board of directors - royal berkshire hospital governance/board... · board of directors wednesday...

Board of Directors Wednesday 29 November 2017, 9.00 – 12:05 Boardroom, Level 4, Royal Berkshire Hospital

We provide a comprehensive service, based on clinical need, not an individual’s ability to pay. We aspire to the highest standards of excellence and professionalism and to put patients at the heart of everything we do. We are accountable to the public, communities and patients that we serve.

Board Meeting – Part 1 Topic Lead Time 1. Opening and Apologies for Absence

Graham Sims

-

2. Patient Story*

Caroline Ainslie

9.00

3. Staff Story a) Ward Accreditation* b) Above and Beyond*

Caroline Ainslie Lindsey Barker

9.10

4. Minutes of 27 September 2017 and Outstanding Actions Schedule and Declarations of Interest

Graham Sims 9.35

Executive Team Performance update 5. a) Chief Executive’s Report

b) Integrated Performance Report c) Finance Report d) QiPPs Update

Steve McManus Executive Team Craig Anderson Mary Sherry

9.40

6. Carter Review: Clinical Outcomes

Lindsey Barker 10.40

7. Winter Plan

Mary Sherry 10.50

8. Skill Mix Review

Caroline Ainslie 11.05

9. a) Standing Orders Review b) Changes to the Constitution

Caroline Lynch 11.15

10. Board Assurance Framework

Caroline Lynch 11.20

11. Corporate Risk Register

Caroline Ainslie 11.25

12. Networked Care Group Update**

Mary Sherry 11.35

Minutes of Board Committee Meetings and Committee updates 13. a) Finance & Investment Committee 18 September 2017,

23 October 2017 and 20 November 2017* b) Audit & Risk Committee 20 September 2017 and 9

November 2017* c) Charity Committee 20 September 2017

Sue Hunt Brian Hendon Graham Sims

11.50

Agenda

* verbal

**presentation

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d) Quality Committee 11 October 2017 e) Workforce Committee 30 October 2017

Alison Hill Julian Dixon

14. Board Work Plan

Caroline Lynch -

15. Date of Next Meeting and Close – 31 January 2018

Graham Sims 12:05

2

Agenda Item 4

Board Wednesday 27 September 2017 9.35 – 13.10 Boardroom, Level 4, Royal Berkshire Hospital Members Present Mr. Graham Sims (Chair) Mr. Steve McManus (Chief Executive) Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance) Dr. Lindsey Barker (Medical Director) Mr. Julian Dixon (Non-Executive Director) Mr. Brian Hendon (Non-Executive Director) Dr. Alison Hill (Non-Executive Director) Mrs. Sue Hunt (Non-Executive Director) Mr. John Petitt (Non-Executive Director) Ms. Mary Sherry (Chief Operating Officer and Deputy Chief Executive) In attendance Mr. Mike Clements (Planned Care Group Director of Finance) (for minute 124/17) Mr. Don Fairley (Director of Workforce) Mrs. Caroline Lynch (Trust Secretary) Mr. Warren Fisher (Planned Care Group Director) (for minute 124/17) Mr Laurie Scott (Planned Care Group Director of Operations) (for minute 124/17) Apologies There were seven governors and three members of staff present. The meeting commenced with a patient story. The Medical Director introduced Elizabeth Porter, Lead Nurse for Adult Safeguarding. Elizabeth gave an overview of an interaction with a patient in the Adult Medical Unit (AMU) who had Chronic Obstructive Pulmonary Disease (COPD). Elizabeth had been asked for provide advice in relation to a female patient who had been actively trying to leave the department. Elizabeth explained that she had assessed the capacity of the patient after talking with her at length and had explained the risks to the patient if she decided to go home. After these discussions Elizabeth had concluded that the patient did have capacity to make decisions about her care. Elizabeth had also engaged with the patient’s children and involved them in discussions regarding their mother’s wishes. The palliative care team had been engaged and had made arrangements for the patient to receive care at home. Following this the patient had been discharged. The patient’s son had returned to the Trust later and reported that his mother had been less anxious and happy to be at home. The Board noted that the patient had been admitted on further occasions since this episode but an advanced medical care plan had been put in place for her to remain at home. The Board noted that all clinical staff received mental capacity training at induction which was case based. The Board thanked Elizabeth for providing the patient story.

Minutes

Minutes of the Board – 27 September 2017 1

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The Director of Nursing introduced Andrew Haydon, Student Nurse. Andrew explained that he lived local to the Trust and had a personal connection through his wife’s need for care prior to him becoming a student nurse. Andrew advised that he had decided to re-train as a nurse at the age of 34 and gave an overview of his placements at the Trust in Caversham Ward, Whitley Ward and the Emergency Department (ED). Andrew reported that the teams at the Trust ensured that student nurses felt an integral part of the team and he had an excellent experience during all his placements. Andrew reported that the Trust had good links with the University of West London and during his placements at the Trust he had attended excellent training courses. Andrew highlighted that it would be useful to have student nurses attending induction sessions who could share their experiences of starting work at the Trust. Andrew reported that whilst not attending placements at the Trust, students could feel isolated and it would be useful to be kept informed of news from within the Trust during the times that students were based at the University or at other trusts. Andrew advised that his passion was to encourage more males to become nurses and that through linking with primary schools more work could be done to change thinking in relation to stereotypes and nursing. The Board thanked Andrew for his story. 116/17 Freedom to Speak Up Guardian Update Joan Potterton, Freedom to Speak Up (FTSU) Guardian, advised that she had been

appointed in January 2017. Following her appointment, she had attended the national training for the role, the national FTSU conference and was also part of the regional network of guardians. The Board noted that the FTSU Guardian had engaged face-to-face with over 1000 staff, attended induction sessions, had met with Counter Fraud Specialist and Datix Manager to discussion triangulation of concerns where relevant and had produced a variety of leaflets and posters to promote her role. The FTSU guardian also had a regular monthly meeting with the Chief Executive and had open access to all Executive Directors at all times. FTSU ambassadors had also been appointed to help promote FTSU. The Chief Executive advised that the FTSU Guardian role had also been promoted through the What Matters programme.

The FTSU Guardian advised that since her appointment 18 concerns had been raised by a

variety of staff groups. The Board noted the categorisation of concerns, of which 7 related to patient safety and quality. The FTSU Guardian advised that, of these patient safety concerns, no significant issues had been identified. The Board noted that future updates from the FTSU Guardian would be submitted to the Audit & Risk Committee on a regular basis.

117/17 Minutes: 31 May 2017 and Matters Arising Schedule The minutes of the meeting held on 26 July 2017 were approved as a correct record and

signed by the Chair.

There were no declarations of interest. The matters arising schedule was noted. Minute 99/17: Chief Executive’s Report: The Board discussed attendance at What Matters sessions by Board members. It was agreed that the Director of Workforce would circulate details of both Phase 1 and Phase 2 sessions to enable participation. Action: D Fairley


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118/17 Chief Executive’s Report

The Chief Executive advised the Care Quality Commission (CQC) had carried out their unannounced inspection on 14 and 15 September 2017. The CQC would be reviewing five core services which included Emergency Care, Medicine, Surgery, Outpatients and Critical Care. The ‘Well Led’ part of the inspection had also been confirmed for between 11 and 13 October 2017 during which the CQC would also be holding a series of focus groups on 11 October 2017. The Director of Nursing advised that the CQC were also inspecting Bracknell Healthspace today. The Chief Executive thanked everyone involved in the preparation for the inspection and highlighted that the CQC had reported that staff had been proud and open with the inspectors. The Chief Executive advised that the What Matters programme was now moving into the next phase having achieved the initial goal of engaging with over 3000 staff during Phase 1. Messages received from staff would be reviewed and used to develop a Trust-wide behaviours framework. The Board noted that the first cohort of 45 staff had started the three year management development programme which had been developed in conjunction with the University of Reading and Henley Business School. The first cohort was from a range of professions and staff grades. The Chief Executive highlighted that the Members’ Open Day took place on 23 September 2017 and expressed his thanks to staff, partners, governors for attending and Hannah Travers for her organisation of the event which had been well attended. The Board noted that Hospital Radio Reading had celebrated its 60th birthday in September and the Chief Executive highlighted the excellent work of the volunteers who ran Hospital Radio. The Chief Executive advised that the Secretary of State, Jeremy Hunt, had announced recently that the Trust was one of the 18 Global Digital Exemplar Fast Followers. The Medical Director advised that a number of Trust staff had recently won awards for their contribution to research at the Thames Valley Health Research Awards; Douglas Findlay, Julie Foxton, Melanie Gager, Sam Clark and Richard Siviter.

119/17 Integrated Performance Report (IPR)

The Director of Nursing advised that there were two cases of C. Diff reported during August. The total number of cases to date was 10 against an upper limit of 27. Of the two cases reported both had root cause analysis completed. In one case, no lapses of care were identified and a further review was required prior to a decision made one the second case. There was one MRSA reported during August which was deemed avoidable as there were lapses in documentation, cannula visual infusion phlebitis (VIP) scoring and antimicrobial prescribing. The importance of VIP scoring would be re-emphasised to staff at induction and mandatory training sessions and would be highlighted in the monthly Safety and Quality newsletter. Screening for sepsis and patients with sepsis receiving intravenous antibiotics within one hour of diagnosis in both ED and acute inpatient wards had improved to over 90% in July and August. The Director of Nursing highlighted that there had been a slight increase in falls during August but no falls reported as resulting in harm. The Trust had reported one serious incident in August which was a never event and the investigation was on-going. Safeguarding training remained a challenge but 65 staff had booked to attend the next


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training session which would increase the overall compliance for Level 3 Children’s safeguarding to target levels. The Director of Nursing advised that single sex accommodation breaches remained a challenge and related to operational pressure. The Trust’s concerns had been raised with NHS Improvement. NHS England were also reviewing the variation in reporting by trusts. It was queried whether there was any significance to a number of metrics not being achieved during August. The Director of Nursing confirmed there was no theme. A query was raised in relation to planning for the Reading Festival. The Chief Operating Officer confirmed that robust planning with partners had take place. The Director of Nursing confirmed that the issue of young people attending ED during the Reading Festival period had been raised with the Local Safeguarding Children’s Board.

The Medical Director advised that the Hospital Standardised Mortality Ratio (HSMR) was as expected. The Mortality Surveillance Committee had not identified an increase in possible or probable harm related to hospital care to date. 100% of women giving birth received 1:1 care during August and there had been a reduction in elective Caesarean sections. The Medical Director advised that the number of diversions had been discussed by the Executive Management Committee and the criteria for diversions had been strengthened and now required the approval from the Executive Director on-call. The fractured neck of femur time to theatre national standard was achieved during August and there had been one breach in door to balloon target in the Myocardial Ischaemia National Audit Project (MINAP) but this related to gaining consent from the patient following discussion with relatives.

The Chief Operating Officer advised that in relation to Referral To Treatment (RTT) incomplete pathway there had been one patient waiting over 52 weeks. This was as a result of the pathway being incorrectly stopped at endoscopy. The Chief Operating Officer advised that the Trust was continually improving ways of recording RTT outcomes and the data quality assurance programme would assist with this work. The Board noted that the 62 day cancer access standard was narrowly missed during August. Work was on-going to review cases at tumour site level.

The Chief Operating Officer advised that the ED access standard remained a challenge and

had been difficult during August. This had been as a result of the changeover of junior doctors’ in the month, the bank holiday weekend and high attendances as a result of the Reading Festival. The high number of attendances had been sustained during September and recently there had been 371 attendances during the weekend with a further 370 attendances the following day. There had been increased support provided to the ED department together with a focus on red and green days in wards areas. The Board queried the reason for the changeover of junior doctors’ affecting ED performance. The Chief Operating Officer advised that additional support was provided but there were delays in decision making and increased attendances. The Medical Director highlighted that the changeover of junior doctors’ was a national issue. The Chief Operating Officer highlighted that work was on-going with the Accountable Care System (ACS) in relation to bed modelling across the system which was a complex piece of work. However, this would not affect winter pressures. It was noted that the financial assumption was that the ED trajectory would be met. The Director of Finance advised that ED performance was reviewed on a monthly basis prior to an accrual being made in the accounts.


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The Board discussed theatre sessional utilisation. It was agreed that a further update on theatre utilisation as part of the QiPP programme updates would be submitted to the Finance & Investment Committee. Action: M Sherry

The Director of Workforce advised that appraisal rate compliance had decreased during

August and mandatory training compliance had also reduced in the month. The Executive team were currently reviewing ways to strengthen accountability for both individuals and managers. Agency spend had also increased during August. The turnover rate had also increased during the month. A query was raised as to how the Trust benchmarked on turnover rate. The Director of Workforce advised that the Trust was a slight outlier. It was agreed that the Workforce Committee would review staff turnover. Action: D Fairley

The Board noted the Health & Safety indicators. The Director of Finance advised that the Health & Safety Committee were focused on fire training compliance and reviewing ways to improve training and an action plan had been developed. Doctors’ manual handling training compliance was also being reviewed if this coincided with junior doctors’ joining the Trust during August to ascertain if training completed in other organisations could be transferred to the Trust.

The Director of Finance advised that the finance report had been omitted from the agenda pack but this would be circulated to the Board. Action: C Lynch

The Director of Finance gave a verbal update on the financial results for August and advised there was a £2.97m deficit. This was in line with budget but below Quarter 1 forecast. The focus was on meeting the budget position. Care Groups were looking to recover their position and corporate areas would need to outperform current performance. Cash was strong at £37.26m. A query was raised as to whether Quality Impact Assessments were carried out in relation to delays in capital spend. The Director of Finance advised that when areas of investment were reviewed quality issues were considered at the same time.

120/17 QIPPs Update

The Chief Operating Officer advised that the current PMO risk assessment of the 2017/18 programmes was £13.8m against a target of £16.9m. The Board noted that the Finance & Investment Committee had reviewed the temporary staffing and procurement inventory management programmes in detail at the September meeting.

121/17 Carter Review: Clinical Outcomes The Medical Director introduced the report and advised that following the Carter review all

trust boards were mandated to review dashboards for at least three clinical or medical specialities each month. The current report set out indicators for Diabetes, Rheumatology, Sexual Health and End of Life Care.

The Medical Director gave an overview of each of the specialities and highlighted that

Diabetes outcomes demonstrated an improved service and End of Life care outcomes demonstrated an exemplary service.

122/17 Standing Financial Instructions Review The Board received the Standing Financial Instructions (SFIs) which had been updated in

order to make the document more user friendly for staff. There had been no material


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changes. The Audit & Risk Committee had recommended that the tracked change version of the SFIs should be submitted to the Board for approval. The Chair of Audit & Risk Committee confirmed that the Committee had reviewed the changes and had recommended the revised SFIs to the Board for approval. The Board queried whether the The Board approved the SFIs.

123/17 Annual Medical Revalidation Report

The Medical Director advised that the purpose of report was to provide assurance to the Board that systems for revalidation and appraisal continued to operate effectively, that the frequency and quality of medical appraisals was monitored, to demonstrate the overall progress made during 2016/17 and that there were effective systems in place for monitoring the conduct and performance of doctors in the Trust to ensure they were up to date and fit to practice.

The Medical Director highlighted that the Trust’s appraisal rate for medical staff during 2016/17 were 93% which compared favourably at both a local and national level. The quality of appraisals would be a focus going forward. The Medical Director advised that the Trust followed the NHS Employment Checks Standards for both permanent and locum appointments.

The Medical Director gave an overview of performance monitoring processes which

included regular supervision and annual appraisal. Concerns related to performance were escalated to the Medical Director. The Revalidation and Appraisal Group supported by a professional advisory panel met on a quarterly basis to discuss and advise on concerns. Any concerns or complaints relating to attitude and behaviour of doctors were also escalated to the Medical Director.

The Board noted that during 2016/17, seventeen doctors were considered by the

Professional Advisory Panel. Courses of actions included coaching, mediation, 360 feedback, services reviews and three were escalated to the Medical Director. Four doctors were formally referred and counselled by the Medical Director. The Medical Director advised that she met on a quarterly basis with the General Medical Council (GMC). During 2016/17 one GMC referral was made. No formal action was taken but the locum doctor was advised regarding Good Medical Practice guidance. One previous referral was closed with a finding of care below standard but this was not significant and a remedial action was put in place.

The Board approved the Annual Report and recommended that the ‘statement of

compliance’ should be signed by the Chief Executive. Action: L Barker 124/17 Planned Care Group Update

The Planned Care Group Director gave a presentation and advised that the focus for the Care Group was excellent patient care, achievement of national and commissioned standards for cancer and Referral to Treatment (RTT), management of elective care alongside emergency workload, maintenance of strong partnerships via the Accountable Care System (ACS), Sustainability Transformation Programme (STP) and strategic networks and financial stability and strong governance.

The Planned Care Group Director highlighted achievements which included improved governance and financial position, sustained cancer improvements, stabilised medical and management teams, service development and positive Getting it Right First Time (GIRFT) reviews.


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The Board noted key challenges for the Planned Care Group included nurse recruitment

and retention, estates, competitiveness/collaboration, finance/activity and achievement of QiPPs.

The Board discussed the never events which had taken place in theatres during the year.

The Planned Care Group Director advised that a number of actions had been put in place to improve processes and the swab policy had been reviewed and updated. Learning from the never event had been shared across clinical governance teams. It was noted that, following the issue which had occurred in theatres during the CQC inspection, there had been a robust surgical debate and CQC inspectors had been present for this.

The Board thanked the team for the presentation and acknowledged the significant improvements achieved by the Planned Care Group.

125/17 Board Assurance Framework (BAF) The Trust Secretary introduced the BAF which had been reviewed by the Audit & Risk

Committee in September. The BAF template would be revised in line with the refresh of Trust’s strategy. The Board noted there had been no changes to the risk ratings for any of the strategic imperatives.

126/17 Corporate Risk Register (CRR) The Director of Nursing introduced the CRR which had been reviewed in detail by the Audit

& Risk Committee in September. The Board approved the recommendations as set out in the report.

127/17 Minutes of Board Committee Meetings The Board received the minutes of the Finance & Investment Committee held in July and

August, minutes of the Quality Committee held in August 2017 and the Workforce Committee held in July 2017.

The Chair of the Audit & Risk Committee gave a verbal update on the meeting held in

September 2017. The Committee had discussed Health & Safety matters and noted that an external review was underway and would be reported by December 2017. In addition a six facet survey that would incorporate assessment of compliance was also on-going. Internal audit would also undertake a further review of Health & Safety in the future. The Committee had also received an update on Cyber Security, had reviewed and recommended the Charity Accounts for approval to the Charity Committee, had received updates from Counter Fraud, Internal Audit and the Data Quality Assurance Programme. The Committee had also reviewed the BAF and CRR in detail and had reviewed non-NHS debt and noted four significant contracts had been awarded.

The Chair advised that the Charity Committee held in September 2017 had received a

presentation on the Charity’s strategy, discussed the upcoming merger with Reading & District Hospitals Charity, spending plans and had noted the Soapbox challenge event had been a great success.

128/17 Information Item: Board Work Plan The Board received the work plan for the year.


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129/17 Date of Next Meeting

It was agreed that the next meeting would be held at 9.30am on Wednesday 29 November 2017. Chairman Date


Board Schedule of Matters Arising and Outstanding Actions Agenda Item 4

Board Date

Board Minute

Subject Decision Owner Expected Submission

Update

Sept 2017

117/17 (97/17)

Matters Arising: Chief Executive’s Report

It was agreed that the Director of Workforce would circulate details of both Phase 1 and Phase 2 sessions to enable participation.

D Fairley Completed

Sept 2017

119/17 Integrated Performance Report (IPR)

It was agreed that a further update on theatre utilisation as part of the QiPP programme updates would be submitted to the Finance & Investment Committee. It was agreed that the Workforce Committee would review staff turnover. The Director of Finance report would be circulated to the Board.

M Sherry D Fairley C Lynch

Item submitted to the Finance and Investment Committee on 20 November 2017 A retention update was submitted to the Workforce Committee on 30 October 2017 Completed

Sept 2017

123/17 Annual Medical Revalidation Report

The Board approved the Annual Report and recommended that the ‘statement of compliance’ should be signed by the Chief Executive.

L Barker Completed

November 2017 1

Title: Chief Executive’s Report Agenda item no: 5a Meeting: Board of Directors Date: 29 November 2017 Presented by: Steve McManus, Chief Executive Prepared by: Caroline Lynch, Trust Secretary Purpose of the Report • To update the Board with an overview of key issues since the

previous Board meeting. • To update the Board with an overview of key national and local

strategic environment and planning developments • This includes items that may impact on policy, quality and financial

risks to the Trust.

Report History None

What action is required?

For information and discussion: the Board is asked to note the report.

Assurance Information Discussion/input Decision/approval

Resource Impact: None

Relationship to Risk in BAF:

Failure to consistently deliver Quality Care and Healthcare Outcomes Failure to achieve Financial Sustainability

Strategic imperatives. This report impacts on (tick all that apply):: Consistently Delivering Quality Care and Healthcare Outcomes Shaping a Fit for Purpose Core Acute Service Shaping a Fit for Purpose Core Elective Service Being a good system partner and exercising system leadership for integration Developing IT and Information Systems Supporting Better Care Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Being a Great Place to Work Achieving Financial Sustainability Well Led Framework applicability: Not applicable 1.Strategy & planning 2. Risk

Management 3. Board capability

4. Culture 5. Learning & development

6. Roles & accountabilities

7. Performance management

8. Stakeholder engagement

9. Information analysis

10. Robust information

• Implications of all local health economy factors are incorporated into planning. • Information is used to improve quality performance. • Processes provide the board with the insight and foresight to manage the performance of the

Trust now and into the future. Publication Published on website Confidentiality (FOI): Private Public This report will be made available on request.

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Key Issues 1. Staff Engagement at the Trust 1.1 In November I met with a variety of teams during my ‘Back to the floor’ sessions. I visited Trauma

& Orthopaedic outpatient department, Respiratory outpatients department as part of a patient experience visit, the Trust Medical Photography team, Children’s Community Nursing team and our Orthotics team.

2. Celebrating Staff Achievement 2.1 The winner of the August Star Card was Natasha Schultz. Natasha’s hard work and dedication

resulted in the successful homebirth team. The team works really well and collaboratively to ensure women are given the choice as to where they give birth. Natasha, along with her two colleagues has managed to improve our homebirth rate up from very low level to being in line with the national average. The team have achieved this by working additional shifts and excess hours to offer this amazing service.

2.2 In October, Colin Baker, Head of Radiotherapy Physics received the NHS England award for

Chief Scientific Officer’s Knowledge Transfer Partnership for Leaders in Healthcare Science. This will encourage close collaboration between NHS healthcare scientists and other national companies.

2.3 This month we congratulated Lisa Revens, who won South East Radiographer of the Year. Lisa was nominated for her abilities as a mentor and role model, skills that are so important as part of our teaching commitment at the RBH.

2.4 On 3 November 2017, Kath O’Hagan, Emergency Nurse Practitioner, won Health Worker of the

Year Award at the Pride of Reading Awards. A colleague said that Kath “has ensured that the nurses of today not only have a great role model to look up to but also the skills and knowledge to give amazing care’.

3. Staff Excellence Awards 3.1 Our Staff Excellence Awards were scheduled for 22 November at Reading Town Hall, in their

Concert Hall. Due to a power failure in Reading town centre on the evening we had to abandon the event after a great start. This was hugely disappointing but we are looking to reschedule the event in the New Year in order to celebrate the achievements of colleagues across the Trust.

4. ‘Hellomynameis…’ Campaign 4.1 During November, we welcomed Chris Pointon, husband of the late Dr. Kate Granger, founder of

the ‘hellomynameis…’ campaign. Dr. Granger started the campaign as a result of her journey as an NHS patient through diagnosis, treatment and palliative care for the rare cancer condition she suffered with.

4.2 Chris was with us both to celebrate our commitment at the Trust to ‘hellomynameis…’ and to promote the initiative and drive Kate’s inspirational legacy even further as part of his tour around the UK and other countries.

4.3 Chris talked about Kate’s legacy and we heard directly from Kate through a video clip of her talking about her core values that she had learnt through her experience of being a patient. Values around communication, recognising that the small acts of kindness really matter and that taking the time to involve the patient regarding decisions about their care is so fundamentally important.

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4.4 Joyce Gustard, one of our patient leaders at the Trust also spoke at this event. Joyce was the

driving force behind getting ‘hellomynameis…’ established here at the Trust. Joyce has been a huge champion for the values espoused by Dr Kate Granger. Joyce is stepping down from her role as a patient leader in a few months and I wanted to thank her for the amazing contribution she has made for patients and staff.

Other issues 5. GMC survey 2017 5.1 Between 21 March to 10 May 2017, the GMC conducted their annual survey to gather the views

of doctors in training and trainers across the UK, on their experiences in taking part in postgraduate medical education. The survey consisted of more than 100 questions and over 75,000 doctors in training and trainers took part. This was 53,335 doctors in training (98.3% response rate) and 24,577 trainers (53.6% response rate).

5.2 Due to the number of questions, the data is large and complex. If the data is broken down to analyse all doctors in training that are completing an acute Foundation programme (excludes ophthalmology, occupational health, public health, radiology and single specialties such as psychiatry and general practice) it is possible to score individual acute trusts.

5.3 If an average of all posts in the Trust was calculated and ranked, the Trust would rank number 1.

The survey covers topics such as overall satisfaction, clinical supervision, reporting systems, work load, teamwork, induction and feedback.

6. Secretary of State for Health, Jeremy Hunt Visit

6.1 On Thursday 9 November, the Secretary of State for Health, Jeremy Hunt, visited the Trust to host a patient safety discussion. He was accompanied by Jacqui Dunkley-Bent who is the Head of Maternity, Children and Young People at NHS England and National Maternity Safety Champion for the Department of Health.

6.2 The event was introduced by Caroline Ainslie, who gave an overview of the Trust’s performance, followed by a talk from Jeremy Hunt and Jacqui Dunkley-Bent about the national focus on making the NHS the safest health system in the world. The event was attended by a cross section of staff and concluded with a question and answer session.

7. Care Quality Commission (CQC) 7.1 Our CQC inspection concluded on 13 October with the well led part of the inspection. We

provided feedback to the CQC about the positive experience in terms of their approach to the inspection and thanked our staff for being open and transparent in their engagement with the CQC. We anticipate that we will receive our draft Quality Report during December 2017.

8. Jacobs the Jewellers 70th Anniversary Celebrations 8.1 Ian Thomson, the Charity Director and I visited Adam Jacobs and his mother Adrienne on 25 July

to discuss their proposal to raise funds for the Royal Berkshire Charity.

8.2 This month, Jacobs the Jewellers officially revealed its 70th anniversary celebrations 2018, ‘Seventy for Seventy’, at its Christmas Showcase in front of over 200 customers. Entirely in keeping with a family business holding the Reading community at its heart, Jacobs’ 2018 program centres around the ambitious goal of raising £70,000 for the Royal Berks Charity, specifically the Berkshire Cancer Centre, in the 70th anniversary of the founding of the NHS.

8.3 The Royal Berks Charity attended the evening celebration and raised £800 through sales of raffle tickets. On the evening Adam Jacobs told the audience about key events that they were taking

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part in next year. A Sky dive, the Reading Half Marathon and Green Park Challenge, and a Charity Golf Day. At least 35 individuals have signed up to take part in an event. I have signed up for the Sky dive.

9. Accountable Care System (ACS)

9.1 The revised governance structure for Berkshire West Accountable Care System has been implemented in line with previous Board discussions. This seeks to improve the focus and speed with which we move to implementing this approach. Areas of attention include new pathways of care, the development of shared services and new forms of contract. We are working with colleagues in NHS England and NHS Improvement to develop these further with proposals being expected to come to Board in January 2018.

9.2 One example of this is where are working with local providers in relation to the Musculoskeletal (MSK) pathway improving both the service to patients and the overall efficiency of this activity.

10. Budget 10.1 The Chancellor in his budget statement yesterday announced what he refers to as ‘additional

monies’ both to support service delivery (£2.8 billion) and capital development (£10 billion). The terms upon which we are able to access these incremental monies are as yet unknown. However, we will be working individually and with ACS and Sustainability and Transformation (STP) partners to seek an appropriate allocation into the local health and social care system.

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Title: Integrated Performance Report Agenda item no: 5b Meeting: Board of Directors Date: 29 November 2017 Presented by: Mary Sherry, Chief Operating Officer Prepared by: Performance Team Purpose of the Report The purpose of this paper is to provide the Board of Directors with an

analysis of quality performance to the end of October 2017.

Report History Executive Management Committee - 27 November 2017

What action is required? The Board is asked to note the report.












Publication Published on website Confidentiality (FoI): Private Public

23 November 2017

Integrated Performance Report

The purpose of this paper is to provide the Board of Directors with an analysis of quality performance to the end of October 2017. The report covers performance against the NHS Improvement (NHSI) Risk Assessment Framework as well as national and local key performance indicators. Contact: Caroline Ainslie, Director of Nursing Lindsey Barker, Medical Director Mary Sherry, Chief Operating Officer Don Fairley, Director of Workforce Craig Anderson, Director of Finance

Contents

Integrated Performance Report Page 2

Introduction Page 3

NHSI Compliance Page 4

Summary Page 5

1. Patient Safety Page 6Harm Free Care Page 6

Incidents Reporting Page 7

2. Patient Experience Page 10

3. Clinical Effectiveness Page 12Mortality Page 12

Clinical Outcomes Page 15

4. Access Elective Waiting Times Page 18

Emergency Waiting Times Page 22

Admitted Patient Experience Page 26

Theatres Patient Experience Page 27

Outpatient Experience Page 28

5. Workforce Page 30

6. Staffing Data Page 31

7. Health and Safety Indicators Page 34

8. Finance Page 35

The purpose of this report is to provide assurance to the Board of Directors on compliance against the NHSI Risk Assessment Framework, national and local key performance indicators. It acknowledges significant and notable achievements, and highlights and discusses areas of concern or where performance has a less than favourable forecast.

Introduction


NHSI Compliance


Accident & Emergency (A&E) o The Trust has not achieved the A&E 4 hour standard for October, reporting 92.6% total performance and Type 1 only reporting at 91.2%. o The Trust continues to be challenged with flow through the hospital and whilst length of stay has reduced in recent months, a number of beds

remain closed as a reflection of staffing pressures through the organisation. o The conversion to admission in October has remained high reporting above 32%. o The weekly Emergency Department (ED) Operational Meeting continues to scrutinise breach reasons and review current challenges within the Trust

impacting the day to day performance. The focus has remained on embedding a Red/Green day approach to support maintaining a manageable level of length of stay (LOS) >7 patients and improve flow in the Trust.

o The Trust Q3 Sustainability and Transformation Fund (STF) performance requirement is to achieve above 93% (cumulative quarter). At the end of October the Trust is not achieving this level of compliance. Performance through November has improved position, however remains under the 93% requirement (92.65%).

o The Trust has gone live with GP streaming from ED and we will be analysing the impact along with other urgent access metrics through November.

Cancer Waiting Times o The Trust is compliant across the core cancer standards in September with 31 day subsequent treatment marginally missing the standard. o Reallocation of breach rules, which are not yet technically possible to report, would have seen the Trust September position improve from 86.4% to

86.9% against the 62 day FDT standard as a result of late referral to the Trust and delays with tertiary centres. o The Trust remains above the national average performance for all cancer standards and we continue to pursue actions to support the delivery of

monthly compliance both at a Trust and tumour site level. o The Trust has achieved cumulative Q3 compliance against all core cancer access standards. o The Trust has achieved the NHSI requirement to report 62 day compliance in the September reporting (November upload). 18 Weeks Referral To Treatment (RTT) o The October RTT position remains compliant against the 92% standard. o Improvements have been seen in data quality and waiting list size as a result from the progressive implementation of the Digital Pathway Solution.

CQC - Well Led CARE - Excellent

October 2017 Summary


CQC - Well Led CARE - Excellent

In summary October has been a month mixed with success and increased challenge for the RBH. Large proportions of our quality and performance metrics have been maintained or improved. However we remain very busy and this is shown most clearly by the continued pressure on our A&E department and the challenge to maintain flow within the hospital, which is a continuing trend into November. Our non-elective services have continued to experience high levels of demand and capacity pressures during October and as we plan for what is expected to be a busy winter period additional actions are being taken to address the current challenges. During October the Trust opened the new GP Streaming Unit which will support us in managing attendance at the hospital within an appropriate environment. We are currently streaming adults through this service with plans to extend to Paediatrics later in the year. We continue to perform well against our patient safety standards. There have been no Trust apportioned case of Clostridium difficile (C.diff) and we continue to maintain all of our patient safety metrics included in our performance report with the exception of two safeguarding training requirements. Across our safeguarding training most have improved with adult safeguarding and Level 3 safeguarding children now achieving the standards, and level 1 nearing the required level. The number of complaints remains low in October and we have seen a significant number of compliments received by the Trust. We continue to perform well in the satisfactions surveys and Friends and Family Test however Maternity has had a small drop this month. We do however remain challenged in respect of mixed sex accommodation (MSA) and continue to work to improve in this area. Our elective services continue to perform well with our routine, diagnostic and the majority of cancer standards achieving compliance against their respective targets. At this mid-point of the year the Trust is compliant against all of the nationally required elective access standards. The budget and latest forecast both planned for a surplus in October, but in practice there was a deficit of £0.18M. The shortfall against budget, of £2.51M, means that we are now £1.41M below year to date Control Total; however we have continued to accrue for STF income because our expectation is that we will still achieve Control Total in the year. Our financial Use of Resources rating remains at a 3, and will continue to do so whilst the year to date result is a deficit. Cash remains healthy at £35.51M, which is £20.59M more than budget, but we expect most of this variance to reverse later in the year.

1. Safety – Consistently Delivering Quality Care and Healthcare Outcomes

Infection Control No Trust apportioned cases of Clostridium difficile (C.diff) were reported in October 2017. The total number of cases reported to date 2017/18 stands at 11 against an upper limit for the full year of 27. 8 Trust apportioned E.coli cases were reported and initial reviews have not highlighted any issues with practice.


CQC - Safe CARE - Excellent

Harm Free CareTarget

variance

Infection Control Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Meeting the C.Diff objective 0 1 1 1 2 1 4 3 0 2 1 0 ▼ N 2 -2

C.Diff due to lapses in care 0 1 1 0 1 0 3 1 0 1 0 0 ◄► N 0 0

C.Diff (Cummulative) 12 13 14 15 17 1 5 8 8 10 11 11 - N 16 -5

MRSA 0 1 0 1 0 0 0 0 0 1 0 0 ◄► N 0 0

MSSA surveillance (trust acquired) 1 1 5 3 3 3 3 2 0 4 8 0 ▼ - - -

Ecoli (trust acquired) infections 4 2 5 2 4 4 5 3 6 7 4 8 ▲ - - -

Antibiotic usage review in 72 hours - - - - - - - - 96.7 - - - - - - -

Sepsis: % of the patients meeting the screening criteria

should be screened for sepsis in ED- - - - - 75.0% 79.0% 88.0% 98.0% 94.0% 96.0% 96.0% ◄► - 90.0% 6.0%

Sepsis: 90% of patients with Sepsis: 90% of patients with

sepsis should receive antibiotics within one hour

(Inpatients)

- - - - - 72.0% 74.0% 83.0% 95.0% 93.0% 93.0% 91.0% ▼ - 90.0% 1.0%

Target Type: N - National / L - Local / H - Hospital

Target Actual

Hospital acquired Grade 3-4 pressure ulcers: Zero Avoidable Grade 3-4 Pressure ulcers. Hospital acquired Grade 2 pressure ulcers: Hospital Acquired Grade 2 Pressure ulcers 18. Following review of the 18 reported Hospital Acquired Grade 2 Pressure ulcers, 9 were deemed Avoidable & 9 Unavoidable. The 100 Days Free from Avoidable Pressure Ulcers Campaign continues: 1 Year pressure ulcer free: Caversham, Short Stay Unit (SSU), Sonning , Coronary Care Unit (CCU) and AMU/HMU. 200 days free: Hunter/Lister (General Surgical Unit), Redlands, Intensive Care Unit (ICU), Acute Stroke Unit (ASU) and Hopkins. 100 days free: Burghfield.




Incidents ReportingTarget

variance

Falls and Ulcers Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

Type Month +/-

Pressure Ulcer Incidence per 1 000 bed days 1.05 0.56 0.42 0.68 0.89 0.77 0.67 0.95 1.10 0.45 0.58 0.94 ▲ N 1.00 -0.06

Grade 2 Pressure Ulcers 21 8 7 14 15 13 13 18 17 7 7 18 ▲ N - -

Grade 3 or 4 avoidable pressure ulcers (SI) 1 1 2 0 2 0 0 0 0 0 0 0 ◄► N 1 -1

Patient Falls per 1 000 bed days 4.2 4.4 4.5 4.4 4.2 5.3 4.9 4.4 4.4 5.6 4.7 4.3 ▼ N 5.0 -0.7

Patient falls resulting in Harm (SI) Avoidable 2 0 0 0 1 0 1 1 0 0 1 1 ◄► - - -

Patient falls resulting in Harm (SI) Unavoidable 1 0 0 0 0 0 0 1 0 0 0 0 ◄► - - -

Nutrition risk assessment in 48 hours of Admission to

Hospital96.7% 96.7% 97.9% 98.0% 98.5% 97.4% 98.0% 99.2% 96.7% 98.2% 96.3% 98.5% ▲ N 95.0% 3.5%


Target Actual

23/11/2017 Integrated Performance Report Page 8


Datix The issues affecting Datix performance in September and October have been resolved and the backlog of unapproved incidents has been cleared and the data validated.


Incidents ReportingTarget

variance

Other Incidents Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Patient safety incidents reported (approved) 445 398 601 640 645 607 557 632 582 530 652 687 ▲ - - -

Number of incidents reported (unapproved) 1095 1226 480 301 183 146 71 43 69 70 26 35 ▲ - - -

Patient Safety Incidents/1000 Bed days 36 34 37 36 33 42 32 32 36 34 30 38 ▲ - - -

Patient Safety Incidents/100 Admissions 9.0% 8.1% 9.4% 9.5% 7.6% 10.9% 7.9% 8.3% 8.0% 8.0% 8.2% 9.4% ▲ N 7.0% 2.4%

All serious incidents (SI) 3 0 8 7 8 2 4 5 5 1 3 3 ◄► - - -

Duty of Candour breaches (SI) 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

Never Events 0 0 0 1 0 1 0 0 0 1 0 0 ◄► N 0 0


Actual Target

Mental Health: • The numbers of mental health related attendances to the Emergency Department (ED) has increased from 241 in September to 270 in October. Child Safeguarding concerns: • Decreased from 79 in September to 63 in October. • 45 of the 63 = 71% for Children and Young People (CYP) who attend and are referred to Child and Adolescent Mental Health Services (CAMHS) or

due to parental mental health disorder.



CQC - Safe CARE - Aspirational

Health and Safety Indicators Target

variance

Health and Safety IndicatorsNov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT

Target

Type Month +/-

Number of detentions under the Mental Health Act to the

RBH5 2 4 1 4 5 3 8 5 5 5 7 ▲ - - -

Number of DOLS (Deprivation of Liberty) applications

applied for2 3 1 2 2 3 4 3 5 6 10 8 ▼ - - -

Number of DOLS (Deprivation of Liberty) applications

granted2 0 0 0 1 0 1 1 1 0 0 2 ▲ - - -

Number of Child Safeguarding concerns raised by the

Trust 82 29 46 45 76 53 66 49 66 55 79 63 ▼ - - -

Number of Adult Safeguarding concerns raised by the

Trust 24 17 25 29 30 25 17 19 24 18 22 30 ▲ - - -

Number of Safeguarding concerns raised against the

Trust - - - - - - 5 2 2 2 4 3 ▼ - - -


SafeguardingTarget

variance

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

TypeMonth +/-

Staff training in safeguarding of Adults (to incl

introductory DoLS & MCA)- - 88.0% 88.2% 88.6% 89.3% 89.2% 90.0% 90.0% 89.0% 89.9% 90.0% ▲ L 90.0% 0.0%

% of relevant staff who have had Safeguarding Children

Level 1 Training- - 86.0% 86.0% 86.2% 87.7% 87.6% 89.8% 89.4% 90.2% 91.7% 94.0% ▲ N 95.0% -1.0%


Level 2 Training- - 93.0% 93.3% 93.7% 93.4% 93.7% 94.1% 93.7% 90.4% 92.0% 94.0% ▲ N 85.0% 9.0%


Level 3 Training- - 86.0% 91.2% 88.6% 87.9% 84.5% 84.5% 84.4% 84.0% 84.6% 91.0% ▲ N 85.0% 6.0%

Mental Capacity Act (MCA) and Deprivation of Liberty

(DoL)s enhanced training- - 80.0% - - 89.3% - - 81.0% - - 80.0% ▼ L 80.0% 0.0%

A&E staff with appropriate training in conflict resolution

incl restraint training: ALL ED Staff- - 77.6% 80.7% 83.0% 81.8% 80.3% 83.0% 79.2% 81.6% 77.0% 72.5% ▼ N 80.0% -7.5%


Actual Target

Actual Target

15 complaints were received in October and 17 were closed (5 in Planned Care, 7 in Urgent Care and 5 in Networked Care). Analysis of the 15 complaints has shown a top theme of Clinical Treatment, similar to previous months (73% of complaints received in October). Analysis of the 210 PALS has shown a top theme of Administration, similar to previous months (33%). The areas which received the most PALS were Paediatrics (10), ED (10 - the same as September), T&O (14 - the same as September), General Surgery (12 - a decrease of 3 on September), Ophthalmology (15 - a decrease of 8 on September), Urology (15 - an increase of 7 on September). The themes across these top areas were mixed. Zero complaints have been referred to the Ombudsman. One complaint was closed outside of 25 days, in Planned Care, which was a complex General Surgery complaint that required several different statements. Of the complaints closed in October the severity rating was: 2 Orange (moderate), 9 Yellow (low), 6 Green (very low). 4 were well founded, 6 partially founded and 3 were not founded. We are awaiting outcomes for 4 complaints; these are being actively sought.


2. Patient Experience – Consistently Delivering Quality Care and Healthcare Outcomes

CQC - Caring CARE - Compassionate

Target

variance

Patient Complaints Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

Type Month +/-

Number of Complaints 12 15 28 20 19 12 34 17 18 25 15 15 ◄► - - -

Complaints avg response (days) 19 18 17 20 18 21 19 19 24 27 22 20 ▼ L 25 -5

Number of complaints returned for a

second review- - - - - - 5 1 4 3 2 3 ▲ - - -

Number of Patient Advisory Liaison

Service (PALS) concerns266 158 265 257 264 238 267 253 223 249 223 210 ▼ - - -

Number of Complaints to Ombudsman 0 0 1 1 0 1 0 0 0 1 1 0 ▼ - - -

Number of Complaints upheld by

Ombudsman0 0 0 2 1 0 0 0 1 0 0 0 ◄► - - -

Number of compliments recieved to

Patient Relations Department64 43 71 65 105 47 80 101 71 87 86 173 ▲ - - -


Actual Target

Trust Inpatient Survey – overall rating The breakdown of the response totals are 66 responded Excellent, 38 Very Good, 15 Good with 1 Fair and 1 Poor. Single sex accommodation breaches Total of 62 (36 - Acute Medical Unit (AMU), 26 – Emergency Department (ED) Observation (Obs) bay). The breaches occurred on 7 days when the Trust had capacity challenges.


