public trust board meeting to be held on ......public trust board meeting to be held on thursday...

PUBLIC TRUST BOARD MEETING

TO BE HELD ON THURSDAY 31st MAY 2018 AT 09.30 AM IN ROOM 10009/11, CLINICAL SCIENCES BUILDING,

UNIVERSITY HOSPITAL, COVENTRY, CV2 2DX

PUBLIC BOARD AGENDA

ITEM TITLE BOARD ACTION PAPER TIME

1. World Class Colleague Award Chairman

For Noting Verbal 10

Standing Items

2. Apologies for Absence Chairman

For Noting Verbal

5

3. Confirmation of Quoracy Chairman

For Assurance Verbal

4. Declarations of Interest Chairman


5. Minutes of Public Board Meeting held on the 29th March 2018 Chairman

For Approval Enclosure 1

6. Matters Arising Chairman


7. Trust Board Action Matrix Chairman


8. Chairman’s Report Chairman

For Assurance Enclosure 3 5

9. Chief Executive Officer and Chief Officers Report Chief Executive Officer


Patient Experience

10. Patient Story Chief Medical Officer


Performance

11. Integrated Quality, Performance and Finance Monthly Report

Operational Performance

Quality and Safety

Finance

Workforce

Chief Workforce & Information Officer


Patient Quality and Safety

12. Infection Prevention and Control Quarter 4 report Chief Nursing Officer


13. Quarterly Mortality Performance Report Quarter 4 Chief Medical Officer


14. Controlled Drug Accountable Officer Report April 2017 to March 2018 Chief Medical Officer


TB Public Agenda 31 May 2018


15. Safe Staffing Report: Acuity and Dependency Chief Nursing Officer


16. Patient Experience Quarterly Report Chief Medical Officer


17. Safeguarding Children and Vulnerable Adults Report Chief Nursing Officer


18. Provider Licence Self Certification Director of Corporate Affairs


19. 2017-2019 CQUIN Scheme for Health Food for NHS Staff, Visitors and Patients Chief Operating Officer


Strategy

20. NHS Staff Attitude and Opinion Survey Results Chief Workforce & Information Officer


21. UHCWi Quarterly Update Report Chief Workforce & Information Officer


Research and Innovation

22. Research and Development Annual Report 2017-2018 Chief Medical Officer


Regulatory, Compliance and Corporate Governance

23. Audit Committee Annual Report 2017/18 Chair, Audit Committee

For Approval Enclosure 18 5

24. Employee Relations Position Report Chief Workforce & Information Officer


25. Register of Interests 2018/19 and Gifts/Hospitality 2017/18 Chief Executive Officer


26. Trust Seal Register 2017/18 Chief Executive Officer

For Noting Enclosure 21 5

27. Gender Pay Gap report Chief Workforce & Information Officer


28. Medical Revalidation Annual Organisational Audit (AOA) 2017/18 Chief Medical Officer


29. Annual Work Programme (deferred from March meeting) Director of Corporate Affairs


30. Matters Delegated to Committees Chairman

For Assurance Verbal 5

Feedback from Key Meetings

TB Public Agenda 31 May 2018


31. Quality Governance Committee Meeting Reports from 16th April and 21st May 2018

Injectable Medicines Policy (Mark Easter)

Printing Policy (Richard Peacock) Chair, Quality Governance Committee

For Assurance Enclosure 25

5


32. Finance & Performance Committee Meeting Reports from 25th April and 22nd May 2018 Chair, Finance and Performance Committee


5

33. Audit Committee Meeting Report from 9th April 2018 Chair, Audit Committee


34. Any Other Business

35. Questions from Members of the Public which relate to matters on the Agenda Please submit questions to our Interim Director of Corporate Affairs by no later than close of business Tuesday 29 May 2018. ([email protected])

36. Date of Next Meeting: The next meeting of the Trust Board will take place on Thursday 26th July 2018 at 10.00 am, in the Clinical Sciences Building, University Hospital, Coventry, CV2 2DX

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

KEY: Standing items (Black), Work Programme items (Green), Action Log Matrix items (Red) Ad hoc items (Blue)

V11

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MINUTES OF A PUBLIC MEETING OF THE TRUST BOARD OF UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

HELD ON THURSDAY 29 MARCH 2018 AT 10.00 A.M. IN ROOM 10009/11 OF THE CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY

AGENDA ITEM

DISCUSSION ACTION

HTB 18/029

PRESENT

Mr A Meehan, Chairman (AM) Professor A Hardy, Chief Executive Officer (AH) Mr I Buckley, Vice Chair (IB) Mrs N Fraser, Chief Nursing Officer (NF) Miss L Kelly, Chief Operating Officer (LK) Professor S Kumar, Non-Executive Director (SK) Mr E Macalister-Smith, Non-Executive Director (EMS) Mrs K Martin, Chief Workforce and Information Officer (KM) Professor M Pandit, Chief Medical Officer/Deputy CEO (MP) Mr D Poynton, Non-Executive Director (DP) Mrs S Rollason, Chief Finance & Strategy Officer (SR) Mrs B Sheils, Non-Executive Director (BS)

IN ATTENDANCE

Ms L Scott, Director of Marketing and Communications Mr G Stokes, Interim Director of Corporate Affairs (GS) Miss R Hough, Head of Corporate Affairs (RH) minute taker

HTB 18/030

APOLOGIES FOR ABSENCE

Mrs B Beal, Non-Executive Director (BB)

HTB 18/031

WORLD CLASS COLLEAGUE AWARD

AH was pleased to present the Trust’s World Class Colleague Award to Rhea Fielding, Senior Physiologist for her time and commitment to provide cover for absent members of staff to ensure patients did not have to have their appointments cancelled. In addition she has recently been published as a co-author on the British Thoracic Societies Standards for Home oxygen, raising the profile of both the department and the Trust.

HTB 18/032

CONFIRMATION OF QUORACY

The Chairman declared the meeting to be quorate.

HTB 18/033

DECLARATIONS OF INTEREST

There were no conflicts of interest declared.

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HTB 18/034

MINUTES OF TRUST BOARD MEETING HELD ON 25 JANUARY 2018

NF requested an amendment on page 3 to read: ‘The first cohort of 8 Trainee Nursing Associates are in their second year and a second cohort of 14 has now been recruited to commence next month’. With this exception, the minutes were APPROVED by the Trust Board as a true and accurate record of the meeting.

HTB 18/035

MATTERS ARISING

There were no matters arising that were not on the action matrix or the agenda.

HTB 18/036

TRUST BOARD ACTION MATRIX

The Trust Board NOTED the items in progress and APPROVED the removal of those actions marked as complete.

HTB 18/037

CHAIRMAN’S REPORT

The Chairman presented the report summarising the commitments he had attended since the previous Trust Board meeting. He advised that the Board Walk Round scheduled for Ward 41 Stroke Medicines had not taken place. There were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the Chairman’s report.

HTB 18/038

CHIEF EXECUTIVE OFFICER AND CHIEF OFFICERS’ REPORT

AH introduced his report and highlighted the main points: He provided an update on the fire incident and advised the Trust Board that he received excellent feedback from Ben Diamond, Regional Commander of West Midlands Fire Service who has commended the Trust for its ability as a large organisation for its support and to ensure minimal disruption and continuation of services. There was no impact to patient or staff safety and the cause of the fire remains under investigation. AH further confirmed that following the Grenfell Tower disaster the Trust had undertaken checks on the building cladding and that this had acted as

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it should have by preventing the fire spreading further. IB and DP noted the speed of social media with the public reporting the outbreak of the fire. KM acknowledged this and replied that it is a difficult situation to manage whereby most patients and members of the public have immediate access to social media. The Trust must communicate accurately when delivering communication messages and the Trust’s priority was to deal with the incident first. AH acknowledged the pressures the hospital was currently under, observing that it is appearing the winter pressures will remain ongoing with increased levels of attendance and acuity of patients. He expressed his thanks to the teams ensuring that the services continued and patient safety is maintained. The Trust hosted a visited by the Secretary of State, Jeremy Hunt MP and Mike Dirkin, Director of Patient Safety, NHSE who spoke about patient safety. AH was pleased to report that this was well attended by 60-70 staff leaders and the event also included a presentation by MP on patient safety and work undertaken with Virginia Mason Institute. He attended a CQC System Feedback Summit and assured the Trust Board that following the last CQC inspection 3-years ago, the Trust can demonstrate the strides it has made with patient safety. AH advised that NHSI and NHSE have announced they are bringing the two organisations together by September 2018. He assured the Trust Board that he and the chief officers would work closely with colleagues to support this transition. AH was pleased to confirm the following appointments:

Dr Margaret Hufton has been appointed to the position of Consultant Paediatrician with Specialist Interest in Respiratory Medicine Consultant

Dr Rajesh Srikantaiah has been appointed to the position of Consultant Paediatrician with Specialist Interest in Respiratory Medicine

Dr Raj Kumar Shrimali has been appointed to the position of Consultant Clinical Oncologist with interest in Urology and Lung

Dr Katharine Marshall has been appointed to the position of Consultant Clinical Oncologist with interest in Lung and Skin

Dr Lucy McAvan has been appointed to the position of Consultant Medical Oncologist

Mr Digant Kamdar has been appointed to the position of Consultant Neurosurgeon

Mr Sandeep Solanki has been appointed to the position of Consultant Neurosurgeon

https://www.england.nhs.uk/publication/nhs-england-board-meeting-papers-29-march-2018/

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LK advised the Trust Board that she had participated in the CQC Feedback Summit following the system review of Coventry which included the pathway for Frail Elderly and the management of this cohort. It has been recognised that patients are entering the acute services when they are in ‘crisis’ and further improvement is required to assist patients to remain at home. LK will be leading this part of work with system partners through the system Board and recommendations are to be submitted by 10th April to the CQC to monitor against any actions plan. BB offered her support for this work noting that the impact extends beyond this cohort and that all system partners should be helping to avoid hospital admissions and faster discharge. SR confirmed that a number of Strategy consultation drop-in sessions had been held at various times to accommodate night shifts and that these sessions have provided some useful feedback. A number of meetings have been held to finalise contracts with providers. The contract with Coventry and Rugby CCG has been agreed. EMC enquired about the contract with Specialised Commissioners and was advised that this organisation has not agreed any contracts with organisations nationally but the position of this had progressed further since the report was written and the risk surrounding this contract has significantly reduced. The main focus for the Trust is to achieve an agreeable contract. MP informed the Trust Board that A&E has been busy and she had undertaken work with LK to ensure safe services are provided and discharges are taking place. This review extended from Emergency Department and MDU services to include other teams feeding into these areas. She reported that she had visited the Bowel Cancer Screening Team and reported that this was a fantastic service provided by the team. AM enquired about the FIT tests and was advised that these were being introduced but the age of offering would not be lowered to the age of 50 years as in Scotland. NF had opened the Trust’s Blooming with Pride event which was well attended by staff. Nearly 500 staff comments relating to what made them proud to work at UHCW had been submitted by the end of the day. She was pleased to inform that the Trust Maternity Team has been awarded the Midwifery Services of the Year by the Royal College of Midwives. She was also pleased to inform that Nicolas Aldridge, Lead Research

