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PUBLIC TRUST BOARD MEETING TO BE HELD AT ON THURSDAY

24 SEPTEMBER 2015 AT 10.00 AM IN ROOM 10009/11, CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITALS COVENTRY& WARWICKSHIRE, CV2 2DX

PUBLIC BOARD AGENDA

ITEM TITLE BOARD ACTION PAPER TIME Standing Items

1. Apologies for Absence Chairman

2. Declarations of Interest Chairman

For Assurance Verbal

3. Minutes of Public Board Meeting Held on the 30 July 2015 Chairman

For Approval Enclosure 1

4. Matters Arising Chairman

For Assurance Verbal

5. Trust Board Action Matrix Chairman

For Approval Enclosure 2

Business Items 6. Chairman’s Report

Chairman For Assurance Enclosure 3 5

7. Chief Executive’s Report Chief Executive Officer

For Assurance Enclosure 4 5

Performance 8. Integrated Quality, Performance

and Finance Monthly Report Chief Workforce and Information Officer

For Approval Enclosure 5 10

9. Trust Development Agency (TDA) Oversight Monthly Self-Certification Requirements – August 2015 Chief Finance and Strategy Officer


Patient Quality and Safety 10. Patient Story

Chief Medical and Quality Officer For Assurance Enclosure 7 10

11. PLACE Annual Report Chief Operating Officer


12. Safeguarding Children and Vulnerable Adults Report Chief Nursing Officer


13. Emergency Care Pathway Update Chief Operating Officer


14. Significant Incident Group Report (including Never Events 6 monthly update) Chief Medical and Quality Officer


TB Public Agenda 24.9.15 FINAL

ITEM TITLE BOARD ACTION PAPER TIME Strategy

15. Joint Vision with University of Warwick Chief Executive Officer / Chair of Faculty


16. Summary of Medical Education Report Chief Medical and Quality Officer


17. Together Towards World Class (TTWC) including TTWC Listening Events Feedback (including NHS Staff Attitude & Opinion Survey Results 6 Monthly Update) Chief Workforce and Information Officer


18. NHS Workforce Race Equality Standards Chief Workforce and Information Officer


Research and Innovation No reports

Regulatory, Compliance and Corporate Governance 19. Annual Audit Letter 2014/15

Chief Finance and Strategy Officer For Assurance Enclosure 16 5

20. Emergency Preparedness Resilience Response Chief Operating Officer


Feedback from Key Meetings 21. Private Trust Board Meeting

Session Report of 30.7.15 Chairman


22. Quality Governance Committee Meeting Report 3.8.15 and 7.9.15 Chair, Quality Governance Committee


23. Finance and Performance Committee Meeting Report 7.9.15 Chair, Finance & Performance Committee


24. Any Other Business 25. Questions from Members of the Public Relating to Agenda Items 26. Date of Next Meeting:

The next meeting of the Trust Board will take place on Thursday 29 October 2015 at 10.00 am, University Hospitals Coventry and Warwickshire


ITEM TITLE BOARD ACTION PAPER TIME Resolution of Items to be Heard in Private (Chairman) In accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997, it is resolved that the representatives of the press and other members of the public are excluded from the second part of the Trust Board meeting on the grounds that it is prejudicial to the public interest due to the confidential nature of the business about to be transacted. This section of the meeting will be held in private session.


Agenda Item 3 Enclosure 1

MINUTES OF A PUBLIC MEETING OF THE TRUST BOARD OF UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST HELD ON THURSDAY 30 JULY 2015 AT 10.00 AM IN ROOM 10009/11 OF THE

CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY

AGENDA ITEM

DISCUSSION ACTION

HTB 15/855

PRESENT

Mrs B Beal, Non-Executive Director (BB) Mr I Buckley, Vice Chair (IB) Mr D Eltringham, Chief Operations Officer (DE) Mr A Hardy, Chief Executive Officer (AH) Mr E Macalister-Smith, Non-Executive Director (EMS) Mrs K Martin, Chief Workforce and Information Officer (KM) Mr A Meehan, Chairman (AM) Mr D Moon, Chief Finance & Strategy Officer (DM) Professor M Pandit, Chief Medical & Quality Officer/Deputy Chief Executive Officer (MP) Professor M Radford, Chief Nursing Officer (MR) Mrs B Sheils, Non-Executive Director (BS) Professor P Winstanley, Non-Executive Director (PW) IN ATTENDANCE Mrs K Beadling, Head of Communications (KB)

Mr S Betteridge, Lead Chaplain (SB) – item HTB/15/866 Mrs J Child, Director of Infection, Prevention & Control (JC) – item HTB/15/865 Mrs E Clarke, Associate Director of Nursing (EC) – item HTB/15/867 Ms S Hollyoak, Macmillan Specialist Palliative Care Nurse (SH) - item HTB/15/866 Dr S MacLaren, Consultant in Palliative Medicine (SM) – item HTB/15/866 Mrs P Young, Corporate Affairs Manager (PY) - note taker

HTB 15/856

APOLOGIES FOR ABSENCE

Mr D Poynton, Non-Executive Director (DP) Mrs R Southall, Director of Corporate Affairs (RS)

HTB 15/857

DECLARATIONS OF INTEREST

MR declared that he was a Trustee of Myton Hospice but assured the Board that this presented no conflict to item 15 on the agenda ‘End of Life Care Annual Report’.

HTB 15/858

MINUTES OF TRUST BOARD MEETING HELD ON 28 MAY 2015

KM noted that the penultimate word on the 3rd line of the second paragraph on page 4 should read ‘work’ and not ‘working’. It was noted that Peter Winstanley should be recorded as Professor Winstanley.

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AGENDA ITEM

DISCUSSION ACTION

The minutes were APPROVED by the Trust Board as a true and accurate record of the meeting subject to the above amendments.

HTB 15/859

TRUST BOARD ACTION MATRIX HTB/15/811 BS requested that the item remain on the action matrix until discussions at Finance & Performance Committee and Quality Governance Committee are concluded. HTB/15/792 BB enquired when the Board Safety and Quality Walkround Programme would be reinstated. The Chairman assured that a meeting had been held recently with the Director of Quality and a new format agreed whereby Non-Executive Directors will be accompanied by an Associate Director of Nursing to undertake walkrounds and the outcomes of those visits will be captured and monitored by the Quality and Patient Safety Department. In response to a query from BB, the Chairman advised that the new format is designed to improve the methodology by which information is captured with a view to having a more systematic method of extracting that learning, which will be received and monitored by the Quality Governance Committee going forward. The Trust Board NOTED the items in progress and APPROVED the removal of those actions marked as complete with the exception of HTB/15/811.

HTB 15/860

MATTERS ARISING

There were no matters arising that were not on the action matrix or the agenda. HTB 15/861

CHAIRMAN’S REPORT

The Chairman presented the report and added that he had recently attended a Chairs and Chief Executives dinner hosted by the University of Warwick; which presented an exciting opportunity to create co-operation and mutual understanding of system collaboration. The Trust Board RECEIVED ASSURANCE from the Chairman’s report.

HTB 15/862

CHIEF EXECUTIVE OFFICERS REPORT

AH was delighted to announce that UHCW NHS Trust had been selected as only one of five organisations nationally to participate in an international development programme with Virginia Mason Hospital and Medical Centre in Seattle. 92 organisations were invited to submit applications for consideration to participate in the development programme with the chosen provider, 63 organisations made submissions. From that 10 organisations were shortlisted and invited to attend for interview including UHCW NHS Trust resulting in progression to the final stage, which included a site visit in early July. He added that Virginia Mason is renowned for being one of the best health care facilities and has an incredible reputation for driving cost saving initiatives and this opportunity will help to accelerate the Trust’s Together Towards World Class (TTWC) programme. Next steps include identifying leads to represent the organisation.

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DISCUSSION ACTION

PW offered congratulations and suggested that the Trust may wish to consider approaching Atul Gawande, General and Endocrine Surgeon, author and public health researcher who is renowned for his work in lower cost improved patient care through service improvement, to present to the Grand Round. IB complimented the Board on this achievement; adding that the Trust is facing a difficult challenge to achieve the financial recovery plan and urged caution not to lose focus. AH provided assurance that discussions with the NHS Trust Development Authority (TDA) and Virginia Mason have focused on a successful partnership that will drive the way forward to achieving the recovery plan. BB added that the Trust must not lose sight of Lord Rose’s recently published Better leadership for tomorrow: NHS leadership review suggesting that this may be an ideal topic for a future Board Seminar. AH proudly shared the news that UHCW NHS Trust had been voted in the top 100 employers; which was in line with the Trust’s TTWC ambition. EMS extended his congratulations and concurred with IB’s note of caution. AH assured that Virginia Mason promotes a LEAN research based approach, whereby LEAN takes grip to accept and adopt cultural change with the result of providing a value added service to the population served. BB sought assurance that partners within the Local Health Economy (LHE) were supportive. AH acknowledged that LHE and wider partnership support was essential to the success of the programme, and confirmed that the Trust was in early discussions with partners. KM added that the opportunity seeks to inspire the Trust’s desire to achieve world class status under the banner of TTWC and help grow the Trust’s brand and reputation internationally. In response to a query from BS; AH confirmed that the TDA are supportive of the programme commencing as soon as possible with plans to visit Seattle by the end of September and it is expected that leads chosen to represent the organisation will visit Virginia Mason before Christmas. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/863

PERFECT WEEK UPDATE

DE was pleased to share with the Board the outcome of a recent exciting Trust-wide initiative ‘The Perfect Week’. A campaign was established to commence the initiative on 8th July 2015 with a view to breaking free from the cycle of failure and improve patient flow. DE delivered a powerful PowerPoint presentation and video emphasising that quality and safety were the key drivers to help improve performance. He advised that the week commenced with 85% performance against the 4-hour wait target and ended with a performance of 99.6% achievement against the target. He praised the exceptional contribution provided by staff across the Trust to proactively progress patient pathways; emphasising the role of Ward Liaison Officers (WLO) supported by staff working in corporate departments to help facilitate seamless patient journeys. He acknowledged the important contribution provided by partners within the Systems Resilience Group (SRG) to support the

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DISCUSSION ACTION

initiative. A snapshot of the data collected during the initiative demonstrated significant improvement in patient discharge, with 20 more patients discharged prior to 12noon each day and 60 patients waiting more than four hours in the Emergency Department compared to 584 six weeks earlier. Medical outliers has been a perennial problem; however, during the Perfect Week the Trust managed to sustain around 20 medical outliers; a significant reduction against a peak of 160. Better engagement with staff injected a sense of pride throughout the organisation and directly led to improved performance. DE expressed his immense pride in the staff within the organisation, which contributes to the Trust’s TTWC vision. He added that there has been unanimous support to run further Perfect Week initiatives and there is lots of opportunity to expand on the success already achieved by using the learning derived. Consideration is also being given to undertaking a whole LHE initiative. PW offered congratulations and suggested that the Trust exploit the opportunity to attract more visibility, kudos and resource; adding that consideration be given to whether there is sufficient data analysis to publish an article in the New England Journal and linking that with the development programme opportunity with Virginia Mason. BB praised the success of the initiative and emphasised the need to consider sustainable therapy services to support seven day working, which is critical to ensuring that patients receive holistic quality focused patient care. DE acknowledged this and added that final analysis of the data will provide five or six key themes to focus on in order to provide a sustainable service going forward, which will also link to the seven day services strategy. AH added that Chief Officers will be challenging Groups at Quarterly Performance Reviews to better understand why performance improved during the perfect week and how that can be sustained. MR observed that there is significant work to be done within the LHE around delayed transfers of care (DTOC) and a programme of sustainability will not be achieved without the support of partners. He assured the Board that he was confident that the Trust can sustain a short-term plan of sustainability but that a more robust plan supported by the SRG is critical to achieving long-term performance. DE added that he will be delivering key messages from the initiative at the next SRG and will be holding partners to account to deliver improvements in DTOC. EMS commended the fantastic partnership working; acknowledging that this was key to success. He observed that the FREED principles underpinned both this initiative and that of the successful ‘breaking the cycle’ initiative approximately two years earlier and sought assurance as to how Chief Officers will maintain the reinvigoration of energy to sustain performance, not underestimating the cultural challenge this presents. DE acknowledged that the command and control structure, which had been implemented to improve focus was lifted as part of the initiative and staff responded well to this approach. The Trust’s focus must be to build on this success and take the lessons learned from bypassing bureaucracy. MP praised the work of staff across the Trust who welcomed the simple approach

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DISCUSSION ACTION

that the five key FREED principles presented. She acknowledged that the communication strategy deployed locally had provided confusing messages and lessons learned will inform changes to future initiatives. IB applauded the success of the initiative but queried that with so many other initiatives taking place concurrently, how would it be possible to establish which initiatives were the drivers to success. He emphasised the need to determine key performance indicators (KPI’s) in order to identify blockages and quickly engage with partners to share issues. DE acknowledged this and advised that this will be a feature of the conversation with the SRG to emphasise the significance of being able to predict potential issues that may impact on performance. One of the challenges has been that UHCW NHS Trust is the only partner with robust data and the task of the SRG is to build a dashboard, in order to provide early warning signs. BS offered congratulations and queried the timetable for the next initiative and the service-wide approach within the LHE. DE acknowledged that partners participation in the recent initiative helped to provide a clear picture and provoked system-wide conversations. He added that the Chair of Coventry and Rugby Clinical Commissioning Group (CCG) is seeking support from the CCG to support a further initiative in October. The Chairman observed that the focus at the SRG appears to be UHCW NHS Trust as the only partner with robust data and he urged Chief Officers to encourage partners to identify KPI’s to support a system-wide approach. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/864

INTEGRATED QUALITY PERFORMANCE AND FINANCE REPORT (IQPFR)

KM introduced the report and reminded board members that a survey had been circulated as an opportunity for all to contribute to the refinement of the IQPFR. She observed that there is no Trust Board meeting in August and assured that an electronic copy of the IQPFR will be circulated to all board members in August. KM acknowledged that the presentation of workforce data on page 15 of the report did not provide a clear picture in terms of correlating data for staff in post and vacancies. She assured the Board that work was in progress to review the presentation for the reporting schedule. The Chairman observed that given the financial recovery plan it is critical to understand real vacancies and those not due to come on stream until later in the year. KM confirmed that this has been recognised and will feature as part of the work to refine the reporting schedule. KM was pleased to report that the Trust was making good progress with the number of starters exceeding leavers for the first time in four months; adding that she and MR had worked hard to address this issue. The Trust will exploit the fact that 94% of staff in the Trust believe that their role makes a difference as this is something that should be capitalised on. KM drew attention to page 16 of the report and in particular the financial controls implemented in July. She added that the Trust is putting processes in place to sustain quality and that Chief Officers believe the organisation has the workforce

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DISCUSSION ACTION

to achieve this, but not necessarily in all the right places. Work is being done to realign resource and empower staff to achieve the best outcomes for patients. In response to a query from IB; DM advised that the Perfect Week initiative enabled the Trust to remove two medical outlier teams consisting of two consultants and six junior doctors resulting in a large cost saving, and that a decrease in agency spend was expected as a result. Furthermore the successful healthcare support worker (HCSW) recruitment campaign means that the Trust will no longer be engaging agency HCSW’s from 1st August 2015. He added that he was cautiously optimistic that the Trust should start to see a reduction in agency spend in July. IB queried the mechanism for the triangulation of planned roles, genuine requirements for temporary staff, identifying permanent shortages and how that translates into better performance. KM concurred that utilising the systems in place such as e-rostering to harvest the full picture is essential and suggested that a future Board Seminar focusing on whole workforce supply would be useful to better understand at a strategic level. PW added that particular attention be paid to clinical posts in order to maximise capacity and improve productivity. BS sought to understand the impact following implementation of the financial controls on staff engagement and whether staff understand the rationale behind the decision taken. KM responded that the reality of the message is very clear but acknowledged that there is more work to do in terms of translating the message to different levels of staff to ensure that it is more meaningful.

KM

In response to a query from EMS in relation to medical outliers; MP assured that a strategic plan is in place, which does not involve the use of medical agency staff. This includes the planned recruitment to substantive consultant positions within renal, respiratory, gerontology and endocrine medicine whose job plans encompass a solution to the management of medical outliers. In response to a query from BS regarding conversion plans from agency to bank staff usage; AH responded that with the right drivers in place the Trust expects to see a clear conversion in reported figures. MR added that with the recent recruitment in HCSW staff, the Trust expects to see a substantial shift. In response to a request from BB; KM advised that there was insufficient data available to provide assurance to the Finance and Performance Committee at this stage as drivers had only recently been put in place, but assured that this information will be available at a future date. She added that there is a national deficit around substantive nurses and the Trust is maximising all options to recruit substantively. There will be a requirement to use some agency within certain specialties but all endeavours are being made to attract more nurses onto the bank to avoid using agency nurses. DM proceeded to present the financial overview highlighting that the Trust is forecasting to meet its planned deficit of £22.4m for 2015/16. However, future savings of £6.7m are required to deliver the plan. Contract income is forecast at £9.8m adverse to plan driven by under performance against activity targets in electives, daycases and critical care. The Trust is reporting a year to date deficit of £10.4m in month 3 (£10.1m against break-even duty), which is £1.2m adverse

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DISCUSSION ACTION

to the planned deficit. This is primarily due to underperformance against activity targets. Trust capital expenditure still remains largely on plan. The year to date cash and cash equivalent increase of £3.3m is a result of the working capital movements in trade receivables and payables, offset by deterioration in the year to date income & expenditure position against plan. The cashflow still assumes that the Trust will receive £31.9m of Public Dividend Capital (PDC), of which £28.9m is revenue support. A financing application for the revenue support will be submitted to the Independent Trust Financing Facility (ITFF) in September. The Trust is forecasting delivery of £26.8m against £28.1m of potentially identified savings: This gives a potential forecast shortfall of £7.2m against the Trust target of £34m for 2015/16. He summarised that the three main risks to achieving the forecast financial position include the inability to deliver elective work; the ability to reduce the agency run rate and delivery of the CIP. In response to a query from the Chairman in relation to HSMR performance as presented on the Trust Scorecard on page 3 of the report; MP advised that performance is presented as green as it is within expected range, although not below 100. In response to a query from PW regarding the Trust’s performance in relation to C-difficile; MR acknowledged that the Trust is one case over trajectory, which demonstrates the same level of performance at the same time last year but, assured that there was no room for complacency and recognised the need for more targeted work. PW observed the upward trend of falls resulting in serious harm and queried whether there was cause for concern; MR responded that the Trust has seen a decrease in the number of falls but alarmingly an increase in falls resulting in serious harm and assured that targeted work is being undertaken. He added that detailed analysis of the incidents revealed a number of risks in the bathroom setting and acknowledged that there was a fine line between balancing patient privacy and providing assistance with toileting. He further added that a range of measures were being introduced to better understand potential risks. The Chairman requested that the Quality Governance Committee continue to closely monitor compliance against the performance standard. It was noted that the Rugby Theatre Team along with senior representatives from Trauma and Orthopaedics have been invited to attend the Finance and Performance Committee in September to present plans to increase theatre efficiency at the Hospital of St Cross in Rugby. The Chairman observed that referral to treatment time (RTT), cancer waiting times, A&E performance and theatre utilisation will continue to receive close scrutiny by the Finance and Performance Committee. Cognisant that there is no Trust Board in August; DM confirmed that a detailed financial report will be circulated to all Board members in August.

MR

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AGENDA ITEM

DISCUSSION ACTION

The Trust Board:

• CONFIRMED its understanding of the contents of the June 2015 IQPFR and NOTED the associated actions and;

• RECOMMENDED sign off of the TDA Board Statements on the basis there has been no change in status.

HTB 15/865

INFECTION, PREVENTION AND CONTROL ANNUAL REPORT 2014/15

MR introduced the Infection, Prevention and Control Annual Report for 2014/15 and welcomed Jenny Child, Director of Infection, Prevention and Control to the Board to present the report. JC advised that the most pressing issue proved to be an increase in MRSA bacteraemia cases reported (nine) in 2014/15; whilst MSSA demonstrated a decrease. Molecular typing showed the strains to be unrelated. An external review helped to shape an MRSA action plan and as at the previous day there had not been a reported case of MRSA assigned to the Trust for five months. The Ebola epidemic in West Africa, and concerns about spread to the UK in August and September 2014 provided an interesting challenge. In conjunction with the Emergency Planning Department and the Infection, Prevention and Control Team a policy was developed based on the Advisory Committee for Dangerous Pathogens policy on viral haemorrhagic fever. The plan was thoroughly tested one weekend in October when a Nigerian student presented with a fever and vomiting; fortunately tests proved negative for Ebola. MR assured the Board that action plans were being implemented; acknowledging that challenges remain in relation to cleaning with work underway to achieve the standard expected. In response to a query from PW; JC advised that she was not aware of any concerns relating to cannula care packs. PW suggested that that the opinion of staff inserting cannulae be sought as part of the audit to monitor compliance with both peripheral and central cannula care as detailed in the action plan. BB observed that at a recent meeting with the Group Manager at the Hospital of St Cross in Rugby, concerns were raised regarding cleanliness. DE responded that ISS Facility Services have been tasked with a 12 week improvement plan but acknowledged that this had not progressed as expected. The Chairman urged that this matter not be allowed to drift. BS observed that the action plan was previously presented to the Board and queried the pace at which progress was being made. MR assured that work is underway to ensure that the right policies and practices are being adhered to. He added that the action plan was being closely managed by MR/JC and acknowledged that there was progress to be made but assured the Board that he was satisfied with the pace. A progress update against the MRSA action plan will be presented alongside the quarterly infection, prevention and control report to the Trust Board In response to a question from BS; MP and MR assured the Board that they were satisfied that medical engagement was occurring at the right pace. MP added that

DE

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DISCUSSION ACTION

the Clinical Director for Radiology and junior doctors routinely attend the Infection, Prevention and Control Committee. JC suggested that medical engagement remains a challenge and that there is still further progress to be made. EMS assured that there is a tight grip on MRSA at Quality Governance Committee but conveyed concern in relation to the graph on page 5 of the quarterly report demonstrating compliance against the MRSA quick action guide for quarter 1. JC assured that the MRSA policy has been reviewed and updated and significant work has been undertaken on screening pathways; improvement is expected in the next quarter. The Chairman thanked JC for her presentation; emphasising that infection, prevention and control remains a high priority for the Trust and the Quality Governance Committee plays a significant role in monitoring progress. The Trust Board NOTED the report and all actions in relation to delivery against the infection control standard.

HTB 15/866

END OF LIFE CARE ANNUAL REPORT MR introduced the End of Life Care Annual Report. The Chairman welcomed SM, SH and SB to the Board to present the report. SM advised that there has been significant progress during the last two years and work is ongoing to engage lead clinicians in medicine, surgery and the emergency department to drive improvements and provide a collaborative approach to end of life care for patients in the last year of life. UHCW NHS Trust enrolled in the NHS Improving Quality TRANSFORMING end of life care –Route to success programme in 2013. Funding was secured from Arden, Hereford and Worcester Local Education and Training Council of £40,000 to support collaborative education and training for Coventry and Rugby. The Chairman observed that ensuring effective end of life care practices is one of the quality improvement priorities that the Trust has committed to achieve in 2015/16 and queried the level of engagement at the End of Life Care (EoLC) Committee. SM responded that end of life care is seen as the responsibility of the Palliative Care Team. The EoLC Committee has extended invitations throughout the Trust to attend but acknowledged that engagement has not been as hoped. The Chairman queried the strategy to improve engagement and MP assured the Board that training is provided to Teams at ward level, and clinicians attending the Mortality Committee had expressed interest in receiving training, which is being arranged. BB praised the work of the EoLC Team for the exemplar service provided to both patients and carers. In response to a query from PW regarding the Liverpool Care Pathway (LCP); SH acknowledged that the LCP was a very good educational tool which was not well managed nationally. UHCW NHS Trust adapted the tool to help inform individualised plans for patients. BC urged not to underestimate the financial implications poor bereavement care had on NHS resources and the need to keep EoLC high on the agenda. MP

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DISCUSSION ACTION

praised the fantastic work undertaken to provide a critical service, which should form part of seven day services. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/867

SAFER STAFFING

MR Introduced the report. The Chairman welcomed EC to the Board who proceeded to provide an update on the actions arising from the National Quality Board (NQB) and National Institute for Health and Care Excellence (NICE) standards relating to Safer Staffing. UHCW has had a long term program in place for understanding and reporting nursing and midwifery staffing levels. The systems in place are consistent with the national guidance received on safer staffing, including the Safer Nursing Care Tool (SNCT). This has consistently been reported through to Board and discussed in detail through sub-board governance systems and the nursing hierarchy and will continue to be used in the medium and long term planning of service models and resource allocation. Changes to service models and configuration utilise these tools in understanding further resource requirements, reallocation or redistribution for patient need. New NICE safer staffing guidance for ED (Draft) and Midwifery have been reviewed and a gap analysis has been conducted. EC provided a summary of the actions taken, which include a safe and supportive observation model approved by Chief Officers Group, a deep dive analysis of wards recommended 1:8 ratio of nurse to patient in the day and 1:12 at night and the ED and Midwifery departments have reviewed staffing in line with new NICE guidance. EC confirmed that the care contact time/hours baseline was completed in July. BB empathised with the challenges that the role of the Ward Manager presents and emphasised the need for making clear across the organisation, the perception of the role and the support that is required. In response to a query from BS in relation to ward leadership; EC confirmed that two away days were externally facilitated to standardise the approach to the Ward Manager role and Practice Facilitators have helped to embed this within the Trust. BS queried what the financial implications were to the Trust; MR responded that the Ward Managers, as budget holders, determine where money is best spent to provide quality care to patients by pragmatically spreading resource. AH observed that whilst national guidance in relation to safer staffing focuses on nursing, the Board endeavours to receive assurance of safer staffing levels across all clinical disciplines. BB observed that international research challenging NICE guidance had been published. MR acknowledged the two pieces of research including that which UHCW NHS Trust contributed to commissioned by NHS England and that of Jane Ball, Deputy Director, National Nursing Research Unit, Kings College Unit. BB praised the Midwifery Service provided by UHCW NHS Trust which is

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DISCUSSION ACTION

considered to be one of the best nationally. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/868

TRUST DEVELOPMENT AUTHORITY OVERSIGHT MONTHLY SELF-CERTIFICATION REQUIREMENT

DM presented the report confirming that all of the board statements on the self-certification requirement had been met. The Trust Board NOTED and APPROVED the submission against the Board and Licence requirements.

HTB 15/869

BOARD ASSURANCE FRAMEWORK: QUARTER 1 UPDATE

MP presented the quarter 1 update and noted that the Trust Board approved the Board Assurance Framework (BAF) for 2015/16 at the May meeting. Given that the first quarter of the year has now elapsed, each of the risks has been reviewed by the responsible Chief Officer and the updated position in terms of progress against the actions outlined. Whilst progress has been made, and there are no specific areas of concern to highlight, the risk scores have remained static as it is only 4-months into the current financial year and some of the actions have a longer lead in time because they are aimed at achieving an annual objective. Following agreement at the Risk Committee the risk associated with the PFI and issues in relation to structural fire compartments, MP also formally escalated the risk to the Board. The Chairman observed that corrective action taken should result in reduced likelihood of the risk materialising and suggested that the BAF appears to demonstrate otherwise but with improving consequence ratings and suggested that this be reviewed.