2. Patient Experience – Consistently Delivering Quality Care and Healthcare Outcomes

CQC - Caring CARE. - Compassionate / Aspirational

Surveys and FeedbackTarget

variance

Trust Patient Survey Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Trust Inpatient Survey - overall rating 95.7% 97.4% 96.9% 93.5% 97.8% 97.8% 96.8% 98.1% 97.4% 96.4% 100.0% 98.4% ▼ N 97.0% 1.4%

Friends and Family Test (FFT) Response

Inpatients45.2% 42.1% 47.0% 46.6% 45.9% 42.6% 50.4% 53.2% 57.0% 52.2% 43.2% 51.1% ▲ N 30.0% 21.1%

FFT Recommendation Rates Inpatients 98.9% 98.9% 99.0% 98.6% 98.9% 99.0% 98.6% 99.5% 99.1% 99.4% 99.3% 99.6% ▲ N 98.0% 1.6%

FFT Recommendation Rates Maternity 96.7% 97.5% 96.2% 97.6% 96.5% 96.7% 97.2% 95.5% 96.8% 96.3% 95.3% 93.8% ▼ N 95.0% -1.2%

Single sex accommodation - breaches 41 71 190 95 54 50 112 16 22 75 63 62 ▼ N 0 62

Number of positive feedback posted on

NHS choices- 15 22 19 10 13 16 19 13 11 26 10 ▼ - - -

Number of negative feedback posted on

NHS choices- 4 2 3 4 3 4 1 5 2 2 8 ▲ - - -


Actual Target

3. Clinical – Consistently Delivering Quality Care and Healthcare Outcomes


The HSMR weekday and weekend mortality gap has begun to reduce as both weekday and weekend mortality improve; weekday emergency mortality is now statistically significantly better than the expected against national due to much lower deaths in last 2 months. The Clinical Data Quality Group and Clinical Outcomes and Effectiveness Committee (COEC) continue to monitor Dr Foster alerts for specific diagnostic codes. The Mortality Surveillance Group continues to monitor possible or probable avoidable harm related to hospital care and sharing learning points across the Trust.

CQC - Effective CARE - Excellent

National HSMR Peer Comparison rolling 12 month Aug 16 – Jul 17

(National Acute non-specialist)

HMSR Monthly Trend, Aug 16 – Jul 17



The centralised process of reviewing deaths began in October 2016 in response to national guidance on Learning from Deaths. All cases are screened at the point of death certification against a checklist of ‘concern’ measures. If any of these flag up a concern, the case is sent for full mortality review by a consultant to assess the quality of care given and to identify any lessons to be learned to improve future care. All cases are given a grading from ‘no suboptimal care’ (i.e. no concern about the quality of care) through to ‘possible or probable avoidable death ‘where different care might have changed the outcome). Serious incidents are declared where actual or near miss significant harm has occurred or there is significant learning for the organisation which warrants in-depth investigation. Reporting a case as a SIRI therefore does not necessarily mean it was an avoidable death. There were 13 deaths of patients with learning disabilities. These cases are automatically subject to full review. Where applicable, these reviews are cross-organisational with information and learning shared.




Learning and actions from the mortality review process: October 2016 – July 2017 Over the 10 months between October 2016 – July 2017 all adult inpatient deaths have been subject to an initial ‘screening ‘ review. 28% of adult inpatient deaths have been subject to full review. 14 deaths were identified as receiving suboptimal care (less than highest quality) which may have made a difference to these patients’ outcome (possible or probable avoidable death).

Probable avoidable death identified and actions taken: One ‘probable avoidable’ death has been identified. This related to a patient who experienced delayed diagnosis and treatment for a very rare complication of a medical condition. This was reported as a serious incident requiring investigation (SIRI). Improvement actions taken following the investigation have included: improved diagnostic testing; increased senior review; and improved clinical ownership of patients being treated by several specialties.

Actions taken as a result of possible avoidable deaths: • Training for Emergency Department (ED) staff on electrocardiogram (ECG) interpretation. • Simulation training for making decisions under pressure. • Improved handover information. • Acute medical patients to receive daily consultant review. • Establishment of a helpline for the diagnosis and management of rare conditions. • Bed base review undertaken to inform the clinical services and estates strategies.

Key learning points identified through all mortality reviews: • Need to ensure a clear management plan, particularly for patients admitted at weekends or moved between wards. • Clear consultant ownership of patients, to avoid delays if multiple specialist involvement. • Importance of timely completion of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) orders and ‘Medical Advance

Plans’ (MAPs). • Importance of managing diagnostic uncertainty and consulting with colleagues. • Recognising deteriorating patients. • Importance of good communication and handover including adherence to hospital policy such as escalating concerns and

seeking help.

A monthly update with themes and learning points identified is circulated to all specialties from the Mortality Surveillance Group.



The overall caesarean section (CS) rate in October was 27.87% which is within expected parameters . There has been a decrease in the elective caesareans (12.34%) this month.

The number of deliveries on the Midwife-Led Unit (MLU) has increased to 15% of total births.

There were four unit diversions due to inadequate staffing and capacity for workload. Five women were diverted, three to Great Western Hospitals (GWH), and two to Wexham, one for assessment only. There were three other occasions when divert was attempted but other units were unable to support.

The first publication of the National Maternity and Perinatal Audit (NMPA) of 16 measures based on 2015/16 births in NHS maternity services highlighted the Trust obstetric haemorrhage at 3.7% against a NHS mean of 2.8% (range 1.1% and 5.6%). This was investigated at the time. An action plan of changes to practice, guidelines and training was completed. Data is routinely monitored with reduction in 16/17.



Monitoring Clinical OutcomesTarget

variance

Maternity Care Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Women giving birth: 1:1 delivery of care 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% ◄► N 98.0% 2.0%

Midwife : birth ratio (util ised

workforce) 1:32 1:30 1:28 1:32 1:29 1:30 1:31 1:29 1:32 1:31 1:31 1:31 - L 1:30

Caesarean Sections - Elective 15.5% 14.8% 13.3% 14.2% 15.1% 15.2% 13.2% 12.7% 17.7% 10.8% 15.0% 12.3% ▼ N 12.0% 0.3%

MLU No of deliveries (proportion of

total) 20.0% 16.2% 21.9% 20.8% 18.4% 20.9% 15.3% 15.9% 14.0% 18.0% 11.0% 15.0% ▲ N 20.0% -5.0%

No of times women diverted 0 3 3 4 1 3 3 3 3 5 1 5 ▲ N 0 5

Percentage of Unexpected NICU

admissions over 37 weeks- 4.8% 5.4% 4.1% 5.7% 4.6% 5.8% 5.0% 2.4% 4.7% 4.4% 5.0% ▲ N 6.0% -1.0%

Number of births - - - 422 454 413 430 470 464 452 487 479 ▼ N - -


Actual Target


The reduction in the neck of femur performance is a combination of limited capacity and patient complexity. The clinical teams are working hard to ensure protocols are in place for medical optimisation prior to theatre, including possible point of care testing to reduce delays due to anticoagulation. One hospital acquired Venous thromboembolism (VTE) was reported in October. This was confirmed in a patient with a history of recent surgery and an investigation is underway.




variance

Other Clinical Indicators Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Fractured Neck of Femur: Surg in 36

hours62.9% 77.8% 79.6% 93.1% 82.8% 77.5% 63.8% 80.6% 86.8% 86.8% 81.4% 81.0% ▼ N 85.0% -4.1%

VTE Risk Assessment 95.1% 95.3% 96.1% 95.3% 95.1% 95.4% 95.2% 95.7% 96.8% 95.4% 96.5% 98.6% ▲ N 95.0% 3.6%

VTE Incidence (Hospital & Community

Acquired)49 45 42 44 46 52 51 44 51 42 43 33 - - - -

Datix: Number of VTE Incidence

(Hospital Acquired) 3 2 0 3 0 2 1 0 1 0 0 1 - - - -

Datix: % VTE Incidence (Hospital

Acquired)6.1% 4.4% 0.0% 6.8% 0.0% 3.8% 2.0% 0.0% 2.0% 0.0% 0.0% 3.0% - - - -


Actual Target


Stroke Care • Transient Ischaemic Attack (TIA) assessments within 24hrs for high risk patients continues to fluctuate and is below the target window for

September and October. Pending consultant recruitment, interim solutions are being developed. • Our 90% stay has remained above target, yet this still features as a concern and steps are underway to monitor and identify both capacity and

process issues. • Consultant review within 14 hours of admission is a challenge with stroke admissions external to the Stroke Unit and it is having a negative

effect on Best Practice Tariff (BPT). Regional and CCG discussions continue to review and recommend how the BPT process is managed, including exceptions.

Cardiac Care • Figure provided one month in arrears due to validation. • One breach in month, discussed at the MINAP meeting; a patient self-presenting to ED saw a delay in the activation of the Percutaneous

Coronary Intervention (PPCI) pathway.




variance

Stroke Care Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Proportion of people with high risk TIA

fully investigated and treated within

24hrs (IPM national target)

90.0% 88.0% 86.0% 92.0% 93.0% 80.0% 97.0% 88.0% 76.0% 92.0% 87.0% 84.0% ▼ N 90.0% -6.0%

Proportion of patients spending 90% of

their inpatient stay on a specialist

stroke unit (national target)

86.0% 78.0% 77.0% 91.0% 88.0% 86.0% 75.0% 90.0% 95.0% 83.0% 84.0% 89.0% ▲ N 80.0% 9.0%

Proportion of stroke patients scanned

within 24 hours of hospital arrival

(local target based on Admission)

98.0% 100.0% 97.0% 100.0% 100.0% 96.0% 98.0% 96.0% 98.0% 98.0% 98.0% 96.0% ▼ N 94.0% 2.0%

Proportion of Patients discharged to

preadmission address94.0% 93.0% 88.0% 97.0% 91.0% 91.0% 100.0% 92.0% 96.0% 94.0% 92.0% 93.0% ▲ N 90.0% 3.0%



variance

Cardiac Care Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Myocardial Ischaemia National Audit

Project (MINAP): Call to Balloon target

less of than 150 minutes

100.0% 100.0% 100.0% 91.0% 100.0% 100.0% 100.0% 100.0% 90.0% 100.0% 100.0% 0.0% ◄► N 82.0% 18.0%


Project (MINAP): Call-to-Balloon target

of less than 120 minutes

91.0% 100.0% 100.0% 91.0% 100.0% 92.0% 100.0% 100.0% 82.0% 100.0% 100.0% 0.0% ◄► N 86.0% 14.0%


Project (MINAP): Door-to-Balloon target

of less than 90 minutes

100.0% 100.0% 100.0% 91.0% 100.0% 100.0% 100.0% 100.0% 85.0% 100.0% 83.0% 0.0% ▼ N 97.0% -14.0%


Target Actual

Actual Target

18 weeks RTT The October RTT incomplete position is compliant against the 92% standard. Long Wait Incomplete Pathways There are no patients reported as waiting over 52 weeks. Long Wait Closed Pathways The Ophthalmology patient previously reported to the Trust Board was treated during October. Diagnostics Monitoring (DM01) 6 Weeks Wait The Trust remains compliant against the DM01 99% standard for October. As part of the Trusts Data Quality Assurance Programme, the planned review of the DM01 dataset commenced during Q2.


4. Access – Consistently Delivering Quality Care and Healthcare Outcomes.

CQC - Responsive CARE - Excellent

18 weeks RTT Actual Target Target

variance

Waiting Times: 18 weeks RTT Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

Type Month +/-

18 Weeks: incomplete pathways 94.0% 93.1% 92.5% 93.4% 93.4% 93.3% 92.8% 92.9% 93.1% 92.2% 92.5% 92.2% ▼ N 92.0% 0.2%

18 Weeks: incomplete pathways (total number) 31685 31475 31225 30822 31136 31785 32484 31160 33349 23715 23747 24089 - - - -

18 weeks complete patients (Admitted clock

stops)1960 1550 1831 1655 2191 1462 2864 2508 2054 1752 1616 2124 ▲ - - -

18 weeks complete patients (Non Admitted clock

stops)9718 7771 8716 8129 9055 6994 6699 6486 6119 5428 5454 6904 ▲ - - -

52 Weeks - Admitted 10 4 2 1 0 1 0 0 0 0 1 1 ◄► - 0 1

52 Weeks - Non-admitted 4 2 0 0 0 1 0 0 0 0 0 0 ◄► - 0 0

52 Weeks - Incomplete 7 2 1 0 0 0 0 0 0 1 1 0 ▼ N 0 0

Diagnostics Waiting < 6 weeks (DM01) 99.5% 99.2% 99.4% 99.5% 99.5% 99.5% 99.9% 99.4% 99.6% 99.1% 99.3% 99.5% ▲ N 99.0% 0.5%

Diagnostics in 6 weeks (number) 4827 4676 4422 4384 4764 4891 5226 5472 5668 5358 5043 5712 ▲ N - -


4. Access – Digital Pathways Solution (DPS)



During 2016/17 a decision was taken to change the approach to the management of the Referral to Treatment (RTT) standard to address the known data quality issues associated with the metric. Through discussion with the local teams, the CCG and NHS Improvement it was agreed that the Trust would undertake a significant change programme to; 1. Operationalize the collection of information used to derive RTT pathways 2. Create a set of tools which encourage live management of patient pathways with performance being a bi-product. 3. Digitally enable the process to reduce the burden of data input. Work commenced during 2016/17 to create a user interface integrated within the Cerner EPR that could be processed by our DPS solution to manage the most variable aspect of RTT (outpatient appointments). This replacement for the ‘Green Form’ outcome forms, with a workflow driven tool was completed and deployed in May 2017. This step provided a platform both to enable increased capture of clinical information but fundamentally it enabled us to move away from RTT codes to plain English outcomes of the appointment that is converted into RTT code by the DPS solution. This was the first phase of the programme and whilst it was the most challenging, the benefit in enabling better capture of information and consistent application of rules was fundamental to the success of the solution. At this stage we had improved the process but no logic/rules were dominant. The second and third phases of this work are largely technical refinements to the solution logic/rules that derives pathways. However it is at this stage that the most significant gains in terms of RTT specific reporting and accuracy are found which is why the most variance in the reported numbers can be seen from Aug 17. Where a change is made to the rules it affects the whole dataset. When the changes are scrutinised it is simple to see that the vast majority of operational events are correct (referrals etc) but the associated RTT code was incorrect. By staying with the approach that any logic / rules being used needed to be high level in order to assure consistent and transparent application of rules we have been able to manage a complex transition within the live/operational environment whilst gradually increasing the operational ownership of the patient information. The two main impacts of this programme; 1. Significant reduction in data quality issues within the dataset and a reduction in the associated resource required to ‘clean’ 2. Simplification of the data entry requirement has encouraged the live management of patient pathways rather than retrospective management of a performance standard.

An example report – Graphical Incompletes A demonstration of the current incomplete waiting list profile (22 Nov 17) with full drill-through to patient data functionality . Supported by detailed Pathway Viewer.

4. Access – Digital Pathways Solution (DPS)



Phase 1 Phase 2 Phase 3

Jan

-18

Phase 4

Action Implement DPS Tool Automated Clock Start Automated Clock Stop Rolling Data Assurance

Expected Delivery May-17 Aug-17 Jan-18 Mar-18

Status Complete - to time Complete - to time On track Not started

Output

- New tool becomes available to Performance team - Coincide with rollout of EPR Outcome form (Mpage) - Limited use of 'logic' across both start and stop actions - Parallel running of logic and manual code entry processes

- Training on new tool complete with new reports available to operational teams - Manual clock start codes no longer processed

- EPR manual event functionality (expected Dec 17) to replace code reliant process - Manual clock stop codes no longer processed

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- Monthly data assurance interogation utilising quality account audit methodology - Risk assessed cohort taken from reporting data as well as non-RTT

What DPS is doing

- High level exclusion criteria (TFC 317, 324, 656, 290, 654, 318, 422, 651, 658, 650, 314, 652, 424, 653) i.e. Non-reportable subspecialties set as NON-RTT. - Referral clock starts logic limited to GP referrals - Addition to waiting list logic in place (restricted to Elective/Therapeutic) - Both manual codes and operational outcomes are being processed No lower level exclusions

- Start logic changed. Removed restriction of GP only. - Source of Referral start exclusions (A&E, C2C) - all other sources included - AWL logic refined at tfc level (410, 262, 361 cannot start pathways on AWL)

- AWL logic refined at tfc level (410, 262, 361, 303, 800 cannot start pathways on AWL) - Final refinements to clock start logic to a service level (exclusions expected to be, GP direct access echo, Virtual Fracture

N/A

Impact - Limited impact to incomplete volumes - Increase in numbers of Admitted clock stops

- c.10,000 incorrectly started pathways removed - Rate of addition reduced - Significant reduction in incomplate pathway numbers. 8 in 10 <18 weeks. (DQ inflation removed) - Performance compliance maintained at Trust level

- Ability to record operational outcomes against admin actions re-provided (replacement of code reliant process)

- Repurpose the roll of DQA team

Benefit

Positive - Environment available for operational development and UAT - Platform allows for easy view of the logic output to support live refinements - Code is reading and prioritising operational event outcomes - Reduction in errors Negative - Visibility of RTT pathways restricted to the performance team

- No requirement for operational / clinical teams to correctly identify pathway starts (Now automated based upon logic criteria) - Significant reduction in errors

- DPS functionality in full use - Operationally required information repurposed to derive RTT status - Reporting processing time reduced from 15 days to 48 hours (October reporting - Nov - completed within 72 hours) - Management of RTT pathways and performance becomes 'Live' process best managed through operationally focused tools.

- Rolling assurance that logic is correct. - Early identification of issues

Issues identified and action taken

No issues

July 17 - June RTT snapshot corrupted during processing. NHSE/I made aware RBH would not be able to submit. Extension of reporting window negotiated. The issue in the processing has been corrected and the snapshot retaken. Successfully provided RBH position within deadline.

Oct 17 - issue identified relating to 98 codes which affected the reporting of clock stops and in some tfc incomplete pathways. Can be seen in the Aug and Sept figures. Relates to oversight in the logic code base that was incorrectly setting as non-RTT

N/A



104 day breaches: At the end of October nine patients have been reported to the Clinical Commissioning Group. Three of the nine are confirmed cancer and two of the nine are being treated at a tertiary centre. Of the remaining seven patients being managed at RBH, the key themes resulting in longer waits are complex diagnostic pathways and patient availability. September and Q2 Performance The Trust is compliant across the core cancer access standards in September 17 and Q2, with 31 day subsequent surgery marginally missing the standard.


Outpatient ExperienceTarget

variance

Cancer Pathways Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Cancer 2 week wait: cancer suspected 97.1% 96.6% 95.5% 98.0% 96.5% 94.8% 96.2% 95.0% 93.8% 94.8% 94.7% 95.3% ▲ N 93.0% 2.3%

Cancer 2 week wait: cancer suspected - QTR 0.0% 96.6% 0.0% 0.0% 96.7% 0.0% 0.0% 95.4% 0.0% 0.0% 94.4% 0.0% ◄► N 93.0% -

Cancer 2 week wait: breast patients 99.4% 98.1% 96.3% 98.8% 97.3% 93.2% 98.3% 94.9% 95.1% 94.4% 98.6% 98.2% ▼ N 93.0% 5.2%

Cancer 2 week wait: breast patients - QTR 0.0% 98.6% 0.0% 0.0% 97.4% 0.0% 0.0% 95.5% 0.0% 0.0% 95.8% 0.0% ◄► N 93.0% -

Cancer 31 day wait: to first treatment 97.4% 99.5% 96.9% 98.1% 96.8% 96.8% 97.1% 99.5% 97.3% 98.5% 98.6% 96.9% ▼ N 96.0% 0.9%

Cancer 31 day wait: to first treatment - QTR 0.0% 98.2% 0.0% 0.0% 97.2% 0.0% 0.0% 97.9% 0.0% 0.0% 98.2% 0.0% ◄► N 96.0% -

Cancer 31 day wait: drug treatments 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.7% 100.0% 100.0% 100.0% 100.0% ◄► N 98.0% 2.0%

Cancer 31 day wait: drug treatments - QTR 0.0% 100.0% 0.0% 0.0% 100.0% 0.0% 0.0% 99.4% 0.0% 0.0% 100.0% 0.0% ◄► N 98.0% -

Cancer 31 day wait: surgery 97.2% 100.0% 83.3% 95.8% 90.9% 100.0% 100.0% 95.2% 100.0% 88.9% 85.0% 92.3% ▲ N 94.0% -1.7%

Cancer 31 day wait: surgery - QTR 0.0% 97.7% 0.0% 0.0% 89.7% 0.0% 0.0% 98.3% 0.0% 0.0% 90.3% 0.0% ◄► N 94.0% -

Cancer 31 day wait: radiotherapy 96.9% 97.1% 93.1% 98.2% 96.6% 97.5% 97.8% 95.6% 97.0% 96.6% 96.6% 87.9% ▼ N 94.0% -6.1%

Cancer 31 day wait: radiotherapy - QTR 0.0% 95.4% 0.0% 0.0% 95.8% 0.0% 0.0% 96.8% 0.0% 0.0% 96.7% 0.0% ◄► N 94.0% -

62 day consultant upgrade: all cancers 100.0% 100.0% 100.0% 100.0% 0.0% 50.0% 100.0% 100.0% 100.0% 66.7% 66.7% 100.0% ▲ - - -

62 day consultant upgrade: all cancers - QTR 0.0% 100.0% 0.0% 0.0% 80.0% 0.0% 0.0% 80.0% 0.0% 0.0% 71.4% 0.0% ◄► - - -

62 Day GP Ref 82.1% 90.8% 82.1% 83.6% 91.9% 81.9% 81.7% 85.8% 84.9% 85.4% 86.4% 86.9% ▲ N 85.0% 1.9%

62 Day GP Ref - QTR 0.0% 86.0% 0.0% 0.0% 85.7% 0.0% 0.0% 83.3% 0.0% 0.0% 85.6% 0.0% ◄► N 85.0% -

62 Day screen Ref 88.9% 100.0% 69.0% 100.0% 91.3% 92.9% 100.0% 94.7% 87.5% 100.0% 94.1% 100.0% ▲ N 80.0% 20.0%

62 Day screen Ref - QTR 0.0% 90.9% 0.0% 0.0% 80.4% 0.0% 0.0% 95.4% 0.0% 0.0% 93.5% 0.0% ◄► N 80.0% -

Incomplete 104 day waits 6 4 3 4 7 7 7 4 5 8 7 9 ▲ N 0 9


Actual Target



The above chart shows 2627 Ambulance Handovers by month. October 2017 is following the same trend as the previous month, although handover demand is still considerably greater than in 2016/17. Compliance was 79.29%.

A total of 9465 patients were seen in the Emergency Department during October 2017. Of these, 3008 patients went onto be admitted, equating to 31.78% conversion.


A&E ExperienceTarget

variance

Waiting Times: A&E Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

Type Month +/-

A&E: 4hr Limit (type 1 &2) 93.3% 91.8% 88.3% 91.3% 94.5% 93.3% 90.1% 95.8% 95.6% 91.3% 90.5% 92.6% ▲ N 95.0% -2.4%

A&E: 4hr Limit (type 1 &2) - QTR 0.0% 92.7% 0.0% 0.0% 91.4% 0.0% 0.0% 93.1% 0.0% 0.0% 92.5% 0.0% ◄► N 95.0% -

A&E 4hr Limit (Type 1 only) 92.4% 90.8% 86.8% 89.9% 93.7% 92.4% 88.5% 95.2% 95.0% 90.0% 89.1% 91.2% ▲ N 95.0% -3.8%

A&E 4hr Limit (Type 1 only) - QTR 0.0% 91.8% 0.0% 0.0% 90.2% 0.0% 0.0% 92.0% 0.0% 0.0% 91.4% 0.0% ◄► N 95.0% -

A&E Type 1 (number) 9249 9238 9158 8112 9380 9280 9862 9565 9700 8991 9645 9465 ▼ - - -

Trolley Waits: 12 hour decision to admit (DTA) 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

Ambulance Handover : 30 Minutes 36 98 96 38 24 32 33 28 42 35 26 ▼ N 0 26

Ambulance Handover : 60 Minutes 9 14 16 0 1 1 1 0 1 1 1 ◄► N 0 1

A&E: 4hr Limit (type 1 &2) trajectory 0.0% 0.0% 0.0% 0.0% 0.0% 91.0% 91.0% 91.0% 92.0% 92.0% 92.0% 93.0% ▲ N - -


Target Actual

4. Access - A&E Performance Dashboard



Q2 Q3 Feb-18Jan-18

92%

92.51%

93%91.4%

93.05%

Q1

90% or better than Q4 16/17 90% or better than Q2 16/17 90 % or better than Q3 16/17 Must be 95% or better in March 18

Additional Requirements Implementation plan for A&E Front Door Streaming

and Trusted Assessor

Full Implementation of A&E Front Door Streaming


Sustainability of A&E Front Door Streaming


0.00%93.30% 90.08% 95.84% 95.59% 91.34% 90.46% 90.45%

91.5%

95%Achievement

91.4% 91.8%

21/11/2017INFORMATION CORRECT AT

Quarterly TARGET

Quarterly PERFORMANCE

Monthly TARGET

Monthly PERFORMANCE

93.5%90.0% 93.3%92.9% 91.2% 92.1%

92.62%

91.75%

92.8%

#DIV/0!

Mar-18

92.6%

#DIV/0!

95%

#DIV/0!

93.30%

90.08%

95.84% 95.59%

91.34%90.46%

92.62%

90.45%

0

2000

4000

6000

8000

10000

12000

14000

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

April May June July August September October November December January February March

A&E Performance Tracker - Type 1 and 2 Combined

2016/17 Activity Projected Activity 2017/18 Activity 2016/17 Performance NHSI Trajectory 2017/18 Performance


4. Access - Exception Report Emergency Department



4. Access - Exception Report Emergency Department


Action continuing to be taken to pull performance back Prime concern is delivering this as a quality standard for patients not least in the context of the safety of the department when flow is not sufficiently maintained, particularly where patients backlog in the evening and overnight and cannot be admitted to an appropriate care setting. On-going now being further embedded • ED consultant often staying on post midnight to support the department, team recognise this is not sustainable. • Daily Ops Meeting focussing on patient level flow management, planning for the day with follow up action and weekend planning in

advance. • 7 day Consultant cover on wards now supported by Junior staff. Additional immediate actions due to current performance • Daily examination of performance and breaches to identify corrective action. • Temporary offer of extended hours to emergency nurse practitioners (ENPs). • Additional Registrars in evenings and at weekends to support the late evening medical take. • Continue with the ED streaming programme, now including Paediatrics. • Weekly meeting with PCU to ensure maximisation. • Review Paediatric pathway from arrival to ascertain best model. Planned next steps • Medical Ambulatory area to opened in early November – planned to increase ambulatory pathways/reduce overnight bed

requirement. • Work with CCG to finalise pathways and protocols for streaming to help improve flow in ED. • Investigate whether GP streaming will help to identify more patients. • National Surge workshop planned with NHSI on Tuesday 28th November to identify surge reason and planned actions to mitigate.

Delayed Transfers of Care (DTOC) Whilst the proportion of admitted patients formally identified as DTOC and the associated lost bed days number has reduced, the actual number of patients identified has increased in October. The DTOC KPIs will be reviewed by the Head of Performance and Head of Information with the intention of providing increased depth of information available to the Board in relation to DTOC and Medically Fit for Discharge (MFFD) The DTOC position remains a significant challenge both for the Trust and wider health system. The Trust will continue its escalation to the CCG, community and social services, all patients medically fit and those formally recorded as DTOC. However this remains an issue and is a priority at the A&E delivery board. The Trust is continuing to seek assurance of the intended reduction in DTOC directly associated with the central allocation through the Better Care Fund (BCF).




Admitted Patient ExperienceTarget

variance

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

Type Month +/-

Delayed Transfers of Care (%) 8.2% 6.6% 5.8% 5.3% 6.2% 6.1% 5.2% 6.2% 5.5% 6.2% 8.2% 4.8% ▼ N 3.5% 1.3%

Number of Delayed Transfers of Care (No. of

patients)135 102 111 95 114 85 106 101 95 106 106 114 ▲ N - -

Number of Delayed Transfers of Care (Lost bed

days)1546 1171 1017 848 1149 923 952 862 791 944 946 889 ▼ N - -

Average elective length of stay - excluding 0 day

LOS2.5 2.6 2.7 2.7 2.4 2.6 2.6 3.4 2.8 2.4 2.5 2.6 ▲ N - -

Average non-elective length of stay - excluding 0

day LOS (Length of Stay)6.3 6.1 6.5 6.5 6.2 6.1 6.3 6.0 5.5 5.7 5.4 6.0 ▲ N - -

Percent of Ambulatory Care of Non elective

Admissions23.7% 24.7% 22.3% 21.0% 22.7% 23.0% 23.8% 22.8% 21.8% 21.6% 16.7% 19.1% ▲ N - -


Target Actual

Hospital Cancellation on the day of surgery (non-clinical) The Trust is compliant against both cancelled operations standards with 12 patients cancelled on the day of surgery. All patients were booked within 28 days. Theatre Utilisation Where a list is given up and not backfilled staffing plans have been adjusted to ensure that agency usage is kept to a minimum and that staff are not on duty surplus to requirements. Better forward planning has increased ‘intentionally dropped sessions’. As previously reported to the Board, the Trust has adjusted it’s method of calculation in relation to theatre utilisation to provide a more focused view. In list utilisation – In list utilisation has improved in October. On the day cancellations decreased to 6.61% in October from 7.25% in September. A monthly cancellation meeting is in place to manage, review and agree actions for reducing cancellations. Sessional Utilisation - A total of 106 lists (13.5% of the total available) have been intentionally not backfilled during October. Of the remaining 685 lists available 7% were cancelled lists.




Theatres Patient ExperienceTarget

variance

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

Type Month +/-

Hospital Cancelled Ops on day of surgery - non

clinical (Numbers)13 17 32 10 26 11 13 5 14 14 21 12 ▼ - - -

Hospital Cancelled Ops on day of surgery - non

clinical (Percentage)0.3% 0.5% 0.8% 0.3% 0.5% 0.3% 0.3% 0.1% 0.3% 0.1% 0.5% 0.3% ▼ - - -

Cancelled Ops not re-scheduled < 28 days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ◄► N 5.0% -5.0%

Urgent Operations Cancelled 2nd time 0 0 0 0 0 0 0 0 0 0 0 0 ◄► N 0 0

In List Theatre Utilisation 91.1% 87.9% 88.7% 88.4% 89.3% 90.9% 88.6% 88.6% 87.4% 85.1% 85.6% 88.0% ▲ L 90.0% -2.0%

Sessional Theatre Utilisation 86.0% 80.0% 87.0% 85.0% 90.0% 85.0% 90.0% 87.4% 91.0% 90.0% 94.0% 93.0% ▼ L 90.0% 3.0%


Target Actual

The Trust is continuing with its modernisation and data quality programme in outpatients. As reported in previous months Outpatient metrics remain under review as part of the Trust’s Data Quality Assurance Programme and we continue to interrogate the information capture, processing and assurance processes. During Quarter 2 both the Referral and Outpatient datasets have commenced ‘Deep Dive’ review through our locally commissioned assurance programme with Draper and Dash and will be analysed during quarter 3. The Outpatient Modernisation Programme is in the process of gathering information on the reasons that drive the levels of cancellation shown above to understand where improvements or transformative projects would be beneficial. Where information has not been provided in the table above our information team continues to work closely with operational staff to identify and validate data sources in order to increase the availability of our outpatient information. Where possible we will update with historic information in future reports to the Board. Advice and Guidance (A&G) is an area that the Trust will be working with local commissioners and NHS England to increase utilisation over the next 12-24 months (CQUIN). The current measure used locally is to assess the proportion of requests through A&G that are responded to within 10 working days however this only includes requests for A&G through the eRS system. Requests via other communication routes e.g. telephone are not included in this calculation. We are exploring the capability and development need of the national e-Referral Service (eRS) system, to deliver a useable mobile platform that would enable ease of use for both primary care and hospital clinicians using a 24 hour turnaround as the aim.




Outpatient ExperienceTarget

variance

Waiting Times: Outpatient Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

Type Month +/-

% Appointments cancelled by RBFT 12.4% 12.4% 12.9% 12.8% 12.7% 12.9% 11.2% 12.1% 12.7% 12.9% 13.7% 12.9% ▼ L 15.6% -2.8%

% Appointments cancelled by patient 12.1% 13.7% 12.1% 12.5% 12.5% 13.1% 12.8% 13.4% 13.3% 13.6% 13.9% 13.3% ▼ L 12.3% 1.0%

DNA Rate - - - - 4.4% 4.8% 4.8% 4.7% 4.9% 4.7% 5.1% 4.9% ▼ - - -

New to Follow Up Ratio - - - - - - - - - - - - - - - -

% Advice and Guidance 71.7% 55.3% 69.8% 73.6% 86.3% 65.5% 74.8% 81.1% 67.1% 75.9% 76.7% 88.4% ▲ L 90.0% -1.6%

% Appointments at Virtual clinic - - - - - - - - - - - - - - - -


Target Actual


4. Access – CAT Dashboard

As metrics and datasets become available, where appropriate we will include a baseline position and target range for each CAT. Further work on refining current and defining new metrics is underway.

CQC - Responsive CARE - Aspirational

5. Workforce – Being a Great Place to Work

Appraisal Rate - Appraisal figures are up by 1.2% from last month. A campaign targeting non-complaint managers and individuals has resulted in improved appraisal figures (there were cases where appraisals had been done but not reported in order to be recorded). Completed Mandatory Training - The Mandatory and Statutory Training (MAST) figures are up 0.8% and are at an historic high (at least going back to 2013). This month’s improvement has been driven by improvements in Safeguarding compliance. Sickness Absence - The sickness rate has very slightly increased, this is to be expected as part of a seasonal variation, but with increased capacity in the Employee Relations (ER) team due to staff members returning from Maternity Leave we will be offering more assistance to managers to identify issues and offer support for early intervention wherever possible. Vacancy Rate - Recruiting into nursing posts has continued to be competitive. The staff nurse Open Day on the 30th September was successful, there were 20 appointments made. There has been an increase in new starters for the month of October, 30 band 5 nurses started in the Trust in October. One offer was made through the Nursing and Midwifery Council (NMC) agency interview day. We continue to work with agencies to find nurses with NMC registration for interviews. 232 offers were made during the Philippines recruitment, and 25 of the nurses have passed their English language testing system (IELTS). 16 have passed their Cognitive behavioural therapy (CBT) and 3 have received their NMC decision letter. 3 of the nurses arrived in the Trust on Wednesday 25th October 2017. We are currently working on more robust Social Media campaign and having more presence in the Universities across the country. Agency Spend - October has seen a reduction of 0.4% to a figure of 3.7%, the lowest this financial year. We have implemented an online registration process for substantive staff to make joining the bank easier. Since April 2017, a total of 314 people have joined the bank. This is a mixture of substantive staff as well as bank only. From early 2018 we will be engaging in a joint bank with Berkshire Healthcare Foundation Trust with the aim of reducing agency spend even further as the bank grows.


CQC - Safe / Effective CARE – Resourceful / Excellent

Caring CultureTarget

variance

Workforce Indicators Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Appraisal rate 87.7% 88.3% 88.7% 89.0% 88.7% 88.7% 87.0% 86.5% 85.4% 81.4% 86.7% 87.9% ▲ L 90.0% -2.1%

Completed Mandatory Training 84.4% 84.8% 84.5% 83.9% 83.8% 84.3% 84.0% 84.9% 85.1% 84.6% 86.1% 86.9% ▲ L 90.0% -3.1%

Sickness/absence 3.4% 3.5% 3.5% 3.5% 3.5% 3.4% 3.4% 3.4% 3.4% 3.3% 3.3% 3.3% ▲ L 3.0% 0.3%

Vacancy rate 8.2% 8.3% 8.5% 8.7% 8.8% 11.0% 11.5% 11.4% 9.8% 10.8% 11.0% 7.1% ▼ L 6.0% 1.1%

Agency spend % of total staff cost 5.0% 5.5% 3.3% 4.0% 4.9% 4.4% 4.3% 4.4% 4.8% 5.1% 4.1% 3.7% ▼ L 5.0% -1.3%

Rolling 12 month Workforce Turnover 16.1% 15.7% 16.4% 16.2% 16.2% 16.8% 16.6% 16.1% 15.9% 16.0% 16.0% 15.8% ▼ L 14.0% 1.8%

Time to fi l l vacancy - - - - - - - - - - - - - - - -

Agency cap - - - - - - - - - - - - - - -


Actual Target


Nurse staffing levels are monitored daily at the Operational Meeting and Senior Nursing huddle. Risk assessment of any shortfall is carried out and staff movement and/or the use of temporary staff is undertaken to ensure that safe staffing levels are always maintained. The level of planned staffing levels change to reflect the needs of our patients. This may alter depending on the number of occupied beds on a ward, changes in patient acuity or any specific 1:1 care needs.

6. Staffing Data – Being a Great Place to Work


Caring CultureTarget

variance

Staffing Data Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

% Fill rate of Registered Nurse Shifts (RN) 95.4% 92.0% 92.5% 92.8% 92.6% 92.7% 92.2% 93.3% 91.8% 91.0% 91.4% 92.5% ▲ N 90.0% 2.5%

% Fill rate of Care Support Worker Shifts (CSW) 102.0% 106.0% 107.3% 107.2% 107.5% 106.6% 109.6% 107.8% 106.2% 104.3% 102.2% 103.0% ▲ N 90.0% 13.0%


Target Actual


The Lord Carter report recommends that all trusts record Care Hours Per Patient Day (CHPPD) as a single, consistent metric of nursing and healthcare support workers deployment on inpatient wards and units. The CHPPD is calculated by taking the actual hours worked (split into registered nurses/midwives and healthcare support workers) divided by the number of patients occupying beds on the ward at midnight. It should be noted that CHPPD does not take into account patient acuity, ward environmental issues, patient turn over or movement of staff for short periods. Benchmarking is now available on the Model Hospital Portal but limited to data from August 2017. The median score for October is 6.9.




This graph shows the CHHPD in August 2017 for RBH (7.9) compared with the national and peer group medians. This shows RBH as better staffed than the National median. However, according to our records the Trust reported 7.1 for August and this is currently being clarified with NHS Improvement. This is the most up to date comparative data available on the Model Hospital site. For October 2017 RBH median is 6.9.



Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reportable incidents: The Trust reported five incidents to the Health and Safety Executive (HSE) in the month of October. • Patient suffered rib fractures from an un-witnessed fall • Member of staff 7 day absence caused by trip due to lift not levelling with the floor • Member of staff 7 day absence caused by burns when moving a container of soup • Two members of staff exposed to notifiable biological agents via a needle stick injury and a blood splash to their face. • Patient harm RIDDOR incidents remain reportable to the HSE whom notify the CQC directly.


7. Health and Safety Indicators – Being a Great Place to Work

CQC - Safe / Well Led CARE - Excellent

Health and Safety IndicatorsTarget

variance

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

TypeMonth +/-

RIDDOR reportable Incidents 2 0 1 1 1 4 4 4 2 2 3 5 ▲ - -

Total non clinical incidents reported 60 61 76 56 56 76 77 102 65 76 72 73 ▲ - -

Abuse/V&A (Patient to staff) 17 27 27 21 21 26 23 43 33 32 40 45 ▲ - -

Body fluid exposure/needle stick injury 11 14 16 10 11 16 32 22 14 12 12 12 ◄► - -

Building works 13 8 17 0 5 16 3 23 5 13 3 2 ▼ - -

Slips and Trips 10 3 6 8 5 4 8 4 4 5 10 1 ▼ - -

Musculoskeletal - Inanimate object 2 1 2 4 4 5 3 2 3 1 2 2 ◄► - -

Staff receiving H&S related training Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Month +/-

Manual Handling non patient every 3 years 84.0% 82.9% 82.8% 83.3% 81.4% 79.4% 80.6% 80.7% 82.1% 83.2% 84.1% 86.1% ▲ > 90.0% -3.9%

Conflict Resolution 67.2% 67.8% 68.2% 70.4% 70.1% 75.6% 76.2% 76.1% 79.3% 79.3% 80.0% 78.8% ▼ > 90.0% -11.3%

Fire (Annual) 81.2% 82.1% 80.2% 79.8% 80.6% 80.5% 80.3% 81.8% 81.7% 81.5% 84.2% 84.7% ▲ > 90.0% -5.3%

Nursing and AHP Manual handling training

every 3 years92.3% 92.5% 93.4% 93.3% 93.4% 92.6% 92.5% 92.9% 92.3% 91.8% 93.0% 92.8% ▼ > 90.0% 2.8%

Doctors manual handling training every 3

years58.1% 58.2% 60.0% 58.9% 60.0% 58.1% 59.8% 58.8% 61.1% 59.0% 59.3% 57.7% ▼ > 90.0% -32.3%

Civil and Enforcement Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Month +/-

Personal Injury claims 0 0 0 0 2 0 2 0 0 1 0 0 ◄► - -

Interaction with Regulators 0 1 0 2 0 1 0 1 0 0 0 0 ◄► - -


Actual Target

8. Finance - Achieving Financial Sustainability


Income from activities (excluding drugs income) - Behind YTD Sustainability and Transformation Fund (STF) Control. Behind YTD control total for the first time this year, but STF accrued in full, £4.05m YTD, on the basis that we still expect to achieve full year control total. Total Cost, excluding drugs – Pay costs worse than Q2F, largely driven by nursing and medical staff costs in the care groups. Non Pay (excluding drugs) also high, with PCG £0.38m above Q2F and UCG £0.26m above Q2F. Cash (£M YTD) – Cash remains high, but we still expect most of this variance to reverse later in the year. QIPP Delivery (£M) - In month QIPP delivery low compared to budget of £1.7m and forecast of £1.4m. Key reason for this is an adjustment to the savings achieved in previous months on the Temporary Staffing Programme. Use of Resources - Use of Resources is 3 (where 1 is good and 4 is bad), triggered by negative Income and Expense (I&E) margin.

CQC - Well Led CARE - Resourceful

Financial ProficiencyTarget variance

(based on budget)

Financial Efficiency Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target

TypeMonth +/-

Income from activities (excluding

drugs income)- - - - - 24.14 27.58 27.68 26.78 26.04 26.86 27.53 ▲ >= 28.64 -1.12

Total cost, excluding drugs - - - - - -29.32 -29.62 -29.76 -29.38 -28.88 -29.18 -30.51 ▲ <= -29.36 -1.15

Cash(YTD) £M 14.81 13.09 11.43 13.14 14.40 19.21 20.44 22.82 29.73 37.25 35.50 35.51 ◄► > 14.92 20.60

QIPP Delivery (£M) 1.61 1.04 1.91 2.63 1.73 0.80 0.84 1.26 0.93 1.60 2.00 0.55 ▼ > 1.69 -1.14

Use of Resources - - - - 0 2 3 3 3 3 3 3 ◄► <= 3.00 0.00


Actual Target

Title: Director of Finance Report Agenda item no: 5c Meeting: Board of Directors Date: 29 November 2017 Presented by: Craig Anderson, Director of Finance Prepared by: Graham Butler, Deputy Director of Finance Purpose of the Report To update the Board on the financial results of the Trust for October

2017.

Report History This report was presented to the Finance & Investment Committee on

20 November 2017.


The Board is asked to note the report.




Failure to deliver the Trust’s financial budget.