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Nurse has been nominated for a HSJ Value Award for his work of Evolution of the Research Workforce. KM informed the Trust Board that the Trust’s website had been launched on 29 January 2018 and that this has seen an increase by 12% of visits to the site. There have been some challenges to the Trust’s clinical coding and regular audits and data quality checks are now undertaken as routine. The result is that the Trust is now within the upper quartile for depth of coding across the NHS. DP stated that he was much more assured that there was now more accurate recording which impacts the Trust’s income and that this also meant a better depth of clinical governance. The Trust Board was informed that Robin Arnold, Director of ICT was retiring. They expressed their appreciation of commitment to his work and AH expressed his thanks for his support to the Trust during the WannaCry attack last year. KM confirmed that this role had been merged with the Director of Transformation to further support the EPR programme and workforce and clinical coding and transforming services. The results of the 2017 National Staff Survey have been released and she was pleased to report that the Trust’s overall engagement core was just above the national average. There were also elements of positivity including Trust appraisals, reporting of incidents and the effectiveness of work around UHCWi. She confirmed that a more detailed report would be presented to the next meeting in May. The Gender Pay Gap Report is due to be submitted and she advised that the figures for this were detailing a 80/20 split where the most highest paid are male Consultants. Overall this details a 35% pay gap. She confirmed that a more detailed report will be presented at the next meeting once the figures have been clarified. The Trust Board NOTED the Chief Executive and Chief Officer’s reports and RATIFIED the consultant appointment made.

HTB 18/040

ROYAL COLLEGE OF SURGEONS’ INVITED INDIVIDUAL REVIEW REPORT

AM agreed to bring forward item 11 given its importance and public profile. He asked MP to present the report. MP presented the report which provided the background to the request

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made by the Trust during June 2017 to the Royal College of Surgeons (RCS) for an invited individual review due to there being two ongoing inquests in patients under the care of a particular consultant and two further serious incidents going the through the Trust’s Serious Incident Group. The Trust agreed the terms of reference with the RCS which was conducted during September 2017 and the final report was received in January 2018. MP confirmed that altogether the review looked at five clinical records and a range of staff had been interviewed. The review concluded that there were no concerns with the individual’s technical competence in relation to the cases but that there were concerns relating to team work and behaviours. In total, 16 recommendations have been presented in three areas relating to the individual, team and the Trust. AM enquired about the process for monitoring surgical performance. MP advised him that surgical practice is now highly regulated following the Shipman and Bristol Heart scandals. This process includes reviewing complaints, SIs, never events, deaths and also compliments and awards. There are national mortality registries and audit data is published by surgical societies annually. There are also 360o reviews, annual appraisal and revalidation and MP assured the Trust Board that surgical consultants recognise these methods of performance monitoring. The Trust’s local system for monitoring includes analysis of inpatient deaths, unique morbidity scorecards, Serious Incidents Group and Patient Safety Meeting. Data is reported to the Quality Governance Committee via the Patient Safety Committee. AM also enquired about the Root Cause Analysis (RCA) process and requested assurance that this process had improved. MP assured that it had and that all RCA chairs meet with all relevant individuals to review the case. Whilst this may increase the time taken to complete RCAs, it has seen an overall improvement and decline in the number of delayed actions. MP assured IB that surgeons were comfortable at raising their concerns and challenges and that they felt supported to do so. She advised that the Patient Safety Committee reports are a good source of information which is discussed and the learning is reported back to the teams. This process has been reflected in the staff survey results. Regarding this team they have been working hard to address the concerns relating to their communication style, have undertaken human factors training as a surgical team and have applied the learnings to the whole team. She advised that five years ago they were on a level 3 with Health Education England. MP further advised the Trust Board that all staff are empowered to raise their concerns, even during surgery.

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DISCUSSION ACTION

DP enquired how the staff were monitored in different specialities and that it appeared this individual had not been attending meetings. MP informed him that attendance monitored at Quality Improvement and Patient Safety (QIPS) meetings and multi-disciplinary team (MDT) meetings. An individual’s attendance record also informs their appraisal. Where any non-attendance is not justifiable, this is discussed. The attendance of this individual had not fallen below the threshold. EMC observed the current RCA process and the reliance the Quality Governance Committee (QGC) places on this but QGC had not determined that this was an issue. He was however concerned about the timeliness of the report being presented in January following a 3-month delay from the investigation in September. MP assured EMC that the Trust had received immediate feedback from the RCS which clearly advised that there were no patient safety concerns but the recommendation for a mentor was actioned immediately. MP confirmed that not all the recommendations were included within the letter and clarification on what was termed ‘complex spinal operations’ was needed about which the RCS provided a later response. MP advised that a Clinical Advisory Committee (CAG) has been set up to monitor the action plan; members include MP, GS Director of Quality, Director of Communications, CD and GM of Neurosurgery and the Ethics Committee Chair. MP confirmed that patients involved in the review had been written to and that the Committee were now looking at all cases for which the surgeon is deemed as needing mentoring. NF asked MP if any patient contact had been made with the Trust following the BBC report. MP replied that there had been a total of 15 contacts to date, and many of these patients and their families had been in support of the surgeon. A few individuals had requested to see their medical records and had enquired about the type of surgery they had received. All patients have been offered the chance to meet with the team or MP. BS asked when CAG would be able to report to the Trust Board, MP advised that this would be dependent on the timeline for recommendations to be completed. AM stated that had been no questions submitted in advance of the meeting taking place and enquired if there were any questions the public wished to raise. Michele Paduano, BBC West Midlands Health Correspondent asked, given that MP had been aware of issues raised about the surgeon in 2014 was it right that she is leading the current process. AH replied that MP is the Responsible Chief Officer and CMO. She is in

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charge of the investigation and had called for the independent review. MP advised him that of all cases the Consultant had undertaken had been looked at, of these 6 were open craniotomies and 37 were complex spinal cases. All these cases would have a review conducted and she further confirmed that, in the case of DD raised by Mr Paduano, this had been looked at by the GMC. Mr Paduano further enquired how Mr Bridgeman became to be treated if the surgeon had been stopped several years ago from performing on meningioma cases. MP informed him that the surgeon had been stopped from performing base of skull surgery and that meningiomas can occur anywhere in the brain; in the case of this patient the surgery was craniotomy and not base of skull surgery Mr Paduano then handed a personal letter to the Chairman. AH informed the Trust Board that he was very confident of the current process which remains ongoing. AM thanked the public for the questions and advised the public that the Trust is a learning organisation and welcomes valid criticism. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/039

INTEGRATED QUALITY, PERFORMANCE AND FINANCE REPORT

The presented report covers the period ending 28th February 2018 and each Chief Officer discussed their relevant section. LK presented the performance report and noted its pertinent points: The Trust key indicator for 4-hour Emergency Care was not achieved and had declined to 78.1% compared to 81.4% in January; this is owing to the immense winter pressures. The Trust did not have any 12 hour breaches and she highlighted that this was a virtually unique position to be in. There is continuous work to improve the performance of this 4-hour target via strengthening governance arrangements of the Board to review a rigorous range of indicators including time to triage, assess ambulatory care including discharge. Work has been undertaken with UHCWi and the coaches and external support have been used to set standards. She also confirmed that stranded patients, longer than 7 days, are reviewed on a regular basis. Additional winter funds will improve patient flow and support Red to Green, which ensures patients’ clinical needs are reviewed on a daily basis. System work with Warwick Delivery Board has focused upon mental health work, in particular CAMHS, with the commissioning group. Work is also

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looking at GP primary care service to enable elderly patients to be seen prior to attending A&E from care homes. A pilot is being conducted by the CCG to improve this. IB confirmed that the Finance and Performance Committee had discussed the GP services. LK replied that whilst the Out of Hours GP service is commissioned by the CCG, the Trust has an arrangement, funded by the CCG and provided by GP Alliance, in which a 12-hour, seven day service is provided to allow patients to be reviewed by a GP at the front door. The patients are then streamed appropriately into Trust services if this is required. She reported that she had undertaken a visit to Luton and Dunstable University Hospital where learnings from this visit included strengthening the confidence of staff and is assured the recent appointment of Rob Simpson as Clinical Director will support this. DP praised the efforts of staff and the challenges of discharging patients when the Trust is receiving approximately 600 attendances a day and each patient is reviewed twice daily and enquired about any repercussions and how any delays are managed. LK advised him that the Trust’s SAFER principles include twice daily board rounds which can be more challenging for some specialities than others. However not all patients receive two reviews if their condition will not rapidly change during the day, these patients will receive a nurse follow-up to undertaken any actions required. Generally, patients will move through the pathways but it can be frustrating where assessments for nursing homes are awaited AM supported DP’s praise and noted that, in comparison, Addenbrooke’s Hospital recently cancelled their electives list which was still not reinstated and they are receiving c.300 attendances daily.

NF supported the work undertaken for Red to Green helping teams assess patients. This has seen a 40% improvement and medicines to take out (TTOs) are now undertaken the day before discharge. This has aided the patient to be discharged home sooner in the day.

EMC stated that he had undertaken a Board Walk Around within Trauma & Orthopaedics which had a number of medical outliers and enquired if the Trust had any learning from the winter period. LK confirmed that another review would be undertaken at Easter to establish what has worked well. She reminded Trust Board that actions undertaken had included scaling down elective work before the national request was received.

AM enquired about the statistic of bed occupancy at 102% and was advised that this was because additional beds had been opened over the winter period. There has also been an improvement in the use of beds at St Cross, Rugby which was currently at 85%.

SK complimented the positive movement and asked if it was known what was happening at Coventry Health Centre. LK explained that they are

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working with West Midlands Ambulance Service to make better use of the centre which included reviewing the process undertaken in Worcester. They were also looking at housing a paramedic at the centre to attend to a specific cohort of patient. She further confirmed that the scope of UHCW@Home Service was being reviewed to expand the practice and cohort of patient.

AH noted that the CQC system review had recognised that there was a high proportion of elderly attendees at the Trust compared to those who access primary care and a dedicated STP work stream for the care of elderly has been set-up. LK informed Trust Board that the target for six week diagnostics waits had been achieved.

Referral to treatment (RTT) has seen an improvement during February achieving 82.4% with significant improvements being made across specialities but this has not achieved the national 92% target.

She assured Trust Board that whilst elective surgery had been cancelled following receipt of the national letter, a programmatic approach to ensure as many services were kept open as possible such as cancer and dermatology.

