open to members of the public and the...

TRUST BOARD AGENDA(open to members of the public and the press)

DATE: Wednesday 19 October 2016

TIME: 1300 -1400 (approx.)

VENUE: Boardroom, executive officees, 2nd

floor, Royal Free Hospital

Distribution

CHAIR: Dominic Dodd Chairman of the trust board

TRUST BOARDMEMBERS:

Stephen Ainger Non-executive director

Deborah Oakley Non-executive directorJenny Owen Non-executive directorProf Anthony Schapira Non-executive directorVacant Non-executive directorDavid Sloman Chief executive

Caroline Clarke Chief finance officer and deputy chief executive

Prof Stephen Powis Medical director

Deborah Sanders Director of nursingKate Slemeck Chief operating officer

INVITED TO ATTENDDr Mike Greenberg Divisional director of women’s and children’s

servicesDavid Grantham Director of workforce and organisational

developmentProf George Hamilton Divisional director of surgery and associated

servicesDr Robin Woolfson Divisional director of transplant and specialist

servicesEmma Kearney Director of corporate affairs and communicationsAndrew Panniker Director of capital and estatesPeter Ridley Director of planningDr Steve Shaw Divisional director of urgent careAlison Macdonald Board secretary (minutes)Dr Chris LaingDr Anja Drebes

Hester Wain

Associate medical director – patient safetyConsultant HaematologistClinical Lead for Thrombosis and AnticoagulationDeputy director of patient safety and risk(for item 2016/178 only)

Ms Yvonne Carter Head of Infection Prevention & Control Nursing(for item 2016/181 only)

APOLOGIESCOPY FORINFORMATION:

Governors (agenda only)

Julie Dawes Interim trust secretary

TRUST BOARD MEETING1

The next meeting of the trust board will take place on Wednesday 19 October 2016 at 1300 in the boardroom,executive offices, 2nd floor, Royal Free Hospital.

Dominic DoddChairman

A G E N D A

ITEM LEAD PAPER

ADMINISTRATIVE ITEMS

2016/173 Apologies for absence D Dodd

2016/174 Declaration of interests D Dodd 1.

2016/175 Minutes of meeting held on 28 September 2016 D Dodd 2.

2016/176 Matters arising report D Dodd 3.

2016/177 Record of items discussed at the Part II board meeting on 28September 2016

D Dodd 4.

PATIENT SAFETY AND EXPERIENCE

2016/178 Quality improvement/patient safetyVenous thromboembolism (VTE) prevention - Dr Anja Drebes,consultant haematologist and clinical lead for thrombosis andanticoagulation

S PowisC Laing

2016/179 Patients’ voices S Shaw

ORGANISATIONAL AGENDA

2016/180 Nursing/midwifery staff monthly report (August 2016) D Sanders 5.

2016/181 Director of infection prevention and control (DIPC) - quarterlyreport

D Sanders 6.

2016/182 Medical staff appraisal – six monthly report S Powis 7.

OPERATIONAL AGENDA

2016/183 Chair’s and chief executive’s report D Dodd /D Sloman

8.

2016/184 Trust performance dashboard K Slemeck 9.

2016/185 Financial performance report C Clarke 10.

Governance and regulation: reports from board committees

2016/186 Shadow group board (13 October 2016) D Dodd Verbal

2016/187 Finance, investment and performance committee (18 October2016) plus Q2 self-certifications

D Dodd 11.

2016/188 Patient safety committee (22 September 2016) S Ainger 12.

2016/189 Patient and staff experience committee (17 October 2016) J Owen Verbal

2016/190 Audit committee (15 September 2016) D Oakley 13.

1 In accordance with the Health & Social Care Act 2012, all Trust Board meetings must be held in public. All decisions which require the board’scollective approval can only be made at a Trust Board (or a Part II meeting held in closed session to discuss confidential matters).

OTHER BUSINESS

2016/191 Questions from the public D Dodd

2016/192 Any other business D Dodd

2016/193 Date of next meeting – 23 November 2016 D Dodd

Paper 1

Register of interests – trust board My 2016 1

REGISTER OF INTERESTS OF MEMBERS OF THE BOARD OF DIRECTORS

Executive summary

The trust constitution requires trust board members to declare interests which are relevant andmaterial to the NHS board of which they are a member. The register of interests is presented ateach board meeting.

There have been no changes to the declaration of interests since the last board meeting.

Action required

Board members are asked to provide an update if they have any other changes in interests notnoted in the attached.

The board is asked to ratify the updated register, subject to any further changes made.

Public Patient andCarer involvement

The register will be made available to the public.

Report From Dominic Dodd, chairmanAuthor(s) Alison Macdonald, board secretaryDate 11 October 2016

Report to Date of meeting Attachment number

Trust Board 19 October 2016 Paper 1

Version 9Updated 19/9/16

Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public.

REGISTER OF THE INTERESTS OF MEMBERS OF THE TRUST BOARD

Board Member andpositionDate of latestamendment/confirmedcorrect

Directorships,including non-executive directorshipsheld in privatecompanies or PLCs(with the exception ofthose of dormantcompanies)State whendirectorshipcommenced

Ownership or part-ownership of privatecompanies, businessor consultancies likelyor possibly seeking todo business with theNHSState when interestacquired

Majority orcontrolling shareholdings inorganisations likelyor possibly seekingto do business withthe NHSState when interestacquired

A position ofauthority in a charityor voluntaryorganisation in thefield of health andsocial care

State when positionaccepted

Any connection with avoluntary or otherorganisationcontracting for NHSservices


Researchfunding/grants thatmay be received byan individual or theirdepartment

State whenfunding/grantcommenced

Interests in pooled funds that are underseparate management (any relevantcompany included in this fund that has apotential relationship with the Trust mustbe declared)

State when interest acquired

Dominic Dodd,Chair19/9/16

UCLPartners1

Director of ownconsultancy firm

ImprovementDirector for trust inNHSI’s financialspecial measuresprogramme,assigned toCroydon HealthServices.Assignmentequivalent to circa5 days, to becompleted by endOctober 2016.Paid position.

Member of NHSI’sChairs’ AdvisoryGroup. Unpaidposition.

Nil Nil Nil Nil

1The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.




Directorships,including non-executive directorshipsheld in privatecompanies or PLCs(with the exception ofthose of dormantcompanies)

State whendirectorshipcommenced











Non-executive directors

Stephen AingerNon-executivedirector5/1/16

Chair DownshireHill Residents’Association.

Nil Nil Nil Nil Nil Nil
















Deborah Oakley,non-executivedirector13/5/16

Medicines andHealthcareProductsRegulatoryAgency Non-ExecDirector

Nil Nil Nil Medicines andHealthcareProductsRegulatoryAgency Non-Exec Director

Nil I work for Veritas InvestmentManagement. The firm investsmoney on behalf of clients. Clientportfolios are invested in varioushealthcare companies whichmay do business with the trustand with the NHS more broadly.These investments include butare not limited to: SonicHealthcare; Roche; Novartis;GlaxoSmithKline, United Health,Alphabet, Oracle and others.Clients also invest in pooledfunds which are managedexternally and invest in a broadrange of healthcare companieswhich may do business with thetrust and the NHS.I and my family have personalholdings in pooled funds whichare managed externally andinvest in a broad range ofhealthcare companies whichmay do business with the trustand the NHS.I do not have any directinvestments in companies whichmay do business with the trust orwith the NHS.
















Jenny Owen,non-executivedirector6/4/16

Nil Nil Nil Board memberof Housing andCare 21

Trustee ofAlzheimer’sSociety

Housing 21 andCare 21

Alzheimer’sSociety

Nil Nil

ProfessorAnthony SchapiraNon-executivedirector13/5/16

Upper HampsteadWalk Residents’Association.AHV Schapira Ltd

Non-executivedirector, Ministryof Justice

Nil Nil Parkinson’sDisease SocietyResearchStrategy Group

Nil MedicalResearchCouncil,Wellcome Trust,Parkinson’sDisease Societyand othercharitablesources ofresearch funding

Nil

Executive directors

Caroline ClarkeDeputy chiefexecutive &director offinance11/4/16

Member, AdvisoryBoard to TheLearning Clinic

Nil Nil Trustee

Royal FreeCharity (1/4/16)

Nil Nil Nil
















Professor

Stephen Powis,

medical director

16/5/16

Director of HSL

(appointed by

RFL)

Nil Nil Employee of

UCL

Trustee

Peter Samuel

Trust

Trustee

Healthcare

Management

Trust

Trustee

Moorhead Renal

Trust

Trustee

Royal Free

Charity (1/4/16)

Member ofgoverning body,Merton NHSClinicalCommissioningGroup

Trustee

Healthcare

Management

Trust

Moorhead RenalTrust and variousother sources ofcharitable fundingheld bycolleagues withinthe academicrenal department

No individualfunding butcollaborate onresearch withinacademicresearchdepartmentfunded by avariety of sourceseg MRC, KidneyResearch UK.

Nil

Deborah SandersDirector ofnursing7/4/16

Nil Nil Nil Board member,The Royal FreeHospital Nurses’Home of RestTrust

Nil Nil Nil
















Kate Slemeck,executive directorof operations7/4/16

Nil Nil Nil Nil Husband worksfor Canon whoprovide thetrust’s managedprint service.

Nil Nil

David SlomanChief executive15/4/16

Director,

UCLPartners2

Trustee/Non-executive director,Skills for Health

Chair of North

Central London

Sustainability and

Transformation

Plan

Nil Nil LondonProcurementPartnershipboard member.

Relative whoworks for Ernst &Young

Member of HSJ’sProduct AdvisoryBoard

Member of NHSImprovementCEO AdvisoryGroup (January2016)

Nil Nil

2The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.
















Non-voting directors

David Grantham

Director of

Workforce and

OD

7/4/16

Nil Nil Nil Board Member

and Treasurer

London

Healthcare

People

Management

Academy –

March 2013

Chair of NHS

Employers

Medical

Workforce

Forum – August

2010

Board MemberHealth EducationNorth and EastLondon(HENCEL) – July2014Board Memberand TreasurerLondonStreamliningProgramme(s) –March 2014

Nil Nil
















Mike Greenberg

Divisional director

women’s,

children’s and

imaging services

7/4/16

Nil Nil Nil Nil Relative of COOof Optum Labs, asubsidiary ofOptum

Nil Partner with HCA in Wellington

Diagnostic and Outpatient

Centre LLP since 2007

George Hamilton

Divisional director

surgery and

associated

services

6/6/16

Nil Nil Nil Nil Consultantshares in W.Docwhich is affiliatedwith theWellingtonHospital.

Nil Nil

Emma Kearney

Director of

corporate affairs

and

communications

7/4/16

Director, EK

Consulting Ltd

Nil Nil Nil Nil Nil Nil

Andrew Panniker

Director of capital

and estates

7/4/16

Nil Nil Nil Nil Director, Royal

Free Charity

Development Co

Nil Nil
















Peter Ridley

Director of

Planning

19/7/16

Nil Nil Nil Nil Nil Nil Nil

Steve Shaw

Divisional director

urgent care

7/4/16


Robin Woolfson,

Divisional director

transplant and

specialist

services

7/4/16


Paper 2

Matters arising – trust board 19 October 2016

Trust Board Matters Arising report as at 19 October 2016

Actions completed since last meeting of the Trust Board

Minute No

Action Lead Complete Board date/ agenda item

Outstanding

FROM TRUST BOARD HELD ON 28 SEPTEMBER 2016

2016/160 Medical appraisal and revalidation Six monthly appraisal report to the October

meeting including more information on ID checks and future arrangements for the responsible officer.

S Powis On agenda 2016/182

2016/170 Questions from the public – falls information Raise this at CQRG

S Powis/ D Sanders

FROM TRUST BOARD HELD ON 27 APRIL 2016

2016/77 Patient safety committee report Board to receive training on corporate

manslaughter S Powis Programmed for November 2016 meeting

FROM TRUST BOARD HELD ON 6 APRIL 2016

2016/54 Chairman and chief executive’s report Progress reports on pathology joint venture to the

shadow group board and finance and performance committee.

M Dinan Agreed at May shadow group board that this should be programmed for July, following a customer/investor annual review. Deferred to September as HSL annual accounts not received. Report discussed at finance investment and performance committee and further work required. Now programmed for November trust board meeting.

Paper 3

1

MINUTES OF THE TRUST BOARD

HELD ON 28 SEPTEMBER 2016

Present

Mr D DoddMr S AingerMs C ClarkeMs D OakleyMs J OwenProf S PowisMs D SandersProf A SchapiraMr D Sloman

ChairmanNon-executive directorChief finance officer and deputy chief executiveNon-executive directorNon-executive directorMedical directorDirector of nursingNon-executive directorChief executive

Invited to attendMr D GranthamDr M GreenbergMs E KearneyMr A PannikerMr P RidleyDr S ShawMs A Macdonald

Director of workforce and organisational development (from 2016/158)Divisional director for women’s, children’s and imaging servicesDirector of corporate affairs and communicationsDirector of capital and estatesDirector of planningDivisional director – urgent careBoard secretary (minutes)

Others in attendanceMs M M DevaneyMs H WainMs G Singh

Head of patient safety and risk (for item 2016/156)Deputy director of patient safety and risk (for item 2016/156)Falls programme project lead (for item 2016/156)

2016/151 APOLOGIES FOR ABSENCE AND WELCOME Action

Apologies for absence were received from:

Ms K Slemeck Chief operating officerProf G Hamilton Divisional director for surgery and associated

servicesDr R Woolfson Divisional director, transplant and specialist services

The chairman welcomed those present to the meeting.2016/152 DECLARATION OF INTERESTS

The report on the register of interests was noted and entries confirmed to becorrect. No director had any further interests to declare.

2016/153 MINUTES OF MEETING HELD ON 27 JULY 2016

The minutes were accepted as an accurate record of the meeting.

2016/154 MATTERS ARISING REPORT

The matters arising report was noted.

Paper 3

2

2016/155 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 27 JULY2016

The report was noted.

2016/156 QUALITY IMPROVEMENT/PATIENT SAFETY – FALLS PREVENTIONPROGRAMME

Ms M M Devaney, head of patient safety and risk, Ms H Wain, deputy director ofpatient safety and risk, and Ms G Singh, falls programme project lead, were inattendance for this item.

The deputy director of patient safety and risk introduced the item, explaining thatfalls prevention was a key element of the patient safety programme and the aimwas for a 25% reduction by March 2018. A falls prevention strategy had beenagreed in 2014. The falls programme project lead then described the projectwhich had started with the need to harmonise the approach across the sites in theenlarged trust. The trust’s standard improvement methodology (“Breakthrough”)had been used and piloted in ten wards which were spread across the three maintrust hospitals and covered different specialties. Each ward had a medical,nursing and therapies falls lead and a falls champion. The programme includedan opportunity for wards to meet together to share experiences and learning everythree months, between these sessions active action took place on the individualwards. The trust’s harmful falls rate was currently below the national average butthe aspiration was to reduce this further. The programme had raised awarenessof the need to report incidents, resulted in better use of handover and bettercommunications. There was more willingness to talk openly about mistakes andlearn from them.

The chairman asked how the challenge of harmonisation between different siteshad been approached. The project lead responded that teams had beenencouraged to learn from each other and agree on the approach which wouldwork best rather than this being imposed from above. In answer to anotherquestion she added that the falls prevention package was a range of interventionsand approaches that could be customised to reflect the particular circumstancesof different areas. The head of patient safety and risk added that the team werelooking at how to spread the programme to other wards and the emphasis was oncelebrating successes, for example talking in terms of how many days there hadbeen since the last fall. On ward 8 west at the Royal Free it had been more than720 days since the last fall with harm.

The chief executive asked what had helped the project succeed and the responsewas that this came down to leadership and good data.

The chairman thanked the head of patient safety and risk, deputy director ofpatient safety and risk and falls programme project lead for coming to the boardand providing such an interesting and positive presentation and invited the teamto consider what might be done by the board to celebrate these kinds ofsuccesses.

Actionowner?

2016/157 PATIENTS’ VOICES

The director of corporate affairs and communications read out a complaint and a

Paper 3

3

compliment, both of which related to the non-emergency patient transport service.

The compliment was from a patient for the transport service they had received,which described the staff they had encountered as being friendly, efficient, caringand attentive. They also spoke of excellent management.

The complaint was from a patient’s wife. The patient had waited more than threehours after their appointment time for the transport to arrive. Every time shetelephoned to find out when the transport would arrive she was told they were“five minutes away” and the person answering the telephone was rude and cut heroff. In the end the patient did not attend their appointment as the ambulancearrived so late.

The compliment related to the new transport provider; the complaint to theprevious company.

The divisional director – urgent care would present this item next time. SS

2016/158 CARE QUALITY COMMISSION INPECTION REPORT

The director of nursing presented the report, noting that the trust had first beeninformed of the visit about one year ago. The trust had been rated overall as“good” and “good” for each of the hospitals and each of the hospital servicesinspected. However the safety domain had been rated as requires improvement.The report contained regulatory breaches relating to the suitability of the premisesprovided for the child and adolescent mental health services (CAMHS) and aresponsive action plan was required to address this, which would be submitted to,and monitored by, NHS Improvement. The report contained helpful commentsand recommendations which would be worked on in order to move from good tooutstanding. However the intention was to approach this through improvementmethodology rather than a detailed action plan. This would involve more of a peergroup approach and a measurement plan. Quarterly meetings would take placewith divisions.

Ms Owen, non-executive director, commented on the positive comments madeabout the volunteers and the need to celebrate this. The director of nursingcommented that the volunteers had been delighted by the report.

The chairman commented that this was an excellent result and a testament to thehard work and commitment of the trust’s staff.

The chief executive commented that the report referred repeatedly to staff feelingable to be open about mistakes and raise risk issues, which was very positive. Itwas also noteworthy that the inspection had taken place only 18 months after theacquisition.

The board noted the report and agreed that the patient safety committee wouldremain the responsible committee for the CQC.

2016/159 NURSING AND MIDWIFERY STAFFING MONTHLY REPORT

The director of nursing presented the report which covered June and July 2016 asthere had been no August meeting.