MP/ RS

The Trust Board:-

• NOTED the updated BAF as at quarter 1; • RECEIVED ASSURANCE in relation to the management and mitigation of

the risks and; • ACKNOWLEDGED the BAF remains reflective of the current risks to the

achievement of the strategic objectives.

HTB 15/870

CORPORATE RISK REGISTER

MP introduced the report and updated the Board of the current highest rated risks entered on the corporate risk register. She added that clinical risks are monitored at Quality Governance Committee and non-clinical risks at Finance and Performance Committee, with the Risk Committee receiving a more detailed corporate risk register report each month. EMS queried whether the Risk Committee was confident the risk scores were correct. MP confirmed this to be the case and assured that the Risk Committee

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DISCUSSION ACTION

reviews all new risks and, where necessary, request risk holders attend the Committee. The Chairman enquired whether the Board Committees were comfortable with the monitoring arrangements in place. EMS responded that the Committee will continue to monitor the risk register and hold risk owners and Executive Leads to account to stimulate the desired trajectory of improvement but observed that the Quality Governance Committee does not have any delegated authority. AH acknowledged this and advised that this will be considered as part of the Board Committee Review. BB emphasised that risk owners and handlers have an obligation to ensure that risks are regularly reviewed and updated on the register and as such is a requirement of risk owners/handlers and not a request as suggested in the report. The Trust Board NOTED the risk register report.

HTB 15/871

MEDICAL REVALIDATION AND APPRAISAL 6-MONTHLY UPDATE

MP introduced the report to provide an update on medical appraisal and revalidation within the Trust. She provided an overview of quarterly appraisal rate for 2014/15 and noted that overall annual compliance was 82.5%. EMS emphasised that the message to all clinicians must be that it is a ‘duty’ and not a ‘request’ to complete appraisal. MP assured that the Trust takes a robust approach in terms of non-compliance, explaining that 20 doctors were reported to the General Medical Council (GMC) for non-compliance and assured the Board that all of the 20 doctors have either successfully completed an appraisal or are scheduled to do so. MP advised that there were now over 100 trained appraisers in the Trust providing a ratio of 1:5 appraiser to appraisee. It is intended that in-house appraiser training sessions will be held bi-annually to ensure that the ratio remains consistent and will support compliance for completed appraisals. In terms of revalidation; the Trust has 532 prescribed connections and to date 396 recommendations have been issued to the GMC for these connections. Since the previous report to Board in February 2015, 85 recommendations have been made, of which 79 recommendations to revalidate have been submitted and accepted. There are six deferrals due to ongoing internal processes or insufficient evidence. In response to a query from BB; MP assured that educational supervision is monitored through the appraisal process. Discussion ensued in relation to Clinical Excellence Awards (CAE’s) and links to appraisal and revalidation. MP confirmed that clinicians without a valid appraisal or job planning meeting would not be eligible for CAE’s. The Trust Board:-

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DISCUSSION ACTION

• NOTED the report and progress made against the action plan to date; • APPROVED the action plan and; • APPROVED the ‘Statement of Compliance’ confirming that the Trust as a

designated body is compliant with regulations.

HTB 15/872

PRIVATE TRUST BOARD MEETING SESSION REPORT: 25 JUNE 2015

The Chairman had nothing further to add to the report and there were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/873

QUALITY GOVERNANCE COMMITTEE MEETING REPORT 6 JULY 2015

EMS presented the report and reinforced that the Committee will continue to monitor the risk register and hold risk owners and Executive Leads to account; providing assurance of this through the Chair’s report to Board. There were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/874

FINANCE & PERFORMANCE COMMITTEE MEETING REPORT 6 JULY 2015 IB noted that BS Chaired the meeting. BS observed good challenge and debate with the focus including elective activity, approval of the corporate financial risks and monitoring of the financial recovery plan. There were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/875

AUDIT COMMITTEE MEETING REPORT 13 JULY 2015 IB observed that KPMG have been appointed as external auditors to the Trust as of 1st April 2015. The Trust Board RECEIVED ASSURANCE from the report.

HTB 15/876

ANY OTHER BUSINESS

There was no other business conducted. HTB 15/877

QUESTIONS FROM MEMBERS OF THE PUBLIC There were no questions from the public.

HTB 15/878

The next Public Trust Board will be held on Thursday 24 September 2015 at 10.00 am at University Hospitals Coventry & Warwickshire.

Page 13 of 14


AGENDA ITEM

DISCUSSION ACTION

The minutes are approved

SIGNED

…………………………………………........................

CHAIRMAN

DATE

…………………………………………........................

Page 14 of 14

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ACTION MATRIX PUBLIC TRUST BOARD MEETINGS

24 SEPTEMBER 2015 AGENDA ITEM 5 ENCLOSURE 2

The Trust Board is asked to NOTE the progress with regards to the actions below and to APPROVE the removal of those that are marked completed.

AGENDA ITEM ACTION RESPONSIBLE

OFFICER COMPLETION DATE

UPDATE REMOVAL

ACTIONS FROM MAY 2015 MEETING HTB/15/811 INPATIENT HOSPITAL CENSUS

BB emphasised the need for internal accountability and suggested that it might be helpful as a Board to invite Clinical Directors of respective pathways to an appropriate forum to share the actions that have been taken to address issues.

DE Oct 2015 Scheduled at a Board Seminar when Group plans are discussed in October Continues to be the subject of debate at Finance and Performance Committee (F&PC)/ Quality Governance Committee (QGC) – need to agree a strategy so as not to cut across Performance Management Framework.

No - BS requested that the item remain on the action matrix until discussions at F&PC and QGC are concluded

HTB/15/814 PATIENT EXPERIENCE QUARTERLY REPORT

BB observed that it would be helpful to have a status of the backlog of complaints referred to the Parliamentary Health Service Ombudsman in the report going forward.

MP Sept 2015 Sarah Conlon emailed and advised for inclusion in the next report and going forward.

Yes

HTB/15/815 NURSING AND MIDWIFERY REVALIDATION

The Trust Board requested an update be presented to the Trust Board in September following completion of the pilot sites

MR Sept 2015 Scheduled for September Trust Board

Yes

1





UPDATE REMOVAL

ACTIONS FROM JUNE 2015 MEETING HTB/15/838 CHIEF EXECUTIVE OFFICERS REPORT

It was agreed that a future Board Seminar would be dedicated to productivity.

RS Oct 2015 To be scheduled on Board seminar programme

No

HTB/15/839 YOU SAID WE DID CAMPAIGN

DP praised the report and suggested that it would be helpful to receive information around user feedback where no action had been taken and the mitigation to support no further action in any future reports.

MP Dec 2015 To be provided within the next report to Trust Board in December

No

HTB/15/843 FREEDOM TO SPEAK UP

The Trust Board requested a progress report in six months detailing statistics and analysis of concerns raised.

RS Dec 2015 No

HTB/15/845 EQUALITY AND DIVERSITY ANNUAL REPORT

The Trust Board agreed to receive a presentation/report on the NHS Workforce Race Equality Standard to a future meeting of the Trust Board.

KM Sept 2015 Scheduled for September Trust Board

Yes

ACTIONS FROM JULY 2015 MEETING

2





UPDATE REMOVAL

HTB/15/864 INTEGRATED QUALITY PERFORMANCE AND FINANCE REPORT

IB queried the mechanism for the triangulation of planned roles, genuine requirements for temporary staff, identifying permanent shortages and how that translates into better performance.KM suggested that a future Board Seminar focusing on whole workforce supply would be useful to better understand at a strategic level.

KM February 2016

Scheduled in February 2016 on Programme of Board Seminars

No


PW observed the upward trend of falls resulting in serious harm. The Chairman requested that the Quality Governance Committee continue to closely monitor compliance against the performance standard.

MR Sept 2015 QGC discussed the matter in greater detail on 3rd August 2015 and a thematic analysis report is to be presented to QGC on 7th September 2015 to provide further assurance of the actions taken.

Yes

3





UPDATE REMOVAL


BB observed that at a recent meeting with the Group Manager at the Hospital of St Cross in Rugby, concerns were raised regarding cleanliness. DE responded that ISS Facility Services have been tasked with a 12 week improvement plan but acknowledged that this had not progressed as expected. The Chairman urged that this matter not be allowed to drift.

DE Sept 2015 QGC discussed this matter in greater detail on 3rd August 2015. The Director of Estates and Facilities and ISS Divisional Manager attended QGC and gave assurance that controlled measures continue to be monitored monthly through the Infection, Prevention and Control Committee (IPCC). The IPCC will report progress to QGC to provide further assurance.

Yes

HTB/15/869 BOARD ASSURANCE FRAMEWORK (BAF): QUARTER 1 UPDATE

The Chairman observed that corrective action taken should result in reduced likelihood of the risk materialising and suggested that the BAF appears to demonstrate otherwise but with improving consequence ratings and suggested that this be reviewed.

MP/ RS Sept 2015 Meeting arranged for 15th September with RS and AM to review BAF

Yes

4

AGENDA ITEM 6 ENCLOSURE 3

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

REPORT TO THE TRUST BOARD: PUBLIC

24 SEPTEMBER 2015 Subject: Chairman’s Report Report By: Andy Meehan, Chairman Author: Andy Meehan, Chairman Accountable Executive Director:

Andy Meehan, Chairman

PURPOSE OF THE REPORT:

To update the Trust Board of the key details of meetings and events attended by the Chairman.

SUMMARY OF KEY ISSUES:

Since the last Board meeting, the major meetings and areas of interest were as follows:

• CQC Quality Summit • Together Towards World Class (TTWC) Board meetings • Board to Board with PFI meeting • Outstanding Service and Care Awards evening • Warwickshire Health and Well-Being Board • Pathology Stakeholder Board meeting

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one):

To Deliver Excellent Patient Care and Experience To Deliver Value for Money To be an Employer of Choice To be a Research Based Healthcare Organisation To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS: Financial: None Highlighted HR/Equality & Diversity:

None Highlighted

Governance: None Highlighted Legal: None NHS Constitution: None Highlighted Risk: None Highlighted

COMMITTEES/MEETINGS WHERE THIS ITEM HAS BEEN CONSIDERED: None –the report is for the Trust Board.



24 September 2015

Subject: Chief Executive Officers Report Report By: Andy Hardy, Chief Executive Officer Author: Andy Hardy, Chief Executive Officer Accountable Executive Director: Andy Hardy, Chief Executive Officer

PURPOSE OF THE REPORT: To update the Trust Board of the key details of meetings and events attended by the Chief Executive Officer and key policy issues.

SUMMARY OF KEY ISSUES:

Summary of Activity This month I have been involved in the following:

- Virginia Mason progress meetings - OSCAs – 11 September 2015 - Urgent and Emergency Care Roadshow – 21 September 2015

Consultant Appointments – there have been twelve consultant appointments since the last Trust Board Meeting, as listed below:

- Dr. Sarah Nicolle – Consultant Haematologist - Dr. Maria Mushkbar - Consultant Haematologist - Dr. Chris Harrold – Consultant in Acute Medicine and Diabetes and Endocrinology - Dr. Sofia Anastassiadou – Consultant in Acute Medicine and Renal Medicine - Mrs. Anna Chapman – Consultant in Trauma and Orthopaedics – Foot and Ankle - Dr. Karin Leslie – Consultant in Obstetrics (Special interest in Fetal Medicine) - Dr. Richard Westerman - Consultant in Trauma and Orthopaedics – Lower Limb Arthroplasty - Mr. Konstantinos Sarantos - Consultant in Trauma and Orthopaedics – Lower Limb Arthroplasty - Mrs. Suzanne Turner – Consultant Ophthalmologist Glaucoma - Mr. Ankur Barua – Consultant Ophthalmologist Corneal - Mr. George Angelepoulos – Consultant in Gynaeoncology - Mrs. Wedisinghe Lilantha – Consultant in Obstetrics & Research

Chief Officer Portfolio changes: the board is asked to note the following changes that have taken place:

- Professor Mark Radford, Chief Nurse is now the Director of Infection Prevention and Control (DIPC) - David Eltringham is now the executive lead for health and safety

Policy Issues and Publications: The following are key issues and reports that have been published that I would bring to the attention of the Trust Board.

- The TDA and Monitor have produced rules around supporting NHS providers to get the best quality agency staff whilst reducing their overall costs. These rules include a ceiling for each provider, mandatory use of framework agencies for procuring agency staff and limits on the amount that agency staff can be paid per shift.




24 September 2015

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one): To Deliver Excellent Patient Care and Experience To Deliver Value for Money To be an Employer of Choice To be a Research Based Healthcare Organisation To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED: The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS:

Financial: None Highlighted HR/Equality & Diversity:

None Highlighted

Governance: None Highlighted Legal: None NHS Constitution: None Highlighted Risk: None Highlighted

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED: None - report is for the Trust Board


PUBLIC TRUST BOARD PAPER

Title Integrated Quality, Performance & Finance Report – Month 5 – 2015/16

Author Miss Lynda Cockrill, Head of PPM Analytics Responsible Chief Officer

Mrs. Karen Martin, Chief Workforce and Information Officer

Date 24th September 2015 1. Purpose To inform the Board of the performance against the key performance indicators for the month of August 2015. 2. Narrative The most key contents of the report are:

• Areas of underperformance – Headlines. This section allows three KPIs to be reported on. These have been selected on the basis of their profile and acuity.

• The flash report section flags those significant matters occurring outside of the ‘reported’ month.

In this report, 24 of the 67 KPIs are breaching the standard / target and a further 10 are in amber or “watching” status. 3. Areas of Risk As detailed in areas of underperformance – Headlines. 4. Recommendations The Board is asked to confirm their understanding of the contents of the August 2015 IPR and note the associated actions. Name and Title of Author: Miss Lynda Cockrill, Head of PPM Analytics Date: 24th September 2015

Integrated Quality, Performance and Finance Reporting Framework Reporting period: Month 5 – August 2015

Section Page

Trust Scorecard 3

Trust Heatmap 5

Scorecard matrix 6

Areas of underperformance 7

Flash report 9

Key achievements 10

Finance overview – position summary 11

Finance overview – statement of comprehensive income 12

Finance overview – statement of financial position 13

Finance overview – cost improvement programme 14

Workforce overview 15

Appendix 1 – Ward Staffing Levels 17

Integrated Quality, Performance and Finance Reporting Framework

Contents


Trust Scorecard Reporting Month August 2015

Compliance KPI: NHS TDA Accountability Framework, National Standard, local contract standard. Strategic KPI: Reflective of UHCW strategic objectives.

N.B. Compliance KPIs are mapped to relevant UHCW strategic objective.

3


Trust Scorecard Reporting Month August 2015

Compliance KPI: NHS TDA Accountability Framework, National Standard, local contract standard. Strategic KPI: Reflective of UHCW strategic objectives.

N.B. Compliance KPIs are mapped to relevant UHCW strategic objective. 4


Trust Heatmap

5

Behind plan On plan Ahead of plan

Improving

CAS Alerts (Overdue) Number of complaints registered Theatre utilisation – Main Breaches of the 28 day readmission guarantee 18 week RTT Admitted & Non-admitted Forecast recurrent and non recurrent efficiency compared to plan (£,000) Personal Development Review Non-Medical Mandatory Training Compliance Sickness rate Temporary costs and overtime as a % of total pay bill No of pts recruited into NIHR portfolio – cumulative Performance in initiating trials (quarterly) Performance in delivery of trials (quarterly)

Medication errors causing serious harm HSMR (basked of 56 diagnostic groups)

Reported harmful patient safety incidents Serious Incident (Number) and Serious Incidents (Overdue) Harm Free Care Falls per 1000 occupied bed days resulting in serious harm C-UTI Last minute non-clinical cancelled ops (elective) 31 day diagnosis to treatment cancer target 62 days urgent referral to treatment cancer target Liquidity days Capital Services Capacity Peer reviewed publications (calendar year cumulative)

Not Changing

Number of never events reported – cumulative

MRSA bacteraemia (Trust acquired) – cumulative Same sex accommodation breaches SHMI Number of maternal deaths Maternity FFT No of touchpoints achieving 15% Surgical Safety Checklist (WHO) Urgent ops cancelled for the second time RTT - 52 week waits 12 hour trolley waits in A&E Combined risk rating Forecast I&E compared to plan (£,000) Research critical findings and serious incidents

Staff turnover rate Job evaluation survey tool (JEST) score

Deteriorating

Clostridium difficile (Trust acquired) – cumulative Friends and Family Test A&E and IP Coverage Friends and Family Test A&E and IP Recommenders Theatre efficiency –Main, Rugby and Day Surgery Theatre utilisation – Day Surgery & Rugby 18 week RTT – Incomplete Delayed transfers as a percentage of admissions 30 day emergency readmissions Personal Development Review Medical Portfolio research studies open to recruitment Submitted research grant applications – cumulative Doctor trainers provisionally accredited Commercial income invoiced £000 – cumulative No of specialties at HEWM Level 3 and 4 Pressure Ulcers 3 and 4

Eligible patients having VTE risk assessment Diagnostic waiters, 6 weeks and over Two week cancer wait (GP referral to OP appointment) A&E 4 hour wait target Vacancy rate against TDA workforce plan

Scorecard matrix|


Areas of underperformance | Headlines

The Trust’s overall performance has improved this month, though underperformance continues against the elective pathway targets including RTT incomplete pathways (18 week referral time for admitted and non-admitted (planned failure of the target)). The delays transfers of care have deteriorated since last month. The A&E 4 hour wait target continues to be achieved and performance against cancer targets has improved this month. The Trust has met the last minute non-clinical cancelled operations target for the second time this year, which is a significant improvement against last year’s performance. Performance against the medical personal development review has deteriorated this month to its lowest this year. The Trust’s sickness rate has improved this month to 4.01%, just above the 4% target. Although there has been a slight improvement in mandatory training figures, these are still below the new target threshold of 95%. There have been three reported C-Difficile cases in August and therefore the year to date target has been breached by one case. Three areas, Acute Medicine, Geriatrics and Obstetrics and Gynaecology are now being reported at HEWM level 3, which is an increase from last month. E-referral appointment slot issue national data is currently not available following the upgrade from Choose and Book to NHS e-referral service as the national team are not currently issuing reports. Pressure ulcer information for August is delayed pending outcomes of root cause analyses.

Domain Indicators achieved

Indicators in exception

Indicators in watching

status

Total indicators

Excellence in patient care and experience 24 14 6 44

Deliver value for money 4 1 0 5

Employer of choice 2 3 2 7

Leading research based health care organisation 2 4 2 8

Leading training and education centre 1 2 0 3

7

Scorecard Summary | 33 KPIs achieved the target; 29 of which are classified as ‘compliance’ measures and 4 as ‘strategic’ KPIs

Issues/ Actions:

• Sustainable adherence to Cleaning Standards remains a challenge. The Trust average ICNA score for August was 75%. This was highlighted at the Cleaning Assurance Group and is being addressed by the Director of Estates and Project Co. ISS will produce a report for IPC Committee for September 2015. An overall Improvement plan was received by QGC in August 2015.

• Two wards had a period of increased incidents (PII) in May & June (4 cases). MTD review has been undertaken and action plans are being monitored by the Infection Prevention and Control Committee.

• The 100 days C-Diff free campaign continues to increase engagement and staff ownership of C-Diff prevention. 70% of wards are now over ‘a year clear’ and six wards have reached 1000 days. Since commencement in Aug 2012, all wards have had a period of being 100 days free.

• Training sessions continue around hand hygiene, cleaning of commodes, Dekomed & Tristel. Audits against the stringent 5 moments Hand hygiene has commenced.

• Meetings will be held with the CCG and Microbiology to review C-Diff cases.

Clostridium difficile (Trust acquired)|Year to date performance is one case over trajectory


Areas of underperformance | Headlines Elective access indicators| The Trust continues to face challenges in the delivery of its elective access indicators including 18 week RTT and Cancer pathways

RTT: Root cause of current under performance: Backlog 3583 (admitted & non-admitted) has not met the trajectory due to insufficient elective activity being delivered and some capacity constraints and adequate validation. Specialities off trajectory include; T&O, General Surgery, Cardiology Urology, Gynaecology, Plastic surgery and Max Fax. Recovery plan: • Trust wide approach to reduce admitted and non-admitted

backlog by increasing efficiency, maximising capacity, and increased validation.

• Specialty recovery meetings chaired by Chief Officer where revised actions plans are being presented and monitored weekly (i.e. optimise theatre productivity and reduction in closed sessions).

• UHCW is working with the CCG to transfer some activity to the private sector, specifically General surgery, T&O and Cardiology.

62 days standard: Root cause of current underperformance; (i) Fewer Urology patients treated in July and therefore fewer breaches. Fewer Gynaecology breaches due to the successful management of the pathway despite consultant vacancies; (ii) An increase in lung breaches (6 in the month) due to a number of patients that have complex diagnostic pathways. Performance will reduce in August (following the trajectory) as more Urology patients are treated. Recovery plan: • Urology: Additional operating time; additional consultant appointments

and service improvement to current pathways. • Gynaecology: Recruitment to consultant appointments; Support from

surgeons in Sandwell and West Birmingham. • Lung: Retention of the thoracic surgeon locum to deliver additional

capacity. • Pathology 1 consultant and 1 locum appointments commence Sept 2015. • Head & Neck: Business case to recruit 5th consultant developed and

scheduled for approval at October Planning Unit meeting.

8


Areas of underperformance | Headlines Flash Report | August 2015

9

Date announced for the next Perfect Week Following the success of the previous Perfect Week, held in July, the Trust has announced that the next Perfect Week will take place between Wednesday November 11, and Wednesday November 18. and will involve stronger roles with the Trust’s health and social care colleagues.

Two Grade 3 pressure ulcers occurred on two wards. Root Cause Analysis (RCA) identified these as being avoidable because further preventative actions could have been taken. Issues: 1. Heel elevation was not commenced until tissue damage had occurred 2. Slide sheets were not readily available and consistently used when handling

and moving patient in bed contributing to shear damage Actions: • Performance meetings have been held with WM and Modern Matron to

discuss causation, review the actions already taken and further actions to be taken.

• Actions are specific to the wards and include: early identification of patients risk of heel damage and implementation of appropriate interventions. Availability of slide sheets – now stored in plastic bags (single patient use) at the bedsides. Additional education at ward level relating to the impact of not utilising slide sheets every time a patient is moved, to include all staff involved in handling and moving patients.

• A Trust wide action plan has been developed for 2015/16 focusing on reduction and sustaining reduction of pressure ulcers.

• Performance meetings have also commenced led by ADN Education and Research with ward managers and Modern Matrons reporting multiple Grade 2 pressure ulcers over a 6 month period – to review clinical practice, identify good practice, gaps, areas for improvement, share practice and learning from other wards/organisations.

The Trust’s bid for support to the ITFF has been put back until December The Trust put in a bid for cash support to the Independent Trust Financing Facility (ITFF). This was initially scheduled to go to the ITFF Board in October; however the Trust has now received feedback that this has been pushed back until the December Board. The Trust will seek to manage the interim cash requirement and may require the use of a short term working capital facility; however, a range of options are being explored. To receive permanent cash support the Trust requires a fully signed off FRP. Although internal sign off has been secured, further sign off is required by the TDA.

Nurse specialling Following a deep dive review of specialling usage and costs during April, additional controls were introduced to reduce costs. This included weekly review of requests both in and out of hours and identification of ‘patterns’, one to one meetings with Ward Managers and Matrons to discuss ‘specials’ and ensure the Enhanced Care Guidelines and risk assessments were being undertaken appropriately and consistently, wider discussions at Nursing Quality Fora, review and challenge by ADN for each request prior to escalation to DCNO/CNO for final agreement. An Enhanced care team is currently being recruited to, which will negate further the use of ‘specials’ via an agency, and will also provide additional staff to our internal Bank (TSS).

Pressure Ulcers (Trust associated)|The Trust reported two grade 3 trust associated pressure ulcers relating to July.


Key Achievements | August 2015

Research and development success Elizabeth Bailey, Midwife Research Fellow, has been selected to join a Cancer Research UK innovation workshop on early years cancer prevention. Multidisciplinary teams will develop their research ideas over the 3 day event, then will pitch their proposal to the CRUK judging panel. The successful team will be awarded a grant of up to £20,000. Dr Chris McAloon, Research Registrar in Cardiology, was awarded the Royal College of Physicians and NIHR Clinical Research Network clinical trainees award in recognition of his outstanding contribution to research in the NHS. The award includes a £1000 prize and informal mentorship from the National Specialty Lead for Cardiology. Chris will be awarded his prize at the prestigious Royal College of Physicians’ Harveian Lecture on 15 October 2015.

Nomination for health informatics award A University Hospitals Coventry and Warwickshire NHS Trust (UHCW) doctor is a finalist for a national digital healthcare rising star award. Dr Tim Robbins has been nominated in the Rising Star of 2015 category in the E-Health Insider (EHI) Awards. The award is to recognise the work of health informatics staff under the age of 30 who are achieving excellent results and making an outstanding contribution to healthcare.

The Trust maintains performance for 4 hour total time in A&E The Trust continues to hit the 4 hour total time in A&E target since first achieved on June 21st. August performance achieved 97.74%. Figures published by NHS England for July show the Trust is ranked 5th out of all England Trusts that have a type 1 A&E facility for its overall 4 hour performance.

10

Mortuary team nomination The Mortuary Team has been shortlisted for a prestigious national award by a member of Warwickshire Police for their service and compassion shown when working with bereaved families. They are finalists in the Mortuary Assistant (APT) Team or Individual category of the Good Funeral Awards.

UHCW named as top PLACE in region The Trust has scored top marks for its patient food and cleanliness in the recent PLACE (for Patient-Led Assessments of the Care Environment) survey. PLACE is a system where inspection teams led by patients assess hospitals and hospices in areas such as patient and visitor food options, cleanliness, condition and maintenance, and the privacy, dignity and wellbeing of healthcare facilities. This year for the first time, patients were also surveyed on whether care environments were dementia friendly. University Hospital in Coventry and the Hospital of St Cross in Rugby scored highly on all categories, including 100% for cleanliness at both hospitals. UHCW was the only hospital trust in the region to achieve this rating. Overall, the Trust achieved the best scores in the West Midlands for an acute NHS trust for three out of the five indicators.


Finance overview | position summary

Ten finance performance indicators are in escalation this month.

One indicator has moved out of escalation in month 5; EBITDA achieved.

All other indicators remain in escalation.

Debtors over 90 days accounting for more than 5% of total debtors remains in escalation at month 5. There are still a number of commissioning invoices relating to the 2014/15 year end outstanding which are now more than 90 days overdue. Year end agreements with the remaining NHS commissioning debtors are ongoing and resolution is expected in September.

The Trust is currently in the process of refreshing its financial indicators.

11


Finance overview | statement of comprehensive income The Trust has accepted a stretch target from the TDA and changed its plan by £3.0m from a £22.4m control total deficit to £19.4m deficit. Future CIP of £4.7m and additional savings of £1.7m are required to deliver the plan.

