out of the 28 other small acute trusts RC1 BEDFORD HOSPITAL NHS TRUST RFF BARNSLEY HOSPITAL NHS FOUNDATION TRUST RLQ WYE VALLEY NHS TRUST RQX HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

National

TargetData PeriodRLQ RLTRJD RJFRFF RFW RGR RJC RQQRNZRNQRN7RMPIW RBD RBT RBZ RC1RA3 RA4 RQXRJNRC3 RCD RCF RCX RD8 RE9

Page 20


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other Trusts in the 'Wessex Area'July 17

Emergency Care 4 hour Standards 95% 82.5%7

N/A 98.4%2

93.2%5

N/A 93.8%3

87.8%6

78.5%8

93.8%4

99.7%1

Qtr 1 17/18

RTT % of incomplete pathways within 18 weeks 92% 91.9%8

99.4%1

85.0%10

92.7%5

97.6%2

92.2%6

92.0%7

91.5%9

93.5%4

94.4%3

Jun-17

%. Patients waiting > 6 weeks for diagnostic 1% 0.0%1

0.0%1

5.6%10

0.7%6

0.2%4

0.2%5

0.9%9

0.8%8

0.7%7

0.0%1

Jun-17

Cancer patients seen <14 days after urgent GP referral* 93% 97.6%2

N/A 86.2%7

99.3%1

N/A 97.6%3

94.7%6

97.1%4

96.4%5

N/A Qtr 1 17/18

Cancer diagnosis to treatment <31 days* 96% 96.1%7

N/A 98.9%2

100.0%1

N/A 96.1%6

97.4%5

98.4%4

98.6%3

N/A Qtr 1 17/18

Cancer urgent referral to treatment <62 days* 85% 85.6%4

N/A 85.1%5

92.3%1

N/A 88.2%2

81.3%7

82.5%6

87.2%3

N/A Qtr 1 17/18

Breast Cancer Referrals Seen <2 weeks* 93% 99.3%2

N/A 68.6%7

97.8%3

N/A 100.0%1

87.0%6

96.1%4

94.6%5

N/A Qtr 1 17/18

Cancer Patients receiving subsequent surgery <31 days* 94% 100.0%1

N/A 100.0%1

100.0%1

100.0%1

98.3%6

97.8%7

98.4%5

96.7%8

N/A Qtr 1 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days* 98% N/A N/A 100.0%1

100.0%1

N/A 100.0%1

99.1%6

100.0%1

100.0%1

N/A Qtr 1 17/18

Cancer Patients treated after screening referral <62 days* 90% 100.0%1

N/A 100.0%1

96.3%4

N/A 85.3%7

94.9%5

90.5%6

100.0%1

N/A Qtr 1 17/18

Key: Better than National Target = Green R1F Isle Of Wight NHS Trust

Worse than National Target = Red R1C Solent NHS Trust

RBD Dorset County Hospital NHS Foundation Trust

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RD3 Poole Hospital NHS Foundation Trust

out of the 10 other trusts in the Wessex area RDY Dorset Healthcare University NHS Foundation Trust

RDZ The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust

RHM University Hospital Southampton NHS Foundation Trust

RHU Portsmouth Hospitals NHS Trust

RN5 Hampshire Hospitals NHS Foundation Trust

RW1 Southern Health NHS Foundation Trust

RDYNational

TargetIW R1C RBD RD3 Data PeriodRDZ RHM RHU RN5 RW1

Page 21


Benchmarking of Key National Performance Indicators: Ambulance PerformanceJuly 17

Ambulance Category A Calls % < 8 minutes - Red 1 75% 65.9%6

72.5%4

70.3%5

73.3%3

75.4%1

62.5%8

74.7%2

63.9%7

- - - Jun-17

Ambulance Category A Calls % < 8 minutes - Red 2 75% 71.9%1

56.4%7

60.0%5

69.7%3

57.0%6

64.7%4

71.8%2

46.4%8

- - - Jun-17

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 71.5%2

57.3%7

60.7%5

69.8%3

58.0%6

64.5%4

71.9%1

47.4%8

0.0%9

0.0%9

0.0%9

Jun-17

Ambulance Category A Calls % < 19 minutes 95% 94.0%3

85.0%8

90.5%4

94.3%2

87.5%6

89.4%5

94.4%1

86.1%7

- - - Jun-17

Key: Better than National Target = Green

Worse than National Target = Red RX9

RYC East of England Ambulance Service NHS Trust

R1F

RRU

RX6

RX7

RYE

RYD

RYF

RYA

RX8 Yorkshire Ambulance Service NHS Trust

North West Ambulance Service NHS Trust

South Central Ambulance Service NHS Foundation Trust

South East Coast Ambulance Service NHS Foundation Trust

South Western Ambulance Service NHS Foundation Trust

West Midlands Ambulance Service NHS Foundation Trust

East Midlands Ambulance Service NHS Trust


London Ambulance Service NHS Trust

North East Ambulance Service NHS Foundation Trust

RX6 Data PeriodRYARX7 RYE RYD RYF RX8National

Target

IW

PerformanceRX9 RYC RRU

Page 22


Data Quality

Analysis:

July 17

Investigate and correct where appropriate the invalid commissioner codes in the APC CDS files

Oct 2017 ProgressingDeputy Director of Information

Commentary:


The information centre carry out an analysis of the quality of provider data submitted to Secondary Uses Service (SUS). They review 3 main data sets - Admitted Patient Care (APC), Outpatients (OP) and Accident & Emergency (A&E).

The latest information is for April 2017 to June 2017. Overall we have 10 red rated indicators. Five of the red indicators are in the Admitted Patient Care (APC) Dataset, one in the Outpatient Dataset and four in the A&E Dataset.

Admitted Patient Care (APC):Two of the red indicators in the APC dataset are Primary Diagnosis and the HRG4 (Healthcare Resource Grouping). Although these improved from last month they remain red due to the high volume of activity on the coding backlog. We also have high number of missing patient pathways. Previous investigation has shown that this relates to Direct Access Endoscopy patients as these are not allocated a pathway at the point of referrral for a diagnostic test in accordance with the national guidance. Prior to recording Endoscopies as daycases these patients would have been recorded in the outpatient CDS. THIS IS NOT A DATA QUALITY ISSUE AND NO FURTHER ACTION IS REQUIRED. We also have a higher than usual number of invalid Commission Codes, these will be investigated and corrected where appropriate. The final red indicator in the APC dataset is the NHS number, this relates mostly to prisoners who's NHS number is not always available. The reported figure is in line with previous months.Outpatients Dataset (OP):The red indicator in the OP dataset relates to patient pathways. This has been red since 2015/16 and was investigated, it is due to the number of patients that have an open episode but a closed RTT pathway, it is not considered a data quality issue.A&E Dataset:There are curently four red indicators in the A&E dataset. The red indicators are the Attendance Disposal, Commissioner Code, Conclusion Time and the First Investication code. The proportion of blank Attendance Disposal codes has been increasing and needs to be investigated. Proportionally the number of invalid Commissioner Code has not significantly changed from last year. The proportion of missing conclusion times has not change significantly however the national average has improved however the number of missing First Investigation codes has risen considerably and needs to be reviewed.

Investigate the number of missing First Investigation codes in the A&E Dataset Deputy Director of Information Oct 2017 Progressing

Investigate the number of missing attendance disposal codes in the A&E Dataset Deputy Director of Information Oct 2017 Progressing

Page 23

Workforce Report

July 2017

24

Workforce Information

25

Overall staffing for month 4 is 2681 FTE inpost, against a budgeted establishment of 2977 FTE (excluding CIP). Active recruitment equates to

228 FTE (Medics 11 FTE, Nursing 100 FTE, Other 117 FTE) Staff in post (substantive) increased by 28 FTE in month. The additional

appointments are a mix of Admin & Clerical, additional Clinical Services and Nursing staff, and particularly an additional 6 FTE within MHLD

which will positively impact on Month 5/6 additional staff usage.

The Trust employs 2681.06 FTE substantive staff (headcount of 3085), plus c 400 bank staff and has 187 volunteers.

Additional staffing (Bank, Agency, Excess and Overtime) equated to 221 FTE in month 4, and has shown a reduction of 10 FTE from the

previous month. Agency usage within MHLD is high due to an increase in service demand. High Bank usage occurs within General Medicine

and AUCC due to covering of unfilled vacancies.

Agency Information

26

Agency Use

Agency usage in month was predominantly to cover vacancies or for additional capacity to match activity. Medical usage has stabilised in month and nursing usage has seen

a slight drop as Whippingham have reduced their rota requirement. A review of the workforce plan with the Medical Director and Director of Nursing is underway to

develop a recruitment strategy as part of the Integrated Improvement Framework.

Agency Use: Breakdown of agency staff groups actual spend:

Highest users of Medical Agency staff:

• General Medicine - Locum Consultant starting Monday 04 September. Core

Trainee - shortlisting stage

• Psychiatry Adult – Consultant: Out to advert. Core Trainee & Specialist

Registrar - shortlisting stage

• Ophthalmology – Consultant: Vacant. Specialty Doctor -2 appointed due to

commence August & September.

Highest users of non-Medical Agency staff:

Mental Health CBU

• CRHT/CMHS/Woodlands/Afton – Vacancies out to advert.

• Attendance at Recruitment Fair for Mental Health is planned for 9th October

2017.

Acute Nursing

• Whippingham/Emergency department/Theatres/Stroke – Vacancies out to

advert.

Agency

27

Agency - Compliance with NHSi ceiling

IOW NHS Trust has exceeded the NHSi ceiling. Month 4 shows that we are £1,367k above the agreed cumulative

ceiling, and in month over by £432k. The below graph shows forecast spend based on current trajectory of spend,

resulting in the Trust overspending by £6,380k by the end of 17/18.

Action to address:

• Development of Recruitment & Retention Plan

• Targeted recruitment drives

• Focus on effective e-rostering

• Authorisation controls

• Weekly reporting

Sickness Information

28

Sickness absence by Area

Sickness absence has increased across Acute, Ambulance and MHLD in July. Acute was 0.11% above its KPI of 3.50%, which equates to a variance of 0.19%

between June and July. Ambulance is 3.11 % above its KPI of 5.50% for July and has seen an increase in month of 1.10% compared to June, this is caused

mainly by increases in Other Musculoskeletal problems and Injury, fracture reasons both of which have doubled the amount of days lost in month. MHLD

is also 0.99% above its KPI target at 5.49% in July and has seen an increase of 0.54% in July.

Trust Wide sickness absence Reasons

Trust sickness absence rate: 4.17%, with a rolling rate of 4.49%. Top reasons for absence in July - Gastrointestinal problems which represent a loss of 142

FTE days between June and July. Similarly there has been an increase of 14.27% in “Other musculoskeletal problems” which represents a loss of 81.01 FTE

days lost. Cough, Cold and Flu has seen a reduction of 9.32% in July, similarly “back problems” have reduced by 7.45 %. This represents a reduction in FTE

days of 18.77 and 14.68 respectfully. There has also been a minor decrease of 2.48% for absence reasons relating to Anxiety, Stress and Depression which

represents a reduction of 21.19 FTE days.

Staff Turnover

29

Staff turnover is stable with month 4 at 0.61%, a minor decrease on Month 3 from 0.62%, but still well below in month target of 5%.

Turnover YTD is 0.59%. Rolling 12 month % is 8.92%.

Mar 17 is shown as a spike due to the end of the financial year, where fixed term contracts finish, along with Earl Mountbatten Hospice

staff TUPE’ing across. Trust Staff Group breakdown % as at July 17.

Mandatory Training

30

Current Trust position (31/07/17) is 80% against the target for 17/18 of 85%. This includes Bank Staff. Reporting data has reverted back to

percentage of total requirements achieved instead of % staff above 85%. Courses reported to board have been reviewed and are in line with

Portsmouth Hospitals NHS Trust and Solent NHS Trust (reflecting Acute & Community and MH Services). MT Policy has been reviewed and is

out for consultation. Medical & Dental staff group compliance remains lowest %. Comprehensive MT data now provided for CBU

performance reports. Resuscitation service staffing increased from 1.6 WTE to 3.0 WTE increasing availability of spaces on courses. Prevent

training was added at the end of July reflecting the low compliance %.

Appraisals Information

31

Rolling 12 month appraisal % at month 4 is 50.03%, the drop in recent months is representative of appraisals that were held 12 months ago but

have not been renewed as of yet. Weekly appraisal report updates by cost centre have been provided to ensure Business Units are aware of their

appraisal rate, and can request details on individual staff members who have an in-date appraisal. Appraisal table by Business unit to identify areas

for focus.

Business Unit

Reviews

Completed -

Rolling Year %

Allergy 25.00

Ambulance, Urgent Care & Community Services 44.67

Chief Operating Officer 25.71

Clinical Support, Cancer & Diagnostic Services 56.81

Finance & Performance Mgt 35.94

General Medicines 49.64

Mental Health & Learning Disability 39.73

Nursing Directorate 24.53

Surgical & Women & Child Health Services 58.31

Transformation & Integration Directorate 65.52

Trust Administration 62.50

Total Rolling % 50.03

Organisational Development Update

32

OD & Overpayments

• Leadership Development Team is now at full compliment and has commenced leadership delivery plan of programmes and interventions

in response to CQC findings and 2016 staff survey results. All CBU’s have a “link facilitator” role to support leadership within CBU’s to be

an advisory link and to present and discuss staff survey results.

• Employee Engagement Strategy is in development.

• Anti-Bullying advisors - Group of anti-bullying advisors have now been selected and will be developed with programme of education and

support.

• Staff Survey 2017 – plans in place to launch this years survey

OverpaymentsThe overpayments outstanding figure has increased from £99K as at June 17 to £119K in July 17. There was £21k in new overpayments

added in July. This was due, in the main, to managers submitting late and incorrect change and termination forms. A point to note,

however, is that nearly £7k was caused by our payroll provider, SBS and have been identified as input and admin errors. The source of the

new overpayments was spread across the business units, although the MH&LD business unit incurred almost half.

Occupational Health & Wellbeing

33

IMPROVING STAFF HWB - CQUIN UPDATE

There are 3parts to this CQUIN indicator:

1a – Improvement of health and wellbeing of NHS staff. A 5% improvement is required in 2 out of the 3 following staff survey questions using the 2015 survey as a baseline:

• Does your organisation take positive action on health and wellbeing?

• In the last 12 months have you experienced musculoskeletal problems (MSK) as a result of work activities?

• During the last 12 months have you felt unwell as a result of work related stress?

1b – Healthy food for NHS staff, visitors and patients

• Maintain the 4 changes from the 2016/17 CQUIN

• Set limits on level of sugar, fat and calories on certain foods

1c - Improving the uptake of flu vaccinations for front line staff

• Achieving an uptake of flu vaccinations by frontline clinical staff of 70% in 1st year, 75% in year 2

Actions to support HWB of staff and achievement of CQUINs are on target & include:

• Work Related Stress

All staff absent due to Work Related Stress whatever the cause, are being sent a letter outlining all avenues of support available.

Incidents of violence and aggression to staff members are followed up by OH outlining avenues of support.

• Look after yourself and your team

Training sessions as part of the High Performing Leaders programme building blocks for Managers started in July, discussion and understanding of Health & Wellbeing (HWB),

support is available and how to recognise symptoms of stress.

• Time Out – Mindfulness Sessions – regular sessions undertaken and available, designed to be quick and easy opportunities to step out for 10 minutes and re -balance

yourself. These are proving popular and can be arranged in work area for teams.

• EAP – Workplace Options contract signed and continues to be the Trust provider for counselling and HWB support for employees and their families. Last quarter report

shows higher use of service both counselling and general advice, likely to be due to raised awareness of the service..

• MSK - 0.5WTE additional Physiotherapy available and letter sent to all employees off sick due to MSK inviting them to take up a referral to physio.

• Healthy Eating – linking with the Sugar Smart Island project led by Public Health to raise awareness of the impact of sugar consumption and promote healthier choices.

Additionally maintaining and building on previous year’s CQUIN to further reduce levels of sugar and portion control.

• Flu campaign – planning and setting dates, times and places for Flu sessions. Vaccine ordered

E-Rostering

34

Trust e-Rostering

The Trust uses Allocate HealthRoster. The system has recently moved to the cloud enabling wider access at home providing more

functionality. This will be released in due course with training and knowledge sharing. One such benefit of this is the availability of bank

staff to book shifts enabling the temporary staffing team to focus specifically on those ‘hard to fill shifts’. As bank only staff is a hard to

access group; plans for a bank launch day are in discussion. This will offer input to support access to this self-booking functionality and

coincides with the move to online payslips, where logins can be supplied and is an opportunity for the organisation to say thank you.

There had been an issue with moving to the cloud with expense claims. Further time to allow for expenses will be given this month-

communication is be available on the e-Rostering intranet page.

Finalising Rosters

Each month all rosters should be locked down in accordance with the lockdown timetable – available on the e-Rostering intranet page. A lot

of time is spent chasing units to finalise. Detail to be disseminated through Performance Reviews. Units not finalised cannot be sent for

upload into ESR and has significant implications with payroll queries and data quality for further reports. Nine units were removed where

no absence or payroll information will be uploaded to ESR.

Finance Report

July 2017

Page 35

Isle of Wight NHS Trust Finance Report 2017/18

Executive Summary & Key Financial Risks

Executive Summary Key Financial RisksKey risks can be summarised as follows:

1. Achievement of deficit plan of £18.835m

2. Recurrent Cost Improvement Programme

3. Cash

4. Full use of Capital Resource Limit

5. Impairment

July 17

The Trust has a cumulative deficit of £8.226m as at 31 July 2017. This is an adverse variance of £0.485m behind the Board approved deficit plan.

The adverse variance to date against the Board approved plan is due to the increased additional expenditure on both agency and the Quality Improvement Plan.

The control total for 2017/18 is a deficit of £0.366m.The current cumulative deficit is £6.6915m behind this control total.

The most likely forecast outturn is £18.8m. This assumes a further £2.4m of additional quality improvement plan costs over the plan deficit, as approved by the Trust Board in May 2017. However, this will be offset by uncommitted centrally held investment funding.

Any best case scenario will be in the region of £11m, assuming full delivery of CCG QIPP plans.Under a Worst Case scenario the Trust will deliver a £30.4m deficit. This includes a shortfall in CIP achievement of £3.5m and further QIPP assigned from the CCG, without equivalent cost reduction, of £4.3m.

Year to date, CIP savings of £1.780m have been achieved, which is ahead of plan by £0.201m.

As at 31 July £0.406m of capital allocation has been spent. The Trust board is meeting on 15th August to prioritise schemes for 2017/18 to the value of the approval Capital Resource Limit of £8.3m.

The cash position for the Trust remains a key risk, with monthly approvals of uncommitted loan funding required. The Trust’s Use of Resources Rating is a score of 4 (1 being best and 4 being worst). This is based on the control total of £0.366m deficit, which the Trust is monitored against with NHSI.

With risks, opportunities and mitigating actions the likely scenarios areBest case £11.mLikely case £18.8mWorst case £30.4mAny risks to the revised forecast need to be mitigated by identification of further opportunities.

The confirmed CRL is £8.3m and the Trust Board held a Capital Seminar to decide priorities for 2017/18. Business cases will then need to be developed and final costs determined with further projects dependant on any funding not committed.

Plans for the CIP programme are now behind schedule. This would have a negative impact on achieving the 2017/18 financial plan.The Trust is currently identifying a shortfall in plans of £4.071m.