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4

The director of nursing then noted that planned versus actual hours was 3% and1% less actual than planned for June and July respectively. She noted that therehad been no shifts where the nurse:patient ratio was below 1:8 on a day shift or1:11 on a night shift in June and two in July, with no patient safety incidentsreported.

The trust had been under the trajectory to achieve the control total of £29m for allagency staff for the first quarter but was currently above the trajectory.

The trust had been successful in recruiting 38 nurses from India and thePhilippines, mainly for theatres and critical care. Currently the immigrationprocesses were going through and a training programme would be put in place.The first cohort of nurses with overseas qualifications had now completed theprogramme to become UK registered nurses, and 18 of them would return to thetrust as registered nurses. A second cohort was now running.

Mr Ainger, non-executive director, asked about the percentage of actual to totalplanned shifts on Adelaide ward in June and the director of nursing respondedthat the correct figure was 95%. Mr Ainger also referred to the low FFT scores forAdelaide and Capetown wards. The director of nursing responded that thecomments had been reviewed and no significant concerns were raised. Thesample sizes were small because many of the patients cared for were unable tocomplete a survey and consideration was being given to whether there was abetter way to capture their views.

The board agreed that the report provided sufficient assurance that the nursestaffing levels were meeting the needs of patients and providing safe care.

2016/160 MEDICAL REVALIDATION ANNUAL REPORT

The medical director presented the report, commenting that this represented thecompletion of the first three year round of appraisal and validation. The overallrate of appraisal was 70%, which was lower than desirable but was the legacy ofbringing two separate organisations and systems together. This year the focuswould be on increasing the rate of appraisal and spreading them more evenlyover the year, rather than being clustered at the end of the financial year.

He concluded by noting that the process had been overseen by Vivienne vanSomeren, the associate medical director - revalidation and professionaldevelopment, who would be retiring shortly. The board recorded its thanks to herand her team in progressing medical appraisal and revalidation in the trust.

Mr Ainger, non-executive director, noted that the report referred to a doctor whoseregistration had been removed and another who had been found guilty of grossmisconduct. He asked whether any look back had been undertaken in relation tothese individuals. The chief executive responded that there were no thematicissues.

In answer to a question from Ms Owen, non-executive director, the medicaldirector responded that there was a detailed action plan to achieve the correctiveaction and the improvement plan summarised in the report.

There was discussion about ID checks for agency doctors and it was confirmedthat the trust only used agency doctors through framework agreements which

Paper 3

5

included the agency undertaking checks and there were local arrangements tocheck the ID of the doctor on arrival at the trust. Additional information would beincluded in the next report.

The medical director said that he would be bringing the six monthly appraisalreport to the next board meeting and this would include future arrangements forthe responsible officer.

The board noted the report.

Medicaldirector

2016/161 CHAIR AND CHIEF EXECUTIVE’S REPORT

The chief executive highlighted the following points from the report:

• The junior doctors’ industrial action had been halted but it was not clearwhat future action there might be in the dispute regarding the new contract

• The new patient transport contract was working well so far

• The trust had been accredited as a centre of global digital excellence

In answer to a question, the director of nursing responded that procurement of thenew transport contract had commenced but would take approximately 18 monthsto conclude.

Ms Owen, non-executive asked about the consultation on nursing shifts. Thedirector of nursing responded that the decision had been made to put all nurses inscope for this consultation, but in the knowledge that it was unlikely that one sizewould fit all. There had been 200 responses received from a nursing workforce ofapproximately 2000, with the majority from ITU, emergency departments andmaternity. The responses were currently being reviewed and the outcomedocument would be published next week. Although no decision had yet beenmade it was likely that modifications would be made to reflect the views raised.


2016/162 TRUST PERFORMANCE DASHBOARD

The chief executive presented the report in the absence of the chief operatingofficer. He noted that the A&E and cancer remained particular performancechallenges. Currently A&E performance was trending at around 90% and thechallenge was to refocus and re-engage the emergency department teams whohad been very stretched for a long time. Action was being taken to try and reducethe pressure on A&E, for example changes to the front end at Barnet Hospital andworking with the CCG to introduce discharge to assess. Regarding cancer, atrajectory was in place to return to compliance by December 2016, although thiswould be challenging for some tumour sites.


2016/163 FINANCIAL PERFORMANCE REPORT

The chief finance officer reported the trust had delivered an actual deficit of £21mat end of August 2016 which was £0.6m adverse to plan. She added that theforecast was over-dependent on reaching a favourable settlement on revenue

Paper 3

6

with CCGs and achieving the full financial improvement plan. The trust hadconfirmed to the regulator that it would not meet the £15m surplus control total,with the key reasons being that the control total relied on a challenging financialimprovement plan and the current revenue position was very different to thatanticipated at the start of the year.

In answer to a question about the trust’s cash position, the chief finance officerresponded that the trust had a working capital facility, which would be required,but which was being deferred for as long as possible. The trust’s cash positionwould be much improved when commissioner debts were paid.


2016/164 SHADOW GROUP BOARD REPORTThe board noted the report from the committee.

2016/165 FINANCE INVESTMENT AND PERFORMANCE COMMITTEE REPORT

The board noted the report from the committee.

2016/166 PATIENT SAFETY COMMITTEE REPORT

The committee chair highlighted the following points from the meeting:

• The committee had been advised of the potential for a contract noticerelating to overdue serious incident reports. The medical director providedan update on this which was that the clinical quality review group was nowsatisfied with the progress made

• The last three committee meetings had been inquorate; there were goodreasons for this, but it meant that the committee could not work aseffectively as it should. The chief executive agreed to look into this issue.

• There was a continuing issue about the number of fire wardens and healthand safety at Chase Farm Hospital


DSl

2016/167 CLINICAL PERFORMANCE COMMITTEE REPORT

The committee chair highlighted the undergraduate preference for Barnet Hospitalas the best teaching site in UCL, primarily due to the quality of the teaching.

The board noted the report from the committee.2016/168 PATIENT AND STAFF EXPERIENCE COMMITTEE REPORT


2016/169 AUDIT COMMITEE

The committee chair highlighted the following points from the meeting:

• The committee had received a presentation on an external assurance

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7

exercise concerning cyber and information security and there was anaction plan due to be completed by March 2017.

• The committee had asked for an assessment against therecommendations in the national data guardian review, and the interimdirector of IT would be attending the next meeting to present this.

• The committee had discussed the well led governance review.

• Internal audit reports had been discussed, with an amber/green conclusionregarding serious incidents and an amber/red assurance on medicinesmanagement.

• The committee self-evaluation had been discussed, which had beengenerally positive but raised issues on composition of the committee withrecent changes meaning there was no longer a NED with recent financialexperience.

• Counter fraud had done a review of gifts and hospitality, since when therehad been a national consultation document issued on this subject. Arevised policy was due to come to the next meeting and the committeewas also considering how declarations of interest should be reported.

• The committee had reviewed the revised board assurance framework.

• The committee had approved the updated speaking up policy andreviewed whistleblowing cases.


2016/170 QUESTIONS FROM THE PUBLIC

A member of the public asked to what extent information about falls was sharedwith other organisations. The chief executive suggested that this would be ahelpful topic to raise with the clinical quality review group.

Medicaldirector/directorofnursing

2016/171 ANY OTHER BUSINESS

There was no other business.2016/172 DATE OF NEXT MEETING

The next trust board meeting would be on 19 October 2016 at 1300 in theboardroom, executive offices, 2nd floor, Royal Free Hospital.

Agreed as a correct record

Signature …………………………………..date 19 October 2016…………………………….Dominic Dodd, chairman

Paper 4

Confidential trust board meeting update – trust board 19 October 2016

ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 28 SEPTEMBER2016

Executive summary

Decisions taken at a confidential trust board are reported where appropriate at the next trustboard held in public. Those issues of note and decisions taken at the trust board’s confidentialmeeting held on 28 September 2016 are outlined below.

• Report from the shadow group board (this was also discussed in the public part of themeeting)

• NCL sustainability and transformation plan (STP) – an update was provided in the publicagenda

• Board assurance framework

• Briefing on the impact of leaving the European Union

• Cancerkin and Maggie’s at the Royal Free Hospital – assignment of Cancerkin lease

The board also discussed the trust performance and financial performance reports.

Action required

For the board to note.

Report From D Dodd, chairmanAuthor(s) A Macdonald, board secretaryDate October 2016



Paper 5

Page 1 of 2

Monthly report of Nursing staffing levels August 2016

Executive summary – including resource implications

The overall trust summary of planned versus actual hours for August was 1% less actualhours than planned:

Site specific data is as follows:• Barnet hospital 1% less actual hours than planned

• Chase Farm hospital 1% less actual hours than planned

• Royal Free hospital 1% less actual hours than planned

In August out of a minimum of 3,100 shifts there were 5 shifts or part shifts reported wherethe nurse: patient ratio dropped below 1:8 on a day shift or 1:11 on a night shiftThere wereno patient safety incidents reported.

Action required

The board is requested to

• consider if the report provides sufficient assurance that the nurse staffing levels aremeeting the needs of patients and providing safe care

Trust strategic priorities and business planning objectives

supported by this paper

Board assurance risk

number(s)

1. Excellent outcomes – to be in the top 10% of our peers on

outcomes

2. Excellent user experience – to be in the top 10% of relevant

peers on patient, GP and staff experience

3. Excellent financial performance – to be in the top 10% of

relevant peers on financial performance

4. Excellent compliance with our external duties – to meet our

external obligations effectively and efficiently

5. A strong organisation for the future – to strengthen the

organisation for the future

CQC outcomes supported by this paper

1 Respecting and involving people who use services

4 Care and welfare of people who use services

5 Meeting nutritional needs

7 Safeguarding people who use services from abuse



Paper 5

Page 2 of 2

8 Cleanliness and infection control

9 Management of medicines

13 Staffing

14 Supporting staff

Risks attached to this project/initiative and how these will be managed (assurance)

Equality analysis

• No identified negative impact on equality and diversity

Report from Deborah Sanders, Director of Nursing

Author(s) Deborah Sanders, Director of Nursing

Date 13 October 2016

References: Supporting NHS providers to deliver the right staff, with the right skills, in theright place at the right time – Safe, sustainable and productive staffing, July 2016,https://www.england.nhs.uk/ourwork/part-rel/nqb/

Paper 5

1

IntroductionThis report provides information on planned versus actual nurse staffing for August 2016 and

an update on progress with the reduction in use of agency nursing and midwifery staff.

Planned versus actual staffingThe overall trust summary of planned versus actual hours for August was 1% less actualhours than planned:

Site specific data is as follows:• Barnet hospital 1% less actual hours than planned• Chase Farm hospital 1% less actual hours than planned• Royal Free hospital 1% less actual hours than planned

Planned versus actual staffingThe tables below shows the planned versus actual hours for August 2016. Galaxy has had

6 closed beds because of seasonal decreased activity with the actual staff numbers reduced

accordingly. The FFT score for Adelaide was 57%. This was based on 7 responses. 4

patients were likely to recommend and made positive comments about the staff, the

atmosphere on the ward and the food. 2 patients were unlikely to recommend and

commented on the noise of other patients at night, snoring and patients walking around the

ward. 1 patient was highly likely not to recommend and commented that the service was

poor, they were not called by their first time, the staff did not respond in time or to the

patients’ needs.

Ward Beds

Registered nurse to

patient ratio

Day Shift

Percent of actual vs

total planned shifts

(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

10 North 32 1:5.3 90% 100% 97% 100% 0 0 88%

8 West 36 1:5.1 92% 100% 96% 98% 6 0 83%

8 North 32 1:4 90% 99% 96% 102% 5 0 87%

10 West 27 1:5 104% 117% 124% 158% 1 0 97%

8 East 26 1:4.3 97% 100% 100% 100% 2 0 86%

6 South 28 1:4 96% 99% 100% 100% 1 0 100%

ITU (RF) vary 1:1/1:2 98% 99% 101% 89% 1 1 n/a

ED (RF) n/a n/a 97% 106% 80% 93% 0 0 87%

ED(BH) n/a n/a 99% 103% 92% 101% 7 0 83%

UCC (CF) n/a n/a 103 79% 65% n/a 0 0 n/a

Adelaide 25 1:6.25 75% 100% 101% 210% 4 0 57%

Capetown 36 1:5.1 97% 128% 148% 210% 4 0 80%

CCU 8 1:2 94% 98% n/a n/a 0 0 100%

CDU 24 1:4.8 100% 103% 96% 193% 4 1 73%

ITU (BH) vary 1:1/1:2 108% 103% 79% 79% 0 0 n/a

Juniper 24 1:4.8 95% 100% 98% 98% 6 0 83%

Larch 22 1:5.5 105% 100% 97% 99% 4 0 67%

Olive 22 1:5.5 96% 101% 99% 87% 1 1 63%

Palm 22 1:5.5 94% 98% 97% 66% 3 0 87%

Quince 24 1:4.8 101% 103% 102% 209% 7 0 88%

Rowan 24 1:4.8 94% 104% 87% 125% 3 0 91%

Spruce 24 1:6 91% 99% 107% 104% 4 0 79%

Walnut 24 1:6 91% 110% 96% 120% 7 0 81%

Urgent Care August 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

6 North 20 1:4 98% 97% 100% 100% 0 0 n/a

5 South 31 1:8 94% 94% 92% 97% 0 0 92%

Neona te RFH vary 84% 99% 74% n/a 0 0 n/a

Galaxy 30 1:4 69% 82% 63% 13% 0 0 n/a

Neona te BH vary 76% 79% n/a n/a 0 0 n/a

Willow 16 1:5.3 120% 148% 105% 55% 1 0 88%

Victoria 48 1:8 96% 98% 149% 97% 0 0 91%

Womens and Childrens August 2016

Paper 5

2

Safe staffing

In August out of a minimum of 3,100 shifts there were 5 shifts reported where the nurse:

patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. There was one night

shift on Juniper where there was a ratio of 1:12. On Damson there were 3 part shifts where

there was a 1:12 ratio, 1 early and 2 lates and a night shift with a 1:12 ratio. There were no

reported patient safety incidents reported on these occasions.

Registered nurse agency staff

On 1 September 2015 Monitor wrote to the trust advising of the rules for nursing agency

spending and setting out the spending ceiling for the trust. The rules are an annual ceiling

for total nursing agency spending for each trust and a mandatory use of approved

frameworks for procuring agency staff. The rules apply to all NHS trusts, NHS foundation

trusts receiving interim support from the Department of Health and NHS foundation trusts in

breach of their licence for financial reasons. All other NHS foundations trusts have been

strongly encouraged to comply.

On 19 October 2015 Monitor wrote to the trust confirming that the agreed ceiling of nurse

agency pay as a % of total nurse pay for the Royal Free London was 9.8% by March 2016

with a further reduction in April 2016. The further reduction % of nursing pay by agency has

not yet been issued rather the trust has been sent an overall control total of £29 million on

agency pay (all staff groups).

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

9 West 26 1:4 96% 95% 116% 64% 0 0 87%

9 North 33 1:4.7 90% 99% 106% 105% 3 0 94%

11 West 22 1:4.8 100% 113% 154% 235% 1 0 100%

11 South 19 1:3.8 97% 100% 100% n/a 0 1 94%

11 East 24 1:4.8 83% 99% 99% 106% 0 0 98%

10 East 24 1:3.4 95% 97% 98% 100% 3 1 100%

10 South 25 1:6.25 87% 97% 92% 98% 3 0 90%

5 East B 10 1:5 97% 99% 143% 148% 2 0 86%

Mulberry 13 1:5 79% 99% 123% n/a 5 0 88%

Transplantation and Specialist Services August 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

5 north A 18 1:4.5 98% 100% 95% 100% 1 0 85%

7East A 20 1:5 101% 100% 115% 103% 2 0 92%

7 East B 13 1:4.3 104% 100% 90% 100% 2 0 86%

7 West 32 1:4 90% 100% 97% 100% 2 0 88%

7 North 24 1:4.7 109% 101% 103% 132% 2 0 91%

Beech 24 1:6 103% 99% 105% 104% 3 0 90%

Canterb'y 25 1:6.25 72% 72% 62% 100% 0 0 100%

Cedar 24 1:4 78% 98% 173% 149% 4 2 83%

Damson 24 1:6 84% 98% 117% 137% 1 0 88%

Wel'gton 39 1:6.5 77% 58% 78% 97% 0 0 94%

Surgery and Associated Services August 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

FallsAttributable

CdiffFFT Score

12 Wesr 15 vary 97% 100% 83% 97% 4 0 n/a

12 South 16 1:4 98% 99% 96% 100% 3 0 100%

12 Eas t B 12 vary 96% 100% 91% 100% 2 0 100%

Private Practice August 2016

Paper 5

3

Year to date the spend on nursing and midwifery staff agency is £97K above plan, with the

overspend occurring in month 5 and 6.

The clinical departments with the highest usage remain critical care on both sites, ED on

both sites and theatres at the Royal Free. There are a number of wards that have been

designated as zero agency wards, with further to be designated in the next month. There

have been recent instances of escalation beds requiring to be opened on wards at the Royal

Free which have led to agency usage on previously declared agency free wards.

Recruitment

Paper 5

4

A key driver to reducing agency cost is recruitment to substantive posts. There are currently

340 nursing and midwifery recruits in the pipeline, 116 have agreed start dates and 224 are

being processed. We continue to hold 2 assessement centres a month alongside one open

a day a month.

The Royal Free London NHS Foundation trust has been selected by Health Education

England, as part of a partnership led by the Whittington, to be one of the eleven test sites for

the pilot of the nursing associate role. Originally 1000 people were to be put through the

pilot but HEE have announced an additional 1000 will be put through. The role is intended to

bridge the gap between healthcare assistants and nurses and create a potential new route

into registered nursing.

1

Equality impact assessment• Positive impact which supports equity of service



DIRECTOR OF INFECTION PREVENTION AND CONTROL (DIPC) QUARTERLY REPORT

Executive summaryThis is the trust report from the director of infection prevention and control for the Royal Free LondonNHS Foundation Trust.

In line with the revised Health and Social Care Act (2008) trusts are required to have appropriatemanagement and clinical governance systems in place to deliver effective infection control. Includedat appendix A are the ten compliance criteria from the Health and Social Care Act to assist the boardin assessing the information provided.