Contract income is forecast at £9.2m adverse to plan driven by under performance against activity targets, risks and penalties. Group expenditure forecasts include cost pressures of £5.8m: • (£4.0m) education & research income and

expenditure timing differences. • (£1.6m) Pathology network. • (£1.5m) cover for medical staff vacancies. • (£0.8m) for specialing of patients. • (£1.4m) premium cost of covering ward nursing

vacancies. • (£1.1m) RTT and capacity issues. • £3.4m staffing , primarily vacancies. • £1.2m activity related variances and other cost

pressures.

The Trust is reporting a year to date deficit of £13m in month 5 (£12.3m against break-even duty), which is £1m adverse to the planned deficit. This is primarily due to underperformance against activity targets noted above.

12


Finance overview | statement of financial position

The statement of financial position shows the assets, liabilities and equity held by the Trust and is used to assess the financial soundness of an entity in terms of liquidity risk, financial risk, credit risk and business risk. • The TDA has requested organisations to assess

the scope to reduce capital expenditure in 2015/16 (due to pressures on the capital budget at a national level) and defer the draw down of loans into the following year. Capital Planning Review Group have identified a number of schemes where slippage is likely and expenditure can be deferred to 2016/17 giving a forecast reduction of £7,088k to property, plant and equipment.

• There are corresponding reductions in the capital loan balance and non current liabilities as this borrowing will now be deferred to 2016/17 in line with the new capital programme.

• The Trust’s application for a revenue loan of £25.9m will now be made in December 2015.

13


Finance overview | CIP The Trust is forecasting delivery of £29.3m

against £30.6m of potentially identified savings: This gives a potential forecast shortfall of £4.7m against the Trust target of £34m for 2015/16.

Headlines • £2.8m delivered in August against a plan of £3m. • £11.4m delivered against a cumulative year to date plan of £12.2m. • Forecast delivery of £29.3m against the Trust target of £34m, giving a forecast

shortfall of £4.7m. • 35% of the potential savings are classified as opportunities. • 48% of the potential savings are related to commissioning contract income. • 20% of the potential savings are non recurrent and will require permanent

schemes to reduce them. • 59% of schemes have had their QIA fully signed off by the Chief Medical

Officer and Chief Nursing Officer.

Risks • The Trust has not fully identified £34m of CIP schemes. If the

Trust does not deliver £34m of CIP, this will impact on its ability to deliver the financial plan for 2015/16.

• The CIP plan was phased with the majority of delivery expected from month 4 onwards, therefore as the Trust has not fully identified its CIP the gap between plan and delivery is starting to increase exposing that there is still significant risk around delivering the full year plan.

• If schemes are not identified and implemented imminently, there will be a greater pressure on Groups to deliver savings in the latter part of the financial year and may result in further reliance on non recurrent measures which will need to be factored in financial planning for 2016/17.

• A number of income schemes are dependent on maintaining patient flow through the hospital during the coming months to deliver in full.

• Newly identified schemes need to come from non contract income generation and cost reduction methods to deliver the remaining £4.7m.

Key Actions • Groups to have continue documenting schemes to identify 100%

of their CIP targets. • Group to ensure delivery of identified schemes. • Groups and Corporate functions to complete all necessary

documentation for all schemes currently identified to allow progression to full sign off.

• CIP Steering Group to continue scrutiny of Group positions to ensure that work is being progressed to identify and delivery of targets. This will include provision of support to unblock obstacles where necessary.

14

Workforce Information | Headlines


15

31st August 2015 WTE ISS WTE

TDA Plan Target WTE

WTE Variation from Plan

Trust WTE 6442.66 625.2 6586.52 143.86

Trust Total Including ISS 7067.86

(excluding bank and ad-hoc locums) Starters & Leavers |All Staff Groups

Starters & Leavers |Nursing

•The Trust’s staff in post is 143.86 wte away from the TDA plan of 6586.52. The gap to the TDA plan has widened by a further 41.21 wte since last month.

•Trust’s monthly staff in post has decreased by 14.39 wte since last month.

•Recruitment of the Enhanced Care team and Newly Qualified Nurses continues with 34 wte for the Enhanced Care team commencing in October and 52 wte Newly Qualified Nurses in October/November. This will aid the Trust in bridging some of the gap against the TDA plan.

•Please note that the Trust data includes Junior/Rotational Doctors resulting in spikes of both leavers and starters at the rotation periods, notably April, August and December.

•The Trust’s Nursing starters are of a significantly lower rate than the leavers in August although 52 Newly Qualified Nurses will commence over October and November.

Staff Group

Staff In Post WTE 31st July

2015

Staff In Post WTE

31st August 2015

Variance

(WTE)

% Variance

Add Prof Scientific and Technic 230.02 232.32 2.30 1.00

Additional Clinical Services 1353.36 1355.47 2.11 0.16

Administrative and Clerical 1178.70 1184.00 5.3 0.45

Allied Health Professionals 374.20 370.66 -3.54 -0.95

Estates and Ancillary 1.00 1.00 0 0

Healthcare Scientists 318.87 315.77 -3.1 -0.97

Medical and Dental 887.97 891.47 3.5 0.99

Nursing and Midwifery Registered 2075.94 2054.97 -20.97 -1.01

Students 37.00 37.00 0 0

Totals 6457.05 6442.66 -14.39 -0.22

ISS 623.80 625.2 1.4 0.22

Staff in Post | Variation from TDA Plan

Staff in Post | Monthly Variation

Integrated Quality, Performance and Finance Reporting Framework 16

Workforce Information | Headlines Pay Costs| Provided by Finance

•Temporary costs (Overtime, Bank, Agency) equate to 15.06% of the Trusts total pay bill, which is a decrease from 15.93% last month. There has been a marked reduction in agency spend from last month.

Mandatory Training |Topics Mandatory training compliance is currently 85.48%. 1 topic is above 95% - Hand Hygiene Non Clinical 14 topics are between 85% and 95% 18 topics are below 85% The 6 topics with the lowest compliance which are under 75% are shown in the table below, one of which remains under 50%.

Absence| Specialty Group

Absence| Staff Group

•Absence target is 4% •Absences are continually monitored and robustly managed •The Managing Attendance policy in currently under review.

Specialty Group % Abs Rate (FTE)

218 Ambulatory Services 3.36%218 Anaesthetics Specialty Group 5.36%218 Cardiac & Respiratory 4.75%218 Care of the Elderly 4.14%218 Clinical Support Services Specialty Group 5.13%218 Core Functions inc delivery unit, PFI & ETR 2.36%218 Delivery Unit 6.14%218 Emergency Department Specialty Group 5.18%218 Hospital of St Cross 6.25%218 Imaging 4.19%218 Neurosciences Specialty Group 3.33%218 Oncology and Haematology 3.27%218 Pathology Netw ork Cov & Warw icks 3.68%218 Renal Specialty Group 2.92%218 Surgery Specialty Group 4.11%218 Theatres Specialty Group 4.62%218 Trauma & Orthopaedics Specialty Group 3.55%218 Women & Children Specialty Group 3.75%Totals 4.01%

Topic Target CompliantNon-Compliant

% Compliance

Advanced Life Support Update - Annual 447 232 215 51.90%Advanced Life Support - 4 Yearly 109 45 64 41.28%Advanced Paediatric Life Support (APLS) update - Annual 136 99 37 72.79%NPSA Obtaining Venous Blood - 3 Yearly 865 633 232 73.18%Paediatric Life Support Update - Annual 103 76 27 73.79%Paediatric Life Support - 4 Yearly 103 75 28 72.82%


The figures reported above are submitted to the DoH via Unify on a monthly basis to support NHS England Safer Staffing along with the ten expectations from the NQB. These figures show the previous months Trust wide nurse staffing, along with exceptions and actions being taken. Patients are able to view this information on the Trust’s Internet Site.

17

Agenda item 9 Enclosure 6


Title Trust Development Authority (TDA) Oversight – Monthly Self Certification Requirements Aug 2015

Author Lynda Cockrill, Head of Performance & Programme Analytics Responsible Chief Officer

David Moon, Chief Finance and Strategy Officer

Date 24th September 2015 1. Purpose This paper presents the proposed self-certification against the Board Statements and the Monitor Provider License Compliance statements for the month of Aug and seeks approval of these prior to submission to the NHS Trust Development Authority (TDA). 2. Background and Links to Previous Papers It is a requirement of the TDA regulatory regime that a Trust Board approved submission against these statements is made on the last working day of each month. The regime was introduced as a forerunner to NHS Trusts becoming licensed as Foundation Trusts (FT) because Monitor requires that the Board of Directors of each Foundation Trust considers compliance against these on a monthly basis as a core component of the FT governance framework. In the event that compliance is declared and subsequent events suggests this not to have been the case, Monitor will intervene in the Trust and as such, the TDA mirrored the Monitor arrangements in order that Trusts are accustomed to making declarations and confident in their processes for declaring compliance in readiness for when their FT license is granted. It is important therefore that Board members are satisfied that the Trust is compliant where compliance is being declared, and members are therefore encouraged to consider each statement and to seek further assurances where this is felt necessary. 3. Narrative Appendix A details the Trust’s assessment against each of the Board Statements. The Trust is able to report compliance against all statements. Appendix B details the Trust’s assessment against the Monitor license conditions and the Trust is declaring full compliance. 4. Areas of Risk Although compliance against all statements can now be reported, work must continue to maintain the levels of information governance training, in order that the Trust remains compliant in forthcoming years against level 2 of the information toolkit, and therefore against Board statement 11.

5. Governance Self-assessment and submission against the Board and License conditions is a regulatory requirement of the TDA. 6. Responsibility David Moon, Chief Finance Officer 7. Recommendations [A] The Board is invited to note:

1. The proposed August submission against the Board and License requirements.

and [B] approve:

1. Submission of the document to the TDA. .

Page 2 of 2

APPENDIX A

OVERSIGHT: Monthly self-certification requirements - Board Statements Compliance

CLINICAL QUALITY

1. The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to

adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

YES

2. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with the Care Quality Commission’s registration requirements. YES

3. The Board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements. YES

FINANCE

4. The Board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from time to time. YES

GOVERNANCE

5. The Board will ensure that the trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS Constitution at

all times. YES

6. All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner.

YES

7. The Board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance. YES

8. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily. YES

9. An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

YES

10. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets as set out in the NTDA oversight model; and a commitment to comply with all known targets going forward. YES

11. The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit. YES

12. The Board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies.

YES

13. The Board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

YES

14. The Board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan.

YES

http://www.hm-treasury.gov.uk/

APPENDIX B

OVERSIGHT: Monthly self-certification requirements - Compliance Monitor Page

Reference (PDF document) †

Annex Page

Number ‡ Compliance

1. Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions).

64 5 YES

2. Condition G5 – Having regard to monitor Guidance. 66 7 YES

3. Condition G7 – Registration with the Care Quality Commission. 68 9 YES

4. Condition G8 – Patient eligibility and selection criteria. 69 10 YES

5. Condition P1 – Recording of information. 74 15 YES

6. Condition P2 – Provision of information. 76 17 YES

7. Condition P3 – Assurance report on submissions to Monitor. 77 18 YES

8. Condition P4 – Compliance with the National Tariff. 78 19 YES

9. Condition P5 – Constructive engagement concerning local tariff modifications. 79 20 YES

10. Condition C1 – The right of patients to make choices. 80 21 YES

11. Condition C2 – Competition oversight. 81 22 YES

12. Condition IC1 – Provision of integrated care. 82 23 YES

† https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285008/ToPublishLicenceDoc14February.pdf

‡ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285009/Annex_NHS_provider_licence_conditions_-_20120207.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285008/ToPublishLicenceDoc14February.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285009/Annex_NHS_provider_licence_conditions_-_20120207.pdf



Title Improving the patient experience for blind/visually impaired and deaf /hearing impaired patients

Author Barbara Hay, Head of Diversity Sarah Conlon, Patient Experience Manager

Responsible Chief Officer

Meghana Pandit, Chief Medical and Quality Officer

Date 24th September 2015 1. Purpose The purpose is to share with the Board the awareness video which has been produced to equip all staff with the basic skills and knowledge they need for when caring for a patient who is blind/visually impaired or deaf/hearing impaired. 2. Background and Links to Previous Papers This story forms part of the Patient Story Programme. 3. Narrative

It was recognised that the hospital experience for patients who are blind/visually impaired and deaf /hearing impaired needed to be improved. This can only be achieved if staff are equipped with the knowledge and understanding of these patients’ needs, and this led to the development of this awareness video. The video illustrates the correct and incorrect way of communicating and caring for these patients and will provide staff with invaluable bite-sized pieces of information, which will help them feel more confident when caring for a blind/visually and deaf/hearing impaired patient. This video is part of a training package developed by the Equality and Diversity Team, Patient Experience Manager and the Head of Volunteers. To complement this video a communications box has been funded by the Volunteers Service. This box contains key equipment to help and support staff with the additional needs of these patients’ which will ensure their hospital stay is improved. This training package will be rolled out to all wards, across the two hospital sites in autumn 2015. 4. Areas of Risk All staff need to be empowered by this video and learn the key lessons to ensure that patients who are blind/visually or deaf /hearing impaired receive a first class hospital experience.

5. Governance This paper relates to the NHS Constitution in the following ways: Principle 1 - the NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy, and maternity or marital or civil partnership status. Principle 4 – The NHS aspires to put patients at the heart of everything it does….NHS services must reflect and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers. Principle 7 - The NHS is accountable to the public, communities and patients that it serves. Equalities Act 2010 The Public Sector Duty (Equality Act 2010) to advance equality of opportunity involves, in particular, having due regard to the need to: • Remove or minimise disadvantages suffered by people due to their protected

characteristics. • Take steps to meet the needs of people with certain protected characteristics where

these are different from the needs of other people. • Encourage people with certain protected characteristics to participate in public life or in

other activities where their participation is disproportionately low. The Act states that meeting different needs includes (among other things) taking steps to take account of disabled people’s disabilities. It describes fostering good relations as tackling prejudice and promoting understanding between people from different groups. It explains that compliance with the general equality duty may involve treating some people more favourably than others. 6. Responsibility

Barbara Hay, Head of Diversity Jenny Gardiner, Director of Quality Meghana Pandit, Chief Medical and Quality Officer 7. Recommendations The Board is invited to note: Patient Story – The hospital experience for a patient with hearing and/or visual impairment Name and Title of Author: Barbara Hay, Head of Diversity Sarah Conlon, Patient Experience Manager Date: Thursday 24th September 2015

Page 2 of 2



Title Patient-Led Assessments of the Care Environment (PLACE) Annual Report Author Lincoln Dawkin – Director of Estates and Facilities Responsible Chief Officer

David Eltringham – Chief Operating Officer

Date 24 September 2015 1. Purpose To provide the Board with a summary update of the outcome of the Patient-Led Assessments of the Care Environment 2015 (PLACE). Background information to PLACE is described in the document (PLACE 2015), which is available for inspection should it be required. 2. Background and Links to Previous Papers The NHS Constitution establishes a number of principles and values of the NHS in England, which additionally extend to private and voluntary sector providers supplying NHS services. Included amongst these are:

- Putting patients first - Actively encouraging feedback from the public, patients and staff to help improve services - Striving to get the basics of quality of care right - A commitment to ensure that services are provided in a clean and safe environment that is fit

for purpose Patient-Led Assessments of the Care Environment (PLACE) are a self-assessment of a range of non-clinical services which contribute to the environment in which healthcare is delivered, in both the NHS and independent/private healthcare sector in England. Participation is voluntary. These assessments were introduced in April 2013 to replace the former Patient Environment Action Team (PEAT) assessments which had been undertaken from 2000 – 2012 inclusive. These are the second results from the revised process. The PLACE programme aims to promote the above principles and values by ensuring that the assessment focuses on the areas which patients say matter, and by encouraging and facilitating the involvement of patients, the public and other bodies with an interest in healthcare (e.g. Local Healthwatch) in assessing providers in equal partnership with NHS staff to both identify how they are currently performing against a range of criteria and to identify how services may be improved for the future. The third year of PLACE assessments were carried out across the country between January and May 2015 at all NHS patient organisations. The PLACE programme offers a non-technical view of the buildings and non-clinical services provided across hospitals, hospices and independent treatment centres providing NHS funded care. It is based on visual assessments, not relying on the application of any technical or scientific tools.

The audit process assessed a number of key indicators in developing the PLACE score and is acknowledged as being an NHS nationally recognised standard of performance. The outcome of this assessment also reports into the Care Quality Commission (CQC).

• The team for UHCW audits consisted of:

University Hospital (UH) Patient Assessors:

Volunteers from Health Watch Coventry Inspection Team: David Powel and Infection Control Team

Rugby St Cross (RSC) Patient Assessors: Mr David Hardiman and Mrs Kay Harvey

Inspection Team: David Powell and Juliet Starkey

3. Narrative The audit covered a number of areas, reported under the following five headings:

• Patient Food – review of the meal service and presentation, hydration and also sampling of the meals on offer to patients.

• Privacy and Dignity – assessment of ward privacy, dignity and wellbeing of the patients. • Environment – assessment of the external area of the site including car parking, décor and

signage and the internal areas of the hospital including public toilets décor and internal signage. • Cleanliness – assessment of the cleaning standards around the site ensuring areas were free

from all visible removable dirt including dust, stains, litter, blood, body substances, hair, cobwebs and insects. This list covers the majority of the issues during an assessment however other items are recorded when seen.

• Dementia - focusses on flooring, decor and signage, but also includes such things as availability of handrails and appropriate seating and, to a lesser extent, food. The items included in the assessment do not constitute the full range of issues requiring assessment which, in total, are too numerous to include in these assessments. However they do include a number of key issues, and organisations are encouraged to undertake more comprehensive assessments using one of the recognised environmental assessment tools available.

A copy of the comparative results is attached in Appendix 1. We have the best results in the region for an acute Trust. Overall, we score higher than any other acute Trust in the West Midlands for cleanliness, food and hydration, condition, appearance and maintenance, and dementia. Only three acute Trusts in the West Midlands have scored higher than us (and then only just) for privacy and dignity. Site Year Cleanliness Food

Overall Food Ward

Food Organisation

Privacy Dignity and Wellbeing

Condition, Appearance and Maintenance

Dementia

UH 2013 94.28% 85.04% 96.21% 93.27% 2014 98.17% 88.13% 89.96% 77.37% 97.74% 93.07% 2015 100.00% 95.24% 94.58% 97.45% 89.92% Change 1.83% 7.11% 3.16% 4.38% St Cross

2013 96.65% 74.81% 94.37% 93.10%

2014 99.47% 86.19% 92.51% 76.53% 91.15% 96.12% 2015 100.00% 88.97% 92.75% 96.15% 87.20% Change 0.53% 2.78% 1.6% 0.03%

Page 2 of 4

Recommendations Also following a greater involvement during this year’s PLACE inspection from Health Watch, a number of recommendations have been made by the team to further enhance the inspection process for 2015/16, these will be factored into the process going forward for future inspections. These include:

• A greater number of ‘Patient’ representatives as part of the inspection team. • An increased number of inspection teams • Greater time allowed for the inspection. • Individual copy of all scoring sheets provided to all team members.

It is also recommended that further investment is undertaken at St Cross to ensure a robust on-going environmental maintenance program is in place going forward. This will address areas such as:

• An increase in the investment in public spaces/corridors at St Cross. • A revised lighting scheme across the site.

We have also most recently, following a number of concerns raised in relation to the cleaning standards, developed a robust action plan with our soft service providers ISS. This 12 week program covered a multitude of areas within the cleaning service and will be closely monitored going forward to ensure an improvement is achieved and sustained. The trust Board is requested to support this approach.

4. Areas of Risk

Quality & Safety: the maintenance of a high standard of patient environment is linked closely to minimizing Hospital Acquired Infections (HAI) at the organisation – any reduction in standards would potentially lead to an increase in HAIs. Regulatory; the annual PLACE score feeds into the CQC, a reduction in current standards would have a detrimental affect on the outcome of CQC assessments undertaken at the Trust.

Patient Experience – any reduction in the patient environment will have a direct impact on the patient experience.

5. Governance

The NHS Constitution gives patients the right to be treated in a clean, safe, secure and suitable environment and to receive suitable and nutritious food and hydration and the PLACE assessment links to this.

6. Responsibility Lincoln Dawkin – Director of Estates and Facilities 7. Recommendations

The Board is invited to NOTE the content of the above report and the proposed approach to make further improvements for PLACE 2016.

Lincoln Dawkin – Director of Estates and Facilities

Page 3 of 4

Date: 8 September 2015

Page 4 of 4



Title Safeguarding Vulnerable Adults & Children Report Author Gilly Attree, Named Nurse for Safeguarding Children Responsible Chief Officer

Professor Mark Radford, Chief Nursing Officer

Date 24th September 2015 1. Purpose The purpose of this paper is to update the Trust Board on safeguarding activity and findings from Serious Case Reviews. 2. Background and Links to Previous Papers The Trust Board last received a report in June 2015 as part of the regular reporting cycle. This additional report has been provided following feedback from the CQC in relation to safeguarding being an area for development. 3. Narrative Safeguarding activity across the Trust continues to grow as the agenda for adult and children’s safeguarding expands. The Child Sexual Exploitation work is gathering momentum and the Trust is working closely with partner agencies to address the issue. PREVENT training is now mandatory for all staff, and further adult safeguarding training is now in place.

Level 3 child protection training is now being delivered to a larger cohort of staff. A training trajectory has been compiled to demonstrate how this will be achieved. The current cohort will be compliant by the end of September. The larger cohort will be compliant by the end of February 2016.

Audits are being carried out to demonstrate practice compliance with guidance and recommendations arising out of Serious Case Reviews. A business case to expand the current team, which will enable the delivery of more training and the ability to plan audits in advance, monitor safeguarding activity in the Trust better and forge closer links with the local domestic violence teams, has been submitted to the Planning Unit to strengthen the current arrangements. 4. Areas of Risk Currently the Trust is not meeting the minimum of 90% compliance with staff trained to level 3 in child protection competence. As of 31st July, 87.11% of identified staff were in date and competent. The remaining shortfall will all be trained by the end of September 2015.

PREVENT training needs to be delivered to all staff. This is possible if an IT solution can be generated to capture all those who complete on line training. Face to face sessions are also available.

5. Governance The Trust Board will continue to receive regular reports relating to the Safeguarding agenda. 6. Responsibility Mark Radford, Chief Nursing Officer. 7. Recommendations The Trust Board is asked to NOTE the update and raise any questions or concerns.

Trust Board

Safeguarding Adults & Children’s Report

24th September 2015

1. Introduction

The purpose of this report is to update the Trust on recent safeguarding activity for both children and adults and in particular in relation to Serious Case Review findings.

2. Safeguarding children – themes from Serious Case Reviews

There have been four Serious Case Reviews (SCR) for children undertaken recently. A further complex case is being discussed and a recent case has been submitted for a SCR.

A summary of the recommendations arising are included in Appendix 1.

One case (child) is completed and has been published on the Local Safeguarding Childrens’ Board (LSCB) website. The second case (child) is due to be finalised and approved as it has recently been concluded in the criminal justice system and is due for publication. The third and fourth cases are still in draft. The Trust has committed to undertake audits to evidence learning from these reviews to be presented to the Safeguarding Vulnerable Adults & Children Committee (SVACC) and LSCB.

One of the common themes identified in SCRs is domestic violence. Currently, during the antenatal period, women are routinely asked about the issue of domestic violence / abuse. They should be asked on at least two occasions, however, a West Midlands wide review of domestic homicides identified that only a small percentage of cases had evidence that this had been discussed. In light of these findings, an audit of routine domestic violence questioning has been undertaken. It demonstrates that routine enquiry does take place at the Trust but that further work needs to be undertaken to ensure that the questioning takes place on two occasions rather than just one (see figure 1a and 1b).

Figure 1a

1

67%

33%

Were routine DVA questions asked in the antenatal period?

Yes No

Figure 1b

A further theme is related to “overlaying” where a parent or partner sleeping with a child accidently rolls or lays upon them causing injury. A second audit is currently taking place to demonstrate compliance with recent guidance on safe sleeping for babies. This includes community midwifery staff asking to see where a newborn baby is placed to sleep, both in terms of the sleeping receptacle and the location.

A new draft Trust-wide Domestic Violence policy is in progress to cover the organisation as a whole. It replaces the previous policy which was maternity specific to ensure a wider remit. The September meeting of SVACC is due to ratify this policy.

3. Children subject to child protection plans

There are currently 651 children in Coventry subject to child protection plans. Of these, 33 relate to unborn babies. This equates to 5% of the total number. This has a significant impact for maternity services in relation to the number of meetings maternity staff are required to attend, reports that are required to be submitted and multi-agency communication that needs to take place.

This activity is supported by the Safeguarding Team in terms of attendance at meetings when capacity is over stretched, the provision of advice, guidance and oversight with report writing and addressing any difficulties as they arise.

Hospital alerts are raised and maintained via the IPM and CRRS clinical systems for all children subject to child protection plans. Alerts are also raised for all victims of high risk domestic violence abuse and any children in the household. These cases are discussed twice per month in a multi-agency forum. There are approximately twenty cases discussed at the Multi Agency Risk Assessment Conference (MARAC).

2

Most referrals to children’s social care are submitted by maternity staff. The number of referrals increased from 483 in 2013 to 800 in 2014. The increase in activity is attributed to a number of factors, including training, high profile cases and greater professional awareness of risk factors and analysis of environment / circumstances in which families are living. Referrals related to specific issues are highlighted in figure 2.

Figure 2

Number of Refferals

Physical Neglect FGM Previous S/C Involvement

DVA Behavioural Parental Behaviour

Request for Information

Sexual/CSE Outcomes Received but No referral

Total number

of Referrals

Made No.

Referrals No.

Referrals No.

Referrals No. Referrals No.

Referrals No.

Referrals No.

Referrals No.

Referrals No.

Referrals No. Referrals

2015 -

2016

APR 0 2 6 14 5 1 2 6 0 23 59

MAY 0 7 4 9 3 4 10 6 0 30 73

JUN 2 4 6 12 4 1 16 11 0 17 73

JUL 1 5 6 18 6 1 6 11 2 47 103

AUG 0 0 0 0 0 0 0 0 0 0 0

SEP 0 0 0 0 0 0 0 0 0 0 0

OCT 0 0 0 0 0 0 0 0 0 0 0

NOV 0 0 0 0 0 0 0 0 0 0 0

DEC 0 0 0 0 0 0 0 0 0 0 0

JAN 0 0 0 0 0 0 0 0 0 0 0

FEB 0 0 0 0 0 0 0 0 0 0 0

MAR 0 0 0 0 0 0 0 0 0 0 0

4. Safeguarding Adults- Serious Case Reviews

There are three adult (Mrs G) cases reviews undertaken by the Local Safeguarding Adults Board (LSAB).

One is a fire incident, and the executive summery was published in early September. There were no recommendations for UHCW. The fire service took the lead on this case and recently presented at the Health Overview and Scrutiny Committee (HOSC).