There are 28 patients currently waiting over 52 weeks. The Trust Board observed that this target has seen continued good progress and LK reported that work with the Prison Service relating to their escorts have assisted seeing these patients in a more timely manner. The Trust continues to be one of the highest performers of the 62 day cancer target. This target had been achieved for February and it is expected to be met again for March. MP presented the Quality and Safety report and explained the main points to the Trust Board: The Trust’s latest available Hospital Standardised Mortality Ratio was reported at 101.63. There was one overdue serious incident (SI) remaining at the end of January. She assured the Trust Board that learning across the Trust had improved and safety huddles were now held in all areas, Grand Round is held on a Friday, safety messages are sent out consistently and changes made to the Datix form has seen reporting increased. MP confirmed that the Human Factor Training had been delivered to approximately 1,000 staff.

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She was pleased to report that the Complaints Team have maintained their turnaround time of less than 25 days by achieving 93%. MP advised that there had been no medication errors resulting in harm. NF reported that the Trust infection control rate had been sustained for C-Difficile. Unfortunately the MRSA screening targets had been missed for both elective at 92.7% against 95% and emergency patients 88.7% against 90% and she advised that work with the modern matrons was taking place to improve this. The MRSA decolonisation score remains at 100%.

In terms of the harm free safety monitoring this is reporting at greater than 90%. There had been one grade 3 avoidable ulcer which had been the first since April 2017. The performance for falls has been sustained throughout the year.

SR advised that the Trust was forecasting a £22.4million deficit two of the drivers for which includes the slippage of the £4m car park income and the £7.6m STF monies. AH provided the Trust Board with an update on the new car park, explaining that the contract with the land owners would be signed this week, the planning application is to be submitted after Easter and consultation with the public will be held. The Trust Board recognised that the development of the additional 1,602 spaces will have a positive impact for patients and staff. The Cost Improvement Programme remains at £29.1milion against the target of £29.1million. As at month 11 the Trust was reporting capital expenditure of £11.5m against its forecast outturn of £27.6m against the original plan of £40.2m. The Trust Board recognised that the Trust’s financial position does not look good but has been observing lots of work being undertaken to address this. AH supported this and reminded them the Trust had been recognised for having below average reference costs, good governance controls following work on Lord Carter and the PWC Financial Improvement Programme (FIP2). AM asked about the recently announced staff pay award and was advised that this was still to be accepted following completion of national negotiations. KM advised that within the report the current vacancy rate for nursing staff is 18%. Work is being undertaken to understand why staff are leaving the Trust and the Trust has introduced an exit interview to understand this. HR are working with managers to improve quality of discussions and that these

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are undertaken. EMC observed that the ward staff fill rate had improved to 96%, this is a good achievement. Positive work has been undertaken to reduce the agency spend, which has halved over the last 2 years. However the last six weeks have seen this increase which could be related to current pressures and providing additional capacity along with the requirement of staffing safely. KM further clarified that within the report, the reported 26.5% of staff being absent with cold, cough and influenza, is a subset of those off sick in total. AH stated that the Trust is still trying to improve its mandatory training rate, currently achieving 91.95% against the target of 95%. The Trust Board RECEIVED the Integrated Quality, Performance and Finance report.

HTB 18/041

BOARD ASSURANCE FRAMEWORK INCLUDING CORPORATE RISK REGISTER

MP presented the report which included detail of the latest position of the Board Assurance Framework (BAF) 2017/18 and the Corporate Risk Register as at March 2018. MP reminded the Trust Board that they had approved the BAF for 2017/18 and that regular updates had been provided throughout the year. She provided assurance that the Risk Committee had reviewed the updates to the BAF during March and had proposed the following changes to the scores:

BAF Risk 2 Meeting Financial Targets: to be downgraded to reflect the change in the forecast outturn which had since been accepted by NHSI

BAF risk 3 Failure to achieve GOOD following CQC inspection: to be increased to reflect the Risk Committee’s view that the consequence of failing to achieve Good should be rated as 4 and not a 3

BAF risk 7 Failing to secure financing for the capital programme: to be downgraded due to capital finance since being secured.

MP further advised that the format of the BAF has been altered to reflect the links that should exist between the controls for a risk and the assurance that assesses the effectiveness of the controls. There were four new assurance ratings proposed, scoring 0 (No independent assurance) to 3 (External Review).

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EMC advised that he was cautious of the proposed external reviews. MP advised him that this would not be for all external reviews. MP advised the Trust Board that the next Strategic Board meeting in April would include discussions to create a new BAF for 2018-21 which will relate to the delivery of the Trust’s strategy. The Trust Board APPROVED the score changes to the three BAF risks.

HTB 18/042

MEDICAL EDUCATION QUARTERLY REPORT

MP welcomed Dr Sailesh Sankar to present the report which provided an update on activity within medical education since November 2017. Dr Sankar confirmed that there had not been a Deanery visit since the last report. He further confirmed that the National Student Survey had not been completed because of the student union’s national protests. Owing to this it had not been possible to monitor the progress of Warwick Medical School in terms of ranking. He assured Trust Board that informal feedback has been received on phase 2 and 3. The Trust continues to expand the number of 50:50 clinical teaching fellows, in part to address issues. Medical Education is currently recruiting to various teaching posts that will reduce the need for locums and address teaching requirements. Dr Sankar confirmed that supervisor training has been set and will be reported at the next meeting of Trust Board. Dr Sankar reported that gaps in the rotas were impacting on trainee opportunities by limiting their hours but that this also impacts on patient safety. A number of options are being explored including collaborative working with universities in India and the UAE on an International Fellowship Programme via the Government’s Learn and Return scheme. Whilst costs would be incurred to set this up it would give recognition of the Trust on an international scale too. Following the standard review of the Foundation Programme there were only two areas of concerns whereby there is no phlebotomy service on a Sunday which is being addressed via a business case and issues regarding staff parking permits. AH confirmed that he had personally looked into the issue of car parking permits and confirmed that all requests to the Trust had recently been fulfilled where individuals had applied and met the criteria. Mandatory training for resus and simulation is improving, albeit slowly. Catherine Baldock has been leading on the national ReSPECT

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programme. BS recognised the relationship between Health Education West Midlands (HEWM) and Warwick Medical School had not been positive or as productive in recent years and that this has been a gradual process to overcome. She felt that HEWM would have viewed the Trust quite critically because of this. SS expressed thanks to BS for her support in moving this along, reporting that 100% of students get their first choice of jobs applied for. This was supported by the Trust Board. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/043

GUARDIAN OF SAFE WORKING HOURS TRIMESTER REPORT OCTOBER 2017 TO JANUARY 2018

MP introduced the report which provided assurance that junior doctors in training were safely rostered and their working hours are compliant during the period of 1 October 2017 to 31 January 2018. She welcomed Dr Andreas Ruhnke to present the report. Dr Ruhnke informed the Trust Board that there was a current vacancy rate of 40 whole time equivalent (wte) staff over the 4 months. The shortfall in rotas was being covered by locums. Rotas can be filled with nurse physicians and doctors from abroad but this is a very lengthy process and makes it difficult to attract people. There has been a significant increase in exception reports. More than 50% of these have been dealt with within seven days but the delayed review times were owing to the unfamiliarity of the electronic reporting system. This has since been improved by educating the supervisors and trainees. Work schedules have been reviewed following F1s becoming in arrears. To resolve this, shift start and finish times have been amended by half an hour to ensure handovers can start at 4pm. He assured the Trust Board that these amended times will continue be closely monitored. Dr Ruhnke further noted that it was difficult to report on who had breached their hours because locums were not on the e-rostering system. The Rota Oversight Committee have invited companies to present and will be meeting on 3rd May 2018; there are two companies currently interested. Dr Ruhnke advised that there had been one individual who had breached the 56-hour limit by a significant margin. The West Midlands Regional Meeting of Guardians of Safe Working Hours confirmed that a fine would not be imposed on the Trust because the trainee, nor the supervisor, was aware of total working hours limit.

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KM advised that the total hours of junior octors is a joint responsibility by the individual with the Trust. She assured the Trust Board that the introduction of an electronic system will make this easier to manage. In conclusion Dr Ruhnke assured the Trust Board that there were no breaches. SK asked if the Trust benchmarked itself with other of training providers. Dr Ruhkne assured him that the Trust does well by offering a wealth of opportunity and that not only are individuals requesting to come here they are also choosing to stay at the end of their traineeship. Furthermore, the Trust has a lower vacancy rate than other organisations. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/044

CALDICOTT GUARDIAN ANNUAL REPORT

MP introduced the annual report which advised of the work undertaken by the Caldicott Guardian during 2017/18 and plans for 2018/19. As of 1st January 2017, responsibility of recording requests to the NHS Digital Bowel Cancer Screening System was transferred to the Trust’s Senior Information Risk Officer (SIRO) but that these requests were not captured within the report. She confirmed that the role of Caldicott Guardian remained shared between herself and the Director of Quality. A self-assessment of the Caldicott Guardian checklist was undertaken and plans to improve compliance include improving the internet page content, quarterly testing of switchboard to ensure details are accessible and scheduling bi-annual meetings for the Caldicott Guardians to meet with the SIRO and Head of Information Governance. During 2017 there were 32 applications to the Caldicott Guardian were submitted and all of these were approved. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/045

ELECTRONIC PATIENT RECORD (EPR) PROGRAMME UPDATE

NF introduced the report which provides an update on the status of the EPR programme with respect to the preparation of the business case that supports the investment required to deploy a world class electronic patient record across the Trust. NF welcomed Robyn Tolley, who is leading the programme. He advised that this is the largest transformational project over the next few years for

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AGENDA ITEM

DISCUSSION ACTION

the Trust. The system currently in use is nearing the end of its life and requires replacing. The programme currently looks at replacing the systems in maternity and renal and the patient administration system (PAS) but the Trust is also keen to procure e-prescribing which will improve services. The OJEC notice was published on 30th November 2017 which received seven suppliers completing the selected questionnaire. Of these, three suppliers were shortlisted but one subsequently withdrew. Robyn Tolley confirmed that the two suppliers had now completed their product demonstrations and the Trust had entered negotiations with the aim to procure a service whilst aiming to reduce costs. AM was assured that the programme had proceeded through the correct governance processes. IB further supported that this had been discussed in detail at the Finance and Performance Committee and the commercial process had been completed appropriately. DP enquired if the procurement process had included visits to other organisations utilising the systems. NF advised him that this had happened, but that she had not been part of this in order to maintain her independence as senior responsible officer (SRO) for the programme. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/046

STRATEGY REFRESH

SR presented the 2018–2021 Strategy which aims to empower staff though UHWi and describes the need to vertically and horizontally integrate pathways to manage local demand growth and ensure sustainable specialised services. This recognises that Coventry has a growing population and the Trust’s aim to provide world class services. By empowering staff this will achieve implementation and spread of the improvement methodology UHCWi. The approach is to support lean methodology which improves patient care and reduces waste. The Strategy aims for the Trust to integrate ‘vertically’ with primary care, community health and social care to help people stay well and reduce demand. New models of care will be developed outside of hospital will improve both quality and efficiency. She advised that the Trust continues to work with the network of providers within the STP but will also develop partnerships outside of the Trust’s network such as Oxford University Hospital NHS Foundation Trust and Worcester Acute Hospitals NHS Trust.