In line with the Health and Social Care Act (2008, rev 2015) Code of Practice on the prevention andcontrol of infections and related guidance, trusts are required to have appropriate management andclinical governance systems in place to deliver effective infection control. Within criterion 1 of theCode of Practice is a requirement that there is a programme of activity and planned development forIPC within the organisation to keep to a minimum the risk for infection and the general means bywhich it plans to control such risks.

Action required / recommendationThe Board is asked to confirm that the report provides sufficient information to provide assurance ofsustained compliance with the Hygiene Code and to approve the Annual IPC programme.

Trust strategic priorities and businessplanning objectives supported by this paper

Board assurance risk number(s)

1 Improving clinical effectiveness R12 Enhancing the patient experience

CQC outcomes supported by this paperOutcome 8 Cleanliness and infection control

Risks attached to this project / initiative and how these will be managed (assurance)The revised Hygiene Code Risk matrix will be monitored at the Infection Control Committee.The risks associated with the Hygiene Code have been included in the Board Assurance Framework

Report From D Sanders, Director of Nursing and DIPC.

Author(s) D Mack, Microbiology Consultant, Lead IPC DoctorHusam El-Mugamar, Consultant Microbiologist, IPC DoctorDianne Irish, Consultant VirologistY Carter, Head of IPC NursingIPC team

Date October 2016

3

1. Introduction

The Health and Social Care Act (2008) Code of Practice on the prevention and control of infections andrelated guidance outlines the actions NHS Trusts in England must take to ensure a clean environmentfor the care of patients, in which the risk of infection is kept as low as possible. The 10 compliancecriteria are attached at appendix A. The criteria have been revised for the 2015 edition, including alarger focus on antimicrobial stewardship, an element of which has been included in CQUIN for2016.17. Frontline staff Influenza vaccination has also been included as a CQUIN for 2016/17.

Monitoring Progress against the Health and Social Care Act, including internal audit.

Compliance with the hygiene code will continue to be monitored through the Infection Prevention andControl Committee. The Trust’s internal auditors annually assess trust arrangements and ensure robustevidence of compliance in all criteria. The CQC inspection report from February has been received,whilst there is no specific ‘infection prevention and control’ improvement recommendation, the IPC teamwill support Clinical Divisions and Services to make improvements in the infection prevention and controlelements raised in the core service reports.

2. Infection report

2.1 Meticillin-sensitive and Meticillin-resistant Staphylococcus aureus bacteraemia. (MRSA andMSSA)

Reduction of hospital acquired Staphylococcus aureus bacteraemias including those due to MRSAcontinue to be an important infection control priority for the trust. The target for 2015-16 is zero for allorganisations.

The last trust attributed case was in June 2015. There have been 3 cases of MRSA bacteraemiaidentified from samples within the trust laboratories, two not attributed to the Trust and one pendingarbitration decision.

Hospno

Sampledate

locationTreatment

Sitestatus specialty directorate Attribution

1 9.5.16 Galaxy BH OPD Paediatrics W&C Final – 3rd party

2 15.7.16 A&E BH A&Eattend

Renal TASS Barnet CCG

3 27.8.16 MRDU5EB

MRDURFH

Dialysis/i/p Renal TASS Provisionally agreed 3rd partyby CCG and Trust – awaitingarbitration assignment.

2.2 MRSA trust acquisitions

The trust MRSA acquisition rate remains low across all sites, (an acquisition is defined as any patient notpreviously known to be MRSA positive but has been swabbed whilst in the RFLNHSFT after the first 48hours of admission and found to be positive). Although the national requirement has reduced, the trustscreening process remains inclusive of in-patient admissions as it is felt to be integral in reducingacquisition rates and contributes to safer patient care.

2.3 Clostridium difficile (C.diff)

The RFLNHSFT has integrated infection control measures across all sites to minimise the risk of C. difficile.Measures include educational programmes, comprehensive antibiotic policies, good bed management withearly isolation of symptomatic patients and enhanced environmental cleaning. The microbiology, IPC andpharmacy teams continue to perform Clostridium difficile ward rounds to ensure that all elements of thecare and treatment of patients with C. difficile are being appropriately managed.

4

The external threshold objective for the trust for 2016/17 is 66 attributable cases. The trust was belowthreshold for Q1, with 14 cases, but above threshold in Q2 with 24 cases – a combined total of 38 cases,five cases above threshold.

Following revisions to its risk framework Monitor confirmed that for the purposes of its governance riskratings of foundation trusts’ with effect from quarter one 2015/16 national performance against the C.difficile indicator will include only those infections that result from a lapse in care. Lapses in care infectionsare determined by the local clinical team applying a checklist based assessment developed by PublicHealth England, with outcomes reviewed and agreed by local commissioners. Currently the lapses in careeither agreed, or following arbitration are 2, relating to an outbreak of C.diff on Cedar Ward, which is nowdeclared over. There remain some outstanding cases awaiting completion of the RCA process and awaitassignment.

The trust C.difficile ‘action log’ incorporates activity across the trust and is driven through the fortnightlydivisional lead/C.diff action group.

Main activity• RCAs from all sites continue to be discussed at fortnightly meetings to disseminate learning to all

areas.• Learning from antimicrobial audits has provided evidence for a revised patient prescription chart

with enhanced antimicrobial section. This has now been rolled-out across Trust.• Revised guidance on C.diff recognition, signs and symptoms and prompts for sending samples now

on every ward IPC notice board.• The annual audit of staff knowledge and practice has been feedback to Divisional Leads to

incorporate learning actions into Divisional improvement plans.

Outstanding priorities• Final alignment of IPC policies and antimicrobial policies• Clinical audit programme being aligned across all sites.• PPI and laxative protocols to be reviewed.• Continue programme of re-skilling and competence assessment of ward staff to ensure patients with

C.diff are cared for by competent and knowledgeable staff in any ward area of the enlarged trust.

The reduction in ‘lapses in care’ is significant for safe patient care and for assurance of high standards ofinfection prevention practices. In line with the aspiration target of 13 or less ‘lapse in care’ and threshold of66 toxin positive cases, the trajectory for 2016/17 is shown below.

5

April16

May16

June16

July16

Aug16

Sept16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

RFH cumul 6 7 9 16 18 24BH cumul 0 1 5 6 11 13CFH cumul 0 0 0 1 1 1cumulativecases 6 8 14 23 29 38cumulativeobjective 6 12 17 23 28 33 39 45 50 56 61 662015/16cases

7 16 20 29 32 39 43 49 53 58 62 68

2.4 E.coli bacteraemias

All E.coli bacteraemias are part of the mandatory reporting of health care associated infections (HCAIs),there is currently no improvement target associated with this infection. A breakdown by division and theapparent source of the infection is reported at the fortnightly divisional leads IPC meeting to guide futurereduction activity. The average case number per quarter remains around 20 cases with only minorvariation.

2.5 Carbapenemase producing enterobacteriaceae (CPE) and other non-fermenting (CP-NF)organisms

There have been sporadic cases of CPE and NF-CPOs, but no outbreaks of increased incidence. Whereindividual cases have been identified, all contacts have been screened with no evidence of transmission.Screening of high risk areas at Barnet Hospital has now commenced, on Mulberry (oncology andhaematology) and Critical care with a full training package for staff by the IPC team.

2.6 Orthopaedic surgical site infection reportCurrently the mandatory requirements from DH for surveillance are being undertaken across all trust sites.

Total knee replacement SSI report – July to September 2016.

Total operations Total infections

Royal Free Hospital 37 0Barnet Hospital 1 0Chase farm Hospital 71 0

Total 109 0

Total hip replacement SSI report – July to September 2016.Total operations Total infections


Total 96 0

Repair neck of femur SSI report – July to September 2016.

6

Total operations Total infections


Total 82 5

Spinal surgery SSI report – July to September 2016.Total operations Total infections


Total 44 1

3 Viral respiratory infections

178 respiratory infections were identified in the Virology laboratory at Royal Free Hospital, 16 werefrom patients at Barnet and Chase Farm Hospitals and 162 were from Royal Free Hospital.At the RFH site, there were 11 influenza infections (3 type B and 8 type A). Although higher thanwould be expected for this time of year, a proportion of those were in individuals who had beenabroad. In addition, there were 80 rhinovirus infections, 9 adenovirus infections, 4 coronavirusinfections, 32 enterovirus infections, 3 parechovirus infections, 5 human metapneumovirusinfections, 11 parainfluenza infections and 7 RSV infections.Sixteen respiratory infections were identified by the Virology Laboratory at Royal Free Hospital fromsamples submitted from BCF site. There were 6 rhinovirus infections, 4 enterovirus infections, 2parainfluenza infections, 1 influenza infection, 1 RSV infection, 1 coronavirus and 1 adenovirusinfection.

Other viral infections

There was only one case of measles during this quarter in comparison to the last quarter when 15cases were identified and 13 were managed at the RFH site. In addition, there were 10 cases ofvaricella zoster infections (chickenpox or shingles) which required infection prevention and controlintervention as well.

Norovirus infection

There were 10 cases of norovirus infection, five of them were patients with immunodeficiency disorderswith chronic infection.

4 Serious Incidents, outbreaks related to HCAIs

Barnet Hospital

Pseudomonas & MRSA- Starlight Ward (SCBU)

MRSA - Two babies were identified with the same ‘type’ MRSA from weekly screens during July onStarlight ward within a week of each other indicating apparent transmission. The mother of one of thebabies was also tested positive for MRSA. IPC measures were instituted, with no further cases.Pseudomonas aeruginosa - Three babies – a set of twins and another baby- were identified withPseudomonas aeruginosa from clinical swabs within a week of each other in July. Outbreak meetings wereinitiated, but the unit remained opened with IPC special measures in place. Specific actions includedchlorine clean of incubators, change of incubator humidifiers between babies and tracking of incubatorsbetween babies. Water from all outlets were sampled and tested negative for pseudomonas. All babies inthe unit were screened weekly for four weeks for pseudomonas, with no further cases identified. Formal SIprocess has taken place; no further recommendations but awaiting the final report.

7

Clostridium difficile Outbreak - Cedar Ward

There were two C. diff toxin positive cases on Cedar from July 26th and 5th August with confirmed 020typing. A third case was reported on August 25th, and later confirmed as the same ribotype. This representsclear transmission and a ‘lapse in care’. Outbreak precautions were implemented and the ward remainedopened to admissions and discharges. Outbreak meetings were held, first on 30/08/2016, then weeklythereafter, inclusive of PHE and NECLCSU representatives. Daily environmental audits were done alongwith increased IPC presence undertaking education and training on IPC practices. The entire ward wasterminally cleaned and HPVd (fogged). The outbreak was declared over on 27th September after more than28 days with no new cases. The index case had one negative sample, but was re-tested and foundpositive. The case is waiting ribotype, but has been classified as relapse rather than new infection. Aseparate work stream to drive cleaning improvements forward has been initiated and a final review meetingis planned for the end of October.

Chase Farm Hospital

Annual air testing / verifications on the airflow of all of the Theatres at CFH and surgicentre were carriedout in September. The general use Theatres 1&2 and 3&4 failed, some with less than half the flow raterequired. Remedial work has been undertaken – Theatre 2 is now compliant, but theatre 1 remains at about75% compliance – theatres 3 and 4 are being re-tested. The age of the ventilation plant and currentphysical condition make it very unlikely that full air change rates will be accomplished and maintained.The risks are balanced between the clinical need for patients to have the surgery they require compared torisk of infection. There are no reports of infections from these theatres in the past year. Records indicatethat the flow rates were not 100% compliant in the previous year, with no recorded infections. Estatesteams will continue to look at possible up-grades to the ventilation systems and re-test six monthly ratherthan the required annual testing to detect early reduction in change rates. This will be added to the Trustrisk register by SASS Leads. The IPC risks indicate that surgery can continue with additional testing andremedial work if flow rates do not drop. This will be discussed further at the Surgical Divisional Board.

Royal Free Hospital

10 South period of increased incidence of C.diff

Two patients have been identified with C.diff within one week at the end of September. Full IPC measureshave been instituted. A case of Norovirus has also been identified within 10 South. The IPC team areworking with the senior ward teams to investigate and rectify issues in environmental cleaning and clinicalpractice.

5. SIs.Month & no. of deaths Associated HCAI LocationOct 15 0 deathNov 15 0 deathDec 15 0 deathJan 16 0 deathFeb 16 0 deathMar 16 0 deathJul 16 0 deathAug 16 0 deathSept 16 0 death

6. Hand hygiene

The DH Saving Lives programme High Impact intervention audit tool is used to audit, monitor and reporthand hygiene compliance.

Compliance rates are now included as part of the matrons indicators within the performance reportingsystem, monitored and reported by the Divisions. The Hand Hygiene campaign is underway for 2016/17,including with a revised campaign for raising awareness across all trust areas. The Trust participated in thenational Hand Hygiene Torch Relay Tour, part of the World Health Organisation and Infection PreventionSociety programme to raise awareness of the importance of hand hygiene with staff and the public.

8

Deborah Sanders and IPC nurses receive torch from Gillian Kelly, Deputy Director of Nursing andGovernance and Agatha Katsande, Senior Nurse Infection Control / PLACE Lead, Barnet Enfield andHaringey Mental Health University Teaching NHS Trust

7. MRSA and C.diff annual audit

The clinical areas undertake audits of clinical practice throughout the year, but periodically the IPCT auditstaff knowledge and skills in the management of patients with MRSA and C.diff.

MRSA audit summary.

Knowledge and skills varied across all wards with many different gaps in knowledge and skills in differentstaff groups. The following actions are incorporated into the improvement plan.

1) Up-date infection information in Infection prevention and control notice boards situated on all wards,for public view for patients and staff.

2) Training of Clinical Practice Educators (CPEs) by IPC PEs to cascade best practice in managementand care of patients with MRSA.

3) Revision of isolation protocols by PEs4) Clarification of screening and decolonisation protocols within MDT meetings5) Inclusion of MRSA measures at staff handover and safety briefing meetings within wards.6) Ward level IPC up-dates arranged between wards and the IPC team at dates/times suitable locally.7) Re-stock of patient information leaflets regarding MRSA within each ward.

C.diff audit summary

9

This C.diff audit demonstrated a good level of basic knowledge about the management of patients withdiarrhoea and the isolation and investigation procedures particularly among the nurses. One of the keyfinding of this audit demonstrated that there is a lack of understanding of the Bristol stool chart type 5, 6 or7 as an assessment to trigger when to implement infection control measures across all groups whendealing with patient with diarrhoea.

0

20

40

60

80

100

120

140

Knowledge of C.diff management

RFH BCFH

The IPCN’s will work closely with the ward managers and clinical practice educators to improve the areasfor development identified in the findings. It is also recommended that doctors should be more engagedand work together with the nurses in initiating assessment and implementing tests when a patientpresenting with diarrhoea. The following actions are incorporated into the improvement plan.

1) Up-date infection information in Infection prevention and control notice boards situated on all wards,for public view for patients and staff.

2) Training of Divisional Clinical Practice Educators (CPEs) by IPC PEs to cascade best practice inmanagement and care of patients with C.diff.

3) Revision of isolation protocols by Divisional CPEs for ward staff4) Inclusion of C.diff measures at handover and patient safety meetings within wards.5) Ward level IPC up-dates arranged between wards and the IPC team at dates/times suitable locally.6) Re-stock of patient information leaflets regarding C.diff within each ward.7) Daily sluice and commode checks to be undertaken and signed on record chart kept on sluice wall.

All records to be copied and kept as evidence of on-going monitoring8) Ensure Stool Charts are in use, stocked within the ward and of the latest version.9) Correct Sporicidal cleaning agents are available in the sluice for sluice and commode cleaning and

for cleaning in isolation rooms of C.diff patients

8 Antibiotic CQUIN

Protective Antiinfectives Policy

The policy was agreed at the CQUIN group and subsequently modified in light of suggestions from thedrugs and therapeutics committee. Several antibiotics including piperacillin-tazobactam and carbapenemswill now require a code from microbiology before pharmacy will dispense for off-policy use.

Policies under discussion

10

Surgical Prophylaxis – discussed at last ASC. Awaiting feedback from max-faxNeutropenic Sepsis – EWSBP – EWPaediatrics (incl NICU) – Dr Santanu Maity

Antibiotic CQUIN

The National CQUIN ‘Antimicrobial Resistance and Antimicrobial Stewardship’ accounts for 0.25% of the

Trust’s income for 2016-17 and is estimated to be worth £1 million. The CQUIN has two parts: the first

aimed at reducing total antibiotic consumption and certain broad-spectrum antibiotics and the second

focused on antimicrobial stewardship and ensuring antibiotic review within 72 hours. Part A requires

submission of antibiotic consumption data to show the following:

• Reduction of 1% or more in total antibiotic consumption against the 2013-14 baseline

• Reduction of 1% or more in carbapenem against the 2013-14 baseline

• Reduction of 1% or more in piperacillin-tazobactam against the 2013-14 baseline

Part B requires evidence of empiric review of antibiotic prescriptions within 72 hours. Evidence will be

submitted via monthly audits of 50 sample prescriptions. By the end of quarter 4 it is expected that an

empiric review within 72 hours is carried out for at least 90% of cases in the sample.

In Q1, we achieved a 39% and 38% reduction in Piperacillin-tazobactam and carbapenem use respectively.

Our monthly audit data demonstrate that we are consistently achieving prescription review rates of >90%.

However, our total antibiotic consumption increased by 1.8%. This is being addressed by the CQUIN group

– areas lacking in stewardship activity are being identified and the deficit remedied (5EB, 6E, 11E in the 1st

instance). The CQUIN program also includes training for nurses as administrators – key responsibilities

include advising prescribers if:

- documented prescription duration has expired with no indication of review, even if the drug chartallows for signing of further doses

- appropriate for IV to oral route switch- 48/72 hour review has not been undertaken and documented- review of antibiotics if C.diff is identified- patient transfers between wards to ensure seamless prescribing and hand-over.