The next case is a System Wide Review which related to pressure ulcer care in the community setting. The patient died at UHCW after being admitted. The System Wide Review commended UHCW on including the Next of Kin in decision making and record keeping. There were no recommendations for UHCW, although the one action was to review our annual record keeping audit and this has been completed. The executive summary is due to be published in September 2015.

3

The final case is to be presented to the Coventry Safeguarding Adult Board in November 2015. This case has UHCW clinical involvement, and related to care transfer to a nursing home following a community fall, and subsequent back injury managed at UHCW. Whilst there were issues in care and management post community, there are a number of recommendations highlighted in the draft report.

The completed actions for UHCW are as follows;

• To improve the neurosurgical ward care plan to include a communication section.

• To verify that the discharged plans for patients reflect their individual care needs i.e. back brace care and their possible responsibilities as a carer pre their admission to hospital

• To verify back brace training for patients/carers is delivered as standard as part of the discharge care planning process for this cohort of patients and their carers

• To ensure all staff are aware of sepsis 6 and the serious implications for patients

• The outstanding action is as follows; • To ensure the Coroner is notified when a patient is subject to safeguarding in

the event of death.

In order to comply with this action, a task and finish group is to be formed to review other examples of how this is achieved. Paperwork will be aligned with this requirement, and submitted for approval to the Quality Standard Committee and the Safeguarding Vulnerable Adults and Children Committee. The revised target date for this action to be completed is January 2016. Without this level of robustness in relation to informing the Coroner of a safeguarding concern when a patient dies, there is the potential for this aspect to be over looked, and for safeguarding enquiries to be compromised.

5. Domestic Violence

The adult Emergency Department is proactively referring any cases of disclosed domestic violence where children are in the household. A dashboard of this activity is included figure 3a and 3b. The information gathered demonstrates the local demographics, gender of victim, the day of the week that the incident occurred, ethnicity and the postcode of where the incident took place. Other information gathered allows for deeper understanding of the complexity of the issues identified, including any weapons used, repeat victims and highlighting via the CRRS alert system the number of times a victim presents to UHCW.

4

Figure 3a

Figure 3b

Domestic violence is reported locally in Coventry at a rate of 1:3 households at any one time. A business case is in development by UHCW to include a role for dealing specifically with domestic violence abuse. This will enable the organisation to respond more effectively to victims and also to deliver training.

UHCW is represented at the National Scrutiny Panel to ensure that MARAC’s are as effective as possible.

5

68%

21%

9%

2%

Place of Incident

HOME

NOT SPECIFIED

PUBLIC PLACE

OTHER

6. Referrals to Adult Safeguarding

The number of referrals to adult safeguarding rose from 250 in 2013 to 320 in 2014. This increase in activity is attributed to improved staff awareness and understanding of the factors that contribute to adult safeguarding/abuse. An audit is underway to quality assure the process is being adhered to and is effective. This includes a review at the Safeguarding Vulnerable Adults & Children’s Board of actual referral documentation.

7. CQC Findings

The recent CQC report concluded that safeguarding in the Trust needs to be developed, in particular in relation to increasing the number of staff trained to an appropriate level, both for adults and children.

There is a training programme underway that includes face to face sessions on the Mental Capacity Act, Deprivation of Liberty Safeguards, Mental Health, Restraint and PREVENT. This is aimed at all patient facing practitioners requiring level 2 competence. A training trajectory is in place which will achieve 95% compliance by 31st March 2016.

PREVENT training is now mandated for all Trust staff. A training trajectory is being compiled to address this, with the aim of achieving 95% of all staff by 31st March 2016.

8. Conclusion

The team continues to work well together and are prioritising the increased training requirements for both adults and children, whilst continuing to meet the requirements of the Trust as a whole, including learning from SCRs. Our commitment to the multiagency safeguarding agenda for both adults and children is increasing, with the high profile Child Sexual Exploitation activity, the Multi Agency Safeguarding Hub, and the on-going demands of the domestic violence activity. A business case is being submitted to increase the capacity of the safeguarding team as a whole. This will enable on-going training needs to be met, advice, support and guidance to be more readily available and evidence of safeguarding obligations and requirements being met.

Author: Gilly Attree Lead Nurse for Safeguarding Children

6

Appendix 1 KH Recommendations for UHCW NHS Trust Nil Multi-Agency Recommendations for UHCW NHS Trust Coventry LSBC should ensure that all agencies should have policies and procedures in place for identifying families that are proving hard to engage. Have protocols in place for sharing information about families that are hard to engage. Monitor staff compliance with procedures. Evidence UHCW have developed a specific Paediatric Did Not Attend (DNA) policy. This will be audited in April 2016 GD – Child T Recommendations for UHCW NHS Trust UHCW midwifery services will introduce a standard check of the sleeping arrangements at the post natal home visit. This will be explained to parents in the antenatal period and will form part of a safe sleeping assessment for all babies. Evidence Policy in place and had been audited twice by the Maternity Risk Team in April and July 2015. The outcome of the audit has indicated that further training is required. Multi-Agency Recommendations for UHCW NHS Trust Nil ND – Child C Recommendations for UHCW NHS Trust UHCW to develop a process which demonstrates explicitly that routine questions in relation to domestic violence and/or abuse are asked on at least two occasions in the ante natal period

7

Evidence Implement process. Community midwives will use attendance sheet in GP practices to record asking routine domestic violence/abuse questions on at least two occasions in the antenatal period. Those women attending hospital for their ante natal care will have their clinic card completed in the pre-printed relevant section. From 1.5.15 midwives have begun to return completed attendance sheets from cases where a pregnancy has completed. This is being recorded on a database. Hospital notes will reflect that the issue of domestic violence/abuse has been raised on at least two occasions in the ante natal period. This will evidence compliance with the policy and demonstrate the maternity services understand the importance of the subject matter. This will be audited in August 2015 Multi-Agency Recommendations for UHCW NHS Trust LSCB to continue to monitor the local agency progress relating to their response to Domestic Violence. Evidence UHCW will provide the Quality and Effectiveness Sub-Committee of the LSCB with the outcome of audits re joint screening notifications. JP Recommendations for UHCW NHS Trust There are no recommendations as at September 2015. Evidence N/A Multi-Agency Recommendations for UHCW NHS Trust N/A

8


Title Emergency Care Pathway Update Authors David Eltringham, Chief Operating Officer

Alan Cranfield, Deputy Chief Operating Officer – Medicine Mark Kemp, Deputy Chief Operating Officer - Surgery

Responsible Chief Officer

David Eltringham, Chief Operating Officer

Date 24th September 2015

The National Waiting Time Standard for A&E is set by the Department of Health and features in the Trust Development Authority and NHS England Accountability Framework. It measures the percentage of A&E attendances where the patient spends four hours or less in A&E from arrival to transfer, admission or discharge for which the target is 95%.

Purpose The purpose of this paper is to provide an overview of the Trusts Emergency Pathway and its performance against the 95% Emergency Department (ED) standard, set out in the jointly agreed plan between the Trust, Coventry and Rugby Clinical Commissioning Group (CCG), NHS England, Trust Development Agency (TDA) and Partner Organizations, which outlines those activities being pursued to improve and sustain our position going forward.

As already alluded to, there are external dependencies and actions provided through partner organizations that affect and influence the Emergency Pathway and these need to be recognized and understood. Therefore, to better facilitate this, the report will be broken down into 2 distinct parts:

• The Trusts Emergency Pathway and its performance against the 95% ED standard.

• External influences on the Emergency Pathway.

Part 1

The Trusts Emergency Pathway and its Performance Against the 95% ED Standard.

1.1 Background • The Trust’s ED Performance has been above the 95% Constitutional 4 hour standard for

the past 2 calendar months (11 weeks in total). • Prior to this the Trust last achieved the standard in April 2014. Table 1 reflects the position

over the last 18 months.

Agenda Item13 Enclosure 10

Table 1

2014/15 % April 2014 95.6 May 2014 94.2 June 2014 93 July 2014 92.9

August 2014 93.1 September 2014 91.5

October 2014 91.5 November 2014 90.5 December 2014 87 January 2015 84.1 February 2015 85.6

March 2015 84.2 2015/16 %

April 2015 81.8 May 2015 85.5 June 2015 88.2 July 2015 98.2

August 2015 97.7

• The full year performance for 2014/15 was 90.37% and the year to-date position for 2015/16 is 90.27%.

• It is not realistically possible for the Trust to meet the 95% standard for the full year (2015/2016) given its performance in the early part of it, as this would require a sustained performance of 98.55%; even maintaining a 95% trajectory going forward the Trust would only be in a position to achieve 93%. Nevertheless, continued effort will be made to get as close to the full year target as possible.

• The Trust planned and undertook a ‘Perfect Week’ exercise (8th to 15th July) along with partners to help improve its position and although the hospital was achieving the standard some weeks ahead of the exercise, the engagement was successful and projected the Trust into a stronger position. A separate report detailing this exercise has been prepared and will be discussed at the Finance and Performance Committee meeting in October 2015.

• The Trust has determined to undertake a further Perfect Week exercise on 3 or 4 occasions throughout the year and the next is planned for 11th November. The CCG will take a stronger leadership role in promoting partner response and we, as a Trust, will pursue the event with the same vigour as we did in July.

• UHCW does take its performance very seriously and has agreed Trust actions (against a wider plan) with the CCG, TDA, NHS England and Community Partners to improve its performance and these are reflected in Table 2 overleaf.

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Table 2

A&E Recovery Plan

The establishment of a Medical Decisions Unit (MDU) to incorporate a GP Assessment Unit and an Ambulatory Clinic Establish a GP in ED model as part of the PMCF initiative Introduce Frail Elderly Assessment model

Discharge to Short Term Support Correctly aligning patients with early discharge using Short Term Support provided in the community..

Simple Discharge Project

To improve Internal processes to facilitate early discharge and improved patient experience through the rationalization and standardization of activities that affect simple discharge (TTOs, use of Hospitality Lounge, patient transport requirements and weekend discharge).

Complex Discharge Project More efficient and timely discharge through improved assessment and ward processes.

Increase the Number of Weekend Discharges

Put in place actions that will improve the number of discharges on Saturdays, Sundays and Bank Holidays.

• The above actions will continue going forward, but their introduction intended to see a

recovery against the 4 hour standard by August 2015, which has been achieved and this is reflected in the recovery trajectory at Appendix 2.

• The Trust will retain an ongoing focus on its central pillar of Getting Emergency Care Right (GECR) which seeks to focus Trust staff, on internal ownership of the Emergency Care Pathway through the creation of 25 safety standards, and a set of principles to apply to each patient (FREED metrics1). Central to this is a continuous campaign to make sure that every member of staff understands the importance of timely, effective emergency care as our guiding principle in patient care.

1.2 What does the data tell us? Table 3 below provides a direct comparison of the same periods for the past 24 months (by year). A further and more complete suite of data is provided at Appendix 1. • Attendance patterns to A&E (all types and Type 1). • Conversion to admission from A&E (all types and Type 1). • Ambulance conveyances to A&E. • Discharge profile. • Delayed Transfers of Care. • Age profile – attendances >65 years. • Outlier patients (those patients who are outside of a specialist ward aligned to their

medical condition).

1 FREED = Facilitate effective discharge; Right person, right place; Early specialist input; Eliminate unnecessary diagnostics; and, Daily senior Review

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Table 3

• The data shows some increases in activity relating to A&E attendances and

ambulance conveyances; these are not excessive rises. • Positively, the number of patients admitted from A&E has reduced by 10.43%, the

majority of which are attributable to the introduction of new pathways into Acute Medicine through the establishment of a Medical Decisions Unit (MDU), incorporating a GP Assessment Unit (GPAU) and Ambulatory Emergency Care (AEC).

• The results of these changes has been an overall reduction of 5.54% (3005 patients) in non-elective admissions overall.

• Our discharge numbers show a downward trend (3.06%) The numbers over the preceding 12 months reflected a profile that mainly exceeded 5000 discharges per month, whereas the discharges for the 5 months Jan - Jun 2015 were on or below that number, before once again increasing from Jun – Aug. These changes are as a result of 3 things:

1. A reduction in admissions has led to a reduction in discharges (because there are empty beds).

2. Reducing the number of patients admitted who are subsequently discharged with a zero day length of stay.

3. The ‘Perfect Week’ exercise in July, including the work-up to it, has improved performance and therefore discharge rates.

• The continued rise in Delayed Transfers of Care has now ceased and presently stands at 5.5% (from a previous high of >8%) against a target of 3.5%, which equates to 38 beds; the number does however fluctuate.

• The number of outlying patients is at its lowest for some considerable time and presently stands at 33 from a previous high of >120 and this is in part as a result of the work during the ‘Perfect Week’. Again this figure is subject to fluctuation.

• The number of patients attending who are >65 years of age has remained constant. As the Trust is in a positive position, in that we are attaining the 95% A&E standard, this is a different picture to that previously reported, but the result of our previous underperformance has reflected negatively in our:

• Admitted Referral to Treatment Time (RTT) performance. • 62 Day Cancer Indicators • Cancelled Operations

The RTT position is summarised in Table 4 below and examples of our plans to deal with it can be found in Table 5.

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Table 4

The Trust has developed an action plan for the recovery of the RTT 18 weeks (admitted pathways) standard. This is a joint plan with the Coventry and Rugby CCG. It has been shared with the System Resilience Group (SRG) and with the TDA. A summary of actions is included in table 5. The Trust has a trajectory for recovery of RTT for March 2016. The successful delivery of the action will ensure that this recovery trajectory timeframe is achieved. The recovery trajectory is being validated by IMAS who have requested a number of changes, which are being actioned and should be completed by the end of September. The Trust will also review the trajectory with the TDA. The action plan will also support the delivery of the 62 day cancer standard and the cancelled operations standards.

Table 5

Demand and Capacity analysis Action Revised RTT recovery trajectory (IMAS) Intensive Support and Management Identifying best practice in terms of health economy wide RTT governance and organisational arrangements that drive performance.

Visit Leicester and Luton & Dunstable NHS Trusts

Protect Elective capacity from emergency flows

Ring fence 48 (wards 32 & 33 short stay) surgical beds at UHCW site. Standard Operating Procedure (SOP) required plus criteria for breaching ring fencing policy.

Maximise capacity in Day Surgery Work with transformation team to revised day surgery unit timetable. More efficient use of recovery areas. Transfer day surgery from wards to DSU.

Theatre efficiency and productivity. Individual Group action plans to reduce the "closed" theatre session rate (the number of theatre lists not used as a result of consultant leave).

Expanding consultant surgeon capacity Pay consultants to undertake SPA's out of hours thus freeing time for more elective operating. Paying these sessions at an enhanced rate.

The Trusts Cancer position is summarized at Table 6 and examples of our plans to deal with it are at Table 7. However:

• Additional capacity is being set up in specialities where the Two Week Wait (TWW) standard is not being met, including breast and dermatology.

• The breast symptomatic target has failed as a direct consequence of a shortfall in the Consultant Workforce. The Surgical Group anticipate that this target will be achieved in September (it will not be achieved in August).

• An additional locum Breast Surgeon is being recruited on a short term basis until existing vacancies are filled

• A urology cancer action plan has been prepared and is ready for sign off, which includes additional theatre capacity and consultants.

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Table 6 Standard: Jul-15 Qtr1 / YTD DoH Tolerance TWW suspected cancer 93.4% 94.2% 93% TWW breast symptomatic 77.1% 89% 93% 31 day - 1st treatment 99.6% 99.1% 96 % 31 day - subsequent treatment -surgery 98% 96.7% 94% 31 day - subsequent treatment -chemo 100% 100% 98% 31 day - subsequent treatment - radio 95.7% 95.7% 94% 31 day - subsequent treatment - other 100% 100% No tolerance set 31 day - rare cancers 100% 100% No tolerance set 62 day - 1st treatment 86.4% 83.3% 85% 62 day - national screening programme 93.6% 92.2% 90% 62 day - consultant upgrade 87.2% 93% CCG tolerance = 85% 62 day - treated on or after day 100+ 4.5 23 CCG Tolerance = 0 62 day - treated on or after day 105+ 4 22.5 TDA tolerance = 0 Table 7

Demand and Capacity Analysis Action

Expand capacity for 31/62 CT guided lung biopsies.

Utilise the CT scanner in oncology (for routine work) which is not currently used as a daily service commitment, thereby freeing up space and capacity in radiology for specialist investigation.

Manage CT/MRI capacity during equipment replacement programme.

Mobile scanners to ensure that capacity is not interrupted during equipment refurbishment.

Reduce processing time for pathology specimens and reduce subsequent turn round times.

Implementation of Vantage software to reduce processing time for pathology specimens

Plan to deliver 62 day pathway for each subset of urological cancer with a focus on TURBT

Review backlog for each treatment sub group

Expanding diagnostic capacity Consider the establishment of weekend day case diagnostic ENT sessions.

Weekend operating Ensure that all day lists are held each Saturday and Sunday

1.3 Actions to maintain performance against the 4 hour standard and reduce the RTT Our over-arching strategy required to continue to manage this situation is three fold:

• Maintain a reduction in emergency admissions. • Improve flow within the capacity available to the hospital. • Increase discharges – simple and DTOC/Medically Fit For Discharge (MFFD)

A number of examples of specific projects/continuing work streams which focus on the delivery of this strategy are:

The creation of Medical decisions Unit (MDU), incorporating a GP Assessment Unit

(GPAU) and an Ambulatory Emergency Care Facilities (AEC). The establishment of an Acute Frailty Unit (AFU) is also being pursued.

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This will:

- Reduce the number of admissions to the hospital by improving the efficiency of the assessment processes.

- Direct elderly patients away from admission. - Improve access and utilization of Ambulatory Emergency Care/Hot Clinics. - Reduce congestion in the Emergency Department (ED)

This model does rely on support from partners across the health economy, as pathways out of the hospital are required to prevent admission. The Introduction of a GP in ED model has commenced its incremental

implementation. This has and will:

- Reduce the number of patients with primary care issues in ED. - Reduce total congestion in ED. - Improve relationships/intraoperative waiting between GP’s in ED and the hospital at

large. - Create a platform for further work to improve Urgent and Emergency Care in Coventry

and Warwickshire. Improve simple discharge planning and delivery

- Continuing with GECR initiatives and campaign - Promoting Board Rounds and Ward Rounds and testing consistency and quality through

Peer Review - Concentrating on pre-noon discharges to establish early flow - To drive for an admission/discharge balance each day including weekends - Strict planning for patients with a length of stay longer than 14 days. - Reinforcement and understanding of the important role of the Integrated Discharge

Team - Daily case management of delays - Continue the development of “Home First” which is an initiative that seeks to provide

community support in the home or normal place of residence to those patients who require it, rather than transferring them to another care provider (e.g. nursing home, or home with care).

Continued pursuit of tactical solutions, for example

- Command and Control arrangements - Utilization of contingency capacity - Daily review of cancellations - Visible leadership and communications - Patient stories and staff stories - Simple discharge planning and early TTO’s - Matching staffing to demand

Pursuit of the CEOs challenge

- All TTOs to be written at the time of discharge decision to facilitate early movement - Speeding up the roll out of pharmacy computers on wheels (COWs) to reduce time from

prescribing to dispensing - Increased portering provision to pharmacy. - ‘Ring fenced’ elective beds to better facilitate surgical activity

• 24 beds on 33, surgery

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• 12 beds on 23, gynaecology - The further development of Acute Medicine pathways. - Bank holiday Monday initiative to encourage senior clinical presence on the wards to stimulate discharge activity ahead of returning to work.

1.4 Winter Resilience Funding

Historically, Trusts have created ‘winter plans’ against a known increase in activity over the winter period, in actual fact, this level of activity is now a year round phenomenon. The Trust has invested significantly in its GECR programme (£8.3M) to counter the effects of increased demand and this includes:

• Increased staffing across the ED with specific emphasis on known times of peak activity.

• Increase of clinicians across the busy area of Acute Medicine, with particular emphasis on evening and night times.

• Improved nursing presence within the major assessment areas to cope with the increased demand.

• The provision of additional nursing support to the base wards areas. • To provide an increase in doctors to support those patients who were not

accommodated in the specialist ward commensurate with their condition (outliers). • To accommodate the additional workload it is necessary to bolster the clinical support

areas such as Imaging, Therapy and REACT. • The use of Medihome/UHCW@Home as a ‘virtual ward’ to allow patients to go home

and continue their treatment, whilst remaining under the care of the hospital consultant has provided an increase in capacity to the hospital of 30 beds.

In addition to the funding committed to GECR, the Trust is moving away from a home service provided through MediHome (now part of the Hospital @Home Group) to one provided by the Trust. The running costs of these 30 virtual beds, which will be provided through winter resilience funding are identified to be similar to that of MediHome (£1.2M), but the flexibility of how we shape the service is significantly greater and more attractive. 1.5 Risks Although the Trust is presently meeting the 4 hour A&E standard, the risks associated with it not doing so are:

1. Clinical risk to patients – Patients waiting for extended periods of time may have a poor care experience. This risk is mitigated by constant review of the pathway and the surveillance of patients waiting in the Emergency Department. Clinical resource is key and we are reviewing our footprint.

2. Reputation – Regulators, staff, patients and communities may form a poor view of the service offered by UHCW. This risk is mitigated by constant efforts to manage pressure, rapid response to specific feedback/complaints, communication strategies which keep all stakeholders informed of waiting times, actions to address issues, and through regular briefings to all groups.

3. Performance – Poor performance is currently being reported against the RTT Standards and Cancer Standards in part as a result of our previous poor A&E performance, which has a deleterious effect for patient access; this represents an active risk. This paper has set out actions to mitigate the performance against these and result in improvements.

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Part 2

External Influences on the Emergency Pathway There are external dependencies and actions provided through partner organizations that affect and influence the Emergency Pathway and that are pivotal in ensuring that the Trust is able to meet the constitutional 4 hour ED Standard. It is therefore important that these activities are recognized, documented and understood. The Chief Executives of the partner organizations have met and committed to set out a compelling vision of the health economy, which establishes a direction of travel for the next 3 years and is likely to include some radical suggestions for the future of the health economy. Andy Hardy has taken on the role of Senior Responsible Officer for this piece of work. The Directors from each of the partner organizations, including UHCW, have established a much more robust approach to programme management of the work-streams that have been established to improve flow across the health economy. A single Programme Management Office (PMO) is being established with a programme board operating on behalf of the SRG chaired by Andy Hardy. Work-streams will be established and led by a director from the partner organizations, operating on behalf of the SRG and with authority across partner organizations. The work-streams will establish that:

1. No patient will be directed to the hospital where their care can be delivered elsewhere. 2. No patient will be admitted to the hospital unless they need an acute hospital bed.

3. No patient will remain in hospital for more than 24 hours once they are medically fit for

discharge.

4. No patient will be placed in, or remain in long term care without a clear need. Sections 2.1 and 2.2 below set out the specific pieces of work which are currently in train. 2.1 Additional Capacity

2.1.1 Delayed Transfers of Care (DTOC) DTOC has a significant impact on hospital bed capacity. This is a reportable metric and is defined as - ‘the number of patients in delay should not exceed 3.5% of the attributable bed base’, which for UHCW is 38 beds. The summary position of delays as of Wednesday 9th Sep 2015 was:

• Total number of patients who are medically stable to leave the hospital but require

an external provision to support discharge = 110

• Of that number, the total number of patients in formal delay (DTOC) = 73 The Trust has attended regional escalation meetings associated in particular with DTOC, which have set a recovery trajectory agreed by the SRG on behalf of the Health Economy. It is however important to recognize that presently Partner organizations are unable to provide the capacity to meet this need; the consequence is that patients remain within the acute setting. To try and improve that position partners have:

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• Increased Community Capacity to Improve Flow - Through additional funding streams the CCG has been in a position, through partners, to fund additional community capacity (including staff recruitment) in the form of short term packages of care in the patient’s home and the commissioning of short term bedded facilities. Although this will have had some effect, it has had no significantly sustainable positive influence on the DTOC position outlined above.

• Established a Single Brokerage to Improve Access to Community Services - The

use of a single Brokerage is a positive step forward and reduces administrative bureaucracy; it is however limited in its influence by the lack of capacity.

• Engaged GE Healthcare Finnamore, an external consulting agency to evaluate

capacity requirements within the community that would help inform discharge processes and pathways.

2.2 Community Plans Community partners have agreed with the CCG, NHS England, TDA and the Trust, actions to improve the emergency pathway and thereby performance that will positively influence the ED 4 hour standard and these are contained in table 8 below. Table 8 Wrap Around Domiciliary Care Service

Provide additional short term support, including night time support as required in order to prevent unnecessary A&E presentation and hospital admission and facilitate a supported discharge home.

Care Home Support Strategy

GP Enhance care home service in place covering 50% of elderly care home residents. Quality review being complete by Dec 15. Including joint monitoring with LA’s and improved access to specialist community advice, guidance & training e.g. infection prevention, tissue viability.

Primary Care Frailty Team

Aiming to reduce length of stay from 11 days to 3.5 days. It will operate 12 hours per day x 7 days per week from 1st Oct 15, with a target of 12 patient interventions/day supporting them back into the community.

Warwickshire Social Worker in A&E & AMU

To provide additional capacity for Rugby patients to prevent admission from A&E & AMU

Extended hours for Acute MH Assessment Team (AMHAT)

Extend the hours of operation over the week-end from 9-5 to 9am-7.30am (22.5 -hour service) to include additional specialist & older adult mental health practitioner to support discharge.

Summary The Trust’s ED Performance is presently above the 95% standard having achieved it in both July and August 2015 (11 weeks in total). The challenge going forward is to sustain this level of performance. Failure to maintain this will have implications on other constitutional standards including: Admitted Referral to Treatment Time (RTT); 62 Day Cancer Indicators; and, cancelled operations. There are risks that accompany such a position and these surround the potential for clinical risk to patients, reputation and performance going forward. Accordingly the Trust has agreed continuing actions (against a wider plan) with the CCG, TDA, NHS England and Community Partners to maintain its improved performance. In recognizing that this is a system responsibility, strategically, the Chief Executives of the partner organizations have committed to set out a compelling vision of the health economy

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which establishes a direction of travel for the next 3 years and is likely to include some radical suggestions for the future of the health economy. This will include a Programme Board operating on behalf of the SRG, from which, work streams will be established and led by a director from one of the partner organizations. These work streams will concentrate on establishing 4 key themes:

1. No patient will be directed to the hospital where their care can be delivered elsewhere. 2. No patient will be admitted to the hospital unless they need an acute hospital bed.

3. No patient will remain in hospital for more than 24 hours once they are medically fit for discharge.

4. No patient will be placed in, or remain in long term care without a clear need.

The Trust Board is invited to:

1. Note the contents of this report. 2. Note the success that the recent changes to the emergency pathway (particularly

within Acute Medicine) have had on performance.

3. Note the risks to sustained performance set out in the paper and the actions being taken to mitigate those risks.

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Appendix 1

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Appendix 2 A&E Recovery Trajectory The following represents the actions and predicted trajectory for the recovery of the UHCW 4 Hour ED Target. The trajectory reflects a more consistent achievement of the target from the end of August 2015



Title Significant Incident Group Report, Including Action Plans and Never events.