A deficit position in of the planned £18.835m results in reliance on uncommitted loans from Department of Health and associated interest payments. Current borrowing is £5.686m in 2017/18 and £14.030m carried forward from previous years. A further £1.563m will be received in August and £4.105m has been requested for September.

A previous capital project for ICU/CCU merger resulted in an Asset under construction of £0.20m. As this project is no longer progressing, this amount will need to be written off as impairment.

Page 36


Income and ExpenditureJuly 17

To date the Trust is reporting a deficit of £8.226m against a deficit plan to date of £7.741m, a negative variance of £0.485m.This is based on the Board approved deficit plan of £18.835m for 2017/18.Included in this is £1.162m of expenditure related to Quality Improvement Resource, and is the reason for the deterioration of the in-month position compared to last month.

The in-month position is a deficit of £2.329m, a negative variance of £0.761m against plan.

A summary of the income and expenditure position to date is set out in the table below.

The Trust control total for 2017/18 was a deficit of £0.366m.The phased plan to date for this control total is a deficit of £1.535m. The current cumulative deficit is £6.691m behind this control total, as follows:

Page 37


Income and ExpenditureJuly 17

An overall summary of the income and expenditure position by Business Unit and directorate is set out in the table below

Page 38


Clinical Business Unit Financial Performance

A summary of the income and expenditure position by Clinical Business Unit is set out in the table below.

July 17

The adverse variance in month was caused by the remaining allocation of CIP.

In total the Operational Division is overspent by £1.411m, however QIP funding has not been allocated to individual budgets. This equates to £0.848m of the current overspend, which is mainly attributable to pay.The agency premium funding has been allocated to the CBU’s from centrally held funds. However agency usage is causing a cost pressure of £0.124m.

The in-month improvement on Surgery, Women’s & Children’s Health has resulted from the allocation on agency premium funding for June and July.

Medicine is overspent as a result of the premium costs and mitigating risks with the Urgent Care Service (£0.224m)

Overachievement on income relates to:-

Surgery, Women’s & Children’s Health improved income position on Mottistone.Both Ambulance, Urgent Care and Community and Medicine have seen an increase in income associated with over achievement of CCG non-contractual income for non-Island residents.Overachieved income on Chief Operating Officer is matched to overspends on both pay and non-pay relating to EMH and MLaFL

Page 39


Corporate Directorate Financial Performance

A summary of the expenditure position by Corporate Directorate is set out in the table below.

July 17

Work is underway to ensure the Corporate Structure is reflected in the financial ledger, this included the creation of the Human Resources & Organisational Development Directorate and the reallocation of the Cost Improvement Plan.

In total corporate division is overspent by £0.269m, however QIP funding has not been allocated to individual budgets. This equates to £0.281m of the current which includes the external governance review which took place in June.

Income is not achieving against planned budget for both Car Parking (£0.028m) and NHS Creative (£0.337m). NHS Creative reduction in income is partly offset by reduction in both pay and non pay expenditure. Overall NHS Creative is £0.047m below plan.

Trust Admin will be completing business cases to support additional cost these include £13k (annual commitment of £40k) contribution to the STP and non-recurrent training support £15k.

Page 40


IncomeJuly 17

Overall, income is £0.354m better plan to date.

As the main CCG contracts for 2017/18 are on a block contract basis there are currently no variances against expected income, however the CCG has stated that they will support additional expenditure incurred for the Urgent Care Service. The walk in service did not cease until the end of June 2017, this was a QIPP scheme for the CCG and was a recurrent reduction of income to the base line of £0.400m. Therefore it is assumed the CCG will support the income for the first quarter.

NHS England is underperforming against contract this relates to Neonatal, Breast Screening and Secondary Dental

Page 41


Phasing and forecast outturn

Plan phasing Forecast outturn

Quality Improvement Resource (QIP)

July 17

The Board approved plan of £18.835m deficit is expected to be delivered as shown in the graph below.The red line identifies the actual position achieved.

In May 2017 the Board approved an indicative £2.4m of additional expenditure in addition to the £18.835m deficit, in respect of Quality Improvement Resources identified to address the issues raised by the Trust being placed into Special Measures.

To date £1.162m of this expenditure has been incurred, and is included in the current year to date deficit position. Much of this has been at agency costs.

The expenditure has been incurred in the following areas:• £0.500m Mental Health & Learning Disabilities• £0.348m Ambulance, Urgent Care and Community• £0.314m Corporate Areas

The best case scenario will be in the region of £11.0m deficit, with the assumption that the CCG will support the QIPP risk share and none of the investment reserve and contingency reserve are utilised.

The most likely forecast outturn is £18.8m. This assumes a further £2.4m of additional quality improvement plan costs over the plan deficit, as approved by the Trust Board in May 2017. However, this will be offset by uncommitted centrally held investment funding.

Under a Worst Case scenario the Trust will deliver a £30.4m deficit. This includes a shortfall in CIP achievement of £3.5m and further QIPP assigned from the CCG, without equivalent cost reduction, of £4.6m and additional costs relating to the Quality Improvement plan.

Page 42


AgencyJuly 17

The in month spend on agency staff is £0.848m.

Cumulative agency spend is £3.024m, which is £1.367m above the NHSI ceiling of £1.241m

Actual agency spend is almost equivalent to 2016/17 despite having Poppy Unit open in 2016/17.

Actions

• Several CIP plans, cost avoidance initiatives have been implemented for 2017/18. However the Trust is not seeing an overall reduction in agency usage.

• All areas have been tasked with reducing the agency spend and reviewing agency is part of the IIF

2017/18 ACTUAL SPEND

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTAL£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £ '000 £'000 £'000

Medical 402 487 501 473 1,863

Nursing 106 188 408 341 1,043

Clinical 16 30 1 33 79

Administration 3 6 9 1 19

Other 8 7 5 0 20

Total spend - month 535 718 924 848 3,024

Total spend - cumulative 535 1,253 2,176 3,024 3 ,024 3,024 3,024 3,024 3,024 3,024 3,024 3,024

Ceiling - month 413 414 414 416 416 416 416 4 16 417 417 417 418

Ceiling - cumulative 413 827 1,241 1,657 2,073 2,489 2,905 3,321 3,738 4,155 4,572 4,990

Variance to ceiling 122 304 510 432 1,367

Page 43


CIP PerformanceJuly 17

Cumulatively there is an achievement of £1.780m against a target of £1.579m year to date.

The full year requirement for 2017/18 is £8.613m.

At present there are schemes identified for £4.542m, this would result in a shortfall of £4.071m

The tables identify the targets currently in place and the Clinical Business Units and Corporate Directorates that these are owned by.

Page 44


CashJuly 17

The cash balance held at the end of July is £3,154k which is £654k more than the adjusted plan. However, the actual cash balance has reduced in year by £4.1m reducing from £7.3m to £3.2m at the end of July. The major movements in cash are as follows:- Operating Deficit Cash (£4.9m)Increased Debtors mainly due to Payment in Advance of annual contracts (£3.5m)Payments for Capital items due to higher than planned Capital Creditors at the end of 2016/17 (£3.1m)Uncommitted Loan receipts £5.7m Increase in Creditors due to in year accruals £2.0mPayment are being managed to ensure critical payments can be made and this resulted in BPPC figures of 93% for volume and 83% for value for the year to July.


Capital ProgrammeJuly 17

Our initial CRL, now confirmed by NHS Improvement is based on forecast depreciation of £6.570m plus the £1.7m slipped from the capital programme in 2016/17 and £50k expected charitable donations.Year to Date spend is £406k (£115k in month), against a plan of £2.988m.

The Trust Board held a Seminar on 15th August, where they decided on the priorities for this year, with the major projects including the following:-• Sevenacres CQC Compliance• DSU Improving Patient Flow• Ambulance CAD Hardware• Paediatric Assessment Unit• Ophthalmology Satellite Unit• Maternity Utility Area• Mottistone upgrade• Level C DDA Compliance• LIMS Telepath upgrade

Costs of these projects will now have to be determined.

Prioritisation of Equipment and IM&T RRP by the CBU's has been completed and business cases are being prepared and approved by Capital Investment Group.

Page 46


Use of Resources RatingJuly 17

NHS Improvement’s new Single Oversight Framework and Use of Resources Rating were introduced from 1 October 2016, replacing the Financial Risk Rating.

The Trusts Use of Resources Rating as at 31 July 17 is set out below.

Against the NHSI Control Total, the Trust’s Use of Resources Rating is a score of 4 (Table 1)

Against the Board approved deficit plan, the Trust’s Use of Resources Rating is a score of 3.6 (Table 2)

This is against a score of 1 being best and 4 being worst.

Page 47


Single Oversight Framework

Ref IndicatorTimeframe (If different to current data)

Threshold May-17 Jun-17 Jul-17YTD/Annual

Figure

1 3% 4.36% 3.90% 4.17% 4.07%

2 5% 0.62% 0.62% 0.61% 0.59%

3 - 0.00% 0.00% 0.00% 0.00%

4 2016 - - 44%

5 Q4 2016/17 - 639.31

6 - 19 26 36 104

7 Q1 2017/18 - 63.00%

8 0 0 0 0 0

9 - 3 3 3 -

10 0 13 9 5 34

11 - 33.00% 13.54% 25.8% 34.37%

12 90% 83.89% 87.59% 94.38% 87.90%

13 <15% >15% 13% 13% 16% 13%

14 90% 100.00% 100.00% 100.00% 100.00%

15 95% 99.55% 99.46% 99.39% 99.28%

16 - 3 2 1 -

17 7 3 3 1 8

18 0 0 0 0 0

19 Jan-17 - - 89.6 (low)

20 Jan-17 - - 99.6 (as exp)

21 Published June 2017 1 - 1.047

22 - 5.9% 5.6% 6.0% 6.05%

23 Published 15th November 2016 - - 28.0%

24 90% 96.80% 88.05% 89.16% 92.17%

25 90% 95.40% 97.78% 98.53% 96.00%

26 - 0 0 0 0

27 95% 93.94% 97.62% 88.20% 95.24%

28 - 33% 33% 33% -

29 - 9% 9% 9% -

30 90% 0%* 0%* 0%* 0.00%

31 - 67% 50% 86% -

32 - 1 2 2 3

33 Submitted in August 2017, figures from April 2017 - 0 1 0 -

*0 responses in April, 1 response in May, 0 responses in June, 1 response in July

**Pending further validation, snapshot as at end of month Please note that the Mixed Sex Accomodation figure for May has now changed due to further validation

Emergency Re-Admissions within 30 days following an elective or emergency spell at the provider

Men

tal H

ealth

Pro

vide

rs

Hospital Standardised Mortality Ratio (DFI)

Hospital Standardised Mortality Ratio - Weekend (DFI)

% Clients in settled accommodation**

Clostridium Difficile - Infection rate

% Clients in employment**

Community scores from Friends and Family Test - % positive

Admissions to adult facilities of patients who are under 16 years old

ST Segmented elevation myocardial infarction (STeMI) 150 minutes (As at month of submission)

Return of Spontaneous Circulation (ROSC) in Utstein group

Stroke 60 minutes (Thrombolysis delivery within 60 minutes)

Mental Health scores from Friends and Family Test - % positive (Recommended)

Care Programme Approach (CPA) follow up - proportion of discharges from hospital followed up within 7 days - MHMDS

July

Staff Sickness

Staff Turnover

Executive Team Turnover (Staff within Trust Board)

NHS Staff Survey - Response Rate

VTE Risk Assessment

Proportion of temporary staff

Community Providers

Clostridium Difficile - Variance from plan

Am

bula

nce

Pro

vide

rs

CQC Inpatient/Mental Health and Community Survey - Response Rate

Acu

te P

rovi

ders

Occurance of any Never Event

Ambulance see and treat from Friends and Family Test - % positive

Current Data

-

Staff Friends and Family Test % recommended - Care

MRSA Bacteraemias

NHS England/NHS Improvement Patient Safety Alerts Outstanding

Emergency C-Section rate

Summary Hospital Mortality Indicator

-

Org

anis

atio

nal H

ealth

Indi

cato

rs

Maternity scores from Friends and Family Test - % Positive

A&E Scores from Friends and Family Test - % Positive (% Recommended)

Inpatient Scores from Friends and Family Test - % Positive (Response rate)

Mixed Sex Accomodation breaches

Written complaints - Rate

Page 48



ON Wednesday 6th September 2017

Title Chief Operating Officers Report


Shaun Stacey, Chief Operating Officer

Author(s) Rachel Buswell-Green, Personal Assistant to DCOO

Purpose To inform Trust Board of current service issues, mitigating actions and good news affecting the five clinical business units.


Receive X Approve




Trust Leadership Committee n/a

Audit & Corporate Risk Committee n/a

Charitable Funds Committee n/a Finance, Investment, Information & Workforce Committee

n/a

Mental Health Act Scrutiny Committee n/a Remuneration & Nominations Committee

n/a

Quality Governance Committee n/a Information & Communications Technology Assurance Committee

n/a


n/a

Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream n/a Section/Clause n/a Current Status/ RAG n/a Section/Clause n/a Current Status RAG n/a Section/Clause n/a Current Status RAG n/a Staff, stakeholder, patient and public engagement: n/a Executive Summary & Analyis:

The report provides a brief overview of current service issues and challenges, mitigating actions and good news, affecting the five clinical business units.

• Surgery, Women’s and Children’s Health Clinical Business Unit (SWCH) • Ambulance, Urgent Care and Community Clinical Business Unit (AUCC) • Clinical Support, Cancer and Diagnostic Service Clinical Business Unit (CSCDS) • Medicine, Clinical Business Unit • Mental Health and Learning Disabilities Clinical Business Unit (MHLD)

This report covers the period 24th June to 11 August 2017

Enc M


Recommendation to the Board: The Trust Board is asked to receive and note the contents of the report. The Board are to be aware that this report format is a work in progress as proposed completion dates for mitigating actions will be added from July onwards. We are working with PIDs to ensure that data around attendance in and out of hours is also included in the report on a monthly basis.

The report format has been altered to show the issues and mitigating actions for Ambulance, Community and Urgent Care within the AUCC business unit as requested; although there are no specific issues for Urgent Care this month, this will be present on the next report.

Attached Appendices & Background papers Urgent Care Service Out of Hours Attendances from June – July 2017. For following sections – please indicate as appropriate:

Trust Goals & Priorities All Trust Goals and Priorities Principal Risks (BAF) 671 through to 676


n/a

Date: 24th August 2017 Completed by: Rachel Buswell-Green


CHIEF OPERATING OFFICERS REPORT

TO TRUST BOARD 6th September 2017

The purpose of this report is to provide a brief monthly overview of current service issues, challenges, or risks affecting the five clinical business units (CBU) balanced with good news, and opportunities. This report covers the period 24th June to 11th August 2017 . Mental Health & Learning Disabilities (MH&LD): Issue Mitigation Action Owner Completion Date Capacity and Capability to deliver the change agenda alongside core business

Clinical Commissioning Group (CCG) have indicated they will fund a further 2 post (Band 8a and Band 4) to support the transformation work required, however, nothing further has progressed. Training is being prioritised based on risk.

Head of Operations and CCG

30th September 2017

Trust patient feedback mechanisms do not work for MH&LD

MHLD CBU to look at other providers in relation to how they get patient feedback.

Head of Operations

30th November 2017

Training – there has been very little investment over recent years in staff training and development and therefore there are significant skills deficits as identified by the Care Quality Commission (CQC)

Training is being prioritised based on risk which links to the CQC report.

Head of Nursing & Quality

18th December 2017

Good News and General Update:

1. No new Serious Incidents Requiring Investigation (SIRI) were reported during this time 2. The CBU are piloting the use of HealthAssure for the wider Trust. This is progressing well, and the

CBU can already see the benefits this will afford in terms of supplying the CQC with required information, and also robust document control

3. The Trust has appointed a new Director for Mental Health, who will support with the development of the strategic direction for the services and also addressing CQC findings

4. The Trust has appointed an Associate Medical Director to support the CBU for 2 days per week. This post-holder is providing supervision to the consultants working for the CBU, and again is supporting in the development of the Strategic direction for the services and also addressing CQC findings

Medicine Issue Mitigation Action Owner Completion Date Urgent Care Service (UCS) staffing and financial challenges

Despite the GP UCS rota being managed and covered, this is still challenging to sustain. In terms of financials, the finance teams from the Trust and the CCG are working to finalise the costs the service has incurred.

Medicine CBU/Trust Finance team

Rota cover challenges are ongoing Finance is planning to complete the costing by the end of August 17

Achieving 100% compliance with implementation of SAFER Bundle on all wards

There has been good progress with the implementation of SAFER:

- Reviews of all stranded patients has been completed daily on Appley and Colwell since 3 July 17

- A plan to roll out all the elements of the SAFER bundle has been written and full ward roll out will commence in September and run until December 17

Matron and Head of Nursing & Quality

As per IIF timetable


Underachieving Referral to treatment (RTT) targets in Gastroenterology and Hepatology

A part time consultant has been offered a fixed-term post. The consultant will job share with Dr Grellier. Options of gaining support for additional outpatient clinics are being explored through Solent Alliance – meeting taking place in August.

Head of Operations

Ongoing

Good News and General Update: 1. Through the implementation of the SAFER bundle and the review of patients with a length of stay

(LOS) of more than 7 days, there has been a 25% decrease in the number of patients with a LOS over 7 days since July 2017

2. Reduction in the number of Falls resulting in Harm 3. Good initial feedback from the CQC regarding the Urgent Care Service (UCS) walk-in service Ambulance Urgent Care and Community

Issue Mitigation Action Owner Completion Date Ambulance Failure to meet the current performance standards

The service is undertaking a deep dive into the current performance and the contributing factors; this is being supported by the Head of Operations (HOO) for the CBU

Head of Operations

31st August 17

Implementation of the new Ambulance Response Programme (ARP) standards recently issued by the Department of Health (DoH)

The service is undertaking a workforce workshop on the 29th August 17 in order to determine the workforce changes required in order to meet the new guidelines. The service will be supporting this with a paper recommending actions to be taken, gaps in service and timelines in order to support these changes The Trust will be asking the DOH for a deferment to implement the reporting of the new standards to the 1st April 18

Head of Operations Head of Operations Clinical Director

31st August 17 6th September 17 31st August 17

Urgent Care

Implementing sustainable change in order to meet the 4 hour emergency care standards (within the Emergency Department (ED) and the Medical Assessment Unit (MAU)

Continued work with the Urgent Care Service Improvement Lead to implement and embed change Implementation of Red to Green in MAU

Head of Operations

Asap

Inadequate workforce and skill mix of staff within the ED and MAU

Reviews of the existing staffing model with the appropriate professional leads are taking place and following this, a report will be completed outlining the recommendations and actions required by the Trust, which will be presented to Trust Board

Head of Operations

4th October 17

Community

Quality concerns within the community nursing team and the significant backlog of Continuing Healthcare Care (CHC) reviews

Head of Nursing & Quality (HONQ) has been redirected to focus on community nursing only for next 6 months An advert will be issued for an interim HONQ for ambulance and MAU/ED. Interim arrangements involve using HOO and Urgent Care Improvement Lead

Head of Nursing & Quality Urgent Care Improvement Lead & Head of Operations

Asap

Significant volume of transformation schemes within the community services requiring immediate action and delivery with limited resource within the CBU E.g.