9 Flu CQUINThe Trust Flu Planning Group has convened and activity is minuted at fortnightly meetings. The CQUIN isfor a 75% uptake of the flu vaccination in frontline staff. Each Division is represented to embed activitywithin clinical teams. Currently 93 peer vaccinators have been trained to vaccinate colleagues within theworkplace to enable easy access to the vaccinations and improve vaccine uptake. The vaccines weredelivered in the last week of September and the vaccination of staff has commenced.

10 CleaningQuarter 1 report highlighted failures at Barnet Hospital to achieve National Standards ofCleanliness requirements for minimum standards. The report now includes pre and postrectification scores to identify where failures have been and the subsequent improvement followingrectification. A dedicated work stream is now in place to embed improvements and ensuresustained improvements within the cleaning processes at Barnet Hospital. This includes Facilitiesstaff, IPC staff and nursing leads and contractors to focus individual appropriate elements.

11

2016BGH1st

Score

BGH2

ND

Score2016

CFH1st

Score

CFH2nd

Score2016

RFL1st

Score

RFL2nd

Score

Very High Risk - > 98% Very High Risk - > 98% Very High Risk - > 98%

July 92.00% 99.00% July 98.72% 0.00% July 97.00% 98.00%

August 90.85 99.20% August 98.58% 0.00% August 98.00% 98.00%

September 89.57% 99.27% September 98.79% 0.00% September 97.00% 98.00%

Average 90.81% 99.16% Average 98.70% % Average 97.33% 98.00%

High Risk - > 95% High Risk - > 95% High Risk - > 95%

July 95.16% 97.52% July 97.80% 0.00% July 95.00% 96.00%


September 91.38 98.02% September 97.35% 0.00% September 96.00% 96.00%


Significant risk < 83% -87% Significant risk < 83% -87% Significant risk < 83% -87%

July 92.65 91.44% July 94.77% 0.00% July 94.00% 95.00%


September 89.80% 91.7% September 95.98% 0.00% September 96.00% 96.00%


12

Appendix A

Paper 7

Page 1 of 5

Appraisal and revalidation of medical practitioners

Executive summary

As at 30 September 2016 there were 1039 doctors linked to the designated body and the

trust has 142 appraisers

Of the 517 appraisals due between 1 April 2016 and 30 September 2016, 40.8% (211) have

been completed within the reporting period.

Since 1 April 2016, 52 revalidation recommendations have been made to the GMC, of which

17.3% (9) were deferral requests.

Since the last report in February 2016 we have appointed and trained 3 additional

appraisers. Refresher training has been completed by a further 14 appraisers.

Improvements have been made in the support for doctors with appraisal and is now followedby a robust escalation process for missed or late appraisals

Steps have been taken to ensure that ID checks are carried out for agency doctors

As advised to the board at the September board meeting, it is proposed to advertise the post

of responsible officer and make an appointment subject to board approval.

Action required/recommendation

The board are asked to note the recommendations:

• Review the way doctors are allocated appraisers

• Recruit appraisers to ensure 200 available

• Ensure all appraisers complete on line or other refresher training

• Further work with clinical directors to ensure that each directorate is contributing tothe appraiser pool and that this is recognised in departmental job planning

• Focus on support for appraisers and improving the quality of appraisals




number(s)


outcomes



Paper 7

Page 2 of 5



x





x



x

CQC Regulations supported by this paper

Regulation 4 Requirements where the service provider is an individual or partnership

Regulation 5 ⃰ Fit and proper persons: directors x

Regulation 6 Requirement where the service provider is a body other than a partnership x

Regulation 7 Requirements relating to registered managers

Regulation 8 ⃰ General

Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 15 Premises and equipment

Regulation 16 Receiving and acting on complaints

Regulation 17 Good governance x

Regulation 18 Staffing

Regulation 19 Fit and proper persons employed x

Regulation 20⃰ Duty of candour

Regulation 20A⃰ Requirement as to display of performance assessments

Care Quality Commission (Registration) Regulations 2009 (Part 4)

Regulation 12 Statement of purpose

Regulation 13 Financial position

Regulation 14 Notice of absence

Regulation 15 Notice of changes

Regulation 16 Notification of death of a service user

Regulation 17 Notification of death or unauthorised absence of a service user who is

detained or liable to be detained under the Mental Health Act 1983

Regulation 18 Notification of other incidents

Regulation 19 Fees

Regulation 20⃰ Requirements relating to termination of pregnancies

Regulation 22A⃰ Form of notifications to the Commission


Compliance with GMC guidance is a statutory requirement

Equality analysis


Report from

Author(s) Prof S Powis, Dr V van Someren

Paper 7

Page 3 of 5

Medical Appraisal and Revalidation

Quarterly report for the trust board

Authors

Prof Stephen Powis, Responsible Officer

Vivienne van Someren Associate Medical Director for Revalidation and Professional

Development

11/10/2016

Executive summary

• All doctors with a licence to practice have now been subject to the first revalidation

round.

• As at 30 September 2016 there were 1039 doctors linked to the designated body.

• Their overall appraisal rate for 2016/7 so far is 40.8%

• 52 revalidation recommendations have so far been made to the GMC, all on time.

• A formal escalation process has been embedded to facilitate an appraisal rate of

90%.

• Steps have been taken to ensure that ID checks are completed for all agency doctors

Purpose of the paper

NHS England requires the responsible officer of all designated bodies to present an annual

organisational audit of revalidation processes to the board and this paper constitutes an

update on the first two quarters of 2016/7.

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Medical appraisal

Completion figures reported to NHS England

Appraisal rates for doctors attached to the Royal Free London NHS Foundation Trust as of

30 September 2016

Q1Apr 2015 to

Jun 2015

Q2Jul 2015 toSep 2015

The number of doctors with whom thedesignated body has a prescribedconnection

1045 1039

The number of doctors due to hold anappraisal meeting in the reporting period

390 127

The number of those doctors above whoheld an appraisal meeting in the reportingperiod

151 60

The number of those doctors above whodid not hold an appraisal meeting in thereporting period

239 67

The number of doctors above for whomthe RO accepts the postponement isreasonable

5 2

The number of doctors above for whomRO does not accept the postponement isreasonable

234 65

The trust has 142 appraisers.

Out of 1039 doctors, the overall app rate for 2016/7 is currently 40.8%

Revalidation Recommendations made to GMC

Recommendations from 1 April 2016 to 30 September 2016

Positive recommendations 42

Deferral requests 9

Non engagement notifications 1

Deferrals were mainly related to incomplete appraisals. The commonest problem is

completing patient and colleague 360s in time

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Risk and Issues

• Appraisal rates remain below target of 90% by 31 March 2017

Recommendations

Actions undertaken or in progress

• Following guidance from NHS England, a formal escalation process has now beenembedded to ensure that appraisal rates are monitored from start to finish. Theprocess commences with sending a reminder email to doctors approximately 2-3months prior to their appraisal. The process finishes with a formal letter stating thatthe RO is considering implementing REV 4 (i.e. notifying the GMC and asking for anearly revalidation date

• Steps have been taken to ensure that ID checks are carried out for agency doctors:- A tick box has been added to the Allocate authorisation to agree to have inducted

the doctor on arrival and carried out an ID check- A tick box to agree an ID check has been undertaken has been added to the Bank

locum timesheet- Our Medical agencies have been contacted to ask that a tick box is added to their

timesheet for agency doctors- Guidance is sent with the CV pack detailing what the manager needs to do on the

doctors arrival- A review of the Temporary Staffing Policy is being undertaken to ensure Induction

and ID checks are covered adequately. This should be added to the amendmentsthat will need to be made following the outcome of the junior doctors contract

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1X:\ Chair and CEO report 19 October 2016

CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

Executive summary

This is a combined chairman’s and chief executive’s report containing items ofinterest/relevance to the board.

Action required

The board is asked to note the report.

Report From D Dodd, chairman and D Sloman, chief executiveAuthor(s) A Macdonald, board secretaryDate October 2016



Paper 8


CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

A TRUST DEVELOPMENTS

CHASE FARM HOSPITAL REDEVELOPMENT UPDATE

The Chase Farm Redevelopment build programme is continuing at pace with the concreteframe complete up to the second floor and a topping out ceremony planned for January2017. Construction is running on time and on budget. Contracts have been exchanged withLinden Homes for the sale of Parcel A, and the sale is due to be completed by 31st October.Revenue savings are being tracked on a monthly basis, and the savings on site are currentlyahead of plan. Detailed workforce and efficiency plans are being worked up as part of thetrust’s overall financial improvement plan.

ROYAL FREE HOSPITAL EMERGENCY DEPARTMENT UPDATE

The Royal Free emergency department redevelopment is being undertaken under twocontracts. The first has been completed, which provided a new dedicated paediatrics'emergency department and waiting area, new staff facilities and office accommodation and anew ambulatory care unit.

Contract 2 started on the 26 September 2016 and will be comprise three phases. The firstphase of the construction works will deliver Part 1 of majors, a new reception desk, and therapid assessment and treatment area including new LAS handover facilities. Phase 2 willprovide a new imaging facility including two x-ray rooms and one CT suite, and a six beddedresuscitation unit. The final phase completes the majors facility and delivers a new 30bedded CDU, which replaces the temporary facility. Contract 2 is programmed forcompletion in March 2018. This stage of the development scheme is particularly challengingfrom both a build and operations perspective due to the live nature of the environment. Theclinical and project teams are working closely to maintain clinical operations at all times.

FIRST FLOOR OUT-PATIENT REFURBISHMENT WORK STARTING SOON AT THE RFH

Work to refurbish the first floor out-patient department at the Royal Free Hospital will startsoon.

Work will be carried out in phases, and will take place over evenings and weekends to avoiddisruption. The first phase of works will include the corridor located next to the main hospitallifts, the adjacent toilets, clinic 5 and the main corridor area. The toilets will be closed whilework takes place, but all other areas will remain accessible to staff and patients.

The refurbishment will include the replacement and relocation of current reception desks tocreate a more spacious working environment for staff, and improve accessibility for patientswith communication and access requirements. Walls and ceilings will be re-plastered andredecorated and works will also include improved lighting, ventilation and flooring.

GROUND FLOOR PUBLIC TOILETS

The public toilets on the ground floor, between the main hospital entrance and the atrium,are currently being refurbished. This includes the male, female and accessible toilets as wellas baby change room. There are signs directing patients and visitors to the closestalternative facilities and the anticipated completion date is 22 November 2016.

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B REGULATION

The NHS Improvement Q2 self-certification is included separately on the agenda.

C BOARD AND COUNCIL MATTERS

NON EXECUTIVE DIRECTOR APPOINTMENTS

The process for the recruitment of two non-executive directors is continuing. It is currentlyexpected that a recommendation by the nominations committee will be presented at thescheduled council of governors meeting on 15th November 2016.

D LOCAL NEWS AND DEVELOPMENTS

NORTH CENTRAL LONDON SUSTAINABLITY AND TRANSFORMATION PLAN(STP)

The national planning guidance for 2016-17 outlined a new requirement for the developmentof STPs, or area plans. STPs are a means of planning services systemically rather thanorganisationally and bring together commissioners, providers and local authorities from alocality to plan health and social care over a five year timeframe.

There are 44 STPs, each headed up by a triumvirate of a commissioner, provider andcouncil representative, with one of these taking the lead as convenor. The main STP for RFLpurposes is NCL, David Sloman being the convenor of this area plan. Royal Free Londonhas an interest in three STPs – North Central London, North West London and Hertfordshire& West Essex.

The STP vision is:

• To improve health and wellbeing outcomes for the people of North Central Londonand ensure sustainable health and social care services, built around the needs oflocal people.

• To develop new models of care to achieve better outcomes for all, focused onprevention and out of hospital care.

• To work in partnership to commission, contract and deliver services efficiently andsafely.

The STP is currently developing the plan on an iterative basis. A submission was made toNHS England in June setting out initial thinking and this is continuing to be refined anddeveloped. A progress update as at September 2016 is on the trust’s website at Septemberupdate . Further thinking will be submitted by the end of October and it is anticipated that theSTP will be in a position to discuss potential long term solutions from early 2017.

All of this work has been based on the case for change, which is also on the trust’s websiteclinical case for change, developed by the STP’s Clinical Cabinet, who are advising on theplan to ensure it reflects the best clinical expertise from a range of health and care

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professionals. An on-going programme of engagement and discussion with local people isalso shortly to be commenced which is expected to continue over the coming months.

NON-EMERGENCY PATIENT TRANSPORT SERVICE

On 21 August 2016, the trust transferred the responsibility for the delivery of the non-emergency patient transport (NEPT) service to a new interim service provider, DHL. DHL isan experienced NEPT provider and provides all patient transport provision across all thetrust’s hospitals and satellite sites, including the renal dialysis services.

DHL took over the operation of the SRCL Ponders End HQ, transferring all personnel andfleet as planned. The service transition period was planned to be fully completed by 1October 2016 when the operating system known as Cleric would be fully operationalproviding up to the minute information on patient journeys, greater visibility of real timeactivity data and provide the trust teams with improved access to performance data.

DHL completed the transition to the Cleric operating system ahead of their planned date,with the renal service fully transferred on 16 September and the remainder of the servicecompleted on 23 September. Overall, the general feedback on the transition has beenpositive. However, on the final transition to the DHL system on 23 September, there were anumber of events relating to patient pick-ups.

There has been a reduction both in incidents and calls to the patients advice and liaisonservice (PALS) compared to the same period in the previous year, with PALS seeing areduction of 55% and incidents reducing by 60%.

Current levels of key performance indicator (KPI) performance being achieved far exceedthose on the previous PTS contract, although some remain off track.

100 DAYS SINCE THE LAST SURGICAL NEVER EVENT

On 23 September 2016 the trust achieved the important milestone of not having had asurgical never event for 100 days. This milestone was last reached in February 2015.

In April 2015, funding was received from the NHS Litigation Authority (NHSLA) for the trust’sPatient Safety Programme (PSP) to incorporate a safety improvement plan, which included adedicated work stream programme for safer surgery. A cross site multi-disciplinary team(MDT) improvement group aligned their local approaches to the ‘WHO Checklist’, comparingand sharing documentation and data to understand where variation in current processesexists. Improvements have been clinically led by anaesthetics, nursing and surgicalspecialties across our main hospitals.

DISCHARGE LOUNGES AT BARNET HOSPITAL AND THE ROYAL FREE HOSPITAL

The discharge lounges at Barnet Hospital and Royal Free Hospital have been redesigned toprovide a safe and comfortable place for patients to wait to go home once they aredischarged from their ward. They are staffed by nurses and healthcare assistants, equippedwith comfortable chairs and tables and refreshments are available. The lounge will managepatients' transport and medication to take away (TTA) needs.

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CHASE FARM HOSPITAL – NEW CLOCK CAFE AND GREEN GYM

As part of Healthy Living Week (HLW), the Clock cafe and outdoor green gym were officiallylast month, to help staff, patients, visitors and the local community stay healthy.

CFH is working with partners including Enfield Council, Macmillan Cancer Support,Tottenham Hotspur Football Club and Medirest to encourage adults and young people to eatmore healthily and get more active.

Gary Mabbutt MBE, former England and Tottenham Hotspur footballer and patron ofDiabetes UK, joined Fiona Jackson, director of CFH, to offically open the cafe and greengym.

The event included food tastings, gym demonstrations and smoothie making. Following theopening Macmillan Cancer Support and the Tottenham Hotspur Foundation led a walkinggroup, with staff joining the group receiving a free pedometer and t-shirt.

The new cafe, run by Medirest on behalf of the trust, serves healthy main meals, snacks,sandwiches and drinks, as well as newspapers, magazines and toiletries. The outdoor gymis equipped with a combination of cardio, strength and toning work stations for those whowant to improve their levels of fitness and health.

LUNG CANCER TEAM NOMINATED FOR HEALTH SERVICE JOURNAL (HSJ) AWARD

The lung cancer team at the RFL has been nominated for an award by the Health ServiceJournal after developing a new lung biopsy method.

The new ambulatory lung biopsy service, based at Barnet Hospital, enables the vast majorityof patients to be discharged just 30 minutes after their biopsy. The method also allowsbiopsy patients who suffer a collapsed lung to be treated at home as out-patients.

The biopsy team, led by Dr Sam Hare, consultant radiologist and lead for chest imaging, wasnominated for the acute sector innovation award and will compete with eight other trusts. DrHare is required to complete a presentation and interview about the biopsy method to ajudging panel made up of senior figures from the health sector. The winners of each awardwill be announced on 23 November.

PATIENT FRIENDS AND FAMILY TEST (FFT) UPDATE

The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feedback on their care and treatment to enable hospitals and other providers to improveservices. It asks patients whether they would recommend hospital wards, A&E departmentsand maternity services to their friends and family if they needed similar care or treatment.

The FFT results are reviewed by the patient and staff experience committee and reported toevery public meeting of the trust board.

The tables below show the combined scores for all sites and then the results by site forSeptember 2016.

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Royal Free Londoncombined data

% likely/extremely likely torecommend September 2016

(range: 0 – 100%)

Number of patient responses

In-patient 89% 1310

A&E 82% 4694

Barnet Hospital % likely/extremely likely torecommend September 2016

(range: 0 – 100%)


In-patient 86% 380

A&E 80% 2480

Antenatal care 98% 51

Labour and birth 97% 115

Postnatal hospital ward 95% 109

Postnatal community care 100% 277

Out-patients 94% 124

Chase Farm Hospital % likely/extremely likely torecommend September 2016

(range: 0 – 100%)


In-patient 94% 173


Royal Free Hospital % likely/extremely likely torecommend – September 2016

(range: 0 – 100%)


In-patient 89% 717

A&E 83% 2214

Antenatal care 98% 59

Labour and birth 92% 66

Postnatal hospital ward 89% 66

Postnatal community care 100% 277


*The postnatal community care question is only reported as a whole trust figure and not splitby site.