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She explained that the Strategy is supported by six objectives which have been identified to assess whether the Trust is delivering to the strategy. AH supported this, advising that whilst it is a newly developed strategy which is proposed, it has been built upon the existing strategy which still resonates with staff. UHCWi underpins the strategy and the objectives. SR informed the Trust Board that the enabling strategies to support this will be reviewed by the Strategy Unit in April. AM added that most of the non-executive directors had looked at the Strategy during a workshop session and on this basis no questions were raised. The Trust Board APPROVED the 2018 – 2021 Strategy.

HTB 18/047

TOGETHER TOWARDS WORLD CLASS

KM presented the report which describes the progress made on the programme since its launch in March 2014. She advised that this had evolved over time and that this is the overarching programme for the Trust’s organisational development journey. She highlighted the specific outcomes within the report relating to World Class Experience, World Class Services and World Class Leadership. Staff are now becoming more involved with the hub located in the atrium which has received 800-900 interactions. She confirmed that two key training sessions are now in place for staff, these being New Managers/Leader Introduction and Take a Coach Approach and these are aimed to develop staff to support the Trust on its cultural journey. The programme has been supported and developed with the Virginia Mason Institute supporting the Trust Guiding Team. She indicated that the Trust had possibly developed enough to use its own agenda at the meeting to lead the future direction of travel independently. IB informed KM that he had attended the Introduction to UHCWi passport session and had been impressed by the level of support that this offers but also by the engagement and eagerness of the staff. He was now assured to see the things joining together and recognised that this had been challenging to do. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/048

MAGGIE’S CENTRE

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AGENDA ITEM

DISCUSSION ACTION

AM declared that he, IB and NF were trustees of UHCW Charity but this was not a conflict. AH was pleased to announce that the Trust’s University Hospital site has been chosen as a location for a Maggie’s Centre to be developed. This has been an ongoing 4-year process but this will lead to internationally recognised services being delivered from the Trust. He advised that the clinical teams were excited that this was now progressing and would be complementing the suite of services already provided by the Trust, providing psycho-social support which the Trust did not have. He confirmed that the centre would be aligned to the cancer team. A visit was undertaken last week and a possible location for their uniquely designed buildings has been determined. NF fully supports the programme and reported that she had visited the Maggie’s Centre in Glasgow. The services they provide, and its setting, provide patients with new hope where there is nowhere else to turn to. DP questioned the fundraising to support the development and future involvement of the Trust. AH confirmed that there was no financial contribution required by the Trust other than to offer the land for the building to be developed. Maggie’s Centre have their own fundraising model which is in two stages, the first raises funds for the building development and the second phase fundraises for ongoing costs of the service. AM observed that this would be beneficial and supportive with the City of Culture coming to Coventry, The Trust Board SUPPORTED the development of a Maggie’s Centre.

HTB 18/049

INFORMATION GOVERNANCE TOOLKIT (IGTK) ANNUAL SUBMISSION

The report provides the final scores of the Information Governance Toolkit version 14.1 which will be submitted by 31 March. GS reminded the Trust Board that the requirement for achieving 95% of staff trained and compliant with information governance was always challenging but since the report had been written, he was delighted to announce that this had been achieved. The Board welcomed this news. GS also advised that the clinical coding scores had been received and 90% had been achieved.

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AGENDA ITEM

DISCUSSION ACTION

The Trust Board APPROVED the submission of the IG Toolkit scores.

HTB 18/050

COMMITTEE TERMS OF REFERENCE

GS presented the Terms of Reference for the Trust Board committees; Quality Governance Committee, Finance and Performance Committee, Audit Committee and Remuneration Committee. AH believed that a lot of the Trust Board time was taken up by attending the number of meetings and enquired if the members would be supportive of decreasing the number of non-executive directors from four to three and also decreasing the chief officers by one member. He suggested that this would free up time that could be spent in the hospital. GS advised that there was no legislation stating a required number of members attending meetings but reminded the Board that meetings would need to be quorate. The non-executive directors were concerned that by decreasing the number could cause issues relating to quoracy due to absence. The Committee Chairs were not supportive of decreasing the number of members owing to the depth of discussion currently held in meetings that could be lost. The Trust Board APPROVED the terms of reference for the committees.

HTB 18/051

MATTERS DELEGATED TO COMMITTEES

There were no matters delegated to the Committees.

HTB 18/052

QUALITY GOVERNANCE COMMITTEE MEETING REPORTS OF 19 FEBRUARY AND 19 MARCH 2018

The Trust Board RECEIVED ASSURANCE from the reports.

HTB 18/053

FINANCE AND PERFORMANCE COMMITTEE MEETING REPORTS OF 28 FEBRUARY AND 21 MARCH 2018

The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/054

AUDIT COMMITTEE MEETING REPORTS OF 12 FEBRUARY 2018

The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/055

ANY OTHER BUSINESS

There were no other issues arising.

HTB 18/056

QUESTIONS FROM MEMBERS OF THE PUBLIC

There were no further questions from members of the public.

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HTB 18/057

DATE OF THE NEXT MEETING The next Public Trust Board will be held on Thursday 31 May 2018 at 10.00am in the Clinical Sciences Building, University Hospital, Coventry, CV2 2DX.

SIGNED

………………………………………….................

CHAIRMAN

DATE

………………………………………….................

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

31 MAY 2018

1

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

AGENDA ITEM ACTION RESPONSIBLE OFFICER

COMPLETION DATE

UPDATE REMOVAL

ACTIONS FROM NOVEMBER 2017 MEETING

HTB 17/196 CHIEF EXECUTIVE OFFICER AND CHIEF OFFICERS’ REPORT

KM was pleased to report that as part of the talent mapping process 70% of staff had now received a talent rating. This will help identify staff with potential to progress to the next level and inform succession planning as part of the wider OD programme. EMS suggested it would be helpful to hold a strategic talent discussion as a Board. KM would be pleased to deliver a session around succession planning at a future Strategic Board meeting.

KM June 2018 23.05.18 – A programme is being confirmed for the Strategic Board which will commence in June 2018. 25.01.18 - Scheduled on the Strategic Board Work Programme for June 2018.

No

PUBLIC TRUST BOARD PAPER

Subject: Chairman’s Report

Report By: Andy Meehan, Chairman

Author: Andy Meehan, Chairman

Accountable Executive Director: Andy Meehan, Chairman

Date: 31 May 2018

PURPOSE OF THE REPORT:

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

SUMMARY OF KEY ISSUES:

The key meetings and areas of interest, since the previous Board meeting were as follows:

Attended the Quarterly Review Meeting with NHSI

Facilitated a Board Walk-rounds in both AMU2, the Coronary Care Unit and the Centre for Reproductive Medicine

Attended monthly Charity meetings

Attended End of Life Care Committee meeting

Attended the Midlands and East Chairs Networking meeting

Attended the UHCW Charity Board of Trustees meeting

Attended the UHCW & Project Co Board to Board meeting

Met with Andrew Bostock and Rob Chidlow (KPMG – external auditors)

Attended the CWPS Stakeholder Board meeting

Met with the new Chair and CEO of George Eliot Hospital (along with Andy Hardy)

STRATEGIC PRIORITIES THIS PAPER RELATES TO:

To Deliver Excellent Patient Care and Experience

To Deliver Value for Money

To be an Employer of Choice

To be a Research Based Healthcare Organisation

To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

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

IMPLICATIONS:

Financial: None

HR/Equality & Diversity:

None

Governance: None

Legal: None

NHS Constitution: None

Risk: None


Title Chief Executive and Chief Officer Updates

Author Chief Officer’s

Responsible Chief Officer

Andy Hardy, Chief Executive Officer

Date 31 May 2018

1. Purpose This paper provides an update to the Board in relation to the work undertaken by each of the Chief Officers each month and gives the opportunity to bring key issues in relation to areas within their respective portfolios and external issues to the attention of the Board.

2. Background and Links to Previous Papers The paper is presented to each Trust Board meeting.

3. Narrative Each of the Chief Officers has provided brief details of their key areas of focus during April and May 2018.

Mr Andrew Hardy – Chief Executive Officer Since the last Trust Board meeting I have hosted and participated in the following meetings, discussions and events:

Briefed staff at both University Hospital and Rugby St Cross following the recent CQC Inspections

Attended the Quarter 4 Performance Review meetings

Attended the Junior Doctors Induction

Attended the Nuneaton and Bedworth Health Overview and Scrutiny Panel to provide an update around the Better Health, Better Care, Better Value (BHBCBV) - formerly STP

Attended the Quarterly Review Meeting with NHS Improvement

Attended a dinner with Professor Lord Bhattacharyya

Facilitated a Leadership Forum (attended by Andy Street)

Attended the Coventry Health and Well-being Board

Attended a CIPFA Board meeting and dinner in London

Attended the West Midlands Provider Organisation Chief Executives Meeting in Birmingham

Attended Control Total meeting with Mark Mansfield at NHS Improvement

Attended the Better Health, Better Care, Better Value (STP) meetings

Attended a Liaison Committee Meeting

Attended Virginia Mason Guiding Team meetings

Met with Councillor Faye Abbott regarding BHBCBV (STP)

Met with local residents from Wyken

Attended the Coventry and Warwickshire Local Workforce Action Board (LWAB)

Attended the PF Innovation Awards ceremony in London

Attended the Leading Together Residential 2 Q&A session (Service Leader Cohort 10)

Attended the West Midlands Health and Wellbeing STP Executive Group

Undertook an Infection Control visit on Wards

Attended the UHCW / Project Co Board to Board meeting

Attended the ‘Moving to Good and Beyond’ - Developing QI Capabilities and Culture event in London

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Attended the ‘Blooming with Pride’ event at Rugby St Cross

Attended the STP Roundtable event with Jeremy Hunt for Chief Executive Officer’s in London

Participated in the Future Vision Leadership Development and Training Programme Design Event

Attended the Use of Resources events

Attended the CHKS Top Hospitals Awards in London

Attended the Digital Future Conference (with Sam Jones) in London

Attended the NHS Elect Advisory Board in London

Attended the NHS Improvement Lean in Healthcare Conference in London

Attended the NHS Partnership with Virginia Mason Institute (VMI) Dinner in London

Attended the VMI Transformation Guiding Board Meeting in London

Attended the West Midlands Academic Health Service Network (WMAHSN) Board meeting

Attended the Coventry University Chancellor's Dinner

Met with the new Chair and CEO of George Eliot Hospital (with the Chairman of UHCW) Consultant Appointments: Through the nominated Chief Executive Representative and other Committee Members, the Trust Board is advised to note and ratify the following appointments:

Appointed Candidate Consultant Position

Dr Tarvinder Dhanjal Consultant Cardiologist / Electrophysiologist

Dr Timothy Derk Hoong Woo Consultant Musculoskeletal Clinical Radiologist

Dr Emer McLoughlin Consultant Musculoskeletal Clinical Radiologist

Dr Rachit Shah Consultant Musculoskeletal Clinical Radiologist

Dr Jassie Tan Consultant Clinical Radiologist with subspecialty interest in Chest and Cardiac