Strategic objectives. This report impacts on (tick all that apply): Consistently Delivering Quality Care and Healthcare Outcomes Shaping a Fit for Purpose Core Acute Service Shaping a Fit for Purpose Core Elective Service Being a good system partner and exercising system leadership for integration Developing IT and Information Systems Supporting Better Care Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Being a Great Place to Work Achieving Financial Sustainability Well Led Framework applicability: Not applicable 1.Strategy & planning 2. Risk









8. Finance - Achieving Financial Sustainability


Income from activities (excluding drugs income) - Behind YTD Sustainability and Transformation Fund (STF) Control. Behind YTD control total for the first time this year, but STF accrued in full, £4.05m YTD, on the basis that we still expect to achieve full year control total. Total Cost, excluding drugs – Pay costs worse than Q2F, largely driven by nursing and medical staff costs in the care groups. Non Pay (excluding drugs) also high, with PCG £0.38m above Q2F and UCG £0.26m above Q2F. Cash (£M YTD) – Cash remains high, but we still expect most of this variance to reverse later in the year. QIPP Delivery (£M) - In month QIPP delivery low compared to budget of £1.7m and forecast of £1.4m. Key reason for this is an adjustment to the savings achieved in previous months on the Temporary Staffing Programme. Use of Resources - Use of Resources is 3 (where 1 is good and 4 is bad), triggered by negative Income and Expense (I&E) margin.

CQC - Well Led CARE - Resourceful

Financial Proficiency Target variance (based on budget)

Financial Efficiency Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct DoT Target Type Month +/-

Income from activities (excluding drugs income) - - - - - 24.14 27.58 27.68 26.78 26.04 26.86 27.53 ▲ >= 28.64 -1.12

Total cost, excluding drugs - - - - - -29.32 -29.62 -29.76 -29.38 -28.88 -29.18 -30.51 ▲ <= -29.36 -1.15Cash(YTD) £M 14.81 13.09 11.43 13.14 14.40 19.21 20.44 22.82 29.73 37.25 35.50 35.51 ◄► > 14.92 20.60QIPP Delivery (£M) 1.61 1.04 1.91 2.63 1.73 0.80 0.84 1.26 0.93 1.60 2.00 0.55 ▼ > 1.69 -1.14Use of Resources - - - - 0 2 3 3 3 3 3 3 ◄► <= 3.00 0.00


Actual Target

2

Overall Financial Performance - behind both Q2F and Budget in month, with variance to Q2F driven largely by cost

Key Messages: • Behind YTD STF Control Total for the first time

this year, but STF accrued in full, £4.05m YTD, on the basis that we still expect to achieve full year control total

• Shortfall against Q2F Income is mainly due to low Drugs income, which is partially offset by low Drugs cost. Therefore underlying reason for bottom line shortfall v’s Q2F is cost

• Pay (£0.33)m worse than Q2F with high Nursing cost in Gastro, General Surgery, Oncology, ENT and Theatres and Medical staff costs in Urology, Oncology, Ophthalmology and T&O.

• Non Pay exc Drugs (£0.41m) worse than Q2F of which the biggest part is due to non delivery of CIP targets.

• Agency pay cost for the month £81k less than cap with YTD underspend against cap of £823k.

• Cash of £35.5m, £21.7m up on Budget due to a number of factors (see slide 19). All bar £3.1m of the variance is expected to reverse later in the year.

• Use of Resources is 3. (where 1 is good and 4 is bad), triggered by negative I&E margin

• Key Actions : • For key actions see separate income, pay,

drugs, non-pay sheets.

£mActual Vs Q2F Vs Budget Actual Vs Q2F Vs Budget

Income 34.14 (0.68) (1.72) 230.29 (2.48) (5.25)Pay (19.15) (0.33) (1.61) (131.82) (0.18) 1.41 Drugs (3.81) 0.29 0.40 (26.56) 0.97 1.90 Non Pay ex Drugs (10.92) (0.41) 0.43 (71.60) (0.75) (0.32)Other (0.44) (0.00) (0.00) (3.08) (0.01) (0.03)Exceptional Items (0.00) 0.00 0.00 (0.14) (0.00) (0.13)

Surplus/(Deficit) (0.18) (1.14) (2.51) (2.91) (2.45) (2.42)

Use of Resources 3

Control Total YTD (2.87) (1.41)

Actual Q2F Budget Actual Q2F Budget

Cashflow from Operations 1.64 (1.98) 3.48 2.12 (1.98) 3.48

Cash 35.51 29.86 14.92 35.51 29.86 14.92

EBITDA 1.64 2.79 4.21 10.22 12.67 12.61

EBDITDA margin 4.8% 8.0% 11.8% 4.4% 5.4% 5.4%

Net Surplus/(Deficit)

Actual £m Vs Q2F £mVs Budget

£m Actual £m Vs Q2F £m Vs Budget £mUrgent Care 3.48 (0.55) (0.66) 21.99 (0.53) (1.48)Planned Care 2.16 (1.18) (0.77) 15.40 (1.32) (0.48)Networked Care 1.06 (0.84) (0.80) 6.40 (1.73) (2.78)E&F (1.85) (0.05) (0.07) (13.01) (0.09) (0.14)Corporate Services (5.03) 1.50 (0.21) (33.69) 1.23 2.46

Total Trust (0.18) (1.14) (2.51) (2.91) (2.45) (2.42)

MONTH YTD

MONTH YTD

MONTH YTD

3

Income – Shortfall in the month against Q2F of £(0.68)m due to Drugs & Devices

Key Messages for month • Income from Activities – £0.34m ahead of Q2F with the main

issues as follows: – Non Elective shortfall of £(0.89)m, split between NCG &

PCG with variances of £(0.62)m and £(0.32)m respectively. The NCG variance is all against Specialist Medicine, whilst the PCG variance is against Abdominal Surgery £(0.17)m and Orthopaedics £(0.10)m.

– The favourable variance under ‘Other’ is mainly due to a corporate Q2F phasing adjustment of £1.50m which was included in Q2F to offset the optimism risk of the Care Groups.

– Under NHSE guidance 20% of CCGs’ CQUIN income cannot be assumed until authorised by NHSI. This generates the adverse variances. The in-month impact of this has been mitigated by reduction in provisioning.

– The YTD BWCCGs Contractual marginal rate adjustment is a net benefit of £0.82m (a favourable in-month swing of £0.25m). This applies to activity below contract plan for the specific PODs covered by this adjustment.

– Since the start of the year, activity data for both Phlebotomy and Direct Access pathology (as reported by BSPS) has been unreliable. An estimate for the value of unreported YTD activity has been included in the results of £1.76m in the expectation that commissioners will pay for this.

• Drug & Devices Income is behind Q2F by £(0.60)m but this, in

turn, reflects reduced drug & devices expenditure. • Other Operating Income is £(0.42)m behind Q2F. This relates to

charitable receipts being less than Q2F by £(0.43)m. • STF funding for M7 has been accounted for in full, £0.9m, on the

expectation that the STF targets for Qtr 3 will be met. However, in M7 the Trust was below its Financial Control total and in M7 the Trust was slightly under the A&E access milestone for Qtr 3.

Actions • Resolve Pathology activity reporting issues re BSPS. – MS/HA

Income

Actual £mVs Q2F

£mVs Budget

£m Actual £mVs Q2F

£m Vs Budget £mIncome from Activities 27.53 0.34 (1.11) 186.60 (0.60) (1.74)

Drug & Devices 3.31 (0.60) (0.40) 24.10 (0.83) (1.47)Other Patient Care Income 0.42 (0.01) (0.01) 2.24 (0.17) (0.71)Other Operating Income 1.98 (0.42) (0.20) 13.29 (0.88) (1.33)STF 0.90 0.00 0.00 4.05 0.00 0.00

Total Income 34.14 (0.68) (1.72) 230.29 (2.48) (5.25)

MONTH YTD

Analysis of Income from Activities£m Actual vs Q2F vs Budget Actual vs Q2F vs BudgetA&E 1.72 (0.00) (0.01) 12.15 0.09 0.71Non Elective 7.28 (0.89) (0.49) 51.93 (1.05) 0.44Elective (incl Daycase) 4.95 (0.35) (0.57) 32.86 (0.40) (2.78)Outpatient (incl Procedures) 6.63 (0.27) (0.06) 43.13 (0.53) (0.05)Maternity 2.50 (0.01) (0.06) 16.15 (0.18) (0.84)Critical Care 0.96 (0.09) (0.09) 6.99 (0.18) 0.08Renal Dialysis & Post Transplant 0.85 (0.08) (0.08) 5.98 (0.16) (0.41)Direct Access (Pathology & Radiology) 0.88 (0.06) (0.11) 5.79 (0.13) (0.81)CQUINs 0.51 (0.06) (0.06) 3.59 (0.44) (0.44)Other 1.25 2.15 0.41 8.04 2.39 2.38Total Income from Activities 27.53 0.34 (1.11) 186.60 (0.60) (1.74)

Month YTD

4

Pay costs – worse than Q2F for month and YTD, but better than YTD Budget by £1.4m Key Messages • Pay cost is an overspend of (£0.33m)

against Q2F, driven by UCG and NCG with partial off set by Central contingencies and underspend in Corporate areas.

• Comparison against budget in month distorted because of £1.8m switch of budget from Pay to Clinical Service and Supplies in NCG to get budget for BSPS in the same line as actual cost is recorded

• Overspends against Q2F principally in Nursing pay and Medical pay, £0.40m in UCG and £0.25m in PCG

• UCG £0.25m of overspend driven by high enhancements in the month, GP streaming in ED and new intake of Midwives.

• PCG overspend principally in Medical pay, with high cost in Urology, Oncology, Ophthalmology & T&O

• Corporate Other is £0.33m below Q2F due to unutilised contingencies.

• £0.71m agency pay in month, which is £0.08m below NHSI ceiling. Bank pay was up vs. budget by £0.33m.

• The number of agency cap breaches in month was 439,of which 70 were wage cap breaches and are outside of our control (i.e. we pay within price cap, but the agency takes a smaller margin).

Actions: • Care Groups to develop action plans to

return YTD pay cost to forecast. Action: (WF/WO/JL)

Pay Costs £M

Group DescriptionM04

2017/18M05

2017/18M06

2017/18M07

2017/18 MoM varMonth vs.

Q2FYTD vs.

Q2FMonth vs

BudgetYTD vs Budget

Medical Staff 5.66 5.99 5.74 5.80 (0.06) (0.21) (0.35) (0.41) (1.14)Nursing 7.48 7.31 7.29 7.65 (0.37) (0.34) (0.37) (0.31) (0.18)PAMs 1.09 1.09 1.10 1.09 0.02 0.00 (0.02) 0.02 0.20Scientist and PTBs 0.85 0.83 0.81 0.88 (0.07) 0.07 0.21 (1.93) (0.21)Pharmacists 0.21 0.22 0.20 0.18 0.02 0.03 0.04 0.08 0.25Admin & Management 2.67 2.58 2.56 2.63 (0.07) 0.08 0.26 0.14 1.74Ancil lary & Maintenance 0.84 0.79 0.81 0.85 (0.03) (0.05) (0.07) 0.11 (0.33)Other Pay 0.10 0.14 0.09 0.07 0.02 0.10 0.13 0.70 1.08Pay 18.91 18.95 18.61 19.15 (0.54) (0.33) (0.18) (1.61) 1.41By Care Group/DirectorateUCG 6.22 6.21 6.22 6.39 (0.17) (0.40) (0.64) (0.37) (0.77)PCG 6.00 6.09 5.95 6.13 (0.18) (0.25) (0.31) (0.24) (0.23)NCG 3.93 4.04 3.84 3.94 (0.10) (0.05) (0.03) (1.27) (0.00)Total Care Group 16.15 16.34 16.01 16.46 (0.45) (0.69) (0.97) (1.88) (1.00)Chief Medical Officer 0.20 0.19 0.19 0.19 (0.00) 0.05 0.09 0.02 0.11Chief Nursing Officer 0.32 0.31 0.32 0.32 (0.01) 0.02 0.06 0.02 0.20Chief Exec & Non-Execs 0.23 0.20 0.19 0.22 (0.03) (0.02) (0.01) (0.03) (0.04)Chief Operating Officer 0.04 0.04 0.04 0.04 (0.00) 0.00 0.01 0.03 0.16Workforce and Organisational Development 0.26 0.25 0.26 0.27 (0.01) (0.00) 0.00 0.01 0.16Finance 0.29 0.27 0.30 0.25 0.05 0.04 0.07 0.06 0.21IT 0.38 0.33 0.30 0.35 (0.05) 0.02 0.06 0.02 0.28Estates & Facil ities 0.87 0.82 0.85 0.88 (0.03) (0.06) (0.08) (0.06) (0.07)Corporate - Other 0.17 0.18 0.17 0.17 0.00 0.33 0.59 0.21 1.39Capital Charges & PDC Dividend - - - - - - - - -TOTAL Other 2.76 2.61 2.61 2.69 (0.09) 0.36 0.80 0.27 2.41Pay 18.91 18.95 18.61 19.15 (0.54) (0.33) (0.18) (1.61) 1.41

VS. Q2F VS BUDGET

5

Non Pay Costs – Drugs – Cost down on Budget and Q2F in month and YTD with a decrease in Income.

Key Messages • Drugs income as % of Drugs cost now at 85% v’s 88%

average in the last three months • Drugs cost is £0.29m lower than Q2F with decrease in Drugs

Income driven by PCG. • PCG Drugs income as % of Drugs cost now 88% YTD, which

compares to 88% this time last year.

Non Pay - Drugs

Actual £mVs Q2F

£mVs Budget


£m Vs Budget £mUrgent Care (0.32) (0.01) (0.02) (2.17) 0.01 (0.06)Planned Care (1.72) 0.15 0.25 (12.13) 0.25 0.72 Networked Care (1.46) 0.44 0.46 (12.15) 0.74 1.25 Other (0.31) (0.29) (0.29) (0.11) (0.03) (0.01)

Total Drugs (3.81) 0.29 0.40 (26.56) 0.97 1.90

MONTH YTD

6

Non Pay Costs – Excluding Drugs – worse than Q2F

Key messages • Comparison against budget in month distorted

because of £1.8m switch of budget from Pay to Clinical Service and Supplies in NCG to get budget for BSPS in the same line as actual cost is recorded

• Overspends v’s Q2F principally in UCG, (£0.26m) and PCG (£0.38m)

• The overspend in UCG is largely CIPs not achieved, (£0.15m) and high spend in X-Ray and Cardiology.

• The overspend in PCG was driven by high Clinical Supplies costs in Theatres (£0.22m) and CIPs not achieved (£0.08m).

• The overspends above were offset by lower than Q2F cost in HFMS and corporates, with the underspend in HFMS driven by adjustments following the recently completed 16/17 audit

• SLR by Specialty against budget is shown in slides 10,12 and14.

Actions:

• UCG and PCG to develop action plans to return their care group spend to YTD forecast. Action: WF & WO

Non Pay ex Drugs

Actual £mVs Q2F

£mVs Budget


£m Vs Budget £mClinical Service & Supplies (4.08) 0.06 1.23 (27.34) 0.20 0.70 General Supplies & Services (0.55) 0.04 0.01 (3.79) 0.08 0.09 Establishment Expenses (0.37) (0.04) (0.05) (2.10) (0.02) 0.20 Other Establishment Expenses (1.50) (0.03) (0.03) (10.24) (0.02) 0.01 Prem, Trans & Fixed Plant (1.46) 0.17 0.12 (10.04) 0.29 0.32 Depreciation (1.38) 0.02 0.07 (9.91) 0.01 0.13 Leases (0.22) (0.02) 0.05 (1.20) (0.05) 0.69 Miscellaneous Services (1.36) (0.60) (0.97) (6.98) (1.25) (2.46)

Total Non Pay ex Drugs (10.92) (0.41) 0.43 (71.60) (0.75) (0.32)

Non Pay ex Drugs

Actual £mVs Q2F

£mVs Budget


£m Vs Budget £mUrgent Care (1.25) (0.26) (0.32) (7.74) (0.30) (0.87)Planned Care (2.72) (0.38) (0.39) (16.32) (0.45) (0.47)Networked Care (1.68) 0.05 1.09 (11.23) 0.15 0.31 Estates & Facilities (1.28) (0.02) (0.04) (8.79) (0.09) (0.23)HFMS 0.17 0.11 0.12 0.77 0.26 0.38 Other Corporate (4.16) 0.09 (0.03) (28.29) (0.31) 0.56

Total Non Pay ex Drugs (10.92) (0.41) 0.43 (71.60) (0.75) (0.32)

MONTH

MONTH

YTD

YTD

Presentation title here

2017/18 QIPP Programme – Progress Report

8

Service Line Reporting – October 2017 actual and variance to Budget (£’000)

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £kDirect Income

Income 8,145 (1,079) 12,728 (391) 11,440 44 1,827 (296) 34,141 (1,721) Direct Expenses

Pay (3,944) (1,266) (6,126) (244) (6,390) (370) (2,693) 268 (19,154) (1,611) Non Pay (3,143) 1,544 (4,445) (133) (1,566) (336) (5,573) (246) (14,728) 830 Exceptional - - - - - - (438) (4) (438) (4) Other - - - - - - (0) 0 (0) 0

Direct Contribution 1,058 (800) 2,157 (768) 3,484 (662) (6,878) (277) (179) (2,506) SLR Income (IP only)

Elective Tariff Income 5 5 (7) (4) 1 (0) - - 0 0 Non-Elective Tariff Income 419 372 (204) (200) (215) (172) - - (0) (0)

Educ. & Training Income 199 - 285 - 288 - (773) - (0) - SLR Indirect Recharges

Radiology recharge (72) (1) (67) (9) 139 11 - - (0) (0) Pathology recharge - - - - - - - - - - Ward recharge - - - - - - - - - - Theatre recharge - 3 138 (21) (138) 19 - - (0) (0) Patient Meals (56) 3 (40) 2 (88) 3 185 (8) - (0) Bed Linen (13) - (21) - (26) - 59 - - - Portering (21) 46 (50) 0 (115) 1 186 (47) 0 0 Estates recharge (166) (0) (215) 0 (214) (0) 595 0 0 (0) Depreciation & Leases (139) (0) (339) 0 (331) 0 810 (0) (0) 0

Total direct & indirect costs (7,555) 328 (11,166) (406) (8,729) (672) (6,871) (36) (34,320) (785)

SLR Contribution excl. Ovhds 1,214 (373) 1,637 (1,001) 2,786 (800) (5,816) (332) (179) (2,506)

Contribution margin % 15% 13% 24% -318% -1%Overhead recharges

Clinical Coding (22) 0 (46) (0) (21) (0) 89 0 (0) 0 CNST premiums (35) (0) (407) 0 (946) 0 1,388 (0) 0 (0) Corporate serv. recharge (393) 0 (523) 0 (427) (0) 1,343 0 (0) (0)

• Finance (85) 0 (111) (0) (50) 0 246 (0) (0) (0) • HR (121) 0 (170) 0 (170) (0) 461 0 (0) (0) • IM&T (187) (0) (242) 0 (207) (0) 636 0 0 (0) • Corp. Other - - - - - - - - - -

Other Overheads (764) 24 (1,482) (35) (1,958) (44) 4,204 55 0 (0)

Total Overhead (1,214) 24 (2,458) (35) (3,352) (44) 7,024 55 0 (0)

SLR NET MARGIN 1 (349) (821) (1,036) (566) (845) 1,208 (277) (179) (2,506)

NETWORKED PLANNED URGENT CORPORATE TOTAL

9

Service Line Reporting – YTD October 2017 actual and variance to Budget (£’000)

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £kDirect Income

Income 57,220 (4,335) 85,969 (505) 75,422 222 11,680 (632) 230,291 (5,250) Direct Expenses

Pay (27,439) (5) (42,118) (228) (43,524) (771) (18,741) 2,414 (131,821) 1,410 Non Pay (23,382) 1,558 (28,454) 250 (9,906) (934) (36,419) 705 (98,162) 1,579 Exceptional - - - - (0) (0) (3,080) (29) (3,080) (29) Other - - - - - - (136) (133) (136) (133)

Direct Contribution 6,399 (2,782) 15,397 (483) 21,992 (1,484) (46,696) 2,325 (2,908) (2,424) SLR Income (IP only)

Elective Tariff Income 35 7 10 21 (44) (28) - - (0) 0 Non-Elective Tariff Income 2,417 1,937 (1,262) (1,456) (1,155) (481) - - (0) (0)

Educ. & Training Income 1,387 - 1,984 - 2,005 - (5,376) - 0 - SLR Indirect Recharges

Radiology recharge (512) (42) (435) (48) 947 90 - - (0) (0) Pathology recharge - - - - - - - - - - Ward recharge - - - - - - - - - - Theatre recharge (30) (12) 931 (129) (901) 141 - - (0) (0) Patient Meals (389) 8 (277) 5 (626) 26 1,292 (39) - (0) Bed Linen (88) - (142) - (176) - 405 - (0) - Portering (149) 58 (330) (2) (837) 1 1,317 (57) 0 0 Estates recharge (1,164) (0) (1,505) 0 (1,502) (0) 4,172 0 0 0 Depreciation & Leases (970) (0) (2,380) 0 (2,320) 0 5,669 (0) (0) 0

Total direct & indirect costs (54,123) 1,564 (74,709) (151) (58,846) (1,448) (45,521) 2,862 (233,199) 2,827

SLR Contribution excl. Ovhds 6,935 (827) 11,991 (2,091) 17,382 (1,736) (39,217) 2,230 (2,908) (2,424)

Contribution margin % 12% 14% 23% -336% -1%Overhead recharges

Clinical Coding (154) 0 (322) (0) (150) (0) 625 0 (0) 0 CNST premiums (247) (0) (2,849) 0 (6,620) 0 9,716 (0) 0 (0) Corporate serv. recharge (2,770) 0 (3,687) 0 (2,978) (0) 9,435 0 (0) (0)

• Finance (610) 0 (795) (0) (354) 0 1,758 (0) (0) (0) • HR (856) 0 (1,200) 0 (1,204) (0) 3,261 0 0 (0) • IM&T (1,303) (0) (1,693) 0 (1,420) (0) 4,416 0 0 (0) • Corp. Other - - - - - - - - - -

Other Overheads (5,380) 26 (10,427) (60) (13,798) (61) 29,605 95 0 0

Total Overhead (8,550) 26 (17,285) (60) (23,546) (61) 49,381 95 0 0

SLR NET MARGIN (1,615) (801) (5,294) (2,152) (6,163) (1,797) 10,165 2,325 (2,908) (2,424)

NETWORKED PLANNED URGENT CORPORATE TOTAL

10

SLR by Specialty (Slides 11-16) - Commentary

Key Messages • PCG • Theatres and Anaesthetics down on monthly budget by (£0.41m) with main drivers being direct contribution and lower Theatres

recharges. • Trauma and Orthopaedics (£0.20m) worse than monthly budget driven by direct contribution with partial off set in better Theatres

recharges. • Abdominal Surgery is (£0.17m) short on monthly budget mainly due to Income.

• UCG • Paediatrics and Cardiology shortfall to budget in the month is (£0.42m) and (£0.23m) which is driven by direct contribution. • Respiratory and Obstetrics/Gynaecology worse than budget (£0.14m) and (£0.10m) respectively, driven by lower rechargeable FCE

Income and direct contribution.

• NCG • Specialist Medicine is (£0.38m) behind monthly budget as a result of lower Direct Income. • Pathology is an overspend against budget of (£0.22m) primarily in Pay cost. • Pharmacy and Networked Other combined £0.37m better than budget due to lower direct pay and non pay cost and higher

rechargeable FCE Income. • Obstetrics and Gynaecology is better than month budget by £0.20m primarily due to direct contribution pay cost. • Urgent Other and Urgent Care Group combined £0.19m better than budget which is driven by Direct Income.

Appendix (iii) : Care Group Financials SLR by Specialty – M07 UCG

DOF Report Craig Anderson

11

Thousands

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k

Direct IncomeIncome 5,050 208 8 6 1,047 (151) 1,037 89 1,565 (259) 2,528 (44) 206 194 11,440 44

Direct ExpensesPay (2,634) (210) (157) (22) (528) (5) (423) (21) (1,017) (89) (1,310) (13) (320) (8) (6,390) (370) Non Pay (661) (83) (29) (6) (298) (71) (140) (42) (254) (86) (148) (42) (36) (6) (1,566) (336) Exceptional - - - - - - - - - - - - - - - - Other - - - - - - - - - - - - - - - -

Direct Contribution 1,755 (86) (178) (22) 221 (227) 474 27 293 (433) 1,070 (99) (151) 179 3,484 (662)

SLR Income (IP only)Elective Tariff Income (1) (2) - - 3 2 - (0) - (1) - - - - 1 (0) Non-Elective Tariff Income (307) (13) - - 51 (9) 30 (166) 11 16 (0) (0) - - (215) (172)

Educ. & Training Income 118 - 7 - 28 - 18 - 45 - 59 - 13 - 288 -

SLR Indirect RechargesRadiology recharge 171 15 - - (12) (2) (14) (3) (4) (0) (0) 0 - - 139 11 Pathology recharge - - - - - - - - - - - - - - - - Ward recharge - - - - - - - - - - - - - - - - Theatre recharge (3) (3) - - - - (1) (1) - 1 (134) 22 - - (138) 19 Pharmacy recharge - - - - - - - - - - - - - - - - Clinical Engineering recharge - - - - - - - - - - - - - - - - Therapies recharge - - - - - - - - - - - - - - - - Medic recharge - - - - - - - - - - - - - - - - Patient Meals (16) 2 (17) 0 (13) 1 (15) 0 (7) 0 (16) (1) (5) 0 (88) 3 Bed Linen (7) - (2) - (3) - (4) - (2) - (5) - (1) - (26) - Portering (102) (8) (1) 1 (2) 5 (3) 1 (1) 1 (5) (1) (1) 2 (115) 1 Estates recharge (70) (0) (7) 0 (20) 0 (19) 0 (40) (0) (46) (0) (12) (0) (214) (0) Depreciation & Leases (206) 0 (5) (0) (21) 0 (12) 0 (31) (0) (46) (0) (9) 0 (331) 0

Total direct & indirect costs (3,529) (288) (218) (27) (898) (72) (630) (65) (1,358) (173) (1,711) (35) (385) (12) (8,729) (672)

SLR Contribution excl. Ovhds 1,330 (95) (202) (21) 231 (230) 455 (142) 263 (416) 876 (79) (166) 182 2,786 (800)

Contribution margin % 26% -2440% 22% 44% 17% 35% -81% 24%

Overhead rechargesClinical Coding (2) (0) - - (4) (0) (5) (0) (3) 0 (7) 0 - - (21) (0) CNST premiums (184) 0 - - (19) 0 (4) 0 (44) 0 (694) (0) - - (946) 0 Corporate serv. recharge (201) 0 (8) (0) (43) (0) (28) (0) (60) 0 (69) (0) (16) (0) (427) (0)

• Finance (20) 0 (1) (0) (7) 0 (4) (0) (8) (0) (7) (0) (2) (0) (50) 0 • HR (67) (0) (5) (0) (15) (0) (11) (0) (26) 0 (35) (0) (10) (0) (170) (0) • IM&T (114) (0) (2) (0) (21) (0) (13) (0) (27) 0 (27) (0) (4) (0) (207) (0) • Corp. Other - - - - - - - - - - - - - - - -

Other Overheads (712) (23) (36) 0 (113) 2 (82) (1) (172) (3) (803) (21) (40) 1 (1,958) (44)

Total Overhead (1,099) (23) (45) 0 (179) 2 (120) (1) (280) (3) (1,573) (21) (57) 1 (3,352) (44)

SLR NET MARGIN 231 (117) (247) (20) 53 (227) 335 (144) (17) (419) (697) (100) (223) 183 (566) (845)

URGENT OTHERURGENT CARE

GROUPNeil Derbyshire Andre Van Wyk Jon Swinburn Peter DeHalpert Rosie Jones

EMERGENCY MEDICINE STROKE CARDIOLOGY RESPIRATORY PAEDIATRICSOBSTETRICS AND GYNAECOLOGY

Appendix (iii) : Care Group Financials SLR by Specialty – YTD M07 UCG


12

Thousands

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k

Direct IncomeIncome 33,555 1,528 25 8 7,672 89 6,496 235 11,355 (750) 16,352 (773) (33) (116) 75,422 222

Direct ExpensesPay (17,367) (127) (1,048) (86) (3,738) (22) (2,898) (45) (6,821) (264) (9,418) (210) (2,234) (18) (43,524) (771) Non Pay (4,568) (250) (160) 5 (1,800) (209) (754) (60) (1,437) (229) (962) (185) (225) (4) (9,906) (934) Exceptional - - - - - - (0) (0) - 0 - - - - (0) (0) Other - - - - - - - - - - - - - - - -

Direct Contribution 11,620 1,151 (1,184) (73) 2,134 (143) 2,844 130 3,097 (1,242) 5,972 (1,167) (2,492) (139) 21,992 (1,484)

SLR Income (IP only)Elective Tariff Income (48) (23) - - 8 5 2 1 - (4) (7) (7) - - (44) (28) Non-Elective Tariff Income (2,475) (152) - - 670 (29) 578 (383) 60 72 11 11 - - (1,155) (481)

Educ. & Training Income 823 - 51 - 193 - 125 - 314 - 409 - 90 - 2,005 -

SLR Indirect RechargesRadiology recharge 1,134 100 - - (68) 2 (89) (13) (29) (1) (2) 2 - - 947 90 Pathology recharge - - - - - - - - - - - - - - - - Ward recharge - - - - - - - - - - - - - - - - Theatre recharge (18) (17) - - (2) (2) (1) (1) (2) 3 (878) 158 - - (901) 141 Pharmacy recharge - - - - - - - - - - - - - - - - Clinical Engineering recharge - - - - - - - - - - - - - - - - Therapies recharge - - - - - - - - - - - - - - - - Medic recharge - - - - - - - - - - - - - - - - Patient Meals (106) 13 (122) (0) (91) 5 (102) 6 (48) 3 (108) (3) (49) 1 (626) 26 Bed Linen (50) - (11) - (20) - (31) - (16) - (38) - (10) - (176) - Portering (736) (35) (7) 4 (19) 20 (23) (0) (9) 5 (34) 1 (9) 6 (837) 1 Estates recharge (491) (0) (51) 0 (140) 0 (132) 0 (282) (0) (321) (0) (85) (0) (1,502) (0) Depreciation & Leases (1,451) 0 (33) (0) (146) 0 (83) 0 (219) (0) (324) (0) (63) 0 (2,320) 0

Total direct & indirect costs (23,653) (316) (1,433) (78) (6,023) (206) (4,112) (113) (8,863) (482) (12,086) (237) (2,676) (16) (58,846) (1,448)

SLR Contribution excl. Ovhds 8,203 1,037 (1,357) (70) 2,520 (141) 3,089 (260) 2,866 (1,164) 4,680 (1,005) (2,618) (132) 17,382 (1,736)

Contribution margin % 24% -5380% 33% 48% 25% 29% 8054% 23%

Overhead rechargesClinical Coding (11) (0) - - (27) (0) (37) (0) (24) 0 (49) 0 - - (150) (0) CNST premiums (1,291) 0 - - (131) 0 (30) 0 (310) 0 (4,858) (0) - - (6,620) 0 Corporate serv. recharge (1,389) 0 (59) (0) (303) (0) (198) (0) (424) 0 (487) (0) (117) (0) (2,978) (0)

• Finance (146) 0 (9) (0) (48) 0 (28) (0) (56) (0) (51) (0) (15) (0) (354) 0 • HR (471) (0) (36) (0) (110) (0) (81) (0) (184) 0 (250) (0) (73) (0) (1,204) (0) • IM&T (772) (0) (14) (0) (145) (0) (89) (0) (184) 0 (186) (0) (29) (0) (1,420) (0) • Corp. Other - - - - - - - - - - - - - - - -

Other Overheads (5,014) (50) (257) 2 (796) 17 (577) 2 (1,208) (0) (5,643) (36) (303) 4 (13,798) (61)

Total Overhead (7,705) (50) (316) 2 (1,258) 17 (843) 2 (1,966) (0) (11,038) (36) (420) 4 (23,546) (61)

SLR NET MARGIN 498 987 (1,673) (68) 1,262 (124) 2,245 (258) 901 (1,164) (6,358) (1,041) (3,038) (129) (6,163) (1,797)

Rosie Jones

URGENT CARE GROUPEMERGENCY MEDICINE STROKE CARDIOLOGY RESPIRATORY PAEDIATRICS

OBSTETRICS AND GYNAECOLOGY URGENT OTHER

Neil Derbyshire Andre Van Wyk Jon Swinburn Peter DeHalpert

Appendix (iii) : Care Group Financials SLR by Specialty – M07 PCG


13

Thousands

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k

Direct IncomeIncome 4,681 (111) 2,901 (130) 2,750 (70) 148 (41) 2,116 1 133 (40) 12,728 (391)

Direct ExpensesPay (1,433) (47) (773) (73) (1,041) (22) (1,325) (62) (991) (22) (561) (18) (6,126) (244) Non Pay (679) 106 (94) (34) (708) (2) (1,465) (152) (1,119) (4) (380) (47) (4,445) (133) Exceptional - - - - - - - - - - - - - - Other - - - - - - - - - - - - - -

Direct Contribution 2,569 (52) 2,034 (237) 1,001 (93) (2,642) (256) 5 (25) (809) (105) 2,157 (768)

SLR Income (IP only)Elective Tariff Income (6) (6) (1) 1 1 1 - 0 (1) (1) - - (7) (4) Non-Elective Tariff Income (93) (85) (139) (67) 4 1 - - 24 (49) - - (204) (200)

Educ. & Training Income 69 - 39 - 47 - 70 - 45 - 17 - 285 -

SLR Indirect RechargesRadiology recharge (50) (11) (12) (2) (1) 0 - 0 (4) 3 - - (67) (9) Pathology recharge - - - - - - - - - - - - - - Ward recharge - - - - - - - - - - - - - - Theatre recharge (835) 2 (915) 107 (294) 23 2,182 (154) - 0 - - 138 (21) Pharmacy recharge - - - - - - - - - - - - - - Clinical Engineering recharge - - - - - - - - - - - - - - Therapies recharge - - - - - - - - - - - - - - Medic recharge - - - - - - - - - - - - - - Patient Meals (21) (3) (8) 4 (5) 1 - - (6) 0 - - (40) 2 Bed Linen (6) - (4) - (1) - (7) - (2) - (1) - (21) - Portering (5) (1) (3) (1) (2) (0) (36) (0) (3) 2 (1) (0) (50) 0 Estates recharge (45) (0) (18) (0) (25) (0) (38) 0 (62) 0 (26) 0 (215) 0 Depreciation & Leases (61) 0 (15) (0) (52) (0) (78) 0 (116) 0 (18) 0 (339) 0

Total direct & indirect costs (3,135) 47 (1,842) 1 (2,130) 1 (767) (369) (2,304) (21) (988) (65) (11,166) (406)

SLR Contribution excl. Ovhds 1,515 (155) 958 (195) 671 (67) (549) (409) (121) (70) (838) (105) 1,637 (1,001)

Contribution margin % 32% 33% 24% -371% -6% -632% 13%

Overhead rechargesClinical Coding (16) (0) (5) 0 (6) (0) (0) 0 (18) (0) - - (46) (0) CNST premiums (158) 0 (183) 0 (48) (0) - - (18) 0 - - (407) 0 Corporate serv. recharge (120) 0 (69) (0) (140) (0) (81) (0) (69) (0) (44) 0 (523) 0

• Finance (19) 0 (5) (0) (19) (0) (36) (0) (23) (0) (10) 0 (111) (0) • HR (38) 0 (22) (0) (29) (0) (37) 0 (28) (0) (16) (0) (170) 0 • IM&T (64) 0 (42) 0 (91) 0 (8) (0) (18) (0) (18) (0) (242) 0 • Corp. Other - - - - - - - - - - - - - -

Other Overheads (390) (13) (276) (4) (253) (6) (216) (5) (266) (4) (81) (2) (1,482) (35)

Total Overhead (684) (13) (533) (4) (446) (6) (298) (5) (372) (4) (125) (2) (2,458) (35)

SLR NET MARGIN 831 (168) 425 (199) 225 (73) (847) (414) (493) (74) (963) (108) (821) (1,036)

PLANNED CARE GROUPABDOMINAL SURGERY

TRAUMA & ORTHOPAEDICS HEAD & NECK

THEATRES & ANAESTHETICS

BERKSHIRE CANCER CENTRE PLANNED OTHER

Jon Simmons Tom Pollard Will Flannery Liz Brannigan Helen O'Donnell

Appendix (iii) : Care Group Financials SLR by Specialty – YTD M07 PCG


14

Thousands

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k

Direct IncomeIncome 31,814 497 19,305 (397) 18,417 (8) 915 (354) 14,607 54 912 (299) 85,969 (505)

Direct ExpensesPay (9,634) 7 (5,288) (391) (7,327) (196) (9,156) (314) (6,778) (35) (3,935) 700 (42,118) (228) Non Pay (4,725) 340 (456) (64) (4,308) 297 (8,673) (150) (8,025) (783) (2,267) 609 (28,454) 250 Exceptional - - - - - - - - - - - - - - Other - - - - - - - - - - - - - -

Direct Contribution 17,455 844 13,560 (852) 6,783 94 (16,914) (818) (196) (763) (5,290) 1,011 15,397 (483)

SLR Income (IP only)Elective Tariff Income 40 35 (32) (18) (3) (3) - 0 4 5 - - 10 21 Non-Elective Tariff Income (729) (819) (884) (374) 19 (5) (8) (8) 340 (250) - - (1,262) (1,456)

Educ. & Training Income 477 - 271 - 323 - 484 - 312 - 117 - 1,984 -

SLR Indirect RechargesRadiology recharge (305) (43) (75) (6) (11) (0) (0) (0) (45) 2 - - (435) (48) Pathology recharge - - - - - - - - - - - - - - Ward recharge - - - - - - - - - - - - - - Theatre recharge (5,485) 89 (6,061) 736 (2,081) 27 14,558 (981) (1) 0 - - 931 (129) Pharmacy recharge - - - - - - - - - - - - - - Clinical Engineering recharge - - - - - - - - - - - - - - Therapies recharge - - - - - - - - - - - - - - Medic recharge - - - - - - - - - - - - - - Patient Meals (141) (18) (53) 28 (37) (7) - - (47) 1 - - (277) 5 Bed Linen (38) - (29) - (7) - (47) - (14) - (6) - (142) - Portering (36) (1) (18) (0) (16) (1) (236) 0 (20) 4 (5) (4) (330) (2) Estates recharge (317) (0) (128) (0) (177) (0) (265) 0 (435) 0 (184) 0 (1,505) 0 Depreciation & Leases (426) 0 (101) (0) (366) (0) (546) 0 (815) 0 (125) 0 (2,380) 0

Total direct & indirect costs (21,106) 374 (12,209) 303 (14,328) 121 (4,364) (1,445) (16,179) (810) (6,522) 1,306 (74,709) (151)

SLR Contribution excl. Ovhds 10,495 88 6,451 (485) 4,428 105 (2,975) (1,807) (916) (1,000) (5,493) 1,007 11,991 (2,091)

Contribution margin % 33% 33% 24% -325% -6% -602% 14%

Overhead rechargesClinical Coding (113) (0) (36) 0 (44) (0) (3) 0 (127) (0) - - (322) (0) CNST premiums (1,104) 0 (1,281) 0 (335) (0) - - (129) 0 - - (2,849) 0 Corporate serv. recharge (840) 0 (472) (0) (958) (0) (601) (0) (506) (0) (311) 0 (3,687) 0

• Finance (133) 0 (33) (0) (137) (0) (259) (0) (162) (0) (70) 0 (795) (0) • HR (269) 0 (155) (0) (205) (0) (258) 0 (201) (0) (111) (0) (1,200) 0 • IM&T (437) 0 (284) 0 (616) 0 (83) (0) (142) (0) (130) (0) (1,693) 0 • Corp. Other - - - - - - - - - - - - - -

Other Overheads (2,734) (34) (1,923) 14 (1,759) (18) (1,541) (9) (1,899) (7) (572) (7) (10,427) (60)

Total Overhead (4,790) (34) (3,713) 14 (3,095) (18) (2,145) (9) (2,660) (7) (883) (7) (17,285) (60)

SLR NET MARGIN 5,705 54 2,738 (472) 1,334 88 (5,119) (1,816) (3,575) (1,006) (6,376) 1,000 (5,294) (2,152)

PLANNED CARE GROUP

Jon Simmons Tom Pollard Will Flannery Liz Brannigan Helen O'Donnell

ABDOMINAL SURGERYTRAUMA &

ORTHOPAEDICS HEAD & NECKTHEATRES &

ANAESTHETICSBERKSHIRE CANCER

CENTRE PLANNED OTHER

Appendix (iii) : Care Group Financials SLR by Specialty – M07 NCG


15

Thousands

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k

Direct IncomeIncome 5,114 (350) 1,835 (583) 63 5 614 (143) 518 (8) 8,145 (1,079)

Direct ExpensesPay (1,395) (67) (1,574) (55) (215) 70 (458) (1,186) (304) (27) (3,944) (1,266) Non Pay (1,693) 394 (437) (8) 53 63 (970) 1,111 (96) (15) (3,143) 1,544 Exceptional - - - - - - - - - - - - Other - - - - - - - - - - - -

Direct Contribution 2,026 (23) (176) (646) (98) 137 (813) (217) 119 (50) 1,058 (800)

SLR Income (IP only)Elective Tariff Income 2 2 3 3 - - - - - - 5 5 Non-Elective Tariff Income (75) (166) 515 255 - - - - (21) 284 419 372

Educ. & Training Income 69 - 75 - 15 - 37 - 4 - 199 -

SLR Indirect RechargesRadiology recharge (9) 4 (36) (2) - - - - (27) (4) (72) (1) Pathology recharge - - - - - - - - - - - - Ward recharge - - - - - - - - - - - - Theatre recharge - 0 - 3 - - - - - - - 3 Pharmacy recharge - - - - - - - - - - - - Clinical Engineering recharge - - - - - - - - - - - - Therapies recharge - - - - - - - - - - - - Medic recharge - - - - - - - - - - - - Patient Meals (16) (0) (41) 3 - - - - - - (56) 3 Bed Linen (5) - (8) - - - - - - - (13) - Portering (7) 43 (7) 4 (0) 0 (6) (1) (1) 0 (21) 46 Estates recharge (56) 0 (58) (0) (9) 0 (34) 0 (8) 0 (166) (0) Depreciation & Leases (68) (0) (34) (0) (9) 0 (23) 0 (5) 0 (139) (0)

Total direct & indirect costs (3,249) 375 (2,195) (57) (180) 132 (1,491) (76) (440) (46) (7,555) 328

SLR Contribution excl. Ovhds 1,862 (140) 233 (382) (102) 137 (840) (219) 61 230 1,214 (373)

Contribution margin % 36% 13% -161% -137% 12% 15%

Overhead rechargesClinical Coding (12) 0 (10) 0 - - - - - - (22) 0 CNST premiums (18) 0 (18) (0) - - - - - - (35) (0) Corporate serv. recharge (218) (0) (99) (0) (15) 0 (40) 0 (21) 0 (393) 0

• Finance (42) (0) (20) 0 (2) 0 (17) 0 (4) 0 (85) 0 • HR (38) (0) (46) (0) (9) 0 (18) 0 (9) (0) (121) 0 • IM&T (138) (0) (33) (0) (4) 0 (4) 0 (7) (0) (187) (0) • Corp. Other - - - - - - - - - - - -

Other Overheads (361) 29 (249) (0) (29) (1) (94) (4) (31) (1) (764) 24

Total Overhead (609) 29 (375) (0) (44) (1) (133) (4) (52) (1) (1,214) 24

SLR NET MARGIN 1,253 (110) (142) (382) (146) 137 (973) (222) 9 229 1 (349)

INTEGRATED MEDICINE SPECIALIST MEDICINE PHARMACY PATHOLOGY NETWORKED OTHER

NETWORKED CARE GROUP

Vacant Vacant Sakeb Hussein

Appendix (iii) : Care Group Financials SLR by Specialty – YTD M07 NCG


16

Thousands

Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k Actual £k Var £k

Direct IncomeIncome 35,229 (1,117) 13,780 (2,452) 383 (31) 4,268 (799) 3,560 64 57,220 (4,335)

Direct ExpensesPay (9,572) (55) (10,836) (76) (1,651) 211 (3,320) (37) (2,059) (48) (27,439) (5) Non Pay (13,610) 1,109 (3,032) 75 (86) 1 (5,777) 660 (878) (286) (23,382) 1,558 Exceptional - - - - - - - - - - - - Other - - - - - - - - - - - -

Direct Contribution 12,047 (63) (89) (2,453) (1,354) 181 (4,829) (176) 623 (271) 6,399 (2,782)

SLR Income (IP only)Elective Tariff Income 10 1 25 7 - - - - 0 (1) 35 7 Non-Elective Tariff Income (394) (986) 3,100 803 - - - - (290) 2,120 2,417 1,937

Educ. & Training Income 480 - 520 - 101 - 259 - 28 - 1,387 -

SLR Indirect RechargesRadiology recharge (90) 0 (235) (10) - - - - (188) (33) (512) (42) Pathology recharge - - - - - - - - - - - - Ward recharge - - - - - - - - - - - - Theatre recharge (9) (8) (21) (4) - - - - - - (30) (12) Pharmacy recharge - - - - - - - - - - - - Clinical Engineering recharge - - - - - - - - - - - - Therapies recharge - - - - - - - - - - - - Medic recharge - - - - - - - - - - - - Patient Meals (109) (1) (280) 9 - - - - - - (389) 8 Bed Linen (35) - (52) - - - - - - - (88) - Portering (51) 58 (49) 10 (0) 0 (46) (11) (3) 1 (149) 58 Estates recharge (392) 0 (409) (0) (63) 0 (241) 0 (59) 0 (1,164) (0) Depreciation & Leases (478) (0) (238) (0) (61) 0 (160) 0 (32) 0 (970) (0)

Total direct & indirect costs (24,346) 1,103 (15,153) 4 (1,861) 212 (9,544) 613 (3,218) (367) (54,123) 1,564

SLR Contribution excl. Ovhds 10,978 (999) 2,272 (1,638) (1,378) 181 (5,017) (186) 80 1,816 6,935 (827)

Contribution margin % 31% 16% -360% -118% 2% 12%

Overhead rechargesClinical Coding (85) 0 (69) 0 - - - - - - (154) 0 CNST premiums (123) 0 (124) (0) - - - - - - (247) (0) Corporate serv. recharge (1,515) (0) (704) (0) (105) 0 (296) 0 (150) 0 (2,770) 0

• Finance (302) (0) (142) 0 (12) 0 (123) 0 (32) 0 (610) 0 • HR (271) (0) (327) (0) (65) 0 (129) 0 (65) (0) (856) 0 • IM&T (942) (0) (235) (0) (28) 0 (44) 0 (54) (0) (1,303) (0) • Corp. Other - - - - - - - - - - - -

Other Overheads (2,529) 35 (1,747) 6 (208) (1) (675) (14) (221) (1) (5,380) 26

Total Overhead (4,251) 35 (2,644) 6 (313) (1) (971) (14) (372) (1) (8,550) 26

SLR NET MARGIN 6,727 (964) (372) (1,632) (1,690) 180 (5,988) (200) (292) 1,815 (1,615) (801)

NETWORKED CARE GROUP

INTEGRATED MEDICINE SPECIALIST MEDICINE PHARMACY PATHOLOGY NETWORKED OTHER

Vacant Vacant Sakeb Hussein

17

Extract from August month return to NHSI – included as information for the Board

This extract is included so that the Board can be sighted on the SOCI submission to NHSI and in particular to the line by line variances to budget, which may be different to those shown in the management accounts due to virements made since the 2017/18 plan was submitted to NHSI.