Author Yvonne Gatley, Associate Director of Quality Responsible Chief Officer

Meghana Pandit, Chief Medical and Quality Officer

Date 24 September 2015 1. Purpose To provide the Board with a summary of the Significant Incidents Requiring Investigation (SIRIs) reported in the past 6 months (February-July 2015) and to provide a progress report on the completion of related action plans. 2. Background and Links to Previous Papers This report is presented to the Trust Board on a six-monthly basis. The last report was received and considered at the February meeting. 3. Narrative All SIRIs (including never events) are reviewed at the weekly Serious Incident Group (SIG) meeting, which ensures that investigations are undertaken and appropriate actions are put in place to reduce identified risks. Details of investigations (including root causes and lessons learned) are also presented monthly to the Patient Safety Committee. Incidents that fall into the SIRI category (NHS England’s Serious Incident Reporting Framework) are also reported to the Trust’s commissioners. Each SIRI has to be investigated by root cause analysis and the commissioners require a copy of the investigation report and action plan within a timescale of 60 working days (previously 45 days prior to 1st April 2015) from the date of notification, unless a clock-stop has been negotiated with them. Some categories of SIRI have a 6 month deadline, e.g. those that require external investigation. The report details the SIRIs that were reported, opened, and closed from February-July 2015. Following each SIRI, action plans are produced which are aimed at preventing such incidents from re-occurring or in the event that they do re-occur, that the consequences are minimised. This also serves to ensure that lessons are learnt and shared within the Trust. The report details the bi-monthly SIRI Action Plans reports to Patient Safety Committee.

4. Areas of Risk All incidents hold opportunities for learning. If the Trust does not learn from its incidents, then improvements will not be made and similar incidents may occur. 5. Governance The Trust Board receives this report on a twice yearly basis. The NHS Constitution gives patients the right to expect NHS bodies to make efforts to continuously improve the quality of the healthcare that they provide, which includes making improvements to safety effectiveness, and experience. The Serious Incident investigation process links to improving quality and safety and also aligns to the Trust’s “Learn” and “Improve” Values. 6. Responsibility Meghana Pandit, Chief Medical & Quality Officer – Chief Officer Responsible for Patient Safety Jenny Gardiner – Director of Quality Yvonne Gatley – Associate Director for Quality (Safety and Risk) 7. Recommendations The Board is invited to NOTE the report and to raise any questions or concerns.

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SIGNIFICANT INCIDENT REPORT TO TRUST BOARD SEPTEMBER 2015

Yvonne Gatley Associate Director of Quality (Safety and Risk) 1.0 Background This is the second report on serious incidents (SIs) to be presented to Trust Board

(the last one was in February 2015). The report provides a summary of incidents that

met the criteria for reporting to the CCG (Serious Incidents Requiring Investigation) for

the 6-months February to July 2015.

Over the last decade the NHS has made significant progress in developing

standardised reporting and investigating when things go wrong, a key part of this

being the management of serious incidents.

Following the implementation of the Health & Social care Act 2012, a revised Serious

Incident Framework was published in 2013. This was reviewed during 2014 and a

revised framework was released by NHS England in April 2015.

In broad terms, serious incidents are events in health care where the potential for

learning is so great, or the consequences to patients, families and carers, staff or

organisations are so significant, that they warrant a comprehensive response. The

Framework describes the circumstances in which such a response is required and the

procedures for investigating the incident to ensure that lessons are learned.

Serious incidents can extend beyond incidents which affect patients directly and

include incidents which may indirectly impact patient safety or an organisation’s ability

to deliver ongoing healthcare.

Serious Incidents include:

• Acts and/or omissions occurring as part of NHS-funded healthcare (including in the

community) that result in:

• Unexpected or avoidable death of one or more people. This includes

suicide/self-inflicted death; and

homicide by a person in receipt of mental health care within the recent

past

• Unexpected or avoidable injury to one or more people that has resulted in

serious harm;

1

• Unexpected or avoidable injury to one or more people that requires further

treatment by a healthcare professional in order to prevent:—

the death of the service user; or

serious harm;

• Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts

of omission which constitute neglect, exploitation, financial or material abuse,

discriminative and organisational abuse, self-neglect, domestic abuse, human

trafficking and modern day slavery where:

• healthcare did not take appropriate action/intervention to safeguard against

such abuse occurring; or

• abuse occurred during the provision of NHS-funded care.

• A Never Event - all Never Events are defined as serious incidents, although not all

Never Events necessarily result in serious harm or death.

• An incident (or series of incidents) that prevents, or threatens to prevent, an

organisation’s ability to continue to deliver an acceptable quality of healthcare

services, including (but not limited to) the following:

• Failures in the security, integrity, accuracy or availability of information often

described as data loss and/or information governance related; • Property damage; • Security breach/concern; • Incidents in population-wide healthcare activities like screening and immunisation

programmes where the potential for harm may extend to a large population; • Inappropriate enforcement/care under the Mental Health Act (1983) and the

Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS);

• Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services; or

• Activation of Major Incident Plan (by provider, commissioner or relevant agency) • Major loss of confidence in the service, including prolonged adverse media

coverage or public concern about the quality of healthcare or an organisation

At UHCW these incidents are reviewed and monitored by the weekly Significant

Incident Group (SIG), which is chaired by the Director of Quality. SIG has been

meeting since the inception of Clinical Governance back in 2001, its terms of

reference having been updated over the years to its present configuration. Members

2

of the group include the Chief Medical & Quality Officer (CMO), Chief Nursing Officer

(CNO), Deputy CMOs, Associate Directors of Nursing, Head of Legal Department and

representatives from the local commissioners, the Emergency Department and the

Obstetrics Department. SIG is responsible for supporting the Trust Board in assuring

that serious incidents are proactively monitored, reviewed, reported and investigated

and that lessons learned are shared with all relevant parties.

SIG reviews each investigation report and considers and approves the

recommendations and associated action plan.

The Quality Department maintains a database (Datix) of all on-going and completed

investigations and action plans and has a process for escalating actions that have not

been completed within their agreed timescales.

Serious Incidents and the work of SIG are monitored via the Patient Safety Committee

which reports to the Quality Governance Committee.

Following the Francis Report of the Mid Staffordshire NHS Foundation Trust Public

Inquiry the Care Quality Commission (CQC) regulation 20: Duty of Candour was

implemented in October 2014. Regulation 20 is to ensure that providers are open and

transparent with people who use their services It sets out some specific requirements

that providers must follow when things go wrong with care and treatment, including

informing people about the incident, providing reasonable support, providing truthful

information and an apology when things go wrong (known as the Duty of Candour).

SIG ensures that the Trust fulfils its duty by checking that it has been applied in

relevant cases.

2.0 Summary of SIs (including Never Events) February - July 2015 This report is a summary of serious incidents that met the criteria for reporting to the CCG for

the 6-months February to July 2015. According to the Serious Incident Framework each of

the Trust’s Serious Incidents Requiring Investigation (SIRI) must be investigated and a report

submitted to the commissioners within 60 working days from the date of reporting (prior to 1st

April 2015, the deadline was 45 working days). Clock-stops can be requested under certain

circumstances, e.g. a case that has gone to HM Coroner or a case that the police are

investigating.

3

SIG also reviews serious incidents that have been reported by staff that do not meet the

definition for reporting externally but nonetheless require a thorough review. The group

reviews these incidents in the same manner, requiring a report and action plan from the lead

investigator and following up the actions via Datix.

According to the national framework serious incidents have to be reported by the Trust that

identifies them, whether or not they are attributable to the reporting organisation. Examples

of this for the period February to July 2015 are:

• 6 MRSA bacteraemia were reported during the period. Of these, 3 MRSA

bacteraemia reported in February and 1 in July 2015 were attributable to UHCW.

• There was an intra-uterine death reported by UHCW in July, for whom all the care

was provided by another Trust and will therefore be investigated by that Trust.

2.1 Number of SIRIs reported by month

0

5

10

15

20

25

FEB MAR APR MAY JUNE JULY

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2.2 Broad types of SIRI reported by month

MRSA

bacteraemia Maternity C Diff death /outbreak

Other Infection

Pressure Ulcer (3&4)

Patient Fall

Other SIRI

Never Events TOTAL

FEB 3 0 1 2 5 2 0 0 13 MAR 1 3 0 1 6 2 1 0 14 APR 0 2 1 0 8 2 2 0 15 MAY 0 2 0 0 5 5 1 0 13 JUNE 1 1 1 0 8 8 1 0 20 JULY 1 2 0 0 9 5 2 1 20 2.2.1 Categories of “Other SIRI” Month Definition of “Other SIRI MAR Data breach APR Unexpected death x 2 MAY Unexpected deterioration JUN Unexpected death JUL Unexpected death, Delayed diagnosis There were significantly more SIRIs reported in June and July, mainly due to pressure ulcers

and patient falls. The investigation outcomes from these are being collated for review to

5

ascertain any common issues or causes from which the Trust can learn lessons. Reports

will be considered by the Tissue Viability Team and the Falls Steering Group respectively.

2.3 Never Events 2 never events were declared during this 6 month period:

1. Misplaced Naso-gastric tube (declared February)

• Investigation completed and all actions have been implemented

• This never event had been reported as a serious incident in October 2014 but the

never event status was not agreed until February 2015 due to lack of clarity around

the definition of the never event and national guidance on NG tube placement.

2. Retained foreign object post-procedure (reported July)

• Investigation under way, led by Deputy CMO. Report to be presented to SIG for

approval.

2.4 Overdue SIRIs Graph to show no. of overdue SIRI reports by Month

The graph above demonstrates the Trust’s performance in terms of closing its serious

incidents within the SI timeframe (i.e. investigation report to be submitted to the

commissioners within 60 working days from the date of reporting (prior to 1st April 2015, the

deadline was 45 working days).

6

There has been marked improvement since the extended timeframe was introduced in April.

Some investigations were taking longer than the allocated 45 working days in order to

produce a thorough report and this has been recognised nationally. The 60-day timeframe is

much more manageable for investigating complex cases.

3.0 SI Action Plans 3.1 Process

• Each action plan is approved by SIG following investigation of a serious incident

• Each action is assigned an owner, who is informed by SIG

• Each action is then logged on the Datix system with the action owner & date for

completion

• Actions are followed up by Quality Department and progress notes are recorded

• In order to improve the escalation process the following additional steps have been

introduced:

• Overdue actions are escalated to the relevant Specialty management team

• Overdue actions are included as part of the Specialty Group quarterly

performance reviews

• Actions remaining overdue are escalated to Patient Safety Committee

• Chief Nursing Officer & Chief Medical Officer follow up with a formal letter

• Leads are required to attend PSC to discuss progress with their actions

3.2 Actions

• 194 new SI actions were assigned 01/02/15 – 31/07/15

• 63 actions due for completion prior to 31/07/15 are now overdue (see range of dates

due for completion in graph below)

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3.2.1 Graph to show the year from which actions were overdue closure

The remaining action from 2013 is an Obstetric Epilepsy guideline; the final version is now

due to be uploaded to eLibrary in October 2015 (delayed further awaiting a pending Royal

College of Obstetricians guideline).

3.2.2 Graph to show number of overdue actions that were escalated to Q1 Group Performance Reviews The graph below shows the number of overdue actions that were discussed by each Group

at their Quarter 1 performance review with the Chief Officers. Several have since been

addressed.

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4.0 Examples of actions taken as a result of SI Reporting 4.1 Never Events Never event July 2015

• Retained fragment of metal following maxillo-facial surgery. Fragment discovered

on subsequent X-ray.

• There are currently no plans to remove the fragment.

• Patient discharged from hospital fit and well.

• Duty of Candour / Communication with Patient/Family: Patient was seen by

Maxillofacial Consultant as an outpatient – full disclosure of incident given.

• RCA investigation is being led by Deputy CMO and Associate Director of Nursing.

Never events review. All specialties are reviewing their services against the 2015/16

Never Events list to identify any potential risks and to address these.

Junior Doctors.

• Presentations on incident reporting, human error and never events have been

given to FY1 and FY2 doctors by the Associate Director of Quality (Safety & Risk)

and the Patient Safety Manager. There are plans for further sessions to be

presented for other grades.

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• There is junior doctor representation at Patient Safety Committee, which is another

opportunity for sharing lessons.

• The representatives write a Newsletter for all trainees covering safety related

learning.

4.2 Duty of Candour • The Trust’s Duty of Candour policy was presented to Grand Round on 7th July 2015.

This included the introduction of stickers to be placed in patient records with the

purpose of highlighting a relevant incident and documenting that the duty of candour

has been applied. This will facilitate auditing of the records. The policy also includes

a patient information leaflet that can be handed to patients (or relatives) who have

been involved in an incident that falls within the duty of candour requirement (i.e.

when a patient suffers “moderate” or “major” harm or death as a result of a patient

safety incident).

• SIG has adapted the Trust’s SI report format to include a section for recording the

initial duty of candour apology to patients and families and a standard action relating

to duty of candour for each relevant incident. This will ensure that these actions are

followed up in the same manner as all SI actions.

4.3 Medication Incidents

• The reporting rate for medication errors is improving. There was 1 SIRI reported in

July, which is undergoing investigation.

• Medication safety walkrounds are carried out on wards. Reports are presented at

Patient Safety Committee. Where required, wards are then given actions for

improvement, which are followed up by Pharmacy.

• Medication Safety Officer identified to comply with a recent patient safety alert.

• New medication safety forum is being set up.

4.4 Other Actions

• Serious falls investigations are being reviewed by the Associate Director of Nursing

(Quality & Patient Safety) to ensure that all relevant learning is being captured and

shared to reduce the risk to patients.

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• Dr Townsend, ITU Consultant presented two cases that he had investigated for SIG to

the Grand Round. Both cases had been detected through the Trust’s mortality review

process and revealed learning points for clinicians. One case was relating to a failure

to recognise STEMI (ST Segment Elevation Myocardial Infarction) and the other one

was about the inappropriate treatment of a patient’s megaloblastic anaemia (patient

was given a blood transfusion rather than oral folic acid). The Grand Round meeting

was well attended and the presentations were very well received. There are plans to

present other cases to future Grand Rounds.

• SI approved actions (from 1st April 2015) have been reviewed to establish their

relative strengths & weaknesses, based on a paper from the United States, “Root

Cause Analysis Squared”. Paper discussed at Patient Safety Committee. Findings

will inform future action plans resulting from SIs to try to strengthen them and hence

reduce the risk of their recurrence.

• SIG provides cases for sharing across the organisation to the Trust’s quarterly safety

newsletter, ‘Safety Matters’ to ensure that safety messages are being communicated.

• Specialties are required to produce their own safety newsletters for staff.

• Specific safety incidents give rise to the creation of Trust safety alerts that are

circulated to relevant staff for immediate review and action.

• The Trust’s Sign up to Safety Campaign has been informed by some of the learning

from SIRIs, e.g. the focus on the deteriorating patient / sepsis, the handover process,

human factors.

5.0 Conclusion

The SI process continues to perform well as demonstrated by:

The improvement in the number of investigations being completed within the required

timeframe.

The additions of duty of candour sections to the investigation reports.

The senior level attendance at SIG and their scrutiny and oversight of all serious

incidents.

Attendance of CCG representative at SIG to provide assurance to commissioners.

Feedback to staff via Grand Round and targeting of junior doctors’ education

sessions.

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Sharing of safety lessons via Trust and specialty newsletters.

The process for escalation of overdue actions – providing the Trust with assurance

that actions from serious incidents are recorded and followed up. This requires

further attention to ensure more timely completion of actions and/or more realistic

timescales for completion.

SIG’s review against the Duty of Candour Policy to ensure that the Trust complies

with current legislation. This will be audited in October 2015.

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Title Joint Vision with the University of Warwick Author Maggie Allen, Graeme Currie, Ceri Jones, Richard King,

Caroline Meyer, Lesley Roberts and Peter Winstanley. Responsible Chief Officer

Peter Winstanley (Chair of Faculty) and Andy Hardy (Chief Executive Officer)

Date 24th September 2015 1. Purpose A Board Seminar was held jointly with the University of Warwick (the Provost and VC-Elect, Professor Stuart Croft, and academics from Business School, Medical School and WMG) on 2nd April 2015 to consider the ‘education’ and ‘innovation’ elements of an evolving joint academic strategy. This paper summarizes progress since April and looks forward to the next joint Board Seminar on 5th November. 2. Background and Links to Previous Papers • The Board recognizes that membership of the Association of UK University Hospitals (a

consequence of partnership working with Warwick Medical School) is an important factor in TTWC1 and delivery of the highest standards of patient care.

• The scope for ‘Health Education’ and ‘Health Research’ at Warwick requires broader partnership-working that is the case for more traditionally-structured University-AUKUH partnerships. Thus the present initiative involves WBS and WMG as well as WMS.

• It should be noted that this initiative does not hamper partnerships between the Trust and other Universities.

3. Narrative 3.1 Progress in Health Education. Undergraduate ‘Student Experience’ in the Trust A) The inclusion on the Board of a Non-Executive Director with special interest in education2 has

been greatly appreciated (both by Dr Allen and Prof Roberts) and is already leading to enhanced visibility at Board level of education issues.

B) The Trust appointed a Quality Improvement Officer for MBChB at the beginning of 2015. The following have been delivered through this appointment to date: • Regular ‘forums’ now ensure that the ‘student experience’ is better understood and enable

problems to be identified faster than previously possible. Weekly one-to-one ‘drop in’ sessions also allow problems to be identified/rectified promptly.

• A monthly newsletter now highlights new initiatives and opportunities to enhance learning, skills or CV development, and allows feedback in a ‘you said, we did’ style.

• Training initiatives for the MBChB administrative staff have supported a culture-shift towards a more customer-focused service.

C) Increased financial accountability has been communicated to all block-leads. A self-evaluation document has been issued to all departments to obtain baseline information around teaching activity. This includes information on who delivers teaching, whether

1 ‘Together Toward World-Class’ 2 Brenda Sheils

teaching clinics are in place, whether revision sessions are available, whether the department provides clinical personal tutoring support etc.

D) Efforts are being made to improve interfacing between the University VLE (Moodle) and the UHCW medical education website – progress will be reported to the Board in Q2 2016 (later that otherwise because of the change in Associate Medical Director for Education (AMDE)).

E) The Trust is considering appointment of an undergraduate deputy to the AMDE role, anticipated to lead to improved interaction with WMS. This was previously a challenge due to the diverse and multiple roles of the AMDE meaning core meeting attendance could not be guaranteed.

F) Physical changes: • A Student Learning Area has been re-established. This is well utilised and includes a

social area with access to facilities to prepare drinks and lunch. • A communication screen has been commissioned for the canteen area and will form the

central information channel for medical students. This is in response feedback calling for improved timeliness of key information.

Postgraduate A) WMS and the Trust are seeking to work more collaboratively in joint provision of Post-

Graduate Taught courses (PGT; including CPD activity) but this has not advanced since April 2015, partly because of an ongoing review of PGT in WMS. Meanwhile, as the WMS review concludes, it seems prudent to await appointment of the new AMDE (following the imminent departure of Dr Allen) before developing plans.

B) WMG-IDH: • The MSc in Healthcare Operational Management is being marketed and will start in

October 2016. (This involves Professor Meghana Pandit3 as Course Director). • Joint PhD studentships are under discussion. • The relevance of the planned Masters in Research Methods to Academic Clinical Fellows

and Clinical Lecturers is under discussion. • A portfolio of digitally-delivered short courses aimed at NHS workers who work with

overweight/obese patients is being developed with WISDEM. The course is entitled Practitioner Training: Eating Behaviour and Behaviour Change.

C) WBS: • Three WBS PhD students (funded by WBS as part of its contribution to the West Midlands

CLAHRC) will work in the Trust UHCW. One is studying patient safety, the second is focused on flexing the workforce in a manner dependent upon patient acuity and the final student is evaluating leadership development in UHCW. A potential fourth student is under discussion.

• WBS is developing a healthcare specialism to its Executive MBA, to launch October 2016, consisting of 4 elective modules and an innovation project (This involves Professor John Colley as lead)

• As part of Monash-Warwick Alliance funding, WBS is developing a blended learning MSc. Healthcare Innovation and Leadership, to be launched October 2017 (currently Professor Graeme Currie is leading this, but will step aside on appointment of Professor of Healthcare Improvement Science). The MSc can be cannibalised to deliver bespoke executive education offerings.

D) Financial models for shared PGT (whether WMS, WMG or WBS) need to be developed but this matter has not advanced since April. On reflection progress could be better assured if there was involvement of the Academic Registrar (Dr Mike Glover) who is leading University consideration of ‘TRAC’4.

3 Meghana Pandit is the Chief Medical Officer of the Trust. 4 Transparent Approach to Costing see: http://www.hefce.ac.uk/funding/finsustain/trac/history/

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http://www.hefce.ac.uk/funding/finsustain/trac/history/

3.2 Progress in Innovation. A) The Joint Innovation Strategy for UHCW-UoW was agreed in April 2015. The main objectives

outlined in the strategy were to: • Understand the opportunities for innovative collaboration • Identify strategic priorities for collaboration • Develop mechanisms to facilitate collaborative working • Ensure that Intellectual Property is managed appropriately • Increase the number of collaborative projects • Deliver cultural change

B) A one-day joint meeting was held on 6th July 2015 at Warwick Medical School to explore these objectives further. The meeting was attended by: • UHCW RD&I department • Science & Technology for Health GRP • Institute for Digital Healthcare, WMG • Warwick Medical School • Warwick Business School • Warwick Engineering in Biomedicine • Department of Chemistry • Warwick Ventures

C) There was agreement in a number of areas, including: • A Steering Group should be established. (In the first instance this would include a small

number of individuals from the UHCW RD+I department and the Science & Technology for Health GRP).

• A “virtual collaboration space” (including a database of collaborations) should be developed, to act as a hub for collaborative projects.

• There should be a regular opportunity for collaborators to meet – the preferred option was to link this to the Friday lunchtime UHCW Grand Rounds.

• A joint approach to management of intellectual property needs to be finalised. This is almost complete.

D) The Steering Group is due to meet on 28th September 2015 and quarterly meetings are scheduled thereafter.

3.3 Progress in Research. A) Development of a joint strategy for research was not discussed on 2nd April 2015 because the

incoming Dean (Professor Sudhesh Kumar) requested additional time; discussion is planned for 5th November 2015 in a Board seminar.

B) It is relevant to note that the Research, Development and Innovation Department at UHCW held their inaugural Summit event on 10th July 2015. • Over 100 delegates attended. The WMS Clinical Trials Unit, WMG and the School of Life

Sciences attended for the University of Warwick.] • Andy Hardy voiced his ambition to have a centralised hub for research and

innovation, which set the tone for a stimulating day. • Delegate feedback was overwhelmingly positive and will be used when planning

next year's Summit. 4. Areas of Risk Whereas academic partnership-working is long established in ‘big civic’ University Hospitals (whose medical schools may be over a century old) the Trust has been a University Hospital for

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just over a decade and is still building its academic reputation. This would be adversely affected by a failure to realize the present Joint Vision. 5. Governance This paper links to the Trust’s ambition to become a leading training and education centre. 6. Responsibility Karen Martin is the chief officer in the ‘Joint Operating Group’ that is overseeing developments for both Trust and University; in this she reports to the CEO. 7. Recommendations The Board is invited to note: • The progress that has been made since April 2015. • The plan for a Board seminar on 5th November to consider a proposed joint research

strategy. Name and Title of Authors:

• Maggie Allen (Associate Director for Medical Education) • Graeme Currie (Professor of Public Management, WBS) • Ceri Jones (RD&I at the Trust) • Richard King (Innovation Lead for the Trust) • Caroline Meyer (Professor of Digital Healthcare WMG) • Lesley Roberts (Professor of Medical Education WMS) • Peter Winstanley (Non-Executive Director and Chair of the Faculty of Medicine).

Date: September 2015

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Title MEDICAL EDUCATION REPORT TO UHCW TRUST BOARD – September 2015

Author Dr Maggie Allen, Associate Medical Director for Education Responsible Chief Officer

Professor Meghana Pandit , Chief Medical and Quality Officer

Date 24 September 2015 1. Purpose The Trust sees education, research and learning as central to improvement and it is our stated objective to be a Leading Training and Education Centre. We are the major undergraduate (UG) teaching partner to Warwick Medical School (WMS), and offer postgraduate (PG) training in almost all specialties. The Trust Board will be informed and updated on progress against this objective, and on substantial internal and external pressures that impinge upon Medical Education. We ask the support of the Board in maintaining the Trust’s focus on, and excellence in, Medical Education and Training. 2. Background and Links to Previous Papers

• UHCW is one of the UK’s largest and busiest NHS University Teaching Trusts.

• We have a mature and strengthened partnership with WMS, which allows us to combine excellence in teaching and research with high quality medical education. The Trust recognises that its association with Warwick has improved recruitment of high quality doctors at all levels.

• The delivery of postgraduate education and training is recognised as a Trust core activity. Approximately 250 Foundation, Core and Specialty trainee doctors appointed by Health Education West Midlands (HEWM) undertake training, and patient care, within the Trust.

• Both areas must operate in line with the new General Medical Council (GMC)

document ‘Promoting Excellence: Standards for Medical Education and Training’ which take effect January 2016.

• Education impinges on many operational areas for the Trust; with regular reports to Patient Safety, Training, Education and Research, and Quality Governance Committees as well as Trust Board.

Medical Education has, of necessity, become more ‘businesslike’. We have a Service Level Agreement with WMS and a Learning Development Agreement with HEWM. These give us a clear framework for facilities, delivery, and in particular quality, of teaching and training, and of ‘working conditions’ for our learners. We are subject to frequent inspection, particularly of PG Training. For both UG and PG training the total income available has dropped considerably in the past two years. For example HEWM now pays only 50% of trainees’ basic salaries and no ‘on call’; the Trust must fund the remainder. Education income now explicitly follows

the learner, and learners may only be assigned if teaching and training is at least satisfactory. Thus we stand to lose income if we do not meet standards, and of course our aim is excellence, but against this we face a number of important challenges. From April 2015 we have identifiable funding for both UG and PG teaching and supervision, facilities, administration etc. We must focus on good quality supervision, with sound standards and accountability against the sessional time allowed, particularly for those with lead roles. Educational time must be protected, but the NHS is under enormous financial and clinical pressure; inevitably these pressures ‘squeeze‘ educational time. From July 2015 all Teaching Leads & Supervisors are required to undergo GMC Trainer Accreditation. The aim is that all must be carefully selected, trained and supported by the Trust. Over the past eighteen months we made good progress against initial requirements for provisional registration by running a large number of tailored ‘in house’ courses, but full (and on-going) accreditation requires each trainer to maintain individual professional development in this area. We require increased emphasis on educational activity at appraisal and revalidation to support this. We return our data to HEWM and WMS and may be asked by the GMC at any stage for our current status, which should be 100% compliance. Specific Postgraduate Training Issues. There have been eight Deanery visits to inspect PG training since January 2014, with a further four due in the latter half of 2015. Such visits impose huge stress and workload upon the PG tutors and administration staff, particularly in data gathering/ analysis. For past visits, three were ‘level 3’, i.e. ‘triggered’ by significant criticisms or concerns, often over locally recognised issues, many of which are operational, rather than directly educational. Two visits to Acute Medicine were Level 4 (triggered by concerns with GMC input). Three ‘problem areas’; Obstetrics & Gynaecology, acute medicine and geriatric medicine, particularly at Rugby, have further high level visits this year. The Trust has responded and is seen as supportive of Education and Training. Our progress is recognised but major ‘front door’ pressures and associated patient safety issues, identified by trainees, continue to worry HEWM. We have appointed a second Clinical Tutor and Non-Executive support and oversight of education by the Trust Board is very helpful, and favourably viewed by the GMC and HEWM. . To acknowledge good news, Ophthalmology, Histology, Radiology, ED and a combined WMS UG and Foundation School visit were favourably reviewed. Also the PG Education teams continue to run many nationally and internationally acknowledged external courses, greatly enhancing the Trust’s specialist reputation. Undergraduate WMS introduced a new curriculum from September 2013. For three years we need to run the old and new curricula alongside each other. This has caused a significant ‘bulge’ in UG teaching requirements and pressure on teachers and educational leads. They have stepped up to the mark to try and ensure neither old nor new curriculum students suffer as the course runs in parallel for three years.