• Frailty • Rehab redesign • Discharge to assess

Senior staff within the CBU are managing time and prioritizing their workload as much as possible. Any risks identified have been shared with executive colleagues Additional resource (1 whole time equivalent (wte) band 5 for 6 months to 31st March) has been bought in to assist with Rehab redesign/discharge to assess

Head of Operations & Clinical Director

Asap


• Wheelchairs • MPPT • ILS

Assistant Operations Manager returns to post within CBU on 1st September 17


1. Recruitment for paramedics is currently live and a good response has already been received 2. ED performance around the 4 Hour Emergency Care Standard has significantly improved 3. District Nurse, Lynn Salmon has been awarded Queens Nurse Award and will be attending a ceremony

in October 17 Clinical Support, Cancer & Diagnostic Services

Issue Mitigation Action Owner Completion Date Improving Interactions and behaviors between staff

A letter detailing the expectations of behaviors has been sent to all Consultants Agreed behavior standards have been set within theatres

Clinical Directors and Theatre Manager

Completed August 17

62 day Cancer waiting times are not currently being achieved due to complex pathways and access to diagnostics

Close monitoring and the tracking of patients throughout their pathway Improving access to diagnostics and addressing the backlog to provide a faster diagnosis

Head of Operations

March 18

The Pathology Telepath system currently has no assured backup for the hardware

A business case for disaster recovery will be presented to the Capital Investment Group on the 21st August 17

Head of Operations

March 18

Good News and General Update: 1. Microbiology received excellent feedback for the ISO (International Organisation for Standardisations

inspections by the United Kingdom Accreditation Service 2. Blood Sciences has successfully cleared the non-conformances identified in their ISO inspection 3. The Clinical Business Unit has gained Wessex funding for Diagnostic Imaging for 2 months to reduce

diagnostic waits

Surgery, Women’s and Children’s Health

Issue Mitigation Action Owner Completion Date Ongoing issues with medicines i.e. left out or lockers not closed. Majority of wards have improved compliance, however issues continue to persist

Relevant ward Matron and Ward Sister are conducting focused audits alongside the Pharmacy team to improve the situation


30th September 2017

Ongoing issues with recruiting nurses to Whippingham ward and recruiting a locum consultant for Urology

Potentially 4 out of the 7 vacancies on Whippingham have now been filled

The reinstatement of the Surgical Assessment Unit is reducing acuity and dependency overnight Following August performance review, agreement to proceed with substantive recruitment to Urology post. Business case in development

Head of Nursing & Quality and the Clinical Director for medical vacancy

Linked to Trust recruitment strategy for hard to fill posts

Increase in 52 week breaches linked to subcontracting within Gynaecology

Patient choice to remain in subcontracted pathway although there are earlier treatment options available. Mitigation in place around offering patient choice much earlier in the pathway to avoid delays pushing into 52 week breaches


Linked to the Referral to Treatment (RTT) recovery trajectory



1. Middle grade doctors for Ophthalmology have been successfully recruited 2. 92% incomplete performance target being met currently 3. The Maternity Service has seen a reduction in women with alcohol and drug dependency and this has

improved outcomes for new born and reduced requirement to be admitted to NICU for drugs withdrawal monitoring. The specialist midwife and multidisciplinary team including the Island Drug and Alcohol Service have worked seamlessly in identifying the correct support and surveillance for this vulnerable group.

Shaun Stacey Chief Operating Officer August 2017

Appendix to COO Report Urgent Care Service In Hours and Out of Hours Attendances 1st June 2017 – 30th July 2017

Out of hours – Relates to all attendance at the Urgent Care Service on Weekends and Bank Holiday and any weekday attendances after 6.30 pm and before 8.00 am In Hours – relates to all attendances at the Urgent Care Service between 8.00 am and 6.30 pm on weekdays excluding bank holidays



ON 6 SEPTEMBER 2017

Title Financial Business Plan 2017/18


Darren Cattell – Interim Turnaround Chief Financial Officer

Author(s) Gary Edgson – Deputy Director of Finance

Purpose To agree the financial budget plan for 2017/18


Receive Approve X







25/07/17 Agreed the final Plan for presentation to Part I of the Board on the 6th September 2017




Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream Finance

Section/Clause 5.5.19

Current Status/ RAG Red

Section/Clause

Current Status RAG

Section/Clause

Current Status RAG

Staff, stakeholder, patient and public engagement: Budget holders involved in budget setting process October 2016 – March 2017, and sign off during July 2017. Executive Summary & Analysis:

An interim budget plan for 2017/18 of £18.835m deficit was approved by Trust Board on 5 April 2017. It was agreed that a final budget plan would be produced after the completion of an independent financial review (IFR) of the Trust’s financial baseline.

Enc N


This IFR was undertaken by KPMG between 5 and 23 June 2017, and received by the Trust Board on 5 July 2017. The final budget plan for 2017/18 of £18.835m deficit is attached. The key changes from the interim plan are:

• £8.613m CIP targets fully allocated to operational budgets • £3.029m investment reserve now subject to Board approval before committing expenditure • £0.800m contingency reserve now subject to Board approval before committing expenditure • All budgets formally signed off at Clinical Business Unit / Corporate Directorate level • Risk of £2.4m additional resourcing for Quality Improvement • Revised capital plan to take account of statutory and regulatory requirements

Recommendation to the Board: The Board is recommended to approve the 2017/18 Financial Business Plan


Financial Business Plan 2017/18 For following sections – please indicate as appropriate:

Trust Goals & Priorities Cost effective, sustainable services Principal Risks (BAF) Risk 712 Financial Resources


Achievement of Statutory Financial Duties

Date: 30 August 2017 Completed by: Gary Edgson – Deputy Director of Finance

_____________________________________________________________________ 1

FINANCIAL BUSINESS PLAN 2017/18

1. Introduction The purpose of this paper is to set out the financial business plan for the Isle of Wight NHS Trust for 2017/18. It shows the movement from the 2016/17 outturn position of £10.960m deficit, to the Board approved (April 2017) interim deficit plan of £18.835m for 2017/18. As part of the interim deficit plan a CIP target of £8.613m, representing 5% of Trust turnover, is required. The control total set by NHS Improvement for 2017/18 is a deficit of £0.366m. 2. 2016/17 Financial Performance The original 2016/17 financial plan was to achieve a deficit of £9.844m. Following submission of the operating and financial plan to NHS Improvement (NHSI) in April 2016, NHSI encouraged the Trust to accept the offer of a new financial control total of £4.630m as follows:

£m Original Plan deficit (9.844) Further increase in CIP from Trust 1.714 Access to Sustainability & Transformation Fund (STF) 3.500 Revised plan deficit Control Total (4.630)

This revised financial plan was approved by the Board in June 2016. The Trust maintained achievement of the planned financial position to Month 7 although the following risks were reported:

• Under-performance of elective activity leading to less income than planned; • Delivery of Cost Improvement Programme by largely non-recurrent means; • Fortuitous use of Balance Sheet Non-Recurring benefits

The Trust financial position from Month 8 was not maintained and deteriorated from the planned position due to the following contributing factors:

• The flow of Medical Patients through the trust meant that a higher occupancy of medical patients contributed to the cancellation of both Inpatient and Day Case Elective activity, leading to less income than planned;

• The higher occupancy of medical patients and utilisation of Day Surgery and other areas has required additional staffing, leading to excess costs being incurred for Nursing staff and Medical Locums.

• A loss of STF funding for Q3 & Q4 due to the operational performance targets and the financial plan not being met mainly as a result of the key points above;

• The impact of QIPP recovery by IOW CCG particularly MH and Community savings previously banked by the Trust as CIP

• Non delivery of required CIP

_____________________________________________________________________ 2

The Trust Board subsequently approved a revised forecast outturn deficit of £12.295m, and this was submitted to NHSI as part of the Month 9 reporting in January 2017. The actual outturn (unaudited) position was a deficit of £10.960m. The Cost Improvement Plan (CIP) target was £10.214m for 2016/17, with a delivery of £7.772m. Within this figure a value of £4.891m has been achieved non-recurrently, resulting in a significant carry forward CIP issue into 2017/18. 3. Financial Strategy Income & expenditure budgets for 2017/18 have been set within the terms of the Budget Setting Framework presented to the Finance Investment, Information and Workforce Committee on 28 February 2017. In accordance with the NHS Improvement Financial Control Totals letters to the CEO dated 30 September 2016 and subsequently 1 November 2016, the control total for the Trust for 2017/18 was confirmed as a £366k deficit, requiring agreement to, and delivery of, the control total as a core part of the NHSI Single Oversight Framework. Acceptance of the control total was also conditional to enable Sustainability & Transformation Funding of £3.485m to be received. The Board agreed to submit a plan to achieve the control total of a £0.366m deficit but recognised the key risks and assumptions to deliver this. This final budget plan reflects a refresh of the 2017/18 financial plans submission to NHSI on 23 December 2016, following the revision to the 2016/17 forecast outturn and Board approved 2017/18 interim deficit plan of £18.835m. 4. 2017/18 Sustainability and Transformation Fund (STF) The STF available to the Trust in 2017/18 is £3.485m. This is contingent upon delivery of the agreed financial control total and achievement of access standards. To mitigate the risk of trusts going off-plan in later quarters, measures are being introduced by NHSI that will apply to the STF regime in 2017/18 and 2018/19. STF payments will be phased so that extra weighting is given to performance towards the end of each year, underlining the importance of consistent high performance. A total of 15% of the funding will be allocated in Quarter 1, 20% in Quarter 2, 30% in Quarter 3 and 35% in Quarter 4. Agreement and delivery of financial control totals represents a key part of the financial oversight regime, and achievement of the year-to-date control total in each quarter acts as a binary on/off switch to secure allocation of STF for that quarter. The phasing of the STF allocation available to the Trust in 2017/18 is:

Criteria Weighting Value Q1 Q2 Q3 Q4% £000s £000s £000s £000s £000s

Financial Control Total 70.0 2,440 366 488 732 854 RTT Incomplete pathways 12.5 436 65 87 131 152 A&E Four-hour wait 12.5 436 65 87 131 152 Cancer 62-day wait 5.0 174 26 35 52 61 TOTAL 100.0 3,485 523 697 1,046 1,219

15% 20% 30% 35%

_____________________________________________________________________ 3

As the Trust has approved a deficit plan which is adverse to the control total, no receipt of any STF has been assumed in the Trust financial plan. 5. Key Assumptions The Financial Business Plans for 2017/18 are based on the following key assumptions:

• The Trust Board approval in April 2017 of a deficit position of £18.835m • Non receipt of the sustainability and transformation fund (STF) of £3.485m, based on

non-achievement of the NHSI control total • The Trust will have plans in place to achieve £8.613m (5%) efficiency savings • Funding all inflationary, external and internal pressures in 2017/18 • A contingency in line with planning guidance of 0.5% of turnover is held in reserve.

Further mitigating action may be available from control over discretionary expenditure if necessary

• Pay inflation of 1% will apply to all staff • Increase in employer Superannuation rates payable from 14.30% to 14.38% • Business planning cost pressures and investments of £3.029m are used in full • The Trust has sufficient capability and capacity to implement the various change

management programmes to enable the required service changes and cost savings to be successfully introduced within the agreed timetable

• No provisions have been made for restructuring costs during the year • A reduction in income from the CCG contract of £6.428m in respect of QIPP • No further QIPP is assigned to the Trust without plans to reduce the associated fully

absorbed cost

_____________________________________________________________________ 4

6. Summary Income and Expenditure Budgets 6.1. Comparison of 2017/18 plan with previous years Table 1 below shows the summary Statement of Comprehensive Income.

Table 2 below shows the adjusted deficit for the year of £18.835m.

Statement of Comprehensive Income

Gross Employee Benefits (121,333) (123,504) (123,072)

Other operating Costs (53,820) (54,919) (54,546)

Revenue from Patient Care Activities 156,054 155,134 146,927

Other Operating Revenue 14,222 15,976 15,637

OPERATING SURPLUS/(DEFICIT) (4,877) (7,313) (15,054)

Investment Revenue 28 16 15

Other Gains & Losses 10 (22) -

Finance Costs (including interest on PFI's & Finance Leases) (28) (237) (773)

SURPLUS/(DEFICIT FOR THE FINANCIAL YEAR (4,867) (7,556) (15,812)

Dividends Payable on Public Dividend Capital (PDC) (3,529) (3,356) (3,068)

RETAINED SURPLUS/(DEFICIT) FOR THE YEAR (8,396) (10,912) (18,880)

2015/16Actual£'000's

2016/17Actual£'000's

2017/18Plan

£'000's

Reported NHS Financial Performance

RETAINED SURPLUS/(DEFICIT) FOR THE YEAR (8,396) (10,912) (18,880)

Impairments Excluding IFRIC 12 Impairments - - -

Donated/Government Grant Assets 38 (48) 45

ADJUSTED FINANCIAL PERFORMANCE RETAINED SURPLUS/(DEFICIT) (8,358) (10,960) (18,835)

Sustainability and Transformation Fund 1,750

SURPLUS/(DEFICIT) excluding STF (8,358) (12,710) (18,835)

2015/16Actual£'000's

2016/17Actual£'000's

2017/18Plan

£'000's

_____________________________________________________________________ 5

6.2. Summary movement from 2016/17 outturn to 2017/18 forecast Table 3 below summarises the main movements on the actual out-turn position to the 17/18 forecast spend.

Summary of movement from 2016/17 outturnto 2017/18 forecast expenditure £'000

Actual out turn (10,960)

Adjust for non recurrent (2,190)

Transition Funding (1,335)

Sustainability and Transformation Fund (1,750)

Underlying recurrent position (16,235)

Pay inflation (assumed 1%) (1,168)

Employer Superannuation rates payable from 14.30% to 14.38% (83)

Apprenticeship Levy (417)

Junior Doctors contract (109)

Paramedics move to Band 6 from Band 5 (109)

Impact of CNST Premium increase (351)

CQC Mental Health non recurrent expenditure in 17/18 (227)

Contingency Reserve (800)

Inflation - rates and utilities (192)

Inflation - drugs (374)

Inflation - other non pay (50)

Decrease in Capital charges & PDC 91

Increase in Interest payments (538)

Investments and pressures identified from business planning (3,029)

CCG - demand plan / tariff increase / efficiency 3,140

CCG - QIPP requirement (6,428)

Isle of Wight Council - demand plan / tariff increase / efficiency (670)

NHSE - demand plan / tariff increase / efficiency 86

CSU - reduced support (19)

NCA and other contract income 34

SURPLUS/(DEFICIT) PRE CIP and STF (27,448)

CIP gap 8,613

SURPLUS/(DEFICIT) PRE STF (18,835)

Sustainability and Transformation Fund -

SURPLUS/(DEFICIT) FOR THE FINANCIAL YEAR (18,835)

_____________________________________________________________________ 6

Table 4 below summarises by area the main movements on the 16/17 out-turn position to the 17/18 forecast spend.

SLA changes at Operational Division relate to Earl Mountbatten Hospice (EMH) provision of services no longer provided in 2017/18.

Operational DivisionPay (107,799) (3,835) (111,634) (4,489) 2,820 (113,303) Non Pay (33,028) (905) (33,933) (359) 391 (33,901) Income 14,036 (172) 13,864 (343) (3,211) 10,310

Sub Total (126,791) (4,912) (131,703) (5,191) 0 (136,894)

Corporate DivisionPay (15,084) (173) (15,257) (541) (15,798) Non Pay (15,448) (126) (15,574) (1,037) (16,611) Income 5,492 5,492 (140) 5,352

Sub Total (25,040) (299) (25,339) (1,718) 0 (27,057)

Reserves 29 (29) 0 0

Capital Charges / PDC / Financing (9,965) (46) (10,011) (447) (10,458)

EXPENDITURE SUB TOTAL (161,767) (5,286) (167,053) (7,356) 0 (174,409)

NHS Isle of Wight CCG 133,660 1,734 135,394 (3,288) 132,106 NHS England 8,699 (226) 8,473 86 8,559 Isle of Wight Council 4,971 253 5,224 (670) 4,554 Commissioning Support Unit 321 321 (19) 302 Non Contractual Activity 1,329 1,329 31 1,360 Southampton University Hospitals 77 77 3 80

INCOME SUB TOTAL 149,057 1,761 150,818 0 (3,857) 146,961

SURPLUS/(DEFICIT) FOR THE YEAR (PRE CIP) (12,710) (3,525) (16,235) (7,356) (3,857) (27,448)

CIP requirement 8,613

SURPLUS/(DEFICIT) FOR THE YEAR (PRE STF) (12,710) (3,525) (16,235) (7,356) (3,857) (18,835)

Sustainability & Transformation Fund 1,750 (1,750) 0 0

SURPLUS/(DEFICIT) FOR THE YEAR (incl STF) (10,960) (5,275) (16,235) (7,356) (3,857) (18,835)

2017/18Forecast

spend£'000's

Movement from 2016/17 outturn to 2017/18 forecast position

2016/17outturn£'000's

Non Recurrent

£'000's

RecurrentUnderlying

£'000's

Pressures & Inflation£'000's

SLA Changes£'000's

_____________________________________________________________________ 7

Table 5 below summarises the pressures & inflation increases highlighted in table 4

Increases marked as ‘Allocated’ have been issued to the relevant Business Unit’s and Corporate Divisions. Contingency and Business Planning increases are subject to Board approval ahead of expenditure being incurred. This is covered in section 6.4.3. 6.3. Proposed opening budgets The summary table below shows the proposed opening budget position by Business Unit. These differ from the forecast expenditure shown in Table 4 as some of the budget will initially be held centrally. This is covered in section 6.4 of this report. Further detail on the allocation of CIP targets to each Business Unit and Corporate Service is shown in section 6.5. This was shared with the Trust Board on 18 July 2017. Budgets have been set within the terms of the Budget Setting Framework presented to the Finance Investment, Information and Workforce Committee on 28 February 2017.

Pay

Pay inflation (assumed 1%) Allocated (1,168)Employer Superannuation rates payable from 14.30% to 14.38% Allocated (83)Apprenticeship Levy Allocated (417)Junior Doctors contract (109)Paramedics move to Band 6 from Band 5 (109)CQC Mental Health non recurrent expenditure in 17/18 (227)Business Planning - Pay Board to approve spend (2,272)Contingency - 80% of £800k allocated to pay Board to approve spend (645)

Sub-total (5,030)

Non-pay

Impact of CNST Premium increase Allocated (351)Contingency - 20% of £800k allocated to non pay Board to approve spend (155)Business Planning - Non Pay Board to approve spend (757)Inflation - rates and utilities Allocated (192)Inflation - drugs (374)Inflation - other non pay (50)Decrease in Capital charges & PDC Allocated 91 Increase in Interest payments Allocated (538)

Sub-total (2,326)

Total pressures & Inflationary increases (7,356)

£000'sSummary of Pressures and Inflationary increases

_____________________________________________________________________ 8

Business UnitOpening budgetpre CIP

CIPFinal

Opening budget

£'000's £'000's £'000'sExpenditureOperational Division

Surgery, Women's & Children's Health CBU (22,572) 1,475 (21,097) Medicine CBU (13,994) 1,154 (12,840) Clinical Support, Cancer & Diagnostics CBU (35,298) 2,255 (33,043) Ambulance, Urgent Care and Community CBU (28,845) 1,095 (27,750) Mental Health and Learning Disabilities CBU (15,967) 423 (15,544) Chief Operating Officer (1,629) 91 (1,538)

Operational Division sub total (118,305) 6,493 (111,812)

Corporate Services

Financial & Human Resources (6,474) 695 (5,779) Nursing (2,474) 203 (2,271) Transformation & Integration (12,122) 609 (11,513) Trust Administration (5,973) 135 (5,838)

Corporate Services sub total (27,042) 1,642 (25,400)

Centrally Held Funding

2017/18 pressures - unavoidable (2,237) (2,237) Commissioner pass through costs (7,243) (7,243) Investments & Cost Pressures (9,175) 478 (8,697)

(for approval before incurring expenditure)

Centrally held funding sub total (18,655) 478 (18,177)

Research & Development 0 0 Depreciation (6,676) (6,676) Dividends Payable on Public Dividend Capital (PDC) (3,068) (3,068) Investment Revenue 15 15 Finance Costs (774) (774) Donated Asset Income 50 50

Expenditure Total (174,454) 8,613 (165,841)

Income - Contracted SLANHS Isle of Wight CCG 132,106 132,106 NHS England 8,559 8,559 Isle of Wight Council 4,554 4,554 Commissioning Support Unit 302 302 Non Contracted Activity 1,360 1,360 University Hospitals Southampton 80 80

Income - Contracted SLA Total 146,961 0 146,961

Retained Surplus / (Deficit) (27,494) 8,613 (18,881)

Donated/Government Grant Assets 45 45

Adjusted Surplus / (Deficit) (27,448) 8,613 (18,835)

_____________________________________________________________________ 9

6.4. Centrally Held Funding An element of the proposed opening budget (£18.655m) will initially be held centrally. The basis of these, and the requirements for releasing into operational budgets, is detailed below: 6.4.1 2017/18 pressures - unavoidable Funding of £2.237m will initially be held centrally to cover known cost pressures in 2017/18 that the Trust is committed to incurring. This funding will be released to operational budgets once the additional cost has been incurred.