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COMMUNICATIONS REPORT

Media coverage

During September, the trust featured positively on BBC’s the One Show, as they covered afollow-up story on Ethan Giles-Bowman, a former patient who had had his ear surgicallyrepaired in 2011 at the Royal Free Hospital. Gary Mabbut, Tottenham Hotspur legend, wasinvited to open the green gym at Chase Farm Hospital and this story featured in Enfield’slocal papers. Jeremy Hunt named the Royal Free London as a centre of digital excellenceand this story was also picked up in the HSJ and other tech publications. The trust receivednegative coverage in local stories about an inquest into a patient’s death at Barnet Hospitaland the induction process for volunteers. The HSJ also criticized the trust for not reaching itsfinancial targets and Chase Farm Hospital was mentioned in The Mirror about NorthMiddlesex Hospital’s A&E. The trust was mentioned in national press about Isabelle Dinoire,the first person to have a face transplant, who had died earlier in the month. The BBCmentioned the trust neutrally in a story about DeepMind’s work in healthcare.Figure 1 shows the number of positive stories that the trust had during September. The trustwas mentioned in 51 positive stories for September.Figure 1

Figure 2 shows how much this positive coverage would cost if these pieces were paid foradvertorials, the total cost would be £51617.74 for September.

41

3

7

0

5

10

15

20

25

30

35

40

45

Royal Free Hospital July Barnet Hospital July Chase Farm Hospital July


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Figure 2

Figure 3 shows the sentiment of our press mentions split as positive, neutral and negative.The sentiment of our coverage is analysed through the tone of our mentions.

Figure 3September Royal Free

HospitalBarnet

HospitalChase Farm

HospitalTotal

Positive 41 3 7 51

Neutral 848 7 2 857Negative 6 4 3 13

Total 895 14 12 921

Figure 4 shows how many media requests the trust received and how many statements andwebsite stories the external and digital communications team issued during the month ofSeptember.

Figure 4

Figure 5 shows the daily breakdown of the trust’s volume of news stories compared to howmany people they reached. Reach can be calculated as higher if the trust is mentioned innational coverage compared to local. There is a three day spike on 13, 14 and 15September as the Royal Free London was mentioned in stories about Pauline Cafferkey’scourt hearing.

£47,482.37

£1,802.48 £2,332.89

£0.00

£5,000.00

£10,000.00

£15,000.00

£20,000.00

£25,000.00

£30,000.00

£35,000.00

£40,000.00

£45,000.00

£50,000.00


RFL value September 2016


September Trust total

Statements 10Mediarequests

33

Websitestories

15

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Figure 5

Figure 6 shows the number of reactions (likes) and comments our posts received, and thenumber of times they were shared across the month of September.

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Figure 6

• The spike on 7 September shows the reaction to a post about the history of

transplant surgery at the Royal Free Hospital. This post reached 4,991 people.

• The spike on 9 September shows the reaction to a video about a son donating

part of his liver to his father in a live liver transplant at the Royal Free Hospital.

This post reached 10,872 people.

• The spike on 24 September shows the reaction to a post about the history of the

Royal Free Hospital. This post reached 2,616.

Twitter activity - September• Total number of followers: 11,378• Increase of 246 compared to August 2016• Percentage increase YOY: 30.33%• No. of posts: 226• Most retweeted tweet: Celia shares why she

decided to donate her kidney to someoneshe'd never met (10 retweets)

• Most clicked tweet: Consultant psychologistwrites book about helping #NHS staff toovercome the emotional challenges of theirwork (18 clicks)

• Most liked tweet: Celia shares why shedecided to donate her kidney to someoneshe'd never met (12 likes)

• The kidney donation tweet reached 3,177people and the book tweet reached 1,001people.

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LinkedIn activity

Figure 7 shows the number of clicks our posts received over September.

Figure 7

• The spike on 8 September shows the reaction to a post about the Royal Free

London receiving £10million from the government to pioneer new technologies.

This post reached 4,140 people.

• The spike on 21 September shows the reaction to a post advertising our

apprenticeship opportunities. This post received reached 3,337 people.

Internal communications

Figure 8 shows a breakdown of how many items the internal communications teamuploaded to our staff intranet, Freenet, during July, August and September.

Figure 8

Figure 9 shows how many stories and notices the internal communications team publishedin the monthly staff magazine, Freepress and the weekly staff e-letter Freemail.

Landing page newsLanding page

noticesFreenet news Events

July 33 12 25 9

August 22 18 28 7

September 38 28 46 12

0

10

20

30

40

50

RFL Intranet three months

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Figure 9

September Total stories andnotices

Freenet 124

Freepress 16

Freemail 62

Managers briefing 21

Figure 10 shows how many briefings and visits the internal communications team arrangedduring the month of June.

Figure 10

September Total amount

Chief executivebriefing

4

Executive shadowing 1

Go-see visits 6

In this time the internal communications team also:

• Provided internal communication support for key trust improvement projects, the

2020 vision transformation programme and the financial improvement programme.

• Promoted the launch of the 2016 NHS staff survey and the actions taken to date in

response to the last two years’ feedback as part of the staff experience retention

plan.

• Launched the winter flu campaign to help achieve the trust’s target of vaccinating

75% of staff.

• Worked closely with the relevant staff groups to promote Healthy Living Week and

launch a range of activities to celebrate Black History Month in October.

• Continued to support the redevelopment of Chase Farm Hospital.

NHS IMPROVEMENT BOARD MEETING – 29 SEPTEMBER 2016

• Update on sustainability and transformation plans (STPs)

• Review and further development of the draft STPs that were submitted in June isunderway. In addition to GPs, CCGs, providers, local authorities and NHSE, plansneed to include ambulance and specialist providers that cross STP boundaries andhave established joint working arrangements with the voluntary and independentsectors.

• The strategic planning guidance asked STP partners to set out plans to engage keystakeholders. Once specific proposals have been developed there will need to be aclear case for change to support local engagement, and consultation wherenecessary.

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• The National Quality Board has recently published an updated safe staffing resourceto help achieve FYFV ambitions as a basis for organisations to assess workforceover the next five years.

• Reiterated the need to close the finance and efficiency gap through improvedproductivity, long-term sustainability and capital requirements. NHSI is building itssupport for providers to implement the Carter review.

• Highlights local authorities and NHS commissioners pooling funding, and STPs areencouraged to consider the impact of social care funding expectations whilemaintaining the formal separation from NHS funding as appropriate.

• To ensure that STP partners have the best chance of implementing their planssuccessfully, local leadership must have sufficient support, including to establisheffective governance for STP partners working together as a system.

• Local leaders have been asked to submit plans in October 2016. The strategic plansfor each footprint will be a key starting point for two-year, organisation-leveloperational plans for 2017/18 and 2018/19.

• In conclusion, NHSI considers that over the coming months it will be important tomaintain a strong focus on the aims of the STP process: to resolve the mostsignificant challenges faced in each local system, taking the necessary decisions toclose the three gaps.

• Operational Planning 2017/18-2018/19

• The planning guidance was published on 22 September and operational planningand contracting will be completed by the end of December 2016. Moving into 2017,organisations should be able to focus on delivery of the next two years of their STPs.

• NHSI expects that provider plans should provide for a realistic level of patient activity;demonstrate improvement in the delivery of core access and NHS Constitutionstandards (or improvement trajectories); reflect the strategic intent of STPs; provideassurance on the approach to quality and the robustness of workforce plans; befinancially stretching; contain affordable capital plans that are consistent with theclinical strategy; be aligned with commissioner plans, and underpinned by contractsthat balance risk appropriately; be internally consistent between activity, workforceand finance plans.

• Single Oversight Framework (SOF)

• Following the consultation on the SOF, NHS Improvement has now published therevised framework and its response to the consultation outcome.

• The paper sought board approval to start monitoring providers using the SOF fromOctober.

• NHSI proposes to publish the first formal segmentation of the sector in November,using the first data collected under the SOF. A shadow segmentation has beencarried out using current data and will be published for the whole sector in October.

• Operational performance of ambulance trusts

• All ambulance trusts face performance issues to varying degrees and performancemeasures have evolved recently with NHS England determining that East of Englandshould use the established counting method and London should use the samemethod but count differently to allow greater triage time.

• New care model update: NHS Improvement’s role in establishing andoverseeing accountable care organisations

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• The paper defines the term Accountable Care Organisation (ACO) as follows:‘ACO is used as a shorthand for multispecialty community providers (MCPs) orprimary and acute care systems (PACS) that involve a single provider takingresponsibility for population health and for managing resources across multipleservices (as a minimum, community health services and general practice services)that have previously been commissioned and provided separately. This wouldinvolve a single contract, underpinned by a single capitated budget’.

• Many activities currently undertaken by commissioners will instead be carried outby the ACO. It is expected that CCGs will pass some of their running costs on toACOs in recognition of this.

• The NCM team is working intensively with six MCPs. Of the PACS vanguards,Northumberland and South Somerset have each initiated processes to award a newcontract.

• The evaluation work stream of the NCM programme has established a core set ofmetrics which are being tracked across all sites and a dashboard is shared withvanguards each quarter which tracks these against the rest of the MCP and PACScohorts and the rest of England. Vanguards have been funded to commission morecomprehensive local evaluations.

• NHSI does not expect to detect statistically significant change for severalquarters, but can track progress of delivery plans.

• Identifying the specific NCM contribution to overall CCG-wide demand iscomplex, given the range of other programmes, system pressures and changes.Over the coming months, the NCM evaluation and metrics team will subject aseries of examples to an ‘impact study’.

• NHSE, NHSI and CQC will jointly decide whether a proposed ACO is likely toimprove quality, health outcomes and financial sustainability for the healtheconomy as a whole and therefore whether an ACO can be set up.

• Operational Productivity Directorate: implementing the Carter review

• The directorate is working to fill a critical mass of posts and its ability tosupport trusts directly will be constrained until it is fully staffed centrally and inregions, and the operating model and working arrangements are established

• In approximately six months’ time, once sufficiently resourced, the directorateexpects to be able to provide analysis and advice to all regional teams in theirinteractions with trusts as well as direct specialist support to approx. six trusts at anyone time in each of the ten identified project areas.

CQC BOARD MEETING – 22 SEPTEMBER 2016

• CQC is aiming to complete the comprehensive inspection baseline programme in allsectors well before the 31 March 2017 deadline, and continue to conduct responsiveinspections and take enforcement action.

• Following the completion of the trust programme in quarter 1, the hospitals teamhave turned their focus to completing ratings in the independent sector. In addition re-inspections will take place at high risk providers.

• Overall, no directorate is meeting their objectives in the timeliness of inspectionreports - the average number of days for reports to be published (overall) was 128 daysin July 2016. To improve timeliness the hospitals team will develop a new reportstructure based on a short summary supported by an evidence appendix.

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• CQC reports that overall, providers rated inadequate and requires improvementimprove on re-inspection. CQC has published reports for 3,353 return inspections (i.e.following the first rating). Of these 1,493 (45%) have improved their overall rating, 1,528(46%) have not changed and 10% have deteriorated.

NHS ENGLAND BOARD MEETING – 29 SEPTEMBER 2016

• NHSE and NHSI have brought forward the annual planning process by 3months and hope to avoid having to intervene in contract disputes inJanuary

• Decisions will be made imminently on STP proposals and how to spreadfunding for NCMs. NHSE is not ‘approving’ STPs, but ‘reviewing andsupporting’. Simon Stevens said: ‘in practice, there will be a cohort [of plans]which are well worked-through and will have our support. There will be otherswhich will require a more deliberative process – involving citizen dialogue”.

• NHS Operational Planning and Contracting Guidance for 2017-2019published on 22 September sets out how planning and contractingprocesses are being changed to support STPs and the financial reset:

• Two year contracts will reflect two year activities, with workforce andperformance assumptions agreed within each local STP

• A two year tariff and National Standard Contract will be issued for consultation,as well as two-year CQUINs

• The timetable for the agreement of contracts will be brought forward fromspring to December

• A system of STP level financial control totals to complementorganisational control totals will be introduced, together with revisedarrangements for managing financial risk.

• NHS performance

• For July 2016 there was 90.3% attainment of the 4 hour target for A&E.There were 490,000 emergency admissions in July 2016. Emergencyadmissions are up 3.8% on the preceding 12 month period

• There were 184,200 total delayed days in July 2016, of which 123,800were in acute care. This is the highest figure since monthly data wasfirst collected in August 2010

• At the end of July 2016, 91.3% of patients were waiting up to 18 weeks tostart treatment. The number of patients waiting to start elective treatmentat the end of the month was just under 3.9 million.

•

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Page 1 of 2

Monitor risk assessment framework report

Executive summary

This paper summarises the trust’s performance against the metrics in the Monitor Risk Assessment framework and sets out our improvement plans, where appropriate.


For information

Trust strategic priorities and business planning objectives supported by this paper


1. Excellent outcomes – to be in the top 10% of our peers on outcomes

X

2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and staff experience

X

4. Excellent compliance with our external duties – to meet our external obligations effectively and efficiently

X

5. A strong organisation for the future – to strengthen the organisation for the future

X



Regulation 5 ⃰ Fit and proper persons: directors

Regulation 6 Requirement where the service provider is a body other than a partnership











Regulation 17 Good governance


Regulation 19 Fit and proper persons employed


Regulation 20A ⃰ Requirement as to display of performance assessments

Care Quality Commission (Registration) Regulations 2009 (Part 4)Regulation 12 Statement of purpose



Report to

Date of meeting Attachment number

Trust Board

19 October 2016 Paper 9

Paper 9

Page 2 of 2



Regulation 17 Notification of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983


Regulation 19 Fees


Regulation 22A ⃰ Form of notifications to the Commission


Equality analysis

No identified negative impact on equality and diversity

Report from Kate Slemeck, chief operating officer Authors Kate Slemeck, Amy Caldwell-Nichols, Temi Salami Date 14 October 2016

September 2016

Monitor Risk Assessment Framework

Performance for

2015/2016 Outturn

and

September 2016

Produced 7th October 2016

Monitor Risk Assessment Framework

Table of Contents

Section Pages

Monitor risk assessment framework dashboard 2015/16 Pages 3 - 4

Monitor governance risk rating 2015/16 - Royal Free London NHS Foundation Trust Page 5

Monitor governance risk rating 2015/16 - Royal Free Hospital Site Page 6

Monitor governance risk rating 2015/16 - Barnet Hospital Site Page 7

Monitor governance risk rating 2015/16 - Chase Farm Hospital Site Page 8

Monitor governance risk rating 2015/16 - Other Hospital Sites Page 9

Recovery trajectory compliance Page 10

Monitor high risk ratings Pages 11 - 24

Monitor low risk ratings Pages 25 - 26

September 2016

Section 1

Monitor Risk Assessment Framework Dashboard

Access Targets & Outcome Objectives

Operational Standards & Targets

September 2016 and Quarter 2

Monitor Risk Assessment DashboardMonth: September 2016

Summary

Risk Assessment Framework Summary A&E Performance against 95% Standard

Month Trend QTD Month Trend QTD

Royal Free London NHS FT Green1

Green1

Royal Free London NHS FT R R

Royal Free Hospital Green1

Green1

Royal Free Hospital R R

Barnet Hospital & Chase Farm Hospital Green1

Green1

Barnet Hospital & Chase Farm Hospital R R

C. difficile Performance against Trajectory 18-weeks RTT Performance

Month Trend QTD Month Trend QTD

Royal Free London NHS FT G G Royal Free London NHS FT G G

Royal Free Hospital G G Royal Free Hospital G G

Barnet Hospital & Chase Farm Hospital G G Barnet Hospital & Chase Farm Hospital G G

Cancer Performance against Targets2

Month Trend QTD

Royal Free London NHS FT R R

Royal Free Hospital R R

Barnet Hospital & Chase Farm Hospital R R

1Monitor framework adjustment applies

218-weeks RTT and

Cancer are reported for August 16

September 2016 Monitor Risk Assessment Scorecard October 2015 to September 2016

Royal Free London NHS Foundation Trust

Monitor Indicators of Governance Concerns - April 2015 - August 2016 Q3 Q4 Q1 Jul-16 Aug-16 Sep-16 Target WeightingRolling

Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 93.4% 87.8% 91.0% 91.3% 89.96% 88.08% >= 95% 1.0 High

**C difficile number of cases against plan 5 0 Compliant Compliant 2 Compliant Q1 <= 17 1.0 Low

**Maximum time of 18 weeks from point of referral to treatment in

aggregate for patients on an incomplete pathways86.7% 89.6% 92.2% 92.2% 92.0% Compliant >=92% 1.0 Low

**Cancer: two week wait from referral to date first seen

All cancers 96.2% 92.9% 93.0% 95.1% 93.9% Compliant >=93%

Symptomatic breast patients 96.4% 89.1% 94.5% 92.95% 94.0% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 99.2% 98.1% 97.6% 96.7% 95.0% Compliant >=96% 1.0

**All Cancer 31 day second or subsequent treatment -

surgery 100.0% 99.1% 98.9% 96.3% 100.0% Compliant >=94%

drug 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%

radiotherapy 100.0% 99.2% 100.0% 100.0% 100.0% Compliant >=94%

**All Cancer 62 days wait for first treatment:

from urgent GP referrals: 73.3% 72.6% 82.6% 75.8% 75.5% Fail >=85%

from a screening service 93.0% 83.3% 94.9% 96.6% 96.6% Compliant >= 90%

Compliance with requirements regarding access to healthcare for people with

learning disabilitiesCompliant Compliant Compliant Compliant Compliant Compliant

Meeting the

6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating: Green1

Green1

Green1

Green1

Green1

Green1

Green: a service performance score of <4.0 and <3 consecutive quarters' breaches

of a single metricWeighting: 2 3 2 3 2

Red: a service performance score of >=4.0 and >=3 consecutive quarters'

breaches of a single metric

* Denotes actual data for April 2016

**18-weeks and Cancer data is not available for April 2016

Note: C. difficile RAG rating applied on the basis of the cumulative quarterly

expression of the trajectory

2015/16

1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary

Low

High

1.0 Medium

1.0

1.0

2016/17

Medium


Royal Free London Hospital

Monitor Indicators of Governance Concerns - April 2015 - August 2016 Q3 Q4 Jun-16 Q1 Jul-16 Aug-16 Sep-16 Target Weighting

Rolling

Risk

Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 93.3% 89.5% 89.9% 90.7% 92.1% 92.7% 85.2% >= 95% 1.0 High