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On the plus side the ‘extra work’ has ensured that UHCW has maintained its overall ‘share’ of UG teaching income over these years. We also have a better understanding of income against activity than previously possible. We have appointed a Quality Improvement Lead for UG Education, who is making substantial improvements to the student experience at UHCW and is looking at teaching activity against UG funding to Departments and Divisions. This will allow us to iron out some major historic imbalances and ensure all know that they are getting income (and that we expect a return). Overrarching Educational Activities. Simulation Suite and Surgical Training Centre The Surgical Training Suite continues its exponential growth in scope and reputation, nationally and internationally. The team have won several prestigious awards and (ably led by Brian Burnett), are tireless in accepting new challenges and opportunities. Over 1500 surgeons, many from overseas, have trained there. Teaching is in place for groups from local schoolchildren through to highly specialised consultants, with emphasis on our local UG and PG learners, including innovative multi-professional courses. This is now a substantially self-funding enterprise. Our Clinical Skills and Simulation Centre is also a well-equipped facility, with Hi-Fidelity (i.e. near reality) simulation particularly suited to teaching on acute medical and surgical emergencies, non-technical skills under stress (e.g. team-working, leadership, communication skills, problem solving, situational awareness) applicable to all clinical disciplines, often as specialty multi-professional teams. We recently appointed two talented clinical leads with slightly different remits to develop the centre; scoping internal courses for our teams and trainees, but also external work to bring in additional funds. This is very timely; there is a HEWM led drive to increase availability of simulation training and a national emphasis to develop the area. The team is now optimistic that they can take on these challenges. We are grateful for Trust investment at a time of great financial stringency. . 3. Areas of Risk

• Clinical Risk. If we lose trainees due to unsatisfactory standards of training we lose high standard clinical staff and will need to employ (at full cost) other clinical staff to fill the gaps. We may not have as much assurance on the standard of those replacement staff. Due to current workload pressures our highest current risk areas are our most pressurised. This is a very real risk; we have had two middle grade Acute Medicine trainees taken away already and adjoining Trusts have had trainees removed in other specialities.

• Financial; as outlined above, funding now directly follows both medical students and PG trainees. Losing the ‘contract’ to teach and train will result in a reduction in income. Retaining that contract is dependent on maintaining high standards.

• Business; the success of our outward reaching educational ventures is in part built upon our general teaching and training reputation.

• Reputation; It is unthinkable that we should not maintain our status as a major teaching and training hospital. This has brought many advantages and improvements to the Trust and our local population and health care community

• Performance; as with clinical risk losing trainees will impact on performance in areas already under particular pressure

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4. Governance This paper links to the Trust’s objective to become a Leading Training and Education Centre. 5. Responsibility Associate Medical Director for Education with UG and PG Education teams, reporting to Chief Medical Officer. 7. Recommendations These need to clearly state what you are asking the Board to consider e.g. The Board is invited to NOTE:

1. The on-going work in respect of UG and PG training and education 2. Continue to provide oversight particularly in respect of HEWM visits.

Dr Maggie Allen. Associate Medical Director for Education Date: 24 September 2015.

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Title Staff Engagement 2014-2015 Author Rajni Martin, Organisational Development Manager

Rachael Atkins, Organisational Development Advisor Responsible Chief Officer Karen Martin, Chief Workforce and Information Officer

Date 24 September 2015

1. Background

In March 2014 the Trust launched Together Towards World Class; the Trust’s organisational development programme. The programme established five core work-streams of focus:

1. World Class Experience

2. World Class Services

3. World Class Conversations

4. World Class Leadership

5. World Class People

Staff engagement forms a key part of all the work-streams above with particular responsibility residing within the World Class Conversations and People work-streams; with World Class Conversations taking the lead for internal staff communications, events and employee recognition and awards; and the World Class People work-stream leading staff engagement activities including:

• First Impressions and Last Impressions (new starter and exiting employee surveys);

• NHS National Staff Survey; • Staff Impressions (the Trust’s local staff survey); • NHS England mandated Staff Friends and Family Test (Staff FFT); and • Together Towards World Class Listening Events (in person staff feedback sessions).

2. Purpose of this paper

This paper provides an update on the World Class People staff engagement activities that have been conducted and are planned between January and December 2015. The primary purpose of these staff engagement channels is to ensure as a Trust we provide several opportunities, at various points throughout the employee life-cycle and throughout the year, to staff to express their voice by giving their feedback, thoughts and opinions about their experiences within the Trust. These channels have also been established as vehicles to enable leaders and managers to gain feedback from staff across the Trust to inform actions taken to improve staff experiences; this encompassing staff engagement, satisfaction, motivation and morale.

Brief outlines of each engagement channel and activity to date is provided below under section 3, also including future activity planned. In section 4 we provide details of actions taken to date in response to staff feedback under the Together Towards World Class Programme. Section 5 presents a discussion of challenges and lessons learned to date in relation to staff engagement along with actions we are taking to address these.

3. Staff Engagement Channels & Activities

3.1 First Impressions and Last Impressions The Workforce Directorate are in the process of leading a review of Trust induction and the Trust Leavers procedure. These reviews have identified that very little feedback is sought from new starters and leavers to the Trust. Feedback from new starters is limited to an evaluation form/’happy sheet’ during Trust induction, and does not evaluate local/speciality level induction. Ad-hoc feedback on the recruitment process is received but no structured system is in place. Review of the leaver’s procedure has identified that exit interviews are not completed consistently and systematically across the Trust in line with the leaver’s procedure. Additionally, feedback and intelligence from these sources are not being used effectively to inform recruitment and retention approaches in the Trust. To address this gap in October 2015 Workforce will be introducing two new staff engagement channels called First Impressions and Last Impressions. These two dedicated surveys are designed to elicit staff feedback on joining the Trust and when they leave. First Impressions will invite new joiners to the Trust to provide feedback on their experience and impressions from the recruitment process through to local induction. Last Impressions will invite staff when leaving the Trust to give feedback about their experience, impressions and reasons for leaving the Trust. The intention of both of these surveys is to provide additional channels to staff at different points in the employee life-cycle to share their feedback and also to provide the Trust with additional intelligence, when combined with other workforce data at a strategic and local level, to develop a deeper understanding of why people choose the Trust as a place to work and also why they leave. Intelligence such as this is important to analyse at a time when the Trust, and NHS, is faced with a challenging and competitive labour market so that it can be used to improve recruitment and retention activities.

3.2 NHS National Staff Survey Feedback and actions arising from the NHS National Survey 2014 were presented to this Board in April 2014. At the time of reporting staff feedback from this survey was used to shape the work of the Together Towards World Class programme and therefore, no separate action plan was developed as actions were already underway to address a number of areas where we need to improve our performance. Areas for improvement highlighted in the National Staff Survey 2014 were:

• Effective team working

• Percentage feeling pressure in last 3 months to attend work when feeling unwell

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• Percentage experiencing discrimination at work in last 12 months

• Percentage agreeing feedback from patients/service users is used to make informed decisions in their directorate/department

• Percentage experiencing physical violence from patients, relatives or the public in last 12 months

• Percentage experiencing harassment, bullying or abuse from staff in last 12 months

All of the areas above were covered by action already underway through the Together Towards World Class programme except 1)the percentage experiencing physical violence from patients, relatives or the public in last 12 months and 2)the percentage experiencing harassment, bullying or abuse from staff in last 12 month.

Focus and attention is currently being given to exploring how we can improve in these areas. This work is being led by the Associate Director of HR – Learning and Organisational Development, alongside Security and Risk colleagues and the Head of Diversity. In section 4 we outline actions and changes that have been taken in response to feedback at a Trust level. This year the NHS National Staff Survey will take place between October and November 2015. Co-ordinated by an external provider, Quality Health on behalf of the Trust, 850 members of staff will be randomly selected to take part. Results of the 2015 National Staff Survey will be presented to this Board in March/April 2016.

Overall, the National Staff Survey provides us with a baseline set of data and an indication of where actions should be focussed. However the results should also be treated with caution, given the small number of respondents. In addition, it is important to review these results in light of other staff feedback we gather through our other staff engagement channels Staff Impressions 2014 (see 3.3), Staff Friends and Family Test (see 3.4) and Listening Events (see 3.5).

3.3 Staff Impressions ‘Staff impressions’ is the name given to the Trust’s own staff survey and when conducted (every two years) surveys all members of staff within the Trust, this is in contrast to the 850 staff members surveyed through the National Staff Survey. Staff Impressions was last conducted in June 2014 when the survey was redesigned to 1) incorporate the first Staff Friends and Family Test (see 3.4) and 2) ask questions aligned to the five areas of the Together Towards World Class programme. The feedback and results from the survey were combined with feedback from the 2014 Listening Events (see 3.5) and this data was used to inform the shape, direction and actions taken under the Together Towards World Class programme at a Trust level. The actions taken were communicated to staff via feedback events and the development of a special edition of InTouch+ in September 2014. At a local level the results were communicated to all Groups who developed local action plans in conjunction with their teams and Change Makers (change champions). These

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are published on the intranet under the Staff Impressions 2014 Results and Actions Plan page. These action plans are being monitored at a local level and through quarterly performance reviews. In section 4 we outline actions and changes that have been taken in response to feedback at a Trust level. Staff Impressions will be conducted in March/April 2016 and the results of this will be used to support a progress assessment of the Together Towards World Class programme. 3.4 NHS mandated Staff Friends and Family Test In April 2015 a paper was submitted to this Board presenting the results of the 2014/15 Staff Friends and Family Test for Quarters 1-4. As a reminder, NHS England introduced the Staff Friends and Family Test (Staff Friends and Family Test) in April 2014. We are required to undertake the Staff FFT in three quarters of the year i.e.

• Quarter 1: April-June; • Quarter 2: July-September; and • Quarter 4: January-March.

Quarter 3: October-December is when the NHS National Staff Survey is conducted and the Staff FFT questions are incorporated into the national survey. NHS organisations can choose to select a sample of staff to survey and are only mandated to survey all staff once a year. Here within the Trust we survey all staff in Quarters 1, 2 and 4 and ask the two mandatory questions about whether staff would 1)recommend the Trust to friends and family to receive care and treatment and 2)recommend the Trust to friends and family as a place to work. We have the option of also asking additional questions to fit with local needs. For example in Quarter 1 2015 (1-30 June) we asked staff additional questions to gather their feedback about areas for improvement and priorities for Together Towards World Class (details provided under Listening Events 3.5). Staff FFT can be completed online or via a paper-based survey. When Staff FFT was introduced in 2014 we saw a steady increase in the number of staff responding and recommending the Trust as a place to receive care and treatment and as a place to work. In 2014 communications and engagement for completing the survey were very centrally driven and co-ordinated to coincide with big staff engagement events e.g. feedback events, Together Towards World Class ‘birthday events’. This year we invited staff to complete Staff FFT in Quarter 1(June) while we also conducted staff Listening Events (see 3.5) hoping to secure similar, if not, improved results to 2014. However, in comparison to our results in 2014, in Quarter 1 2015 we saw a decrease in response rate and a fall in the number of staff recommending the Trust as a place for care and treatment and as a place to work. A summary of Quarter 1 2015 feedback against 2014 is provided in Appendix 1.

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Staff FFT will run at the following times for the remainder of the year (2015/16):

• Quarter 2: 1st – 30th September 2015; and • Quarter 4: 1st – 31st March 2016 (questions included in Staff Impressions 2016)

In section 5 of this report we discuss some of the challenges and lessons we have learned from our staff engagement activities and our planned response to these. Having already taken forward some of the actions early results for our Quarter 2 Staff FFT indicate that there has been a positive impact on the results. Results on 11th September 2015 indicate that 521 staff have completed the survey and said the following:

With another few weeks to go we are sure to see a further improvement in our results compared to Quarter 1 2015.

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3.5 Together Towards World Class Listening Events 2015 Listening Events, essentially a focus group, was introduced in 2014 as a means to gather staff feedback to help inform the shape and direction of the Together Towards World Class programme. As this was a new way of engaging staff in 2014 this year we revised our approach in response to the feedback we received the previous year which meant providing a balance between central and local/team events and ensuring we provided different and multiple ways to give feedback.

Therefore, in June 2015 we:

• added additional questions to the Quarter 1 Staff FFT (creating an online listening event);

• held one hour long Listening Events in central areas e.g. CSB led by Chief Officers and Programme Leads;

• held one hour long Listening Events in local/team areas led by Change Makers; and

• had graffiti boards in local/team areas that were managed by the Change Makers for their team members to write their feedback.

Through each of these formats above we asked staff to share their thoughts on what needed to be addressed to achieve our vision of becoming a world class healthcare provider.

The overall purpose of these engagement activities was to reach a wider staff group than in 2014, particularly staff in local areas as many staff told us in 2014 that they wanted more local events. The engagement activities were also designed to provide Together Towards World Class programme leads with feedback to help validate and shape the content of their work-stream activities for 2015/16. Appendix 2 contains a breakdown of the events and numbers of staff participating. 3.5.1 Feedback from the Listening Events and Staff FFT Feedback from the Listening Events and Staff FFT Q1 2015 was analysed and was categorised into five key themes. The feedback has been organised into a series of mind-maps which have been included in Appendix 3 for detail and reference. A summary of the themes is provided below:

1. In doing what we do This theme related to what staff said about how they would like things in general to be done in the delivery of their work and services. Staff talked about embracing technology solutions to deliver health services and particularly for patients to use in the education and management of their health. Staff also talked about involving the right people at the right time in the redesign of services and care pathways. Here this related to working in greater collaboration

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with staff, patients and healthcare partners – the sense being that earlier involvement and engagement leads to well designed and fit for purpose services. As you would expect many staff talked about the hospital facilities and in contrast to last year’s feedback want to see facilities enhanced so that they provide more of the expected facilities for our patients and visitors in an organisation of this size e.g. better wi-fi, breast feeding areas, vending machines, water fountains around the sites, play areas for children and wheelchairs. In addition to this staff also talked about enhancing the facilities holistically so that they really aided the recovery of patients. Suggestions they gave included making the hospital site more pleasant by having gardens and social areas and improving patient areas on the wards and in waiting areas. One of the key themes that emerged last year was that staff needed to get the basics right particularly in terms of customer services. This year we saw shift in staff talking about being more hospitable towards each other, patients and visitors. Whilst this does not mean they are comfortable with our level of customer service it does indicate that ‘customer service’ is being viewed in the context of this Trust and its people being more hospitable and oriented towards being welcoming, courteous and relationship focused.

2. Care, respect and value us Under this theme there were three key aspects that staff talked about. Firstly, they talked about their working environment and wanting to see improvements in things like the staff rooms and also wanting to see visible signs across the Trust about how staff members are treated by patients and visitors. For example they talked about seeing visible zero tolerance of violence and abuse towards them. From a staff perspective these visible and explicit signs and a clear demonstration of valuing and caring for staff members. Secondly, staff also talked about caring, respecting and valuing them by providing services that enabled them to holistically take care of their health and well-being. Some staff acknowledged that there was effort around healthy eating but limited focus on their physical and psychological well-being. For example staff spoke about the sport and recreation services that were previously on site and felt that little had been done to provide alternatives since the current building was built. They also talked about limited access to services and space that would support their psychological well-being e.g. comfortable staff-only facilities for staff to meet, read, eat and relax or a psychologist for staff to turn when they have complex and difficult patient contact. Thirdly, staff spoke about was how they are recognised and rewarded for their effort and contribution. Staff need/want to feel appreciated by the organisation, their colleagues, and their manger they talked about having a recognition scheme where colleagues, patients, visitors could nominate a member of staff for an award.

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3. Talk, share and inform This theme related to how staff would like to be talked to, how they want to be informed and their desire for information to be shared with them. Staff spoke about wanting to be aware of and understand some of the big change programmes/projects in the Trust e.g. intranet, integrated digital care records, redesign of the main entrance. They expressed concerns about the cost of these projects and not fully understanding the value and benefit of investments to patient care or the Trust and at the same time they were genuinely interested in knowing more about the changes taking place in the Trust. What staff were essentially feeding back is that want to be kept informed about progress and receive status updates regularly -they talked about this in terms of big Trust-wide changes but also things that were important to them or affected them e.g. successes and achievement, car parking passes, friends and family test results, 24/7 working, Trust performance etc. What was striking about the feedback under this theme was that staff last year talked a lot about wanting more and different channels of communication and this year their focus was very much on how they were communicated to. They talked about wanting communications (in person and presented communication) to be transparent, meaningful and relevant to them locally as well as wanting it to be visual and interactive when presented.

4. Develop us This theme is related to the theme of feeling valued and focuses on what staff said about their development as professionals. They talked about staff development and career development being seen as a priority by leaders and managers and felt at times this wasn’t given enough attention beyond compliance and mandatory training. They talked a lot about the skills and capabilities they felt they needed to develop or that needed to be developed in the Trust e.g. ICT, customer service, leadership and management skills, social media, innovation, improvement, business skills, soft skills etc. Staff also shared their ideas for enhancing their careers which included being exposed to new and different experiences; shadowing other professionals, volunteering, through secondments, talent management and defined career pathways. They felt that the Trust needs to have in place a range of opportunities that managers can use to support the development of staff careers.

5. Feel connected The final theme from staff feedback has been called ‘feel connected’ because at the heart of all the things staff said these words captured the sense and feeling of the feedback received. Staff talked about wanting leaders, locally and corporately, be visible and engaging – this was a shift from last year where the focus was predominantly on the visibility of Chief Officers. Staff also talked about the qualities they would like to see in leaders in the Trust and this included leaders who value, recognise and respect; involve and empower and communicate with them.

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Whilst some nostalgia remains with staff about the old hospital and the things they had previously many talked about wanting to feel like they were better connected to colleagues across the Trust and at different sites. This was for a number of reasons including wanting to socialise with them, to learn and share and mostly to know who their colleagues are in the Trust. Staff also talked about wanting to feel connected to patients through the way they interact and by ensuring they are the making patients focus of care provided through the services, facilities and environment we create in the Trust.

The above feedback was presented to Together Towards World Class Board in August 2015 and has been responded to and incorporated into the Together Towards World Class work-stream plans for 2015/16. These plans are due to be presented for agreement and sign-off by the Together Towards World Class Board in September 2015. In October 2015 the feedback from the Listening Events will be presented to the Change Makers alongside the Together Towards World Class programme leads who will be presenting their work-plans and details about how the Change Makers can get involved in various projects to support improvements across the Trust. It is proposed an update on the Together Towards World Class programme for 2015/16 will be presented to this Board in November 2015. In section 5 of this report we discuss some of the challenges and lessons we have learned from our staff engagement activities and our planned response to these.

4 How we have responded to feedback and actions taken

In 2014 all of the feedback that was gathered from the National Staff Survey, Staff Impressions, Staff FFT and the Listening Events was analyzed collectively and addressed through the Together Towards World Class work-streams. The following provides details about the actions we have taken: World Class Experience • Launched a patient experience diary to encourage patients to note down the

questions they want to ask staff about their care. • Introduced a Ward Information Board for each ward with basic information on visiting,

meals and infection control. • Held a patient experience week. • Produced and distributed a set of 12 core patient information leaflets to all areas

across the both hospital sites. These are also available in both written and audio format in both English and Polish.

• Supported a number of departments to enable them to meet their national standards relating to patient information.

World Class Services • Become the first NHS organisation to have its Lean Competency System accredited

by the prestigious Cardiff Business School and have commenced implementing it • Supported elective services changes, including Cardiac Cath Lab and Theatre

booking. • Supported emergency care pathways development e.g. establishing a second

emergency theatre. Page 9 of 19

• Developed an Intellectual Property strategy with Warwick University • Completed the first steps towards an Electronic Patient Records (EPR) system World Class Conversations • Launched Chief Officers’ Forum • Introduced CEO Direct where any member of staff can pose a question to the CEO • Piloted an employee recognition scheme • Introduced Your Week to reduce the number of all user emails • Commenced procurement of a new intranet system World Class Leadership • Developed and introduced a leadership behavioural framework • Developed and implemented Leadership Notes – a guide for the Trust’s Leaders • Developed and implemented Leading Together the Trust’s multi-professional

leadership development programme. The programme incorporates focus on supporting leaders to develop and maintain high performing teams and includes a compulsory master-class on equality and diversity to ensure our leaders lead the way in preventing and tackling all forms discrimination.

• Developed a ‘A day in the life of’ programme’ where Chief Officers spend the day working with a team across the Trust

World Class People • Developed and introduced the Trust values and behavioural frameworks for all staff • Launched a ‘Living Our Values’ Toolkit to support embedding of values in the Trust. It

includes support for individuals and teams on how to constructively challenge each other respectfully when behaviours are not as expected under our UHCW behavioural framework.

• Implemented values based selection process for Band 5 Nurses and HealthCare Assistants

• Introduced first-phase of values based induction • We re-launched the Health and Well-Being events to support the physical, mental and

financial health of staff. This in part responded to feedback on the percentage of staff feeling pressure in last 3 months to attend work when feeling unwell. This question is also incorporated into Staff Impressions, our local survey, alongside a probing question to understand why staff may feel under pressure to come to work. Results highlighted that staff primarily place themselves under pressure to come to work when unwell as to not let colleagues or patients down.

• Introduced a new staff engagement programme • Recruited, introduced and initiated development of ChangeMakers The increase in staff engagement since the launch of the Together Towards World Class programme in March 2014 has started to shift the culture of the organisation. This is most clearly demonstrated by our engagement score in the National Staff Survey 2014 increasing from 3.66 to 3.77 and we have also been recognised by the Health Service Journal as one of the Best Places to Work 2015. This year we have taken feedback from the Listening Events and Staff FFT to develop Together Towards World Class work-streams plans for 2015/16. These plans are due to be approved in September 2015 and an update on the programme will be submitted to this Board. In the section below we discuss some of the challenges with staff engagement and our response to managing these.

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5 Challenges of Staff engagement The Together Towards World Class programme and throughout 2014 we introduced several new ways of engaging staff. We are in the early stages of our staff engagement journey and have experienced several challenges. In particular we have seen response rates to staff surveys, in particular the Staff FFT in Quarter 1 2015, decrease. We believe this is due to several factors:

a. Promoting participation in staff surveys (Staff FFT, Staff Impressions and National Staff Survey) has been centrally driven by the Organisational Development Team. For example the Staff FFT in 2014 was always combined with a staff engagement event where we asked staff to complete their feedback ‘in the moment’ e.g. birthday events. This enabled us to reach a greater number of staff in local areas. However, this centrally driven approach lacked sustainability and this has shown in Staff FFT Quarter 1 2015 results

b. Over reliance on central communications e.g. emails, cascade communications, Your Week and the intranet do not have the reach we would aspire to in the Trust as the majority of our staff work in clinical areas and do not have easy access to computers.

c. The Trust’s change champions, Change Makers, have been great supporters by encouraging staff in their local areas to complete staff surveys but their engagement in these promotion type activities is inconsistent as they themselves vary in levels of engagement, skill and capability. Some are not equipped to manage the scepticism and distrust they encounter which has arisen because of past experiences of giving feedback and feeling that nothing has happened as a result. Additionally, if they lack local level support from their managers and leaders they are unlikely to have the traction they need to encourage staff to participate in feedback activities.

d. Lack of leader, manager and staff understanding about the frequency and purpose of the different engagement channels has meant that local level ownership has been limited – possibly due to operational pressures and because staff engagement has been centrally driven resulting in decreased local level ownership. Additionally, the frequency of Staff FFT, in particular, has led to some staff being confused about whether they should complete it as they feel like they ‘just did it’.

e. A challenge of the Staff FFT is that as results are in for a quarter there isn’t sufficient time to respond and take action in a meaningful way. As a result staff are not seeing, or feel they are being communicated to about actions taken, or progress with actions, in a timely fashion and this may be impacting engagement as staff are unlikely to continue providing feedback if they do not see some action and impact as a result.

We are taking the following actions to help address challenges:

1. The incorporation of Staff FFT results in the Integrated Performance Report has served as a good springboard for the Organisational Development Team

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via the HR Business Partners to meet with Group Management Teams and Ward Managers to educate and raise awareness about staff engagement but in particular the Staff FFT. The purpose of the meeting is to encourage more local ownership over staff engagement activities as well as supporting leaders and managers in how to use the feedback they receive at a local level to make improvements that contribute to improving staff experiences. The hope is that education and raising awareness will increase the confidence of leaders and managers to treat staff engagement as a priority and continuous activity. Attendance at meetings commenced in August 2015 and will continue until all Group Management Team meetings have been attended. Additional support will be provided to Groups as requested by the Organisational Development Team and HR Business Partners.

2. As mentioned above one of the challenges with Staff FFT is the timeliness of responding and acting on staff feedback. Corporately staff feedback has been responded to via the Together Towards World Class programme where each work-stream is incorporating feedback from Staff FFT and the Listening Events into their work plans for 2015/16. Work-stream plans are being presented and approved by the Together Towards World Class Board in September 2015.

Group and Speciality level results are communicated to Group Management Teams and Change Makers through newly introduced visual posters for Staff FFT which should help generate awareness and interest, an example has been included in Appendix 1 of Quarter 1 2015 Trust level results. Visual presentation of feedback is something that we will aim to do for all staff engagement activities. For Staff FFT Quarter 2 2015 results The Organisational Development Team will also provide each Group with a report of their qualitative feedback (cleansed to ensure no-one is identifiable), to view these alongside their quantitative results to enable local areas to respond to feedback from their staff.

3. The Organisational Development Team has also agreed with some local areas e.g. Neonatal, Pathology, CSB etc. to pilot approaches to encouraging participation e.g. ‘pass the baton’ and/or ‘pass the hand gel bottle’. Areas are keen to participate in trying new approaches and are currently being piloted as Staff FFT Quarter 2 2015 runs throughout September. The hope is that the element of competition and buzz created through promotional activity and combined with communication of results weekly via Your Week, communications to Group Management Teams, Ward Managers and Change Makers will encourage and embed Staff FFT as regular feedback channel at a local level.