Dr Sasathorn Chutimaworaphan Consultant in Emergency Medicine

Dr Ali Husain Consultant in Emergency Medicine

Dr Sarah Grieve Consultant Nephrologist with interest in Education

Publications: NHS Improvement has identified seven further trusts to take part in the lean programme to build on the success of the collaboration with the Virginia Mason Institute. These are;

• Derby Teaching Hospitals NHS Foundation Trust • Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust • The Dudley Group NHS Foundation Trust • East Lancashire Hospitals NHS Trust • Royal Surrey County Hospital NHS Foundation Trust • The Hillingdon Hospitals NHS Foundation Trust • University Hospitals Plymouth NHS Trust

Further details of the programme can be found at; https://improvement.nhs.uk/resources/lean-programme/ NHS Providers has published various articles describing how winter affected various parts of the NHS http://nhsproviders.org/mapping-the-nhs-winter

https://improvement.nhs.uk/resources/lean-programme/

http://nhsproviders.org/mapping-the-nhs-winter

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The Kings Fund has published an analysis of health care resources, comparing the UK with other countries. https://www.kingsfund.org.uk/publications/spending-and-availability-health-care-resources NHS Improvement and NHS England have announced further details on how they plan to work more closely together https://improvement.nhs.uk/news-alerts/nhs-england-and-nhs-improvement-working-closer-together/ NHS Providers has published a survey and analysis of the changing nature of regulation in the NHS over the past 12 months http://nhsproviders.org/the-changing-nature-of-regulation-in-the-nhs

Lisa Kelly – Chief Operating Officer In addition to the regular meetings such as, COG, COG Delivery Group, CO/CDG, COAG, F & P, Financial & Quality Star Chamber, Quality Governance Committee, and Risk Committee, I have undertaken the following:

Responding to the fire incident, liaising with the Fire Service and participation in both hot and cold debrief.

Participated in Quarterly Performance Reviews

Participated in Quarterly Performance Reviews with NHSi

Chairing Coventry & Rugby Local A & Delivery Group

Chairing Elective Care Board

Chairing Emergency Care Improvement Board

Chairing Group Managers Meeting

Attending Strategy Group

Chairing Cancer Board

Chairing Trust Health & Safety Committee

Hosted a meeting with Ernst & Young

Met with Junior Doctors

Met with Cherry West at QEHB

Participated in Registrar teaching Q & A

Attended VM Team Guiding Meetings

Attended SIRO meeting

Attended Liaison Committee Meeting

Attended Coventry & Warwickshire A & E Delivery Group

Hosted on call manager meeting

Participated in GEH Service Level meetings

Attended meeting with Surgery Ambulatory Emergency Care Team

Participated in CQC pre and feedback meetings

Attended Strategic Board

Hosted a meeting with Deloitte regarding cancer pathway audit

Hosted a meeting with Staffside regarding car parking issues

A member of the interview panel for Associate Medical Director

Attended Arden LHRP

Hosted Group Manager Away Day

Participated in CQC Use of Resource Assessment

Participated in Cancer team walk around

Attended NHS Digital Event

Attended NHSi Lean Event

https://www.kingsfund.org.uk/publications/spending-and-availability-health-care-resources

https://improvement.nhs.uk/news-alerts/nhs-england-and-nhs-improvement-working-closer-together/

https://improvement.nhs.uk/news-alerts/nhs-england-and-nhs-improvement-working-closer-together/

http://nhsproviders.org/the-changing-nature-of-regulation-in-the-nhs

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Su Rollason – Chief Finance & Strategy Officer Since the last Trust Board Meeting and, in addition to the routine corporate meetings such as COG; COG Delivery Group; COG Quality Star Chamber; Risk Committee; Strategy Board Away Day, F&P, Audit Committee, IDMs, VMI Trust Guiding Team, and Strategy Unit; I have undertaken the following commitments: April 2018 Meeting with Specialised Commissioners STP Finance meeting Conference call with Mrs Grace Colloton - The Advisory Board Company Chief Officers - Day in the Life of Programme - Mortuary (Chris Wookey) Meeting with Mark Mansfield, Regional Director of Finance / Georgina Dean, NHS

Improvement Internal Meeting - Isle of Man Government - Department of Health and Social Care - Prior

Information Notice Chaired Managed Print Service Project Board Meeting Chaired Rugby Theatres Programme Steering Group Weekly EPR update meetings Meeting with Audit Manager regarding potential audit reviews Feedback session with the Department of Health & Social Care - overseas patients and cash

recovery Meeting with Georgina Dean, NHS Improvement Artificial Intelligence Workshop with PwC (Nigel Coates) May 2017 Weekly EPR update meetings Leading Together: CO Q&A Use of Resources Briefing Session ODP sign off meeting with Groups Meeting with Lynda Scott – Finance Communications Strategy Use of Resources Assessment External Audit debrief meeting National Conference - Lean in healthcare: quality improvement to deliver better care Conference call for stroke for all STP FDs Meeting with Coventry and Rugby CCG FD Annual accounts sign off meeting

Professor Meghana Pandit – Chief Medical & Quality Officer/Deputy CEO In addition to all the regular meetings such as Chief Officers Group, Strategy Group, COG Delivery Group, Patient Safety Committee, Risk Committee, Mortality Review Committee, Serious Incident Group (SIG), Medical Concerns meeting, 7 day Services Steering Group, Quality Star Chamber, Quality Governance Committee and my own clinical work, I have undertaken the following activities since the last Trust Board meeting on 29 March 2018:

Visited wards (Boardwalk AMU2, ED, Labour Ward, 30, 31, 43, 41, 42, 20) speaking to Junior Doctors, Nurses, Pharmacists and Consultant colleagues

Patient Safety response Team

Chairing Clinical Advisory Groups regarding Neurosurgery and Histopathology

Consultants meeting

CQC feedback meetings

Call with RCP to discuss TOR for gerontology review

Call with Vice President of RC Pathology

Call with Dean, HEEWM

Chief Officer Forum

Attended Stand Up sessions

Trust Guiding Team and VSST for Theatres Value Stream

Complaint letters review and sign off

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Quarterly UHCW Progress Review Meeting

Quarterly Review Meeting with UHCWi

Attended Grand Rounds

Attended GMC ELA/RO meeting

Junior Doctors Induction

Trust Induction

Regular Revalidation Officer meetings

Managed the response to all internal and external stakeholders and actions resulting from RCS report and media exposure.

Quarterly Performance Reviews

Quarterly NHSI review

Exit meeting with Chris Grocock, Consultant Surgeon

Lecture at Healthcare Operational Management, IDI, Warwick University

Telephone interview John McDermott, The Economist

Attended Royal College of Surgeons Accreditation meeting regarding collaboration with Surgical Training Centre

Attended VSST for Theatre Value Stream

Call with Russell Smith, Post Graduate Dean Health Education England

Speaker at the Registrar Leadership Training Programme

Attended VM Guiding Team Meeting

Attended West Midlands Cancer Alliance Board

Attended Coventry and Warwickshire STP Escalation meeting with NHSE and NHSI

Attended CQC Inspection feedback sessions

Invited speaker at Quality Forum

Theatres Productivity Scheme meetings

Attended Strategic Board

Attended Patient Safety Awards panel in London

ELA / RO Meeting with NHS England

Attended Employment Tribunal debrief

Attended meeting with C&W STP Transformation / Warwickshire Council regarding cancer care (David Hobday / Berni Lee)

Attended Strategic Workforce Committee

Meeting with Gynaecology Oncology Consultants

Breakfast meeting with Consultants

Chaired Disciplinary Appeal Hearing

Chaired AMD - cancer interviews

Attended Use of Resources meeting

Attended UHCWI Lean for Leaders

Attended West Midlands Senate Council Meeting

Nina Fraser – Chief Nursing Officer In addition to all regular meetings; Chief Officers’ Group, Chief Officers’ Delivery Group, Quality Star Chamber, COG Advisory Group, Patient Safety & Effectiveness Committee, Risk Committee, Quality Governance Committee, Nursing & Midwifery Committee/Forums, Serious Incident Group (SIG), Strategy Group; I have undertaken the following activities since the last Trust Board meeting held in March 2018:

Participated in Quarter 4 Performance Reviews (April)

Attended a Quarterly Review with Chief Officers with NHSi in Derby

Met with and welcomed Trainee Nursing Associates (Cohort 2)

Participated in Consultant Interviews for ED

Participated in Value Stream VSST Patient Safety Incidents

Participated in Value Stream VSST Ophthalmology

Participated in the monthly VM Trust Guiding Team meeting

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Undertook a Ward Walkaround at the Hospital of St Cross, Rugby

Attended Coventry and Warwickshire STP Clinical Design Authority weekly meetings

Attended follow-up to the Ideas ‘Den’ in the Innovation Hub where the winner, ‘Heather Smalley’ presented her idea for improvements.

Attended ‘Moving to Good and Beyond – Developing Capabilities and Culture’ (NHSi event)

Participated in the Trust’s ‘Blooming with Pride’ event at the Hospital of St Cross, Rugby

Attended ‘Use of Resources’ Session with Chief Officers

Attended Clinical Strategy Advisory Group Meeting (Coventry University)

Completed all required Mandatory Training to date

Attended International Nurses’ Day Celebration, Coventry Cathedral & celebrations for staff held in the CSB. Awarded the Florence Nightingale Excellence Award for newly qualified nurse, Amber Heal from ward 43 for upholding the Trust’s values.

Attended Digital Future Conference in London with Chief Officers

Chief Officer in attendance at Leading Together Q&A session

Meet with Prof. Guy Daly Dean of Coventry University to explore International Opportunities and joint ways of working

Deputy Chief Nursing Officer

Opened annual pressure ulcer conference attended by 80 plus internal / external delegates - really well evaluated

Continued Induction with quality focussed visits to ED/ acute med/ Surgical wards and services/ theatres / Women’s and children’s / OPD / sterile services / Rugby St Cross wards

Launched PJP 70 day challenge with presentation to Chief Officers Forum

Attended first Strategic Workforce Committee

Established team to attend UTI prevention (national) Collaborative - starts from 24th May

PLACE - taken part in assessment with Healthwatch and Patient Partners

Education & Research

New post holder from 11th June ADN Vicky Williams

New Professor of Nursing, Jane Coad commenced in a joint post with Coventry University

Karen Martin, Chief Workforce and Information Officer I have attended all the usual Chief Officer meetings including COG, F&P, QGC, Strategy Group, Chief Officer Forum, Quality Star Chamber, and Leadership Forums. I have also chaired the new Strategic Workforce Committee and Transforming Workforce Supply Committee. Other commitments have included attending:

Midlands & East Moving to good, and beyond – Culture & Quality event in London

Theatres to shadow as part of “Day in the Life of” Better Health, Better Care, Better Value board meetings

Buddying meeting for Oncology, Haematology and Renal Senior Team

Quarterly meeting held with senior HR Business Partners

A number of informal ward and department visits

A meeting of the Regional Talent Board

Coventry and Warwickshire LWAB Meeting

CWIO Senior Leads Event – discussed how we underpin and will support the new organisational strategy and objectives for 2018/19

NHS Digital Event – London

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Live Waiting Times – 3rd May The newly launched Trust website saw our CWIO teams pooling their expertise with the launch of a new feature where our live waiting times for emergency and urgent care services are now available online in real time. This new service helps members of the public know likely waiting times for our emergency and urgent care services and helps them make an informed choice of where to go. Our PPMO team helped create the coding formula for the website system, ICT built the interface between our website and the data and the communications team ensured engagement behind the new service. It has been soft launched to the public during this pilot phase as we continue to build and expand features and options.