**C difficile number of cases against plan 4 0 Compliant Compliant Compliant Compliant Compliant Q1 <= 8 1.0 Low


aggregate for patients on an incomplete pathways87.5% 89.7% 92.7% 92.7% 92.7% 91.9% Compliant >=92% 1.0 Low


All cancers 98.7% 97.4% 96.1% 96.9% 96.4% 96.2% Compliant >=93%

Symptomatic breast patients 98.8% 95.0% 100.0% 98.2% 94.4% 96.3% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 98.5% 96.5% 94.7% 95.5% 93.4% 91.4% Fail >=96% 1.0


surgery 100.0% 100.0% 100.0% 98.1% 92.3% 100.0% Compliant >=94%

drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%

radiotherapy 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% Compliant >=94%


from urgent GP referrals: 72.6% 69.8% 82.2% 79.7% 64.5% 69.0% >=85%

from a screening service 92.6% 92.6% 83.3% 91.7% 100.0% 93.3% Compliant >= 90%


learning disabilitiesCompliant Compliant Compliant Compliant Compliant Compliant Compliant

Meeting the

6 criteria1.0 Low


Green1

Green1

Green1 Red Green

1Green

1

Green: a service performance score of <4.0 and <3 consecutive quarters'

breaches of a single metricWeighting: 2 3 3 3 4 3







2015/16


1.0 Low

1.0 Low

1.0 High

High


Barnet Hospital

Monitor Indicators of Governance Concerns - April 2015 - August 2016 Q3 Q4 Jun-16 Q1 Jul-16 Aug-16 Sep-16 Target WeightingRolling

Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 91.5% 82.2% 87.4% 91.3% 87.6% 84.4% 86.6% >= 95% 1.0 High

**C difficile number of cases against plan 1 0 Compliant Compliant Compliant 2 Compliant Q1 <= 7 1.0 Low


aggregate for patients on an incomplete pathways91.6% 91.6% 91.9% 92.2% Compliant >=92% 1.0 High



Symptomatic breast patients 94.3% 81.5% 92.9% 89.6% 91.8% 90.5% Fail >=93%

**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=96% 1.0



drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%

radiotherapy N/A N/A N/A N/A N/A N/A Compliant >=94%


from urgent GP referrals: 76.0% 75.5% 92.6% 80.0% 78.7% 80.0% Fail >=85%




Meeting the

6 criteria1.0 Low


Green1

Green1 Red Green

1Green

1Green

1


breaches of a single metricWeighting: 2 3 2 4 3 3 3







2015/16


1.0 High

1.0 Low

1.0 High

Low

2016/17


Chase Farm Hospital

Monitor Indicators of Governance Concerns - April 2015 - August 2016 Q3 Q4 Jun-16 Q1 Jul-16 Aug-16 Sep-16 Target WeightingRolling

Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >= 95% 1.0 Low

**C difficile number of cases against plan 0 0 Compliant Compliant Compliant Compliant Compliant Q1 <= 0 1.0 Low

*Maximum time of 18 weeks from point of referral to treatment in

aggregate for patients on an incomplete pathways87.8% 87.8% 90.7% Fail Fail >=92% 1.0



Symptomatic breast patients 96.6% 91.7% 89.6% 92.5% 93.2% 96.2% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% Compliant >=96% 1.0 Low



drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98%

radiotherapy N/A N/A N/A N/A N/A N/A Compliant >=94%


from urgent GP referrals: 69.1% 72.3% 80.0% 80.4% 90.6% 82.0% Fail >=85%




Meeting the

6 criteria1.0 Low


Green1

Green1

Green1

Green1

Green1

Green1


breaches of a single metricWeighting: 1 2 2 2 0 2



* Denotes actual data for March 2016

**18-weeks and Cancer data is not available for March 2016



2015/16


1.0 High

1.0 Low

1.0 High

High


Other Satellite Sites

Monitor Indicators of Governance Concerns - April 2015 - August 2016 Q3 Q4 Jun-16 Q1 Jul-16 Aug-16 Sep-16 Target Weighting

Rolling

Risk

Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours >= 95% 1.0

**C difficile number of cases against plan Q1 <= 0 1.0


aggregate for patients on an incomplete pathways>=92% 1.0



Symptomatic breast patients 91.7% 42.9% 100.0% 80.0% N/A 100.0% Compliant >=93%

**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% N/A 100.0% 100.0% N/A Compliant >=96% 1.0 Low


surgery >=94%

drug >=98%

radiotherapy >=94%


from urgent GP referrals: 50.0% 84.8% N/A 100.0% 100.0% N/A Compliant >=85%




Meeting the

6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating:


breaches of a single metricWeighting: 2 2 2







2016/172015/16


1.0 High

1.0

1.0 High

High Risk Indicators Commentary and Exception Report Month: September 2016

Risk Assessment Framework ‐ commentary Trust performance overview The table below summarises the performance against standard for each site of the Royal Free London, showing that we are currently non‐compliant on:

A&E; RTT; 2 week wait cancer; and 62 day cancer.

Period Reported Indicator

Description Standard STF All Royal Free Barnet Chase

Farm Other

Sep‐16 AE Patients admitted, transferred or discharged within 4 hours

95% 95% 88.1% 85.2% 86.6% 100%

Aug‐16 C Difficile Cases

Lapses in care <=0 0 Compliant Compliant 2 Compliant

Aug‐16 RTT Patients on incomplete pathways waiting less than 18weeks

92% 92% 92.0% 91.9% 92.2% 90.7%

Aug‐16 Cancer 2 week waits ‐ All cancers

93% 93.9% 96.2% 92.2% 94.0% 89.3%

2 week waits ‐ Symptomatic breast

93% 94.0% 96.3% 90.5% 93.2% 100.0%

31 day waits diagnosis to first treatment ‐ All cancers

96% 95.0% 91.4% 100.0% 100.0% N/A

31 day waits diagnosis to first treatment – Surgery

94% 100.0% 100.0% 100.0% 100.0%

31 day waits diagnosis to first treatment ‐ Drug

98% 100.0% 100.0% 100.0% 100.0%

31 day waits diagnosis to first treatment ‐ 94% 100.0% 100.0% N/A N/A


Radiotherapy 62 day waits from GP referral to treatment

85% 78.1% 75.5% 69.0% 80.0% 82.0% N/A

62 day waits from screening service referral to treatment

90% 96.6% 93.3% 100.0% 100.0% 96.7%

Our focus remains on our areas of sustained non‐compliance in A&E and Cancer. RTT performance has been compliant since June and we are progressing with the next phase of development for the RTT patient tracking list (PTL). Diagnostics continues to be compliant with the 6 week standard in August, including a return to standard for the Cystoscopy modality. The Strategic Transformation Fund (STF) For 2016/17 NHS Improvement has allocated additional funding from the STF to trusts delivering against agreed target recovery trajectories. Our trajectories for all indicators are summarised in the table below – green indicates that we have met the trajectory, red that we have not. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

A&E 4 hour standard 90% 92% 93% 95% 95% 95% 92% 90% 91% 91% 92% 92%

18‐weeks RTT Incomplete Pathways 90% 91% 91% 92% 92% 92% 92% 92% 92% 92% 92% 92%

18‐weeks RTT Volume of 52 Weeks Breaches

5 5 5 5 5 5 0 0 0 0 0 0

99% of Diagnostic Pathways to be Seen within 6‐weeks

99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%

Cancer 62 days from GP Referral 79.7% 75.2% 76.1% 77.4% 78.1% 74.4% 78.2% 83.8% 85.2% 85.3% 85.2% 85.2%


A&E Delivering performance against both the 95% standard and our STF trajectory remains very challenging, with September performance at 88.1%. Our investigation into this suggests that we have seen consistent increases in demand. Part of this may be attributable to increased volumes of patients arriving from Enfield, suggesting there may be some switching from the North Middlesex. We also continue to see high levels of delayed transfers of care, representing a backlog of patients waiting for care outside of hospital (either NHS community care or local authority social care). We will shortly launch a recovery programme based on the principles of the NHS England Safer, Faster, Better guidance1 and covering the main areas of improvement recommended by NHS Improvement, including implementation of the SAFER bundle across our hospitals and the implementation of all “Discharge to Assess” pathways. On 14th October, we met NHS England and key members of our local A&E delivery board to discuss our programme and agree system‐wide actions that will support resilience in the system over winter, including:

‐ Additional GP out of hours availability delivered by Barnet CCG, and ‐ Work with London and East of England Ambulance Services to improve coordination.

Cancer 62 day We have progressed work on our Cancer 62 day performance improvement programme. Performance against the 2 week wait standard has remained on track and, while overall 62 day performance is below the STF trajectory, activity volumes have increased, indicating that tumour sites have been addressing their backlogs. We expect this trend to continue in September and anticipate returning to our STF recovery trajectory in October. We did not deliver performance above standard for the 31 day wait from diagnosis to first treatment standard. This was primarily driven by breaches in the urology pathway. We are investigating this further to prevent this from re‐occurring. As highlighted in the August report, a remaining major risk is around theatre capacity for renal and HPB patients. Current performance is reliant on ad‐hoc availability of theatre lists and we have not yet identified a sustainable increase. Between 9th October 2016 and 16th October 2016, we are merging our Infoflex databases for managing cancer services to provide consistency across Royal Free, Barnet and Chase Farm sites and improved views of the data. This is being closely managed to ensure that it does not negatively affect the service during the merge.

1 http://www.nhs.uk/NHSEngland/keogh‐review/Documents/safer‐faster‐better‐v28.pdf

of 1

FINANCE PERFORMANCE REPORT 2016/17 – Month 6

Chief Financial Officer’s Message

Year to date

actual deficit of

£28.4m; £30.8m

adverse from plan

1 The Trust delivered an actual deficit of £28.4m at end of September 2016 which was

£30.8m adverse from plan. Key factors that are driving the year to date variance

from plan are:

1. Credit notes issued for prior year activity income

2. Under recovery of PPU income resulting in reduced contribution

3. Underperformance against activity income

4. Overspend on pay mainly relating to junior doctor vacancies

5. High level of outsourcing costs


For Discussion









Equality analysis


Report from Caroline Clarke

Author(s) Senior Finance Team

Date 14th October 2016


Trust Board Public 19th October 2016 Paper 10

Financial Performance Report

September 2016

1

FINANCIAL PERFORMANCE EXECUTIVE SUMMARY

September 2016

Measure Description Status Position Trend Variation

Normalised

Net Surplus /

(Deficit)

Net income and

expenditure excluding

profit from fixed asset

disposals and fixed asset

impairments

Net surplus/(deficit) in

month:

Plan £0.5m, Actual (£24.4m),

Variance (£24.9m) adverse

Net surplus/(deficit) YTD:

Plan (£14.7m), Actual

(£45.5m), Variance (£30.8m)

deficit

NHS Clinical Income: The year to date (YTD) clinical income values as at 30th

September shows an under performance positon of (£22.5m) which primarily

relates to prior year credit notes issued.

Other Income: (£0.2m) adverse from plan in month and (£5.6m) adverse YTD. The

adverse variance relates primarily to private patient reduced activity and pharmacy

wholesaling.

Pay excluding Integration: (£0.5m) adverse from plan in month and (£4.0m)

adverse YTD. Overspend is mainly due to unallocated CIP targets.

Non-Pay excluding Integration & TEDD: (£2.9m) adverse from plan in month and

(£7.1m) YTD. Key overspent areas are outsourcing, patient transport and

unallocated CIP targets.

Integration: £0.2m favourable in month and £1.2m favourable YTD.

CIP Savings

Savings against the

recurrent CIP savings

plan. The plan includes

both cost efficiency or

income generation

schemes.

CIP in month:

Plan £1.5m, Actual £3.2m,

Variance £1.7m favourable

CIP year to date:



Actual delivery of plans in M6 was of £3.2m, which is £1.7m favourable when

compared to plan.

Capital

Expenditure

Year to date cumulative

expenditure in non-

current assets.

CAPEX in month:



CAPEX year to date:



Capital expenditure for the month is £4.9m which is £1.3m less than plan.

All programmes are on track and witin CAPEX limit.

Cash

Cash held with the

government banking

service and in commercial

banks.

Cash flow in month:

Plan (£20.2m), Actual (£1.6m),


Cash balance:


Variance (£9.5m) adverse

The cash balance is below the planned level in September due to the lower than

expected receipts of the planned prior year NHS over performance and the

outstanding debtor from the land sale that occurred within the period. In addition

the GP Lead programme that the Trust is hosting continues to impact cash due to

non-payment and late receipts for GP salaries.

The £7.0m cash balance reflects the Income and Expenditure deficit position on-

recovery of NHS debts and outstanding land sale debtor.

2015/16

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Capital Service Cover 1 1 1 1 1 1 2 3

Liquidity 4 4 4 4 2 2 4 4

Normalised I&E Margin 1 1 1 1 1 1 1 2

I&E Margin Plan Variance 2 2 2 2 3 1 4 4

Overall 2 2 2 2 2 1 2 3

Monitor

Financial

Sustainability

Risk Rating

(FSRR)

Monitor measures an

organisations financial

risk on a scale of 1-4 with

4 being the lowest risk

and 1 the highest risk.

2016/17 Actual 2016/17 Plan

Monitor FSSR: Trusts with a Normalised I&E margin of less than -1% are rated as 1

for this metric. A rating of 1 on any metric means the overall rating cannot exceed

2.

0.0

2.0

4.0

6.0

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

£m

Plan

Actual

0.0

2.0

4.0

6.0

8.0

10.0

12.0

O c t… N o v… D e c… J a n… F e b…

M a r… A p r… M a y… J u n… J u l… A u g… S e p…

£m

Plan

Actual

0.0

50.0

100.0

150.0

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

£m

Plan

Actual

-30.0

-25.0

-20.0

-15.0

-10.0

-5.0

0.0

5.0

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

£m

Plan

Actual

A

R

G R

A

R

2

Paper 11

F,I&P report – 18.10.16 1

REPORT FROM FINANCE, INVESTMENT AND PERFORMANCE COMMITTEE HELD ON 18OCTOBER 2016 - QUARTER 2 2016-17 NHS IMPROVEMENT (MONITOR) SUBMISSION

Executive summary

At its meeting on 18 October 2016, the finance, investment and performance committee wasasked to recommended to the board that the following statements were approved for submissionto NHS Improvement (Monitor) as part of the Quarter 2 2016-17 monitoring submission. As theboard papers were circulated prior to the committee meeting taking place, their agreedrecommendation will be reported to the board verbally.

For finance:

We will maintain at least a rating of 2 for the next quarter and 3 in the final quarter of2016/17

For Governance that:

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance withall existing targets (after the application of thresholds) as set out in Appendix A of the RiskAssessment Framework, other than the 62 day cancer target and the A&E target; and acommitment to comply with all other known targets going forwards.

With respect to the 62 day cancer target and the 4 hour A&E target, the governanceadjustment agreed with Monitor on 30 May 2014 has now expired and been replaced withtrajectories we have agreed as part of the Strategic Transformation Fund. These areshown in the commentary for the performance report.

While we do not expect to meet the 95% A&E standard for 2016/17 and are projecting areturn to compliance against the 62 day standard in December 2016, we are making everyeffort to improve performance.

From Quarter 3 onwards the trust will be operating under the new Single Oversight Frameworkand has been given a shadow rating.

A verbal update will be given on the other matters discussed at the meeting.

Action required

The board is asked to approve the above statements for submission to Monitor (NHSImprovement)

Equality impact assessmentNo negative impact on equality or diversity.

Report From Dominic Dodd, interim chair of the finance and performance committeeAuthor(s) Alison Macdonald, board secretaryDate 10 October 2016



Paper 12

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FINAL

10 October 2016 at 1732

REPORT FROM PATIENT SAFETY COMMITTEE HELD ON 22 SEPTEMBER 2016

Executive summary

The patient safety committee met on 22 September 2016. A verbal update from the meeting

was provided at the trust board held on 28 September 2016 but for completeness, a written

report outlining the key matters of interest and areas for action is provided.

QUORUM

The committee was not quorate on this occasion. The chief finance officer agreed to attend

the meeting for the first hour to cover those items where an immediate decision relating to

authority delegated from the trust board was needed and to provide input and assurance at a

senior level where necessary. All actions arising from the discussions would be ratified at

the next meeting of the committee in November and any urgent items would be circulated for

approval via e-mail.

The board is asked to note that this was the third occasion this calendar year where the

committee had not been quorate, at least for part of the meeting, and is an example of the

pressure the senior team is under.

Final report

The trust had received the final report from the CQC following their inspection of the trust in

February 2016. The trust was rated as good overall as a provider and rated good at each

hospital site and for each core service at all sites.

The committee noted that out of a total of 92 domains, only five were rated as requires

improvement. The trust was however rated as requiring improvement for the safety domain

overall at the Royal Free Hospital site. The medical director explained that the results were

aggregated at a site level, as such if two or more services received a requires improvement

rating, then the overall rating was requires improvement. He added that many of the safety

issues were already on the trust’s radar, but there was a combination of small issues that

could have been managed better.

It was noted that a requires improvement rating for specialist community mental health

services for children and young people (CAMHS) for the safe and responsive domains had

also been received. Many of the issues identified related to the site environment /

infrastructure and regulatory breaches. Consequently, the children services team had been

asked to develop a responsive action plan to the regulatory breaches, and discussions would

be had with regards to satisfying the need for extra space for the service. The action plan

was due to be submitted to NHS Improvement in October. The committee was asked to

delegate authority for signing off the action plan to the trust executive committee (TEC) as it



Paper 12

Page 2 of 4

FINAL

10 October 2016 at 1732

would not meet again until November; this was agreed.

The CQC had undertaken a quality summit hosted on the Royal Free Hospital site on 8

September to present the findings of the inspections to trust stakeholders, local authority,

commissioners and partners. An action plan would be developed and would be taken

forward by the deputy director of clinical governance and performance.

The committee was pleased to see the excellent ratings, noting that this was unprecedented

for a London trust, and offered its thanks and congratulation to all concerned.