4. Access to paper copies of surveys has been made easier by providing a

printable copy for leaders, managers and Change Makers to distribute. Although preference remains for online completion to reduce the time and cost burden of data capturing from paper copies.

5. All areas are soon to be in receipt of dedicated learning laptops which we hope

will support staff to get access to staff surveys more readily.

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6. Work is being planned to develop a sub-group of the Change Makers to take a greater lead on staff engagement activities in terms of its promotion and to support the analysis of qualitative feedback e.g. from Staff FFT as well as supporting and leading ‘quick wins’ to respond to staff feedback with appropriate support. The reason for this is that it would a be a good demonstration of staff being empowered to lead improvements and changes thereby helping to establish the role and value of staff feedback within the Trust.

7. We are also introducing a monthly Partnership and Engagement Forum that is

chaired by the Chief Workforce & Information Officer which will play a greater role in leading response to staff feedback. In addition, a newly refreshed quarterly JNCC meeting, Chaired by the Chief Executive will be introduced.

We are actively investing time and effort to position different staff engagement channels as frequent and continuous staff feedback mechanisms within the Trust. Early indications are that this is having an impact on the Staff FFT as discussed above. 6 Governance As indicated above at a corporate level separate action plans are not developed for each of the different engagement channels, therefore the Together Towards World Class programme board, chaired by the Chief Executive, retains oversight of staff engagement, achievements and risks.

7 Recommendations This paper has been submitted for information and review by the Board. Name and Title of Author: Rajni Martin, Organisational Development Manager & Rachael Atkins, Organisational Development Advisor Date: 14 September 2015

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Appendix 1: Staff Friends and Family results The two charts below show a comparison of Staff FFT 2014 results with Quarter 1 2015 results. *figures in the brackets represent the number of staff responding to the survey Question 1: Recommend the Trust as a place to receive care and treatment

81

86

91

79

5

6

3

7

14

8

6

14

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2014 Qtr 1 (1933)

2014 Qtr 2 (1148)

2014 Qtr 4 (1089)

2015 Qtr 1 (180)

Recommender Non-recommender Unsure

Question 2: Recommend the Trust as a place to work

64

76

84

64

12

10

7

19

24

13

10

17

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2014 Qtr 1 (1933)

2014 Qtr 2 (1148)

2014 Qtr 4 (1089)

2015 Qtr 1 (180)

Recommender Non-recommender Unsure

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Example Staff FFT Poster displaying results from Quarter 1 2015

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Appendix 2: Together Towards World Class Listening Events 2015

Engagement activity Number of events

Number of participants

Central Events led by Chief Officer/Programme Lead

CSB FM Building Pathology at UH

St Cross board room

Paediatrics Seminar Room

George Eliot – Pathology

Rotunda Staff Restaurant

Warwick Hospital – Pathology

Ward 22 & 24 Seminar Rooms

Burton Hospital – Pathology

Various pre-scheduled team meetings

Clinical Skills Room

17 122

Local events - Change Maker led Listening Events & graffiti boards

13 289

Staff FFT – additional questions responded to 33

Total 31 444

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Appendix 3: Themes and feedback from Listening Events 2015 and Staff FFT Q1 2015

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Title Workforce Race Equality Standard (WRES) Author Barbara Hay, Head of Diversity Responsible Chief Officer

Karen Martin, Chief Workforce and Information Officer

Date 24 September 2015 1. Purpose • To inform Trust Board of the new Workforce Race Equality Standard (WRES) • To provide assurance to Trust Board that UHCW is compliant with NHS England’s

requirement to report on Black Minority Ethnic (BME) workforce statistics • For the Trust Board to note the content of the WRES report in particular the actions to

address gaps and/or issues with data collection 2. Background and Links to Previous Papers It was agreed at the Trust Board meeting held on 25th June 2015 that the WRES report would be presented at a future Board meeting when all relevant statistics had been collated. The NHS Equality and Diversity Council (EDC) announced on 31st July 2014 that it had agreed action to ensure employees from BME backgrounds have equal access to career opportunities and receive fair treatment in the workplace. The move follows recent reports which have highlighted disparities in the number of BME people in senior leadership positions across the NHS, as well as lower levels of wellbeing amongst the BME population. The EDC pledged its commitment, subject to consultation with the NHS, to implement this as one measure to improve equality across the NHS, which would start in April 2015. 3. Narrative The WRES, for the first time, requires organisations employing almost all of the 1.4 million NHS workforce to demonstrate progress against a number of indicators of workforce equality, including a specific indicator to address the low levels of BME Board representation. The WRES Standard will be included in the 2015/16 Standard NHS Contract. The regulators, the Care Quality Commission (CQC), National Trust Development Agency (NDTA) and Monitor, will use both standards to help assess whether NHS organisations are well-led. The Standards will be applicable to providers, and extended to clinical commissioning groups through the annual CCG assurance process. The report is presented in the mandated reporting template which will allow for easier bench-marking and standardised responses across the NHS.

Simon Stevens, Chief Executive of NHS England, said: “The Five Year Forward View sets out a direction of travel for the NHS – much of which depends on the health service embracing innovation, engaging and respecting staff, and drawing on the immense talent in our workforce. “We know that care is far more likely to meet the needs of all the patients we’re here to serve when NHS leadership is drawn from diverse communities across the country, and when all our frontline staff are themselves free from discrimination. These new mandatory standards will help NHS organisations to achieve these important goals.” (NHS England website)

http://www.england.nhs.uk/ourwork/futurenhs/

The work stemming from the WRES will support the Trust’s TTWC programme in all areas. 4. Areas of Risk Regulatory risks; the regulators, the Care Quality Commission (CQC), National Trust Development Agency (NDTA) and Monitor, will use the WRES to help assess whether NHS organisations are well-led. If the Trust does not meet the required standards, regulatory action may follow; this could also negatively impact on the Trust’s reputation. 5. Governance Implementation of the WRES is in keeping with one of the guiding principles of the NHS as set out in the Constitution in that the NHS is under a duty to promote equality in the services that it provides. A Working Group is being established and a further report will be submitted to the Trust Board in December 2015 which will identify how the issues and gaps will be addressed. 6. Responsibility Barbara Hay, Head of Diversity, is the lead for implementation of the WRES working in partnership with ESR & Workforce Information team, Staffside, Learning & Development, HR Business Partners and TTWC. The responsible Chief Officer is Karen Martin (Chief Workforce and Information Officer). 7. Recommendations

1. Approve the content of the WRES report 2. Approve the immediate publication of the WRES report 3. Agree to receive a further report and action plan in December 2015 identifying how

issues and gaps will be addressed.

Name and Title of Author: Barbara Hay, Head of Diversity Date: 4th September 2015

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Trust Board (Public) 24 September 2015 – Workforce Race Equality Standard Report

Indicator 2 - there is no meaningful data available for the previous year. need to carry out a system review to determine a more robust way of capturing data. Indicator 4 - No requirement to record centrally within the Trust. Cannot retrieve the data from ESR due to technical issues. IBM are aware and it is a known error waiting to be resolved. Working towards finding a resolution for collecting and reporting centrally. We will be carrying out campaigns to encourage all staff, but particularly BME employees to update their profile and report all training on the ESR system. We have identified that although there are 820 ISS employees who are contracted under the Trust's contract of employment, ISS do not record the relevant information for this report in the same way. This means that we are not able to map across the information. As part of the action plan to be developed to address issues raised by this report we will be looking at how we can ensure that information about ISS staff is aligned with that of the Trust.

All user communication has been distributed explaining the importance of recording this information and guides on how to amend this information within ESR.

No requirement to record centrally within the Trust. Cannot retrieve the data from ESR due to technical issues. IBM are aware and it is a known error waiting to be resolved. *only qualification data available. Known error with training report being investigated* Available data relates to CPD opportunities available to Healthcare Assistant workforce and highlights 14.5% of qualifications commenced by BME employees in 2013 & 2014.

Working towards finding a resolution for collecting and reporting centrally.

UHCW has seen an improvement from 2013 to 2014. The percentages presented reflect the % of that particular group of respondents i.e. 30% of the respondents who were white were experiencing harassment, bullying or abuse from patients, relative or the public in the last 12 months.

The percentages presented reflect the % of that particular group of respondents. UHCW has seen an increase in white members of staff reporting harassment, bullying and abuse and a small decrease in the numbers of BME staff reporting this.

We will be offering the opportunity for BME staff to join a BME network which will enable them to highlight and discuss issues of discrimination as well as other issues they feel impact on them as BME employees.. These issues will be escalated to the appropriate department and or committee. Communication to

organisation regarding the importance of keeping personal information up to date.

= white 81.7%, BME 18.3%UHCW Board = white 93.31%, BME 7.69%

= white 81.7%, BME 18.3%UHCW Board = white 100%, BME 0%


PUBLIC TRUST BOARD PAPER Title Annual Audit Letter 2014/15 Author PricewaterhouseCoopers LLP (letter) Responsible Chief Officer

David Moon, Chief Financial and Strategy Officer

Date 24th September 2015 1. Purpose This paper and the attached letter provides a high level summary of the results of the Trust’s external audit for 2013/14 and is presented to the Trust Board for assurance. 2. Background and Links to Previous Papers This paper and the accompanying document follow on from the presentation of the Annual Accounts 2014/15 and discussion that took place at the extraordinary Trust Board meeting held on 2nd June 2014, at which the annual accounts for the period 2014/15 were adopted at the recommendation of the Audit Committee. 3. Narrative Following the approval process outlined above, the Trust’s external auditor, PricewaterhouseCoopers LLP (PWC) have issued their Annual Audit Letter for the period 2014/15, which confirms the unqualified opinion that was issued. A section 19 letter has however been issued by PWC to the Secretary of State as set out on page 7 given the Trust’s financial position in terms of the requirement to break even over a 3-year period. This also impacts upon the value for money conclusion in that at the time of writing, the Financial Recovery Plan was not in place. This letter marks the conclusion of the audit process for the financial year 2014/15 and is provided to the Trust Board by way of assurance. 4. Areas of Risk There are no specific areas of risk highlighted within the Annual Audit Letter aside from the aforementioned financial position, of which the Trust Board is already aware. 5. Governance The annual audit of the Trust’s financial and quality accounts is a statutory and regulatory requirement. The Annual Audit letter is received by the Trust Board each year and features in full in the Trust’s Annual Report. 6. Responsibility The Chief Finance Officer is primarily responsible although the Quality Account element rests with the Chief Medical Officer. 7. Recommendations The Trust Board is asked to RECEIVE the Annual Audit Letter 2014/15 and to raise any questions in relation to the same.

www.pwc.co.uk

Government and Public Sector

University Hospitals Coventry and Warwickshire

NHS Trust Annual Audit Letter

2014/15 Audit

June 2015

http://www.pwc.co.uk/

UHCW NHS Trust – Annual Audit Letter June 2015

Members of the Audit Committee University Hospitals Coventry & Warwickshire NHS Trust Clifford Bridge Road Coventry CV2 2DX

June 2015

Ladies and Gentleman

We are pleased to present our Annual Audit Letter summarising the results of our 2014/15 audit. We hope this provides a useful source of reference for you.

Yours faithfully

PricewaterhouseCoopers LLP

Code of Audit Practice and Statement of Responsibilities of Auditors and of Audited Bodies

In April 2010 the Audit Commission issued a revised version of the ‘Statement of responsibilities of

auditors and of audited bodies’. It is available from the Chief Executive of each audited body. The

purpose of the statement is to assist auditors and audited bodies by explaining where the responsibilities

of auditors begin and end and what is to be expected of the audited body in certain areas. Our reports

and management letters are prepared in the context of this Statement. Reports and letters prepared by

appointed auditors and addressed to members or officers are prepared for the sole use of the audited

body and no responsibility is taken by auditors to any member or officer in their individual capacity or to

any third party.

PwC Cornwall Court

19 Cornwall Street Birmingham

B3 2DT


Contents

Introduction 6

Audit Findings 7

Final Fees 10


The purpose of this letter

This letter provides the Trust’s Board with a high level summary of the results of our audit for 2014/15, in a form that is accessible for you and other interested stakeholders.

We have already reported the detailed findings from our audit work to the Audit Committee in the following reports:

Annual Audit Plan – November 2014;

Audit Committee Update Reports for work carried out during 2014/15 – quarterly;

Audit opinion for 2014/15 financial statements, incorporating the value for money conclusion –

June 2015.

Report to those charged with Governance (ISA (UK&I) 260) – June 2015; and

Report on the Annual Quality Account – June 2015.

We have included in this report our significant audit findings. You can find a summary of our key recommendations in Appendix A.

*Our work on the Quality Account was undertaken as a piece of non-audit work this year.

Scope of work

We carry out our audit work in accordance with the Audit Commission’s Code of Audit Practice (NHS), International Standards on Auditing (UK and Ireland) and other relevant guidance issued by the Audit Commission.

You are responsible for preparing and publishing the Trust’s financial statements, including the annual governance statement. You are also responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in your use of the Trust’s resources.

As auditors we need to:

form an opinion on the financial statements;

review the Trust’s annual governance statement;

form a conclusion on the arrangements that you have in place to secure economy, efficiency and

effectiveness in your use of the Trust’s resources; and

carry out any other work specified by the Audit Commission, which this year comprised work on

the Trust’s Quality Account.

We have carried out our audit work in line with our 2014/15 Audit Plan that we issued in November 2014.

Introduction


Accounts We audited the Trust’s accounts in line with approved Auditing Standards and issued an unqualified audit opinion in June 2015.

Accounting issues We identified the following key issues and estimates during our audit work:

Legal Claims – The Trust has been subject to an ongoing employment tribunal case during the past 12 months. We received a letter from the Trust’s legal advisers on this claim which is not inconsistent with the advice the Trust has received. This confirmed that any potentially liability is estimated not to be material.

PFI Lifecycle – your prepayment balance decreased during 2014/15 to £25.6 million (prior year £31 million), although still remains a significant estimate on the Trust balance sheet. This amount represents payments made to the PFI company that have not yet been spent on asset lifecycle replacements.

Property Valuations – A key area of judgement in your accounts remains around the valuation of your estate, particularly the main hospital and ‘Modern Equivalent Asset’ values. Your in-year valuation resulted in an increase of £11.2 million to the value of Property, Plant and Equipment in your accounts. Through a review of base data and an assessment against national and local trends we are satisfied with the overall valuation of your assets.

Adjustments to the Accounts We identified no material misstatements in the draft accounts.

Financial Standing The Trust has recorded a deficit of £16.9 million in 2014/15, and has submitted a deficit plan for 2015/16 of £22.4 million. The Trust has relied upon PDC financing during 2014/15, and is likely to need to do so again in 2015/16. The Manual for Accounts guidance from which you prepare your accounts states that an NHS body will have concerns about its “going concern” status only if there is a prospect of services ceasing altogether. There is no evidence that this is the case. In order to further support the preparation of the accounts on a going concern basis, the Trust has obtained from the Trust Development Authority a letter which confirms that they will make sufficient cash financing available to the Trust over the next 12 month period We therefore concluded that the Trust has appropriately prepared its accounts on a going concern basis.

Section 19 Referral Auditors of NHS bodies have a specific responsibility under section 19 of the Audit Commission Act 1998 (s19) to refer immediately to the Secretary of State for Health any matter where they have reason to believe the body or an officer of the body:

a. is about to make, or has made, a decision which involves or would involve the incurring of expenditure which is unlawful; or

Audit Findings


b. is about to take, or has taken, a course of action which, if pursued to its conclusion, would be unlawful and likely to cause a loss or deficiency.

NHS Trusts have a statutory duty to break even over a three-year period (or a five-year period with the agreement of the NHS Trust Development Authority). If the Trust has, in the auditor’s view, a realistic recovery plan for years 2 and 3 such that it is projecting breaking even over a three-year period, there would be no duty to refer as neither the s19(a) nor s19(b) tests would be satisfied. If there was no realistic recovery plan then a referral under s19(b) would be appropriate.

The Trust recorded a deficit of £16.9m in 2014/15, and has submitted a planned deficit plan of £22.4 million to the Trust Development Authority. This would result in a cumulative deficit at the end of year 2 of £39.3 million. To recover this in year 3 would require a surplus of the same amount. The Trust does not have a plan in place to achieve this statutory duty. As a result we wrote to the Secretary of State outlining these facts in what is referred to as a section 19 referral letter.

We decided that a ‘Public Interest Report’ was not required.

Our value for money conclusion Our value for money code responsibility requires us to carry out sufficient and relevant work in order to conclude on whether the Trust has put in place proper arrangements to secure economy, efficiency and effectiveness in the use of resources.

The Audit Commission guidance for 2014/15 included two criteria:

1. The organisation has proper arrangements in place for securing financial resilience; and

2. The organisation has proper arrangements for challenging how it secures economy, efficiency and effectiveness.

The focus of the first criteria is whether the organisation has robust systems and processes to manage financial risks and opportunities effectively, and to secure a stable financial position that enables it to continue to operate for the foreseeable future. A number of the issues noted in this letter impact on this criterion:

The Trust is unlikely to meet its statutory break-even requirement;

A financial recovery plan has yet to be put in place to recover the deficit over the period required by law; and

In delivering its financial plans for 2015/16 the Trust will continue to require cash financing to meet its liabilities as they fall due.

We also considered the following factors:

A number of external factors have contributed to the Trust’s financial performance;

The Trust has met their Cost Improvement Programme target in full and has robust governance arrangements in place to manage this process now and in the future;

There are proper arrangements for challenging how the Trust secures economy, efficiency and effectiveness; and

There have been no adverse CQC reports or other regulatory findings during the year.

Taking all of the factors together, we decided to issue a qualified (except for) conclusion on the Trust’s value for money conclusion. This stated that “In considering the Trust’s arrangements for securing financial resilience, we identified that the Trust does not have a financial plan to achieve its statutory break-even duty over a three year period and will continue to require external cash financing”.


Annual Governance Statement (AGS) The aim of the AGS is to give a sense of how successfully the Trust has coped with the challenges it faces and of how vulnerable the organisation’s performance is or might be, drawing on evidence on governance, risk management and controls.

We reviewed the AGS to see whether it complied with relevant guidance and whether it was misleading or inconsistent with what we know about the Trust. We found no areas of concern to report in this context.

Quality Account

You have a legal duty to publish a Quality Account which must contain the elements required by Quality Accounts Regulations. The Department of Health asked the Trust to obtain independent assurance over the Quality Account, and you asked us to carry out this work. We are required to issue a limited assurance conclusion on whether anything has come to our attention that causes us to believe that:

the Quality Account is not prepared in all material respects in line with the information requirements prescribed in the Schedule referred to in Section four of the Regulations (“the Schedule”);

the Quality Account is not consistent in all material respects with the sources specified below; and

the specified indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account have not been prepared in all material respects in accordance with Section 10c of the NHS (Quality Accounts) Amendment Regulations 2012 and the six dimensions of data quality set out in the NHS Quality Accounts - Auditor Guidance 2014/15 issued by the Department of Health.

We carried out this work in line with guidance issued by the Department of Health. This work was carried out during May and June 2015. The findings were discussed with the Trust in June 2015 and reported to the Audit Committee in July 2015.


We reported our fee proposals in our audit plan. Our actual fees charged were as follows:

2014/15 outturn 2014/15 fee proposal

2013/14 final outturn

Financial Statements 100,000 100,000 100,000 Quality Account - - 10,000 Use of Resources 24,260 24,260 24,260 Total audit fee 124,260 124,260 134,260

Our fees for other non-audit services provided are as follows:

We undertook a CQC preparedness review and our support was aimed at providing the Trust

with insight into areas of strengths and weakness identified to inform continuous quality

improvement and to help the Trust to prepare for a CQC inspection. The total fees for this work were £98,000.

We also undertook a review of your Quality Accounts for £10,000. This work was previously undertaken as part of our audit responsibilities.

Final Fees

In the event that, pursuant to a request which you have received under the Freedom of Information Act 2000 (as the same may be amended or re-enacted from time to time) or any subordinate legislation made thereunder (collectively, the “Legislation”), you are required to disclose any information contained in this report, we ask that you notify us promptly and consult with us prior to disclosing such information. You agree to pay due regard to any representations which we may make in connection with such disclosure and to apply any relevant exemptions which may exist under the Legislation to such information. If, following consultation with us, you disclose any such information, please ensure that any disclaimer which we have included or may subsequently wish to include in the information is reproduced in full in any copies disclosed.

©2015 PricewaterhouseCoopers LLP. All rights reserved. 'PricewaterhouseCoopers' refers to PricewaterhouseCoopers LLP (a limited liability partnership in the United Kingdom) or, as the context requires, other member firms of PricewaterhouseCoopers International Limited, each of which is a separate and independent legal entity.


Title NHS England EPRR Core Standards 2015 Author John Dodds, Emergency Planning Manager Responsible Chief Officer

David Eltringham, Chief Operating Officer

Date 24 September 2015 1. Purpose It is a requirement of NHS England that UHCW NHS Trust submits a self-assessment report against the NHS EPRR (Emergency Preparedness, Resilience and Response) National Core Standards. The purpose of the report is to identify the current status of EPRR within UHCW NHS Trust, and the work plan to ensure full compliance within the year. It is a requirement that the report receives executive support and is approved by the Trust Board. The assessment is via a red, amber, and green classification: Red Not Compliant Amber Not Compliant, but in the EPRR work programme Green Fully compliant 2. Background and Links to Previous Papers The NHS needs to be able to plan for and respond to a wide range of incidents and emergencies that could affect patient care. These could be anything from severe weather to an infectious disease outbreak or a major transport incident. In 2013 NHS England commissioned the first self-assessment process for EPRR core standards, which was completed by the Emergency Planning Department at UHCW NHS Trust. Subsequent Core Standards returns have been submitted for 2014 and 2015 and were presented to the Trust Board. This paper outlines the EPRR Core Standards submission for 2015 for the Trust. Narrative The Trust is currently fully compliant (marked green) with 78 of the 84 core standards. The remaining six standards are graded as ‘amber’ meaning that there is a plan to have them in place within the financial year. Work has already begun on implementing these changes within the Emergency Planning Department. The areas that the Trust are not fully compliant with relate to ongoing training packages; the introduction of 4 new Core Standards relating to Pandemic Flu; and some minor Chemical, Biological, Radiological and Nuclear (CBRN) equipment requirements, in relation to which advice from West Midlands Ambulance Service (WMAS) is awaited; this does not however impact on the Trusts ability to respond to these incidents The Emergency Planning Manager has already completed a training needs analysis and has developing a training and exercising programme for UHCW NHS Trust, whilst the Emergency Planning Officer has completed training for the new members of the Trust On Call Management Rota. In addition, staff have undertaken Silver Commander Training, and Strategic Leadership in a Crisis training. The Trust has also participated in several multiagency exercises.


3. Areas of Risk The following areas of minor risk apply in regards to the six standards that are graded as ‘amber’;

• CPD portfolios are being developed for on call staff, but this will not compromise the on call function.

• New standards have been introduced in relation to Pandemic Flu preparedness. The trust has a Pandemic Flu plan, but again this is under going review, and the trust will be able to undertake a proportionate response if required.

• We are awaiting some guidance on minor pieces of CBRN equipment from WMAS, but this will not affect the Trusts ability to respond to such an incident

4. Governance The Trust is a category 1 responder for the purpose of the Civil Contingencies Act 2004 and as such, has a clear set of roles and responsibilities in respect of emergency preparation and response at a local level. The Trust Board is ultimately responsible for ensuring that appropriate arrangements are in place to ensure that the Trust can respond in accordance with requirements. Progress against the action plan will be monitored and declared through the Arden, Herefordshire and Worcestershire NHS England Emergency Planning Advisory Group and the Arden Local Health Resilience Partnership. 5. Responsibility The Emergency Planning Manager is the responsible manager for ensuring the rectification plan is completed, reporting to the Accountable Emergency Officer at UHCW NHS Trust; the Chief Operating Officer. 7. Recommendations [A] The Board is invited to note:

1. The full compliance with 78 of 84 standards required by NHS England. 2. The rectification plan that is already in place to ensure that the remaining six

standards are achieved as soon as possible. and [B] Approve

1. Submission of the attached to NHS England. Name and Title of Author: John Dodds, Emergency Planning Manager Date: September 2015

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NHS England EPRR Core Standards Self Assessment 2015 Report to UHCW Trust Board

NHS England EPRR Core Standards

Self Assessment 2015

September 2015

Report by:

John Dodds Emergency Planning Manager

On Behalf of:

Claire Bonniger Associate Director of Nursing (Delivery)

Emergency Planning Lead

And

David Eltringham Chief Operating Officer

(Accountable Emergency Officer)

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Contents

Contents ....................................................................................................................... 2

List of Abbreviations ..................................................................................................... 3

1.0 Situation .............................................................................................................. 4

2.0 Background ......................................................................................................... 4

3.0 Assessment ......................................................................................................... 5

4.0 Recommendations ............................................................................................... 5

5.0 Work Plan and Action Tracker ............................................................................. 6

Page 2 of 17


List of Abbreviations AHW AT Arden, Herefordshire and Worcestershire NHS England Area

Team BC Business Continuity BCP Business Continuity Plan CBRN Chemical, Biological, Radiological and Nuclear CCG Clinical Commissioning Group COG Chief Officer’s Group COO Chief Operating Officer DIM Detection, Identification and Monitoring ED Emergency Department EPAG Emergency Planning Action Group EPM Emergency Planning Manager EPO Emergency Planning Officer EPRR Emergency Preparedness Resilience Response EPSC Emergency Planning Steering Committee GRS Global Resilience Services HART Hazardous Area Response Team HAZMAT Hazardous Materials ICC Incident Control Centre IOR Initial Operational Response ISO22301 International standard for business continuity JESIP Joint Emergency Services Interoperability Programme LHRP Local Health Resilience Partnership MIP Major Incident Plan. NAIR National Arrangements for Incidents Involving Radiation NHS National Health Service NOS National Occupational Standards PHE Public Health England PPE Personal Protective Equipment QGC Quality Governance Committee RAG Red, Amber, Green SOP Standard Operating Procedure SORT Special Operations Response Team Tac-Ad Tactical-Advisor TNA Training Needs Analysis UHCW NHS Trust University Hospitals Coventry and Warwickshire NHS Trust WMAS West Midlands Ambulance Service

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1.0 Situation The Arden, Herefordshire and Worcestershire NHS England Area Team have set a date for the 31st July 2015 to submit a “RAG” rated self assessment on the EPRR Core Standards 2015. This assessment needs to have been approved by COG and a draft paper submitted for review by the Trust Board, or Quality Governance Committee. NHS England will accept an assurance (letter dated 30th June 2015, to all AEO’S) from the Accountable Emergency Officer (COO) that if the core standards submission cannot be signed off by the Trust Board by this date, that the process for approval is being undertaken, and this was submitted with the Core Standards Return. The self assessment process for 2015 includes a “peer review” of the three Acute Trusts in the Arden cluster, along with Coventry and Warwickshire Partnership Trust, and the three CCGs, undertaken in August 2015, and a presentation to the LHRP in September 2015 of the level of compliance with the Core Standards. In addition, an additional section has been added for 2015, undertaking a “deep dive” into Pandemic Flu preparedness. As this is a new section, these standards are included in the EPRR Work Programme for 2015/16. Whilst the trust has a Pandemic Flu plan, it is currently being reviewed, therefore being highlighted as Amber with the Core Standards. The “RAG” rating is as follows;

• Red – Not compliant with core standard and not in the EPRR work plan within the next 12 months.