Key data 01PLANYTD 01ACTYTD 01VARYTD 01PLANCY 01FOTCY 01VARCYPlan Actual Variance Plan Forecast Variance

30/09/2017 30/09/2017 30/09/2017 31/03/2018 31/03/2018 31/03/2018Expected YTD YTD YTD Year ending Year ending Year ending

Sign £'000 £'000 £'000 £'000 £'000 £'000Performance against control total

Surplus/(deficit) before impairments and transfers +/- (2,809) (2,729) 80 6,127 6,127 0Adjusted financial performance surplus/(deficit) including STF i +/- (3,680) (2,740) 940 4,629 4,651 22Control total +/- (3,686) (3,686) 0 4,617 4,617 0

Performance against control total +/- 6 946 940 12 34 22Performance against control total excluding STF

Adjusted financial performance surplus/(deficit) including STF +/- (3,680) (2,740) 940 4,629 4,651 22Less sustainability & transformation fund (STF) +/- (3,156) (3,154) 2 (9,012) (9,012) 0Adjusted financial performance surplus/(deficit) excluding STF +/- (6,836) (5,894) 942 (4,383) (4,361) 22Control total excluding STF +/- (6,840) (6,840) 0 (4,395) (4,395) 0

Performance against control total excluding STF +/- 4 946 942 12 34 22Adjusted financial performance as a % of Turnover (I&E Margin)

Including STF % (1.85%) (1.40%) 0.46% 1.14% 1.15% 0.01%Excluding STF % (3.50%) (3.06%) 0.44% (1.11%) (1.11%) (0.00%)

EBITDAEBITDA value +/- 7,054 8,306 1,252 25,702 25,980 278as a percentage of related income % 3.55% 4.24% 0.69% 6.34% 6.45% 0.11%Underlying position +/- (2,937)

Efficiencies iTotal recurrent efficiencies i + 6,508 7,469 961 16,150 16,424 274High risk schemes + 1,610 1,296 (314) 4,170 4,254 84Total unidentified efficiencies i + 0 0 0 0 0 0Total identified efficiencies i + 7,255 7,469 214 16,897 16,897 0

Total efficiencies + 7,255 7,469 214 16,897 16,897 0Total efficiencies as a percentage of expenditure (before efficiencies) % 3.46% 3.62% 0.16% 4.05% 4.07% 0.02%Capital

Gross capital expenditure + 9,597 0 9,597 25,500 28,318 (2,818)Disposals / other deductions - 0 0 0 (3,370) (4,389) 1,019

Charge after additions/deductions + 9,597 0 9,597 22,130 23,929 (1,799)Less donations and grants received - (1,248) 0 (1,248) (2,500) (2,500) 0Less PFI capital (IFRIC12) - 0 0 0 0 0 0Plus PFI residual interest + 0 0 0 0 0 0 g p p adjustments +/- 0 0 0 0 0 0

Total CDEL +/- 8,349 0 8,349 19,630 21,429 (1,799)Cash

Cash and cash equivalents at period end + 13,842 35,502 21,660 16,482 20,196 3,714DH capital financing i +/- 0 332 332 0 2,818 2,818DH interim revenue financing i +/- 0 0 0 0 0 0

Agency and contractTotal agency costs excluding outsourced bank + 6,840 5,094 1,746 12,149 12,149 0Agency ceiling + 5,836 5,836 0 10,320 10,320 0Agency costs as a percentage of gross payroll costs i % 5.93% 4.53% (1.41%) 5.33% 5.32% (0.00%)

TurnoverTotal operating income + 199,723 196,150 (3,573) 407,806 405,427 (2,379)Less capital donations/grants income impact - (1,248) (272) 976 (2,500) (2,500) 0Less 1617 STF post accounts reallocation - 0 0Total turnover + 198,475 195,878 (2,597) 405,306 402,927 (2,379)

18

Capital Expenditure Summary Key messages: • The table shown at the

foot of this page shows expected phasing of projects spend.

Project NameProject Value

Funding (see code

below)

Date approval expected

Date approval

given

Date approval expected

Date approval

given Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Q1 Q2 Q3 Q4Future years Notes

South block chillers 500 I Nov-17 Nov-17 500

Dingley services relocation 1,100 I Jul 17 1,100 Space at Reading Uni being developed completion Sept 18

Maternity HMA 800 I Jan 17 200 300 300 Construction due to start in Oct 17

Emergency Dept 500 I Nov 17 500

ICU - pendants / alterations 500 I Nov 17 500

Pre op assessment and ward building 1,000 I 2018/19 1,000 Not expected to take place in 2017/18

Linac bunker LA03 1,500 I / C Aug 17 1,500

Pathology reconfiguration 2,000 I May 16 400 400 400 400 400

Renal unit at WBCH 1,300 C Nov 16 325 325 325 325

Linac LA03 1,920 PDC Aug 17 1,824 96

Cardiac cath lab 1,723 L Jan 17 1,723 Construction due to start in Oct 17

Endoscopy AER 1,200 I Oct 17 1,200

Replacement endoscopes 600 STF Oct 17 600

EPR - programme of works 3,415 I Apr - Sept 17 683 683 683 683 683

STP - programme of works 710 I Apr - Sept 17 100 160 113 113 113 111 Infrastructure security - programme of works 740 I Apr - Sept 17 148 148 148 148 148

Infrastructure licences 800 I Sep-17 800

Ingenica - phase 2 - see assumptions 700 L Jul 15 25 25 25 25 25 575

ED Streaming 996 PDC May 17 332 332 332 Due for completion November 17

22,004 332 2,363 2,788 5,928 2,612 5,856 138 1,138 138 136 575

Funding codes

C Charity Assumptions

I Internally funded Ingenica Quarterly payments commencing January 2018 for 7 year lease period as per stage 1

L Lease

PDC DoH funded

STF STF funnded

T Third party grant

BoardCIG Expected cashflowFY 17/18 FY 18/19

October 17 Performance against capital budgets is shown in the table below:

2017/18 Original Plan

2017/18 Revised Forecast

Spend to Date Commit-ments

Orders to be raised Sub Total

£m £m £m £m £m £m

Equipment below £100k 0.96 0.96 (0.48) (0.30) (0.18) (0.96)

Equipment over £100k 9.16 9.16 (0.13) (2.80) (6.23) (9.16)

Engineering Compliance 3.61 3.61 (1.27) (0.83) (1.51) (3.61)

Estate Major Works 10.16 11.16 (0.68) (1.65) (8.83) (11.16)

IM&T Department 7.08 7.08 (2.54) (0.99) (3.55) (7.08)

IM&T Other 0.70 0.70 (0.00) (0.00) (0.70) (0.70)

Transformation Fund 0.50 0.50 (0.00) (0.00) (0.50) (0.50)

Total 32.17 33.17 (5.10) (6.57) (21.50) (33.17)

Approved Grant Q1 Q2 Q3 Q4 Total

£m £m £m £m £m £m £m

Equipment below £100k (0.00) (0.00) (0.30) (0.30) (0.30) (0.06) (0.96)

Equipment over £100k (2.16) (1.92) (0.75) (1.50) (2.00) (0.83) (9.16)

Engineering Compliance (0.00) (0.00) (0.75) (1.00) (1.25) (0.61) (3.61)

Estate Major Works (5.05) (2.30) (0.00) (0.75) (1.50) (1.56) (11.16)

IM&T Department (1.10) (2.50) (0.55) (0.80) (1.05) (1.08) (7.08)

IM&T Other (0.00) (0.00) (0.20) (0.20) (0.20) (0.10) (0.70)

Transformation Fund (0.05) (0.00) (0.20) (0.25) (0.00) (0.00) (0.50)

Total (8.36) (6.72) (2.75) (4.80) (6.30) (4.24) (33.17)

19

Cash Flow Statement

Key messages • Cash £35.5m, ahead of Q2F by

£5.65m and ahead of budget £20.5m due to:

NB - Against 17/18 APR Budget Q2 ForecastYTD September 2017 Mth October 2017 YTD October 2017 YTD October 2017

Actual Actual Actual 17-18 Q2 Forecast£000 £000 £000 £000

Opening cash Balance 14.40 35.50 14.40 14.40

Income 196.15 34.14 230.29 232.78Expenditure (excl Depr'n) (187.57) (32.50) (220.07) (220.12)

Cash generated 8.58 1.64 10.22 12.66

Working Capital(Increase)/decrease in inventories (0.37) (0.65) (1.02) (0.32)(Increase)/decrease in receivables 7.12 (1.24) 5.88 8.83(Increase)/decrease in provisions 2.99 0.60 3.59 3.10(Increase)/decrease in assets held for sale 0.00 0.00 0.00 0.00Increase/(decrease) in payables 7.65 0.77 8.42 4.28

17.39 (0.52) 16.87 15.89

Investing ActivitiesCapex (Capital expenditure) (0.93) (1.45) (2.38) (9.31)Proceeds from sale of property, plant and eq 0.00 0.00 0.00 0.00PDC receipt 0.00 0.00 0.00 0.66PDC paid (2.25) 0.00 (2.25) (2.25)

(3.18) (1.45) (4.63) (10.90)

Financing ActivitiesInterest income/ (Expense) (0.44) 0.02 (0.42) 0.04Interest expense 0.00 0.00 0.00 (0.45)Other 0.25 0.32 0.57 (1.76)

(0.19) 0.34 0.15 (2.17)

Loan Drawdown 0.00 0.00 0.00 0.00Loan (Repayment) (1.50) 0.00 (1.50) 0.00

Net increase/(decrease) in cash 21.10 0.01 21.11 15.48

Closing Cash Balance 35.50 35.51 35.51 29.88

£mOpening balance at 01/04 higher than planned 3.1More 16/17 STF than planned 1.5Delay in Capex spend 7.0Decrease in creditors, inc suppliers payment witheld (1.3)Other expenditure - HMRC VAT (0.2) Sale of Battle 2.5NHSE/NHLA receipts 7.9

20.5

20

Long term cash scenarios

Key message: the Trust cash balance should be expected to remain positive across the next 12 months.

£'000

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18Scenario 1Month end cash as currently forecast / planned

14,482 14,737 14,763 13,842 14,915 16,111 16,542 19,959 18,163 18,163 18,163 18,163

Divergence from plan at 31/07opening balance 3,100 3,100 3,100 3,100 3,100 3,100 3,100 3,100 3,100 3,100 3,100 3,100additional 15/16 STF 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500Delay in 17/18 capex 3,900 3,413 2,925 2,438 1,950 1,463 975 488 0Delay in payments to CSC 2,600 2,600 2,600 2,167 1,733 1,300 867 433 0Timing of Battle site receipts (2,000) 2,500 2,500 2,500 2,500 2,500Grant received in advance for WBCH

1,300 1,300 1,300 1,083 867 650 433 217 0

Increase in accrued costs 3,200 2,133 1,067 0Other 905 603 302 0Sub-total 28,987 31,886 30,056 26,630 26,565 26,624 23,417 25,697 22,763 22,763 22,763 22,763

Mid-month low expected £2M lower than month end

(2,000) (2,000) (2,000) (2,000) (2,000) (2,000) (2,000) (2,000) (2,000) (2,000) (2,000) (2,000)

Scenario 1 26,987 29,886 28,056 24,630 24,565 24,624 21,417 23,697 20,763 20,763 20,763 20,763

Scenario 2Full year QIPPs are in line with latest estimate

(293) (406) (725) (1,290) (1,624) (2,002) (2,706) (2,739) (2,739) (2,739) (2,739)

Activity income 1% below plan (1,226) (1,530) (1,841) (2,169) (2,494) (2,790) (3,121) (3,427) (3,733) (4,033) (4,333) (4,633)Underperformance results in loss of 17/18 STF for Q2 to Q4

(2,250) (2,250) (2,250) (9,000) (9,000) (9,000) (9,000)

Scenario 2 25,761 28,064 25,809 21,735 20,781 17,959 14,044 15,313 5,291 4,991 4,691 4,391

Scenario 3Delay in commissioner receipts for contract overperformance

(450) (600) (750) (900) (1,050) (1,200) (1,350) (1,500) (1,650) (1,800) (1,950) (2,100)

Scenario 3 25,311 27,464 25,059 20,835 19,731 16,759 12,694 13,813 3,641 3,191 2,741 2,291

Mitigation AQ2 to Q4 capex spend halved 912 1,825 2,737 3,950 5,162 6,375 7,813 9,251 10,689 10,689 10,689 10,689

Mitigation A50% reduction in cost relating to activity income below plan - with 6 month delay

139 298 457 613 765 920 1,084 1,247 1,395

Mitigated Mid Month Low Cash 26,224 29,288 27,796 24,785 24,893 23,134 20,507 23,064 14,330 13,880 13,430 12,980

NHSI Monthly from Annual Plan Assume stays flat

Title: QIPPs Update 2017/18 Agenda item no: 5d Meeting: Board of Directors Date: 29 November 2017 Presented by: Mary Sherry, Chief Operating Officer Prepared by: Clare Yates, Head of Transformation Purpose of the Report To update the Board on the status of the QIPPs for 2017/18, including

the Month 6 position.

Report History None

What action is required? The Committee is asked to note the report and actions.


Resource Impact: Impact on financial sustainability


Failure to achieve Financial Sustainability

Strategic objectives. This report impacts on (tick all that apply):: Consistently Delivering Quality Care and Healthcare Outcomes Shaping a Fit for Purpose Core Acute Service Shaping a Fit for Purpose Core Elective Service Being a good system partner and exercising system leadership for integration Developing IT and Information Systems Supporting Better Care Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Being a Great Place to Work Achieving Financial Sustainability Well Led Framework applicability: Not applicable 1.Strategy & planning 2. Risk









November 2017

1 Key Points 1.1 The current cost saving schemes for 2017/18 (to deliver in-year) total £17.2m in year

against a target of £16.9m.

1.2 The PMO risk assessment of these plans as at 11 October is £13m. This is a decrease since last month.

1.3 As at 10th November, the in-year PMO risk assessed total of £13m includes pay savings totalling £6.6m, non-pay savings of £5.4m and drug savings totalling £1m.

1.4 The number of income schemes currently totals £721k, risk assessed at £398k and with a delivery YTD of £158k. The table below shows the three areas with income schemes.

Summary of current position & achievement as at November 10, 2017 ytd:

Programme Full Year In YearRisk

Adjusted M072017/18 saving

achieved to date

Planned Care BAU 163 143 72 3 22

Networked Care BAU 564 523 281 20 116

Workforce and OD BAU 56 56 44 5 20

TOTAL 783 721 398 27 158

Income (£000's)

2 Key Changes since last month

2.1 In Month 7 the Trust delivered £548k against a budget of £1.7m and a forecast of £1.4k. In Month 7, the temporary staffing, procurement inventory management and pathology programmes under-delivered.

2.2 Procurement, Planned Care Business As Usual and Medicines Optimisation over-delivered against forecast this month.

2.4 A summary of the in-year, risk assessed and savings achieved to date for the QIPP schemes is shown overleaf:

Summary of current position & achievement as at November 10, 2017 ytd:

Programme Budget Full Year In Year Risk Adjusted M07

2017/18 saving

achieved to date

Planned Care BAU 1,113 1,784 1,438 1,247 164 807

Urgent Care BAU 1,249 2,334 1,433 1,186 29 627

Networked Care BAU 1,406 1,462 1,367 1,161 101 819

Estates & Facilities BAU 1,023 959 832 581 53 112

Finance BAU 148 153 127 151 32 134

IM&T BAU 809 733 446 295 - 112

Workforce and OD BAU 113 75 75 86 8 70

Commercial 8 - - - - -

CEO BAU 98 86 86 80 8 29

COO BAU 38 60 60 110 22 110

CMO BAU 36 30 30 30 3 18

CNO BAU 122 95 95 91 1 77

Pathology Joint Venture - 1,000 1,000 901 - 365

Temporary Staffing 2,500 3,311 3,311 1,403 456- 1,081

Medicines Optimisation 1,004 1,069 1,069 1,067 148 624

Medical Workforce 2,000 2,284 2,133 1,234 111 749

Procurement BAU 1,200 1,011 1,007 956 188 455

Acute Medical Pathway 175 175 175 175 - -

Outpatients Modernisation 50 154 154 117 - 104

Patient Flow 1,000 864 864 702 5 893

Carter Support Services Review - - - - - - Carter Clinical Services Admin & Structure Review

150 192 151 97 34 43

Procurement Inventory Management 1,935 667 667 387 - 173

Theatres 728 817 672 936 99 613

Digital Hospital - - - - - -

Health Records 35 17 12 25 - - TOTAL 16,898 19,333 17,204 13,017 548 8,016

Cost (£000's)

2.5 The Trust Improvement Board agreed that the following key actions should take place to mitigate the gap in the RAG figure and improve the in-year delivery:

• The Digital Hospital team will validate the proposed savings for 2018/19 in line with the current implementation timescales and input into the PMO tracker;

• New IM&T schemes proposed need to be checked for double-counts and inputted into the tracker following appropriate forecasting;

• There is scope for the Estates and Facilities teams to develop their schemes to attain greater assurance around the in-year figure, therefore increasing the RAG rating.

2.6 The table below shows the budgeted targets by area versus the current position as at Month 7:

Care Group / Corporate QIPP Target In Year Variance RAG Variance YTD Actuals

Networked Care 4,241 4,348 107 3,357 -884 2,134

Planned Care 6,000 6,427 427 5,574 -426 3,819

Urgent Care 3,963 3,986 23 2,542 -1,421 1,559

0

EFM 1,048 931 -117 673 -375 174

IM&T 935 749 -187 295 -640 112

Finance 250 173 -77 181 -69 164

0

Workforce & OD 141 100 -41 165 24 149

CNO 123 95 -28 91 -32 77

CEO 114 102 -12 80 -34 29

COO 38 160 122 210 172 210

CMO 37 30 -7 30 -7 18

Commercial 8 0 -8 0 -8 00

Trustwide 0 103 103 -181 -181 -429TOTAL 16,898 17,204 306 13,017 -3,881 8,016

QIPP Budget vs. Tracker £'000s

3 Conclusion and Next Steps

3.1 To note the delivery of the cost QIPPs.

Title: Carter Review: Clinical Outcomes Dashboard Agenda item no: 6 Meeting: Board of Directors Date: 29 November 2017 Presented by: Lindsey Barker, Medical Director Prepared by: Sam Harmer, Head of Information Purpose of the Report To present the clinical outcomes dashboard to the Board as

required in the Carter Review

Report History

What action is required? The Board is asked to review the report.




Failure to consistently deliver Quality Care and Healthcare Outcomes

Strategic objectives. This report impacts on (tick all that apply):: Consistently Delivering Quality Care and Healthcare Outcomes Shaping a Fit for Purpose Core Acute Service Shaping a Fit for Purpose Core Elective Service Being a good system partner and exercising system leadership for integration Developing IT and Information Systems Supporting Better Care Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Being a Great Place to Work Achieving Financial Sustainability Well Led Framework applicability: Not applicable 1.Strategy & planning 2. Risk








N/A Publication Published on website Confidentiality (FoI): Private Public

1. Background

1.1 The Lord Carter Review gave a recommendation that:

1.2 “NHS Improvement and NHS England should establish joint clinical governance by April 2016 to set standards of best practice for all specialties, which will analyse and produce assessments of clinical variation, so that unwarranted variation is reduced, quality outcomes improve, the performance of specialist medical teams is assessed according to how well they meet the needs of patients and efficiency and productivity increase along the entire care pathway.”

1.3 As part of this recommendation NHS Improvement was asked to bring all existing

clinical registries and data source feeds into its new structure in order to produce National and Local Dashboards for each clinical specialty by July 2016.

1.4 Provider trust boards were mandated to review dashboards for 3 clinical or medical specialties each month and to benchmark themselves against the established metrics and best practice and routinely track progress by October 2016.

2 Dashboard

2.1 To date, dashboards containing clinical outcomes for Trauma, Orthopaedics, Critical Care, General Surgery, Renal, Urology, Emergency Department, Acute Medical Unit, Elderly Care, Hip Fracture, Audiology, Neonates, Maternity, ENT, Ophthalmology, Gynaecology, Haematology, Oncology, Paediatrics, Diabetes, Rheumatology, Sexual Health and End of Life Care have been presented.

2.2 The next dashboard containing indicators from Anaesthetics and Respiratory is attached.

3 Future Plans

3.1 The Quality Governance Team and Informatics will continue to work with all specialties to ensure that clinical outcome measures are identified

3.2 The only specialties which have not presented to Board are Neurology, Pain, and Dermatology. The following measures for these specialties are planned; they will be presented once the relevant data is available:

Dermatology

• Assessment Monday to Friday within 24 hours of dermatology referral.

• Complete BCC excision rates of 10 patients per month.

• Number of cases of erythema classed as E3 in phototherapy per month

Pain

• Inpatient review by Acute Pain Service within 24 hours of referral

• Percentage of patients with adverse outcomes post intervention for pain relief

• Patient feedback on clinical effectiveness of pain intervention

Neurology/ Neuro-Rehab

• Proportion of neurology outpatient referrals deemed urgent following consultant triage that are seen within 14 calendar days. Target 95%

• Interval to review or advice advancing patient pathway following routine inpatient referral on EPR. Target 24h

• Motor gain during admission (mean)

• Cognitive gain during admission (mean)

4 Recommendations

4.1 The Board is asked to:

• Note the report

5 Attachments

5.1 The following are attached to this report:

(a) Appendix 1 – Clinical Outcomes Dashboard

22nd November 2017

Clinical Outcomes Report - Draft

The purpose of this paper is to provide the Board of Directors with an analysis of benchmarked clinical outcomes in line with recommendations from the Carter Review. The report includes the specialties: Anaesthetics and Respiratory. Contact: Lindsey Barker, Medical Director Katie Elcock, Head of Governance & Improvement Sam Harmer, Head of Information

Contents

23/11/2017 Clinical Outcomes Report Page 2

The purpose of this report is to provide assurance to the Board of Directors regarding the clinical effectiveness of services in the Trust through review of key clinical outcome data, benchmarked against nationally available datasets as required by the Carter Report. This report includes the specialties: Anaesthetics and Respiratory.

Introduction


1. Anaesthetics – Consistently Delivering Quality Care and Healthcare Outcomes

Post-operatively patients are taken to Recovery to recover from the anaesthetic and to ensure they are stable before transfer to the ward for ongoing medical care. The measures above relate to the patient’s condition post-operatively in Recovery. The aim is for all patients to have a temperature >36; to have a pain score of <5; and not to experience nausea or vomiting (though nausea and vomiting are recognised complications and therefore a certain incidence rate is to be expected). These measures and the data collection for them are currently under development which is why there is currently no benchmark given. In the Anaesthetic Department plans are in place sign up to Anaesthesia Clinical Services Accreditation (ACSA) by 2018, which will provide an opportunity to benchmark performance and identify opportunities for quality improvement. However, this will require funding for an annual subscription. There is an excellent training programme in place which ensures appropriate mentoring, high quality tutorial and exam preparation for trainee staff. There are also plans to institute a rolling equipment replacement scheme in order to allow for the introduction of new technologies as they become indicated. These plans are aligned with the department’s clinical service strategy.


2. Respiratory – Consistently Delivering Quality Care and Healthcare Outcomes

The in-hospital mortality rate is taken from Dr Foster data and covers deaths of all patients under a respiratory physician across the Trust. The respiratory mortality rate is consistently below the nationally expected rate with little variation between weekdays and weekends. All respiratory ward deaths are audited and reviewed for any shared learning. The respiratory team provides a seven day service to the ward.

Whilst more of an operational performance measure, the 2 week wait for lung cancer is extremely important to the safe delivery of care to patients and has a direct impact on outcomes. Meeting the 2 week wait referral target for lung cancer patients requires co-ordination between the CAT, the CT scanning department, and the clinic, with rapid triage of GP referrals. Initial problems post-CAT reorganisation have been overcome and now the team is consistently above the target of 93%, due to flexibility with clinics and CT scan appointments.

Tuberculosis (TB) treatment completion is monitored nationally and all cases reviewed at local cohort review meetings. The TB treatment completion numbers are above the target of 85% and are comparable to other Thames Valley providers. Efforts are made by the TB team to maintain good close relationships with this diverse patient group during treatment to avoid patients being lost to follow up.

Full completion of the Chronic Obstructive Pulmonary Disease (COPD) discharge bundle helps to provide the appropriate clinical support for patients as they leave hospital and reduce readmissions. There is a new rolling national audit on all patients admitted for COPD which incorporates a best practice tariff (BPT) awarded for achieving 60% compliance with completion of a COPD discharge bundle and being seen by a member of the respiratory team within 24hours. Whilst the discharge bundle measure is currently being met, the BPT target is not being achieved due to the current shortage of respiratory nurse staffing.


Title: Winter Plan Agenda item no: 7 Meeting: Board of Directors Date: 29 November 2017 Presented by: Mary Sherry, Chief Operating Officer Prepared by: Mandy Claridge, Director of Operations Purpose of the Report • To brief the Trust Board on the plans being implemented to

support the hospital through the critical winter period • To brief the Board on how the winter period will be monitored in

terms of quality & safety, clinical outcomes and performance, in particular in regard to the delivery of the required Emergency Department (ED) performance trajectory


The Board are asked to note the report

Assurance Information x Discussion/input Decision/approval

Resource Impact:

Strategic imperatives. This report impacts on (tick all that apply):: Consistently Delivering Quality Care and Healthcare Outcomes Shaping a Fit for Purpose Core Acute Service Shaping a Fit for Purpose Core Elective Service Being a good system partner and exercising system leadership for integration Developing IT and Information Systems Supporting Better Care Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Being a Great Place to Work Achieving Financial Sustainability Well Led Framework applicability: Not applicable 1.Strategy & planning

2. Risk Management

3. Board capability








1

1 Background

1.1 This winter plan has been derived from the overall work plan of the West Berks A&E Delivery

Board and the various directions and guidance received from NHSE on the key actions that are required by all systems in respect of both the winter period 2017/18 and the longer term development of urgent and emergency care pathways.

1.2 The in hospital actions have been derived from a combination of the Trust’s on-going continuous improvement approach to urgent and emergency care under the domains of Front Door pathways, Effective Ward practices and Integrated Discharge improvement programmes and the various directions and guidance from NHSE/I in preparation for this winter and points to a number of actions by partners as part of the overall system wide West Berks A&E Delivery Board Plan.

1.3 Account has also been taken of a lessons learnt exercise held at the A&E Delivery Board and a Trust action plan derived from a clinical review of front door emergency care last winter.

1.4 Both committees are asked to note that the plan is still subject to a small number of final adjustments and so should consider this plan to be at final draft stage prior to circulation which will be supported by a number of communication exercises which are being planned over the next few weeks.

2 Key Components of the Plan 2.1 The plan sets out arrangements to support effective patient flow through the Royal Berkshire

Hospital (RBH), plans with our system partners to control attendances/admissions to the Trust and increase the outflow of medically fit patients safely home or to an onward care environment.

2.2 Under the umbrella of Valuing Patients’ Time and Supporting Staff key components of the plan are to:

i) Model and predict activity supported by appropriate escalation responses ii) Focus on right patient in the right place first time and reducing multiple patient

moves to ambulatory care services iii) Utilise short stay environments wherever appropriate, supported by proactive

discharge processes iv) Target internal processes and delays to reduce delays each day and

implement safe discharge plans v) Support staff at times of increased pressure and balance staffing levels across

all areas vi) Communicate and escalate with system partners as necessary

2.3 Due to significant staffing and space constraints, we do not have options this winter to open

extra bed capacity and the reality is that we must consolidate our bed base and optimise our staffing, so that we try to avoid stretching our staffing too thinly or over using agency staff to open up day areas overnight.

2.4 In essence, therefore, this is an efficiency plan focussing on managing patients to the right service/bed first time and reducing delays in patient care. The aim is to achieve a shorter time in hospital for each patient and an easier route for safe discharge in order to reduce bed occupancy.

2

2.5 Both committees are asked to note that for the critical period 22/12/17 – 19/1/18 senior clinical and operational staff will be clearing diary time to provide additional support to the hospital and a wider group of Deliver a Difference volunteers are being asked to provide an additional presence during this time and through February and March.

2.6 During this period the Trust will be supported 24/7 by senior clinical and operational teams both on site and on call including overnight and at weekends.

2.7 A targeted amount of additional resource is intended to be deployed over the critical weeks to support this plan, however this is currently subject to confirmation given the financial position.

2.8 A significant issue facing the Trust as we move into the winter period is a further step up in attendances to ED which is presently adversely affecting performance. A significant proportion of this high activity is children. This is being examined and further counter measures will be sought.

2.9 Both committees are also asked to note that the plan also sets out arrangements to maintain so far as is possible elective activity where it is safe to do so in support of urgent and cancer patients and to minimise the cancellation of routine patients.

3 Monitoring of the Plan and Performance against Trajectory 3.1 The progress of the winter period will be closely monitored by a newly formed internal

Clinical Board particularly so that clinical quality issues can be identified and addressed whilst also focussing on performance, and escalation will take place at the West Berks A&E Delivery Board for system escalation and support.

3.2 The impact of external actions (eg improved diversion of 111 patients, increased access to primary care, ambulance service changes) will be directly monitored externally by the A&E Delivery Board and indirectly by monitoring attendance levels to the Trust.

3.3 The current performance against the trajectory is shown in Appendix 5, tracking forward

against the requirement for Q3 and Q4 3.4 A KPI dashboard is in the final stage of development for use internally over the winter period

to monitor the impact of the various actions in the plan and the overall position across the hospital in terms of activity and acuity. This will then be used to identify adjustments that may need to be made to the plan, particularly in relation to the new ways of working, which may require adjustment.

3.5 As noted previously to the Board there are four KPIs of particular interest which will be

closely monitored as they will be directly pertinent to our ability to meet the required ED trajectory:

i) % Ambulatory Pathways (intended impact: to reduce bed requirements for

admissions) 3.6 The ambulatory programme set a target of 30% of medical conditions being seen through

ambulatory pathways and to reduce the demand for in patient beds and progress against this intention is good. This has already contributed to avoiding the use of 9 beds escalation beds in MAU and the reduction of 12 beds in Elderly Care over the summer (in response to staffing concerns).

3.7 Further improvements are anticipated with a significant change of pathway commencing in

November with the opening of a new ring fenced area and closer working between Acute Physicians and ED due to better co location. The intention is to advance this in order to reduce the use of escalation beds as acuity goes up over the winter and to mitigate the impact of the Bank Holiday period.

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ii) % DTOC (intended impact: to release bed occupancy and in particular reduce the need to open escalation beds)

3.8 DTOC reduction trajectories have been submitted to NHSE/I as part of the Better Care Fund

submissions after agreement with all 3 Local Authorities and these form a key action in the West Berks A& E Delivery Board plan.

3.9 It has been mandated that each area achieved 3.5% reduction in total DTOCs. Currently we are modelling on 4.2% which is expected this will reduce occupancy by 9 beds within the Trust.

3.10 This is subject to further review at A&E Delivery Board as this is not currently being achieved across all Local Authorities.

3.11 Again, delivery of this will be utilised to reduce bed occupancy and minimise the use of escalation spaces as described above. iii) % conversion of ED attendances to primary care via the implementation

of GP streaming (intended impact: to relieve pressure on ED and allow increased focus on sicker patients)

3.12 GP streaming was implemented on time for adults in line with national requirements and has

made an excellent start and children are now being referred to this service. Issues are the robustness of the staffing model in terms of cover and the risk that this may in fact result in an overall activity increase and we do believe this may already be the case. However, from a performance point of view as long as these patients continue to be seen at 100% performance then an increased denominator can help. iv) Number of ‘stranded’ patients ie those in hospital over 7 days (intended

impact: reduction in hospital stays will release bed occupancy

3.13 A relentless focus on internal delays and reducing patients in hospital over 7 days will be required throughout the period in order to free up further bed occupancy. This is challenging and will be supported by ward buddying by senior staff in support of the clinical teams.

3.14 Other key measures that will be kept under close scrutiny include:

Activity and conversion to admission Acuity through ED and on short stay and in patient wards Length of stay in hospital Length of stay on discharge Flu numbers

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3.15 Quality and safety and clinical outcome measures are subject to final confirmation into the plan and will be included in the publicised version at the end of November.

4 Flu Risk

4.1 A further risk to the winter plan is the concern regarding increased flu rates.

4.2 Both committees are asked to note:

i) we are already well advanced with a comprehensive and energetic flu vaccination programme in terms of protecting staff

ii) the Trust flu plan will be implemented as required and flu rates will be closely monitored

iii) partnership working will be used to ensure that patients are care for at home wherever clinically appropriate and that capacity across the system is managed carefully

5 Next steps 5.1 Final editing of the plan will be complete by 28th November including the finalisation of the

KPI, quality and safety and clinical outcome dashboards. The quality and safety aspects will include patient experience.

5.2 A series of communication exercises is being timetabled to run over the next few

weeks.

6 Modelling of actions to the Delivery of ED Trajectory for Q3 and Q4

6.1 The Board will be aware of the challenge the Trust is facing in delivering the Q3 and Q4 trajectories and, as would be expected, massive effort is being directed at the achievement of these requirements, particularly as this standard is a clinical quality standard and as such poor performance potentially means a poorer patient experience for our emergency patients.

6.2 Specific modelling of the actions against these trajectories is in progress, including the impact of a recent stepped increase in activity through ED and the implementation of ED streaming.

6.3 Both committees will be updated on this modelling at their respective November meetings.

6.4 This modelling will be kept under close review throughout the winter period.

7 Risks

7.1 As briefed in the last report to both committees there are a number of risks in this plan, and these risks remain as follows:

i) Staffing challenges, financial and space constraints have prevented the Trust being able to establish additional bed capacity. To mitigate this risk we will continue a strong focus on improving length of stay and reducing internal delays in order to maximise bed utilisation and release bed occupancy.

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ii) Our staffing recruitment and retention issues are expected to continue over the winter, which will present on-going pressure on the hospital overall and on our existing bed base. To mitigate this risk we will continue the focus on the recruitment and retention action plans and work on further mitigating actions to provide additional support to wards in various ways, which are currently being worked through.

iii) We cannot be totally sure of the impact of the various actions to reduce the pressure on admissions/bed requirements by increasing the conversion to ambulatory pathways and the release of occupancy through DTOC reductions. To mitigate this risk we will keep a strong oversight and focus in these areas.

iv) The implementation of GP streaming does present an inherent risk of additional patients attending the Trust site which, whilst this may actually improve the performance in terms of the denominator, may present an additional pressure on the service. Furthermore, there is an additional risk to the commissioned capacity due to the availability of GPs. This will remain under close scrutiny.

v) The recent pattern of attendances has seen a step increase, currently trending at an average of 335 attendances in ED with the associated pressure on admissions. We recently saw 386 patients through the ED in a day with only 50 patients being minors and 40 through resus and 25 referred to GP streaming. At one point c. 40% of the patients in the ED were children. Admissions that day were 131. This mix indicates an increase in acuity through the ED and an onward demand on beds. We are currently looking at how to respond to this potential onward pressure.

8 Conclusion

9.1 As previously brief to both committees:

ii) The Trust, in line with other years, has been planning for winter throughout the summer including lessons learned from last winter and has received support across the whole system in developing the plans presented.

iii) To a large degree the Trust is therefore well advanced with its winter

planning and in complying with the requirements of NHSE/I.

iv) However, there are a number of risks still remaining in relation to the coming winter and a number of mitigating actions have been noted in this paper. These risks do still present a material challenge for the delivery of the required performance against the ED standard. Further consideration of mitigation will be on-going.

v) Both A&E delivery Board plans and the Trust’s internal plan referred to, will

be iterative and continue to develop as required and in response to the winter circumstances as they unfold.

vi) Oversight of these plans will take place externally via the A&E Delivery Board

and internally via the Winter Clinical Board.

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Final Draft

Valuing Patients’ Time, Supporting Staff

Winter Resilience Plans

1st December 2017 – 31st March 2018

2017/2018

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INTRODUCTION This plan sets out arrangements to support effective patient flow through the Royal Berkshire Hospital (RBH), plans with our system partners to control attendances/admissions to the Trust and increase the outflow of medically fit patients safely home or to an onward care environment. It incorporates the work of internal and system wide work to address issues that affect patient pathways and nationally recommended best practice. Under the umbrella of Valuing Patients’ Time and Supporting Staff we will:

i) Model and predict activity and support with escalation responses as appropriate and practical ii) Strive to care for the right patient in the right place first time and reduce multiple moves in patients’ pathways iii) Stream as many patients as possible across front door locations to ambulatory care services wherever it is safe to do so iv) Treat patients in short stay environments wherever appropriate and support with proactive discharge processes v) Target internal processes and delays to ensure that patient pathways are advanced each day and that safe discharge plans are implemented vi) Support staff at times of increased pressure, unblock issues in patient pathways and carefully monitor staffing levels to achieve a balance across all areas vii) Communicate and escalate with system partners as necessary to support whole system flow

Given that we have limited options to flex our bed capacity and significant staffing constraints, the reality we face over the winter is to consolidate our bed base to optimise our staffing so that we avoid the need to stretch our staffing too thinly or risk opening up day care areas as short notice, particularly overnight. In essence therefore this is an efficiency plan with a focus on striving to manage patients to the right service/bed first time and reduce delays in patient care, thereby achieving a shorter time in hospital for each patient and an easier route for safe discharge home or to an appropriate location for their onward care needs. This plan and the progress of the winter period will be closely monitored by an internal Clinical Board and West Berks A&E Delivery Board for escalation, particularly so that clinical quality issues can be identified and addressed. For the critical period 22/12 – 19/1 senior clinical and operational staff will be clearing diary time to provide additional support to the hospital and a wider group of Deliver a Difference volunteers are being asked to provide an additional presence during this time and through February and March. During this period the Trust will be supported 24/7 by senior clinical and operational teams both on site and on call including overnight and at weekends. Potentially, pending financial constraints, a targeted amount of additional resource may be deployed over the critical weeks to support this plan. The plan is set out in the following domains:

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1. ADMISSION AVOIDANCE WITH PARTNERS 2. FRONT DOOR PROGRAMME ACROSS ALL SPECIALTIES

3. EFFECTIVE WARDS / IN HOSPITAL PROCESSES

i) Enhanced 111 service ii) Increased access to primary care services iii) Ambulance Service ARP programme incl

Frailty support iv) GP Directory for alternatives to referral v) Frequent attenders programme

i) ED controls and escalation plan ii) Front Door Huddles iii) Primary Care Streaming iv) ED Frailty service v) Ambulatory Care Pathways vi) Acute Medical Model vii) AMU /SSU support actions viii) Surgical Pathways ix) Paediatric Pathways x) Mental Health Pathways

On Wards: i) Ward/Board rounds ii) Early discharge process iii) SAFER bundle iv) Tracking/reducing LoS > 7 days v) Next Steps on EPR vi) Internal standards/response times vii) 7 day working viii) Infection control management ix) Outlier management In Support of Wards: i) Ward Buddies ii) Expediting delays and resolving issues iii) Escalation to external partners iv) Deliver a Difference Volunteers

4. INTEGRATED DISCHARGE & PARTNERSHP WORKING

5. FLOW MANAGEMENT SYSTEM & COMMUNICATION

6. QUALITY & KPI MONITORING

i) Criteria led discharge ii) Weekend discharge plans/ahead iii) Redesigned Integrated Discharge Team iv) CHS support programme v) RBH/BHFT joint review of bed management

and flow arrangements vi) Discharge to Assess/Trusted Assessor vii) DTOC reductions to reduce bed occupancy viii) Visible system wide bed management ix) Early Supported Discharge service

i) Predictors & activity monitoring ii) Bed management & escalation iii) Elective management plan iv) Safe Staffing plans v) Support services provision vi) Daily reports & communication tools vii) Daily Ops Meetings viii) Clinical Site Management Hub ix) OOH management and escalation x) System wide flow management xi) Escalation & working partners xii) System wide comms plan xiii) Service Plans 18/12-19/12

i) KPI Dashboard/patient flow metrics

ii) Quality Indicators - care group governance

iii) Clinical Outcomes incl Harm Assessment

iv) RBH Clinical Oversight Board (weekly)

v) West Berks A&E Delivery Board

1. ADMISSION AVOIDANCE WITH PARTNERS

i) Enhanced 111 service 3

• New arrangements increasing clinical response to assess all calls with revised protocols and access to alternative services to avoid referral to A&E ii) Increased access to primary care services

• Increased hours in GP services to increase patient’s access to treatment in primary care iii) GP Directory for alternatives to referral

• Increased access to alternatives to A&E or referral to Acute Medicine incl option to refer to Ambulatory Care • This will include hot clinics and advice lines such as RACOP, heart failure, jaundice hotline, rheumatology flare clinic, gastro IBD clinic, ENT ARC, rapid

access chest pain clinic and falls clinic iv) Direct line to Acute Physician at Trust

• Acute Physician to cover referral phone to Acute Medicine to consider appropriate treatment options incl referral to Ambulatory Care v) SCAS: Ambulance Response Programme (ARP)

• Increased ambulance response, with altered response times, to increase non conveyance / reduce attendance at A&E • Falls response service where resources allow

vi) Frequent attenders programme • Bespoke treatment plans for cohort of patients identified as potential frequent attenders to A&E

** Where any of these arrangements identify referral to A&E or Acute Medicine this will be expedited to ensure appropriate early referral**

2. FRONT DOOR PROGRAMME ACROSS ALL SPECIALTIES

i) Emergency Department (ED) controls and escalation plan • Continue Consultant led Senior Triage Assess and Treat (STAT) for all ambulance arrivals 08.00 and 22.00hrs 7 days a week • On arrival all walking adults are now streamed for treatment in ED or Primary Care service • From December: On arrival all walking children will be streamed for treatment in ED or Primary Care service • Continued management of ED patients as ambulatory to achieve discharge from ED wherever safe to do so including:

- implementation of the new ED Frailty service as it comes into use - increased focus on potential referral to hot clinics/outpatients, advice lines such as RACOP, heart failure, jaundice hotline, rheumatology flare clinic,

gastro IBD clinic, ENT ARC, rapid access chest pain clinic and falls clinic ***App will become available to help with this decision making ** • Closer working with Acute Physicians and POD/ECPOD to agree management of ED patients to Ambulatory Care Unit, Acute Medical Unit, and day

treatment options including Battle Day Unit (BDU) • Increase use of BDU as an alternative to admission for patients requiring transfusions and procedures • New referral pro forma for all emergency referrals from GPs and utilisation of revised clerking form as it is implemented • Timely streaming of critically ill patients to their correct environment (HMU, ICU, CCU, ASU, NOF/HFU).