Report from Health and Safety Committee

The trust head of health and safety provided an update from the most recent meeting of the

health and safety committee. As reported previously, the provision of fire wardens remained

low. Ward / departmental engagement on this matter had improved slightly but more work

was needed to improve this further. It was noted that the director of capital and estates was

reviewing whether it was possible to reduce the number of fire wardens (five) required per

shift pattern. The issue of fire safety was also addressed later on in the meeting in respect of

the trust risk register and a request that greater assurance was needed regarding the action

being taken to address the lack of fire wardens and fire safety more generally.

The chair noted that the contractor for the redevelopment of Chase Farm Hospital had a

good system for tracking and recording near miss incidents but was concerned to note that

there was no record of mitigating actions, lessons learned or improvements for the future to

prevent such near misses from becoming incidents in the future. He added that the trust had

a duty of care to its staff and patients and therefore the trust needed to ensure that this

process was robust and complete. The head of health and safety agreed to pick this up as

part of the Chase Farm Hospital walk around, and added that in terms of compliance data

more generally good improvements had been seen on the Chase Farm hospital site.

Trust serious incident (SI) investigation performance update report

The deputy director of patient safety and risk noted that the TEC was receiving a weekly

update on the number of overdue serious incidents (SIs) and had requested that the dates

for closure be included in the report. She added that numbers were stable (13 currently

overdue) but that the SI process was being streamlined to enable timelier reporting. The

medical director reported that the CQRG had been concerned about the number of overdue

SIs and if there was no improvement made, it was likely that they would issue the trust with a

contract query notice. He added that commissioners were fully sighted on and involved in

the trust’s SI process, and had also been advised that the trust put effort into investigating

non-reportable SIs. Although this set a good example and was appreciated by the divisions,

the committee appreciated that concentration should be on closing nationally mandated SIs.

The chair noted the current position, particularly that the trust was on the cusp of receiving a

potential contract query notice, and requested that all effort be made in reducing the number

of overdue SIs.

The chief finance officer left the meeting after this item.

Venous Thromboembolism (VTE) prevention compliance and incident rates

The consultant haematologist and the pharmacist for clinical governance provided an update

on the national strategy for VTE prevention which arose following the health select

committee’s published report on mortality and morbidity, and the work undertaken by the

Paper 12

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FINAL

10 October 2016 at 1732

trust in this regards. A trust thrombosis committee was established in 2010 with the aim of

reducing the number of hospital acquired thromboses and achieving the goals set out in the

VTE CQUIN.

The committee noted the successes as a result of VTE interventions; the risk assessment

(RA) was now incorporated into the drug chart therefore ensuring the prescribing of

thromboprophylaxis and RA was co-located in the one place; a pharmacy based competency

framework to conduct VTE was developed; the CQUIN goals had been achieved; and

significant quality improvements had been made. Further effort would be given to ensuring

good clinical practice was embedded to achieve a high level of standard of care,

standardisation in clinical practice across the whole organisation, and development of an

electronic tool to collate VTE data.

The chair congratulated the VTE team on the success thus far and suggested that this would

be a good topic for presentation at the public board meeting in October or November.

Review of hospital transfers at RFL NHS FT

The divisional director for women, children and imaging division introduced the item,

explaining that this had been a wide ranging review including information from PALS,

complaints and claims and covered a number of issues across the three hospital sites;

patient experience, non-emergency patient transport and transfer times. An action plan had

been developed and was presented to TEC where it requested that the director of nursing be

the executive lead for that project.

The chair asked how the issues relating to patient experience and safety would be

managed. The divisional director for women, children and imaging division noted that the

action plan suggested various monitoring committees, but asked whether the medical

director and director of nursing could decide whether this needed to be overseen by the

patient safety committee and patient and staff experience committee. The first step,

however, was to establish which of the actions in the plan, if any, had been agreed and

actioned thus far.

The chair asked that the report be brought back to the next meeting when the director of

nursing would be in attendance, alongside an update on what was being done in terms of the

action plan and process for monitoring and clarity on accountability for implementation.

Action required





number(s)


outcomes

x



x



x



x

Paper 12

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FINAL

10 October 2016 at 1732





























Regulation 19 Fees




Any risk will be outlined in the report.

Equality analysis


Report from Stephen Ainger, non-executive director and chair of the patient safety

committee

Author(s) Veronica Jackson, committee secretary


Paper 13

Page 1 of 4

FINAL 10.10.16

REPORT FROM AUDIT COMMITTEE HELD ON 15 SEPTEMBER 2016

Executive summary

The audit committee met on 15 September 2016. A verbal update from the meeting wasprovided at the trust board held on 28 September 2016 but for completeness, a written reportoutlining the key matters of interest and areas for action is provided.

ASSURANCE ITEMS

Well led governance reviewThe committee considered the timing of the proposed review noting the outcome of therecent CQC inspection and the proposed transition to a Group model. The head of internalaudit noted that there was precedent for postponement but added that another less intensivebut probing self-assessment may be helpful in the interim, and could provide a baseline fordevelopment of the group governance.

It was agreed that a recommendation from the committee to postpone the review, given itconsidered that adequate sources of assurance were already available, would be made tothe board. A review of group governance would be required once the transition wascompleted. The chief finance officer agreed that some form of self-assessment was neededat this stage however, and that this should be done before the end of the year.

CybersecurityThe trust’s interim director of IT updated the committee on the CSC’s cyber security team’sreview of the trust’s information systems. CSC was a consulting group that had been askedto provide an in-depth analysis of the trust’s current infrastructure and security, and toprovide recommendations for improvement.

The committee noted there were were five red / amber rated recommendations arising fromthe review. The interim director of IT reported that an action plan was in place to address thefindings which was overseen by the trust’s head of infrastructure and the informationgovernance group and confirmed that all actions would be completed by the end of the year,and that the committee could assume that was the case unless it heard otherwise. In termsof costs, it was noted that approximately £60-70k of investment was needed to address therecommendations.

In summing up, the committee noted the red / amber rated recommendations, that planswere in place to rectify these, and that the cash was available to enable this.

The interim director of IT had also provided a list showing the trust’s position in relation to thenational data guardian’s (NDG) 10 security standards. The committee requested that a morecomprehensive report on this be taken to the November meeting.

Board assurance framework (BAF)The committee noted that the BAF had been reformatted in particular to be structured aroundthemes, and with sources of assurance, gaps and mitigations added. The general



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consensus of the audit committee was that the format was much improved.

The chair raised the issue of future assurance items for discussion at the committee, notingthat both the annual clinical audit processes update and the revised cyber security paper inrelation to the NDG standards would be presented at the next meeting. No other assurancereport was requested.

INTERNAL AUDIT

Electronic prescribing medicines administration (EPMA) programme managementThe committee received internal audit’s review of how the trust had applied the lessonslearned from the patient administration system (PAS) / patient master index lessons learnedreport to the e-prescribing and medicines administration (EPMA) programme. An overallassessment of ‘Partial assurance with improvements required’ (Amber-Red) was given.

It was noted that the implementation of EPMA had been postponed (now expected March2017). All the recommendations had been accepted by management and the completiondates were still considered realistic.

Serious incidents (SIs)The committee received internal audit’s review of the trust’s processes for reporting andresponding to serious incidents and was pleased to note the positive rating of ‘Significantassurance with minor improvement opportunities’ (Green-Amber). It was noted that a copyof the report would be taken to the patient safety committee in September for discussion,particularly in the context of reconciling the results of internal audit’s review with the findingsfrom the CQC inspection where the trust was rated as ‘requires improvement’ for the safetydomain.

Counter FraudThe committee discussed “declarations of interest” and “gifts and hospitality” and requestedthat the current registers be presented to the next meeting. It was noted thatrecommendations arising from a proactive review were in the process of being put in placeand that oversight of the registers was still to be decided.

AUDIT COMMITTEE

Outcome of the assessment of audit committee effectiveness 2015-16The committee discussed the composition of its membership. The head of internal auditsuggested the adoption of a lay member with a formal accountancy qualification couldstrengthen the committee’s expertise.

It was noted that the trust was in the process of recruiting two non-executive directors. Thecommittee would await the outcome of the recruitment process before making arecommendation to the board.

WHISTLEBLOWING

Speaking up policy and procedure (incorporating raising concerns andwhistleblowing)The committee received a report highlighting changes to the trust’s existing whistleblowing /raising concerns policy and procedure. The changes reflected the proposedrecommendations within the national integrated freedom to speak up policy and feedbackfrom the trust’s speaking up guardian. The committee was asked to note one change inparticular in relation to supporting staff, namely that the trust would not tolerate harassmentor victimisation of a member of staff who raised a concern, and that they would not beaffected detrimentally in terms of promotion etc.

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The committee noted the contents of the report and approved the revised changes.

MINUTES OF PREVIOUS MEETING

Confirmed minutesThe confirmed minutes of the audit committee held on 25 May 2016 are attached forinformation at Appendix 1.

Action required





number(s)


outcomes

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Regulation 19 Fees



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Risks attached to this project/initiative and how these will be managed (assurance)Any risk will be outlined in the report.

Equality analysis• No identified negative impact on equality and diversity

Report from Deborah Oakley, non-executive director and chair of the audit committee

Author(s) Veronica Jackson, committee secretary


Paper tbc Appendix 1

1 Last update 13.07.16 at 0934 VJ, DCO, LCFS

Minutes of the Audit Committee 25 May 2016

Present: Ms Deborah Oakley Non-executive director (committee chair) Mr Stephen Ainger Non-executive director Ms Jenny Owen Non-executive director In attendance: Ms Caroline Clarke Chief financial officer and deputy chief executive Ms Lubna Dharssi Assistant director of finance – financial control Mr Stevan Burtenshaw Ms Gemma Higginson

Senior consultant - RSM Senior consultant – RSM (left after item 12/16-17)

Mr Joe Farnell Ms Lynn Pamment Mr Charles Martin

Manager, KPMG Engagement leader – PricewaterhouseCoopers Engagement manager - PricewaterhouseCoopers

Ms Julie Dawes Mr Will Smart Ms Debbie Kirby Mrs Dawn Atkinson Mr David Sloman Mr David Grantham Ms Veronica Jackson

Interim trust secretary Chief information officer (items 5/16-17, 11/15-16,18/16-17 and 19/16-17 only) Head of external communications (for item 7/16-17 only) Deputy director – clinical governance and performance (for item 7/16-17 only) Chief executive (item 16/16-17 only) Director of workforce and organisational development (item 29/16-17 only) Committee secretary (minutes)

ACTION

1/16-17 APOLOGIES FOR ABSENCE

Apologies were received from: Members: Dean Finch - non-executive director Attendees: Neil Thomas - head of internal audit Dean Gibbs –senior manager, internal audit Mike Dinan - director of financial operations.

2/16-17 DECLARATIONS OF INTEREST

The audit committee board members confirmed no change to their declarations presented in the report.

3/16-17 MINUTES OF THE AUDIT COMMITTEE MEETING HELD ON 18 JANUARY 2016

The minutes were agreed as a true record of the meeting.

ACTION LOG AND MATTERS ARISING

4/16-17 Review open actions log (for noting)

The committee reviewed the action log:

108/15-16 - the finance team were now giving regards to the LLP benchmarking framework. The director of financial operations reported that benchmarking would be included in the NHS Improvement (NHSI) agency staff reduction self-assessment tool taken to the September finance, investment and performance committee.

120/15-16 - the director of financial operations was drafting a paper on this matter for submission at a future meeting. The trust secretary added that this was an area that would be reflected upon as part of the work on reviewing the standing financial instructions. The chief information officer had provided a position statement on the

MD

FINAL



contractual relationship with but it was noted that the committee’s focus on tender waivers had moved on from its original discussion and now concerned the process and audit trail for such waivers rather than solely value for money.

121/15-16 – the assistant director of finance - financial control confirmed that this had not been a cash loss and was captured in the bad debts section of the annual report. This would be closed.

98/15 - the chief finance officer reported that the finance team had reviewed other trust’s cost improvement plans and their plans to improve financial turnaround to get a sense of what action was being taken, and it was noted that the trust’s financial improvement plan was in line with NHSI guidance. It was considered that an appropriate level of review across wider trusts had been undertaken and the action would be closed.

5/16-17 Matters arising

The committee welcomed the chief information officer (CIO) to the meeting. They thanked him for his report which provided a position statement on the trust’s contractual relationship with but reiterated the point raised under 4/16-17 above that the committee’s focus had changed since its original discussion on the tender waiver. As such the report was noted.

The chief information agreed to stay for those additional items on the agenda (11/16-17, 18/16-17, 19/16-17) where his input would be appreciated.

6/16-17 Notice of discussion of items marked ‘for information’ (by exception)

The main focus of the meeting on this occasion was scrutiny of the trust’s annual report and accounts, including the quality report, for 2015-16.

ROYAL FREE LONDON NHS FT ANNUAL REPORT AND ACCOUNTS 2015/16

7/16-17 Annual report, including Annual Governance Statement (AGS), audit committee annual report, quality report and annual accounts

The head of external communications and the deputy director of clinical governance and performance joined the meeting at this point.

A further version (v22) of the annual report and accounts had been circulated last minute; all were asked to refer to this version at the meeting. It was noted that this was a living document and was continually being updated; as such further changes had been made since v22 was circulated.

The chair opened the meeting by expressing the committee’s thanks to all involved for the professional preparation of the annual accounts, annual governance statement (AGS), audit committee annual report and quality report.

Quality account 2015-16

The committee had recommended a number of changes to the report mainly in relation to consistency and clarity at their workshop on 16 May 2016. It was noted that further revisions, including those suggested by the committee which remained outstanding, were expected to be made to the account after the audit committee meeting. The committee acknowledged the challenges associated with bringing the document together from numerous different sources and of responding to stakeholder feedback within a very tight timeframe.

For reference, the changes were listed below:

Page 123 – addition of extra narrative to address the variation in performance against the inpatient diabetes priority. The head of external communications was



still awaiting comment on this from the associate medical director for clinical performance.

Page 126, second bullet – should state that there was a dementia priority for 2016-17, not an inpatient diabetes priority. The deputy director of clinical governance and performance confirmed that this change had been made following circulation of v22.

Page 165 – the reference to the 2% increase in relation to the IG Toolkit was incorrect; it was a decrease. The senior data protection officer had confirmed this was a decrease earlier in the day and the report would be amended accordingly.

FFT data - there was reference to different metrics throughout the report and it was noted that a chart had been removed. The head of internal communications noted that this was a legacy chart and had been removed and replaced with a line stating that the trust’s FFT scores were mentioned elsewhere in the report. The committee asked that a suitable chart be reinstated.

Page 176 – a reference to HSEP services would be added under the urgent care division section.

Page 209 – an explanation of what the complaints data referred to and how it was achieved would be added. It was also agreed that the trust’s performance against its internal target for responding to complaints over the year would be added, and the duplicated paragraph would be removed.

Page 223 – removal of [latest].

Limited assurance report

The committee received PwC’s limited assurance report on the quality accounts and mandated indicators. PwC confirmed the content of the quality report was sufficient in terms of the statutory requirements and was consistent with that seen elsewhere. The committee congratulated the quality team on this successful report. However, PwC informed the committee that the opinion on the data quality work for two indicators (18 weeks and A&E) would be qualified; this was in line with national trends. Furthermore, the committee were informed that in both cases the trust had been understating performance by a small margin. The head of external communications confirmed that there was a place marker in the report for the limited assurance report.

Subject to the revisions above, the audit committee approved the quality report for the year ending 31 March 2016 for submission to the trust board for approval later that day.

Annual Report

The committee received a near final version of the annual report. The committee had recommended a number of changes to the report at their workshop on 16 May 2016. The majority of these had been addressed, with the exception of the chair’s request that the paragraph on the trust’s reported deficit position in the introduction of the report be strengthened to provide a clear picture of the recurrent position. The chief finance officer agreed to follow this up outside the meeting.

In relation to the reference to consultant payments on page 76, the text would be reworded to show the 2016/17 figure compared to 2015/16. The chief finance officer considered that the an element of the 2016/17 consultant payments were attributed to the Vanguard programme of work and Chase Farm Hospital specialist consultancy, adding that the figures were not out of kilter. Mr Ainger, non-executive director suggested it would be helpful to provide an example of where consultancy services had been employed.

Subject to the revisions above, the audit committee approved the annual report for the year ending 31 March 2016 for submission to the trust board for approval later that day.

Annual governance statement (AGS)

The committee had reviewed the AGS, which formed part of the annual report and had been prepared after taking into account Monitor guidance and the head of internal audit

DA, DK DA, DK DA,DK DA,DK DA,DK DA,DK AM, JD CC AM, JD



(HoIA) opinion for 2015/16, and suggested some changes prior to the audit committee meeting. The head of internal communications confirmed that these changes (cyber security and EBITDA) had been incorporated. PwC confirmed that they had reviewed the AGS and had no area of concern to report.

Subject to the revisions above, the audit committee approved the annual report for the year ending 31 March 2016, including the AGS, for submission to the trust board for approval later that day.

Audit committee annual report

All agreed to the additional paragraph in the ‘conclusions’ section which stated that the committee had given regards to the trust’s financial position throughout the year and had given careful consideration to the preparation of the accounts on a going concern basis at the year end. Ms Owen, non-executive director commented that the wording accurately reflected the member’s conversation on this issue at the audit committee workshop, and Mr Ainger, non-executive, was content with the reference made to ‘securing payments from commissioners’ adding that this addressed the comments he raised at the workshop.

Subject to the revisions above, the audit committee approved the annual report for the year ending 31 March 2016 for submission to the trust board for approval later that day.

Annual accounts

Audit committee members and key finance colleagues had reviewed the trust’s account in detail at its workshop on 16 May 2016; an update on the issues to note from that meeting was provided. The director of finance – financial control noted that there been a number of changes to the accounts presented the previous week, which included a recalculation in relation to the area used to inform the valuation of the car park on the Chase Farm Hospital site, a small adjustment to the cash position, and movements on the reclassification of payments, accruals and receivables. It was noted that trust’s deficit had moved slightly from £32m to £31.4m.

The audit committee approved the annual accounts for the year ending 31 March 2016 for submission to the trust board for approval later that day. It asked that the board note that the report on the 2015/16 audit by the trust’s external auditors was near completion and the proposed unqualified audit opinion on the financial statements.