6.4.2 Commissioner pass-through costs Funding of £7.243m will initially be held centrally to cover high cost drugs. These costs will be passed onto either NHS Isle of Wight CCG or NHS England. This is an indicative value, and the income for these has been included in the Contracted SLA allocations. This funding will be released to operational budgets once the cost of these drugs has been incurred by the relevant Clinical Business Units.

6.4.3 2017/18 investments and cost pressures The remaining £9.175m of centrally held funding is allocated for investments and cost pressures estimated to be required for 2017/18. Of this, £5.346m will be released to operational budgets upon approval by the Trust Leadership Committee of:

a) the investment or service development commencing (for example, via a Business Case), and

b) the resulting additional cost being incurred.

Pay Inflation 1,168 Employer pension contribution increases 83 Apprenticeship Levy 417 Junior Doctors Contract implementation 109 Paramedics rebanding 109 CNST Increase 351

TOTAL 2,237

2017/18 pressures - unavoidable £'000

NHSE Cost per case - Non PbR Drugs 2,895

CCG Cost per case - Non-Pbr Drugs 2,121 CCG Cost per case - Healthcare at Home 2,227

TOTAL 7,243

Pass-through costs funded by income £'000

_____________________________________________________________________ 10

Following review by the Finance Investment Information Workforce Committee on 27 June 2017 and Trust Board on 5 July 2017, the remaining £3.829m covering contingency (£0.800m) and Investments (£3.029m) will only be allocated to operational budgets following approval by Trust Board.

The uncommitted investments and business planning risks are listed in Appendix 1. 6.4.4 Centrally held funding allocation to Business Units A summary of all centrally held funding and indicative allocation of this funding to CBU’s/Corporate budgets is shown in Appendix 2. 6.5 Application of STF and CIP to opening budgets The forecast Trust deficit position for 2017/18 has been shown to be £27.448m, excluding any CIP target and STF allocation. As the control total of £0.366m deficit has not been achieved, no allowance for receipt of STF funding has been included. To achieve the Board approved deficit plan a CIP requirement of £8.613m is required. This equates to 5% of turnover.

£m Forecast deficit 2017/18 excluding CIP & STF (27.448) CIP to be delivered 8.613 Forecast deficit assuming CIP, excluding STF (18.835) Access to Sustainability & Transformation Fund (STF) 0 Deficit plan (18.835)

Capacity - Agency premium to cover vacancies 3,289 Rates & Utilities inflation 192 Drugs inflation 374 Pay Incremental drift, maternity and recruitment premia 487 CQUIN delivery 500 Mental Health CQC 227 Mental Health 1:1's 95 Strategic Estates Partner - Management 82 Strategic Estates Partner - Fees 100

Sub Total 5,346

Contingency 800 Investments and Business Planning Risks (appendix 1) 3,029

Sub Total 3,829

TOTAL 9,175

Investments and cost pressures £'000

_____________________________________________________________________ 11

The monthly phasing of the CIP target for 2017/18 is shown below:

CIP plans have been developed over recent months, the total planned CIP equate to £4.83m the table below provides a summary of the planned CIP’s for the clinical business units and corporate directorates:

Following Trustwide CIP meetings the remaining CIP target of £3.783m has been allocated based on the following methodology and targeting specific CIP schemes:-

• Reduction in Agency usage • Reduction in sickness • Job Planning • IIF Efficiencies

_____________________________________________________________________ 12

The table below shows the total allocation of the £8.613m plan across all areas of the Trust:-

6.6 Phasing of 2017/18 budget plan The phasing of the overall 2017/18 budget plan is shown below. This reflects the seasonality profile of both income and expenditure forecasts. It also takes into account a reduced CIP target in Q1, rising from Q2 onwards due to the lack of firm plans in place for the early part of the financial year.

_____________________________________________________________________ 13

6.7 Budget sign off All budgets have been formally signed off at Clinical Business Unit / Corporate Directorate level. Each budget has been signed by:

• Clinical Director (CBU’s) • Head of Operations (CBU’s) • Executive Director (Corporate Directorates) • Interim Chief Executive Officer • Executive Director of Financial Resources

7. Agency expenditure The financial outturn on agency staff in 2016/17 was £7.6m. This was against a control total of £4.99m. Of this, £4.3m was offset by vacancies and a further £3.3m incurred in agency ‘premium’ costs. For 2017/18 the control total has again been set at £4.99m. Due to a combination of vacancies across the Trust, and the additional resourcing for quality improvement in responding to the requirements of the recent CQC inspection report, there is considerable risk that the Trust will be unable to keep within the control total of £4.99m in 2017/18. As shown in section 6.4.3, £3.3m has been set aside in the financial plan in centrally held funding for agency premium costs. 8. Commissioner Income 8.1 NHS Isle of Wight CCG The Trust has a contract in place with the Isle of Wight CCG for 2017/18 as outlined below.

Acute 71,054 2,995 74,049 5,443 (2,442) 77,050 Ambulance 7,250 7,250 3 7,253 Community 18,974 402 19,376 (40) (2,238) 17,098 Mental Health 20,049 577 20,626 407 (1,348) 19,685 Out of Hours 1,996 1,996 (96) (400) 1,500 Sparsity 4,867 4,867 0 4,867 Cost per case & investments 8,136 (906) 7,230 (2,577) 4,653 Transition 1,334 (1,334) 0 0

TOTAL 133,660 1,734 135,394 3,140 (6,428) 132,106

2017/18Contract£'000's

Service2016/17outturn£'000's

Non Recurrent

£'000's

RecurrentUnderlying

£'000's

Demand planTariff increase

Efficiency£'000's

QIPP reduction£'000's

_____________________________________________________________________ 14

During the contracting negotiations, the CCG highlighted that there was a requirement for £10.75m Quality, Innovation, Productivity and Prevention (QIPP) programme to be delivered. As a result of this, £6.428m was assigned as a ‘risk share’ to the Trust and therefore the income received by the Trust was reduced by this amount. This has already been included in the overall £18.835m deficit position. The balance of £4.322m was retained by the CCG. This presents a potential further risk to the Trust that this further income reduction could be passed onto the Trust during the year. The CCG basis for QIPP programme is shown below, including the split between that already allocated to the Trust and the balance still currently remaining with the CCG.

In reaching contractual agreement, both parties accept that there is a requirement to work in partnership to ensure that the savings programme included within the risk share are delivered. Additional work is required to finalise the details for each area of what outcomes/actions trigger the CCG applying to the Contract the savings held in the Risk Share around the impact of 2017/18 schemes. Programme Groups will commence during June 2017. Both parties acknowledge that there is a high level of risk for the Trust and the CCG in delivering both the 2017/18 Cost Improvement Plans and Quality, Innovation, Productivity and Prevention (QIPP) programme. Both parties recognise the system wide challenges regarding patient flow and the impact this may have on capacity. The CCG and Trust will work together to help to manage and mitigate the financial risk as the year progresses.

Trust£'000

CCG£'000

TOTAL£'000

Acute contractPLCV (950) (317) (1,266)Out-patients (670) (670) (1,340)Urgent/Ambulatory Care (326) (326) (652)Excess bed days (231) (231) (462)ENE baseline adjustment (266) (266) (531)Sub Total (2,442) (1,809) (4,251)

Community cost rebasing (990) (330) (1,320)Community transformation (248) (248) (496)Community Rehab rebased (1,000) (1,283) (2,283)Sub Total (2,238) (1,861) (4,098)

Mental Health rebasing (1,045) (348) (1,393)Mental Health transformation (304) (304) (607)Sub Total (1,348) (652) (2,000)

Urgent Care walk in (400) 0 (400)

TOTAL (6,428) (4,322) (10,750)60% 40%

_____________________________________________________________________ 15

8.2 NHS England The Trust also has in place a contract with NHS England for £8.559m.

9. Additional resourcing for Quality Improvement The Trust has secured through NHS Improvement and the Improvement Director specific additional resources to progress improvements against Governance, Leadership and Risk following the CQC outcome and the Trust being placed in Special Measures. In addition, to support the rapid improvement required to ensure patient safety and delivery of the Integrated Improvement Framework actions in a timely manner, Trust officers have begun to identify a number of urgent additional resources that are required. At present the cost of anticipated requirements are £3.444m, categorised as: • Included in existing £18.835m deficit plan - £1.019m • Not included in existing £18.835m plan (Recurring) - £1.787m • Not included in existing £18.835m plan (Non Recurring) - £0.638m A list of the additional resourcing requirements identified is shown in Appendix 3. This is therefore a potential further risk of £2.4m to the delivery of an £18.835m deficit.

Specialised 2,700 49 2,749 Specialised Non PBR drugs 2,895 2,895 Public Health 995 25 1,020 Primary Care - Regisration Authority 25 25 Secondary Care Dental 1,370 34 1,404 Secondary Care Offender Health 455 11 466

TOTAL 8,440 119 8,559

2017/18 Contract

ex CQUINS£'000's

CQUINS£'000's

2017/18 Contract

Value£'000's

Service

_____________________________________________________________________ 16

10. Risks and opportunities to delivery of £18.835m deficit plan 10.1 Upside to delivery of deficit plan CCG QIPP - there is a requirement for the Trust and CCG to work in partnership to ensure that the QIPP savings programme of £6.4m included within the risk share is delivered. Should the programme reduce demand on services, and equivalent cost be reduced by the Trust, then there will be a financial benefit to the Trust. Non commitment of investments funding – as shown in section 6.4.3, a sum of £3.029m has been included in the Trust financial plan to cover investments and business planning risks. If this was not committed in full then any balance would contribute to a reduced deficit position. 10.2 Downside to delivery of deficit plan Additional resourcing for quality improvement – the additional costs of £2.4m identified in section 9 are not included in the £18.835m deficit plan. Non Delivery of CIP – in 2016/17 the Trust delivered 76% of its required CIP programme. In the event of a similar level of delivery in 2017/18, a shortfall of £2.1m could be expected. CCG QIPP balance – as shown in section 8.1, there is currently £4.3m if QIPP held by the CCG. There would be a negative impact on the Trust financial plan if this target was to be accepted by the Trust with no equivalent fully absorbed cost reduction.

_____________________________________________________________________ 17

11. Cashflow The following table shows the planned cash flow monthly profile for 2017/18 and shows the monthly balances of the current and expected cash borrowings:-

The Trust’s deficit position in 2016/17 means that it has borrowed up to its maximum 30 days borrowing limit, ending the year with a Revolving Working Capital Facility of £14.030m. This includes £1.735m borrowed in 2015/16. These are repayable in July 2020 and will incur an interest charge at 3.5% until repaid. The total interest paid will amount to £1.854m over the life of the facility. In order to support the cash borrowing requirement for 2017/18, the Trust Board have approved the movement to a Department of Health (DoH) Uncommitted Loans facility. Monthly uncommitted loan facility requests for April to September 2017 have already been approved as part of the cash management process through NHS Improvement. This will enable the Trust to retain the minimum balance of £1m at the end of each month in line with the NHS Improvement requirement. An additional £1.7m balance is being held to support the slippage in the 2016/17 Capital Programme. These loans are repayable 3 years after issue and will incur interest charge at 1.5%. Further requests will be made as the year progresses with the amounts determined in line with the Board approved deficit plan for 2017/18. It is anticipated that for 2017/18 total uncommitted loan funding of £17.5m will be required, and will result in total cash financing of £31.265m at the end of the financial year.

_____________________________________________________________________ 18

12. Capital Planning The Trust’s Capital Expenditure is planned to be £8.320m in 2017/18. This is made up of a Capital Resource Limit of £6.570m, projects from 2016/17 slipped into 2017/18 of £1.7m, and charitable donations of £50k. The major projects planned for 2017/18 include:-

Operational and Executive Teams have reviewed the prioritised list in line with statutory and regulatory requirements. Prioritised projects for IM&T RRP have also been presented to and approved by Capital Investment Group. The remainder of the large proposed capital projects were presented to Trust Board Seminar in August 2017.

Mental Health Estate - CQC 1,054

Estates backlog 750

Medical Equipment 1,160

IM&T RRP 1,166

IM&T New 809

Service Developments 2,681

Other 400

Contingency 300

TOTAL 8,320

Capital scheme £'000

_____________________________________________________________________ 19

13. Financial Outturn The best case scenario will be in the region of £11.0m deficit, with the assumption that the CCG will support the QIPP risk share and none of the investment reserve and contingency reserve are utilised. The most likely forecast outturn is £18.8m. This assumes a further £2.4m of additional quality improvement plan costs over the plan deficit, as approved by the Trust Board in May 2017. However, this will be offset by uncommitted centrally held investment funding. Under a Worst Case scenario the Trust will deliver a £30.4m deficit. This includes a shortfall in CIP achievement of £3.5m and further QIPP assigned from the CCG, without equivalent cost reduction, of £4.6m and additional costs relating to the Quality Improvement plan.

_____________________________________________________________________ 20

14. Financial Recovery Plan The Trust is required to develop a Financial Recovery Plan to deliver the budget for 2017/18 and to aim to deliver the Control Total of a £0.366m deficit, recognising the significant risk associated with this. The Recovery Plan will detail:

• The detail of the VALUE of recovery required • A clear plan of HOW recovery will be achieved • Clarity of WHO is responsible and accountable for actions • A timeline setting out WHEN key recovery milestones should be delivered to ensure

pace • Visibility of the ESCALATION arrangements to ensure officers are held to account • Agreement of the COMMUNICATION plan to have confidence that financial recovery

is owned as an organisation, aligned with quality and safety • Identification of the RESOURCE needed to deliver the plan • Details of the CIP schemes underpinning delivery of the plan

It is proposed that an outline Financial Recovery Plan is developed by 30 September 2017.

_____________________________________________________________________ 21

Appendix 1 – Investments and Business Planning Risks

2017/18 Investments and Business Planning Risks, to be agreed £'000's WTE

Surgery, Women's and Children's HealthMottistone - Band 3 HCA 11 0.50 SWCHS Mgmt - PAU Operational Lead already agreed at TLC 30 0.50 Rolling replacement 39 Paeds Reporting 13

93 1.00

MedicineJ62547 Gen Med Mgmt - Patient Flow Coordinator (Modern Matron) 39 1.00 Alcohol nurse 137 2.00 Heart Failure Nurse 64 1.00 Consultant to support 7 day service 156 1.00 Medical Workforce - Recommendation from Royal College (RCP) 903 7.87 Band 6 Assistant Ops manager 33 1.00 Rolling replacement 48 Weekend discharges to enhance throughput 120

1,501 13.87

Clinical Support, Cancer & DiagnosticsRadiology 7 Day Working Enhancements 22 Pre-op Assessment Unit Band 6 agreed at TLC 34 1.00 Pre-op Assessment Unit Band 3 agreed at TLC 21 1.00 Cancer Nurse Specialists already agreed at TLC 62 2.00

139 4.00

Ambulance, Urgent Care and CommunityIncrease of 2.32 WTE Paramedics to support frontline in achievement 107 2.32 Increase of 5.64 WTE call handlers (Band 3) and 4.42 WTE clinical ad 307 5.64 Increase of 15 WTE to support community redesign (rehab element) 276 15.00 Assumes funding from CCG or scheme will not be agreed (690) Call Handling Staff 77 2.94 Rolling replacement 50 Community Nursing Electronic 64

191 25.90

Mental Health and Learning DisabilitiesCRHT (currently using agency to cover Single Point of Access) 166 5.54

166 5.54

Chief Operating OfficerCOO Management Team Service improvement and safety Nurse Band 87 1.00 Bed Management Activity and capacity planning Nurse Band 7 Post 65 1.00

152 2.00

Financial & Human ResourcesUpgrade of Erostering approved by TLC 49

49 0.00

Strategic & CommercialRolling replacement 10

10 0.00

Trust AdministrationPrint Room 30

30 0.00

TrustwideCompensatory Rest Proposal Trust Wide 0 Safer Staffing 245 Requirement to support additional activity of 300 455

700 0.00

TOTAL 3,029 52.31

_____________________________________________________________________ 22

Appendix 2 – Opening budget centrally held funding and indicative allocation to CBU’s/Corporate budgets

INDICATIVE VALUES FOR BUSINESS UNITS / CORPORATE DIRECTORATESCentrally

HeldFunding

Total

Surgery, Women's & Children's

Health Medicine

Clinical Support, Cancer &

Diagnostics

Ambulance, Urgent Care

and Community

Mental Health and Learning

Disabilities

Chief Operating

Officer

Financial & Human

Resources Directorate

Nursing Directorate

Strategic & Commercial Directorate

Trust Admin Directorate

To be allocated

Trustwide£ £ £ £ £ £ £ £ £ £ £ £

2017/18 pressures - unavoidablePay Inflation 1,168,000 214,373 115,488 258,865 252,130 163,734 16,644 55,104 22,126 63,460 6,076

Employer pension contribution increases 83,000 15,234 8,207 18,395 17,917 11,635 1,183 3,916 1,572 4,510 432

Apprenticeship Levy 417,000 76,536 41,231 92,420 90,016 58,457 5,942 19,673 7,899 22,656 2,169

Junior Doctors Contract implementation 109,000 40,996 46,368 3,136 0 10,572 0 7,928 0 0 0

Paramedics rebanding 109,000 109,000

CNST Increase 351,000 351,000

SUB TOTAL 2,237,000 347,138 211,294 372,817 469,062 244,398 23,768 86,621 31,598 90,626 359,677 0

Pass-through costs funded by incomeNHSE Cost per case - Non-PbR Drugs 2,895,485 106,980 20,105 2,711,575 56,146 679 0 0 0 0 0

CCG Cost per case - Non-Pbr Drugs 2,121,000 23,551 865,393 1,218,925 13,131 0 0

CCG Cost per case - Healthcare at Home 2,227,000 2,227,000

SUB TOTAL 7,243,485 130,531 885,498 6,157,500 69,277 679 0 0 0 0 0 0

2017/18 investments and cost pressuresCapacity - Agency premium to cover vacancies 3,289,000 567,000 1,518,000 343,000 570,000 291,000

Rates & Utilities inflation 192,000 192,000

Contingency 800,000 800,000

Investments and Business Planning Risks 3,029,427 92,700 1,500,547 138,500 190,964 166,000 151,716 49,000 10,000 30,000 700,000