Communications:

As we get ready to celebrate the 70th anniversary of the NHS, the trust will be hosting a

number of events and activities across its sites and locations to mark this special

occasion. Members of staff will be attending a special service of thanksgiving at

Westminster Abbey. A number of our staff have been recognised in special NHS70

awards for their commitment to care.

We supported a national nursing campaign #endPJparalysis to encourage patients to get

up, dressed in their own clothes and moving to boost their recovery.

We featured one of our patients Alathea, 93 years young within our local campaign and

Professor Brian Dolan, who created the initiative, asked for her story to be featured as part

of the national #endPJparalysis campaign. The story also had strong social media

engagement locally including 500 likes/loves and 162 shares.

Nominations for our annual Outstanding Service and Care Awards (OSCAS) were

launched on 10 April and the ceremony will take place in September.

Equalities

14th – 18th May 2018 NHS Equality Diversity and Human Rights Week. Working in

partnership with the Faith Centre, Health and Wellbeing Team, and Learning &

Development team to promote NHS Equality, Diversity and Human Rights week, Dying

Matters week, Learning at Work week and Mental Health Awareness Week. A number of

events have been arranged which are currently being promoted including the Trust’s third

Embrace Equality Enhance the Experience open day.

Training - We have supported training on Equality and Diversity for volunteers and a

Leading Together Unconscious Bias session. Working in partnership with other NHS

organisations, UHCW will host the first 3 pilot sessions of the BME (Black and Minority

Ethnic) Stepping Up Leadership Programme on 31st July–2nd August.. It will be

evaluated with a view to provide BME staff with relevant training and development.

Performance and Programme Management Office (PPMO):

The Performance team has focused on the monthly and quarterly packs for this financial

year which have been well received. A clear plan is now in place for a performance

framework which will start to move forward through effective performance reporting.

The Corporate Information team has created a data quality strategy and framework for

the Trust which is in the final stages of sign off. In addition collaborative working between

central admin teams and validators has been supported impacting our waiting list profiles.

The Information Systems Development team has been focused on server upgrades, walk

in centre data inclusions into ED numbers and has supported EPR developments for

data extract queries as part of the procurement process.

The Clinical Coding team has achieved the coding deadline for April which has been a

challenge in previous months. Work continues to explore income opportunities through

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collaborative working with clinicians, Outpatients and the Emergency Department. The

coding for UHCW continues to be in the upper quartile for depth of coding across the

NHS.

Workforce:

We have made good progress in relation to our Health and Wellbeing offer for staff:

o Regular Health and Wellbeing Event on 20th April with over 600 staff attending.

Staff were able to talk to many of our support services, obtain information and

discounts on a range of activities, try taster sessions and also receive free health

screening checks

o Our second Green Gym was officially opened on the UHCW site 27th April by

the Trust CEO.

o Shortlisted for the HPMA awards for our holistic work on Health and Wellbeing

within the Trust.

o Preparing for the launch of our first Kaido Wellbeing challenge ‘Walk the Great

Wall of China Challenge’. Kaido Wellbeing is an inclusive and holistic wellness

programme, designed to engage everyone, regardless of health status or location.

o New counsellor joined our Occupational Health team to provide mental health

support for staff at both Trust sites.

Launched a joint initiative with National Express to provide staff with a discounted annual

bus pass with over 80 staff have taking up the offer, so far.

Preparing to issue our annual 100% Attendance Letters for all staff that have not had

any sickness absence for the past 12 months, to staff to say thank you and well done on

this significant achievement. Eligible staff will receive their letters in May/June.

Nationally, there has been an issue with the number of visa’s (certificate of

sponsorships) being issued by the Home Office to overseas medical doctors. We have

also been affected with 8 new medical appointments that have initially been declined but

will be reconsidered next month.

Held Listening Events during April and early May in response to our 2017 NHS National

Staff Survey results. The events encouraged staff to be able to expand on their

responses in the survey and to suggest ways in which improvements could be made.

Actions plans will be developed during May and shared back with staff.

Our first cohort of 13 staff will commence the Level 6 Chartered Managers Apprenticeship

Degree in May 2018. The degree will run over 4 years at Coventry University. UHCW are

the first cohort to embark on this journey.

ICT

ICT have been shortlisted for Patient Safety Award for the Red Blood Cell calculator –

we have seen a significant reduction in units of blood issued compared to a rise in activity.

Emergency department agency nurses set up on e-learning portal to remotely complete

training on UHCW systems.

A new on-call service was implemented for out of hours calling within ICT. Callers are

now routed to the most appropriate resource when logging a call

Following capital purchases at end of financial year, a large number of replacement

servers and infrastructure are currently being replaced.

Innovation

As part of our push to encourage ideas from staff, our second Ideas Den ran in March

2018 with 5 ideas presented to the Panel. The winning idea, Non-Clinical Volunteers Kit

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was presented by Heather Smalley, Information System Developer and this will receive

support from the Trust to progress the idea further.

3 submissions were made to the NHS Testbed competition and all were successful, so

will progress to the next stage of submission. Another Testbed application within the Trust

was made by Dr Robbins, which relates to diabetes.

Transformation

Patient Flow – a steering group has been set up and first meeting arranged to progress

mapping of the work plan, KPIs and data requirements

Paperless new patient referrals –to increase speed for patients being referred our new

paperless referral systems will enable GPs to quickly refer patients electronically in a more

safe and secure way than fax or slower postal systems. We are working with the Local

Medical Committee to understand their issues around implementation of this new process

which needs to be done by beginning of October 2018 to meet new national guidelines.

Theatres – Current work is focussed on processes required for locking down of theatre

lists

Virtual video – Consultations using video enable those less mobile to access timely

healthcare advice. We have a business case under development and are currently

applying for NHSe testbed funding, having been successful in the first stage.

I-Nexus – in a move to streamlining our business processes, we have hosted workshops

(9th &10th May) involving clinical and corporate staff in a new project management tool to

enable more efficient working.


Title World class care received from the Critical Care Team

Author Sarah Brennan, Patient Insight Manager

Responsible Director

Meghana Pandit, Chief Medical and Quality Officer/ Deputy CEO

Date 31st May 2018

1. Purpose Mr H shares his hospital experience when he was cared for by UHCW NHS Trust’s Critical Care Team. He highlights many individuals from the Critical Care Team and the wider multi-disciplinary team who made a difference and impacted on his experience positively. 2. Background and Links to Previous Papers

This story forms part of the Patient Story Programme 2018/19 which was agreed by the Patient Experience and Engagement Committee in February 2018 for this financial year.

3. Executive Summary Mr H wanted to formally recognise and acknowledge the staff and volunteers who took great care of him and his family during his time in Critical Care during August and September last year.

When a person is admitted to Critical Care it can be a frightening and confusing time for a patient however Mr H felt that the care he received from many individuals made his care whilst in hospital a calmer and more positive experience. He details in his story how this care has impacted positively in his recovery at home and that staff went above and beyond to reassure his wife in what was a difficult time for her also.

This feedback will be shared with all the teams involved in Mr H’s care.

4. Areas of Risk

No risks identified.

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks The Patient Story Programme links to our strategic objective to deliver excellent patient care and experience and supports the patient experience key performance indicators outlined in the Trust’s Quality Strategy.

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6. Governance NHS Constitution This story highlights that UHCW NHS Trust staff demonstrated the following principles of the NHS Constitution:

Provide all patients with safe care, and to do all you can to protect patients from

avoidable harm.

Maintain the highest standards of care and service, treating every individual with

compassion, dignity and respect, taking responsibility not only for the care you

personally provide, but also for your wider contribution to the aims of your team

and the NHS as a whole.

Involve patients, their families, carers or representatives fully in decisions about

prevention, diagnosis, and their individual care and treatment.

7. Responsibility

Meghana Pandit, Chief Medical Officer and Quality Officer/Deputy CEO

Nina Fraser, Chief Nursing Officer 8. Recommendations The Board is invited to note Mr H’s story. Name and Title of Author: Sarah Brennan, Patient Insight Manager Date: 31st May 2018

Specialties/ Departments / Staff groups concerned

Critical Care

Why was this Story chosen World class care received from the Critical Care Team

Storyteller Mr H

Please detail what you thought was good about your care and treatment at UHCW? Please detail what you thought was good about your care and treatment at UHCW? Where could we have improved? What actions would you like to see the Trust Take?

I would like to formally recognise and acknowledge the staff and

volunteers who took such great care of me and my family during

my month in Critical Care during August and September last year.

I only have fractured memories of that time, I was very confused

and probably wasn’t always the easiest patient to treat (that may

be an understatement), but their skills and professionalism

meant that I’m able to write these words.

It is difficult for me to put the immense gratitude I feel into

words, but I want to recognise their hard work and dedication,

and say a huge thank you to everyone who helped me to find my

way back to the land of the living. In no particular order:

The consultants and doctors, including Roger who was very

understanding about the frustration and confusion I was

experiencing, and Dhushy who organised many transfusions for

me (which were occasionally challenging but he kept ownership

throughout, phoning in from home to ensure I received the

treatment I needed).

Das, who sorted out a radio for me and gave me a good talking to

when I was particularly despondent. He also gave me my voice

back when he sorted out my speaking valve, and that was

massively uplifting for me.

Vasu, as I’m sure you know, is quite quiet – but his mere

presence was so reassuring and calming when I was suffering.

His patience knows no bounds, and he was so kind and attentive

– he took the time to talk to me and remind me who I was, which

I imagine is a difficult thing to do when the first time you meet

someone they are in a coma.

Pedia, whenever I think of her I can’t help but smile. She is

We are Listening : Patient Story

World class care received from the Critical Care Team

amazing, her personality and attitude really helped me through a

difficult time. She spent considerable time talking to me,

explaining everything to me and giving me some good

motivational chats that really worked and helped me to realise

that I might be able to get back to my former self. Even now I

think of things she said and they help me to push myself on with

my recovery.

Mac shaved me and kept me looking presentable, and stayed

with me before, during and after my cardiac arrest – he literally

saved my life. Maxine (my wife) was also particularly grateful for

the time spent talking to her and explaining exactly how I was

when she telephoned for updates late at night.