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• As early referral to specialties as possible and escalation to on call consultant if needed – with use of fast track protocols as appropriate – including early referral to SAU

• Escalation by ED consultant/ED coordinator to specialty Matrons in anticipation of any delays in patients being reviewed in ED and site manager out of hours

• Consultant and Senior Nurse coordination of the department to oversee management of patient volumes, allocation of resource, adherence to clinical standards for assessment, treatment and referral, actions to achieve ED components of 4 hour pathways and timely handover of ambulance patients. As per ED Escalation Plan, incl importance of maintaining separate stream for minors and majors when under pressure

• ED Frailty Service – new service will commence to support ED provide alternatives to referral to ECPOD in order to safely achieve discharge from ED for elderly frail patients, this will include the use of the Observation Ward to avoid admission.

• Expediting Minors patients: maintaining resource to deal with minors patients in a timely manner to avoid high volumes of patients in ED/ED waiting room and delayed decision making/unidentified clinical risk

• Use of the Observation Ward (Target typical LoS of < 12 hours) for: Patients who require a period of extended care under the ED team beyond 4 hours, pending the outcome of tests and for whom an admission can

be avoided. Patients awaiting transport outside the working hours of the Discharge Lounge. Patients who can be managed by the Occupational Therapy (OT)/ED Frailty team avoiding referral into AMU or IP beds, where safe to do so. Where discharge not guaranteed prior to nightfall, but likely next morning, these patients will stay overnight and be reviewed by 1130 am for

admission to avoid risk of further overnight stay. Target is one overnight stay. An exception may be mental health patients, who may stay two nights if this is in their best interest, likely pending transfer to an appropriate unit.

These pathways will be supported by proactive escalation throughout each day (adults and children), including to BHFT at Director level, to achieve transfer as fast as possible.

ii) Primary Care Streaming

• GP available 08.00 – 23.00 7 days a week • Second practitioner from 16.00 to 23.00 7 days a week • Joint governance arrangements between RBFT and Berkshire Healthcare • Adults from October (in place) Paediatrics from December

iv) ED Frailty Service – new service commences 8th January 2018 • Frailty practitioners working in ED from 8 am to 8 pm • 7 day service • Role to identify frail elderly and support team to avoid admissions • Experts in community and admission avoidance schemes • Starts Monday 8 January 2018

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iii) Front Door Huddles & Hospital @ Night (H@N)

• In ED: 08:00, 15:30 and 21:30 huddles to assess patient volumes, clinical safety and appropriate deployment of staff, to be joined by other specialties where possible

• On AMU: 08:00 huddle to assess sick patients, early discharges and staffing; 15:00 Consultant Acute Physician with incoming POD to assess the afternoon/evening position and then move across to join ED 15:30 huddle

• H@N: 22:00 meeting to assess: overall hospital position, support required at front door, management of sick patients and allocation of ward based tasks overnight. All specialties to attend

v) Ambulatory Medicine • From November: transfer to new ring fenced unit with 5 days access to ambulatory care 10.00 – 22.00 • SOP to be used as a framework whilst new unit established. This will evolve over time. • To start with referrals will be accepted up to 19:00 and decisions will be made regarding the management of patients between 19:00 and 21:00 to enable closure of

the unit at 22:00 • Acute Physician will work across into ED as and when required to assist in decision making regarding ambulatory pathways • At weekends peripatetic ANPs to deliver this service ‘virtually’ across the front door and support same day discharge • Extended Acute Physician presence for ambulatory care until 18.00 in addition to POD • Volunteer support being sought to assist this new unit.

vi) Acute Medicine • Telephone referrals by GPs to be taken by Acute Physicians to triage to appropriate area and increase use of ambulatory pathways which will include options for

attendance the next day or direction to other ambulatory services such as hot clinics/outpatients, advice lines such as RACOP, heart failure, jaundice hotline, rheumatology flare clinic, gastro IBD clinic, ENT ARC, rapid access chest pain clinic and falls clinic

• ‘Walk in’ GP accepted patients to attend directly to new Ambulatory Medicine service • GP accepted patients arriving by ambulance to attend ED STAT bay for initial assessment and, via discussion with Acute Physician or POD/ECPOD, agree decision as

to ambulatory or AMU/specialty pathway • Closer working between Acute Physicians, ED team and POD/ECPOD to enable decision making earlier in patient pathways and to control/reduce the demand for

overnight stays/IP beds, particularly in the evening and at weekends • Developing single clerking pro forma to reduce work for junior doctors, starting with information direct from GPs • Electronic Bed requesting to get right patient in right place first time • POD/AP huddle at 15:00

vii) Acute Medical Unit / Short Stay Unit support actions 6

• Bay 5 (‘Narnia’) to remain at 9 beds and part of AMU • Nurse staffing model and case mix for using these 9 beds, additional Band 5 to free up second coordinator, however will include additional support to strengthen

staffing • Establishment of Clinical Site Management Hub in space vacated by ambulatory service to include closer working with Porters and Domestic staff • 7 day Consultant led ward rounds with additional ward round on Short Stay Unit provided by Acute Physicians • Implementation of staff’s Rapid Improvement Event requests – a number of suggestions already acted upon, further work over the winter period viii) Acute Surgery • From December: 7 day Surgical Assessment Unit (SAU) to increase direct admissions and to progress to the service continuing to 10pm during the course of the

winter (dependent on staffing) • Early decision making in patient journeys and response to escalation from ED • For patients referred from ED, as early referral as possible and specialty response @ < 1 hour or faster if possible or necessary and speedy transfer to SAU • To implement, as they develop, the use of electronic referrals from the ED, according to agreed guidance. ix) Trauma & Orthopaedics • Timely attendance at ED for Orthopaedic expected patients • For patients referred from ED, as early referral as possible and specialty response @ < 1 hour or faster if possible or necessary • Where possible additional Orthopaedic Registrar presence in ED • High volume response process to be triggered via On Call Consultant

x) Paediatric Pathways • New staffing model agreed with Observation Bay staffing now separated from ED, open 7 days a week • Streaming to Primary Care to commence in December • Operational management within ED to ensure escalation managed within department

xi) Mental Health Pathways • Access to CRHTT (Crisis Response Home Treatment Services) 24/7 – BHFT alternatives to hospital admission pathway • Collaborative and productive relationship with PMS (Psychological Medicine Service) improving mental health liaison including attendance at Daily Ops meeting to

identify patient flow issues from Observation Ward and any IP issues • Bed Optimisation Project working on both bed management (gatekeeping) and creating more capacity within PPH to facilitate better patient flow incl from front

door/Obs Ward • Weekly DTOC Monitoring with a Berkshire West System wide teleconference to drive down inappropriate delays within MH system. • Weekly Out of Area Patient S Monitoring and driving down both acute overspill and specialist placements.

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3. EFFECTIVE WARDS / IN HOSPITAL PROCESSES To ensure maximum patient flow a continued drive on the following is required:

i) Daily ward/board rounds - expediting today and planning for tomorrow: • Ideally: • AM board rounds: to identify sick patients, discharges and next steps • PM board rounds: to identify whether EDLs for the current and next day discharges still need completing and highlight this to the medical team • A strong focus on the prioritisation of:

• the sickest patients. • patients for discharge. • active progression of all other patients’ pathways. • creation of ‘ready to take’ and ‘sleep easy’ bed spaces for key patient groups (for instance NOF bed, HASU, CCU) • controlled use of side rooms, daily review and designation, supported by infection control team. • criteria based discharges, particularly for weekends. • Actions on wards to:

- follow up on actions from ward rounds, to achieve discharges as fast as possible - use of the discharge lounge as ‘the norm’. - actions overnight to enable early morning discharges and transfers to the discharge lounge (ward clock). - contact with AMU/Short Stay to ‘pull’ patient to IP from early morning (one before 10).

ii) Work towards full implementation of SAFER Bundle across all wards

Senior review daily All patients to have Anticipated Date of Discharge:and work daily on actions to achieve this Flow: discharge one patient from each ward and admit one patient before 10 Early discharge: 1/3 before 12 and 80% by 18:00, plus we need to pull more discharges into the afternoon/early evening – currently 40+ patients leaving 20:00 onwards and then challenge to fill those beds Review – next steps, Red 2 Green every day - especially to avoid over 7 day stays

• Red/Green Board Rounds – positive actions every day - reduce non clinical waits • Planned sessions with nursing and clinical teams on pyjama paralysis and 1000 days – valuing patients’ time • Internal delays discussed at ops meeting each morning & weekly review of complex pathways

iii) Next Steps on EPR/ Red & Green days • Next steps for all patients pathways are recorded on EPR with internal electronic referrals and tracking of waits

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• Use this to support Red/Green days for each patient

iv) Tracking/reducing LoS > 7 days • Targeting daily actions to avoid LoS > 7 days • Daily 7 day ‘stranded’ patient report and review, ensure all patients over 5 days are on target with their plans – expedite & escalate issues daily • 7 day stranded internal target is 230 to maintain flow • Weekly review of ward performance metrics and complex patients led by Directors of Operations and Directors of Nursing • External causes of delays will be escalated via the resilience calls and onward to Urgent Care Operational Group & A&E Delivery Board on a monthly basis for more

significant issues

v) Ward Buddies • Matrons and senior managers to support board rounds and each ward generally to help progress and unblock actions for patients • Volunteers to support wards in various ways – patient feeding, ward reception cover, portering

vi) 7 day working • Weekend Consultant ward rounds and junior team on all medical wards • Review of criteria led discharge Sat / Sun, by Ward Coordinators • Huddles at weekends to prioritise consultant work and potential discharges for Monday • Dedicated Pharmacy Discharge Team comprising of a ward based Pharmacist and a Technician available to support with urgent TTAs on a Saturday and Sunday from

11.00 to 16.00 (This is in addition to the current Saturday and Sunday dispensary service)

vii) Infection Control measures and processes: • Outbreak communications as per policy and including:

- internal staff via face to face, written comms/notices on wards and internal e mail, Round Up and Weekly Blog - external to patients and the public via website and media

• Visual management at Ops Centre to track bays/wards affected and decisions made on cleaning/opening beds/wards • Daily review of infection status on EPR by Matrons and proactive management to IC guidelines as a norm • Daily update from Infection Control Team, with IC working closely with CSMs and Daily Operations Directors to be clear on bed capacity available/closed

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viii) Outlier management • The ‘outlier buddy’ system will continue as follows:

Hunter/Lister – Rheumatology/Endocrinology Sonning – Elderly Care

Dorrell – Renal Escalated MAU Bay 5 – APs

Hopkins – Gastroenterology

• The numbers and spread of outlying patients will be kept under close review, and we will work hard to balance the numbers across the IP wards. • Outlier doctor will be recruited to support the care of outlying patients (subject to resources and availability) . The DOOs and DoNs will review the

escalation plan on a Friday each week with reference to surgical TCIs for Monday, current spread of outliers and staff on medical and surgical wards.

ix) Discharge Lounge & Battle Day Unit (BDU) Stretcher Lounge • Given the temporary location of Discharge Lounge adjacent to Battle Day Unit, joint working between the two units to achieve:

- Early/throughout the day use of Discharge Lounge as the ‘norm’ from wards - Early transfer of stretcher patients - Maximum use of Battle Day Unit to offer last day treatments from wards and avoid admission at front door

• BDU now has medical cover and medical consultants are now actively considering further opportunities for patients who may be cared for on this unit in order to shorten their LoS

• Patients may be cared for their to accommodate their last day’s care or to avoid the need for admission • Potentially CINs (4-6 hours) patients will be cared for here to assist maintain service during Cath Lab refurbishment

4. INTEGRATED DISCHARGE & PARTNERSHIP WORKING i) Discharge to Assess / Trusted Assessor/Hip Fracture Early Supported Discharge

• The current pilot will be extended across the hospital building on the success of the pilot on Hurley Ward. • Hip Fracture Early Supported Discharge (ESD) will be extended across orthopaedics / trauma / hip fragility • We will be seeking an external review of our developing arrangements with partners for the increase in opportunities to discharge to assess/trusted

assessor across the system in order to further expand these ii) DTOC reductions to reduce bed occupancy & CHS Service

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• Reading and Wokingham have committed to reduce their DTOC to 3.5% and W Berks to 5% supported by national funding. We are therefore working on a prediction of 4.2%, which if realised will be a material reduction on last year

• This is intended to release bed occupancy to increase beds available each day and roughly equates to 7 beds • In addition our project with CHS will continue – this will mean that our self funding patients and their families will continue to be benefit from support to identify

appropriate nursing and residential care in a timely manner. The LoS reduction currently being released by this initiative equates to 6 beds and has contributed to the current overall LoS reduction

iii) Redesigned Integrated Discharge Service

• Consultation has taken place over the summer to reorganise our Satellite Navigation team and the parallel Integrated Discharge Service in the community into a single Integrated Discharge Team. A manager has been appointed and will come into post during the winter period.

• As this new approach becomes established opportunities for enhanced support to all wards for patients with complex discharge needs will be developed in discussion with Matrons and Ward Sisters

iv) Community Hospital bed programme

• Work is being advanced with community partners to improve the pathways to community hospital beds in order to all beds across the system are fully utilised and accessed in a timely manner

• The output from these discussions with our community partners will be fed back into all organisations and adjusted arrangements trialled over the winter period

v) Visible system wide bed management • A project is being advanced to go live with a bed management system which will draw live data from RBH and Community units – the aim is increased visibility and

therefore a more integrated approach to the timely transfer of patients

5. FLOW MANAGEMENT & COMMUNICATION

i) Predictors and activity monitoring • Comprehensive predictor tool built into EPR, with 4 weekly review and re-profile against activity • Daily and weekly review of ambulance arrival times with monthly meeting with SCAS • GP referral times and number to be reviewed weekly • GP streaming numbers will be monitored daily and weekly • KPI dashboard will review keep metrics to enable us to ‘take the temperature’ of the hospital incl attendances, ambulatory, admissions, case mix (resus, majors,

minors, GP streaming), LoS in hospital and on discharge, 7 day patients ii) Bed capacity and escalation arrangements

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• In recognition of staffing and space challenges the Trust is adopting an approach of consolidating beds and focussing on recruitment and retention to staff these appropriately rather than attempting to open new capacity

• In addition measures to protect ambulatory and day care areas are being taken to minimise i) reduce the demands for overnight beds and ii) reduce the options to bed day care areas overnight apart from exceptional circumstances

• There will be a continuous drive to control length of stay and maintain current length of stay improvements (4.7 from 5.5) and challenge a further reduction of 0.5 days – derived from flow information from the Daily Ops meetings.

• These decisions will aim to deliver a balanced position across the Trust utilising the following options: a) Continue the flexible use of surgical capacity to support medical escalation and the need for medical outliers, taking careful account of the elective demand

requirement b) Balance the distribution of medical outliers in order to balance workloads and acuity across the medical teams c) Flex the current 12 beds closed on Burghfield and Mortimer when required: identifying patients with CRT / discharge dates for each week on Friday.

Prepare to open on Sunday pm with closure Wed pm. Plans to be agreed each Friday. d) Continue to use 9 beds only AMU Bay 5/’Narnia’ (model to be agreed) – remaining space vacated by Ambulatory service to be used to establish Clinical Site

Management Hub so will not be available to be used for escalation ** Redlands is excluded from these options in order to protect ring fenced Orthopaedic work as per Infection Control protocol ** e) ICU escalation plan agreed both internally and with ED f) Bedding day care areas only to be used in absolute extremis and authorised at Director level

• Use of up to 12 external (at Circle Reading) beds for medically stable patients with neurological or musculoskeletal conditions requiring rehab with a predicted long length of stay but with discharge destination of home and a clear anticipated discharge date. This will provide the additional benefit of taking the opportunity to test new ways or working for the future.

iii) Elective management plan • The Trust will work hard to maintain is service for elective patients, although mindful that sensible adjustments may need to be made in early January. Theatre lists

will therefore be constructed as follows: a) Treatment of clinically urgent and cancer patients b) Maximum use of Day Care beds where appropriate c) Protection of Cancer and RTT standards

• Elective admissions will continue be closely scrutinised as part of the daily Ops process and any potential decisions about the need to cancel cases will be made in

the light of the prevailing situation each day, with the aim to minimise cancellations wherever possible.

iv) Staffing plans & staffing huddles • Staffing levels and recruitment/retention issues will be kept under close scrutiny throughout the winter period

12

• Daily nursing staffing huddles will take place each day after the daily Ops Meeting • Nurse staffing levels will then be further monitored by Matrons throughout the day and Senior Duty Nurse at weekends • A further assessment of nurse staffing levels will take place late afternoon/early evening ahead of the night • Other staffing levels including medical staffing will take place at daily Ops Meeting and throughout each day • New Medical Rota Co Ordinator will maintain continuous review of medical cover/locum requirement in consultation with Senior Medical staff • On Call Manager and On Call Director will sanction locum booking over weekends and out of hours

v) Support service

• Portering and housekeeping to be constantly reviewed and escalated as required at the Operational meeting. • Portering and housekeeping supervisors will be offered the opportunity to link closely into the Clinical Site Management Hub once it is established

vi) Patient transport

• Patient transport to be booked in a timely manner and reviewed by SCAS and discussed at daily operational meeting and escalated as required

vii) Daily reports & communication tools • The Night Management report will be the key means of communication to senior staff on the hospital position at the start of each day – this gives broadly the

position across the hospital contributing factors/actions required at the start of day and moves will be made during the winter to enable ED to directly input into this report. We will work to find ways to allow the overnight ED team to input into this report prior to going off shift – which may be assisted by the us of the digital app noted below.

• The Night Management report will be used to flag the bed requirements for ED, and mostly particularly the situation regarding long waiting patients requiring early transfer to wards – Matrons will use this report as the indicator of action required at the start of the day

• Cascade bleep messages will be used at the start of the day if more immediate actions are required and throughout the day as necessary • All daily reports to be collated through daily operational meeting with exceptions prioritised • Daily escalation out to system partners will occur supported by the Directors of Operations and Chief Operating Officer • In addition a new digital app (CEM Books) will trialled over the winter to provide improved real time data about the situation in ED

viii) Daily Ops Meetings & Daily Management • To be held daily in the Ops Centre Level 3 at 09:30 and 15:30 to ensure safe organisation of the hospital overnight • This meeting will also designate the escalation status of the hospital according to the OPEL framework internally. Ward escalation and intranet will be updated

according to this designation • 17.00 handover meeting between CSMs, Daily Operations Director and On Call Manager to be held in the Clinical Site Management Hub – if required Matrons

will be asked to attend this meeting if the hospital position requires further decision making going into the evening. On Call Director may be asked to attend as well if the situation requires it

13

• The key purpose these meetings is to understand the daily situation and share problem solving to ensure patient safety and both clinical and operational issues are addressed

• Each day a senior operational manager will take the role of Daily Operations Director and will lead the Ops Meetings and keep an oversight of the day taking escalated action as required

• The 9.30 meeting is the key meeting of the day and all specialty areas and key departments are expected to attend and report their position and any issues for which they require support including any issue that might affect their contribution to the smooth running of the hospital that day – and to update CSM and Daily Operations Director if anything materially changes during the period

• The overall position of the hospital will be considered, appropriate information cascaded and agreements made on actions required • The 15:30 meeting will assess the progression of the day and further action to secure a safe hospital going into the evening and overnight. This will include an

explicit discussion to be regarding the next day’s early discharges ie a patient per ward to be discharged/transferred to the Discharge Lounge before 10:00 the next day

• Each Friday at 15.30 a weekend plan meeting will be held, with On Call Managers and On Call Directors attending – this meeting will agree the plan for the Friday overnight period and throughout the weekend. As part of this meeting the DoO/DoN will specifically agree the bed capacity/escalation arrangements.

ix) Clinical Site Management Hub • As the Medical Ambulatory Unit vacates it current location on AMU/’Narnia’ the Clinical Site Manager team will establish a new hub and operate from there, but

still closely link with the OT and Medical teams who will continue to be based in the current AMU Night Management Office • Portering and housekeeping supervisors will be offered the opportunity to work closely with the CSMs in this location

x) OOH management and escalation

• On Call and overnight/weekend hospital management arrangements are set out in the attached handbook • The commitments required of the On Call Management team will be require adjusted working hours and staff will be supported to manage their diary

commitments accordingly

xi) System wide flow management, escalation & working with partners • The Trust will apply the OPEL framework internally and ward escalation boards and intranet will be updated regularly • Regular communication with SCAS to ensure close monitoring of the hospital and system position, with the deployment of HALO support to ED when required • The work to improve bed flow between acute and community beds will go on throughout the winter period • Regular communication will take place particularly between RBH and BHFT to work in partnership throughout the period • Regular escalation will take place between RBH and all system partners with bi weekly system calls to monitor delayed patient pathways • This system escalation will move to daily when the Trust is on Opel 3 level escalation • The Trust and system partners will participate in escalation arrangement designated by NHSE/I • Monitoring of activity levels will take place daily and throughout each 24 hour period • Ambulance flows post the October introduction of ARP will be closely monitored as well as weekly review of handover times with SCAS partners

14

xii) Specific Arrangements and Service Plans 18/12-19/12 • A directory of services will be published w/c 18th December once rotas are fully completed • This directory and all rotas will be kept under close review and adjustment as needed • Diary arrangements will be adjusted during this period including the suspension of a number of key meetings to enable additional focus and support to staff to be

provided

xiii) System wide communications plan • A system wide communications plan has been developed with system partners and will be deployed throughout the period to keep patients informed regarding

options for care

xiv) Linked plans: a) Cold Weather Plan b) Flu plan c) Infection Control Policy d) Mortuary Capacity Plan

6. QUALITY & KPI MONITORING i) KPI Dashboard

TO BE ADDED

ii) Quality Indicator Dashboard

TO BE ADDED

iii) Clinical Outcomes incl Harm assessment TO BE ADDED

iv) RBH Clinical Oversight Board • Implementation of this Board is intended to give additional support throughout the winter period in order that the situation in regard to attendance/admdisison

volumes and any issues of concern regarding staffing, quality and safety and any risk to clinical outcomes is understood and addressed • Members of this group will include COO, MD and DoN together with senior Care Group leaders. A process for raising concerns to this Board will be implemented

15

• This Board will also monitor Weekly ED performance and will examine the reasons for breaches and agree improvement actions. • Improvement actions will either be those for immediate attention or to be fed into the RBFT Front Door and Patient Flow improvement Programme which focuses

on both the medical and surgical pathways.

v) West Berks A&E Delivery Board • System wide plan and internal RBFT plan will be kept under scrutiny by this Board and actions agreed with partners as required

7. APPENDICES Predictor model Bed capacity plan On Call Winter Handbook Opel Escalation Policy Cold Weather Plan Flu Plan Infection Control Policy Internal Standards Acute Medicine / Ambulatory Care SOP ED Escalation Plan Mortuary Capacity Plan

16

Title: Nursing Skill Mix Review Agenda item no: 8 Meeting: Board of Directors Date: 29 November 2017 Presented by: Caroline Ainslie, Director of Nursing Prepared by: Joan Potterton, Assistant Director of Nursing Purpose of the Report This report presents the annual Ward Nursing Skill mix review based

on data collected in July 2017. It outlines the methodology used and presents the findings along with the proposed establishments. The paper also includes a supplementary paper in appendix 3 that outlines the skill mix for non-ward areas that are subject to differing models of staffing than standard ward based nursing skill mix. Maternity skill mix is outlined in appendix 4.

Report History Workforce Committee 30 October 2017


The Board are asked to note the report and agree the proposed ward skill mix.

Assurance Information Discussion/input Decision/approval x

Resource Impact:











1 Background

1.1 Royal Berkshire NHS Foundation Trust has a duty to ensure staffing levels are

adequate so that our patients are cared for by appropriately qualified and experienced staff in safe environments. This right is enshrined within the NHS constitution 2015 and Health Act 2009, which make explicit the Board’s corporate accountability for quality.

1.2 Demonstrating sufficient staffing is one of the essential quality and safety standards

required to comply with the Care Quality Commission (CQC) regulation.

1.3 In November 2013 the National Quality Board (NQB) issued guidance to optimise nursing, midwifery and care staffing capacity and capability (How to ensure the right people, with the right skills, are in the right place, at the right time. A guide to nursing midwifery and care staffing capacity and capability, 2013).

1.4 The publication sets out 10 expectations of NHS Providers and Commissioners,

expectation 3 of the guidance recommends the use of evidence based tools to inform decisions about actual staffing levels.

1.5 In July 2016 the National Quality Board (NQB) issued updated guidance and expectations for nursing and midwifery staffing. This updated guidance continues to support the need for a triangulated approach to staffing decisions based on patient’s needs, acuity and risk, using evidence-based tools and triangulated with professional judgement. The three key expectations are themed as follows:

Expectation 1 Expectation 2 Expectation 3 Right Staff 1.1 Evidence-based

workforce planning 1.2 Professional

judgement 1.3 Compare staff with

peers

Right skills a. Mandatory training,

development and education.

b. Working as a multi-professional team.

c. Recruitment and retention

Right Place and Time 3.1 Productive working and eliminating waste. 3.2 Effective deployment and flexibility 3.3 Efficient employment and minimising agency

2 Context and Drivers 2.1 On 14th July 2016 NHS Improvement wrote to the Trust advocating an approach to

deciding clinical staffing levels based on patients’ needs, acuity and risks, which is monitored from ‘ward to board’. The letter highlights that The Care Quality Commission also supports this triangulated approach to staffing decisions, rather than making judgements based solely on numbers or ratios of staff to patients. They have also made it clear that there is a need to manage staffing within our triple aim which includes managing within the funds available.

2.2 Using care hours per patient’s day, combined with outcome measures for patients, workforce data and financial indicators is also advocated to get a rounded view of staffing so that decisions achieve the best possible, safe and effective care for patients.

2.3 The last formal skill mix review undertaken at the Royal Berkshire Foundation Trust was in July 2016.

2.4 The National Quality Board (2016) updated guidance advocates an annual strategic

staffing review to be agreed by the Trust Board so the next review will be in July 2018.

3 Methodology 3.1 Three methods of modelling ward establishments were used :-

• The Shelford Group Safer Nursing Care Tool (SNCT, 2013) to establish patient acuity. SNCT scores are periodically validated by senior nurses. The average scores for the past 12 months have been used to take account of seasonal variation.

• CHPPD data. • Professional Judgement – the senior nursing team convened a structured

meeting with each ward sister/charge nurse and matron which enabled a discussion of professional judgements on staffing requirements, deployment of the staffing resource, factors impacting on staffing such as ward/department geography and the impact on quality including patient feedback, safety and effecting care indicators within the ward quality dashboards.

3.2 This meeting afforded the opportunity for engagement with ward sisters/charge nurses and enabled scrutiny and challenge of assumptions related to specialist requirements. As part of the discussion an opportunity was also taken to discuss factors that are thought to affect staff retention.

3.4 When considering the proposed staffing levels the following principles were applied: • Ideally wards should be no larger than 30 beds. The optimum ward size is

between 26-28 beds. • There should be a supervisory Band 7 on every ward as detailed in the

Francis recommendations and highlighted in the July 2016 NQB guidance as ‘essential in enabling ward managers to discharge their supervisory responsibilities and ensure standards are maintained’.

• Skill mix (ratio of registered nurses to health care assistants) should be between 60:40 and 70:30.

• On wards with more than 20 beds there should be a senior nurse of Band 6 or above in charge on each shift.

• An uplift of 22% into ward budgets to allow for annual leave, sickness and absence, other leave and training and development. This is broken down into 16% annual leave, 3% sick/other leave and 3% training. Benchmarking with other trusts shows an uplift of between 20 and 25%.

3.5 The review also draws on observations of the quality of care provided over the past 12 months using the quality measures of: Friends and Family test, formal complaints, avoidable serious harm falls and avoidable hospital acquired grade 3/4 pressure ulcers.

3.6 In line with the July 2016 guidance data on compliance with mandatory training is

also included.

4. Findings

4.1 General findings: • A number of wards have been reconfigured since the last skill mix review in

July 2016. • In order to maintain safe patient care a number of beds have been closed in

elderly care and some surgical wards on and off since March 2017. • Following the utilisation of an evidenced based triangulation methodology the

review proposes the need for an overall peer reviewed WTE establishment of 877.70 WTE. The funded establishment currently sits at 847.33 WTE.

• The difference between proposed establishment and the funded establishment is 30.37WTE. With the exception of AMU this equates to a small number of WTE staff per ward.

4.2 One to one care: • One to one staffing is regularly required to provide safe care for patients with

raised acuity due to confusion or those with severe mental ill health. Usage across the trust is approximately 8.5 WTE per month; highest use is in ED and paediatrics.

• Expenditure for 1:1 care is not included in the budgeted establishment and is unpredictable to plan.

• The use of the Care Crew in elderly care has been a successful initiative and mitigates some of the 1:1 usage in elderly care.

4.3 Acuity is higher in urgent care wards than it was when the last skill mix review was

done in July 2016. Acuity has reduced in some of the planned care and elderly care wards but this is because beds have been closed on these wards on and off since March 2017. When considering staffing requirements acuity does not take account of the requirement to have a supervisory ward sister/charge nurse. It should also be noted that the acuity tool does not take into account specific demands of intravenous drug administration which has been highlighted in some areas such as Sidmouth and Whitley ward.

4.4 The skill mix (ratio of registered nurses to health care assistants) is largely

acceptable with most wards having a skill mix in the range of 60/40 – 70/30. Some of the elderly care wards have higher ratios of unregistered staff. In some of these wards there are band 4 Assistant Practitioner roles and whilst these staff are still unregistered workforce they work at a higher skill level than HCAs.

4.5 Turnover and vacancies

• Turnover of registered nurses and midwives over the past 12 months is 14.55% which is better than last July when it was 16.1%. RBH turnover is higher than other acute large trusts indicating the current challenges we face in this workforce.

• National data illustrates that turnover rates are slightly higher in London and the South than in the Midlands and North of England.

May 2017 Turnover Leavers – 12 months

Leavers Rate - 12 months

Acute – teaching Oxford University FT 595 15.09%

Acute - Large

Hampshire Hospitals FT 220 12.69%

Frimley & Heatherwood FT 335 12.78%

RBH FT 245 14.55%

• Vacancy rates across inpatient wards range from 0.64% to as high as 55%.

The majority of the vacancies are at band 5. The total number of vacancies has decreased slightly since the last review but the number of registered nurse vacancies has increased. Vacancies are only partially off-set by use of bank, agency staff and overtime. There has been a reduced use of agency with a corresponding increase in use of NHSP.

Registered Nurse Vacancies

Registered and unregistered vacancies

NHSP Agency TOTAL

August 2015- July 2016

July 2016

288

July 2016

343

£1,551,440 £4,478,605 £6,030,045

August 2016 – July 2017

July 2017

323

337

£2,810, 940 £3,535,996 £6,346,936

• Care Group Directors of Nursing receive twice a day staffing reports from

Optimise and hold safe staffing ‘huddles’ with the matrons to review staffing levels. In addition there is a senior duty nurse at weekends to manage staffing. Staff are effectively deployed across wards by, if necessary, moving staff between wards to spread and manage the risks across the organisation.

4.6 Care Hours Per Patient Day (CHPPD)

• From 1st May 2016, CHPPD has been reported monthly to NHS Improvement through UNIFY.

• The CHPPD is calculated by taking the actual hours worked (split into registered nurses/midwives and healthcare support workers) divided by the number of patients occupying beds on the ward at midnight.

• It should be noted that CHPPD does not take into account patient acuity, ward environmental issues, patient turnover or movement of staff for short periods.

• CHPPD is skewed by other factors particularly in planned care- staffing for the General Surgical unit includes staffing for Surgical Assessment Unit (SAU) which is closed at night and the unit also accommodates a significant number of day cases that would not be included in the patient count at midnight. Staffing for Dorrell, Sonning and Hopkins on optimise where the CHPPD data is extracted from includes staffing for the day units on these wards and therefore patient count at midnight does not reflect the staffing that is required for the day cases.

• CHPPD included in this report provides benchmarked data against national and peer data. The most up to date comparative data available on the Model Hospital site is for April 2017.

4.7 Clinical Indicators

• Friends and Family has been calculated as the average score for each ward over the 12 month period August 2016 to July 2017. The scores are very positive with thirteen wards attaining scores above 99%.

• There is a correlation between the higher numbers of falls and avoidable grade 3 &4 pressure ulcers on wards with the highest number of staff vacancies.

4.8 Staff retention

On discussion with wards sisters/charge nurses the following are considered to affect staff retention: • The ability to take breaks. Most wards now do 12 hour shifts; it is therefore

imperative that staff can take a break. • The lack of an area/space to take a break if they get one in some wards. • The ability to take annual leave at times that staff can choose. • Being moved off their ward to cover staff shortages on other wards. • The application of sanctions for non-compliance with mandatory training and

appraisal and how inequitably this is applied. • Conflicting priorities on ward routine, such as timings of ward rounds.

5. Conclusion for wards and specialist areas

• The skill mix review has identified a shortfall of 30.37 WTE in ward areas; with the exception of AMU this equates to a small number of WTE per ward. In specialist areas a shortfall of 20.67 WTE has been identified – please see narrative in appendix 2 and 3 for detailed explanation.

• It has been identified that there may be an opportunity for some wards to explore new ways of working and utilise the current establishment differently by, for example, reviewing rosters, considering changing the skill mix between registered and unregistered staff, roll reconfiguration, better integration with therapy staff and more utilisation of volunteers at mealtime.

• There may also be an opportunity to work with pharmacy to consider different ways of working to find a more efficient way of administering intravenous medicines on wards where there is an identified high usage of IV medicines.

• Whilst alternative skill mix and roles, and alternative ways of working may address

the deficits in some wards the senior nursing team make the following recommendations:- An uplift of 2.65 WTE registered nurses in ASU to enable 1 nurse per bay at

night. An uplift of 2.76 WTE in AMU to allow an additional co-ordinator 5 days per

week on the day shift and an additional HCA each morning and at night. An uplift of 4.87 WTE in Paediatric ED to allow for a band 7 ED sister and an

additional 7.5 hr shift to be worked 14:00 – 22:00 by a band 5 and an increase in the play team at band 3 to give additional support to the trained staff.

6. Recommendations

• An uplift of 2.65 WTE registered nurse in the Acute Stroke Unit • An uplift of 2.76 for AMU • An uplift of 4.47 WTE in paediatric ED • Where possible look at reconfiguration of shifts and review of skill mix to include

role substitution. • Explore different ways of working with pharmacy. • Continue to monitor staffing and quality indicators across all wards. • Continue to recruit to establishment across all wards • Continue focused work on retention and career pathway development and

development of new roles.

7. Attachments

The following are attached to this report:

Appendix 1 – Skill mix review template July 2017

Appendix 2 – Narrative

Appendix 3 – Skill mix for specialist areas

Appendix 4 – Maternity Skill mix

Appendix 1 – Skill mix

Gap Workforce

CHPPD RBH

CHPPD Peer

CHPPD National

< 50%Adelaide Oncology 23 36.3 1.60 28.13 77.49% 36.8 34.59 35.37 1.43 6.34 16.8 7.77 1.60 79/21 -0.50 100% 3 0 0 92.3Dorrell + EDBU Ophthalmology 21 30.64 1.30 22.42 73.17% 31.76 23.61 25.94 5.82 8.32 15.91 9.12 1.51 70/30 -1.12 99.30% 2 0 0 97.5Trauma Unit Trauma 30 44.5 1.50 37.98 85.35% 47.91 34.40 36.59 11.32 5.39 7.6 7.3 1.60 56/44 -3.41 98.40% 5 0 1 77.6Hopkins + Greenlands Urology

2333.64 1.36 22.7 67.48% 35.3 27.05 30.00 5.30 8.69 5.72 7.06 1.53 65/35 -1.66 98.60% 0 0 0 90.3

Sonning ( Ward only) Gynae

1520.2 1.34 20.07 99.36% 20.29 8.40 10.93 9.36 11.34 8.9 8.23 1.35 67/23 -0.09 99.60% 1 0 0 83.6

Redlands Elective orthopaedic 30 32.52 1.08 26.52 81.55% 32.79 19.77 21.36 11.43 6.89 7.6 7.3 1.09 60/40 -0.27 99.51% 1 0 0 95.4General surgical Unit and IF Beds General Surgery

4365.7 1.50 54.11 82.36% 64.9 52.85 59.91 4.99 10.8 7.59 7.4 1.50 67/33 0.80 99.70% 3 0 0 91.8

SAU 5 9.5 9.5 72/23 0.00 100%Totals 190 273.00 9.68 211.93 279.25 200.67 49.65 10.18 -6.25 15 0 1

Loddon Respiratory 26 40.2 1.55 26.9 66.92% 40.20 37.96 35.74 4.46 7.26 7.07 6.29 1.55 61/39 0.00 99.32% 2 0 0 88.8

Kennet Respiratory 26 40.2 1.55 33.2 82.59% 40.2 41.27 40.1 0.10 7.05 7.07 6.29 1.55 61/39 0.00 99% 6 1 0 100Sidmouth Gastro 28 39.06 1.40 31.25 80.01% 40.22 41.74 39.64 0.58 5.73 5.70 6.06 1.44 66/34 -1.16 99.10% 2 1 0 95.3Short stay unit Acute medicine 22 30.6 1.4 26.1 85.29% 35 31.98 27.44 7.56 no data no data no data 1.59 55/45 -4.40 99.70% 2 1 0 85.1AMU Acute medicine 39 + 4HMU 85.1 2.0 58.1 68.27% 92.1 NA NA no data no data no data 2.14 64/36 -7.00 99.20% 7 0 0 83.7Whitley Cardiology 28 39.17 1.40 31.48 80.37% 40.6 42.15 40.35 0.25 6.13 7.58 8.01 1.43 62/38 -1.43 98.50% 5 1 0 91.4Totals 173 274.33 5.89 207.03 288.32 195.10 12.95 -13.99 24 4 0

Burghfield Elderly Care 28 39.37 17.62 44.75% 44.70 28.36 31.38 13.32 6.06 6.53 6.75 1.60 54/46 -5.33 98.05% 5 1 1 80.7Caversham Neuro rehab 12 18.94 17.78 93.88% 18.85 20.69 20.89 -2.04 6.47 6.04 6.75 1.57 60/40 0.09 100% 0 1 0 89.4Emmer Green Hip Fragility 24 37.66 34.67 92.06% 37.44 35.08 37.96 -0.52 6.62 6.53 6.75 1.28 74/26 0.22 98.77% 1 0 1 85.8Hurley Elderly Rehab 30 41.44 34.00 82.05% 41.99 32.39 31.58 10.41 7.69 6.53 6.75 1.4 45/55 -0.55 100% 1 3 1 87.8Castle Rheum 29 39.95 35.29 88.34% 39.26 43.01 42.04 -2.78 6.20 5.75 6.03 1.35 64/36 0.69 98.90% 4 3 0 88.5Mortimer Elderly Care 28 41.2 26.74 64.90% 44.7 26.93 33.91 10.79 6.72 6.53 6.75 1.60 54/46 -3.50 95.48% 6 2 3 85.4Woodley Elderly Care 28 39.37 35.33 89.74% 41.31 45.70 44.93 -3.62 5.62 6.53 6.75 1.48 58/42 -1.94 97.19% 2 1 0 86Victoria 22 42.07 28.21 67.05% 41.88 35.39 34.71 7.17 7.34 7.74 7.13 1.90 66/34 0.19 96.62% 2 1 0 85.2Totals 201 300.00 229.64 310.13 267.55 32.73 -10.13 21 12 6

TRUST TOTAL 564 847.33 648.60 877.70 -30.37 60 16 7

PLANNED

Staff in post

Current WTE/bed

Current Staffing

Compliance with Stat & Mand training

Avoidable G3/4 Pressure Ulcers

WTE/ bed Skill Mix

Variance between

professional judgement and curent

budget

Peer reviewed

Professional Judgement

(WTE)

SNCT WTE - July

2017

Carter bencmarking - April 2017SNCT Mean

average over 12 Months

NETWORKED

FFT Complaints

Falls resulting in serious

harm

Clinical IndicatorsModelling methods

CARE

GRO

UP Ward Specialty Beds

Funded Establishment

Difference between

Professional Judgement &

12 Months Mean SNCT

(WTE)

Proportion staff in post

(%)

URGENT

Appendix 2- Narrative

Urgent Care

Respiratory wards- Lodden and Kennet

The funded establishment for Kennet and Loddon is 40.20 WTE this aligns with professional judgement and closely to SNCT.

Acute Medical Unit

The funded establishment for AMU is 85.1 WTE. Professional judgement shows a need for 92.1 WTE. This is a large ward of 43 beds consisting of 5 bays and a HMU of 4 beds. The increase in establishment would support the requirement for a second co-ordinator on the day shift (Monday-Friday) which is felt necessary to manage flow and ensure staff get breaks. An additional HCA on a short shift each morning and at night would allow one HCA per bay and the HMU.

Short Stay Unit

The funded establishment for SSU is 30.6 WTE, this aligns closely with SNCT 31.98 and Professional judgement of 35 WTE. Although it has been identified that an additional HCA would be ideal it is recognised that the current staffing levels are adequate and the increase is not affordable.