Drugs inflation 373,515 64,000 32,383 195,438 40,392 39,920 0 1,310 0 0 72

Pay Incremental drif t, maternity and recruitment premia 487,000 487,000

CQUIN delivery 500,000 500,000

Mental Health CQC 227,000 227,000

Mental Health 1:1's 95,000 95,000

Strategic Estates Partner - Management 82,000 82,000

Strategic Estates Partner - Fees 100,000 100,000

SUB TOTAL 9,174,942 723,700 3,372,930 676,938 801,356 496,920 151,716 50,310 500,000 384,000 30,072 1,987,000

TOTAL 18,655,426 1,201,369 4,469,722 7,207,255 1,339,695 741,997 175,484 136,931 531,598 474,626 389,749 1,987,000

_____________________________________________________________________ 23

Appendix 3 – Additional resourcing for Quality Improvement

Revenue Expenditure Relating to CQC Recommendations

Expected CostNon Recurring

17/18 £'s

Expected Annual Cost Recurring

£'s

Expected Recurring Part

Year Effect 1718 Funding Source

Philippa Slinger n/a Funded directly from NHSIDarren Thorne n/a Funded from Challenge Fund NHSIHoward Scott (Risk Registers/BAF) n/a Funded from Challenge Fund NHSIAndy Irvine n/a Funded from Challenge Fund NHSIGrant McDonald n/a Funded from Challenge Fund NHSIComms Engagement Person (John Underwood - Freshwater) n/a Funded from Challenge Fund NHSICharles Godden (Job Planning Resource - Eve Richardson) 2 days a fortnight until October TBCMH - Additional Matron (CRHT) 71,872 71,872 Included in budget setting within £18.8m deficit planMH - Additional Matron (Inpatient) 71,872 71,872 Included in budget setting within £18.8m deficit planMH - Additional Matron (Community) 56,987 56,987 Included in budget setting within £18.8m deficit planMH - Quality Improvement Lead (MH Services) 71,872 71,872 Not included in £18.8m deficit planMH Additional IAPT Band 7 Clinical Lead 52,659 26,330 Not included in £18.8m deficit planMH Nurse Led Clinic Band 7 acting up (Nurse prescriber) 52,659 26,330 Not included in £18.8m deficit planMH - Administration Support 9,805 Included in budget setting within £18.8m deficit planMH - OOH CRHT 2.20 wte Band 6 83,671 83,671 Included in budget setting within £18.8m deficit planMH - OOH CRHT 2.20 wte Band 3 53,795 53,795 Included in budget setting within £18.8m deficit planMH - Operational Manager (CRHT) 55,200 23,408 Not included in £18.8m deficit planMH - Operational Manager (EIP) 46,000 19,837 Not included in £18.8m deficit planMH - Project Manager - 0.80 wte Band 7 31,739 13,225 Not included in £18.8m deficit planMH - Project Assistant - 1.00 wte Band 6 33,072 24,804 Not included in £18.8m deficit planMH - Head Of Operations 71,804 71,804 Not included in £18.8m deficit planMH - Operational Manager 71,377 71,377 Not included in £18.8m deficit planMH Nurse Prescribers backfill for Practitioner led Clinics (Long term Agency basis) B6 X 2 to release patients (719) from consultant caseload

TBC Not included in £18.8m deficit plan

MH Clinical Lead (HIOW MH Alliance) 2 days per week x 12 months (Mark Pugh/Richard Samuels) 75,000 Not included in £18.8m deficit planMH - Additional Staffing for Afton Ward Additional 1 trained per night, 1 extra on days and 1 extra band 2 during the day until garden done

204,000 102,000 Not included in £18.8m deficit plan

MH - Additional Staffing for Woodlands 3 wte Band 5 (agency) 272,860 181,907 Not included in £18.8m deficit planMH - Additional Band 2 1.00wte Osborne & Afton for Garden (Assume finished in 6mths) 39,664 19,832 Not included in £18.8m deficit planED Consultant x 2 Agency/Substantive out to advert to work towards 16 hours cover TBC Not included in £18.8m deficit plan

Additional ED Consultants to above - work with Rachel Decaux to define requirements for agreed model TBC Not included in £18.8m deficit plan

OD and Leadership Development additional resource agreed at TLC March 2017 102,522 102,522 Included in budget setting within £18.8m deficit plan

_____________________________________________________________________ 24

Paediatric Nursing Agency April to June (£82618)/Substantive July to March (£84341)x 3 Band 5's 54,505 112,454 112,454 Not included in £18.8m deficit planHR post for BME Equality & Diversity B6 Mid 38,500 28,875 Not included in £18.8m deficit planBand 6 to Band 5 Correct Rebanding TBC Not included in £18.8m deficit planAdditional PMO staffing x 2 Band - out to agency 13,601 12,468 Not included in £18.8m deficit planAdditional PMO staffing x 1 B7 - out to agency 10,344 9,482 Not included in £18.8m deficit planAdditional HR Partner Resource to support CBUs x 5 Wte? (B7 Mid) 46,000 30,667 Not included in £18.8m deficit planClinical resource to support roll out of e-rostering B7 Mid - go out to advert 46,000 30,667 Not included in £18.8m deficit planBackfill for Finance lead for IIF x 1 wte 35,106 Not included in £18.8m deficit planPIDS Interim Information Analyst 3 months 20,000 Not included in £18.8m deficit planPIDS Expert Financial Modeller/CBR/SLR/Financial Business Case Development 50,000 Not included in £18.8m deficit planSIRI Investigating Officers 2.00wte B7 plus 0.50wte B3 admin 102,830 68,553 Not included in £18.8m deficit planAdditional Mandatory Training support to improve compliance (Donna Parkinson) TBC Not included in £18.8m deficit planClinical Standards Facilitator (Lisa Reed/Donna Parkinson) Band 6 to support staff TBC Not included in £18.8m deficit planQuality Improvement Practitioners 2.00wte B7 plus 0.50wte B3 admin 102,830 68,553 Not included in £18.8m deficit planPractice Development Facilitators 4.00 wte Band 6 to support clinical and professional standards 176,040 117,360 Not included in £18.8m deficit planResuscitation Officer Band 6 to increase establishment to 3.0 WTE 70,500 47,000 Not included in £18.8m deficit planBreakaway and Physical Intervention Training for 8 staff to become Tutors 10,000 3,600 3,600 Not included in £18.8m deficit planMedical Devices 0.6 WTE Band 5 MD Trainer 21,500 21,500 Not included in £18.8m deficit planSafeguarding Children Level 3 Training outside of LSCB provision 1,300 Not included in £18.8m deficit planSafeguarding Adult level 2 training 3,500 Not included in £18.8m deficit planSafeguarding Child level 2 training 3,300 Not included in £18.8m deficit plan1 x Band 7 specialist nurse/midwife for child safeguarding 52,659 35,106 Not included in £18.8m deficit plan1 x Band 8a Patient Safety Lead 61,316 40,877 Not included in £18.8m deficit plan1 x band 7 Nursing Professional and Clinical Advisor 52,659 35,106 Not included in £18.8m deficit plan4x band 4 admin posts to support CBU’s in their quality governance and assurance, data reviews, complaint management

112,304 74,869 Not included in £18.8m deficit plan

ITU nurse staffing 56,579 37,719 Not included in £18.8m deficit planImplement ESR OLM (2 years cost only) 1.0 WTE B6 Project Manager 68,075 68,075 Not included in £18.8m deficit planLeadership and OD additional 1.0 WTE B6 leadership facilitator to deliver IIF 44,010 44,010 Not included in £18.8m deficit planWorkforce Planning and development/Apprenticeship Levy 0.6 WTE B2 Administrator 13,150 13,150 Not included in £18.8m deficit planMedical Education Administrator 1.0 WTE B3 24,066 24,066 Not included in £18.8m deficit planHealthassure - OMG decision to seek extension for 1 year & resource TBC 18,000 18,000 Not included in £18.8m deficit planHR & OD Advisor to the Board J Pennycook April to June 2017 inc VAT 48,750 48,750 Not included in £18.8m deficit planDementia move of Shackleton patients (Capital?) 101,000 Not included in £18.8m deficit planShackleton Non Pay Patients to Northbrook Apr-Mar18 221,607 Not included in £18.8m deficit planRevenue RRP TBCLegal training and support eg Duty of Candour/Mental Capacity Act TBCTraining on ligature risks for organisational assessment TBCAutomated locks for ward drug treatment rooms TBCSafer Staffing for wards Acute Inpatients 0.46 wte Reg / 12.91 wte HCA 366,150 274,613 Included in budget setting within £18.8m deficit plan subject Safer Staffing for wards MH 9.25 wte Reg (possible duplication of Afton & Woodlands agency above) 391,250 293,438 Included in budget setting within £18.8m deficit plan subject CQC - Quality Improvement Lead (non medical) 71,872 71,872 Not included in £18.8m deficit planCQC - Quality Improvement Lead (medical) 71,873 71,873 Not included in £18.8m deficit planMH Rehabilitation move to stepdown and supported living TBC Not included in £18.8m deficit planBreakaway training TBC Not included in £18.8m deficit planIndependent Financial Review 35,000 Not included in £18.8m deficit planCQC Admin support Band 4 Jun-Mar18 28,076 Not included in £18.8m deficit planTOTAL 648,199 3,640,537 2,796,146

638,394 2,442,419 1,787,377 Not included in £18.8m deficit plan9,805 1,198,119 1,008,769 Included in £18.8m deficit plan

648,199 3,640,537 2,796,146

_____________________________________________________________________ 25

Top Key Issues & Risks for Raising at Board – 6th Sept 2017 Page 1 of 6

FOR PRESENTATION TO TRUST BOARD ON 6th SEPTEMBER 2017

Top Key Issues and Risks arising from Assurance Committees for raising at Trust Board

Quality Governance Committee meetings held on 25 July and 18 August 2017

Min No: Top Key Issues & Risks for Raising at Trust Board

17/Q/093 Clinical Prioritisation of IT Projects: The Committee was concerned that clinical prioritisation is given to key IT Projects to ensure that they align with clinical need. The Committee recommended that the ICT Assurance Committee and IIF Programme Board ensure that these are aligned and appropriately scheduled. The Committee requested that an Executive Director member of QGC take accountability for ICT related items that impact on clinical care provision.

19/Q/095 Recruitment to key Clinical Roles: The Committee is concerned that a number of critical posts are struggling with recruitment. These have been assessed as being clinically important and need a full recruitment plan for QGC review beyond statement that role is out for recruitment. The roles include: anaesthetist, physicians for ICU, Emergency Care, Paediatric Nurses, Woodlands staffing, and safeguarding. It is essential an enhanced recruitment strategy for these roles is brought to QGC and/or Board as a matter of urgency...

17/Q/095 Relocation of Key Teams due to unsuitable accommodation: The Committee is concerned about the delay in finding suitable alternative accommodation to facilitate the relocation of the Ophthalmology environment, the Speech & Language Therapy and District Nursing teams. It recommends that a full review is undertaken and appropriate plans are implemented at the earliest time.

17/Q/096 Quality Improvement Plan: The Committee highlighted the following areas for further discussion: End of Life Care, E-Rostering and Safe Staffing, Bed flow and Patient Discharge, Ambulance targets and Cancer target for patients waiting up to 62 days for treatment. The Committee recommends that these areas are reviewed as a priority under the IIF.

17/Q/097 &105

Woodlands & new Model of Care for Mental Health: The Committee had reviewed and considered the proposals and recommends that the Board approve the plans.

17/Q/098 QGC approval of Section 31 Rating: The Committee agreed that sufficient evidence was provided to enable it to be formally agreed that Sections A and H are advanced to ‘Substantial Assurance’

17/Q/107 & 112

Discharge & Patient Flow: The Committee was concerned about the continued delay in discharge summaries being issued. It was also concerned that Patient Flow continued to be impacted upon by delayed discharge and requested that this is reviewed by the CBUs and the Chief Operating Officer. The Committee decided that at present they had received Negative Assurance.

17/Q/112 Consultant Job Planning & Workload: The Committee was concerned about the delay in completing the job planning and workload review for consultants and requested that this be reviewed by the CBUs and the Executive Medical Director. The Committee decided that at present they had received Negative Assurance.

Enc O

Top Key Issues & Risks for Raising at Board – 6th Sept 2017 Page 2 of 6

Finance Investment, Information & Workforce Committee meeting held on 25 July 2017

Min. No. Top Key Issues & Risks for Raising at Trust Board 17/F/145 Commissioning Intentions – QIPP1 Savings: The main contract with the CCG includes

a need to deliver QIPP savings of £6.4m in year. The CCG has formally informed the Trust that it does not yet have in place identified programmes that will result in these quality improvement initiations. However, the revenues have already been withdrawn from the Contract. The Committee was clear that the implied £533k per month revenue reduction could not be accepted by the Trust until agreed programmes were in place.

17/F/154 Overseas Patients: The Committee received an update on the Trusts compliance with the Overseas Visitors Charging Regulations and the associated challenges.

17/F/149 Annual Estates Return Information Collection (ERIC) 2016/17: The Committee agreed the annual ERIC return for 2016/17.

ICT Assurance Committee meeting held on 21 July 2017

Min. No. Top Key Issues & Risks for Raising at TLC2 & Trust Board 17/I/022 Civica Paris Risk Mitigation: A Paris Improvement Programme is in place and being

work through alongside the clinical teams, however the Board should note the need to ensure mitigation remains in place for the full time whilst the programme is delivered. The risk mitigation should be monitored through Quality Governance Committee as part of QIP reporting.

17/I/018 ICT Capital requirements and impact: The Board should note the significant reliance on capital funding to support improvement which must be aligned with the system priorities. There is a risk that with no clinical strategy agreed and ICT being a key enabler, that projects could be delayed if earl requirements are not identified with the Informatics Strategy becoming fast out of date.

17/I/023 Information Governance Tool Kit 2017/18: The Board should note the year end position on the IG Toolkit as report through Finance, Investment, Information and Workforce Committee. There is a risk that without a clear plan for 2017/18 aligned with the recent release of the toolkit the Trust may not achieve Level 2 compliance which will have a detrimental impact on reputation and have regulation/contractual impact.

Full Minutes of Meetings

Please note that the full minutes of these meetings are available electronically and have been previously circulated to members. 29 August June 2017

1 Quality, Innovation, Productivity and Prevention (QIPP) Commissioning 2 Trust Leadership Committee

Minutes of the Finance, Investment, Information & Workforce Committee – 25 July 2017 Page 1 of 8

FINANCE, INVESTMENT, INFORMATION & WORKFORCE COMMITTEE

Minutes of the meeting of the Finance, Investment, Information & Workforce Committee held on Tuesday, 25 July 2017 at 1.00 p.m. in the Large Meeting Room, St. Mary’s Hospital, Newport. Present: Charles Rogers Non-Executive Director (Chair) Chris Palmer Executive Director of Financial & Human

Resources (EDFHR) Jon Burwell

Executive Director of Strategy & Planning (EDSP)

Julie Pennycook

Interim Director of HR & OD (IDHROD)

In Attendance: For item 17/F/147&162 Lisa Reed Deputy Director of Allied Health Professionals

(DDAHP) Observers: Maria Lane Head of Financial Management Andrew Wheeler

Head of Financial Accounting

Minuted by: Linda Mowle Finance Governance Officer

Min. No. Top Key Issues & Risks for Raising at Trust Board 17/F/145 Commissioning Intentions – QIPP1 Savings: The main contract with the CCG includes

a need to deliver QIPP savings of £6.4m in year. The CCG has formally informed the Trust that it does not yet have in place identified programmes that will result in these quality improvement initiations. However, the revenues have already been withdrawn from the Contract. The Committee was clear that the implied £533k per month revenue reduction could not be accepted by the Trust until agreed programmes were in place.

17/F/154 Overseas Patients: The Committee received an update on the Trusts compliance with the Overseas Visitors Charging Regulations and the associated challenges.

17/F/149 Annual Estates Return Information Collection (ERIC) 2016/17: The Committee agreed the annual ERIC return for 2016/17.

17/F/141 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND CONFIRMATION

THAT THE MEETING IS QUORATE Apologies received from Vaughan Thomas.

The Chairman confirmed that the meeting was quorate. Charles Rogers and Chris Palmer declared an interest in their roles as Directors of Wight Life Partnership.

17/F/142 MINUTES OF PREVIOUS MEETINGS The minutes of the meetings held on the 27 June 2017 were agreed and signed by the

Chair as a true record.

17/F/143 SCHEDULE OF ACTIONS The schedule of progress on actions arising from previous minutes was noted with the

following comments: a) Min No. 17/F/036 Mandatory Training – Low Compliance Levels of Medical

1 Quality, Innovation, Productivity and Prevention (QIPP) Commissioning

FOR PRESENTATION TO TRUST BOARD ON 6 SEPTEMBER 2017

Enc O2


Staff:: The Committee agreed that mandatory training compliance for Medical Staff be reported through the HR Report. Status – Closed.

b) Min. No. 17/F/112 Agency Spend, Activity and Income: The Committee noted that

the triangulation to the overall financial position is to be included in the Finance Report to the September 2017 meeting. Status – Progressing.

c) Min. No. 17/F/121 SBS Payroll Overpayments: The Committee received and noted

the letter to SBS dated 17th July 2017 and SBS’ two replies of the 20th and 24th July 2017 advising that the ‘contract measures the overpayments caused by NHS SBS and where appropriate the recourse for such errors is through the service credit regime rather than with holding service payments. Full details of repayments plans and the status of recovery will be confirmed to you by the 31st July 2017. (Post meeting note: 09/08/17 The Operational Payroll & Pensions Manager confirmed that 17 overpayment letters will be sent out by 31st July 2017 and that 4 overpayments that had excessive repayment plans in place are being followed up by HR.

d) Min. No. 17/F/132 Reference Costs Submission 2016/17 – Mental Health Costings External Audit: The EDFHR advised that once the final report has been received, this will be circulated to Committee members.

17/F/144 OVERARCHING EXECUTIVE SUMMARY OF HIGHLIGHTS AND LOWLIGHTS The EDFHR presented an overview of the highlights and lowlights of the papers, together

with a summary analysis of the position, risks, opportunities, mitigating actions and level of assurance to be gained.

EXTERNAL INFLUENCES 17/F/145 COMMISSIONING INTENTIONS The EDFHR advised that the main issue is with the CCG contract to deliver QIPP savings

of £6.4m in year. The CCG has formally informed the Trust that it does not yet have in place identified programmes that will result in the quality improvement initiatives and, as a result, there is nothing concrete in terms of delivery of the QIPP. The EDFHR confirmed that a letter dated 26th July 2017 to the CCG from the ICEO formally notifying the CCG of the Trust’s position had been drafted. The EDFHR reported that the level of national QIPP support was still unclear and how this will enable delivery of the QIPP this year.

HUMAN RESOURCES 17/F/146 HUMAN RESOURCES REPORT The IDHROD in introducing the Human Resources Report advised that work is in

progress to revise the context and presentation of the report in time for September’s meeting. From an HR perspective, the report will be clearer about targets and delivery against these. Following feedback, the revised report will then be presented to the Trust Board. The IDHROD highlighted the following main areas of the report:

• Sickness Absence: The estimated cost for June 2017 is £267,500 and for the 12 months to June is £3,721,000. Whilst there has been a reduction in month within Acute, Mental Health & Learning Disabilities and Ambulance, all other departments are above target. Long term sickness has been reviewed and is being managed on a case by case basis. The Committee noted that significant efforts continue to reduce sickness levels in the Trust. The Chairman queried why, if sickness is down, bank, agency and overtime is


higher. The IDHROD agreed to look into this and provide validation. Action: IDHROD

The EDFHR confirmed that sickness by area is included within the Performance Management Reviews. However, medics sickness reporting is not as accurate as the rest of the organisation and the IDHROD is following this up as part of the future review.