Sister Gillian I remember was very kind and understanding, and

my wife was particularly grateful for the regular words of support

when she was responsible for Area 2.

Lucy brilliantly balanced helping me go to the loo whilst reacting

to an emergency. She also phoned my wife for me one night

when I was a bit dazed and confused to tell her I loved her. My

wife remembers how she tried so hard to keep the dialysis

machine going and the tremendous support given to her and my

Mum including timely and heartfelt hugs.

Charlotte was so kind and understanding, I remember being very

down when she went off shift which meant I really trusted her (it

was a scary time and I really was very confused). She had

incredible patience with me, spending time talking to me and

explaining everything, which is why I was able to trust her.

Roberta recognised that I was asking for my wife and telephoned

her to let her know. My wife is also grateful that she called her

on my first evening in when I was particularly upset and she was

able to come in and reassure me.

Helen was very supportive, treating me as an individual and

properly listening to me. My wife is also grateful for the huge

support she gave to her when I deteriorated and was intubated

for the first time, including a timely and heartfelt hug. Her

immense help and support meant we were better prepared to

cope with my being intubated a further 2 times.

Andy has a very calming influence, which I noticed when we

shared some difficult times together.

Sister Wendy gave much appreciated support to me and my

mum when I was reintubated.

Neil was extremely adept at keeping the dialysis going, which

must have been difficult and frustrating – I expect that played a

pretty big part in me being here today to write this. - it was

immensely reassuring when he was there.

Sister Jo helped the Physios to stand me for the first time, and

was so cheerful and gave me such immense encouragement.

Claire, Dale, Debbie and Emma (physiotherapists), who I

frequently sent away with unkind words when they were trying

to help me. Maxine is particularly grateful for the times they

allowed her to stay with me during my sessions of physio, not

everyone would have done this. They have such a calm, kind,

reassuring and encouraging manner and that played such a huge

part in my recovery. Even now they continue to support my

recovery, both physically and more importantly mentally (despite

their job title, their impact is so much more than healing the

body).

Finally, the army of volunteers who all give up so much of their

time – please know the huge difference it made when my family

and friends were visiting twice a day. It was so reassuring to

arrive and see them at the front desk, knowing my visitors would

get access to the unit quickly and never be forgotten. They were

all so kind and supportive and we are so thankful that they were

there.

Since leaving Critical Care, the ICU Steps group meetings and

social media have offered invaluable help and support. I can’t

describe how lonely it feels when you first come out of Critical

Care – talking to others who have walked that path is incredibly

healing, and helped me get through a long night when I suffered

my first post-sepsis infection. These meetings simply would not

happen without Neil, Leanne, Caroline and Amy giving up their

free time to support our recovery.

I know that all of these brilliant people will say that they were

only doing their jobs and that anyone else would have done the

same. But that is simply not true – they are amazing, and we

will be forever grateful for the incredible effect they had. They

went above and beyond and that is the difference that I

experienced my wife remembers and we specifically want to

recognise.

I’m sure there are many other examples of world class care, and I

feel a huge measure of guilt for being unable to remember

everyone who helped me – I would be very grateful if you could

pass on to everyone who works on Critical Care at UHCW how

brilliant they were during my stay. This includes the cleaners and

the food service staff, who all knew me by name and were

cheerful and uplifting every day.

When I visited the ward as part of my follow up I spoke to Amy

Brannan, who explained that although the team were unable to

accept cash gifts they might be grateful for some tea and coffee

to share. Correspondingly I have delivered a small token of our

gratitude to the ward, and I would be grateful if you could ensure

my comments are formally recorded and fed back to those

involved.


Title Integrated Quality, Performance & Finance Report – Month 1 – 2018/19

Author Miss. Lynda Cockrill, Head of Performance and Programme Analytics


Mrs. Karen Martin, Chief Workforce and Information Officer

Date 31 May 2018

1. Purpose To inform the Board of the performance against the key performance indicators for the month of April 2018. 2. Narrative The attached Integrated Quality, Performance & Finance Report covers the reported performance for the period ending 30th April 2018.

The Trust has achieved 8 of the 23 indicators reported within the Trusts performance scorecard. The Trust scorecard aligns the Trust level indicators with the Trusts corporate objectives, highlighting relationships to the CQC domains.

Key indicators in breach are the Trusts performance against:

the 4 hour Emergency Care target;

Referral to Treatment incomplete standards (including 30 breaches of the RTT 52 week wait standard),

Key indicators achieving the target include:

Diagnostic Waiters – 6 weeks and over

Harm Free Care

Cancer 62 day Urgent Referral to Treatment

The Value for Money indicators are in-line with the "Single oversight framework". The Trust is reporting a £5.8m deficit, in line with plan. The forecast position for the year is a £9.7m deficit, also in line with plan.

Measures relating to financial ratings, including the Income and Expenditure Margin Rating in the Trust scorecard, are currently unavailable for April due to minimised external reporting requirements.

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3. Areas of Risk As detailed in the performance trends pages. 4. Recommendations The Board is asked to confirm their understanding of the contents of the April 2018 Integrated Quality, Performance and Finance Report and note the associated actions. Name and Title of Author: Miss. Lynda Cockrill, Head of Performance and Programme Analytics Date: 25th May 2018

Integrated Quality, Performance and Finance Reporting Framework Reporting period: April 2018

Page

Performance Summary

Executive Summary 3

Trust Scorecard 4

Performance Trends 5

Trust Heatmap 6

Group Summary of Performance 7

Quality and Safety Summary

Quality and Safety Summary 10

Quality and Safety Scorecard 11

Performance Trends 13

Ward Staffing Levels 14

Finance and Workforce Summary

Finance and Workforce Summary 15

Finance and Workforce Scorecard 16

Finance Headlines 18

Statement of Comprehensive Income (SOCI) 19

Efficiency Delivery Programme 20

Workforce Information 21

Integrated Quality, Performance and Finance Reporting Framework

Contents

2

Executive Summary

Integrated Quality, Performance and Finance Reporting Framework 3

Indicators

achieved

Indicators in

exception

Indicators in

watching

status

Total

indicators

Objective 1 - Getting to

Good CQC Rating 5 3 2 10

Objective 2 - Meet National

Performance Objectives 2 9 0 11

Objective 3 - Achieve the

Financial Plan 1 1 0 2

All domains 8 13 2 23

8 KPIs achieved the target in April

The Trust has achieved 8 of the 23 indicators reported within the Trusts performance scorecard. The Trust scorecard aligns Trust level indicators

with the Trust corporate objectives, highlighting relationships to the CQC domains. This includes two summary indicators: National Cancer

Standards Achieved (1 month in arrears) - The number of the eight national cancer standards that have been met in the reporting month and

Friends & Family Test - Recommender Targets Achieved - The number of the seven Friends & Family Test Recommender key performance

indicators that have been met in the reporting month.

Targets related to aspects of the emergency pathway (A&E waiting times) and the elective pathway targets including RTT incomplete pathways and

last minute non-clinical cancelled operations continue to underperform. The RTT incomplete position remains below the 92% national target and

has deteriorated by 0.1% to 82.3% for March. There have been 30 breaches of the RTT 52 week wait standard which is an increase of two from last

month.

In March the Trust achieved seven national cancer standards. The Two Week Wait breast symptomatic target for March was not achieved due to

capacity issues. The Trust has achieved all eight standards for the overall year 2017/18.

The Trust’s latest available Hospital Standardised Mortality Ratio is 100.72

At month 1, the Trust is reporting a £5.8m deficit, in line with plan. The forecast position for the year is a £9.7m deficit, also in line with plan.

Measures relating to financial ratings, including the Income and Expenditure Margin Rating in the Trust scorecard, are currently unavailable for April

due to minimised external reporting requirements.

What’s Not So Good?

18 Weeks RTT - Incomplete

RTT 52 week waits

Emergency Care 4 hour wait

What’s Good?

HSMR –basket of 56 Diagnosis groups

National Cancer Standards Achieved

for 2017/18 overall

Harm Free Care

KPI Hotspot


Trust Scorecard

Reporting Month April 2018

4


Trust Heatmap

5

Performance Trends

6 Integrated Quality, Performance and Finance Reporting Framework

Improving

(3 months

consecutive

improvement)

Deteriorating

(red indicators

worsening)

(3 months

consecutive

deterioration)

Deteriorating

(green/amber

indicators

worsening)

(3 months

consecutive

deterioration)

• Harm Free Care continues to deliver against target and has shown three months of improvement.

• Breaches of the 28 Day Readmission Guarantee are reducing as the Trust begins to see improved flow and

reductions in cancellations.

• None of the indicators that are achieving their targets this month have deteriorated for three consecutive months.

• Complaints turnaround times have deteriorated with performance in March of 52%. This is the lowest performance

since November and relates predominantly to consistently high numbers of complaints and capacity issues.

Group summary of performance – A&E and associated metrics


Last minute non-clinical cancelled operation rates has increased to

1.5% for April. Groups with the highest levels of such cancellations

were Neurosciences (5.4%), St Cross and Orthopaedics (3.5%),

Theatres and Anaesthetics (2.8%) and Surgery (2.3%). Bed

availability on the ward, emergency theatre slot required and

unplanned maintenance of heating systems in St Cross theatres

were the main reasons for these cancellations.

The percentage of diagnostic waiters who waited

over 6 weeks has increased this month to 0.47%

against the 1% target. The number of breaches

has risen to 55. 32 breaches were within Imaging,

1 in Cardiology, 16 in Neurophysiology and 6 in

Sleep Studies.. The total number of waiters has

continued to rise and is 11,665 in April.

7

The Trust’s performance against the 4 hour standard for April improved to 84.8% (79.2% March). Towards the end of April improvement was

seen in the delivery of timed pathways within the Emergency Department with significant reductions in the Time to Seen and Time to Decision

measures.

Acute bed occupancy reduced in April to 97% (March 102%) for the University Hospital whilst Rugby remained higher than in previous periods

up to 86%.

The Trust reported improvement in the numbers of patients who are Delayed Transfer of Care (DTOC) in April. DTOC is the primary focus of

daily calls and alongside this there is a twice weekly focus on stranded patients.

Focus remains on monitoring adherence to the ED timed pathways, reviewing Ambulatory Care pathways to support flow and the continued ring

fencing of assessment beds.

Group summary of performance – Referral To Treatment


In March Trust performance was 82.3% which was a deterioration of 0.1% with an

associated 104 backlog increase.

Dermatology (2.6%), Gastroenterology (4.2%) and Plastic Surgery (2.1%) saw the

greatest improvement.

Neurosurgery and Ophthalmology saw a reduction in performance. Neurosurgery

who are currently challenged by inpatient and Neurovascular capacity leading to a

reduction of 4.9%,whilst Ophthalmology continue to be challenged with wait to new

appointments and sourcing Graft and Lens material – resulting in the backlog

increasing by 74.