• Amber – Not compliant but evidence of progress and in the EPRR work plan for the next 12 months

• Green – Fully compliant with core standard. Where a core standard is green the evidence has been recorded against it, where there are any ambers or reds there is a rectification plan against it with a target date for completion.

2.0 Background The NHS needs to be able to plan for and respond to a wide range of incidents and emergencies that could affect patient care. These could be anything from severe weather to an infectious disease outbreak or a major transport incident. Under the Civil Contingencies Act (2004), and the NHS England EPRR Framework, 2013, NHS organisations and sub-contractors must show that they can deal with these incidents while maintaining services to patients. This work is referred to in the health service as ‘emergency preparation, resilience and response’ – EPRR. The core standards will be used in the following way;

• As a minimum standard that all NHS funded organisations and providers of NHS funded care must meet.

• The Accountable Emergency Officer in each organisation is responsible for making sure these standards are met.

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• All NHS Commissioning Board EPRR framework guidance will include relevant extracts from these standards. EPRR control processes will require evidence that the standards are being met.

3.0 Assessment The Trust Self Assessment is follows: Green Fully compliant 78 Amber In Current Work Programme 6 Red Not Compliant 0 The Trust is already working on the rectification programme for the remaining core standards, although several of these have arisen as a result of ongoing reviews to plans, or ongoing training. It is expected that these will be completed before the end of the 2015/16 financial year. The key areas for the Amber ratings are:

• Training CPD portfolios for on call staff – this is an ongoing process • Introduction of new Pandemic Flu Core Standards for 2015 • CBRN decontamination equipment that we are awaiting advice from

WMAS on, but this does not impede the Trusts ability to respond to a CBRN incident

4.0 Recommendations The Emergency Planning Team continues the programme on training, plan reviews, and Pandemic Flu preparedness, which will be implemented by the Emergency Planning Officer and the Emergency Planning Manager to ensure that UHCW NHS Trust becomes compliant with the NHS England Core Standards 2015.

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5.0 Work Plan and Action Tracker Standard Description RAG Evidence / Rectification Plan Responsible Completion

Date Governance

1. Organisations have a director level accountable emergency officer who is responsible for EPRR (including business continuity management)

D. Eltringham – Chief Operating Officer

COO Continuous

2. Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response.

The Emergency Planning Team have a work programme in place detailing short, medium and long term objectives. This work is being overseen by the Emergency Planning Steering Committee.

EPM Continuous

3. Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response.

This is detailed within the Terms of Reference for the Emergency Planning Steering Committee.

EPM Completed.

4. The accountable emergency officer will ensure that the Board and/or Governing Body will receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standards.

The Emergency Planning Department provide a report via Risk Committee and QGC in regards to the activities of the department, including exercise, incident response and resourcing.

EPM Completed.

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Duty To Assess Risk 5. Assess the risk, no less frequently than

annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver it's functions.

The Emergency Planning Officer annually reviews risks that are assigned to that role on the organisations corporate risk register. These risks are those that are highlighted to the organisation through National and Community Risk Registers.

EPO Completed.

6. There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and national risk registers.

Core standards 6 and 7 are completed through representation at the LHRP via the COO, ADN (or nominated representative). UHCW are also represented at an Emergency Planning Sub Group for two area team locations.

COO / EPM Continuous

7. There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your organisation and relevant partners.

8. Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity. Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive):

* UHCW NHS Trust has a Major Incident Plan (currently V14.3), and a Business Continuity Plan, although is currently being updated to v 15.0 To accompany the MIP UHCW has a number of SOPs to ensure a rapid and effective response to specific incidents such as; VIP response. CBRN / Hazmat Hot / Cold Weather Flooding VHF Patients * This has been graded as Green as the full suite of plans are in place, but all undergo continual review in order to ensure they are up to date and current

EPM Continuous

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9. Ensure that plans are prepared in line with current guidance and good practice which includes:

The current BC arrangements are in line with ISO22301, whilst the MIP and CBRN documents are in line with the current JESIP and IOR principles.

EPM Continuous

10. Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources.

The MIP and BCP detail the escalation process required to establish and incident and the level of response it may require.

EPM Completed

11. Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

The MIP and the BCP identify critical activities. During an incident a BC group would be tasked to ensure that this takes place – this is part of the MIP and BCP.

EPM Completed.

12. Arrangements explain how VIP and/or high profile patients will be managed.

Operation Consort is the UHCW SOP for dealing with a protected person in our care. This is inline with WMAS Operation Consort to ensure consistency.

EPM Completed

13. Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content

UHCW are represented at external safety groups and planning meetings alongside our multiagency partners. Internally the different stakeholders throughout UHCW are invited to attend the EPSC.

EPM Continuous

14. Arrangements include a debrief process so as to identify learning and inform future arrangements

The debrief process forms part of the MIP. EPM Completed.

Command and Control 15. Arrangements demonstrate that there is a

resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an

A Clinical Site Manager is based at UHCW ensuring a 24/7/365 day cover. This person can then escalate all issues that require escalation to the on call managers as appropriate.

Lead Nurse for Site Operations

Completed

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ability to respond or escalate this notification to strategic and/or executive level, as necessary.

16. Those on-call must meet identified competencies and key knowledge and skills for staff.

The Trust has a robust on call system, there is currently a review of on call policies and requirements, and as part of this process, detailed competency self assessments are being undertaken, with a view to identifying any gaps.

EPM Ongoing

17. Documents identify where and how the emergency or business continuity incident will be managed from, ie the Incident Control Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist .

The MIP and BCP detail the location of the major incident control room, along with the associated action cards for making the room operational.

EPM Completed.

18. Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident.

A loggist role is detailed in the MIP and BCP. EPM Completed

19. Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response.

The action cards for specific roles within the MIP provide this detail and action sequence.

EPM Completed.

20. Arrangements to have access to 24-hour specialist adviser available for incidents involving firearms or chemical, biological, radiological, nuclear, explosive or hazardous materials, and support strategic/gold and tactical/silver command in managing these events.

UHCW operates and Emergency Planning On Call rota covering 24/7/365 to act as a Tac-Ad to the hospital silver commander. UHCW also has arrangements to speak to NAIR officers for radiation incidents.

EPO Completed.

21. Arrangements to have access to 24-hour During office hours UHCW has a number of Nuclear EPO Completed. Page 9 of 17


radiation protection supervisor available in line with local and national mutual aid arrangements;

Physicists that we can utilise. Out of hours switchboard has the details to contact the NAIR advisers.

Duty to Communicate With The Public 22. Arrangements demonstrate warning and

informing processes for emergencies and business continuity incidents.

The MIP, and associated SOPs include the action cards for a representative from communications for both internal and external incidents. This includes warning/informing in anticipation for an event.

EPM Completed

23. Arrangements ensure the ability to communicate internally and externally during communication equipment failures

Information Sharing – Mandatory Requirements 24. Arrangements contain information sharing

protocols to ensure appropriate communication with partners.

The 3rd On Call Action Card in the MIP details who, and how to communicate with during an incident.

EPM Completed.

Co-operation 25. Organisations actively participate in or are

represented at the Local Resilience Forum (or Borough Resilience Forum in London if appropriate)

UHCW are represented at the LRF by the AHW AT. AHW AT Director of Operations and Delivery

Completed

26. Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA

27. Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained.

The MIP identifies that mutual aid requests and arrangements will be made via the area team.

EPM Complete

30. Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions and duties

As part of the EPSC the Emergency Planning Team provide updates on the planning actions of our partners. The Emergency Planning team also attend local emergency planning groups to ensure the local and regional EPRR functions are delivered.

EPM Complete

33. Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director level

The Chief Operating Officer is invited to attend the LHRP. COO Complete

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Training and Exercising 34.

Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents

The EPM has developed a TNA and Staff have undertaken Silver Commander Training/ Strategic Leadership in a Crisis, and there is an ongoing training programme for on call staff A formal modular training programme is being developed in conjunction with NHS England. The EP lead Nurse for ED, and the EPO, undertake MI and CBRN incident training on a regular basis, including infectious disease management, and IOR (Initial Operational Response) training.

EPM Continuous

35. Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work.

The Trust has participated in a number of exercises, including, Exercise Churchill (hospital evacuation), Ebola, and CBRN. UHCW undertook a large live exercise in October 2014 The trust are participating in a multiagency Pandemic Flu Exercise in October 2015

EPM Continuous

36. Demonstrate organisation wide (including on call personnel) appropriate participation in multi-agency exercises

The trust has participated in numerous multiagency exercises EPM Continuous

37. Preparedness ensures all incident commanders (on call directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation.

This work is forming part of the ongoing on call review, and CPD portfolios are being developed to be distributed to all on call managers.

EPM April 2016

Pandemic Flu (New Standards for 2015) DD1 Organisation have updated their

pandemic influenza arrangements to reflect changes to the NHS and partner organisations, as well as lessons

Current plan is being reviewed and updated to reflect the Arden Operational Plan that has been prepared by the Arden Pandemic Flu Group, of which the EPO is a member.

EPO October 2015

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identified from the 2009/10 pandemic including through local debriefing

The current UHCW Pandemic Flu plan has been developed and reviewed with multiagency partners, but is currently undergoing a rewrite and reformat, in order to make it more user friendly, as the current document is unwieldy, and contains lots of duplication.

DD2 Organisations have developed and reviewed their plans with LHRP and LRF partners

DD3 Organisations have undertaken a pandemic influenza exercise or have one planned in the next six months

Arden Pandemic Flu Exercise planned for 16th October EPM October 2015

DD4 Organisations have taken their plans to Boards / Governing bodies for sign off

Revised plan will be presented to the October Emergency Planning Steering Committee to be supported by COG, and will be subsequently submitted to Quality and Governance Committee for Board.

EPM October 2015

CBRN Core Standards 38 There is an organisation specific

HAZMAT/ CBRN plan (or dedicated annex)

CBRN plan in place – but being reviewed to incorporate changes in guidance. Latest version to be signed off at the September Emergency Planning Steering Committee,

EPO Completed

39 Staff are able to access the organisation HAZMAT/ CBRN management plans.

CBRN SOP and Action Cards available in Decontamination Room

EPO Completed

40 HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate to the organisation.

CBRN and HAZMAT incidents are logged on Corporate Risk Register

EPO Completed

41 Rotas are planned to ensure that there is adequate and appropriate decontamination capability available

All Band 7 Nurses in ED trained in decontamination 24/7 Emergency Planning On Call Rota

EPO completed

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24/7.

42 Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/ CBRN incident and this specialist advice is available 24/7.

Information in CBRN SOP EPO On Call 24/7

EPO Completed

43 There is an accurate inventory of equipment required for decontaminating patients in place and the organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff.

Equipment and inventory available at UHCW. IOR Decon box at RSX

EPO Complete

44 The organisation has the expected number of PRPS suits (sealed and in date) available for immediate deployment should they be required (NHS England published guidance (May 2014) or subsequent later guidance when applicable)

Full quota at UHCW

EPO Completed

45 There are routine checks carried out on the decontamination equipment including: A) Suits B) Tents C) Pump D) RAM GENE (radiation monitor) E) Other decontamination equipment

Completed by ED staff and EPO EPO Completed

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46 There is a preventative programme of maintenance (PPM) in place for the maintenance, repair, calibration and replacement of out of date Decontamination equipment for: A) Suits B) Tents C) Pump D) RAM GENE (radiation monitor) E) Other equipment

In place with Respirex and GRS EPO Completed – suits being

recertified in September

47 There are effective disposal arrangements in place for PPE no longer required.

PPE suits disposed of following NHS England guidelines.

EPO Completed

48 The current HAZMAT/ CBRN Decontamination training lead is appropriately trained to deliver HAZMAT/ CBRN training

EPO and ED Senior Charge Nurse provide training and attend CBRN refresher days.

EPO Completed

49 Internal training is based upon current good practice and uses material that has been supplied as appropriate.

Records of those trained are kept locally in ED

ED Practice Facilitator

Completed

50 The organisation has sufficient number of trained decontamination trainers to fully support it's staff HAZMAT/ CBRN training programme.

Three competent trainers EPM Completed

51 Staff that are most likely to come into first contact with a patient requiring decontamination understand the

Process in place and identified through CBRN SOP EPO Completed

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requirement to isolate the patient to stop the spread of the contaminant.

CBRN Equipment E2 Tent Shell GRS SF3 and SF15 EPM Yes E4 Lights 2 x waterproof lighting units EPO Yes E5 Shower Heads

Inclusive with the structures EPO

Yes E6 Hose Connectors E7 Flooring E8 Waste water pipe and pump E9 Waste Bladder Circa 20,000 litre holding tank EPO Yes E10 The organisation (acute and ambulance

providers only) has the expected number of PRPS suits (sealed and in date) available for immediate deployment should they be required. (NHS England published guidance (May 2014) or subsequent later guidance when applicable).

Full Quota EPO Yes

E11 Providers to ensure that they hold enough training suits in order to facilitate their local training programme

No Respirex Training Suits – currently awaiting distribution from NHS England 3 x Expired PRPS suits used and marked as training suits

EPO Yes

E12 A facility to provide privacy and dignity to patients

As part of the rigid structure EPO Yes

E13 Buckets, sponges, cloths and blue roll 2 x buckets, multiple sponges and blue roll EPO Yes E14 Decontamination liquid EPO Yes E15 Entry control board Entry control board with 3 stopwatches EPO Yes

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E16 A means to prevent contamination of the water supply

As part of the structure

EPO Yes

E18 Minimum of 20 x Disrobe packs or suitable equivalent (combination of sizes)

Available in decontamination room within a cage EPO Yes

E19 Minimum of 20 x re-robe packs or suitable alternative (combination of sizes - to match disrobe packs)

Available in decontamination room within a cage EPO Yes

E20 Waste Bins 2 available in decontamination room EPO Yes Disposable gloves Available in decontamination room EPO Yes E21 Scissors - for removing patient clothes

but of sufficient calibre to execute an emergency PRPS suit disrobe

TuffKut scissors available in decontamination room EPO Yes

E22 FFP3 Masks Available in decontamination room EPO Yes E23 Cordon Tape Available in decontamination room EPO Yes E24 Loud Hailer Available in decontamination room EPO Yes E25 Signage Awaiting advice from WMAS to determine signage

requirements. WMAS are undertaking a CBRN leads day in September, will be raised here if not resolved previously. Once this has been received any signage that is deemed necessary will be sourced and installed.

EPO December 2015

E26 Tabbards identifying members of the decontamination team

Currently looking for the most suitable and cost effective options

EPO December 2015

E28 RAM GENE monitors (x 2 per Emergency Department and/or HART

4 available that have all calibrated within the last 12 months and undergo monthly checks as per NHSE

EPO Yes

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team)

guidance

E29 Hooded paper suits 10 available in decontamination room EPO Yes E30 Goggles Full face visors available in decontamination room.

Awaiting clarity for requirement for goggles from WMAS This will be discussed as part of the signage discussions. If goggles are required then the base level stock of resus goggles [currently 3] will be increased with a supply available as part of the decontamination equipment.

EPO December 2015

E32 Overshoes and gloves Long gloves and overshoes available in decontamination room

EPO Yes

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PUBLIC TRUST BOARD PAPER Title Report of July Private Trust Board Meeting Author Rebecca Southall, Director of Corporate Affairs Responsible Andy Meehan, Chairman Date 24th September 2015 1. Purpose To report in public the substantive business that was transacted in the section of the July Board meeting that members of the public and the press were excluded from pursuant to Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997. 2. Background and Links to Previous Papers The Trust Board is at liberty to exclude members of the public and the press from board meetings when the nature of the business that is prejudicial to the public interest due to its confidential nature. In the interests of transparency however, the Chairman provides a report on the substantive items that were discussed to the next public meeting of the Trust Board. 3. Narrative The following items were discussed and/or approved at the July private session of the Trust Board:

• Patient Story; this item was taken in private to maintain confidentiality. • Care Quality Commission (CQC) Report • Revised EPR Outline Business Case • Diabetic Eye Screening Programme Tender • Working Together to Improve Patient Care: Partnership Working Update

4. Areas of Risk There no specific areas of risk to highlight arising out of the matters discussed. 5. Governance A further report will be submitted to the October Trust board detailing the business transacted in the September Trust Board. Reporting in this way ensures that we are fulfilling our obligations around transparency and openness. 6. Responsibility Andrew Meehan, Chairman Rebecca Southall, Director of Corporate Affairs 7. Recommendations The Trust Board is asked to NOTE the report.

QUALITY GOVERNANCE COMMITTEE 3 AUGUST 2015 - interim report to board Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Quality Governance Committee Committee Meeting Date: 3 August 2015 Quorate: Yes Chair: Ed Macalister-Smith, Non-Executive Director Report submitted by: Ed Macalister-Smith, Non-Executive Director 1. Minutes of the 6 July 2015 meeting were approved with slight amendment and actions were noted as completed or updated. 2. Infection Control and cleaning – ISS Pressures ISS Toby Prior kindly attended QGC. A 12-week Improvement Plan has been developed to address concerns raised against specific cleaning standards. ISS are currently recruiting to a new Head of Cleaning. An interim General Manager has also been appointed to assist. The Improvement Plan is also discussed at the fortnightly cleaning assurance meeting. Staff meetings are held to gain direct feedback and have also been reformatted whereby the Service Management aren’t present to encourage open discussion between staff and the General Manager. Due to the sickness absence challenges ISS have experienced, an additional 22 cleaners have been recruited. Availability of equipment, consumables and materials has also been an ongoing issue for ISS staff. As a result of this the laundering and delivery times of cloths and mops have been altered and additional purchasing has also been put into place to ensure adequate stock levels.

PY observed that the 12 week improvement plan was noted at Trust Board in July to not be progressing as hoped and enquired what the plan was to address this. LD advised that ISS report to the Infection Prevention & Control Committee monthly and assured that controlled measures will continue to be monitored after the 12 week target deadline. EMS requested that the Infection Prevention & Control Committee report back to the next available QGC to provide the Committee with assurance. 3. QPR – Falls with Harm EMS advised that the Trust Board debated the upward trend in falls resulting with serious harm in July and sought assurance of what action was being taken to meet compliance against the performance standard. EC has undertaken an initial analysis and reported that most falls occur at night and will be undertaking a thematic review in the near future. MR suggested that this paper be presented to QGC next month to provide assurance of the actions taken. 4. Risk Register Patient flow, achievement of targets and reputation risks are regular occurring themes. The Risk Committee oversee this register on a monthly basis. There was detailed probing of a number of the risks.

EMS and JG have been in discussions in relation to what risks the Risk Committee wish to escalate to QGC. EMS requested the potential RTT risk to patient harm be reviewed at September’s QGC. 5. Hospital Transfusion Annual Report There has been progress made against the National Performance targets; blood and blood component usage, wastage, blood group O negative issues and traceability. Blood component usage has decreased by 4% due to altering the emergency ratio. Red blood cell usage has also decreased by 360 units due to introducing the red blood cell usage calculator which instructs the amount of blood to give for that specific patient’s weight. Cryoprecipitate has increased which is being closely monitored.

There has been no harm to patients, an excellent record for the service.18 incidents were reported externally.

Developing a 2020 vision – the unit are actively trying to take this service forward and aim to achieve: • Improvement of patient experience • Introduce and monitor Patient Blood Management initiatives • Use intelligence to predict blood usage in order to forward plan services • Facilitate Path Collect (scan patients details from wristband) which has been successfully piloted in ED and

Lab.

Transfusion training has been logged on the corporate Risk Register for some time now however uptake is increasing and the Transfusion Team are providing education and support on the wards as much as possible. 6. Acute Medical Education Action Plan The Director of Medical Education provided an update. The continued scrutiny of the service by HEWM continues to give concern, although the action plan is steadily being completed. Challenges remain, and EMS requested that this item also is re-presented to the full Board. The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same.


QUALITY GOVERNANCE COMMITTEE 7 SEPTEMBER 2015 - interim report to board Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Quality Governance Committee Committee Meeting Date: 7 September 2015 Quorate: Yes Chair: (Acting Chair: Barbara Beal, Non-Executive Director) for Ed-Macalister-Smith, Non-Executive Director Report submitted by: Barbara Beal, Non-Executive Director 1. Minutes of the 3rd August 2015 meeting were approved with slight amendment and actions were noted as completed or updated. 2. CQC Action Plan The CQC Action Plan is to be submitted to the CQC by Friday 11 September 2015. The focus has been on the “must do’s” with a generic action plan around “should do’s” which is a separate piece of work. A robust process will be developed and put in place by the end of October 2015 to address the “should do” recommendations. The Chief Executive Officer has instructed that the Chief Inspector Hospitals Programme Board meetings are to continue to monitor the Action Plan. It was agreed that monthly updates would be provided to the Committee in order to receive oversight of progress. BB emphasised that whilst there is an emphasis on nursing and midwifery that the Trust must recognise that the action plan is relevant to all staff, both clinical and non-clinical. MP assured that the Chief Executive Officer had instructed that the action plan be displayed on the Intranet for all staff to take ownership. The Committee APPROVED the Action Plan for submission to the CQC by 11th September 2015 which will continue to be monitored by the CIH Programme Board with oversight by the Quality Governance Committee and AGREED that the action plan must address the “should do’s”. 3. Quality Performance & Finance Report LC confirmed that plans are moving forward with developing the new Score Card to be in line with the TDA, and the PPMO is meeting with all Chief Officers before issuing the new dashboard to ensure that it is responsive and which KM will introduce at the October Trust Board. The Committee ACCEPTED the report and NOTED progress made. 4. Risk Register JG acknowledged that there is more work to be done around risk management within the organisation and confirmed that a review is to be undertaken in light of this and the feedback provided by the CQC following the inspection in March 2015. BB concurred and emphasised the importance of this, in light of the collaboration with Virginia Mason Institute, USA and requested that a progress update on the review of risk management arrangements be provided to the Committee in October or November, as determined by JG. The Committee RECEIVED and NOTED the report. 5. EPRR Assurance Report The purpose of the report is to provide the Committee with the current position against the NHS EPRR Core Standards annual statement of compliance submission to Arden, Herefordshire and Worcestershire NHS England Area Team. The Trust is currently fully compliant with 78 of the 84 core standards. The remaining standards are graded as ‘amber’ and as such there is a plan to have them in place within the next year. DE assured the Committee that work has already begun on implementing these changes. The Committee NOTED and APPROVED the report. 6. Gerontology Deanery Action Plan BS proposed that a progress update against the Action Plan be presented to the Committee under in readiness for the HEWM visit on 4 November for Acute Medicine and Gerontology. The Committee NOTED progress made and resolved to continue to MONITOR the Action Plan. 7. Risk Register Update (ID 1984) The internal standard for UHCW admitted patients is to budget over 18 weeks to reduce to zero, which is monitored

Agenda Item 22 Enclosure 19.1

on a weekly basis. The risks to delivery which are being focussed on were reported as follows: Impact of backlog size on incomplete pathways Insufficient activity delivered in critical specialities including General Surgery, Plastic Surgery and Max Fax Timeframes for realising additional capacity: Orthopaedics and Gynaecology

. MP urged progress with the standardisation of clinic templates to help reduce waiting times. MK remarked that there is still work to be carried out around this as some clinics are Nurse Practitioner-led. DE added that the aim is to work towards a four week maximum wait which will prove challenging. He further added that a piece of work is being commissioned around the booking process. BS reminded the Committee of the CQC `must do` actions and the necessity of speed and urgency for the March 2016 deadline set. DE emphasised that this was made very clear with the RTT Board; adding more must be carried out in planning terms i.e. more standards to drive this with capacity on the pitch. . In response to a query from BB regarding patient pathway delays; MK assured that patients are seen in order of clinical priority but acknowledged that this does impact on waiting times in some specialities. It was noted that patients experiencing delays, whose condition deteriorates whilst on the waiting list for an appointment, can access to their GP who can make a clinical judgement and request expedition of an appointment as appropriate but it was acknowledged that this could leave some patients exposed to harm. BB requested that the Committee receive an update on the Patient Safety – Audit of Clinical Review, at the November meeting.

The Committee NOTED the report. 8. Falls Report and update on thematic review The purpose of the report is to identify the emerging themes and trends from a review of quarter 1 falls with harm, and identify ongoing actions and recommendations to mitigate further risk. The number of falls with harms has seen a significant increase in Quarter 1 2015/16 in comparison to Quarter 4 2014/15. Total number of falls for Q4 was 624 and for Q1 was 593; a reduction of 31 (5%). April 2015 had 166 falls which is the lowest number reported in the last twelve months. The concurring themes were: Patients were aged 79 or older Scoop hoist was not used for two falls Three patients had fallen prior to coming into hospital Five falls occurred during the day with the remaining ten at night ie 0400 am – 0800 am

Recommendations/Actions: A `Safety Huddle’ commenced in July at the beginning of the night shift with the Falls Lead Nurse working

part of the night shift to assess routines Ward Managers and Matrons have been briefed with Matrons also carrying out night visits There is targeted specific training Performance meetings will be taking place for the Ward Manager and the Matron of a ward that has a fall

with serious harm with EC and the Falls Lead Nurse in attendance EC assured that the work that has been done already has seen an impact on falls reduction for July and August. The number of falls with harm for July was five and in August reduced to one. Reducing harm to patients from falling will remain a priority for the Trust and a review will continue to take place to ensure learning is shared. The Committee ACCEPTED the report and NOTED the progress made.

The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same.

Page 1 of 2 Interim Report to Board

AGENDA ITEM 23 ENCLOSURE 20

INTERIM COMMITTEE REPORT TO BOARD Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Finance and Performance Committee Committee Meeting Date:7th September 2015 Quoracy: Yes Apologies: None recorded. Chair: Ian Buckley Report submitted by: Ian Buckley, Non-Executive Director & Vice Chair 1. Minutes; the minutes of the July meeting were approved as an accurate record. 2. Emergency department has continued to maintain 4hr performance at over 95% and all

involved are making every effort to embed the improvement in new processes and sustain the performance

3. Theatre performance on electives is still disappointing. The committee received a detailed presentation on actions taken at Rugby St Cross which helped identify some of the reasons for failing to meet targets and the disappointing rate of improvement.

4. At month 4 the Trust is forecasting in line with its original financial plan. The Committee signed off the Financial Recovery Plan Trajectories which are aligned to the agreed “stretch” target of £19.4m signed off by the Board. There remains the need to identify CIP savings of £6m

5. The committee received a report on the 2016/17 planning process. It was agreed that the plan should take full account of the implications of the Agency limits and shortfall of new recruits in all areas. It was requested that a plan be produced highlighting optimum performance for all groups in order to give better visibility of areas of expected poor performance.

6. Good progress is being made on recruitment and staff turnover. The new rules on use of agency are being assessed and implications will be highlighted at the next meeting

The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same.

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