Whitley The funded establishment for Whitley is 39.17 WTE, SNCT shows a requirement for 42.15 WTE. Professional judgement recommends an establishment of 40.16 WTE for a bed base of 28. This takes into account the heart failure service being relocated off the ward and an adjustment in the total number of staff on per shift on a late by amending the requirements of RN’s to HCA’s. 1 RN from Whitley supports the Heart Failure ambulatory service at weekends on JSU. The professional judgement assessment of the staffing reflects the additional registered nurse roles including monitoring of the telemetry, providing cardiac advice (this was previously not being provided on lower staffing levels), multiple IV’s (due to the endocarditis and heart failure patients) and the planned cardiac procedures in the afternoon. As the increase identified is small and the ward is not currently up to establishment no increase is recommended. This is one of the wards where alternative ways of working could be explored with pharmacy. Sidmouth The funded establishment for Sidmouth is 39.06 WTE, SNCT shows a requirement for 41.74 WTE. Professional judgement recommends an establishment of 40.22 WTE which includes a cost beneficial skill mix adjustment.

The professional judgement assessment of Sidmouth’s patients was felt to be similar to Whitley’s with their own speciality extended skills (e.g. care and removal of drains, high amount of step downs from ICU). It was recognised that where patients required a nurse transfer to a high monitoring unit or endoscopy this time was not reflected in the review, on average there will be 2-3 a day. The number of patients that are of a higher risk due to detox but not requiring 1:1 was also not felt to be captured appropriately. The Ward Manager reported that Sidmouth would benefit from having 1 extra RN on the long day Monday to Friday to support endoscopy transfers, patients stepping down from HMU/ ICU and staff getting adequate breaks and finishing on time. As the increase identified is small and the ward is not currently up to establishment no increase is recommended. This is one of the wards where alternative ways of working could be explored. Networked Care Elderly Care Wards, Emmer Green, Mortimer, Burghfield, Woodley. The funded establishment across all the elderly care wards shows a difference with respect to professional judgment. This is further complicated by the high vacancy factor and not always achieving the agreed skill mix. The elderly care ward managers have agreed that they would like to trial a hybrid model of shift patterns including both long and short days to aid retention and encourage recruitment. In addition role substitution, staff reconfiguration and skill mix will be reviewed to provide improved coverage. The implementation of the medical support worker over this last year period has shown to be invaluable. Hurley/ Hurley Lodge Hurley is a rehabilitation ward which facilitates a fast turnaround on complex discharges and encourages patient flow through the hospital. Since September 2016 an additional 8 beds (Hurley Lodge) for patients requiring nursing care has been opened. Hurley Lodge patients no longer require medical care. The staffing level currently is still appropriate for the ward area however there appears to be a short fall during mealtimes whereby an additional 0.5 WTE requirement and additional volunteers will be considered. Hurley ward is consistently escalated by one bed but this has been subsumed into the existing establishment. Castle The speciality mix of patients on this ward is extremely diverse and is primarily used as a general acute medical ward. This leads to complex and high acuity patients being moved there as often these types of patients are not suitable to be moved to speciality specific wards. This has led to an increasing complexity in delivering nursing care with patients that are challenging in both their acuity and behaviours. This is evidenced in the acuity scores for Castle. The funded establishment is 39.95 WTE; SNCT shows a requirement for 43.01 WTE and professional judgement 39.26 WTE. Castle Ward also has 7 side rooms. It should also be noted that Castle is the highest scoring department in the organisation in terms of the complexity of the pharmacology used for the patients. Professional judgement indicates that the funded establishment is currently able to provide continuous safe and effective care with a movement of skill across the 24 hour period and the recent addition of a medical support worker.

Caversham Caversham is a 12 bedded neuro-rehabilitation unit and cares for a cohort of patients who are extremely challenging and difficult to manage. The layout of the ward also proves to be challenging, due to its U shape and the 5 (2 to 4 bedded) bays. The ward does take patients with a tracheotomy but due to the fact that there are only 2 trained nurses at any one time, this has been restricted to one patient. The current SNCT review reflects a slight shortfall to the budgeted establishment; however, professional judgment shows there are periods during the morning when the patients are away from the ward undergoing therapy. It is therefore felt that by engaging the therapists in the morning routine the early untrained could be moved to a middle shift. The ward sister is not supervisory in this skill mix. The ward is almost fully recruited to. Victoria Ward Victoria Ward is a 22 bedded Renal/general Medical Ward. It is also the point of contact for all renal patients, on all modalities (1041 patients). The funded establishment for Victoria ward is 42.07 WTE, SNCT shows a requirement for 35.39 WTE, and professional judgement agreed with the ward manager identified 41.88 The SNCT does not reflect the complexity of Victoria ward and the daily support it provides for the Hospital and the acute Berkshire wide renal service. This is further compounded by the acute haemodialysis support the renal team delivers to Wexham Park. These transferred patients are predominantly acutely unwell and require 1-1 nursing care until the initial haemodialysis session is completed. A drop-in service is also available for peritoneal dialysis patients that have suspected peritonitis and are treated in Victoria treatment room. There is currently no out of hours dialysis service but there is a plan for all nurses to be trained in haemodialysis so that there is always a nurse available on every shift. By reconfiguring the WTE the night shift can be increased by 1 x WTE to enable support for patients in outlying wards requiring renal intervention. . Planned Care

Adelaide

The establishment is in line with professional judgement however more than SNCT .This disparity can be attributed to the additional requirements of Charlotte Starmer Isolation Unit (CSU) – This consists of 6 positive pressure side rooms where patients are treated for acute Haematological conditions such as Neutropaenia. Stem cell transplantation now also takes place in CSU.

The National Haematology Outcomes guidelines require that for every two Neutropaenic patients there should be one trained nurse. During early stages of stem cell transplantation a ratio of 1-1 is required. This additional staffing formed part of the transplant business case with funding received from networked care to cover this requirement.

Dorrell

The funded establishment for Dorrell and EDBU is 30.64 WTE; SNCT shows a requirement for 25.94 WTE (for the ward only). Professional judgement shows a requirement of 27.58 for the ward and 4.7 WTE for the EDBU (31.76 WTE). The gap in resource can be managed through flexing staff between the ward and EDBU and through summer de-escalation.

Trauma Unit

The funded establishment for the Trauma Unit is 44.5 WTE; the SNCT shows a requirement for 36.59 WTE. However this is based on 24 beds (therefore 1.5 nurses per bed) not 30 as the acuity tool has not captured the 6 side rooms on Heygrove. Professional judgment shows a need for 47.91 WTE. Reconfiguration of the admin and clerical establishment would allow for the development of a medical support worker role, this would help to offset some of the gap in resource.

Hopkins

The funded establishment for Hopkins (including Greenlands OPD and Admission Suite) is 33.64 WTE. SNCT shows a requirement for 30 WTE for the ward. Professional judgement shows a need for 31.5 WTE for the ward and 3.8 WTE for Greenlands (35.3 WTE). This gap in resource could be managed through weekend de-escalation and summer closures.

Sonning

The funded establishment for Sonning is 20.2 WTE. Professional judgement shows a close alignment to the funded establishment. SNCT shows a need for 10.93 WTE. This disparity is due to the number of day cases that go through the ward which is not picked up by the acuity tool.

Redlands

The funded establishment of 32.52 WTE is in line with professional judgement of 32.79 WTE, however more than SNCT would suggest. This disparity is due to the increased number of orthopaedic day cases that go through the unit which is not picked up by the acuity tool. The WTE of 1:08WTE per bed represents a lean establishment for the specialty.

General Surgery and SAU

The funded establishment for the General Surgical Unit and SAU is 75.2. SNCT shows a requirement of 59.91 WTE for the ward. Professional judgement shows a close alignment to the funded establishment with a requirement of 64.9 for the ward and 9.5 WTE for SAU (74.4WTE). RBH has no surgical HDU and provides bariatric and intestinal failure specialist services. Both of these factors increase staffing requirements

Appendix 3- Skill mix review for specialist areas to include Emergency Department, Intensive Care Unit, Acute Stroke Unit, Coronary Care Unit, Neonatal Unit and Paediatric wards. 1.0 Background 1.1 Specialist areas as outlined above are subject to different models of staffing than standard Ward Based Nursing Skill Mix.

1.2 Specialist areas were last formally reviewed in 2015. This paper provides an update on the schedule of review of those areas and presents the findings along with the proposed establishments.

2.0 Methodology

2.1 Where there are National Guidelines available these were used alongside professional judgement.

2.2 Structured meetings were held with the department sister, the matron for the area and the senior nursing team. This meeting afforded the opportunity for engagement and discussion around individual factors effecting the skill mix and enabled professional challenge to take place. The proposed skill mix for each ward/unit was agreed at this meeting. 3.0 Findings 3.1 Skill mix for the Neonatal Unit and paediatric wards is correct. 3.2 A short fall has been identified in the following areas- see narrative below for explanation in each area. Acute Stroke Unit – 9.59WTE Coronary Care Unit – 2.36WTE Emergency Department – 3.85WTE Paediatric Emergency Department – 4.87 4.0 Recommendation 4.1 There needs to be an uplift of 2.65 WTE in the Stroke Unit to allow for a registered nurses in each bay at night and an uplift of 4.87 WTE in Paediatric ED.

1. Emergency Department 1.1 Methodology. Professional Judgement has been used to establish skill mix. 1.2 Staffing establishment requirements

WORKFORCE

80.5RN (includes 1 x Prac Educator and 1 x 8A) 12.20 HCA. 10.20 RN (ENP)

Total 99.05 82.29 83.08% 102.9 -3.85 93.75 35 0 85.47

Complaints

CURRENT STAFFING

Variance between professional

judgement and current funded establishment

Staff in post

Falls resulting

in serious harm

MODELLING METHODS

Compliance with Stat and Mand

training

Current Funded Establishment

Peer reviewed professional judgement (WTE)

Proportion staff in

post (%)

CLINICAL INDICATORS

FFT Adult

1.3 Conclusion Staffing establishment is currently 99.05 WTE. The Observation ward is currently staffed with 1+1 for 8 bedded patients with a patient mix of mental health patients and elderly so a complex mix to manage. Further to the beds are ambulant patients waiting for investigation results prior to being discharged. The difference between professional judgement and actual establishment reflects the need to increase the resource in the Obs bay. The department also uses an additional 5 WTE (approx.) per month in one to ones.

2. Paediatric Emergency Department 2.1 Context The Paediatric Emergency Department is staffed by the Paediatric nursing team. The team is under constant pressure in a busy department with a high throughput of patients. Currently, there are two trained nurses on any one shift. If a patient is moved to resus, one of the trained nurses leaves the main department to go with them, leaving only one trained nurse. This causes a delay in flow due to the remaining nurse being unable to triage and having to prioritise her current patients. In such a small team it is difficult to release staff for professional development and covering sickness is challenging – this lowers morale and staff retention rates. 2.2 Methodology

The RCN BEST tool was used in order to map activity levels to staffing (see below). At the peak of the day (midday) the tool suggests the department requires 14 staff when they are currently staffed to 2.8wte.

The number of patients that attend the department are approximately one third of the total ED attendances as demonstrated by the graph below.

0

50

100

150

200

250

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17

Aver

age

atte

ndan

ces p

er m

onth

Num

ber o

f att

enda

nces

per

mon

t

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17Paed 2216 2561 2266 2483 1831 2421 2457 2586 2290 2208 2151 2529 2374 2534 2429 2371Adult 6353 6945 6604 7086 6946 6699 6798 6663 6948 6950 5961 6851 6906 7328 7136 7326Adult Avg Attends 212 224 220 229 224 223 219 222 224 224 213 221 230 236 238 236Paed Avg Attends 74 83 76 80 59 81 79 86 74 71 77 82 79 82 81 76

Adult and Paediatric Emergency Department Attendances by Month

2.3 Staffing establishment requirements

WORKFORCE

Paediatric ED

Band 6 = 5.52 Band 5 = 11.22 Band 4 = 1.8 Band 3 =4.19

Band 6 = 5.52 Band 5 = 5.2 Band 4 = 0.8 Band 3 = 4.99

Band 6 = 100% Band 5 = 37.5% Band 4 = 44% Band 3 = 119%

Band 7 = 1.0 Band 6 = 5.52 Band 5 = 12.58 Band 4 = 1.8 band 3 = 6.7

Band 7 = -1.0 Band 6 = 0 Band 5 = -1.36 Band 4 = 0 Band 3 = -2.51 96.50% 2 80.54

Total 22.73 16.51 27.6 -4.87

Staff in post

MODELLING METHODS

Compliance with Stat and Mand

training

Current Funded Establishment


Proportion staff in post (%)

CLINICAL INDICATORS

FFT Complaints

CURRENT STAFFING

Variance between professional

judgement and current funded establishment

The increase of 4.87 would allow for a band 7 ED sister and an additional 7.5 hr shift to be worked 14:00 – 22:00 by a band 5 and an increase in the play team at band 3 to give additional support to the trained staff.

2.4 Conclusion

There is a need for an additional 4.87 WTE.

3. Intensive Care Unit 3.1 Methodology Guidance from the NHS Core Standards for Adult Critical Care (2016) recommends a minimum of 1 to 1 nursing ratios for level 3 patients and 1 to 2 for level 2 patients to deliver direct patient care. In addition it is recommended that there is a clinical co-ordinator; if the unit is greater than 10 beds an additional co-ordinator is required. It is also required that the unit has a dedicated lead nurse and practice educator and that staff new to the unit have a period of supernumerary status. Guidelines have been triangulated with peer reviewed professional judgement. 3.2 Staffing establishment requirements Establishment based on 12 level 3 beds that can be flexed to a mixture of level 2 and 3 (15 beds). The staffing levels excludes separate funding to cover various clinical support services which includes RaCI, Bereavement, ICCA, Technicians, and TVCCN Lead Nurse and Projects (Research)

WORKFORCE

Based on 11.5hr shifts =4.30 nurses per bed = 60.2 plus 22% = 73.44WTE (includes x 2 co-ordinators per shift)Plus I x band 8a lead Plus 1.5 Practice Educator 2 WTE to enable supernumerary status of newly qualified staffTotal = 77.94

7 x 24hrs = 168 divided by 37.5 = 4.48 nurses per bed x 14 (12 x level 3 beds plus 2 x co-ordinator) = 62.72 plus 22% = 76.51WTE

Plus I x band 8a lead Plus 1.5 Practice Educator 2 WTE to enable supernumerary status of newly qualified staffTotal = 81WTE

12 level 3 which can flex to a mixture of level 2 and level 3 77.4 64.21 82.96% 77.94 81 -3.06 26.93 25.3 26.6 0.54 1 0 0 96.22

ComplaintsCompliance with stat and mand training

MODELLING METHODS

No of bedsCurrent Funded

Establishment

Peer reviewed professional judgement

(WTE)

NHS Core Standards for Critical Care 2016

G3/4 Pressure

UlcersCHPPD RBH

CHPPD Peer

CHPPD National

Difference between


National Guidelines

Proportion staff in

post (%)

CLINICAL INDICATORSCURRENT STAFFING

Variance between

professional

judgement and

current budget

Staff in post

Falls resulting

in serious harm

Carter Benchmarking

FFT

3.3 Conclusion Staffing Intensive Care on two sites adds challenges to staffing the unit by reducing flexibility. There is often a requirement for a co-ordinator on both sites. The recommended staffing establishment of 77.94 WTE, if fully recruited to, provides care in accordance with Core Standards. However, the unit has a vacancy of 17%. One to one care for level 3 patients is generally maintained by, when necessary, not providing a transfer/second co-ordinator nurse and by taking staff off clinical support services. This has a negative impact on clinical support services as they are funded separately. Temporary nursing staff are utilised as required to provide safe care. 3.3 Recommendation

Continue to recruit to vacancies and monitor staffing levels.

4. Acute Stroke Unit 4.1 Context In 2010, stroke centres that were able to offer CT scanning and thrombolysis treatment on a 24/7 basis were given national designation of hyper-acute stroke units (HASU).

The RBFT has been a designated HASU since 2010 and in 2013 was recognised as a centre of excellence for thrombolysis and in the latest SSNAP data has been found to be the fastest thrombolysing centre in the UK

The National Clinical Guidelines for Stroke recommend staffing levels for both Hyper Acute Stroke Units (HASU) and Acute Stroke Units (ASU).

4.2 Methodology

The National Clinical Guidelines for Stroke (2016) were used to calculate the total number of staff per bed required in both the HASU and the ASU. The ACUITY of patients was not measured for this skill mix review due to the nature of the Acute Admissions, which would indicate using a higher ratio (SNCT).

The National guidelines were triangulated with professional judgement which took into account the physical environment and utilisation of nurses who provide the thrombolysis service. Care Hours Per Patient day has not been used as the comparative data only provides comparison with an acute medical ward. The National Clinical Guidelines for Stroke recommend provision of 2.9WTE nurses per bed for HASU with an 80:20 trained to untrained skill mix and provision of 1.35WTE nurses per bed with 65:35 skill mix for ASU. 4.3 Staffing establishment requirements The recommended staffing establishment is based on a bed base of 6 HASU, 22 ASU beds and thrombolysis service requiring 5.5 WTE RNs and 1.00 TIA HCA (currently 0.64 WTE- not sufficient to cover TIA clinics 7 days / week). There are 2 additional beds on the ward that are used for escalation that are not currently budgeted to staff and are rarely un-occupied. This presents a cost pressure.

Professional judgement of HASU using National guidance at a ratio of 2:1 demonstrates the requirement to increase the Long day by 1 RN and the night shift by 2 RN (3 RN 24/7 for 6 level 2 patients). The clinical risk of not doing this is that currently only 1 RN is looking after up to 6 level 2 patients at night.

The thrombolysis service (24/7) is provided within this skill mix by the band 6s and band 7, this equates to 5.24WTE (1 nurse per 11.5 hrs shift )

WORKFORCE

HASU

6 12 2.00 6.76 0 5.76 5.76 0 48.00% 17.42 2 100/0 0

5.24 5.24 5.24 0 100.00% 5.24

ACUTE STROKE UNIT22 36.12 1.64 23 13.12 27.64 15 12.64 76.52% 35.05 1.73 63/37

TOTAL 28 48.12 29.76 13.12 33.4 20.76 12.64 69.41% 57.71 54.05 3.66 1.78 -9.59 100% 4 2 0 86.23

CLINICAL INDICATORS

FFT Complaints

Falls resulting

in serious harm

G3/4 Pressure

UlcersSkil l Mix Variance

Compliance with Stat &

Mand training

No of beds

Current Funded

Establishment

Current WTE/bed RN's

UR (unregistered) RN's

Staff in post

Peer reviewed

professional judgement

(WTE)

THROMBOLYSIS

Difference between


NCGS

National Clinical

guidelines for Stroke

(NCGS)

CURRENT STAFFING

WTE/ bedURProportion

staff in post (%)

MODELLING METHOD

4.4 Conclusion

Following the utilisation of an evidenced based triangulation methodology the review proposes the need for an overall peer reviewed WTE establishment of 57.71 WTE in order to meet the skill mix. The funded establishment currently sits at 48.12WTE (difference 9.59 WTE).

Staffing of the HASU beds has been calculated lean against the National Clinical Guidelines for Stroke and the peer reviewed professional judgement is lower than NCGS. The calculation has been made by separating out the functions required to safely manage the Acute Stroke Unit, however the unit operates as a whole with the available staff used across the whole unit.

4.5 Recommendation Continue to monitor staffing and to recruit to vacancies. As a minimum the need for an additional nurse at night needs to be considered to enable one nurse per bay. This equates to 2.62 WTE registered nurses. This would also bring the staffing establishment closer to the NCGS.

5. Cardiac Care Unit 5.1 Context CCU has been taking direct referrals from SCAS for the past 7 years. The Chest Pain Assessment Unit (CPAU= 1 extra bed, not included in this skill mix review. CCU has maintained its position of 1st in the Country for Primary PCI for 7 years, a 24/7 service.

5.2 Methodology The British Association of Critical Care Nursing (BACCN) recommends 1 WTE nurse to 2 patients. The European Society of Cardiology (ESC) supports this and also recommends that a cardiac care unit employ only registered nurses. The BACCN calculation has been based on the assumption that all patients are level 2 but this varies from day to day and there are often times when all patients are not level 2. The ACUITY of patients was not measured for this skill mix review due to the nature of the Acute Admissions, which would indicate using a higher ratio (SNCT). 5.3 Staffing establishment requirements

WORKFORCE

18 31.4 1.70 29.14 92.80% 33.76 49.19 -15.43 8.85 7.58 8.01 1.84 90/10 -2.36 99.34 2 1 0 97.77based on all patients being level 2

No of beds

Current Funded

Establishment

Current WTE/bed

Peer reviewed


(WTE)

National guidelines

Difference between


National Guidelines

CHPPD RBH

CHPPD Peer Compliance

with stat and mand taraining

MODELLING METHODS

Falls resulting

in serious harm

G3/4 Pressure

UlcersCHPPD National

Carter benchmarking April 2017

Proportion staff in post

(%)

CLINICAL INDICATORS

FFT Complaints

CURRENT STAFFING

WTE/ bed

Skil l Mix

VarianceStaff in post

5.4 Conclusions Professional judgment indicates that with the use of long days and long night shifts the current establishment which provides 6 WTE on a day shift and 5 on a night shift is safe if 5 can be maintained on the unit. However, CCU covers direct chest pain assessment unit at night and provides a runner to JSU if coronary intervention is required. If staffing at night runs below 5 due to providing this cover or due to sickness or staff being moved to other areas of the trust it becomes unsafe. 0.4 WTE HCA has been added to the skill mix in order to cover Monday to Friday and support nursing care, rapid turnover and discharges as a direct admission unit. An in-patient list in JSU on a Sunday is supported by an extra RN from CCU. 5.5 Recommendation Maintain the excellent recruitment and retention.

6. Neonatal Unit 6.1 Methodology The Toolkit for High- Quality Neonatal Services and the Plymouth staffing tool for a two shift system are used. The Toolkit for High- Quality Neonatal Services ratios require1:1 for ICU cots, 1:2 for HDU and 1:4 for specialist care cots plus a co-ordinator on each shift. In addition it is recommended that there is a lead nurse and a dedicated practice educator for the unit. Professional judgement is required also required due to the layout of the unit. 6.2 Staffing establishment requirements For 2 ICU, 4 HDU and 14 specialist care cots

WORKFORCE

41.9 WTE (8 WTE per shift) PLUS 1.0 Band 8a lead nurse (also acts as co-ordinator) 0.5 Practice educator1.8 Support worker.

47.1 (8 WTE per shit plus co-ordinator). PLUS 0.5 Practice educator. 1.8 support worker 1.0 Band 8a lead nurse.

2 x ICU 4 x HDU 14 Specialist cots 46.6 44.06 94.55% 45.2 50.4 -5.2 1.4 100 1 0 92.06

CLINICAL INDICATORS

FFT Complaints

CURRENT STAFFING

VarianceStaff in postG3/4

Pressure Ulcers

No of beds Current Funded Establishment


National guidelines

Difference between


National Guidelines

Compliance with stat and

mand training

Proportion staff in

post (%)

6.2 Conclusion Findings from the Neonatal network review showed that 9 WTE staff are required per shift to meet the NHS England Standard Contract. This has not changed since the last skill mix review Professional judgement of the senior nursing team concludes that the workload can be managed with 8 WTE per shift taking into account the layout of the Neonatal Unit. The methodology used recommends that there should be a supervisory/co-ordinator in charge of each shift. This is achieved by counting the Band 8a as the supervisory/co-ordinator person during normal working hours but this person is not counted in the calculations for the shift numbers; there is a shortfall in the provision of a supervisory/co-ordinator member of staff out of hours. On shifts where the number of beds are escalated support is given either from paediatrics or agency nurses are employed to address any shortfalls. 6.3 Recommendation Continue to monitor staffing. 7. Paediatric wards 7.1 Methodology Professional judgement taking into account the RCN Defining staffing levels for children and young people’s services guidance (2013). This guidance takes into account the age ranges of children. Average age ranges have been used to help inform professional judgement. Last year Matron reviewed acuity data for 15 months has also been used 7.2 Staffing establishment requirements Establishment for 4 HDU and 40 ward beds to provide 9 RNs, 1 Assistant Practitioner and 2 support workers on 12hrs day and 8 RNs and 1 assistant Practitioner on a night shifts. Currently all Assistant Practitioners are in training but they are funded at band 4 in the budget. At present 9 beds closed due to vacancies.

WORKFORCE

46.1 WTE RNS(includes 0.5 CNS oncology and 1.0 ward

12.44 (includes 0.73 to do ordering)

4 HDU 40 beds 58.54 46.1 12.44 40.72 28.29 12.44 69.56% 55.73 2.81 98.29 3 0 0 73.98

URProportion

staff in post (%)

CLINICAL INDICATORS

FFT Complaints

CURRENT ESTABLISHMENT

Variance between

professional judgement and current funded establishment

RN's

Compliance with stat and mand training

Staff in post

Falls resulting

in serious harm

G3/4 Pressure

UlcersNo of beds Current Funded

EstablishmentRN's UR

(unregistered)

Peer reviewed


(WTE)- taking into

account the RCN

Defining staffing

7.2 Conclusion Staffing is at the correct level for the paediatric wards 7.3 Recommendation. Continue to recruit to vacancies

Appendix 4 - Report on Maternity Skill Mix Review July 2017

Background Maternity services in the NHS have seen significant change and development in the last decade, driven by an ambition to deliver the best care to women, babies and families. Critical to the delivery of the Better Births (2015) vision is the safe, sustainable and productive staffing of maternity services. Safe, sustainable and productive staffing An Improvement resource for maternity services (National Quality Board 2017) outlines a systematic approach for identifying the organisational, managerial and clinical factor setting factors that support safe staffing of maternity services. This document makes 14 recommendations with regards to staffing requirements for maternity services, three of which are relevant to this skill mix review:

1. Boards are accountable for assuring themselves that NICE recommended tools such as Birthrate Plus are used to assess multi-professional staffing requirements for their maternity services

2. Boards are accountable for assuring themselves that results from using workforce planning tools are cross checked with professional judgment and benchmarking peers.

3. Boards must review midwifery staffing annually, aligned to their operational and strategic planning processes and review of workforce productivity, as well as mid-point review every six months in line with NICE guideline NG4.

Introduction The NQB set out their expectations for safe, sustainable and productive staffing which included three expectations: Right staff; Right skills and Right place and time. This report focuses on expectation 1 Right staff which recommends having evidence based workforce planning, appropriate skill mix and that organisations should review staffing using Birthrate plus workforce planning tool annually and with a midpoint review. This is the annual workforce review. Birthrate plus There are 3 levels of review that can be completed:

• A detailed local assessment of staffing needs can be undertaken which requires collection of maternity activity over a 4-6 month period.

• Differentiated ratios which have been developed from National detailed work as described above can be applied to hospital and community workloads in a ‘top down’ approach. These ratios can be used at a strategic planning level to calculate midwifery numbers based on actual and projected births. The application of skill mix and accounting for additional non-clinical midwifery roles makes this a robust tool.

• The birthrate plus intrapartum acuity tool can be utilized to assess clinical risk within the delivery suite. Differentiated ratios can be used with the intrapartum acuity tool in order to provide a complimentary picture of both overall staffing need and managing peaks and troughs of activity on delivery suite.

Birthrate plus assessors completed a detailed local assessment in January 2015 based on 2014/15 activity and acuity. A top down skill mix review based on 2015/16

27

data was completed using the differentiated ratios to review any changes. This report uses the differentiated ratio methodology using 2016/17 data. Methodology For local strategic planning, the birthrate plus ratios are based on calculating separately and then adding staffing needs for:

• Hospital services, based on the number of births per annum and the percentage of women in the higher need intrapartum categories.

• Community services based on: - The total number of women booked for hospital births and receiving

antenatal and postnatal care from community midwives. These women may give birth in a number of different hospitals and do not relate entirely to the local hospital births.

- The number of home births and case loading midwives.

Determining hospital based staffing requirements The main factor in determining differing staffing needs for different hospital services is that of the workload on delivery suite. Intrapartum care makes the most demand of midwife care in terms of time needed to care for women throughout labour and by the increased ratio of time needed for those in the higher need group. Based on data collected by Birthrate plus they have identified that the likely ratio of number of births per WTE midwife will be: Tertiary services: 38 births per wte DGH with a case mix of more than 50% in category IV and V: 42 births per

wte DGH with a case mix of less than 50% in category IV and V: 45 births per wte

The maternity case mix in RBH is more than 50% in category IV and V. Determining community based staffing requirements Calculations of community midwife staffing requirements are based primarily in the time needed to provide all of the elements of antenatal and postnatal care to women. The current Birthrate plus ratio is: 98 cases per wte midwife The term cases is used rather than births as not all women will have delivered in the RBH so will not be included in the total births in the delivery suite The staffing requirements for homebirths and midwifery led units are 1:35. The skill mix review is based on activity data obtained from the information team. Whilst this method provides a total staffing for hospital and community services it does not give a detailed breakdown for the individual areas, such as postnatal wards, antenatal clinics or delivery suite. Such detail is contained in the detailed local assessment. Determining other related staffing To calculate staffing required to undertake roles not involved in direct clinical care e.g. Director of Midwifery, matrons, practice development, clinical risk, Birthrate plus suggests adding an agreed % to the clinical staffing component usually 8% for DGH. However this is a local decision and is not a recommendation of Birthrate plus. The

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current percentage of staff not involved in direct clinical care is 6.4% and therefore this % has been applied. Maternity support workers are support staff who have replaced midwifery hours, whilst Maternity Care Assistants do not replace midwife hours. For this skill mix review the staff who are classified as maternity Support Workers are nursery nurses, Registered Nurses and Band 3s working in community and MLU. The percentage of midwives to trained support staff most commonly quoted is 90:10. Again this is not a recommendation of Birthrate plus and remains a local decision. The % of midwives to band 3,4&5 support staff at RBH is 87:13 and this is the % that has been applied to the total clinical establishment. It has been recognized that as experience grows of integrating support staff to meet the challenges of providing new care models associated with Better Births, both Birthrate Plus and the RCM are reviewing the scope for increasing the time support workers can free up. Activity 2016/17 Births in the unit 4197 Births in MLU 983 Homebirths 55 Total community activity 7569 Calculating staffing using different ratios Number of

births/episodes Ratio applied

WTE staffing

Births in the unit 4197 1:42 99.9 MLU 983 1:38 25.8 Homebirth 55 1:35 1.5 Total community activity 7569 1:98 77.2 Total clinical midwifery staffing across service (total est – non clinical +MSW band 3, 4 &5)

204.96

Non clinical (add) 6.4% 13.1 218 Maternity support workers (minus)

13% 30.5

TOTAL 187.5 The above skill mix review concludes that for the case mix the midwifery establishment should be 187.5 WTE. This would provide a 1:30 midwife to birth ratio based on 5600 births and 1:28 based on 5300 births. The professional judgment of the Director of Midwifery and the Matrons was that an establishment of 189 WTE would be required for a safe service which is in line with the findings of the above Birthrate Plus review. In 2016/17 there was a decrease in the birth rate (5300) which is predicted to continue in 2017/18 based on booking data for the first six months of the year. As stated above an establishment of 187.5 with a birthrate of 5300 would provide a midwife to birth ratio of 1:28.

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The detailed local assessment completed in February 2015 identified that based on the local case mix a midwife to birth ratio of 1:27 should be provided. A business case was agreed by the Executive team to achieve this ratio with funding phased in over 2 years and funded in 2016/17 financial year. References Better Births National Quality Board (2017) Safe, sustainable and productive staffing: An improvement resource for maternity services, NICE (2015) NICE guideline NG4 – Safe midwifery staffing for maternity settings https://www.nice.org.uk/guidance/ng4 Gill Valentine, Director of Midwifery Linda Rough, Matron Hospital maternity services Jean Sangha, Matron Community and midwifery led services

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https://www.nice.org.uk/guidance/ng4

Title: Standing Orders Review Agenda item no: 9a Meeting: Board of Directors Date: 29 November 2017 Presented by: Caroline Lynch, Trust Secretary Prepared by: Mark Arnold, Deputy Trust Secretary Purpose of the Report The Trust’s Standing Orders are reviewed on an annual basis. A

number of minor changes have been made and the revised document with tracked changes is attached. The Trust’s Constitution will need to be updated to align with the quorum as set out in section 3.37 in the Standing Orders.

Report History Audit and Risk Committee on 9 November 2017

What action is required? The Board is asked to approve the changes to the Standing Orders.













Board of Directors

Standing Orders

Agreed: September 2014 Last Reviewed November 20162017

CONTENTS INTRODUCTION 4 Statutory Framework 4 Delegation of Powers 4 1. INTERPRETATION 5 2. THE TRUST 6 Composition of the Trust 6 Appointment of the ChairmanChair and Directors 6 Terms of Office of the ChairmanChair and Directors 7 Appointment of Deputy ChairmanChair 7 Powers of Deputy ChairmanChair 7 3. MEETINGS OF THE BOARD OF DIRECTORS 7 Calling Meetings 7 Notice of Meetings 8 Setting the Agenda 8 ChairmanChair of Meeting 8 Annual Members Meeting 8 Notices of Motion 8 Withdrawal of Motion or Amendments 9 Motion to Rescind a Resolution 9 Motions 9 ChairmanChair's Ruling 9 Voting 9 Minutes 10 Suspension of Standing Orders 11 Variation and Amendment of Standing Orders 11 Record of Attendance 11 Quorum 11 4. ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION 11 Emergency Powers 12 Delegation to Committees 12 Delegation to Officers 12 5. COMMITTEES 12 Appointment of Committees 12 Confidentiality 13 6. DECLARATIONS OF INTEREST AND REGISTER OF INTEREST 13 Declaration of Interest 14 Register of Interests 14 Royal Berkshire NHS Foundation Trust November 20162017 Standing Orders

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7. DISABILITY OF DIRECTORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY INTEREST 14 8. STANDARDS OF BUSINESS CONDUCT POLICY 14 Policy 15 Interest of Officers in Contracts 15 Canvassing of, and Recommendations by, Directors in Relation to Appointments 15 Relatives of Directors or Officers 15 9. CUSTODY OF SEAL AND SEALING OF DOCUMENTS 16 Custody of Seal 16 Sealing of Documents 16 Register of Sealing 16 10. SIGNATURE OF DOCUMENTS 16 11. MISCELLANEOUS 17 Standing Orders to be given to Directors and Officers 17 Documents having the Standing of Standing Orders 17 Review of Standing Orders 17

Royal Berkshire NHS Foundation Trust November 20162017 Standing Orders

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INTRODUCTION Statutory Framework The Royal Berkshire NHS Foundation Trust (the Trust) is a public benefit corporation authorised by the Independent Regulator of NHS Foundation Trusts under the Health and Social Care Act 2012. The Trust’s principal places of business are: Royal Berkshire Hospital London Road Reading NHS Trusts are governed by statute, mainly the Health and Social Care Act 2012, by their constitutions and by the terms of their authorisation by the Independent Regulator (the Regulatory Framework). The functions of the Trust are conferred by the Regulatory Framework. As a body corporate the Trust has specific powers to contract in its own name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable. The Trust also has a common law duty as a bailee for patients' property held by the Trust on behalf of patients. Delegation of Powers Under the Standing Orders relating to the Arrangements for the Exercise of Functions (SO 4) the Board exercises its powers to make arrangements for the exercise, on behalf of the Trust, of any of its functions by a committee or sub-committee appointed by virtue of SO 5 or by an officer of the Trust, in each case subject to such restrictions and conditions as the Board thinks fit or as Monitor may direct. Delegated Powers are covered in a separate document (Reservation of Powers to the Board and Delegation of Powers). That document is incorporated within the Standing Financial Instructions and has effect as if incorporated into the Standing Orders. 1. INTERPRETATION

1.1 Save as permitted by law, and subject to the Constitution, at any meeting the ChairmanChair of the Trust shall be the final authority on the interpretation of Standing Orders (on which he/she should be advised by the Chief Executive or Secretary).

1.2 Any expression to which a meaning is given in the Health Service Acts or in the

Regulations or Orders made under the Acts shall have the same meaning in this interpretation and in addition:

"ACCOUNTABLE OFFICER" shall be the Officer responsible and accountable for funds entrusted to the Trust. He/She shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust it shall be the Chief Executive. "TRUST" means the Royal Berkshire NHS Foundation Trust. Royal Berkshire NHS Foundation Trust November 20162017 Standing Orders

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"BOARD" means the Board of Directors as constituted in accordance with the Constitution of the Trust. “COUNCIL OF GOVERNORS” means the Council of Governors as constituted in accordance with the Constitution, which has the same meaning as the Board of Governors in the 2003 Act. "BUDGET" shall mean a resource, expressed in financial terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust. "CHAIRMANCHAIR" is the person appointed by the Council of Governors to lead the Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression “the ChairmanChair of the Trust” shall be deemed to include the Deputy Chair of the Trust if the ChairmanChair is absent from the meeting or is otherwise unavailable. "CHIEF EXECUTIVE" shall mean the chief executive officer of the Trust. "COMMITTEE" shall mean a sub-committee appointed by the Board. "COMMITTEE MEMBERS" shall be persons formally appointed by the Board to sit on or to chair specific committees. "DEPUTY CHAIRMANCHAIR" means the non-executive Director appointed by the Trust to take on the ChairmanChair’s duties if the ChairmanChair is absent for any reason. "DIRECTOR" means a member of the Board of Directors. “HE/SHE & HIS/HERS” shall refer to the appropriate postholder and are to be read as the gender of that post which may change. "FUNDS HELD ON TRUST" shall mean those funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument, or chooses subsequently to accept. Such funds may or may not be charitable. "MOTION” MEANS a formal proposition to be discussed and voted on during the course of a meeting. "NOMINATED OFFICER" means an officer charged with the responsibility for discharging specific tasks within SOs and SFIs. “NON-EXECUTIVE DIRECTOR” means a Director, including the ChairmanChair of the Trust, who does not hold an executive office of the Trust "OFFICER" means an employee of the Trust. "SECRETARY" means the Secretary of the Trust or any other person appointed to perform the duties of the Secretary, including a joint, assistant or deputy secretary. "SFIS" means Standing Financial Instructions. "SOS" means Standing Orders.


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2. THE TRUST 2.1 All business shall be conducted in the name of the Trust.

2.2 All funds received in trust shall be in the name of the Trust as corporate trustee. In relation to funds held on trust, powers exercised by the Trust as corporate trustee shall be exercised separately and distinctly from those powers exercised as a Trust.

2.3 The Trust has resolved that certain powers and decisions may only be exercised or made by the Board in formal session. These powers and decisions are set out in "Reservation of Powers to the Board" and have effect as if incorporated into the Standing Orders.

2.4 Composition of the Trust Board - In accordance with the Constitution the

composition of the Board of the Trust shall be: The ChairmanChair of the Trust Up to 7 non- executive Directors Up to 7 executive Directors including:

• the Chief Executive (the Chief Officer) • the Director of Finance • a registered medical or dental practitioner • a registered nurse or midwife • up to 3 other executive directors

2.5 Appointment of the ChairmanChair and Non-Executive Directors – In accordance with the Constitution the ChairmanChair and the other non-executive Directors are appointed and removed by the council members at a general meeting. The appointment process followed will be in accordance with the terms of the Constitution.

2.6 In accordance with the Constitution the non-executive Directors of the Trust will

appoint and remove the Chief Executive as a director of the Trust. The appointment of the Chief Executive is subject to the approval of a majority of the members of the Council of Governors present and voting at a meeting of the Council of Governors.

2.7 Terms of Office of the ChairmanChair and Non-Executive Directors – The

ChairmanChair and the non-executive Directors are to be appointed for a period of office of three years in accordance with the terms and conditions of office decided by the council of governors at a general meeting.

2.8 Terms of Office of Executive Directors - The Board Nomination and

Remuneration Committee of non-executive Directors shall decide the terms and conditions of office including remuneration and allowances of executive Directors.


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2.9 Appointment of Deputy ChairmanChair - For the purpose of enabling the proceedings of the Trust to be conducted in the absence of the ChairmanChair of the Trust, the Council of Governors may appoint a non-executive Director to be Deputy ChairmanChair for such a period, not exceeding the remainder of his/her term as non-executive Director of the Trust, as they may specify on appointing him/her. If the ChairmanChair is unable to discharge their office as ChairmanChair of the Trust, the Deputy ChairmanChair of the Board of Directors shall be acting ChairmanChair of the Trust.

2.10 Any non-executive Director so elected may at any time resign from the office of

Deputy ChairmanChair by giving notice in writing to the ChairmanChair and the Directors of the Trust may thereupon appoint another non-executive Director as Deputy ChairmanChair in accordance with paragraph 2.9.

2.11 Powers of Deputy ChairmanChair - Where the ChairmanChair of the Trust

has died or has otherwise ceased to hold office or where he/she has been unable to perform his/her duties as ChairmanChair owing to illness, absence from England and Wales or any other cause, references to the ChairmanChair in these Standing Orders shall, so long as there is no ChairmanChair able to perform his/her duties, be taken to include references to the Deputy ChairmanChair.

3. MEETINGS OF THE BOARD OF DIRECTORS

3.1 Calling Meetings - Ordinary meetings of the Board shall be held at such times and places as the Board may determine.

3.2 Meetings of the Board will be called by the Secretary, or by the ChairmanChair

of the Trust, or by four Directors (a minimum of one Executive and one Non Executive Director) who give written notice to the Secretary specifying the business to be carried out. The Secretary shall send a written notice to all Directors as soon as possible after the receipt of such a request. The Secretary shall call a meeting on at least fourteen but not more than twenty-eight days’ notice (except in the case of emergencies) to discuss the specified business. If the Secretary fails to call such a meeting then the ChairmanChair or four Directors, whichever is the case, shall call such a meeting.

3.3 Notice of Meetings – Save in the case of emergencies or the need to conduct

urgent business, the Secretary shall give to all Directors at least fourteen days written notice of the date and place of every meeting of the Board of Directors.

3.4 Before each meeting of the Board, a notice of the meeting, specifying the

business proposed to be transacted at it, shall be delivered to every Director, or sent by post to the usual place of residence of such Director, so as to be available to him/her at least 5 clear days before the meeting. ‘Clear days’ excludes bank holidays and weekends.

3.5 Lack of service of the notice on any director shall not affect the validity of a

meeting.


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3.6 Failure to serve such a notice on more than 2 Directors will invalidate the meeting. A notice shall be presumed to have been served at the time at which the notice would be delivered in the ordinary course of the post.

3.7 In the case of a meeting called by Directors or the ChairmanChair in default of

the Secretary, the notice shall be signed either by those Directors or the ChairmanChair and no business shall be transacted at the meeting other than that specified in the notice.

3.8 Setting the Agenda - The Board may determine that certain matters shall

appear on every agenda for a meeting of the Board and shall be addressed prior to any other business being conducted.

3.9 A Director desiring a matter to be included on an agenda shall make his/her

request in writing to the Secretary at least 10 clear days before the meeting, subject to SO 3.3. Requests made less than 10 days before a meeting may be included on the agenda at the discretion of the ChairmanChair.

3.10 ChairmanChair of Meeting - The ChairmanChair of the Trust, or in their

absence the Deputy ChairmanChair of the Board, and in their absence one of the other non-executive Directors in attendance is to chair meetings of the Board.

3.11 If the ChairmanChair is absent from a meeting temporarily on the grounds of a

declared conflict of interest the Deputy ChairmanChair, if present, shall preside. If the ChairmanChair and Deputy ChairmanChair are absent, or are disqualified from participating, such non-executive Director as the Directors present shall choose shall preside.