• Recruitment and Temporary Staffing: This remains a concern and the HR team is continuing to provide new initiatives to improve the situation, e.g the revised request approval process has been implemented from the 1st July 201 and a recruitment campaign has been launched on Wight Link and Red Funnel over the summer holiday period. The Committee noted that due to the high level of vacancies, it has been necessary to utilise temporary staff. The temporary staffing figure for June 2017 is 229.89 FTE.

• Mandatory Training: Compliance across the Trust at June 2017 is measured as

86%. Work continues to ensure that training is appropriate and accessible. Following emphasis on the importance of Bank staff compliance with mandatory training requirements, this has improved and is now measured at 73%.

• Overseas Nurses: The Committee noted that the final cohort of five overseas nurses are scheduled to arrive on Friday, 25th August 2017. The IDHROD confirmed that the evaluation of the cost of employing overseas nurses will be included in the September 2017 HR Report. Action: IDHROD

• E-Rostering: A number of departments across the Trust are not adhering to the

roster approval timetable with 62 units missing the deadline in June and 7 units having to be removed from the payroll. Work continues to improve compliance. The Committee was cognisant with Lord Carter’s review which had highlighted that improved rostering of all clinical staff has the potential to making significant savings.

The Committee noted that although the local target of 8 weeks continues to be non-compliant, the national target is 6 weeks. The Committee considered that the differing targets were causing confusion and proposed executive decision in order to improve e-rostering across the organisation. The IDHROD agreed to take this forward with the Trust Leadership Committee (TLC). Action: IDHROD

• Agency Rules: The Committee requested that the data be expanded to provide understanding and validation of the information. Action: IDHROD

• Volunteering: The Committee requested that assurance be provided that volunteers have had the necessary checks, e.g. safeguarding, before taking up duties. Action: IDHROD

17/F/147 MONTHLY SAFE STAFFING ASSURANCE REPORT The DDAHP presented the Safe Staffing Report for June 2017 highlighting the following

key points: • The overall position is now demonstrating improvement. • Hotspot areas of MAAU and Woodlands are now showing improvement in all

areas • Deep dives are being initiated for Colwell and Appley as there is no improvement

despite temporary staffing being available to support gaps. • Achievement of RN bank request is good and agency fill rate remains at 100%

which indicates achievement of adequately planned staffing. Short notice requests are the difficulty and therefore focus remains on reducing sickness.

• The proportion of agency usage in temporary staffing needs to be reduced. This


poses a challenge as currently the organisation is requiring more staff and recruitment is not able to provide rapid deployment of staff. This is a national issue for both general land specialist nurses.

The Committee noted that the information provided is being improved to provide more detailed information on nursing activity. The June 2017 figures show that every area being measured in the Trust is achieving at least 5 hours Care Hours per Patient per Day. This measure indicates for each ward area and by registered and non-registered staff the number of care hours available for each person in a 24 hour period. The DDAHP advised that information will further improve when the software system ‘Safe Care’ is in place, which will enable on the day monitoring of staff and the assurance of safety management on the day.

ESTATE RESOURCES 17/F/148 ESTATES REPORT The EDSP in presenting the Estates Report highlighted the following key areas:

• Mental Health: A revised proposal has been developed for Sevenacres redesign works which is due for Board review and approval by the 28th July 2017. Options for Shackleton and Woodlands continue to be explored at pace. At Woodlands, anti-ligature risks have been put on hold whilst the service model is reviewed. In the interim, mitigation is in place for all ligature risks and is assured through the Quality Governance Committee.

• Fire Safety and Cladding: The Trust has undertaken a desk top exercise on cladding with the Isle of Wight Fire Service who has provided the Trust with reassurance that current practice and processes around fire safety is robust. The assessment of the cladding has shown it to be a different material to that of Grenfell Tower and is not deemed of risk. No further action on the cladding is currently planned.

• Environmental Risk Audit: The Trust is reintroducing the environmental risk audit process halted in 2016 whilst a revised model was explored. This ensures that the Trust remains compliant with Health & Safety regulations and guidance.

• Catering: The tender evaluation has been undertaken by the Trust and returned to Procurement. It is intended to have a partner commenced with the Trust during August 2017.

17/F/149 ANNUAL ESTATES RETURN INFORMATION COLLECTION (ERIC) 2016/17 The EDSP advised that ERIC is a mandatory collection with which the Trust is required to

comply under the terms of Section 259 of the Health & Social Care Act 2012. In addition, the NHS Standard Contract also requires the Trust to comply with this collection in the manner and timescale set out by the Department of Health. The Committee agreed the Return for approval by the EDFHR subject to Section 8, Internal Floor Area, being confirmed to the EDFHR. Action: EDSP The Committee noted that the final ERIC Return Report will be used to compare performance with other Trusts, and that the Carter efficiency report 2016/17 will be available later in the year/early 2018.

CAPITAL INVESTMENT RESOURCES 17/F/150 CAPITAL INVESTMENT GROUP UPDATE inc BENEFITS REALISATION REPORTS The EDFHR presented the update report from the 14th July 2017 Capital Investment

Group meeting, advising that the capital priorities for larger projects for this year are to be confirmed at the Board Seminar on the 15th August 2017. The EDFHR advised that there is a potential risk to the Capital Programme not been concluded in time for the year end due to the delay in agreeing capital projects, which has resulted in the Capital Programme being included on the Financial Improvement


Programme as a Risk and on the Corporate Risk Datix. Benefits Realisation Reports: The following reports were received and noted:

• Macro Imager • Mortuary Hoist • Pathology Flooring • Mortuary Refurbishment • Colposcopy Couch • Replacement Fire Alarm System

FINANCIAL RESOURCES 17/F/151 FINANCIAL PERFORMANCE REPORT The EDFHR presented the report which covered Month 3 as at 30 June 2017 The

EDFHR highlighted the following points: Key Points :

• The cumulative financial position at Month 3 is a £5.897m deficit against a deficit plan of £6.173m so a positive variance of £276k (within the £18.8m full year deficit plan)

• CIP has delivered £1.112m year to date which is £252k better than plan. The second CIP workshop was achieved in July and the balance of CIP has now been allocated across the organisation. Continued pursuance of schemes is being led through the Financial Improvement Programme The latest CIP schemes for 2017/18 was tabled.

• Cash remains a key risk and payments are being managed whilst ensuring critical payments can be made, resulting in a reduced BPPC compliance in June. Increased focus on debt management with internal resource working with SBS to clear the debts over 60 days. Debt management has been escalated by EDFHR at SBS Board and via a formal letter and SBS have taken action to improve.

• Waivers to SFIs: The Committee agreed waivers nos 1 – 49 totalling £2.8m. The Committee noted that Waivers have greatly improved visibility and PO usage, particularly around the governance of agency spend. It has also highlighted to staff that better planning of vacancies is required going forward but remains the highest single reason for raising waivers to date. Counter Fraud Tender: The Committee noted the timescale and Service Specification. for the contract for the provision of Counter Fraud Services to commence on the 1st April 2018.

17F/152 INDEPENDENT FINANCIAL REVIEW UPDATE The EDFHR reported that the final report of the Independent Financial Review by KPMG

had been presented to the Board Seminar. She advised that the Review had, from an overarching perspective, been very helpful and had provided an oversight of the financial issues over recent years. Any recommendations will be taken into account in the Financial Business Plan for this year in order to deliver a robust Financial Recovery Plan going forward.

17/F/153 FINANCIAL BUDGET PLAN 2017/18 The Committee received the update on the Financial Budget Plan for 2017/18, noting the

key changes from the interim plan, namely: • £8.613m CIP targets fully allocated to operational budgets • £3.029m investment reserve now subject to Board approval before committing

expenditure • £0.800m contingency reserve now subject to Board approval before committing

expenditure/


The Committee agreed the final Plan for presentation to Part I of the Board on the 6th September 2017.

17/F/154 OVERSEAS PATIENTS 2017/18 The EDFHR presented the update report on overseas patients legislation and policies

advising that although the organisation has come a long way in implementing systems and processes to ensure the Trust is adhering to current Overseas Visitor Charging Regulations, there is more to do both to ensure that all income due is collected and to be ready for any further changes in legislation. It is not yet known what the impact of the UK’s vote to leave the European Union will be until exit negotiations are concluded. It will be necessary for the Government to look at options for whether and how reciprocal healthcare arrangements with other EEA countries will operate and this will inevitably bring further changes.

17/F/155 ANNUAL ACCOUNTS 2016/17 – ACTION PLAN The Committee received and noted the Action Plan arising from the audit of the Annual

Accounts covering Pharmacy Stock and Drug Cost Reconciliation, Theatre Stock Values and Direct Debit Payment checks due to payment and accrual duplication. The Committee noted that the action plan is being populated with completion dates as and when actions are taken.

17/F/156 CASH AND BORROWING UPDATE The update report on the uncommitted cash loans was noted. To date the value of

uncommitted cash loans accessed in 2017/18 (April to July) totalled £5.686m. The cash loans are being accessed in line with the Board approved forecast deficit and adjusted for the improved position in the 2016/17 outturn and the 2017/18 year to date position. Further requests will be made as the year progresses with the amounts determined by the level of cash deficit.

17/F/157 NHS CREATIVE TRADING ACCOUNT AND 2017/18 BUSINESS PLAN As a result in the change of executive lead to IDHROD, the Committee deferred this item

to the September 2017 meeting.

17/F/158 FINANCIAL INTEGRATED IMPROVEMENT FRAMEWORK (IIF) The Committee received the July 2017 update report, noting the following progress:

• £8.63 CIP plan allocated across Clinical and Corporate areas • Budget Holder level sign offs cascaded • QIA process embedded • Training requirements identified and methodologies/provisions set up • LTFP final draft to be cascaded week beginning 24 July 2017 • Board to approve prioritization of capital schemes on 15 August 2017 • Independent Financial Review outputs yet to be disseminated

PERFORMANCE INFORMATION 17/F/159 DATA QUALITY REPORT AND DEEP DIVE The Committee reviewed the Data Quality Report noting the red related indicators in the

SUS datasets. Although the risk level for all 5 red rated indicators has been assessed as low, the deep dive has identified the following actions:

• Clinical coding to begin coding all private patient inpatient/daycase activity from October 2017

• PIDS to introduce a DQ metric on the RTT dashboard to review all GP referrals with no pathway assigned by July 2017

• Information Systems to review and update the commissioner table in Symphony to ensure up to date valid codes are applied.

The Committee noted that an agency coder has now joined the team until September 2017 at which point the two trainee coders will sit their accreditation exams. Other options are also being considered to reduce the backlog including coding some activity


from discharge summaries for a short period to allow the team to catch up. The risk level for the delay in coding activity has been assessed as moderate, primarily because without coded activity the Trust is unable to accurately assess activity value against plan or monitor compliance against the PLCV QIPP.

17/F/160 OPERATIONAL PERFORMANCE REPORT INCLUDING ACTIVITY AND

PERFORMANCE REPORT The EDSP presented the Activity and Performance report covering the period July 2017,

which provides an update on the Trust’s performance against the requirements set out in the Service Level Agreements. The Committee was pleased to note the continued level of improvement in performance and hoped that this would remain consistent during the remainder of the year. In order to achieve this continued improvement, it was vital that the Trust ensures commitment to this across the whole of the organisation. The Committee was cognizant that Workforce remains an issue and that the Trust needs to be very clear of the QIPP2 programme activity.

CONTRACTING 17/F/161 CONTRACT STATUS REPORT The EDFHR presented the Contracts Status Report for June 2017 covering 11 contracts

and 2 Contract Performance Notices. With regard to the new provider for the Wheelchair Service, the EDFHR advised that confirmation is awaited that the stock the Trust holds will be transferred across. The EDSP advised that the options for the CHIS3 system will be discussed at a future meeting.

Action by: EDSP

COMMERCIAL AND BUSINESS PLANNING 17/F/162 CQUIN ALLOCATION UPDATE The DDAHP introduced the overview of achievements against CQUIN 4 targets for

2017/18, together with an overview of the milestone work for Quarter 1. The Committee noted that there are 13 national applicable CQUINs for the period 2017/19 and that these are being undertaken over a two year period, rather than a one year period. The DDAHP highlighted the potential risk regarding the supply of antibiotics as there currently was a national shortage, which could prevent the target being reached. The EDFHR requested that this aspect of the CQUIN be reviewed to establish whether it was included in the CCG QIPP programmes, as there was a risk that the CCG would not support the Trust in this respect. In addition, it was felt that the CQUINs needed to be aligned with the CCG QIPP, and that the CQUINs should be included in the CBUs performance report.

Action: DDAHP/EDFHR

CORPORATE GOVERNANCE AND RISK 17/F/163 FOLLOW UP OF INTERNAL AUDIT RECOMMENDATIONS - FIIWC The Committee received the update report on the status of the outstanding

recommendations. In addition, the Committee reviewed the update report on the two audit reports referred by the Audit & Corporate Risk Committee (ACRC), namely Payroll –

2 Quality, Innovation, Productivity and Prevention (QIPP) Commissioning 3 NHS England: Public Health – Child Health Information System (CHIS) 4 Commissioning for Quality and Innovation (CQUIN)


review of repayment policy and Financial Accounting, and that the actions have been taken forward and the ACRC to be advised accordingly at its meeting on 8th August 2017.

17/F/164 FIIWC ANNUAL REPORT 2016/17 The Committee reviewed and agreed the report for presentation to the ACRC on 8th

August 2017. The Committee reviewed the self-assessment check list. The Committee requested that the terms of reference be presented to the September meeting for review.

17/F/165 DATE OF NEXT MEETING • Tuesday, 26 September 2017

• 1.00 – 4.00 p.m. • Large Meetings Room

The meeting closed at 4.05 p.m.

Signed: …………………………………………………. Date: ………………………………… CHAIRMAN

of 14 Quality Governance Committee 25 July & 18 August 2017

FOR PRESENTATION TO PUBLIC BOARD ON 6 SEPTMBER 2017

QUALITY GOVERNANCE COMMITTEE Held on Tuesday 25 July 2017 and Friday 18 August 2017

Please note that this meeting was undertaken over two sessions due to extended discussions on 25 July. It was requested that the remaining items be discussed at an additional session in August.

Session 1 – 25 July 2017

Present: Jessamy Baird Non-Executive Director – Acting Chair Steve Parker Clinical Director, Surgery, Woman’s and Children’s

Health (CD-SWCH) John Doherty Clinical Director Mental Health and Learning Disabilities

(CD-MHLD) Gillian Honeywell Joint Clinical Director, Clinical Support, Cancer &

Diagnostics and Chief Pharmacist (CD-CSCD/CP) Lisa Reed Deputy Director of Allied Health Professionals

(deputising for Acting Director of Nursing Mark Pugh Executive Medical Director (EMD) Deborah Matthews Deputy Director for Quality (DDQ) Gary Cooley Service User Representative (SUR) Dennis Ford, Patient Council Representative Chris Orchin Healthwatch In Attendance: Mandy Blackler Business Manager, Quality Governance Team (BMQG) Andrew Irvine Improvement Consultant - MBI Health Group Glenn Smith Patient Safety Lead For items 17/Q/097/098

Kevin Bond Interim Director of Mental Health

For item 17/Q/099 Stephen Ward MHA & MCA Lead1 Vanessa Flower Patient Experience Lead

For item 17/Q/101 Kathryn Taylor Operational Manager, Endoscopy Department, CSCD CBU

For item 17/Q/100 Amanda Shaw Head of Imaging Observer: Anna Coleridge Carnall Farrar Minuted by: Lynn Cave Board Governance Officer (BGO) Min No: Top Key Issues & Risks for Raising at Trust Board

17/Q/093 Clinical Prioritisation of IT Projects: The Committee was concerned that clinical prioritisation is given to key IT Projects to ensure that they align with clinical need. The Committee recommended that the ICT Assurance Committee and IIF Programme Board ensure that these are aligned and appropriately scheduled. The Committee requested that an Executive Director member of QGC take accountability for ICT related items that impact on clinical care provision.

19/Q/095 Recruitment to key Clinical Roles: The Committee is concerned that a number of critical posts are struggling with recruitment. These have been assessed as being clinically important and need a full recruitment plan for QGC review beyond statement that role is out for recruitment. The roles include: anaesthetist, physicians for ICU, Emergency Care, Paediatric Nurses, Woodlands staffing, and safeguarding. It is essential an enhanced recruitment strategy for these roles is brought to QGC and/or

1 Mental Health Act & Mental Capacity Act Lead

Enc O1


Board as a matter of urgency... 17/Q/095 Relocation of Key Teams due to unsuitable accommodation: The Committee is

concerned about the delay in finding suitable alternative accommodation to facilitate the relocation of the Ophthalmology environment, the Speech & Language Therapy and District Nursing teams. It recommends that a full review is undertaken and appropriate plans are implemented at the earliest time.

17/Q/096 Quality Improvement Plan: The Committee highlighted the following areas for further discussion: End of Life Care, E-Rostering and Safe Staffing, Bed flow and Patient Discharge, Ambulance targets and Cancer target for patients waiting up to 62 days for treatment. The Committee recommends that these areas are reviewed as a priority under the IIF.

17/Q/097 &105

Woodlands & new Model of Care for Mental Health: The Committee had reviewed and considered the proposals and recommends that the Board approve the plans.

17/Q/098 QGC approval of Section 31 Rating: The Committee agreed that sufficient evidence was provided to enable it to be formally agreed that Sections A and H are advanced to ‘Substantial Assurance’

17/Q/107 & 112

Discharge & Patient Flow: The Committee was concerned about the continued delay in discharge summaries being issued. It was also concerned that Patient Flow continued to be impacted upon by delayed discharge and requested that this is reviewed by the CBUs and the Chief Operating Officer. The Committee decided that at present they had received Negative Assurance.

17/Q/112 Consultant Job Planning & Workload: The Committee was concerned about the delay in completing the job planning and workload review for consultants and requested that this be reviewed by the CBUs and the Executive Medical Director. The Committee decided that at present they had received Negative Assurance.

Minute No.

17/Q/089 APOLOGIES FOR ABSENCE

Apologies were received from: • David King, Non-Executive Director • Sarah Johnston, Acting Director of Nursing • Dr Barbara Stuttle CBE, Board Advisor – Nursing • Oliver Cramer, Deputy Medical Director • Andrew Woolley, Clinical Director, Medicine CBU • Chris Smith, Clinical Director, Ambulance Urgent Care & Community (CD-

AUCC) • Muriel Prager, Joint Clinical Director, Clinical Support, Cancer & Diagnostics

and Chief Pharmacist (CD-CSCD) • Philippa Slinger, Improvement Director

17/Q/090 CONFIRMATION OF QUORACY The Chair announced that the meeting was quorate.

17/Q/091 DECLARATIONS OF INTEREST There were no declarations of interest

17/Q/092 MINUTES OF THE PREVIOUS MEETING The minutes from the meetings held on 23 May (Workshop) and 30 May 2017 were

approved.