AM, JD

8/16-17 Head of Internal Audit Opinion

The committee was pleased to note the confirmed rating:

‘Significant assurance with minor improvement potential’ can be given on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control.

This was the second highest rating that could be given.

9/16-17 Going concern

The assistant director of finance – financial control presented a revised version of the report which had been amended following discussion at the audit committee workshop on 16 May 2016. She added that the going concern section of the annual report had been reinforced.

The committee had discussed this at the audit committee workshop and noted the report. The committee also referred to and noted the Monitor guidance in respect of going concern.

EXTERNAL AUDIT



10/16-17 Report to those charged with governance (ISA260)

PwC presented their Report to those Charged with Governance.

There were some significant outstanding matters where PwC’s work had commenced but had not been finalised, but PwC confirmed that this work was almost complete and that they would be in a position to issue their audit opinion on the financial statements on 26 May 2016. Ms Pamment, engagement leader, PwC highlighted two part areas of outstanding work;

1. Assessing and stress testing the trust’s 12 month cash flow - PwC had wanted to confirm that the cash flow position would not cause financial difficulties in the future. Aggressive stress testing was undertaken and PwC considered that steps were in place to assist with the improvement of the trust’s financial position. Their value for money conclusion was subject to satisfactory resolution of this matter.

2. Final approval of the financial statements and disclosures. PwC brought the following to the committee’s attention in particular:

The audit opinion and the value for money opinion would both be unqualified.

Their audit approach continued as set out in the external audit plan. Some areas of testing had been extended and were nearing completion. A number of internal control issues had been identified and raised with key staff.

A number of uncorrected misstatements had been identified which PwC were obliged to report.

They were comfortable with the main judgements in the accounts. A number of control improvements had been recommended; these had

been agreed and accepted by finance colleagues. The chair thanked Ms Pamment, engagement leader, PwC, for the helpful summary. With reference to the key areas of judgement graph on page 12 of the report, she noted that PwC had concluded that management had taken a balanced view in forming the year end accounting judgements, adding that the trust was not an outlier and should be comfortable with its positioning. Noting the summary of internal control deficiencies in relation to procurement, the assistant director of finance - financial control commented that finance had worked with internal audit to review the number of outstanding and duplicate invoices but more work was needed to remove duplicate suppliers off the system. She added that the control matters raised were already on the trust’s radar; the main issue related to the need for finance to tighten their existing processes. Ms Owen, non-executive director, thanked Ms Pamment for the update which she considered to be very reassuring. PwC advised the committee that completion of their work would not lead to any major changes and confirmed verbally that the committee could recommend the accounts to the board for approval later that day. The assistant director of finance – financial control would confirm this in writing after the meeting. The committee agreed that the matters arising from the limited assurance review would be tracked through the committee similar to the internal audit recommendations with a response and deadlines to be brought to the next meeting

LD PwC



11/16-17 Limited assurance report on the quality accounts and mandated indicators

The CIO was in attendance for this item. Further to 7/16-17 above, PwC had informed the committee that the opinion on the data quality work for two indicators (18 weeks and A&E) would be qualified; this was in line with national trends. In response to a question as to whether the CIO’s expectations had been met in this regards, the following was noted: Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge – the CIO considered this was disappointing. The issues were a result of the legacy Barnet and Chase Farm (BCF) hospital and focus was continuing on improving the trust’s efforts in respect of A&E performance. It was noted that the trust’s performance had been understated, albeit by a small variance (0.5%). In response to a question about the implications of the variance, PwC confirmed that the trust was part of a group of trusts that were in the same position and so was not an outlier, and added that there was no regulatory matter to deal with. They also confirmed that there was no major concern from their perspective. However, Mr Ainger, non-executive considered that this could be seen as disconcerting from the casual reader’s perspective. PwC commented that there was likely to be a management response on this matter; as such the committee suggested that this be included in the table at Appendix B. Similarly, Ms Owen, non-executive director suggested that a management response in respect of the RTT indicator also be included. Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways – it was noted that the trust had started reporting its RTT combined performance (RFL and BCF) from May 2015, with the process overseen by the chief executive and CCGs. Over 1.9m pathways had been validated; it was agreed that those patients waiting the longest would be validated first. The CIO noted that retrospective validation would be resolved going forward. He was confident that the processes were now robust and being adhered to correctly and with strong governance. Furthermore, staff were now being trained on the operational processes in relation to clock start / stops.

Mr Ainger, non-executive director considered that it was important to say that management were aware of and had a good grip of the issues related to both indicators. It was agreed that performance against the management responses in respect of both indicators would be monitored at the audit committee.

PwC PwC PwC, WS

12/16-17 Process for assessment of external audit assessment 2015-16

The committee approved the recommended process for the effectiveness review of external audit function for 2014/15. The committee secretary would circulate the proformas for completion and collate responses for reporting at the audit committee in September. The results would be reported to the council of governors. Ms Higginson left the meeting at this point.

VJ

ROYAL FREE LONDON NHS FT ASSET VALUATION 2015-16

13/16-17 Breakdown in movement in valuation

In response to a question, it was not clear in the bridge analysis which columns related to Monitor’s judgement and which related to management’s judgement. The assistant director of finance - financial control commented that the detail shown was the best that could be provided at this late stage, adding that the chief finance officer and director of capital and estates would do a revaluation and follow up with Montague Evans. Ms Owen, non-executive director wished to be assured that the detail provided was correct; PwC confirmed that their in-house validation team had reviewed it and were assured enough to recommend



its inclusion in the annual accounts.

INTERNAL AUDIT

14/16-17 Progress report and technical update

The outstanding red rated recommendations had been discussed with the chief information officer earlier that day. It was noted that the number of overdue recommendations were rising; Mr Farnell confirmed that many of these were related to the cost improvement plan adding that updates had subsequently been received but the actions had yet to move into the full implementation stage. It was noted that the next update to the committee would better reflect those actions that were being taken forward.

He asked that committee to note that there had been five high priority recommendations across the year; not four as stated. There were two overdue at year end in relation to cancelled operations and the cost improvement plan. The HoIA opinion would need to be updated to reflect the current status of the recommendations.

It was anticipated that the recommendations in relation to the approval of timesheets would be implemented as soon as Allocate was embedded trust-wide.

Safeguarding at Chase Farm Hospital

The audit committee had requested that internal audit undertook a further review of the trust’s safeguarding children process in place at the paediatric assessment unit at Chase Farm. The findings were consistent with those identified in the 2015-16 internal audit report undertaken on the trust’s processes for assessing safeguarding concerns for child and adult patients and the recommendations arising from that review, in particular full completion of the trigger stamps, remained relevant. The committee was content with the response to the review.

15/16-17 Annual report and Head of Internal Audit Opinion

Internal audit’s annual report, including the HoIA opinion noted under 8/16-17, was noted. Mr Farnell, manager, KPMG, confirmed that the report would be updated with the recommendations update mentioned under 14/16-17 and a small change requested at the last meeting to change the title of the ‘well led governance’ review to ‘council of governors’.

JF

16/16-17 Strategic and operational plan 2016-17

The committee welcomed the chief executive to the meeting to discuss the proposed internal audit plan for 2016/17. Mr Farnell introduced the report; internal audit had identified a potential 32 new areas for review using their methodology and risk assessment process to its full potential. Discussions had been held with with key people in regards to its content. Quarter 1 (Q1) had been phased, and work was due to start in June (electronic prescribing and medicines administration (EPMA) and cyber security). As this was currently a working draft, the committee’s comments would be incorporated with a final version presented at the September meeting. The chief executive noted that the head of internal audit had spoken with him about the plan in advance of the meeting. He considered that the overall plan of work reflected risks identified in the board assurance framework (BAF) and those emerging risks identified by the board. He added that the issues related to the external environment (e.g. the new government and changes in NHS policy) would need to be factored in, whilst ensuring that the scope and timing of each review was accurate. He made the following comments in terms of the suggested programme of work:

JF



Cancer management – asked whether, in light of the ongoing work in realigning the

pathways and MDTs, this was a Q1 review. He stressed it was important to ensure the timing of this review was appropriate in order to best add value.

Cyber security – this was a critical piece of work; a substantial review was needed. EMPA – was pleased to see this was being given focus. Cultural audit – need to be clear as to what the objectives of this review would be,

particularly in the context of the wider group model. He considered that the trust was not ready to undertake such a review presently.

Comments were also sought from members and attendees; the following was noted:

Redevelopment of Chase Farm Hospital - noted the recent very helpful and reassuring audit on the redevelopment of Chase Farm Hospital but agreed that a further review with a revised scope, given this was a costly and major piece of work, would be useful.

The chief finance officer considered it was important to ensure the timing of the reviews were appropriate. She had no further comment.

Staff survey response – asked whether it was possible to benchmark against other trusts in terms of uptake.

Ms Owen, non-executive director noted the number of audit days planned (475); Mr Farnell, manager, KPMG, confirmed that this was broadly consistent with last year.

The plan needed to remain fluid in order to reflect emerging risks. Recruitment - the scope would be reworded to make explicit that the review would

cover efficiency and pace. Estates strategy – requested that this be undertaken sooner rather than later. Pathology joint venture – this was welcomed; it would be beneficial to review the

governance and management in light of the trust’s role as customer and shareholder in the venture.

Self-certification (CQC and Monitor) – Mr Farnell, manager, KPMG, would check whether the review included the trust’s compliance with its licence. It was suggested that this be brought forward from 2020.

The committee approved the audit plan subject to the changes / consideration of the comments above.

JF

17/16-17 Internal audit review - Chase Farm redevelopment

The committee received the internal audit review of the governance and monitoring arrangements relating to the development of the Chase Farm estate and was pleased to note the rating of ‘Significant assurance with minor improvement potential’. The committee considered this to be a very reassuring report.

It noted that the governance in regards to the business case phase had been positive, but it was necessary to ensure that this would remain effective following the move into the construction phase. Mr Ainger, non-executive director, raised his concerns about the risks associated with the transition from the build to the operational aspects, and suggested that assurance on this specifically would have been helpful. Ms Owen, non-executive director, was pleased to see the report. She asked whether there was adequate capacity to undertake the construction phase. The director of finance responded that this was on track, adding that Natalie Forrest, programme director for hospital integration, was leading on this element of the programme. It was suggested that she could attend a confidential board meeting to speak on this programme of work and offer assurance as necessary.

18/16-17 Internal audit review – Access and activity data



The CIO was in attendance for this item.

The committee received the internal audit review of the trust’s procedures in place to ensure the quality of the data provided to Monitor regarding patients on Referral to Treatment (RTT) pathways. It noted the rating of ‘Partial assurance with improvements required’. Internal audit had spoken with the chief information officer about the review; they confirmed that the trust’s processes had been well designed to enable accurate recording of RRT data but that the rating related to the risks associated with the manual entry of data due to the trust’s patient administration system (PAS) having been without a module for reporting RTT. It noted the high priority recommendation in relation to RTT training (including MaST e-learning level 1) in order to ensure the completeness and accuracy of cancelled operations data on the PAS.

Internal audit commented that such reviews at other trusts did not result in an amber-green rating generally. They added that obtaining a national picture was hard as each trust had its own RTT processes.

The CIO noted that the trust was aiming to meet its RTT improvement trajectory by September. He and the director of workforce and organisational development would ensure that training was a priority issue, and they would continue to ensure a robust process for RTT reporting was in place.

19/16-17 Data quality – cancelled operations recommendations follow up

The CIO was in attendance for this item.

The chair asked how confident the committee could be in terms of the quality of the data presented. The CIO confirmed that the suite of metrics reported to the board were subject to an executive sign off process. He added that there was good assurance in terms of the finance and performance data, but was not confident that this was the case with the full suite of metrics, e.g. HR. It was noted that the data quality assurance framework was 70% completed. Furthermore, the departure of the head of performance and analytics from the trust had impacted on the pace as which the recommendations could be followed up.

He and the chief finance officer noted that the executive team would be asked to consider how data quality affected / was parcelled for each of the board committees, and how this would be reported to the trust board.

The CIO left the meeting at this point.

WS, CC

COUNTER FRAUD

20/16-17 LCFS annual report 2015-16

The report was taken as read. The senior consultant – RSM updated the committee on the self-review toolkit (SRT); the trust had received a green rating overall which therefore assessed the trust as fully compliant with NHS Protect’s standards for providers 2015/16. The amber rating in relation to ’prevent and deter’ area of activity was due to the invoice mandate fraud review undertaken last year not having been agreed and approved by the trust. Furthermore, the lack of assurance and evidence available to demonstrate staff member’s use of, compliance with and reference to the trust’s key financial policies. The chair asked if a follow up of this was planned in order to achieve a green rating; Mr Burtenshaw commented that work would be undertaken to ensure that staff were made aware of the policies etc. and that they would aim to include this in their annual workplan. It was noted that the overall SRT rating at other trusts was generally green. Appendix B of the report would be corrected. Following a suggestion from the chair, the senior consultant – RSM agreed to add a table in the report to show the status of progress against the counter fraud proactive

SB SB SB



recommendations. In the interim, he would email members an update outside of the meeting. Ms Owen, non-executive director, considered that the report should provide examples / narrative on the cases of greater fraud and the scale of potential fraud across the trust; the scale of RSM’s achievements thus far; and value for money. The senior consultant – RSM agreed to update the report to reflect these comments.

In response to a question from the interim trust secretary, it was noted that this report only went to the audit committee and finance colleagues.

SB

21/16-17 Annual LCFS workplan 2016-17

The committee received the counter fraud annual workplan:

The key areas of risk / focus were noted. The reduction in the number of days was noted. Ms Owen, non-executive director considered that contract management should be a

real priority.

The chair asked about the process for non-board director declaration of interests. It was noted that all members of trust staff were asked to self-declare any interests on an electronic register on the finance web-portal. The process for self-declarations would be streamlined to ensure that the form was completed and taken into consideration when undertaking procurement. A decision would need to be taken as to which board committee would have responsibility for the register and reported back to the committee.

The committee approved the workplan.

CC, MD

22/16-17 Benchmarking fraud report

The report was noted.

GOVERNANCE

23/15-16 Board assurance framework (BAF)

It was noted that Peter Ridley, the new director of planning, was now the owner of the BAF. In terms of future audit committee discussion items, it was agreed that the well-led governance review combined with the outcome of the CQC inspection bringing together all the sources of assurance would be taken to the September meeting, and the clinical audit processes item would be taken to the November meeting. The chair asked whether there were any other areas on the BAF where the committee needed additional assurance. There was no comment.

Mr Ainger, non-executive director, was concerned to note that the patient safety committee had been allocated responsibility for R5.3 (cyber security). A decision would be taken as to where this was best placed (trust executive committee / trust board was mooted) outside of the meeting.

It was noted that some risks were still allocated to dissolved committees, e.g. integration committee and strategy and investment committee; new owners would need to be agreed.

A discussion was had on the scoring of the risks; the committee noted that the recommendation to rescore R2.4 (non-emergency patient transport) to 25 had not been made.

The committee’s comments would be relayed to the director of planning for follow up.

PR PR PR VJ

24/16-17 Confirmed minutes of the patient safety committee – 15 January 2016

The minutes were noted.

25/16-17 Confirmed minutes of the clinical performance committee – 18 January 2016




25/16-17 Confirmed minutes of the patient and staff experience committee – 25 January 2016


FINANCIAL

26/16-17 Tender waivers: pharmacy, supplies and projects

A discussion was had on the reasons for extending tender waivers. The committee noted a theme related to the extension of contracts for incumbent providers who were considered the only organisation able to offer the support required. Ms Owen, non-executive director, asked about the tender waiver, specifically how relevant was as a factor for extending the contract. The chair asked whether the Royal Free charity was still funding this was not known but the director of financial operations would be asked to check and report back. Mr Ainger, non-executive director considered that it was not adequate to extend a contract based on the fact that the support provided had worked well elsewhere, adding that benchmarking would provide a more accurate reflection. All agreed that the trust needed to assure itself that the right checks and balances were being undertaken.

MD

AUDIT COMMITTEE

27/16-17 Audit committee annual report 2015/16 to the board

Each year the committee secretary presented an audit committee annual report to provide the board with an overview of the work undertaken by the audit committee during the year and to identify how it had fulfilled the duties required by the board. A full audit committee report for the previous year had been included in the trust’s annual report and accounts 2015/16 and was approved by the audit committee (please see 7/16-17 above). Therefore, there was no separate report on this occasion. The committee extended their appreciation to the committee secretary for preparing the report to such a high standard.

28/16-17 Process for self-assessment of audit committee effectiveness

The committee approved the self-assessment process for 2014/15. As with the process last year, non-audit committee board members would be asked to complete an abridged version of the report. The committee secretary would circulate the proformas for completion and collate responses for reporting at the audit committee in September.

VJ

WHISTLEBLOWING

29/16-17 Incidents of whistleblowing

One new whistleblowing incident had been logged (2016/17 – 01);

The committee noted that there had since been another incident raised and which cited whistleblowing concerns.

It was noted that incident 2015/16-10 had been concluded. The whistleblowing log would be updated to reflect this. The chair raised the issue of closing incidents because no one had come forward with

AM



information which meant that concerns were being left unresolved. The director of workforce and organisational development commented that the HR team adapted the approach they took in relation to each whistleblowing case but without any information they were limited in terms of the action that could be taken.

The chair made reference to the whistleblowing incident

It was agreed that the patient and staff experience committee would review

JO, DG

30/16-17 REFLECTIONS AND IMPROVEMENTS FOR NEXT TIME

There was no comment.

31/16-17 BOARD REPORTING

Due to the close timing of the audit committee and the May trust board, the chair would provide a verbal update at the next board meeting. A written report would be provided to the board on 29 June 2016.

32/16-17 PRIVATE MEETING BETWEEN AUDIT COMMITTEE MEMBERS AND AUDITORS AND COUNTER FRAUD OFFICERS

A decision was not to hold a private meeting as all had met in closed session at the March audit committee meeting.

Date of next meeting: 15 September 2016, 1330 – 1600 in the Institute of Immunology seminar room, Institute of Immunology, second floor, Royal Free Hospital, Pond Street, London, NW3 2QG.