3.12 Annual General Meeting - In accordance with the Constitution the Trust will

hold a members meeting (the “Annual General Meeting”) within nine months of the end of the financial year.

3.13 Notices of Motion - A Director of the Trust desiring to move or amend a

motion shall send a written notice thereof at least 10 clear days before the meeting to the Secretary, who shall insert in the agenda for the meeting all notices so received subject to the notice being permissible under the appropriate regulations. This paragraph shall not prevent any motion being moved during the meeting, without notice on any business mentioned on the agenda subject to SO 3.7.

3.14 Withdrawal of Motion or Amendments - A motion or amendment once

moved and seconded may be withdrawn by the proposer with the concurrence of the seconder and the consent of the ChairmanChair.

3.15 Motion to Rescind a Resolution - Notice of motion to amend or rescind any

resolution (or the general substance of any resolution) which has been passed within the preceding 6 calendar months shall bear the signature of the Director who gives it and also the signature of 4 other Directors. When any such motion has been disposed of by the Board, it shall not be competent for any Director other than the ChairmanChair to propose a motion to the same effect within 6 months; however the ChairmanChair may do so if he/she considers it appropriate.


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3.16 Motions - The mover of a motion shall have a right of reply at the close of any

discussion on the motion or any amendment thereto. 3.17 When a motion is under discussion or immediately prior to discussion it shall be

open to a Director to move:

• An amendment to the motion.

• The adjournment of the discussion or the meeting. • That the meeting proceed to the next business. (*) • The appointment of an ad hoc sub-committee to deal with a specific

item of business. • That the motion be now put. (*)

* In the case of sub-paragraphs denoted by (*) above to ensure objectivity

motions may only be put by a Director who has not previously taken part in the debate and who is eligible to vote. No amendment to the motion shall be admitted if, in the opinion of the ChairmanChair of the meeting, the amendment negates the substance of the motion.

3.18 ChairmanChair’s Ruling - Statements of Directors made at meetings of the

Board shall be relevant to the matter under discussion at the material time and the decision of the ChairmanChair of the meeting on questions of order, relevancy, regularity and any other matters shall be observed at the meeting.

3.19 Voting - Every question at a meeting shall be determined by a majority of the

votes of the Directors present and voting on the question and, in the case of any equality of votes, the person presiding shall have a second or casting vote.

3.20 All questions put to the vote shall, at the discretion of the ChairmanChair of the

meeting, be determined by oral expression or by a show of hands. A paper ballot may also be used if a majority of the Directors present so request.

3.21 If at least one-third of the Directors present so request, the voting (other than

by paper ballot) on any question may be recorded to show how each Director present voted or abstained.

3.22 If a Director so requests, his/her vote shall be recorded by name upon any vote

(other than by paper ballot). 3.23 In no circumstances may an absent Director vote by proxy. Absence is defined

as being absent at the time of the vote. 3.24 The Board may agree that its members can participate in its meetings by

telephone, video or computer link. Participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting.

3.25 A resolution in writing signed by all of the Directors entitled to receive notice of

a meeting of the board of directors shall be as valid and effectual as if it had Royal Berkshire NHS Foundation Trust November 20162017 Standing Orders

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been passed at a meeting of the board of directors duly convened and held and may consist of several documents in the like form each signed by one or more directors.

3.26 A resolution in electronic form sent to all of the Directors entitled to receive

notice of a meeting of the board of directors by electronic communication (for the purposes of this provision “electronic communication” means a communication transmitted (whether from one person to another, from one device to another or from a person to a device or vice versa) (a) by means of an electronic communications network; or (b) by other means but while in an electronic form) to the electronic addresses notified to the Trust by each of the directors, shall be as valid and effectual as if it had been passed at a meeting of the Board of Directors duly convened and held provided that each and every director entitled to receive a notice of a meeting of the board of directors responds by electronic communication to the electronic address from which the resolution in electronic form was transmitted from, confirming their acceptance of the resolution.

3.27 An acting director who has been appointed formally to carry out a vacant

Director’s duties during a period of temporary incapacity, shall be entitled to exercise the voting rights of the executive Director. An officer attending the Board to represent an executive Director during a period of incapacity or temporary absence without being formally appointed to the Board may not exercise the voting rights of the executive Director. An officer’s status when attending a meeting shall be recorded in the minutes.

3.28 Minutes - The Minutes of the proceedings of a meeting shall be drawn up and

submitted for agreement at the next ensuing meeting where they will be signed by the person presiding at it.

3.29 No discussion shall take place upon the minutes except upon their accuracy or

where the ChairmanChair considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting.

3.30 Minutes shall be circulated in accordance with the Boards’ wishes.

3.31 Suspension of Standing Orders - Except where this would contravene any

statutory provision or any direction made by the Secretary of State, any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the Board are present, including one executive Director and one non-executive Director, and that a majority of those present vote in favour of suspension.

3.32 A decision to suspend SOs shall be recorded in the minutes of the meeting and

the circumstances subsequently reviewed by the Audit & Risk Committee. 3.33 A separate record of matters discussed during the suspension of SOs shall be

made and shall be available to the Directors. 3.34 No formal business may be transacted while SOs are suspended. 3.35 Variation and Amendment of Standing Orders - These Standing Orders

shall be amended only if: Royal Berkshire NHS Foundation Trust November 20162017 Standing Orders

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• a notice of motion under Standing Order 3.13 has been given; and

• no fewer than half the total of the Trust’s non-executive Directors vote in

favour of amendment; and • at least two-thirds of the Directors are present ; and • the variation proposed does not contravene a statutory provision or

direction made by the Secretary of State.

3.36 Record of Attendance - The names of the Directors present at the meeting shall be recorded in the minutes.

3.37 Quorum - Four Directors, including not less than two executive Directors and

not less than two non-executive Directors shall form a quorum. 3.38 An officer in attendance for an executive Director but without formal acting up

status may not count towards the quorum. 3.39 If a Director has been disqualified from participating in the discussion on any

matter and/or from voting on any resolution by reason of the declaration of a conflict of interest (see SO 6 or 7) he/she shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business. The above requirement for at least two executive Directors to form part of the quorum shall not apply where the executive Directors are excluded from a meeting.

4. ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION

4.1 The Board may make arrangements for the exercise, on behalf of the Trust, of any of its functions by a committee or sub-committee, appointed by virtue of SO 5.1 or 5.2 below or by a Director or an officer of the Trust in each case subject to such restrictions and conditions as the Board considers appropriate.

4.2 Emergency Powers - The powers which the Board has retained to itself within

these Standing Orders (SO 2.3) may in emergency be exercised by the Chief Executive and the ChairmanChair of the Trust after having consulted at least two Non Executive Directors. The exercise of such powers by the Chief Executive and the ChairmanChair shall be reported to the next formal meeting of the Board for ratification.

4.3 Delegation to Committees – The Board shall agree from time to time to the

delegation of executive powers to be exercised by committees which it has formally constituted. The constitution and terms of reference of these committees, and their specific executive powers shall be approved by the Board.

4.4 Delegation to Officers - Those functions of the Trust which have not been

retained as reserved by the Board or delegated to an executive committee or - Royal Berkshire NHS Foundation Trust November 20162017 Standing Orders

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sub-committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall determine which functions he/she will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain an accountability to the Board.

4.5 The Chief Executive shall prepare a Scheme of Delegation identifying his/her

proposals which shall be considered and approved by the Board, subject to any amendment agreed during the discussion. The Chief Executive may periodically propose amendment to the Scheme of Delegation which shall be considered and approved by the Board as indicated above.

4.6 Nothing in the Scheme of Delegation shall impair the discharge of the direct

accountability to the Board of the Finance Director or other executive Director to provide information and advise the Board in accordance with any statutory requirements or the Independent Regulator.

4.7 The arrangements made by the Board as set out in the "Reservation of Powers

to the Board and Delegation of Powers" shall have effect as if incorporated in these Standing Orders.

5. COMMITTEES

5.1 Appointment of committees - The Board may appoint committees of the Board, consisting wholly or partly of Directors of the Trust or wholly of persons who are not Directors of the Trust.

5.2 A committee appointed under SO 5.1 may, subject to such directions as may

be given by the Independent Regulator or the Board appoint committees of the Board consisting wholly or partly of members of the committee.

5.3 The Standing Orders of the Board, as far as they are applicable, shall apply

with appropriate alteration to meetings of any committees of the Board. 5.4 Each such committee or sub-committee shall have such terms of reference and

powers and be subject to such conditions (as to reporting back to the Board), as the Board shall decide. Such terms of reference shall have effect as if incorporated into the Standing Orders.

5.5 All Board sub-committees will be chaired by a non-executive director. 5.6 Committees may not delegate their executive powers to a sub-committee

unless expressly authorised by the Board. 5.7 The Board shall approve the appointments to each of the committees which it

has formally constituted. 5.8 Where the Trust is required to appoint persons to a committee and/or to

undertake statutory functions as required by Monitor, and where such appointments are to operate independently of the Board such appointment shall be made in accordance with applicable statute and regulations and with the guidance issued by Monitor.


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5.9 The Committees established by the Board are: • Nominations and Remuneration • Audit and Risk • Quality • Charity • Finance & Investment • Workforce

At least two Non-Executive Directors and two Executive Directors are members of each Committee (other than the Audit & Risk and Charity Committees) 5.10 Confidentiality - A member of a committee shall not disclose a matter dealt

with by, or brought before, the committee without its permission until the committee shall have reported to the Board or shall otherwise have concluded on that matter.

5.11 A Director of the Trust or a member of a committee shall not disclose any

matter reported to the Board or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Board or committee shall resolve that it is confidential.

6. DECLARATIONS OF INTERESTS AND REGISTER OF INTERESTS

6.1 Declaration of Interests - Directors must declare interests which are relevant and material to the NHS Foundation Trust of which they are a Director. All existing Directors should declare such interests. Any Directors appointed subsequently should do so on appointment.

6.2 Interests which should be regarded as "relevant and material" are as specified

in the Constitution.

6.3 If Directors have any doubt about the relevance of an interest, this should be discussed with the Secretary.

6.4 At the time Directors' interests are declared, they should be recorded in the

Board minutes. Any changes in interests should be declared at the next Board meeting following the change occurring.

6.5 Directors' Directorships of companies likely or possibly seeking to do business

with the NHS should be published on the Trust’s website. 6.6 During the course of a Board meeting, if a conflict of interest is established, the

Director concerned should withdraw from the meeting and play no part in the relevant discussion or decision.

6.7 Register of Interests – In accordance with the Constitution, the Secretary will

ensure that a Register of Interests is established to record formally declarations of interests of Directors.


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6.8 These details will be kept up to date by means of, as a minimum, an annual review of the Register.

6.9 All appropriate staff will be asked to declare any interest and a record of

interests will be kept.

6.10 The Register of Board interests will be available to the public. 7. DISABILITY OF DIRECTORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY

INTEREST

7.1 Subject to the following provisions of this Standing Order, if a Director of the Trust has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Board at which the contract or other matter is the subject of consideration, he/she shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

The above SO applies if the pecuniary interest relates to the spouse or a cohabiting partner.

7.2 The Board shall exclude a Director from a meeting of the Board while any

contract, proposed contract or other matter in which he/she has a pecuniary interest, is under consideration.

7.3 Standing Order 7 applies to a committee or sub-committee of the Board as it

applies to the Board and applies to any member of any such committee or sub-committee (whether or not he/she is also a Director) as it applies to a Director.

8. STANDARDS OF BUSINESS CONDUCT

8.1 Policy - Staff must comply with the national guidance contained in HSG(93)5 `Standards of Business Conduct for NHS staff”. The following provisions should be read in conjunction with this document.

8.2 Interest of Officers in Contracts - If it comes to the knowledge of a Director

or an officer of the Trust that a contract in which he/she has any pecuniary interest not being a contract to which he/she is himself themself a party, has been, or is proposed to be, entered into by the Trust he/she shall, at once, give notice in writing to the Secretary of the fact that he/she is interested therein. In the case of married persons or persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

8.3 An officer must also declare to the Chief Executive any other employment or

business or other relationship of his, or of a cohabiting partner, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust. A register of declared interests of staff shall be kept and maintained by means of an annual review.


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8.4 Canvassing of, and Recommendations by, Directors in Relation to Appointments - Canvassing of Directors of the Trust or members of any committee of the Trust directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

8.5 A Director of the Trust shall not solicit for any person any appointment under

the Trust or recommend any person for such appointment: but this paragraph of this Standing Order shall not preclude a Director from giving written testimonial of a candidate's ability, experience or character for submission to the Trust.

8.6 Informal discussions outside appointments panels or committees, whether

solicited or unsolicited, should be declared to the panel or committee. 8.7 Relatives of Directors or Officers - Candidates for any staff appointment

shall when making application disclose in writing whether they are related to any Director or the holder of any office under the Trust. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him/her liable to instant dismissal.

8.8 The Directors and every officer of the Trust shall disclose to the Chief

Executive any relationship with a candidate of whose candidature that Director or officer is aware. It shall be the duty of the Chief Executive to report to the Trust any such disclosure made.

8.9 On appointment, Directors (and prior to acceptance of an appointment in the

case of executive Directors) should disclose to the Board whether they are related to any other Director or holder of any office under the Trust.

8.10 Where the relationship of an officer or another Director to a Director of the

Trust is disclosed, the Standing Order headed `Disability of Directors in proceedings on account of pecuniary interest' (SO 7) shall apply.

8.11 All managers must comply with The Code of Conduct for NHS Managers

Directions 2002

9. CUSTODY OF SEAL AND SEALING OF DOCUMENTS

9.1 Custody of Seal - The Common Seal of the Trust shall be kept by the Trust Secretary in a secure place.

9.2 Sealing of Documents - The use of the Trust’s Seal may be authenticated by

the signature of:

a)• the Chief Executive b)• the ChairmanChair of the Trust c)• any other Executive Board Director

Formatted: Indent: Left: 2.62 cm,Bulleted + Level: 1 + Aligned at: 1.27cm + Indent at: 1.9 cm


15

9.3 Where it is necessary that a document shall be sealed, the seal shall be affixed in the presence of two of the directors above. 9.4 As a general guide the seal should be used for:

a)• all land and property transactions which are required to be executed as a Deed

b)• any other contract required to be executed under seal rather than as a simple contract

9.5 Before any building, engineering, property or capital document is sealed it must

be approved and signed by the Finance Director (or an officer nominated by him/her) and authorised and countersigned by the Chief Executive (or an officer nominated by him/her who shall not be within the originating Directorate).

9.6 Register of Sealing - An entry of every sealing shall be made and numbered

consecutively in a book provided for that purpose, and shall be signed by the persons who shall have approved and authorised the document and those who attested the seal.

10. SIGNATURE OF DOCUMENTS

10.1 Where the signature of any document will be a necessary step in legal proceedings involving the Trust, it shall be signed by the Chief Executive, unless any enactment otherwise requires or authorises, or the Board shall have given the necessary authority to some other person for the purpose of such proceedings.

10.2 The Chief Executive or nominated officers shall be authorised, by resolution of

the Board, to sign on behalf of the Trust any agreement or other document (not required to be executed as a deed) the subject matter of which has been approved by the Board or committee or sub-committee to which the Board has delegated appropriate authority.

11. MISCELLANEOUS

11.1 Standing Orders to be given to Directors and Officers - It is the duty of the Chief Executive to ensure that existing Directors and officers and all new appointees are notified of and understand their responsibilities within Standing Orders and SFIs. Updated copies shall be issued to staff designated by the Chief Executive. New designated officers shall be informed in writing and shall receive copies where appropriate of SOs.

11.2 Documents having the standing of Standing Orders - Standing Financial

Instructions and Reservation of Powers to the Board and Delegation of Powers shall have the effect as if incorporated into SOs.

Formatted: Indent: Left: 2.62 cm,Hanging: 1.14 cm, Bulleted + Level: 1+ Aligned at: 1.27 cm + Indent at: 1.9 cm


16

11.3 Review of Standing Orders - Standing Orders shall be reviewed annually by the Secretary to the Trust. The requirement for review extends to all documents having the effect as if incorporated in SOs. The Board of Directors will subsequently review and approve the Standing Orders annually.


17

Title: Changes to the Constitution Agenda item no: 9b Meeting: Board of Directors Date: 29 November 2017 Presented by: Caroline Lynch, Trust Secretary Prepared by: Mark Arnold, Deputy Trust Secretary Purpose of the Report The Trust’s Constitution will need to be updated to align with the

quorum as set out in section 3.37 in the Standing Orders.

Report History Standing Orders Annual Review was submitted to the Audit and Risk

Committee on 9 November 2017


The Board is asked to approve the proposed change to the Trust’s Constitution. This amendment is due to be submitted for approval to the Council of Governors at their meeting on 29 November 2017.













Appendix 1 - Extract of the Constitution

1 Background

1.1 The Trust’s Standing Orders are reviewed annually. During the scheduled review, it was identified that the Trust Constitution needed to be updated to align with the quorum as set out in section 3.37 in the Standing Orders.

1.2 The proposed amendment is to update the quorum of the Board of Directors meeting from one Director and one non-executive Director, to two Directors and two non-executive Directors.

1.3 In line with the approval process, the amended Constitution will be submitted to both the Board of Directors and the Council of Governors.

2 Recommendations

2.1 The Board is asked to approve the amendment to the Constitution.

3 Attachments

3.1 Appendix 1 - An extract of the Constitution is attached to this report.

Appendix 1 - Extract of the Constitution

10.15 Meetings of the Board of Directors are called by the Secretary, or by the Chairman, or by four Directors who give written notice to the Secretary specifying the business to be carried out. The Secretary shall send a written notice to all Directors as soon as possible after receipt of such a request. The Secretary shall call a meeting on at least fourteen but not more than twenty-eight days’ notice to discuss the specified business. If the Secretary fails to call such a meeting then the Chairman or four Directors, whichever is the case, shall call such a meeting.

10.16 Four Directors including not less than one two executive Directors, and not less than one two non-executive Directors shall form a quorum.

10.17 The Board of Directors may agree that its members can participate in its meetings by telephone, video or computer link. Participation in a meeting in this manner shall be deemed to constitute presence in person at the meeting.

10.18 The Chairman of the Trust or, in their absence, the Deputy Chairman of the Board of Directors, and in their absence one of the other non-executive Directors in attendance is to chair meetings of the Board of Directors.

10.19 Subject to the following provisions of this paragraph, questions arising at a meeting of the Board of Directors shall be decided by a majority of votes.

10.19.1 In case of an equality of votes the Chairman shall have a second and casting vote.

10.19.2 No resolution of the Board of Directors shall be passed if it is opposed by all of the executive Directors present or by all of the non-executive Directors present.

10.20 As soon as practicable after holding a meeting, the Board of Directors shall send a copy of the minutes of the meeting to the Council of Governors.

10.21 The Board of Directors is to adopt Standing Orders covering the proceedings and business of its meetings. The proceedings shall not however be invalidated by any vacancy of its membership, or defect in a Director’s appointment.

Conflicts of Interest of Directors

10.22

10.22.1 Each Director has duty to avoid a situation in which the Director has or can have a direct or indirect interest that conflicts or possibly may conflict with the interests of the Trust. This duty is not infringed if the situation cannot reasonably be regarded as likely to give rise to a conflict of interest, or if the matter has been authorised in accordance with this Constitution.

10.22.2 Each Director has a duty not to accept a benefit from a third party by reason of being a Director or doing or not doing anything in that capacity. This duty is not infringed if acceptance of the benefit cannot reasonably be regarded as likely to give rise to a conflict of interest.

Title: Board Assurance Framework Agenda item no: 10 Meeting: Board of Directors Date: 29 November 2017 Presented by: Caroline Lynch, Trust Secretary Prepared by: Caroline Lynch, Trust Secretary Purpose of the Report

To provide the Board with an updated summary of the Trust’s key risks presented within the Board Assurance Framework. To highlight to the Board any material amendments to the BAF following review by the Audit & Risk Committee.

Report History None

What action is required? For information and discussion. The Board is asked to note the report




Failure to respond appropriately to changes in the internal and external environment impacts on viability.



4. Culture

5. Learning & development






• Board understands the internal and external factors affecting delivery of the plan. • Main risks are identified. No significant control issues/gaps and clear responsibilities. • Effective process in place to monitor, understand and address current & future risks


1 Overview

1.1 This report presents a summary of the Board Assurance Framework (BAF) for review as a whole and to note the changes and areas of movement since the September 2017 Board meeting.

1.2 The BAF was submitted to the Audit & Risk Committee on 9 November 2017 for detailed review.

1.3 The Audit & Risk Committee noted that there had been no change to the current risk ratings. The Committee noted that, as part of the internal audit review of Corporate Governance & Risk Management, there would be recommendations made in respect of the format of the BAF. The BAF format would be reviewed in alignment with the refresh of the Trust’s strategy and corresponding strategic objectives.

2 Contact

Contact: Caroline Lynch, Trust Secretary

Title: Corporate Risk Register Agenda item no: 11 Meeting: Board of Directors Date: 29 November 2017 Presented by: Caroline Ainslie, Executive Director of Nursing Prepared by: James Brind, Head of Risk Management

Purpose of the Report To update the Board on the Corporate Risk Register

Report History Integrated Risk Management Committee: October 2017

Audit and Risk Committee: 9 November 2017


The Board is asked to review and approve the recommendations outlined in the paper.




The Corporate Risk Register links into the BAF to assist in driving the Board agenda to ensure sufficient focus is given to those topics - primarily operational - that are presenting the Trust with the greatest risk

Strategic imperatives. This report impacts on (tick all that apply):: Consistently Delivering Quality Care and Healthcare Outcomes Shaping a Fit for Purpose Core Acute Service Shaping a Fit for Purpose Core Elective Service Being a good system partner and exercising system leadership for integration Developing IT and Information Systems Supporting Better Care Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Being a Great Place to Work Achieving Financial Sustainability Well Led Framework applicability: Not applicable 1. Strategy & planning 2. Risk








This report is expected to have a positive impact on the Trust performance against the Well Led Framework Publication Published on website Confidentiality (FoI): Private Public

1 Introduction

This paper reports on the November 2017, Audit and Risk Committee’s review of the Corporate Risk Register (CRR).

2 Corporate Risk Register Review

The Audit and Risk Committee (ARC) agreed the proposal to close the risk - Safe storage of medicines in clinical areas (temperature control)

2.1 The ARC reviewed the following risks and agreed that their scores remain unchanged in this review cycle.

• Reputational Risk from not improving on the Trusts present CQC standards • Meeting ED Clinical standards including the 4-hour standard of 95% seen and

discharge/transfer out in 2017/18 • Pathology Service Quality and Standards • Inadequate data quality • Inadequate infrastructure & services Mgt • Inadequate uptime of key IT systems • Compliance to Electricity at Work Regs • Risk of not achieving financial stability through the delivery of the 2017/18 budget • Staff recruitment • Staff retention • Training compliance

2.2 The ARC agreed to the inclusion of the following risks on the CRR.

• MSK transformation process – score to remain at 12 with consequence score amended to 4 and the likelihood score to 3.

• Resource and Support for the Accountable Care System (ACS) program

2.3 The ARC agreed to increase in the risk score for the risk ‘Achieving agreed performance trajectory re the ED 4 hour standard to access STF monies.’

2.4 It was proposed that the risk score for ‘Cyber Security Management’ be reduced to 12 in this review cycle. On receipt of an earlier report the ARC requested further assurances prior to approving any reduction in the risk score.

3 Recommendations

The Board is asked to review and approve the corporate level risk entries and scoring

4 Attachments

The following is attached to this report: • Appendix 1 – Corporate Risk Register Tracker

Appendix 1 Corporate Risk Register Tracker

Page 1 November 2017, Corporate Risk Register

Corporate Risk Score Tracker – Proposed scores for the November 2017 Trust Board.

Strategic Imperative 1: Consistently Delivering Quality Care and Healthcare Outcomes Page Risk

J F M A M J J A S O N D 5 1.1 Reputational Risk from not improving on the Trusts present CQC standard 2017 12 12 12 12 Strategic Imperative 2: Shaping a Fit for Purpose Core Acute Service Page Risk

J F M A M J J A S O N D 7 2.1 Meeting ED Clinical standards including the 4-hour standard of 95% seen and

discharge/transfer out 2016 20 20 20 20 20 16 16 16 16 16 16 16 2017 16 20 20 20 20 16 16 16 16 16 16

Strategic Imperative 3: Shaping a Fit for Purpose Core Elective Service Page Risk

J F M A M J J A S O N D Strategic Imperative 4: Being a good system partner and exercising system leadership for integration Page Risk

J F M A M J J A S O N D 8 4.1 Pathology Service Quality and Standards 2017 12 12 12 12

9 4.2 MSK transformation process 2017 12 12 NEW

10 4.3 Resource and Support for the Accountable Care System (ACS) program 2017 16 16 NEW Strategic Imperative 5: Developing IT and Information Systems Supporting Better Care Page Risk

J F M A M J J A S O N D 11 5.1 Inadequate data quality 2016 16 16 16 16 16 16 16 16 16 16 16 16

2017 16 16 16 16 16 16 16 12 12 12 12

14 5.2 Inadequate infrastructure & services Mgt 2016 12 12 12 16 16 16 16 16 16 16 16 16 2017 16 16 16 16 16 16 16 20 20 20 20

16 5.3 Inadequate uptime of key IT systems 2016 15 15 15 12 12 12 12 12 12 8 8 8

2017 8 8 8 8 8 8 8 8 8 8 8 18 5.4 Cyber Security Management 2017 16 16 16 16 Strategic Imperative 6: Shaping and Delivering a Fit for Purpose Hospital Estates Strategy Page Risk

J F M A M J J A S O N D 21 6.1 Compliance to Electricity at Work Regs 2016 16 16 16 16 16 16 16 16 16

2017 16 16 16 16 16 16 16 16 16 16 16


Strategic Imperative 7: Being a Great Place to Work (and work with) Page Risk

J F M A M J J A S O N D 22 7.1 Staff recruitment 2017 16 16 16 16

23 7.2 Staff retention 2017 16 16 16 16 24 7.3 Training compliance 2017 15 15 15 15

Strategic Imperative 8: Achieving Financial Sustainability Page Risk

J F M A M J J A S O N D

25 8.1 Risk of not achieving financial stability through the delivery of the 2017/18 budget

2016 15 15 15 15 15 15 20 20 20 20 20 20 2017 20 20 20 20 20 20 20 20 20 20 20

26 8.2 Achieving agreed performance trajectory re the ED 4 hour standard to access STF monies

2017 9 9 15 15


Agenda Item 13a

Finance and Investment Committee Monday 18 September 2017 10.05 – 12.20 Boardroom, Level 4, Royal Berkshire Hospital Members Mrs. Sue Hunt (Non-Executive Director) (Chair) Mr. Steve McManus (Chief Executive) (up to minute 108/17) Mr. Craig Anderson (Director of Finance) Dr. Lindsey Barker (Medical Director) Mr. Brian Hendon (Non-Executive Director) Ms. Mary Sherry (Chief Operating Officer) Mr. Graham Sims (Chairman) In Attendance Dr. Antoni Chan (Associate Medical Director) (for minute 104/17) Mrs. Suzanne Emerson-Dam (Deputy Director of Workforce) (for minute 106/17) Mrs. Caroline Lynch (Trust Secretary) Mr. John Petitt (Non-Executive Director) Apologies 100/17 Declarations of Interest There were no declarations of interest. 101/17 Minutes: 29 August 2017

The minutes of the meeting held on 29 August 2017 were approved as a correct record and signed by the Chair subject to the following amendment: Minute 96/17: July Finance Update: The last sentence would be amended to read: “Urgent Care and Networked Care were below budget and corporate areas were collectively ahead of budget”.

102/17 Matters Arising Schedule The Committee received the matters arising schedule. Minute 89/17: Matters Arising: March Finance Update: The Director of Finance would

confirm the acreage of the decontamination unit on the Battle site. Action: C Anderson Minute 89/17 (83/17): Matters Arising: Emergency Department Streaming Bid: The

Committee discussed the ED streaming project. The Director of Finance advised that following approval by the Board the first phase of the project was on-going. Some issues had been identified such as additional costs regarding utilities and ground works and some costs had not been included in the original report. However, options were being reviewed to ensure the first phase of the project remained within the £996k as approved by the Board in May 2017. In the event of any additional costs Board approval would be sought.

Minutes

1

Finance & Investment Committee September 2017

The Director of Finance confirmed that a complete tender process for the works had not been undertaken due to the timescale required for the project. However, three competitive quotes had been obtained for the works. The Committee queried whether value for money had been obtained in relation to these works. The Director of Finance advised that three quotes obtained had been subject to extensive scrutiny. The Committee noted that phase 1 of the project was due for completion on 2 October 2017. Phase 2 was due for completion mid to late November 2017. It was agreed that the Director of Finance would circulate Phase 1 of the ED streaming works to the Committee. Action: C Anderson

[Section exempt under s43] The Chief Executive advised that a detailed of review of estates capital planning processes

would be undertaken as part of the review by internal audit. This review was being led by the Director of Workforce. The scope of the review had been extended to include assurance for the Board in relation to capital projects generally.

Minute 91/17: Patient Flow Programme Update: The Director of Finance would confirm by

the end of October 2017 the measurement of savings for the Delayed Transfers of Care programme. Action: C Anderson

Minute 92/17: Pathology Joint Venture Update: The Director of Finance would provide a

briefing note to set out the authority for Berkshire Surrey Pathology Services by the end of September 2017. Action: C Anderson

Minute 93/17: Dingley Children’s Centre: The Director of Finance confirmed that the draft

lease was awaited from Berkshire Healthcare Foundation Trust. Minute 95/17: Digital Hospital GDE Exemplar Fast Follower: Cerner Contract: The

Director of Finance would provide an update on the latest position in relation to the effect of GDE Exemplar programme on cash scenarios. Action: C Anderson

103/17 August Finance Update The Director of Finance introduced the report and advised that August performance was a

£2.97m deficit which was broadly in line with budget and ahead of financial control total. Cash was strong at £37m due to timing of receipts and phasing of capital spend.

The Director of Finance advised that Care Group performance was an adverse variance

versus budget. Non-elective activity was reduced and there had been a reduction in elective activity. Delivery of non-pay QIPPs for the Care Groups presented a challenge. Recovery actions from Care Groups were £2.5m and these were being reviewed by the Director of Finance and Chief Operating Officer. A further update on the capital programme phasing and Care Group recovery actions would be provided as part of the Quarter 2 Forecast which would be submitted to the Committee in October. Action: C Anderson

The Committee queried the increase in medical agency costs in the month and whether this

related to cover for annual leave. The Director of Finance confirmed that the increase was currently being reviewed by the Care Groups. However, agency staff were not used to cover annual leave. A further update on medical agency spend would be submitted to the next meeting. Action: C Anderson

The Committee queried the timescale for the implementation of service level management.

The Chief Operating Officer advised that this was being currently piloted in Maternity followed by ED, ENT and rheumatology in September. A report would be submitted to the Committee on the outcome of these reviews. Action: M Sherry

2


The Committee queried the level of detail currently included in the finance report in relation

to service level reporting with regard to the Trust’s commercial interests. It was agreed that the Director of Finance would review as to the appropriateness of this detail being made available in the public domain. Action: C Anderson

104/17 Bracknell Healthspace Spoke Site Review The Associate Medical Director introduced the report and advised that currently outpatient

services were provided at Bracknell Healthspace across more than 30 separate services. However, there was an opportunity to provide further services from the site. In addition, it was noted that running costs, including interest payments, were currently being covered by the services provided.

The Associate Medical Director explained that longer term plans included increasing patient

volume at the site and also looking at different care delivery such as use of telemedicine, virtual clinics. The Committee noted that the Clinical Reference Group which included representatives from commissioners, stakeholders and clinicians would be reviewing options for Bracknell Healthspace at the next meeting on 27 September 2017.

The Associate Medical Director advised that options for the second floor of Bracknell

Healthspace were also due to be discussed at the meeting in September. The Committee discussed the current rental income for Bracknell Healthspace. The

Medical Director explained that the discounted rate had been agreed historically with commissioners but these were being currently reviewed.

105/17 QIPPs 2017/18

The Chief Operating Officer advised that the current PMO risk assessment of the 2017/18 programmes was £13.8m against a target of £16.9m. The Chief Operating Officer highlighted that savings from the Digital Hospital programme had not been included and there would be savings in the current financial year. The Committee noted that detailed reviews of Care Group performance and Business as Usual savings together with the process to deliver were on-going.

106/17 Temporary Staffing The Deputy Director of Workforce introduced the report and advised that agency spend in Month 5 had decreased and bank spend had increased.

[Section exempt under s43]

The overall target for the programme was £2.5m and this had been risk assessed as £2.3m. The Committee noted a number of planned actions which were proposed. However, some of these would be a challenge for the organisation.

107/17 Procurement Inventory Management The Director of Finance introduced the report and advised that the original target saving for

the programme was £1.9m which assumed a full year effect of the 100% of the programme being delivered. The programme was re-phased at the beginning of 2017 and there had been some delays to implementation and therefore to delivery of savings and fewer savings had been achieved in some areas than that set out in the original business case. The programme had been risk assessed at £1.1m

3


The Director of Finance advised that implementation for theatres main stores was planned for September 2017 and the remainder of theatres for December 2017. Following this, a gateway review would be undertaken regarding work carried out prior to implementation of Phase 2 of the programme. A post implementation review would be undertaken in due course.

The Committee discussed the need for a cultural change in adoption of the system and how the behavioural changes needed would be progressed. The Director of Finance advised that it was proposed that scanning volumes by area in order to monitor compliance with the system would help to drive the changes needed.

108/17 Cardiology Implantable Cardioverter Defibrillators (ICDs) and Pacemakers

109/17 PACS Post Implementation Review

The Committee received the post implementation review of the Picture Archiving Communication System (PACS). The Committee noted the recommendations and next steps as set out in the report.

110/17 Berkshire West Accountable Care System Memorandum of Understanding (MoU)

The Committee agreed that the MoU would be discussed at the September Board meeting.

111/17 [Section exempt under s43]

112/17 Work Plan Review

The work plan was noted.

113/17 Key Messages for the Board

It was agreed that key issues to draw to the attention of the Board included:-

• August Finance performance reviewed• Bracknell Healthspace spoke site review received• Detailed reviews of temporary staffing and procurement QIPP programmes• PACS Post Implementation review received

4



The next meeting would be held on Monday 23 October at 10.00am.

SIGNED:

DATE:

Agenda Item 13a

Finance and Investment Committee Monday 23 October 2017 10.05 – 12.15 Boardroom, Level 4, Royal Berkshire Hospital

Members Mrs. Sue Hunt (Non-Executive Director) (Chair) Mr. Steve McManus (Chief Executive) Mr. Craig Anderson (Director of Finance) Ms. Mary Sherry (Chief Operating Officer) Mr. Graham Sims (Chairman)

In Attendance Dr. Antoni Chan (Associate Medical Director) (for minute 118/17) Mrs. Caroline Lynch (Trust Secretary) Mr. John Petitt (Non-Executive Director) Mr. Andy Statham (Interim Director of Strategy) (for minute 123/17)

Apologies Mr. Brian Hendon (Non-Executive Director)

115/17 Declarations of Interest

There were no declarations of interest.

116/17 Minutes: 18 September 2017

The minutes of the meeting held on 18 September 2017 were approved as a correct record and signed by the Chair.

117/17 Matters Arising Schedule

The Committee received the matters arising schedule.

Minute 102/17 (89/17, 83/17): Matters Arising: Emergency Department (ED) Streaming Bid: The Chief Operating Officer advised that the final stage of the project was due for completion at the beginning of December 2017. The Director of Finance advised that Board approval would be sought for any additional costs.

The Chief Operating Officer advised that, on average, 25 to 30 adult patients per day were being referred to the GP streaming service. ED streaming for children was due to begin from November 2017. The Chief Operating Officer advised that the high level of attendances to ED continued. The Committee noted that the GP streaming service was commissioned via the Westcall service. However, the Westcall service continued separately.

Minute 103/17: August Finance Update: The Director of Finance confirmed that medical agency spend had reduced during September.

Minutes

1

Finance & Investment Committee October 2017

118/17 Townlands Spoke Site Review

The Associate Medical Director introduced the report and advised that the Trust had provided outpatient services at Townlands Hospital since 2011 and had increased the number of clinics provided from 4 to 8 when the new building at the facilities had been opened in 2016.

During 2016/17 the Trust had provided outpatient services in more than 40 treatment functions, including dermatology, audiology, cardiology, ophthalmology, trauma and orthopaedics, rheumatology, neurology, urology, ENT and pain management which represented 80% of all outpatient attendances in the respective period.

The Associate Medical Director advised that going forward increased usage of the Townlands facility was being considered. The Committee noted that the building was owned by Oxford Clinical Commissioning Group (CCG) and the top floor of the facility was currently vacant. The Associate Medical Director advised that, as part of the development of the Clinical Services and Estates strategies, possible increases in outpatient attendances at all satellite sites were being reviewed. The Chief Executive gave an overview of discussions held with CCGs in relation to opportunities to expand activity at Townlands.

The Director of Nursing highlighted that if there was to be a substantial change of use of the Townlands facility the Trust would need to register this with the Care Quality Commission (CQC).

It was agreed that a review of West Berkshire Community Hospital would be provided to the November meeting and the report would include the full year costs for the facility.

Action: A Chan 119/17 September Finance Update

The Director of Finance introduced the report and advised that September performance was a £2.74m deficit which was broadly in line with budget. The Emergency Department (ED) Quarter 2 trajectory had been met and therefore sustainability monies had been accrued in full. Cash was strong at £35.5m.

The Director of Finance advised that Care Groups were collectively £2.5m adverse to budget which was offset by corporate areas underspend by £0.5m. In addition, there had been a non-spend in relation to the anticipated costs related to the junior doctors’ contract and restructuring budget.

The Committee noted that elective income was £2.21m below budget. The Director of Finance advised that elective activity was being monitored. However, there had been an increase in emergency surgery and non-elective activity was higher than budgeted which offset the reduction in elective activity. It was agreed that the Director of Finance would confirm elective activity for 2016/17 in comparison to the current year.

Action: C Anderson

The Committee discussed pay spend which was above Quarter 1 Forecast and budget due to Berkshire Surrey Pathology Services (BSPS) and unutilised contingencies. The Director of Finance advised that detailed reviews were being carried out including maternity and elderly care.

The Committee noted the phasing of capital expenditure for 2017/18 and noted planned spend in relation to business cases which had been approved by the Board in January 2017 were not due to be spent until December 2017/January 2018. The Director of Finance gave an update on estates issues which had delayed spend in relation to the Maternity Higher Monitoring Area (HMA) and the Cardiac Catheterisation Laboratories

2


(CCLs). The Committee recommended that interim approval of business cases should be submitted to the Committee in the first instance and final approval only sought from the Board once detailed project plans had been confirmed. Action: C Anderson

It was agreed that progress updates on the Maternity HMA, CCLs and Pathology projects would be submitted to the next meeting. Action: C Anderson

120/17 Quarter 2 Forecast

The Director of Finance advised that the Quarter 2 Forecast was £6.20m which was marginally ahead of budget but full sustainability monies had been included which assumed the ED performance trajectory would be achieved. The Director of Finance advised that Care Groups were forecasting £1.3m shortfall against budget but this was offset by underspend in the corporate areas, reduction in central depreciation and leases costs. The Director of Finance advised that £2m of the restructuring budget was anticipated. Costs related to restructuring included the CEO transformation fund, restructure of the Programme Management Officer, central finance team, procurement, redundancies as a result of the RFID project in addition to funding for the Associate Medical Directors roles, Digital Hospital programme and the Freedom to Speak Up Guardian role.

The Committee noted that the Executive team had discussed whether recovery actions should be sought from Care Groups. However, it had been agreed that Care Groups should be asked to collectively deliver their forecast instead. The Committee sought confirmation that Care Groups were committed to deliver their forecast. The Director of Finance confirmed this was the case. The Chief Executive advised that there was an increased focus by Care Groups on delivery and therefore the Executive were more assured. A list of actions had been prepared by the Care Groups for Executive review.

121/17 QiPPs 2017/18 Update

The Chief Operating Officer advised that the current PMO risk assessment of the 2017/18 programmes was £14.9m against a target of £16.9m. It was agreed that a detailed review of the IM&T and Estates Business As Usual programmes would be provided to the November meeting. Action: M Sherry

122/17 Berkshire West Accountable Care System (ACS) Update

The Director of Finance introduced the report which set out the progress made by Berkshire West ACS in relation to delivery of the Five Year Forward View (5YFV) aims and sought approval for the further development of the system control totals and new contract forms. The Director of Finance advised that the current system gap was £10m. NHS Improvement and NHS England supported the move towards new contract forms. It was noted that the system risk for all organisations in the Berkshire West ACS would be visible as part of the new contract forms. The Director of Finance advised that for 2018/19 the Trust would have an allocated share to meet the system gap.


124/17 Cardiology Implantable Cardioverter Defibrillators (ICDs) and Pacemakers

3



125/17 Acute Contract Update

The Director of Finance introduced the report which set out an update in relation to CCG and NHS England acute contracts for 2017-19. The Director of Finance highlighted the risks in relation to 2017/18 CQUINs.


127/17 MModel Contract

The Director of Finance introduced the report which sought approval to award a contract to MModel for voice recognition transcription service, technology and implementation support as part of the Digital Exemplar Programme. The Director of Finance advised that the transcription contract was part of the Exemplar Programme which the Board had approved in July 2017. The MModel contract was £2.27m over 5 years and the cost included a fixed yearly technology fee of £240k. The solution would deliver savings of £550k in the first year and £863k each year in subsequent years.

The Director of Finance confirmed that the capital component of the project was in line with the Quarter 2 Forecast. The Committee approved the procurement of the MModel transcription service and recommended that a post implementation review should be scheduled in due course. Action: C Anderson


The work plan was noted.



• Review of September Finance performance• Detailed review of the Quarter 2 Forecast• Approved the ICDs and Pacemaker supply contract• Approved the MModel contract as part of the Digital Exemplar Programme• Reviewed updated on the MSK structured collaboration programme.


The next meeting would be held on Monday 20 November at 10.00am.

SIGNED:

DATE:

4

Agenda Item 13b

Audit & Risk Committee Wednesday 20 September 2017 9.30 – 12.05 Boardroom, Level 4, Royal Berkshire Hospital

Members

Mr. Brian Hendon (Non-Executive Director) (Chair) Dr. Alison Hill (Non-Executive Director) Mr. John Petitt (Non-Executive Director)

In attendance

Advisors Ms. Sue Barratt (Partner, Deloitte) Mr. Matt Gould (Senior Manager, PwC) Ms. Debbie Kinch (Local Counter Fraud Specialist) (up to minute 97/17) Mr. Paul Thomas (Senior Manager, Deloitte) Ms. Alice Wainwright (Senior Associate, PwC) (up to minute 98/17)

Trust Staff Mr. Steve McManus (Chief Executive) Mr. Craig Anderson (Director of Finance) Mr. Graham Butler (Deputy Director of Finance) Mrs. Angela Gardiner (Group Financial Controller) (up to minute 96/17) Mrs. Caroline Lynch (Trust Secretary) Mr. Mike Robinson (Associate Director of Infrastructure) (for minute 95/17) Ms. Mary Sherry (Chief Operating Officer) (for minute 101/17) Mr. Graham Sims (Chairman of the Trust)

92/17 Minutes: 15 May 2017

The minutes of the meeting held on 15 May 2017 were approved as a correct record and signed by the Chair subject to the following amendment:

Minute 66/17: External Audit Report: The fourth sentence would be amended to read: “The Partner, Deloitte advised that the Annual Governance Statement would be updated ahead of the audit opinion being issued.”