17/Q/093 REVIEW OF ACTION TRACKER The Committee reviewed the outstanding actions and updated the following:

a) Q/600 – Checklist for NEDs: The Acting Chair requested that a 10 point list

be prepared with mental health team and that feedback be presented at the September meeting

b) Q/606 – QGC Future Work plan: Progress is being made to align with IIF2 & QIP.

c) Q/609 – QIP Actions within IIF: Revised paper included in July papers d) Q/614 – Future Quality Report: Action Closed e) Q/616 – Systm One Roll Out: ICTAC3 monitoring rollout. ICTAC are also

monitoring other critical systems. The Committee requested that a timeline for delivery of roll out; assurance that staff will be fully supported during process and to ensure that risk assessments and mitigations are in place in the event of connectivity issues. The Committee requested that an Executive Director member of QGC take accountability for ICT related items that impact on clinical care provision. Action: As Part of the review of QGC Committee membership an Executive Director member of QGC is to take accountability for ICT related items that impact on clinical care provision.

Action by: Chair

f) Q/617 – Speech & Language Therapy Building: The Committee requested

that a timeline for the relocation of the unit be set and linked to risk register. g) Q/618 – Head of Psychology: This is a whole Trust position not just mental

health. A business case to this effect is being prepared. Human Resources are reviewing recruitment to core clinical vacancies.

h) Q/619 – External Reviews & Audits: Discussion on oversight of external reviews is taking place between the CBU’s and Quality team to improve process. Action Closed.

i) Q/620 – MAU Skill Mix: Update to September meeting j) Q/621 – Operational Performance – Frailty & Geriatrics: Update to

September meeting k) Q/622 – Discharge Procedures: This is not linked to bed flow. Matter is

being discussed at Operational Management Group. Update on patient flow to be presented to October QGC.

l) Q/623 – Day Surgery Unit Redesign: Detailed costing pending. Workshop planned to verify layout of unit. Action Closed.

m) Q/625 – CBU HoNQs4 reviews of incidents in SIRI report: Report has been revised to reflect the HoNQ meeting. Action Closed.

n) Q/626 – Procurement Risks raised by SIRIs: Revised specification SBAR5 in place to resolve issues. Action Closed.

o) Q/627 – Nutrition KPIs to be mapped across CBUs: Process has commenced. The Committee requested that the KPIs be included in reporting and that this was raised with the PIDS team6 Performance Information Team to

2 Integrated Improvement Framework 3 ICT Assurance Committee 4 Head of Nursing & Quality 5 Situation, Background, Assessment, Recommendation (Business Case) 6 Performance Information & Decision Support


allow the dashboards to be updated. Workshop to discuss KPIs the Committee should look at suggested. Specific local KPIs around weight loss are in place but no national KPIs. SEE Committee to review and provide top 3 KPIs.

p) Q/631 – End of Life Care Joint Project with EMH: Included within QIP report. Action Closed.

q) Q/632 – Penalties for non-compliance with mandatory training: A number of measures are in place which can be applied. Levels of compliance are actively improving but further work via management using pay gates and excellence awards to be developed.

QUALITY 17/Q/094 QUALITY REPORT The Executive Medical Director presented the Quality Report and highlighted that this

report is for information only as the data had already been submitted to the CCG and made public. The Committee discussed the report in detail and it was acknowledged that more detailed work was included within the IIF on certain areas. The Committee also noted that the data is discussed by the operational teams within the CBUs prior to release as well as at SEE Committee. The Deputy Director for Quality advised that this report is designed to provide evidence to inform the CCG on specific targets set by the CCG. The Committee agreed that this report would continue to come to QGC but would be for information only. Assurance Level: Limited

17/Q/095 SEE COMMITTEE The top 3 issues raised by the SEE Committee were:

1. Infection Prevention &Control: The Trust has reached its trajectory for CDIF7 -

yearly allowance is 7 - we have now had 7 confirmed cases. 2. Quality metrics: Clinical services must be encouraged to provide valuable and

robust measurements and metrics for the quality report. 3. Audit: Audit requires co-ordination. We need to begin to use audit as a quality

measurement as opposed to a ‘tick-box’ exercise.

The Committee reviewed the report in detail. Vacant positions in critical areas were raised as a concern and although they were being covered by locums it was agreed that HR should review these posts and include update to Board. The Committee was concerned that the Ophthalmology environment and capital plan satellite area has been deferred to 2018/19 and that although the team are mitigating the situation, that this be raised with the Capital Investment Group. It was also noted that Speech & Language Therapy and District Nursing teams were in a similar position and that this would be raised also. The Committee requested that future SEE reports are refreshed with less use of acronyms as it is difficult for lay members to follow the reports. Action: Top Critical Posts vacant within the Trust. HR to review and provide update to Board at the September Board meeting.

7 Clostridium difficile


Action by: EMD Action: Ophthalmology environment and capital plan satellite area situation, Speech & Language Therapy & District Nursing relocation to be raised with the Capital Investment Group to ascertain the timeline for the relocations to take place.

Action by: EMD Assurance Level: Limited

17/Q/096 QUALITY IMPROVEMENT PLAN (QIP) HIGHLIGHT REPORT The Acting Chair advised that the report had been revised to show key areas of focus.

The Improvement Consultant advised that the Quality Improvement Plan [QIP] is driven by the Trust through the infrastructure and governance that has been developed as part of the overall Integrated Improvement Framework [IIF]. He stressed that it is important that the Quality Governance Committee [QGC] adds real value to the overall process and does not duplicate the role and function of the IIF Programme Board; going forward the QGC should have the following role with respect to driving forward the changes required to deliver the Trust’s QIP: 1. Understanding progress and impact against the 9 QIP goals that have been set

and agreed; 2. Discuss, challenge and debate the impact the milestones are having on the

relevant key theme(s); 3. Deep dives as per the IIF Programme Board (IIFPB) against the relevant key

theme(s); 4. Assurance of evidence against the relevant key theme(s) He gave an overview of the Nine QIP Goals and the impact the milestones are having on the key themes. He advised that the QGC is asked to review these along with the risks and general updates though the impact lens. The Improvement Consultant highlighted that the QGC will be requested by the IIF and will at times ask the QGC to undertake some deeper dives of issues from a professional and quality perspective and drew the Committees attention to a range of issues highlighted in the report. To assist in this process it was recommended that QGC consider adding the Head of Project Management Officer as a member of QGC or to be in attendance for the QIP section of the agenda. The Committee discussed the paper and it was agreed that at this stage the Head of Project Management Office would be invited to attend in future as an attendee. Following discussion the Committee highlighted the following areas to be raised at the next Board Meeting – End of Life Care, E-Rostering and Safe Staffing, Bed flow and Patient Discharge, Ambulance targets and Cancer target for patients waiting up to 62 days for treatment. Assurance Level: Limited

17/Q/097 MANAGEMENT OF WOODLANDS & DEVELOPING APPROACH TO LONG TERM MENTAL HEALTH PROVISION

The Interim Director of Mental Health presented the report and advised that the Deep Dive report on Woodlands had been taken to QIPOG8 to consider the mitigations taken with regard to Woodlands and the approach to care within the unit, and any other actions that might be required. He also outlined this issues faced by the unit in relation to ligature risks and explained how these were treated differently depending on the type of mental health unit, i.e. acute in patient, dementia or rehabilitation, and that this

8 Quality Improvement Plan Oversight Group


was not recognised within the CQC criteria. The Interim Director of Mental Health also outlined that Woodlands rehabilitation model needed to be refreshed to allow a less paternal approach to be possible and to allow the reintroduction of normal day to day living environment to be provided. He advised on the measures which were considered during the deep dive and confirmed that the CCG were now collaborating in a revised model which would be sent to the CQC in September. The Acting Chair confirmed that she was pleased that the Woodlands lease had been extended to allow the time for the deep dive to be undertaken and the outcome fully explored. She queried if staffing levels had been included within the model and what was being done to address current issues. The CD-MH&LD confirmed that a rota of agency staff was in place and that recruitment for substantive posts was in place. It was confirmed that this would be included in the final report which would be seen at Board in September. The Improvement Consultant queried if there was clear information on the ligature risks on each area. The Interim Director of Mental Health advised that this was the case and as part of the deep dive this would be extended to include staffing levels so the requirements by area were clearly defined. The Executive Medical Director enquired about risks relating to the use of knives and gardens and were the teams confident that the risks had been addressed. The Interim Director of Mental Health advised that the current view point on these areas was narrow and needed to be expanded to account for different mental health needs as in the case of ligature risks. He advised that following discussion with the CCG they were supportive of the direction being taken so that a long term plan could be produced to demonstrate to the CQC that services were moving in the right direction. He also stressed the long term plan was needed to enable staff to feel heard, engaged and empowered. Assurance Level: Limited

17/Q/098 SECTION 31 & REGULATION 17 PROGRESS REPORT AND COMPLETED ACTIONS FOR SIGN OFF

The Clinical Director – Mental Health & Learning Disabilities presented the progress report in conjunction with the evidence provided for assurance that rating levels could be changed. The Committee discussed in detail each section in turn and agreed the level of assurance shown in the report. The Committee agreed that Section A and H had sufficient evidence in place for them to be completed and the assurance level of Substantial Assurance to be set. Assurance Level: Limited/Positive

17/Q/099 USE OF THE MENTAL HEALTH ACT IN THE ISLE OF WIGHT NHS TRUST 2016-17 The MHA & MCA Lead advised that the report provided a summary of the use of the

Mental health Act to detain mentally disordered patients during the period April 2016 – March 2017 against data for recent years. He confirmed that overall activity levels have decreased in the last 5 years and this was due to a mainly to a reduction in use of Police powers under section 136 and better joint working between NHS, adult social care and police (Operation Serenity); this is the opposite of national trends which have shown a year on year increase.


The MHA & MCA Lead confirmed that the rates for longer term detentions for assessment and treatment show some fluctuation year to year, with a slow increasing trend, in line with national trend, albeit at a slower rate. He advised that for 2017/18 further work is needed to compare this data with national benchmarking data and other local data, such as length of stay. The MHA & MCA Lead provided an update on the DoLS applications and advised that 700 cases currently in residential care caused by the wideness of the use of DoLS by the supreme court, and that these were being reviewed but that they ranked as low priority. Assurance Level: Positive

CLINICAL EFFECTIVENESS 17/Q/100 ULTRASOUND CLINICAL ADVISORY GROUP UPDATE The Head of Imaging gave a brief overview of the scope of the review by the Clinical

Advisory Group together with the progress to date with outstanding 204 GP referrals identified. She also outlined the quality outcomes which have been identified to date as a result of the review. The Joint Clinical Director, Clinical Support, Cancer & Diagnostics advised that the same methodology had been applied as in the case of the Endoscopy review. It was also confirmed that regular updates have been provided on this case to the Trust Board. Assurance Level: Positive

17/Q/101 ENDOSCOPY DEPARTMENT SIRI & LOOK BACK EXERCISE CLOSURE REPORT The Operational Manage for the Endoscopy Department presented a report on the

outcome and recommendations of the review. She confirmed that the Clinical Advisory Group had agreed the following recommendations. • There is no requirement to validate patients who attended endoscopy prior to

November 2015; both the SIRI and HR investigation found that the issue started with the change of booking process. This was agreed by the external medical advisor.

• Disband the Clinical Advisory Group - all members, including the external medical advisor to the group agreed this action.

• Continue weekly validation until December 2017. Exception reporting to Operational Management Group.

• Monthly report on validation to CSCD quality meeting • Seek formal closure of the look back exercise at QGC • Quarterly reports to QCG regarding validation, progress on IST report actions and

update on the Coroners enquiry. She also advised that the whole process has been costly, time consuming and difficult for all the staff involved and that the SIRI came to light only 3 months after the new Endoscopy Unit had been opened and this put a ‘black cloud’ over the opening of the new department for the team. The opening of the unit has never been fully celebrated as staff still feel this would be inappropriate until the coroner has closed the case. The report seeks formal approval of the recommendations outlined above and that the exercise is formally closed. The Committee discussed the report and agreed that it should be closed. . Assurance Level: Positive

Session closed at 12 Noon


Session 2 – 18 August 2017

Present: Jessamy Baird Non-Executive Director – Acting Chair David King Non-Executive Director (attended via phone) Sarah Johnston Acting Director of Nursing & Quality (ADNQ) Lisa Reed Deputy Director of Allied Health Professionals

(deputising for Deputy Director of Quality) John Doherty Clinical Director Mental Health and Learning Disabilities

(CD-MHLD) Annie Hunter Head of Nursing & Quality, Surgery, Woman’s and

Children’s Health (HoNQ-SWCH) (deputising for CD-SWCH)

Dennis Ford, Patient Council Representative Chris Orchin Healthwatch

In Attendance: Mandy Blackler Business Manager, Quality Governance Team (BMQG)

For items 17/Q/107 & 112

Antonia Horn Graduate Trainee - Medical Process Management

Glenn Smith Patient Safety Lead For Items 17/Q/110 &111

Vanessa Flower Patient Experience Lead

For item 17/Q/109 Karen Robinson Consultant Nurse, Infection Prevention and Control Frank Sims Interim Deputy Chief Executive Maggie Oldham Interim Chief Executive Mitchell Gadd Consultant, Freshwater Observer: Charles Godden Associate Non Executive Director Minuted by: Lynn Cave Board Governance Officer (BGO)

Meeting commenced at 9.30am

Minute No.

17/Q/102 APOLOGIES FOR ABSENCE

• Mark Pugh, Executive Medical Director (EMD) • Oliver Cramer, Deputy Medical Director • Deborah Matthews, Deputy Director for Quality (DDQ) • Steve Parker, Clinical Director, Surgery, Woman’s and Children’s Health (CD-

SWCH) • Gillian Honeywell, Joint Clinical Director, Clinical Support, Cancer &

Diagnostics and Chief Pharmacist (CD-CSCD/CP) • Muriel Prager, Joint Clinical Director, Clinical Support, Cancer &

Diagnostics(CD-CSCD) • Andrew Woolley, Clinical Director, Medicine CBU • Chris Smith, Clinical Director, Ambulance Urgent Care & Community (CD-

AUCC) • Gary Cooley, Service User Representative (SUR)

The Acting Chair introduced Charles Godden who is joining the Trust Board as an Associate Non-Executive Director in September and will be joining the Committee as Chair.


David King was in attendance via electronic communication and was able to communicate interactively and simultaneously with all parties for the whole duration of the meeting.

17/Q/103 CONFIRMATION OF QUORACY The Acting Chair confirmed that the meeting was quorate.

17/Q/104 DECLARATIONS OF INTEREST There were no declarations of interest

QUALITY 17/Q/105 MANAGEMENT OF WOODLANDS & DEVELOPING APPROACH TO LONG TERM

MENTAL HEALTH PROVISION UPDATE The Clinical Director for Mental Health & Learning Disabilities (CD-MH&LD) provided a

verbal update on the next steps taken since the meeting on 25 July. He confirmed that as outlined in the Deep Dive paper he had undertaken an on-site review together with an ex CQC inspector during which the staff had clearly articulated all aspects of the mitigations in place to ensure that patients are kept safe whilst in a ‘home like’ rehabilitation environment which is deemed to be the correct environment for these patients. He confirmed that following the visit it was now planned to challenge the CQC recommendations for Woodlands Rehabilitation unit. The Committee considered this report and queried if the CD-MH&LD was confident that staff were able to raise incidents where there was potential risk of harm and that they would act in an appropriate way. He confirmed that he was confident that this would occur. The Acting Chair queried what was being done to address the issue of staffing needs within the unit. The Acting Director of Nursing & Quality confirmed that a staffing review had just taken place and that this showed the unit as Green against the indicators. However, she confirmed that these indicators were being reviewed to make more relevant to mental health areas and that this was being taken into consideration as part of the staffing review. The Patient Safety Lead confirmed that the safety thermometer was being applied across the organisation and that Woodlands was included with a specific data set being used. The Acting Chair advised that the Committee supported the approach but stressed the need for risk to be assessed as part of the environment and that both clinical and estates mitigation needed to be addressed. The CD-MH&LD advised that following a meeting with NHSI no concerns were raised about the model being used. The Acting Chair confirmed that the checklist for Mental Health visits for Non-Executive Directors9 had been shown at Board Seminar. The Committee agreed the approach for Woodlands and recommended to the Board that this be formally approved as appropriate. Assurance Level: Positive

PATIENT SAFETY 17/Q/106 SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRIs) The Committee received the report. The Acting Chair commented that the report did

not provide enough information for the Committee to review incidents in detail as had previously been available and that the report was mainly concerned with performance

9 See QGC Action Q/600


data and didn’t give context. The Patient Safety Lead advised that the report could be amended and outlined the measures in place to review incidents on a twice weekly basis with the Head of Nursing & Quality to define if an incident was a SIRI or an incident from which learning should be taken. He confirmed that the report shows SIRIs in clusters related to themes/other work streams etc., to enable a wider view to be seen and to avoid duplication of work. He advised that the teams were encouraged to report incidents where there is a lower level of harm in order that learning can be taken to put measures into place to head off more serious incidents and thus reduce harm. The Acting Director of Nursing & Quality outlined the work being undertaken on the management of incidents and improving the investigation process, and that this was included within the IIF workstream. The Patient Council Representative queried if the lessons learnt were recorded and accessible to staff. It was confirmed that these are discussed at the CBU quality meetings which are attended by the CBU Heads of Nursing & Quality, and at which all incidents are reviewed and assessed. The Interim Chief Executive advised that an external governance review supported by NHSI was being undertaken and the team would be coming to QGC in due course to review papers and ensure that they were contemporary and able to inform the Board of the key issues and themes together with actions needed to be taken. Action: Patient Safety Lead to review SIRI report with Quality Team leads for next meeting.

Action by : PSL Action: Acting Director of Nursing & Quality to arrange for NEDs to meet with the external governance review team to discuss future papers.

Action by: ADNQ Assurance Level: Limited

17/Q/107 DISCHARGE SUMMARIES UPDATE The Committee received the update report which included details of the background to

the issue together with the current status. The Acting Chair advised that as the Executive Medical Director was not present that he report actions being taken to address the outstanding issues at the next meeting. The Committee noted that the Board had agreed in 2016 that no patient should leave the Trust without their discharge summary and despite this decision improvement was not shown; and requested that a clear plan on moving forward be presented to QGC. The Patient Council Representative queried if a dedicated team should be in place to facilitate the discharge summaries. The Acting Director of Nursing & Quality advised that there were a number of strategies in place at the moment which were in review as part of the forward planning. The Interim Chief Executive advised that she would be discussing this area with the Executive Medical Director and suggested that a deep dive workshop item be arranged into discharge summaries and other key themes following discussions with the Non-Executive Directors (NEDs). She also confirmed that this area was included within the IIF10 and would be discussed at the Quality Improvement Plan Oversight Group meeting.

10 Integrated Improvement Framework


The Graduate Trainee who is working on the project agreed to feedback the Committees comments in advance of the next meeting. Action: Deep Dive Workshop into discharge summaries and other key themes to be discussed with NEDs

Action by: ICEO Action: An update on the current situation regarding discharge summaries within the Trust together with way forward plan at the September QGC meeting.

Action by: EMD Assurance Level: Moved from Limited to Negative

17/Q/108 QUALITY IMPACT ASSESSMENTS The Acting Director of Nursing & Quality advised that, together with the Executive

Medical Director, she was establishing KPIs for the Quality Impact Assessments. She stressed the need for appropriate impact assessment and agreed KPIs for each project to ensure that appropriate monitoring can be ensured. She confirmed that support would be provided via the project management office and advised that the assurance level should be limited as the KPIs and evidence are not yet in place. This report would henceforth be coming to the Committee on a quarterly basis. Assurance Level: Limited

17/Q/109 INFECTION PREVENTION & CONTROL FOCUS ASSURANCE REPORT JULY 2017 ON CLOSTRIDIUM DIFFICILE INFECTION

The Consultant Nurse, Infection Prevention and Control presented the report into the deep dive into Clostridium Difficile (C.Diff) within the Trust and advised that the annual allowable cases set by the CCG was the same as last year. She confirmed that due to the demographics of the Island that discussions were taking place as to whether this was an appropriate level and whether this could be challenged. She gave an overview of the cases to date detailing specific cases, together with measures to raise awareness of C.Diff indicators and level of reporting The Acting Chair stated that it was a good report but that it was not just about C.Diff but included threads about mandatory training, health and safety, bed moves, to name a few and she had concerns over the level of priority of infection control. The Committee recognised the importance of raising awareness of infection control across the organisation and the Interim Chief Executive advised that the Board Advisor for Nursing was looking at infection control within the organisation with fresh eyes and would be reviewing compliance and how effective monitoring can be undertaken; would be providing weekly update to the Executive team and developing an action plan which would be brought to the next QGC meeting. The Acting Director of Nursing & Quality stated that it was important standards of nursing care are consistent and that Infection Prevention & Control (IP&C) is viewed within the wider organisation culture as high importance. The Head of Nursing & Quality (SWCH) outlined the need for clear roles and responsibilities, staff planning and appropriate training to be triangulated and advised that this was being reviewed at the CBU quality meetings. The Acting Chair queried how IP&C was linked to the community and public health. The Consultant Nurse confirmed that a meeting with the CCG, Local Authority, GPs and care homes was planned for September. Action: Update report on how the profile of infection control across the organisation, not only for C.Diff is being assessed including use of action plans, monitoring measures and compliance against the standards, and that this is to be submitted to


September QGC by Board Advisor for Nursing. Action: BAN

Assurance Level: Moved from Limited to Negative

PATIENT EFFECTIVENESS 17/Q/110 I WANT GREAT CARE (IWGC) UPDATE The Patient Experience Lead presented the report and confirmed that the Trust had

extended the contract for IWGC until 31 March 2018. She advised that a procurement exercise would be undertaken with Portsmouth NHS Trust to go out to tender as this would give the Trust more negotiating options and benefits. She outlined the options available from other providers and how they would link to our existing systems to provide realtime data including areas such as Ambulance and Mental Health where they have been problems todate. It was advised that the variable responses across the organisation depend on the focus the individual departments give to promoting the programme but that the CBUs are encouraging the teams to actively promote it and are reviewing at their performance meetings. Work is also taking place with the matrons through the Patient Experience Group. The Committee discussed the options for future systems and it was requested that as part of the procurement preparation that the Interim Turnaround Chief Financial Officer be brought into the contract negotiating process. The Acting Chair also stressed that Healthwatch and the Patient Council should be included within the scoping exercise Action: The Patient Experience Lead to arrange for the Interim Turnaround Chief Financial Officer be brought into the contract negotiating process as well as arranging for the Healthwatch and the Patient Council to be involved with the scoping exercise for the proposed replacement system.

Action by: PEL Assurance Level: Moved from Positive to Limited

17/Q/111 ANNUAL IN PATIENT SURVEY REPORT 2016/17 The Patient Experience Lead presented the report and advised that the results showed

an improvement on the previous year. She also confirmed that the 2017/18 survey was due to be launched . In addition to review by the Patient Experience Group, she advised that the CBUs had their data and an action plan was being developed based on the outcome of the 2016/17 survey. Assurance Level: Limited

CLINICAL EFFECTIVENESS 17/Q/112 7 DAY SERVICE UPDATE The Committee received the update report which included details of the background to

the issue together with the current status. David King confirmed that this report had been reviewed by the Audit & Corporate Risk Committee (ACRC) on 8 August and that it had marked it as negative assurance. He also advised that the ACRC had received a paper on consultant job planning which also was negative assurance and that this had been referred back as the project is not due to complete until the end of the year. In the absence of the Executive Medical Director, the Graduate Trainee who has been supporting the project, explained that it was included within the IIF and had two specific KPIs attached relating to audit and delivery. She gave an overview of the current position on delivery within the CBUs and advised that the deadline for compliance was 2020 and that all projects being reviewed needed to include 7 day services as part of their scope. The Committee discussed the progress to date and the current measures being taken in relation to consultant job planning and workload, how ward rounds are undertaken


and how they will be linked to 7 day service. Charles Godden gave an update on the work he has been undertaking since April in this area. The Committee acknowledged that there was still work to be done and that additional resources had been brought in to support the Executive Medical Director. It also stressed the need for evidence to be provided to show how practice was changing across all medical staff. The Committee was advised that a regular update on this project was included within the forward plan. Action: The Interim Chief Executive to discuss with the Executive Medical Director the issue of consultant job planning and ward rounds, and that he provide an update to QGC at the September meeting on measures which are being taken.

Action by: ICEO/EMD Assurance Level: Moved from Limited to Negative

GOVERNANCE 17/Q/113 INTERNAL AUDIT (TIAA) REPORTS The Committee received the following reports from the Internal Auditors which David

King in his capacity as Chair of the Audit & Corporate Risk Committee, advised had been delegated to the Committee for action. The Acting Chair expressed concern that the papers did not have a designated Executive lead assigned and that a coversheet had not been submitted which would guide the Committees discussion.

a) Review of Patient Pathways – Overall Assurance Assessment – Substantial:

b) Review of Private Patient Income – Diagnostic Tests Arrangements – Overall

Assurance Assessment – Reasonable:

The Interim Chief Executive advised that the process for reviewing these reports through the Assurance Committees needed to be verified and agreed, and that the Executive Medical Director would be asked to review and provide an update to the next meeting. It was also agreed that all future internal audit reports would come with a supporting coversheet. Action: Interim Chief Executive to review the process for reviewing Internal Audit Reports for ACRC and other Assurance Committees.

Action by: ICEO Action: Executive Medical Director to review the Patient Pathway and Private Patient Income reports and provide an update to the next meeting.

Action by: EMD

17/Q/114 MEDICINE SAFETY REPORT The Committee received the report and noted that it was a good paper which clearly

showed that the team were in control of the process and that positive assurance was given. The Patient Safety Lead advised that he would be discussing with the Chief Pharmacist how the paper can be improved to show links to implications for near misses and other incidents. The Deputy Director of Allied Health Professionals also asked that links to the IIF be included also. Action: The Patient Safety Lead to link with the Chief Pharmacist to review the report and include links to incidents.

Action by: PSL


Assurance Level: Positive

17/Q/115 ANY OTHER BUSINESS: a) Date of Next Meeting: It was agreed that the meeting would take place as

scheduled on 26 September and the proposed meeting on 29 September would be cancelled. It was requested that attendance by the clinical members was important to enable discussion to be effective. The Interim Chief Executive or Interim Deputy Chief Executive would also be attending.

b) Chair of QGC: David King will be Chairing the September meeting in the absence of the Vice Chair and will be supported by Charles Godden, Associate Non-Executive Director who is joining the Committee from the September meeting. The position of Chair will be confirmed following the External Leadership Review and will be in place by the October meeting.

c) Future Agendas: It was agreed that the focus of the agenda would be reviewed

so that it related more effectively to the risks rather than the papers driving the agenda. This would be discussed at the QGC Agenda planning session in early September and it was requested that key members of the committee attend to optimise discussion.

d) Assurance Level Definitions: The Acting Chair requested that a review of the

definitions against which all Assurance Committees review papers are assessed should be undertaken.

Action: Board Governance Officer to review definitions of Positive, Limited and Negative Assurance.

Action by: BGO

DATE OF NEXT MEETING The next full Committee meeting will be held on Tuesday 26 September 2017

Time: 9 am to 12 Noon Venue: Large Meeting Room, South Block The meeting closed at 11:30am

Signed: ______________________________ Acting Chair (Jessamy Baird) Date: ________________________________

ICT Assurance Committee 21st July 2017 1

+ FOR PRESENTATION TO TRUST BOARD ON: 6th SEPTEMBER 2017

Minutes of the meeting of the Information & Communication Technology Assurance Committee held at 12 noon on Friday 21ST July 2017 in the Large Meeting Room, South Block, St Mary’s Hospital, Newport, IW PO30 5TG PRESENT: Jessamy Baird Non-Executive Director (attended via conference call) (Acting Chair ) Jon Burwell Executive Director of Strategy & Planning (EDSP) In Attendance: Gavin Muncaster Strategic Manager for ICT & Digital Services (IW Council) Minuted by: Lynn Cave

Board Governance Officer (BGO)

Min. No. Top Key Issues & Risks for Raising at TLC1 & Trust Board 17/I/022 Civica Paris Risk Mitigation: A Paris Improvement Programme is in place and being

work through alongside the clinical teams, however the Board should note the need to ensure mitigation remains in place for the full time whilst the programme is delivered. The risk mitigation should be monitored through Quality Governance Committee as part of QIP reporting.

17/I/018 ICT Capital requirements and impact: The Board should note the significant reliance on capital funding to support improvement which must be aligned with the system priorities. There is a risk that with no clinical strategy agreed and ICT being a key enabler, that projects could be delayed if earl requirements are not identified with the Informatics Strategy becoming fast out of date.

17/I/023 Information Governance Tool Kit 2017/18: The Board should note the year end position on the IG Toolkit as reported through Finance, Investment, Information and Workforce Committee. There is a risk that without a clear plan for 2017/18 aligned with the recent release of the toolkit the Trust may not achieve Level 2 compliance which will have a detrimental impact on reputation and have regulation/contractual impact.

Minute No. 17/I/015 APOLOGIES FOR ABSENCE, DECLARATION OF INTEREST & CONFIRMATION

THAT THE MEETING IS QUORATE Apologies for absence were received from;

David King, Non-Executive Director (Chair) Paul Dubery, Deputy Director of Information Communication & Technology (DDICT) Maher El-Alami, Chief Clinical Information Officer (CCIO) Clare Shand, Head of Human Resources & Organisational Change (IW Council) The Chair announced that the meeting was quorate There were no declarations of interest. Jessamy Baird was in attendance via electronic communication and was able to communicate interactively and simultaneously with all parties for the whole duration of the meeting.

17/I/016 MINUTES OF PREVIOUS MEETING The minutes of the meeting held on 19th May 2016 were agreed as a true record.

17/I/017 REVIEW OF SCHEDULE OF ACTIONS The Committee reviewed the schedule of actions and the following updates were

provided:

a) I/007 – ICT Hardware & Asset Management: Action now closed b) I/014 – External Governance Review Outstanding Actions: The EDSP

advised that the current IT Strategy was due to run until 2019 and confirmed

1 Trust Leadership Committee

Enc O3


that the main principals of the strategy are still valid. However, in line with evolving technology it is being reviewed and an update would be provided. He advised that lack of investment had been an issue but that a proposal for a 5 year indicative budget for the organisation would be covered in the Strategy.

c) I/015 – Current & Proposed IT Training Provision: The EDSP confirmed that this will be covered within the strategy and discussions on shared training opportunities with the local authority are being developed to support programmes such as PARIS.

d) I/017 – Customer Satisfaction Survey: This is now in place. Action now closed.

e) I/018 – Business Continuity & Joint Working with Council: Continues to progress (see Action update I/015).

STRATEGIC 17/I/018 HAMPSHIRE & ISLE OF WIGHT SUSTAINABILITY TRANSFORMATION PLAN –

DIGITAL PROGRAMME UPDATE The EDSP provided an update on the current progress against the 8 STP digital

programmes and confirmed that the projects were progressing at difference paces. This included the Isle of Wight joining the Hampshire Health Record however the CCG were currently challenging the funding requirement for this. He outlined that the Hampshire Health Record system would provide access to records across the area and assist with patients who use multiple providers for their care. Jessamy Baird asked for clarity on what had been achieved to date. The EDSP advised that the projects were all in the early stages of development. The Local Care Board was reviewing and prioritising the local priorities which needed to be informed by the STP priorities to ensure the island has a clear set of asks of ICT. Jessamy Baird queried if they would be linked to the My Life a Full Life. The EDSP confirmed that this was the case but advised that not all the local Vanguard projects were at the same stage and this would impact on progress if clear programmes were not completed.

17/I/019 ISLAND ONE PUBLIC ESTATES, INFORMATION TECHNOLOGY & INFORMATION GOVERNANCE TERMS OF REFERENCE

The EDSP advised that these terms of reference were here for information and confirmed that they had been approved at the last Island One Public Estate, ICT and IG meeting. He outlined that this would continue the joint working initiatives already progressing in areas such as email and Wi-Fi as well as developing a clear integrated island strategy. Gavin Muncaster confirmed that the local authority was committed to continuing the integrated working arrangements.

17/I/020 INFORMATICS STRATEGY UPDATE Update provided within 17/I/017b) action I/014

PERFORMANCE 17/I/021 IM&T INTEGRATED IMPROVEMENT FRAMEWORK The EDSP advised that this report was for information and that all workstreams are

discuss at the Integrated Improvement Framework Programme Board and then reported to Board. The EDSP highlighted that there was a capacity issue within the PIDs team which agency staff was being sourced to support. Colleagues in the local authority are also discussing whether they have capacity as part of joint working. He advised that currently this was not causing significant slippage but this was a watching brief weekly. Jessamy Baird commented that the Amber flag given did not give assurance at which end of the spectrum the action was at and that a more expansive indicator would help


such as Amber/Green or Amber/Red. The EDSP advised that he would discuss this with the IIF Programme Board. He further advised that the IIF Programme Board had agreed how this would be reported consistently and the level of detailed needed at each stage. The summary report sitting next to each Programme Group highlight report gave a summary of the RAG rating for the milestones. Jessamy Baird highlighted that in relation to PARIS system staff were still reporting issues and questioned if the Amber status was appropriate. The EDSP advised that it was the status against the programme of work rather than an individual sub section and did not relate to clinical risk mitigation purposes which would be picked up in Quality Governance Committee. An update on PARIS would be provided later in the agenda. It was confirmed that this would be a regular report for information only to the Committee and would include the summary report on milestone progress for further information. Action: The EDSP to discuss the use of the Amber flag when reporting levels of assurance within the IIF Programme reporting and whether a more expansive indicator should be considered, i.e. Amber/Red – Amber Green etc.

Action by: EDSP

17/I/022 ICT CAPITAL PROGRAMME UPDATE The EDSP gave an update on the progress of the following capital programmes:

a) Paris Project: The EDSP confirmed that the roll out was going well and that he

was attending the fortnightly meetings for both PARIS and TPP to gain assurance. He advised that the upgrade was being tested in August and would go live in September. A number of new templates are being created which will be implemented after the upgrade. The EDSP confirmed that clinical champions are working with the Head of Operations for Mental Health & Learning Disability CBU, to promote engagement with the new system. He advised that currently the community team are using the electronic system but that the inpatient service is still using paper whilst a new template for the core assessment is prepared. This has been deemed not acceptable and therefore the inpatient team is being asked to ensure that Paris is being used with refresher training on this in August. In addition the standard operating procedures are being revised and training provided as part of this. Jessamy Baird highlighted that the teams reported issues of duplication of work and limited access to IT equipment. The EDSP advised that these issues were being addressed and IT hardware needs reviewed by the service and supported by IT to resolve. He advised that printing remained an issue and whilst being addressed through the wider system improvement plan, the Director of Mental Health will be working with the ICT department on seeing if there are other options available. The EDSP advised that a team would be going up to Tees, Esk and Wear Valley Trust to learn from a team who are CQC rated ‘good’ and would be bringing back good practice and learning. He stressed that whilst visits have taken place before, the Trust has developed its own templates instead of using nationally recognised models to fit with local practice. The intent this time is to challenge why the Trust has different practice to others and ensure we use the system correctly. The EDSP advised that a contract notice had been served by NHS England due to the Child Health Information Service (CHIS) not being compliant with their contractual needs. This forms part of the longer term improvement plan up to 2019 and this plan has been agreed with NHS England. It was agreed that in view of the ongoing risks and the length of time frames for delivery that a limited assurance would be given and that future updates would be provided.

b) TPP Project: The EDSP confirmed that the roll out was planned to start in


September and complete in December. A team went to Sussex for a demo from which positive feedback was received as well as a number of areas of improvement which are being worked through with the ICT team. Due to staff movement a risk has been identified in relation to staff resources, this is being worked on with HR and some virtual support will be provided by Sussex. The Board Advisor for Nursing is reviewing the clinical risk mitigation to ensure that procedures are being adhered consistently, ensuring patients are not missed off caseloads. Jessamy Baird queried if issues of connectivity via Wi-Fi and 4G had been reviewed. The EDSP advised that the product was bought because of its off line functionality and would be rolled out with a list of public buildings staff could use to connect to Wi-Fi to upload/download work. The EDSP advised that as part of the project, the Trust is seeking to learn from others and will speak with Solent NHS Trust to establish if any of their lessons learnt could be applied. Action: EDSP to discuss connectivity issues relating to SYSM1 with Solent NHS Trust and whether there is learning which the Trust can use as part of the roll out of the system within the organisation.

Action by: EDSP c) E-Referral: The EDSP advised that the programme was slightly behind the

national schedule compared to others as the start had been delayed. However, there is a robust programme in place to drive the programme forward at pace; there will be challenges for clinicians with the change of working to a fully paperless system but this would be supported by the project manager. Jessamy Baird stated that a hard break would be needed to ensure universal use. The EDSP confirmed that this was planned and advised that in the community clinicians were already paperless and that any issues with compliance would be escalated to the Executive Medical Director.

17/I/023 INFORMATION GOVERNANCE TOOL KIT UPDATE The EDSP confirmed that the new IG Toolkit for 2017/18 had been released and that

he would be discussing the Trusts approach to this with the Interim Deputy Chief Executive in his role as SIRO2 and lead for this. Jessamy Baird queried the level of risk to the organisation of not achieving compliance. The EDSP advised that this was on DATIX as a risk and confirmed that a lot of work would be needed to ensure that the Trust meets the compliance but that this would be factored into the planning.

GOVERNANCE 17/I/024 REVIEW OF ICT RISKS ON RISK REGISTER The EDSP advised that the direction of travel this financial year is for the ICT team to

take oversight of all ICT related systems so that risks are being more effectively managed. He also advised that of the 5 outstanding risks which were deemed high (15 plus) from an IT perspective were progressing and that the risks had been reviewed and the scoring validated. He introduced the new revised reporting format and confirmed that the teams will be reviewing all risks under 15 and ensuring that they were appropriated recorded on DATIX in the coming months. Jessamy Baird requested that the Risk Register be moved to the beginning of future agendas and that the agendas reflect dealing with these risks.

17/I/025 REVIEW OF OUTSTANDING INTERNAL AUDIT RECOMMENDATIONS The EDSP reported that better progress was being made against all the outstanding

recommendations. He confirmed that of the four outstanding actions work was being undertaken in all cases with links to the IIF being established. He reported that these are being left open at this time to ensure that evidence is in place to support assurance. He advised that a limited assurance at this time was appropriate as some of the items remained outstanding and overdue.

2 Senior Information Risk Owner


17/I/026 ITEMS CIRCULATED FOR INFORMATION The Committee received the notes for information from:

a) Executive Lead ICT Programme Group held on 10 May 2017 & 4 July 2017

17/I/027 ANY OTHER BUSINESS a) Future Meetings of ICTAC: It was advised that the Committee would continue

to meet until further notice.

DATE OF NEXT MEETING Date Friday 15 September 2017 Time 12 noon – 1.30pm Venue Large Meeting Room, South Block, St Mary’s Hospital The meeting closed at 1.25pm. Signed: ……………………………………….Chair of ICTAC Date:…………………………………………

trust board papers - isle of wight primary care trust september 2017.pdf · meeting in public on...

Documents