93/17 Matters Arising Schedule


Minute 60/17 (30/17): Matters Arising: Whistle Blowing Update: The Chair advised that the Freedom to Speak Up Guardian (FTSU) would be presenting an update at the September Board meeting. In addition, the Chair was due to meet with the FTSU Guardian later that day.

Audit & Risk Committee

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Audit & Risk Committee Minutes September 2017

Minute 60/17 (31/17): Matters Arising: Reference Costs Recommendations Action Plan: The Director of Finance advised that the data warehouse was being updated as part of the Data Quality Assurance Programme. The tariff rules had been re-written on the data warehouse. However, this was subject to continual audit and further changes could be required. The Committee noted that there had been historic issues in relation to Referral to Treatment (RTT) and ED data quality. However, the on-going data quality assurance work had not identified any material issues.

The Committee noted that the Medical Director had confirmed that the three job plans not up to date had been completed and there was an iterative process to update and change job plans as necessary.

Minute 68/17: Cyber Attack Update: The Director of Finance advised that the serious incident process had been followed in relation to Cyber Attack. A copy of the draft report would be circulated to the Committee. Action: M Robinson

Minute 77/17: Health & Safety Committee Minutes: The Committee discussed Health & Safety including compliance with fire, water, gas and electricity. The Director of Finance advised that the fire policy was reviewed on an annual basis and the Fire Safety Officer also carried out audit testing. Independent assurance from the Fire Brigade had also been received and the Trust was rated as ‘broadly compliant’ which was the highest rating possible. Water hygiene was monitored by the Estates Management Assurance Group (EMAG) and an audit process was in place for low pressure gas. It was agreed that the Director of Finance would circulate the current status of compliance during October 2017.

Action: C Anderson

The Director of Finance advised that a six facet survey, which would include compliance, was on-going and a further update would be provided during November/December 2017. In addition, an external review of Health & Safety was also underway and would be reported by December 2017. Internal audit were also scheduled to undertake a further review of Health & Safety during Quarter 1 2018/19. Action: C Anderson

An update on Health & Safety reviews planned would be reported to the September Board. Action: C Anderson

The Committee discussed the current Health & Safety indicators in the Integrated Performance Report. It was agreed that the information included in the report would be reviewed. Action: C Anderson/J Petitt

94/17 Declarations of Interests

There were no declarations of interests.


96/17 Charity Accounts 2016/17

The Director of Finance introduced the Charity Accounts 2016/17 and advised that the same process used for the Trust’s accounts had been followed. External audit would be issuing a standard letter of representation. The Partner, Deloitte, advised that the audit review had been completed and no major issues had been identified. There had been a focus on legacy income and consideration of any management override. One point of discussion included restricted and unrestricted funds designated to wards. The Director of Finance advised that

Audit & Risk Committee Minutes 2


a standard process had been followed in relation to funds donated to specific wards and therefore these funds were treated as restricted to the specific ward. An administrative charge was levied to ensure central funds were not used. The Committee noted that the Charity Committee were considering the strategy of the Charity in order to raise the profile and to identify a major appeal.

The Committee queried the audit fee for the Charity Accounts. The Director of Finance confirmed this was £5k excluding VAT.

The Committee agreed that a recommendation should be submitted to the Charity Committee to approve the consolidated Charity Accounts 2016/17 and to authorise the Director of Finance to sign the letter of representation. Action: C Anderson

97/17 Counter Fraud Progress Report

The Local Counter Fraud Specialist (LCFS) introduced the report and advised that, as part of the Trust’s participation in the National Fraud Initiative exercise, seventeen data matches were still outstanding and one case had been referred to the immigration authority.

The LCFS advised that three new referrals had been received that related to various issues which demonstrated good fraud awareness in the Trust. The Director of Finance advised that, previously, all issues raised with the LCFS were dealt with by the LCFS. However, management review of all issues raised was now undertaken. However, the LCFS maintained a register and also monitored progress of issues raised.

98/17 Internal Audit Progress Report

The Senior Manager, PwC, introduced the report and drew attention to the review scheduled for completion in the next quarter; Hospital at Night, Key Financial Systems, Follow-Up, Corporate Governance and Risk Management. The Senior Manager, PwC advised that the Health and Safety review had been deferred to be completed during Quarter 1, 2018/19.

The Senior Associate, PwC, advised that a medium risk had been issued as part of the Care Group governance review. Care Group management meetings had been observed as part of the review. Terms of reference for each of the Care Groups had not been maintained. The Committee discussed delegated authority for the Care Groups. The Chief Executive confirmed that authority for Care Group colleagues was, as set out in the Trust’s Standing Financial Instructions (SFIs). The Senior Associate, PwC, advised that there were various levels of discussion in relation to risks across the Care Groups but this was known by the risk management team and related to extraction of data from the Datix system. The Committee noted that Care Group risks were discussed as part of the on-going monthly performance meetings with the Executive. It was agreed that the timing of a follow up internal audit review would need to consider the timescale for the refresh of the Trust strategy. The Senior Manager, PwC, confirmed that the findings of the review had been reviewed with the Chief Operating Officer and Care Group representatives. An action plan from the review would be developed which would be monitored as part of the audit recommendations standard process. The final report would be submitted to the Committee in due course.

Action: M Gould

The Senior Manager, PwC, drew attention to the Sector Update. The Director of Finance advised that the Trust’s financial reporting processes had been subject to an external review which had reported that processes were satisfactory.



99/17 External Audit Progress Report

The Partner, Deloitte, advised that a post audit meeting had been held with the finance team. The audit of the Charity Accounts had been completed. The audit of HFMS Accounts was currently on-going and these would be submitted to the November meeting.

100/17 Audit Recommendations Update

The Deputy Director of Finance introduced the report and advised that there were no requests to remove or amend delivery dates. There were seven reports with outstanding audit actions. Of the 37 actions in those reports, 23 had been completed and five were overdue. The Deputy Director of Finance gave an update on the five overdue actions. It was agreed that the Cyber Security action would be cross referenced to the Cyber update submitted to the Committee. Action: G Butler

101/17 Data Quality Assurance Programme Update

The Chief Operating Officer introduced the report and advised that the upgrade to the Cerner platform had taken place that day. The Chief Operating Officer advised that in order to provide the ED performance data returns there was significant reliance on the Cerner solution to deliver these. All other actions in the Data Quality Assurance Programme were on target.

The Committee queried whether the Draper and Dash reviews had identified any material data inaccuracies. The Chief Operating Officer confirmed that no material data inaccuracies had been identified by the review.

The Committee discussed the schedule of reporting in relation to Data Quality. It was noted that internal audit would carry out further reviews. The Committee noted the significant improvement achieved in relation to Referral To Treatment (RTT) data. The Chief Operating Officer highlighted that the Trust had been asked to share best practice with other trusts. The Chief Operating Officer confirmed that greater assurance had been achieved overall. However, there would be a continuous process on-going to review data quality. The Director of Finance confirmed that all datasets were being reviewed in order to provide assurance to the Board regarding the quality of data.

102/17 Board Assurance Framework (BAF)

The Trust Secretary introduced the BAF and advised that, following review by the Executive team, there had been no change to the current risk ratings. The Trust Secretary advised that the format of the BAF would be revised following refresh of the strategic objectives.

103/17 Corporate Risk Register (CRR)

The Head of Risk Management introduced the report and advised that the format of the report had been amended in order to link to the strategic imperatives.

The Committee discussed the language used in the report and agreed that the Integrated Risk Management Committee should be asked to consider the style of language used in relation to the level of risk. It was agreed that the Director of Finance would liaise with the Head of Risk Management and members of the Integrated Risk Management Committee and a post meeting note would be added to the minutes to outline the revised update.

Action: C Anderson



The Committee discussed each of the recommendations from the Integrated Risk Committee in relation to de-escalation of risks and risk scoring.

The Head of Risk Management advised that in relation to the safe storage of medicines in clinical areas that the controls would be in place by the time of the next review. A new risk in relation to Care Quality Commission (CQC) standards would be reviewed after the CQC inspection. The risk score related to meeting ED clinical standards had been maintained at 16. A new risk in relation to Pathology service quality and standards had been entered ontothe CRR. The Chair queried the score for this risk. The Chair of the Quality Committee advised that the Quality Committee had reviewed the serious incident in relation to Maternity and the Pathology service at its recent meeting. The Committee recommended that the Integrated Risk Management Committee should consider whether the current risk score was appropriate. Action: C Ainslie

The Committee noted the risk score in relation to Cyber Security and recommended that the Integrated Risk Management Committee should be asked to consider whether the current risk score was appropriate. Action: C Ainslie

The Committee noted the recommendation to de-escalate the compliance to Electricity at Work Regulations risk. It was considered that the current risk score should be retained on the CRR until the external review had been completed. Action: C Ainslie

The Committee discussed estates risks in relation to the CRR. The Chief Executive advised that the estates strategy development was linked to the development of the Clinical Services Strategy.

The Committee discussed the risk scores in relation to retention and recruitment and recommended that these should be reviewed by the Integrated Risk Management Committee with a view to assurance provided in relation to the current risk score.

Action: C Ainslie

104/17 Health and Safety Committee Minutes

The Committee received the minutes of the meetings held in May and July 2017. The Director of Finance advised that the level of Board assurance in relation to Health & Safety would be addressed by the external reviews discussed earlier in the meeting.

The Director of Finance advised that the first outcome of the Health & Safety audit was reviewed at the last Health & Safety Committee meeting. The focus for the Committee was risk assessments, Health & Safety awareness and mandatory training. The Chair highlighted the discussion at the July meeting in relation to the statement regarding a Fire Safety management system. It was agreed that the Director of Finance would clarify the current arrangements to the Committee. Action: C Anderson

The Committee noted poor attendance at meetings and also delays in actions being progressed. The Director of Finance confirmed that the Health & Safety Committee were reviewing attendance at meetings and would reintroduce a matters arising schedule to ensure actions were completed in a timely manner.

105/17 Bank Account Authorisations

The Committee noted that there had been no amendments to the Trust’s signatory panel for the Trust and the Royal Berks Charity since the last meeting of the Committee.




107/17 Losses and Special Payments

The Committee noted that, since the last meeting, there had been four payments for other losses to the value of £13,009.90 and eight special payments approved to the value of £7,952.46 which included two legal services cases.

108/17 Use of Single Tenders

The Committee noted that there had been four single tenders awarded since the last meeting of the Committee.

109/17 Review of Non Audit Services

The Committee noted that there were no non-audit services which had been completed or were currently being undertaken by Deloitte. It was agreed that annual updates would be provided to the Committee going forward. Action: C Anderson

110/17 Schedule of Significant Contracts

The Committee noted that there had been four significant contracts awarded since the last meeting of the Committee. The Director of Finance would confirm if the contract related to digital dictation and speech recognition services had been approved by the Board.

Action: C Anderson 111/17 Review of Standing Financial Instructions (SFIs)

The Deputy Director of Finance introduced the revised SFIs which were presented with tracked changes as requested by the Committee. There had been no material changes made to SFIs. However, they had been revised in order to make the document more user friendly for staff. The Committee agreed that the revised SFIs, with tracked changes, should be submitted to the Board for approval. Action: C Anderson

112/17 Audit Committee Work Plan 2017/18

The Committee noted the work plan for 2017/18.


It was agreed that key issues to draw to the attention of the Board included:- • Health & Safety external review and six facet survey incorporating compliance on-

going with follow up internal audit work planned for 2018/19. • Cyber Security Update received• Charity Accounts 2016/17 reviewed and recommended for approval to the Charity

Committee• Counter Fraud, Internal Audit and Data Quality Assurance Programme updates

received• Review of the BAF and CRR• Non-NHS debt reviewed• Four significant contracts awarded


It was agreed that the next meeting would be held on Thursday 9 November 2017 at 9.30am.



115/17 Private Meeting with External Audit It was agreed that a meeting with Deloitte was not required as there were no specific issues

for discussion. 116/17 Private Meeting with Internal Audit It was agreed that a meeting with PwC was not required as there were no specific issues for

discussion. 117/17 Private Meeting of the Committee It was agreed that a meeting of the Committee was not required as there were no specific

issues for discussion. Chair: Date:


Agenda Item 13c

Charity Committee Wednesday 20 September 2017 15.00 – 17.00 Boardroom, Level 4, Royal Berkshire Hospital

Present Mr. Graham Sims (Chairman of the Trust) (Chair) Mr. Craig Anderson (Director of Finance) Mr. Steve McManus (Chief Executive) Dr. Sunila Lobo (Public Governor, Reading)

In attendance Mr. Ian Thomson (Charity Director) Mr. Mark Arnold (Deputy Trust Secretary)

17/17 Declarations of Interests

There were no declaration of interests.

18/17 Minutes for Approval: 31 May 2017 and Matters Arising Schedule

The minutes of the meeting held on 31 May 2017 were approved as a correct record and signed by the Chair.


Minute 10/17: Management Accounts: The Director of Finance advised that effective use of investments would form part of the Charity Strategy which would be presented to the Committee in December. It was agreed that this action would be deferred until the strategy had been developed. Action: C Anderson

19/17 Management Accounts

The Director of Finance introduced the management accounts for the period 1 April to 31 August 2017. The Chair clarified that the accounts related to the Royal Berks Charity only and did not include any information regarding the merger with Reading and District Hospitals Charity (RDHC).

The Committee discussed requests for gift aid donations. The Charity Director advised that if a donor had requested gift aid payment previously then this would be included automatically. However, if a new donor came forward then they would be provided with a gift aid form. The Chair confirmed that gift aid payments should be monitored to ensure payment was correct.

The Director of Finance advised that the current operating costs of 34%, against the budget of 17%, were due to costs relating to running the Soapbox Challenge event which was held on 19 August 2017, such as equipment costs and advertising. Due to the timing of the event, the funds received were not yet included in the accounts.

Minutes

1

Minutes of the Charity Committee 20 September 2017

The Committee discussed the trajectory of the funds. The Charity Director highlighted that there was an overall target to increase funds but also a need to spend funds. The Director of Finance advised that cash was monitored and there were spending plans in place. The Committee requested that further information should be included in the report to set out the amount of cash, reserves, spending plans in place and remaining funds not included the reserves or a spending plan. Action: C Anderson The Chair advised that the Charity Accounts would need to be submitted to the Committee prior to being submitted to the Audit and Risk Committee. The Director of Finance would confirm that the dates scheduled for Committee meeting would comply with submission of the accounts to the Charity Commission. Action: C Anderson

20/17 Charity Director’s Report

The Chair congratulated the Charity Director following his substantive appointment to the role. The Charity Director introduced the report and advised that total income had increased by 15%. The major donor income figure and net legacies had also increased. Spending had increased in comparison with the previous year. It was confirmed that £900k was reserved for the Linear Accelerator (LINAC) project which would be spent in the current year. The Committee discussed the merger with RDHC. The Charity Director advised that he had been working with the finance team at RDHC and the target date for completion of the merger was early October 2017. The Chair clarified that once the merger had been completed the Charity would have responsibility for employees, cash, liabilities and property formally owned by RDHC. The Charity Director confirmed that two employees had already transferred to the Trust. The Director of Finance also confirmed that the Charity would own the Melrose House property. The Chief Executive queried whether the new employees would adopt the Charity’s processes in relation to spending. The Charity Director advised that the cash transferred to the Charity would be restricted funds. However, the role of staff would be realigned with the Charity’s strategy in relation to unrestricted funds. The Charity Director circulated the draft ‘Thank You’ magazine to the Committee. 8,000 copies of the magazine would be published. The Committee discussed the LINAC appeal. The Director of Finance advised that approximately £900k had been donated before the campaign had been launched which could be used to purchase additional equipment or for the refurbishment of the bunkers. A further £100k had been raised after the campaign had been launched. In order to spend the £100k on either additional equipment or the refurbishment of the bunkers, a letter and media statement were required to offer money back to donors. The Chair confirmed that the letter to donors should be reworded to state that there would be a guarantee that any donations would be used towards equipment or to the bunker refurbishment and to offer a refund if requested. The amended letter would not require approval by the Committee. Action: I Thomson The Committee discussed a capital appeal for the Charity. The Chief Executive advised that an appeal could not be developed until the Charity strategy had been agreed. The Charity Director gave an update on recent and upcoming events and projects. The Soapbox Challenge event had been a great success and a date for the same event next year had already been agreed for 18 August 2018. The South Block garden project was on course

Minutes of the Charity Committee – 20 September 2017 2

Minutes of the Charity Committee 20 September 2017

for completion on time and talks were on-going with the Benyon family regarding the date for opening. The Committee discussed sponsorship and the need to have internal guidelines in relation to external parties sponsoring events. The Chair confirmed that this would be deferred until the strategy had been agreed. Action: I Thomson

21/17 Charity Risk Register

The Charity Director introduced the risk register and advised that the ‘loss of key charity staff’ risk had been downgraded from 15 to 9 due to the substantive appointment of the Charity Director. The Committee discussed the score and confirmed that the likelihood would be lower but that the consequence of the risk would not change as a result of the appointment. The Director of Finance would re-consider the risk score. Action: C Anderson

The Chair requested that the Charity Accounts should include a section which stated how, as Trustees, the Committee was complying with its’ obligations. Action: C Anderson

22/17 Charity Strategy

The Charity Director gave a presentation. The Charity Strategy would include information on the strategic plan with Research and Development, investment in people, staff care plan, closer working, increased awareness and increased resources. The Chief Executive advised that the Charity Strategy would need to be aligned with the Trust’s Strategy. The Chief Executive, Director of Finance and Charity Director would meet to discuss strategic aims and link to them within the Trust’s strategy. Action: I Thomson

23/17 Charity Committee Work Plan 2017/18

The Committee noted the Charity Committee Work Plan for 2017/18.


It was agreed that the next meeting would be held at 15.00 on Wednesday 13 December 2017.

SIGNED:

DATE:

Minutes of the Charity Committee – 20 September 2017 3

Agenda Item 13d

Quality Committee Wednesday 11 October 2017 15.00 – 17.05 Boardroom, Level 4, Royal Berkshire Hospital

Members Dr. Alison Hill (Non-Executive Director) (Chair) Mr. Steve McManus (Chief Executive) (via conference call) Ms. Caroline Ainslie (Director of Nursing) Mr. Julian Dixon (Non-Executive Director) Mr. John Petitt (Non-Executive Director)

In Attendance Mr. Mark Arnold (Deputy Trust Secretary) Mrs. Jane Chandler (Deputy Director of Nursing & Governance) Dr. Janet Lippett (Care Group Director, Networked Care) Mrs. Caroline Lynch (Trust Secretary) Ms. Patricia Pease (Associate Director for Safeguarding and Mental Health)

(for minute 86/17) Mr. Graham Sims (Chairman of the Trust)

Apologies Dr. Lindsey Barker (Medical Director)



76/17 Minutes: 30 August 2017 and Matters Arising Schedule

The minutes of the meeting held on 30 August 2017 were approved as a correct record and signed by the Chair subject to the amendment of two minor typographical errors.

The Committee noted the matters arising schedule.

Minute 62/17 (52/17): Installation of Tutela Progress Report: The Committee requested that a date for when the transformation team would complete and report on the case study of the Tutela drug fridge temperature monitoring project. Action: M Sherry

Minute 63/17: Items Referred from the Board: Never Event: Retained Swab: The Director of Nursing confirmed that the investigation was on-going. There had been a discussion on swab counts with CQC inspectors during their visit to the Trust in September 2017. The investigation report would be submitted to the next meeting in December.

Action: C Ainslie

77/17 Items Referred from the Board: Legal Services Update

The Director of Nursing introduced the report and advised that the Head of Legal Services and recently, a paralegal had been recruited into substantive posts. The main challenge for

Minutes

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Quality Committee October 2017

the team had been to review the backlog of cases. The Director of Nursing advised that the current claims had been uploaded onto the Datix system. However, there was now a need to analyse the data in detail, categorise claims and identify themes. The Director of Nursing advised that information on serious incidents was discussed at local clinical governance meetings and shared with relevant teams at the time the incident occurred.

The Committee queried how learning from incidents was shared with staff. The Deputy Director of Nursing & Governance advised that learning from incidents was shared at various stages; feedback was provided at the time of the incident. In the case of a serious incident, feedback was shared after the investigation had been completed. If a claim arose from the incident then this would be submitted to the Board. There was often a long delay in clinical negligence claims being submitted to court. However, these cases would have been reviewed as part of the serious incident process at the time of the incident itself in order to identify themes and further learning.

78/17 Items Referred from the Board: Never Event: Wrong Site Surgery

The Director of Nursing introduced the report which set out details as to how the incorrect toe had been incised. The Director of Nursing highlighted that since the incident the safety pause had been well embedded into all theatres in line with the World Health Organisation (WHO) checklist. In this particular case, the mark on the toe to be incised had been visible and the correct pen had been used.

The Committee discussed how learning was disseminated to staff. The Director of Nursing confirmed that Quality Governance reports were issued monthly and followed up by teams. Morning briefings were held and all theatre teams discussed incidents and fed back to any staff who were not present. It was confirmed that Matrons also performed spot checks in theatres and there was a management team responsible for training staff and ensuring learning was disseminated.

79/17 Quality Account Update

The Director of Nursing introduced the report and highlighted work undertaken in relation to retention. A recruitment Open Day had been held. However, it remained a challenge to recruit nursing and midwifery staff.

The Committee discussed the Digital Hospital Programme and the quality of information available. The Chief Executive confirmed that the Connected Care portal was visible on the Electronic Patient Record (EPR) system and showed information held by other partner organisations, such as local authorities, community and mental health providers, as well as other acute trusts. This platform would become increasingly useful as further information was added to the portal.

The Chief Executive highlighted that the Outpatient electronic system was currently being implemented in a number of services. The Deputy Director of Nursing & Governance advised that progress was slow at present but the system would be used more widely in future. The Committee queried if there was sufficient clinical involvement in implementing electronic systems and whether staff were being supported to use them correctly. The Chief Executive advised that doctors from each Care Group as well as nursing staff were part of the core implementation team.

The Director of Nursing advised that the sepsis target had been achieved and highlighted the good work and performance of the sepsis team. It was also highlighted that the priority for reducing cancellations had improved.

2


The Committee discussed car parking. The Chief Executive advised that alternative solutions such as automatic number plate recognition were being considered and strategies were also being discussed with the local council and Reading Buses. The Committee queried when the barrier to the car park would be fixed and when a timetable for remedial work such as remarking of spaces would be available. The Chief Executive would liaise with the Director of Finance to confirm this. Action: S McManus

80/17 Quality Strategy Update

The Deputy Director of Nursing & Governance introduced the report and advised that the strategy had been substantially re-written to demonstrate how it aligned with the CQC framework domains: safe, effective, caring, responsive and well led. It was emphasised that this was a first draft of the report and targets and objectives were yet to be formulated. The Deputy Director of Nursing & Governance advised that the CQC inspection report outcomes would be included in the final version. Recommendations from the inspection would form the basis of objectives in the report.

The Deputy Director of Nursing & Governance advised that further information would be included in the next draft of the report and feedback received through the What Matters programme. The Director of Nursing advised that a section on development of safety culture would be added to the report. It was agreed that a further update would be submitted to the next meeting in December. The Director of Nursing advised that the CQC inspection report would not be available until December so further objectives would not be included in the December version. Action: C Ainslie

81/17 Corporate Risk Register (CRR)

The Director of Nursing introduced the report and advised that it was anticipated that the scoring of Emergency Department (ED) risk would increase due to the early effects of Winter. It was highlighted that the key risk related to workforce.

The Director of Nursing advised that the risk score for the safe storage of medicine was likely to reduce or be de-escalated from the CRR. A new electronic system had been implemented in September. However, the risk score related to the August review and the new system had not yet been recognised in the risk score.

The Committee noted that there was a new risk relating to pathology service quality and standards. This risk was due to be discussed at the next Integrated Risk Management (IRM) Committee. Action: L Barker

82/17 Serious Incident Annual Report

The Director of Nursing introduced the report and highlighted that the number of serious incidents for delayed treatment and recognising a deteriorating patient were increasing. The Deputy Director of Nursing & Governance advised that extra training had been provided to staff on recognising a deteriorating patient. However, it was a challenge for staff due to the high number of patients being admitted. Staffing levels and acuity of patients was also a contributory factor.

The Committee noted that there was a higher number of incidents in maternity, however, this was in line with the risk level recorded based on the expected type and condition of patients treated in maternity. It was also noted that there was a high number of patient falls in elderly care, which was related to the type of patients being treated. However, there had been no increase in harm suffered as a result of falls.

3


The Committee discussed the theme of poor documentation or communication contributing to an incident. The Deputy Director of Nursing & Governance advised that incidents were multi-faceted and this was a common theme. However, this was not usually a direct cause of an incident. It was advised that handovers were being completed. However, this was an area for improvement. The Committee discussed the Digital Hospital programme and how electronic records could improve communication and documentation. It was highlighted that, during implementation, there would likely be dual processes and staff would need to take extra care to ensure all records were updated and where to look for information.

83/17 Quarterly Updates on Serious Incident Themes

The Director of Nursing introduced the report and highlighted that severe harm falls and pressure ulcers remained low.

The Committee queried the length of time to complete an investigation related to a serious incident. The Director of Nursing advised that there were national frameworks which dictated when an incident had to be reported on the external incident reporting tool, known as STEIS, and the maximum time allowed before an incident was closed. It was noted that, in some instances, incidents were identified, for example, when reviewing notes for a follow up appointment. The incident date was recorded as the date the incident occurred, which could seem that an incident had not been resolved in a timely manner.

The Director of Nursing confirmed that commissioners and the CQC monitored the time taken to close serious incidents and completion of action plans.

84/17 CQC Landing Outstanding

The Director of Nursing advised that the CQC were currently on site for the first day of the ‘well led’ part of the inspection process which was scheduled to last for 3 days. This part of the inspection involved holding focus groups with various staff roles and interviews with senior management. It was highlighted that the focus group with the administration team had taken place and the initial feedback from this had been very positive.

85/17 Executive Quality Assurance and Learning Committee Exception Report

The Director of Nursing introduced the report that set out key issues, risks and themes discussed at the Quality Assurance & Learning Committee.

The Director of Nursing advised that there had been a Never Event reported in August which related to a retained swab. This was the second similar incident in Maternity. It was confirmed that the action log from the first Never Event had been completed. Learning from the first Never Event had highlighted new systems that were needed and the second incident related to a Human Factors issue as the doctors involved had signed to confirm the number of swabs which should have been present.

The Committee noted the number of incidents relating to medication errors had increased as pharmacy had previously been low reporters of incidents. However, the number which had resulted in harm had not increased.

The number of C.Diff cases in the current year had increased to 10, five of which were as a result of lapses of care. The Committee noted that an anti-microbial pharmacist had been appointed.

4


The Director of Nursing advised that an internal review of clinical governance meetings had taken place. Care Groups had been given feedback to improve. It was recommended that a copy of this report would be submitted to the next meeting. Action: C Ainslie

The Deputy Director of Nursing & Governance advised that there was a national CQUIN to reduce the use of antibiotics by 2%. The Trust was already a low user of antibiotics and to reduce the amount by 2% proved a challenge. The Deputy Director of Nursing & Governance confirmed that the target for the Trust was a 1% decrease in the use of antibiotics.

The Director of Nursing highlighted that the Trust had been identified as a potential outlier in the National Maternity and Perinatal Audit for Post-Partum Haemorrhage (PPH). A response had been submitted and this would be circulated to the Committee.

Action: L Barker

86/17 Safeguarding Annual Report

The Associate Director for Safeguarding and Mental Health introduced the report and highlighted that activity had increased in almost all areas and the general complexity of cases was also increasing.

The Committee noted the training compliance had improved; Level 3 compliance was 91% and Level 1 child protection was 93%.

The Associate Director for Safeguarding and Mental Health advised that a project started in 2016/17 with Berkshire Healthcare NHS Foundation Trust to address adults re-attending hospital. The Trust was on target to achieve the CQUIN for this. However, the Digital Hospital programme would need to link with safeguarding to ensure continued partnership working.

The Committee approved the report subject to the correction of the name of the Quality Committee on page 5.


The Trust Secretary advised that the work plan required updating. The Medical Director was due to confirm when the Pathology Implementation Update and the Avoidable Death Review would be submitted to the Committee. Action: L Barker

Items reviewed by the Committee would be removed from the work plan and items agreed for submission to the December meeting would be added to the work plan.

Action: C Lynch



• Increase in delayed treatment and recognising a deteriorating patient as themes inserious incidents

• Safeguarding Annual Report approved• Never Event: Wrong Site Surgery report received• Draft Quality Strategy reviewed

5



It was agreed the next meeting would be held on Wednesday 6 December at 2pm.

Signed:

Date:

6

Agenda Item 13e

Workforce Committee Monday 30 October 2017 10.00 – 11.55 Boardroom, Level 4, Royal Berkshire Hospital

Members Mr. Julian Dixon (Non-Executive Director) (Chair) Ms. Caroline Ainslie (Director of Nursing) Mr. Craig Anderson (Director of Finance) (up to minute 45/17) Dr. Lindsey Barker (Medical Director) (up to minute 45/17) Mr. Don Fairley (Director of Workforce) Mrs. Sue Hunt (Non-Executive Director) Mr. Steve McManus (Chief Executive) (up to minute 45/17) Ms. Mary Sherry (Chief Operating Officer) Mr. Graham Sims (Chairman) (up to minute 45/17)

In Attendance Mr. Mark Arnold (Deputy Trust Secretary) Mrs. Suzanne Emerson-Dam (Deputy Director of Workforce) Mrs. Caroline Lynch (Trust Secretary) Ms. Rosalind Penny (Assistant Director of Organisational Development)



41/17 Minutes: 31 July 2017 and Matters Arising Schedule

The minutes of the Workforce Committee meeting held on 31 July 2017 were approved as a correct record and signed by the Chair. The matters arising schedule was noted.

Minute 31/17 (25/17): Matters Arising Schedule: Pay Award for Non-Agenda for Change Staff: The Committee noted that work had been commissioned to review Care Group structures and to link pay to aims and objectives. The Chair requested that proposals should be submitted to the Committee in May 2018. Action: D Fairley

Minute 31/17 (15/17, 03/17): Matters Arising Schedule: Workforce Key Performance Indicators (KPIs): The Committee noted that not all information had been captured on the report as junior doctors and senior doctors’ absence was recorded in different systems. The Trust was considering an e-rostering system that would record this data. The Director of Workforce would provide an update on the usage of the system at the next meeting. Action: D Fairley

Minute 31/17 (15/17, 10/17): Matters Arising Schedule: NHS Professionals Key Performance Indicators (KPIs): It was confirmed that the joint tender with Berkshire Healthcare for temporary staffing contract would be submitted to the Finance and Investment Committee in November. The Chair requested that an update should be submitted to the Committee in May 2018.

Action: D Fairley

Minutes

1

Workforce Committee 30 October 2017

Minute 31/17 (24/17): Staff Engagement and Retention Review: The Committee discussed the status of the review in relation to the ‘What Matters’ Programme. The Director of Finance advised that the review was an internal audit. The Committee confirmed that the data should be incorporated into the ‘What Matters’ Programme and identified gaps would form part of plans at directorate level.

Minute 36/17: Recruitment and Retention Update: The Committee noted that nursing staff recruited from overseas would work at the Trust for 3 years and there were a number of overseas staff expected in 2018.

42/17 Workforce Key Performance Indicators (KPIs)

The Director of Workforce introduced the report and advised that the vacancy level continued to be a challenge.

The Committee noted that the MAST compliance rate had improved. However, this was below the target rate. The annual appraisal rate had decreased to 80% against a target of 90%. The Committee discussed the various staff groups and levels of compliance. The Director of Finance advised that the Management & Administrative staff group was recording 80% compliance. However, the actual figure was approximately 90%. The Director of Finance would review the quality of the data. Action: C Anderson

The Director of Workforce advised that high turnover negatively affected the appraisal rate. The Committee discussed issues in relation to the Electronic Staff Record (ESR) system. The Director of Workforce advised that a business case was being investigated for an electronic system to record appraisal rates. Action: D Fairley

The Committee discussed the vacancy rate and costs in relation to agency and bank staff used to fill the gaps. It was noted that staffing was recorded on the Corporate Risk Register. The Committee recommended that further detail in relation to vacancies and costs of using temporary staff should be included in KPIs going forward. Action: D Fairley

43/17 Agency Spend

The Director of Workforce introduced the report and advised that NHS Improvement had changed their monthly reporting requirements to include bank staff spend as well as agency spend. The Chair highlighted the work undertaken previously by the Trust to reduce agency spend.

The Director of Finance advised that the list of administrative and clerical temporary staff had been reviewed on a case-by-case basis and, where possible, transferred to zero hours contracts. It was agreed that an update would be provided to the Committee in May 2018.

Action: D Fairley 44/17 Workforce and Organisational Development (OD) Strategy Update

The Director of Workforce introduced the report which set out an update on progress with the Workforce and Organisational Development Strategy. The next phase of the implementation plan was to develop a People Strategy which would incorporate the feedback from the ‘What Matters’ Programme.

45/17 Draft People Strategy

The Director of Workforce introduced the draft People Strategy and advised that further work was required to include additional links and references to the Clinical Services Strategy.

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The Committee discussed the draft Vision statement and how this should represent the ambition of the Trust and how specific areas, such as staff retention, should also link into the Vision statement. The Committee discussed the idea of ‘what a great place to work’ meant to staff at the moment, what this would look like in five years and what it could look like for future generations. It was agreed that the Vision of the Trust should also portray compassion for patients and also consider financial sustainability, staff housing and accommodation and transport links.

The Committee discussed the Mission statement and considered the need to emphasise opportunities, including career development, use of technology, on the job training, research opportunities or simply to make a difference in the area where staff lived. The Chief Executive suggested that the Mission statement should also reference the long history of the Trust. The Committee discussed the themes identified in the People Strategy. It was agreed that there should be recognition of opportunities as a theme in the strategy. The Committee recommended wellbeing, reward and recognition, learning and development including leadership development, equal opportunity and new ways of working should be highlighted as themes, in some way.

It was agreed that the language of ‘What Matters’ should also be incorporated into the strategy. It was also recommended that staff engagement was required to further develop the Mission statement ahead of the submission to the Board in January. Action: D Fairley

46/17 WRES and EDS Update Report

The Committee received the report, noting activities delivered since May 2017, which included the formation of Black and Minority Ethnic (BAME) staff forums, career surgeries and the senior leadership development programme.

The Director of Workforce gave an update on the progress of the Trust’s Equality Delivery System 2 (EDS2) monitoring and highlighted the ‘appointment’ of five volunteer BAME role models and an engagement event held with the Nepalese community.

The Committee discussed the Gender Pay Gap and the need to review data from the Clinical Excellence Awards in relation to values awarded to male and female clinical staff. The Committee discussed the WRES data. It was agreed that appropriate measures and metrics would need to be developed. The Committee recommended that the focus of the metrics should be on retention.

Action: D Fairley

The Committee discussed the Workforce Disability Equality Standard (WDES) reporting standard. The standard would focus on experience of staff with disabilities in the organisation. It was confirmed that the date for completion of the report had been amended to 2019.

The Committee discussed the BAME forum and the need to balance general fairness. The Committee discussed the pros and cons of a forum for BAME staff and the need to ensure equal opportunities for all staff, ensuring we make effective provision for those with disabilities and equal pay for men and women. It was agreed that BAME staff were more likely to require a platform to develop their careers.

47/17 Skill Mix Review

The Director of Nursing introduced the report and advised that the reporting frequency had changed to annual. The report used the three expectations, identified by the National Quality Board (NQB), of right staff, right skills and right place and time.

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The Director of Nursing advised that the senior nursing team had met with all ward leaders. The skill mix review recommended an uplift of 2.65 WTE in the Acute Stroke Unit (ASU) to ensure there was one nurse per bay, the Acute Medical Unit (AMU) by 2.76 WTE to increase the number of co-ordinators to two per shift and to assist with management of patient flow and 4.47 WTE in paediatric Emergency Department (ED). The Committee agreed that the proposed changes to nursing skill mix as set out in the report should be acknowledged. The Director of Nursing advised that there could be further changes to AMU which would reduce bed numbers and negate the need for an additional co-ordinator. Some changes to Paediatric ED skill mix had already been actioned by the Urgent Care Group. The ASU recommendation would be considered further through the budget setting process. It was noted that the report would be submitted to the November Board. Action: C Ainslie

48/17 Guardian of Safe Working Update

The Committee noted the report and expressed their thanks to the author for the quality of the report.

49/17 Retention Update

It was agreed that the Retention Update would be deferred to the January meeting.

50/17 Review of Effectiveness/Annual Report

The Committee noted the report and agreed that this should be submitted to the Board for information. Action: C Lynch


The Committee noted the work plan.


The Committee reviewed the key issues to draw to the attention of the Board, which included:-

• Review of the draft People Strategy and noted the short timescale to complete furtherengagement.

• Workforce metrics to be developed further to focus on retention• What Matters language to be incorporated into the People Strategy as part of the round of

engagement• Agreed that the Skill Mix Review should be submitted to the Board.


It was agreed that the next meeting would be held on Wednesday 24 January 2018 at 10am.

Chair:

Date:

4

Workforce Committee Annual Report 2017

Julian Dixon Chair, Workforce Committee

Caroline Lynch Secretary, Workforce Committee

October 2017

October 2017 1


1 Summary 1.1 The purpose of this report is to give an update on the work on the Workforce Committee

over the past year, and to provide assurance to the Board that the Committee has carried out its obligations in accordance with its terms of reference.

2 Governance 2.1 The Committee was established in 2016 and the first meeting was held in July 2016. 2.2 The role of the Committee is to keep abreast of the external environment and the workforce

consequences and implications, and support the development of the workforce strategy and ensure strategic priorities are being addressed.

2.3 The Committee capture and review the views of staff via relevant staff engagement

mechanisms and develop effective strategies to respond to feedback. 2.4 The Workforce Committee monitor workforce metrics, review areas of concern and report

issues and plans to address them to the Board. The Committee requests and reviews reports and positive assurances from executives on the overall arrangement for Human Resources, workforce planning and learning and development.

2.5 Julian Dixon has been Chair of the Workforce Committee since its establishment in July

2016. 2.6 The Committee’s terms of reference were approved by the Board in July 2017. These are

attached as appendix 1. The Committee also maintains an annual work plan. 3 Meetings and Membership 3.1 The Committee met formally on four occasions between October 2016 and September

2017.

• 24 October • 30 January • 17 May • 31 July

3.2 The attendance record of members of the Committee is as follows:

Member Maximum Number of Meetings Number Attended

Julian Dixon 4 4 Sue Hunt 4 4

Graham Sims 4 2 Jean O’Callaghan 1 1 Steve McManus 3 1 Don Fairley 4 4 Caroline Ainslie, or - 3 Lindsey Barker 4 2 Mary Sherry 4 3 Craig Anderson 2 1

October 2017 2


3.3 The Trust Secretary has attended all meetings. Other Directors and staff have attended meetings during the course of the year to advise and to respond to questions from the Committee. These have included the Networked Care Group Director, Planned Care Group Director, Deputy Director of Workforce and Assistant Director of Organisational Development.

4 Assurance

4.1 The Workforce Committee have received the following annual reports during the year:

• Medical Revalidation • Organisational Development Framework • Staff Survey Results and Improvement Plan • Skill Mix Review • Terms of Reference • Workforce Race Equality Scheme Annual Report

The Committee also received 6-monthly updates on Medical Workforce Productivity.

4.2 The Committee also received regular quarterly reports including:

• Agency Spend • Guardians of Safe Working • Recruitment and Retention • Workforce Plan • Workforce Productivity

4.3 In addition to the regular assurance received from items on the work plan, the Committee

has sought and received assurance on the following specific issues: • Staff Engagement Plan • Conflict Resolution Training • Equality Diversity System (EDS2) • Nursing Revalidation • Talent Management • Succession Planning

October 2017 3


Appendix 1 Workforce Committee Terms of Reference Constitution and Membership The Committee will be appointed by the Board to develop and oversee delivery of the Workforce strategy. The Committee is non-executive in nature and will review and scrutinise papers and recommend to the Board and advise as necessary. The Committee will be chaired by a non-executive director. The membership will include at least one further non-executive director, the Medical Director, Director of Nursing, the Chief Operating Officer and the Director of Finance. Substitutes are not permitted. The quorum will be four members and will include at least two non-executive directors and two executive directors. Members are expected to attend three quarters of meetings in any one financial year. Attendance The Director of Workforce, Medical Director and Director of Nursing will be expected to attend all meetings. The Trust Secretary (or their nominee) will act as secretary to the Committee. The Committee may invite other staff or external advisors to attend for all or part of any meeting. Frequency of Meetings The Committee will meet at least four times a year and at such other times as may be required. Monitoring The work of the Committee will be kept under review by the Board. The Committee will conduct an annual review of its effectiveness with its terms of reference and submit any findings and proposals for changes to the Board of Directors for consideration. Duties The main duties of the group will be: To keep abreast of the external environment and the workforce consequences and implications.

October 2017 4


To capture and review the views of staff via relevant staff engagement mechanisms and develop effective strategies to respond to feedback. To support the development of the OD strategy to include recruitment and retention, education and training and employee wellbeing, prior to approval by the Board. To support the development of the workforce strategy, develop and monitor key measures to ensure strategic priorities are being addressed. To identify and monitor key workforce risks and ensure risks are appropriately included in the Board Assurance Framework. To monitor workforce metrics, review areas of concern and report issues and plans to address them to the Board. The Committee shall request and review reports and positive assurances from executives (directors and managers) on the overall arrangement for Human Resources, workforce planning and learning and development. To scrutinise systems and controls to ensure statutory and regulatory standards regarding workforce are met. To monitor workforce and data and review issues in relation to the development and implementation of relevant HR policies. Reporting The minutes of meetings will be formally recorded and submitted to the Board after each meeting. The Committee will review these terms of reference on an annual basis and report to the Board accordingly. Reviewed by the Committee: 17 May 2017 Approved by the Board: 26 July 2017

October 2017 5

Agenda Item 14

Focus Item Lead Freq May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18Chief Executive Report SM MonthlyTrust Strategic Refresh SM AnnuallyCorporate Risk Register and BAF CAi QuarterlyQuality Strategy CAi AnnuallyIntegrated Performance Report Exec Monthly

Director of Finance Report CA MonthlyQIPPs Update MS MonthlyNHSI Operating Plan CA AnnuallyNHSI Annual Self-Certification CA/CL AnnuallyQuarterly Forecasts CA QuarterlyBudget 2017/18 CA AnnuallyAnnual Report and Accounts and Quality Accounts CA AnnuallyNetworked Care Group Update MS AnnuallyPlanned Care Group Update MS AnnuallyRisk Appetite CAi Once Urgent Care Group Update MS AnnuallyIPR Metrics Review MS AnnuallyPharmacy Lord Carter Plan and Update AnnuallyCarter Review: Clinical Outcomes MS EveryStaff Survey Results DF Once Skill Mix Review CAi AnnuallyFreedom to Speak Up Annual Report JP AnnuallyStanding Financial Instructions Review CA AnnuallyWell Led Framework Action Plan Update SM QuarterlySafeguarding Annual Report CAi AnnuallyCommunications Strategy Update SM AnnuallyN&R Committee Update CL QuarterlyProcess Review GS MonthlyBoard Work Plan CL MonthlyAnnual Revalidation Report LB AnnuallyStanding Orders Review CL AnnuallyWinter Plan MS AnnuallyHealth & Safety Annual Report CA Annually

Board Work Plan

Other Items

Culture, Workforce &

Infrastructure

Strategy and Partnerships

Integrated Performance