• Neurosciences (81.9%)

• Theatres &

Anaesthetics (81.1%)

• Specialist Medicine

and Ophthalmology

(80.4%)

• Surgery (80.1%)

• Trauma &

Orthopaedics (76.9%)

• Clinical Diagnostics

(66.7%)

4 out of 10 groups achieved the National RTT incomplete target

The Trust has reported thirty 52 week incomplete pathway breaches

in March. This was a increase of two from last month. Breaches

occurred in Surgery group (12), Ophthalmology (8), Neurosciences

(6) and one in each of Gynaecology, Dermatology, Pain

Management and Radiology.

Sixteen of the 52 week patients received their treatment in April.

Capacity issues remain a cause of breaches.

Behind target

(number behind)

On target

123

RTT Incomplete 82.3% (Last month 82.4%)

National Target 92%

• Care of the Elderly

(97.8%)

• Oncology,

Haematology and

Renal (94.7%)

• Cardiac and

Respiratory (93.5%)

• Women & Childrens

(93.2%)

Group summary of performance – Cancer Standards


In March the Trust achieved seven national cancer standards. The Two Week Wait

breast symptomatic target for March was not achieved due to capacity issues.

The Trust has achieved all eight standards for the overall year 2017/18.

Following UHCW’s March submission, the Trust has been notified that it is the highest

performing Trust for pre and post treatment staging data completeness for the West

Midlands Region.

Two Week Wait capacity is a concern which is being pro-actively managed with daily

monitoring of referrals. A meeting is taking place with Primary Care colleagues to

promote appropriate Two Week Wait Referrals.

7 cancer

standards

achieved in

March.

100 days and over target not met

3 breaches (5 patients) of the 100 days and over

target were reported in March.

The breaches occurred within:

• Urology (1.5 breaches, 3 patients)

• Head and neck (1 breaches, 1 patient)

• Haematology (0.5 breaches, 1 patient)

2WW 31 day 62 day

Performance against cancer standards by tumour site – 2017/18

1

Quality and Safety Summary

This section includes the Quality and Safety scorecard which contains all relevant indicators that are included within the overarching Trust scorecard,

together with additional pertinent KPIs that enable headline areas such as harm free care to be explored in more detail e.g. with the underpinning

pressure ulcer and falls KPIs. Ward staffing information is also included in this section.


Quality & Safety

Scorecard Indicators

achieved

Indicators

in

exception

Indicators

in watching

status

Total

indicators

Excellence in

Patient care and

experience 26 9 9 44

Leading research

based health care

organisation 2 1 2 5

Leading training

and education

centre

1 0 0 1


9 9 26 Excellence in Patient Care and Experience

Leading Research Based Health Care Organisation

1

Leading Training and Education Centre

The Trust’s latest available Hospital Standardised Mortality Ratio

is 100.72

The number of RTT 52 week waits has risen slightly to 30 for

March.

Clostridium Difficile – the Trust has had four Trust acquired

eligible cases in April. The Trust has a target of no more than 41

for 2018/19.

There are four reported overdue serious incidents for April.

All MRSA screening and decolonisation targets were achieved

for April.

Complaints turnaround has fallen to 52%, the lowest

performance since November 2017.


2 2

11

Trust Scorecard – Quality and Governance Committee



12

Trust Scorecard – Quality and Governance Committee



Performance Trends


Improving

(3 months

consecutive

improvement)

Deteriorating

(red

indicators

worsening)

(3 months

consecutive

deterioration)

Deteriorating

(green

indicators

worsening)

(3 months

consecutive

deterioration)

• Harm Free Care continues to deliver against target and has shown three months of improvement.

• Whilst continuing to achieve target the C-UTI (Catheter related urinary tract infection) indicator has deteriorated

in performance for three months.

• The number of registered complaints has risen for the last three months.

• Alongside this complaints turnaround times have deteriorated with performance in March of 52%. This is the

lowest performance since November and relates predominantly to consistently high numbers of complaints and

capacity issues.


A report for all wards is submitted to the Department of Health via Unify on a monthly basis as per National Quality Board guidance. This information is also

published on the Trust’s Internet Site.

14

Ward Staffing Levels

In April the Registered Midwives/Nurses (RN) fill rate in inpatient areas remain compliant on day and night shift (target of 95%). A total of 16/46 RN Day and

7/46 RN Night areas were non-compliant in April 18 which remains a significant improvement from the previous winter months (24/46 Jan, 32/46 Dec RN

Day). UHCW had inpatient escalation areas open which impacted the ability to fill all RN shifts, however twice daily safe staffing meetings continue to ensure

that the right staff are in the right place at the right time. These are being introduced onto the night shift by the end of Quarter 1. Safe-care training continues

to ensure that e-rosters are managed live and that staff moves and changes are reflected real time on the roster.

RN - Registered Midwives/Nurse CS - Care Staff

1

1 0

Finance and Workforce Summary This section includes the Finance and Performance scorecard which contains all relevant indicators that are encompassed within the overarching

Trust scorecard, together with additional pertinent KPIs such as theatre efficiency and utilisation, which underpin the headline indicators. This

report highlights areas of compliance and underperformance.

The Value for Money indicators have been updated and brought in-line with the "Single oversight framework". The reported position is against

the Trust's plan for 2018/19. Further details on revised KPIs have been provided in the Integrated Finance Report that is submitted to Finance

and Performance Committee.


Indicators

achieved

Indicators

in

exception

Indicators

in watching

status

Total

indicators

Excellence in Patient

care and experience 15 19 2 36

Delivery of value for

money 2 1 0 3

Employer of choice 1 1 5 7

Leading research

based health care

organisation

0 1 1 2

Leading training and

education centre 1 0 0 1


The Trust’s performance against the 4 hour standard for April

improved to 84.8% (79.2% March).

The RTT incomplete position remains below the 92% national

target and has deteriorated by 0.1% to 82.3% for March. There

have been 30 breaches of the RTT 52 week wait standard which is

an increase of two from last month.

In March the Trust achieved seven national cancer standards. The

Two Week Wait breast symptomatic target for March was not

achieved due to capacity issues. The Trust has achieved all eight

standards for the overall year 2017/18 despite challenges in

delivery of the 62 day time to first treatment target.

At month 1, the Trust is reporting a £5.8m deficit, in line with plan.

The forecast position for the year is a £9.7m deficit, also in line with

plan.

Measures relating to financial ratings are currently unavailable for

April due to minimised external reporting requirements.

19 2 15 Excellence in Patient Care and Experience

1 1 Leading Research Based Health Care Organisation

1 Leading Training and Education Centre

Delivery of Value for Money

1 5 Employer of Choice

15


2

1

16

Trust Scorecard – Finance and Performance Committee



17

Trust Scorecard – Finance and Performance Committee



Updates on Control Total

Movements within the control total include over delivery on contract income

(0.1% favourable to plan); other income (3.0% adverse to plan; and pay and

non-pay overspends (3.8% adverse to plan). The Trust is reporting a forecast

deficit of £9.7m as at month 1.

Trust Position Post Technical Adjustment (control total)

Updates on Net Surplus/(Deficit) position (before DH control

adjustment)

The forecast net deficit position is £9.3m, in line with plan.

Net Surplus / (Deficit) position

At month 1, the Trust is reporting a £5.8m deficit, in line with plan. The forecast position for the year is a £9.7m deficit, also in line with

plan.

18

Finance | Headlines April 2018

AGENCY SPEND

£2.2m

£2.2m actual spend on agency

spend against NHSI profile of

£1.8m

Capital

Cost Improvement

Programme delivery is

£14.5m against a target of

£37.5m.

The Trust has a

Provider Sustainability

Fund target of £15.5m.

PSF 39%

Month 1 reports £0.8m PSF

income in line with plan.

Annual Plan £42.8m.

Forecast £42.8m

Capital Expenditure of

£0.5m at month 1.

CONTRACT & ACTIVITY

INCOME

1.9 %

under-

performa

nce

Over-performance on income is

largely driven by Emergency and

Outpatient activity.

Contract income from

activities reports a favourable

variance of £0.8m against a

plan of £42.8m.

(£9,693) (£9,693) 805

(2,994)

(23,401) 22,089

3,497 4

(£40,000)

(£35,000)

(£30,000)

(£25,000)

(£20,000)

(£15,000)

(£10,000)

(£5,000)

£0

Trust Plan ContractIncome

Performance

Other Income Expenditure Additionalsavingsrequired

Reserves NonOperating

Expenditure

Trust Outturn

£'0

00

Trust Plan (£9.285)

(£5.9) (£6.1)

(£9.6) (£9.9)

(£11.8)

(£16.9)

(£14.9) (£15.1) (£15.7)

(£13.7) (£15.7)

(£9.285)

(£18.0)

(£16.0)

(£14.0)

(£12.0)

(£10.0)

(£8.0)

(£6.0)

(£4.0)

(£2.0)

£0.0

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

Mill

ion

s

Trust Plan Cumulative Budget Cumulative Actual Cumulative Forecast

over-performance

year-to-date

Year-to-date delivery of £0.2m

against a target of £1.3m.

Trust is forecasting £22.8m spend

on against the £22.8m NHSI

agency ceiling..


19

SOCI – Statement of Comprehensive Income



The Trust reports a forecast £9.7m

control total deficit at month 1, in line

with the planned control total deficit.

The year-to-date position is a £5.8m control

total deficit, in line with plan.

The forecast position is a £9.7 control total

deficit, in line with plan.

Overall Group expenditure forecasts £23.4m

adverse to budget; largely driven under-

delivery of CIP, and cost pressures, some of

which is held in reserves.

The Trust’s efficiency programme continues

to be measured against the revised target of

£37.5m.

Plan

£'000

Budget

(£'000)

Forecast

(£'000) £'000 %

Budget

(£'000)

Actual

(£'000) £'000 %

Contract income from activities 547,363 547,929 548,734 805 (0.1%) 42,754 43,559 805 (1.9%)

Other income from activities 8,820 26,410 25,712 (698) (2.6%) 1,669 1,731 62 (3.7%)

Other Operating Income 93,278 75,998 73,702 (2,296) 3.0% 5,918 5,658 (260) (4.4%)

Total Income 649,461 650,337 648,148 (2,189) (0.3%) 50,341 50,948 607 (1.2%)

Pay costs (382,659) (360,502) (387,154) (26,652) (7.4%) (30,988) (31,935) (947) (3.1%)

Other operating expenses (220,775) (231,063) (227,812) 3,251 (1.4%) (19,209) (19,061) 148 0.8%

CIP gap to target delivery 23,008 23,008

Additional savings required (919) (919)

Reserves 0 (12,745) (9,248) 3,497 27.4% (1,411) (1,276) 135 9.6%

Total Operating Expenses (603,434) (604,310) (602,125) 2,185 0.4% (51,608) (52,272) (664) 1.3%

EBITDA 46,027 46,027 46,023 (4) (0.0%) (1,267) (1,324) (57) 4.5%

Depreciation (24,986) (24,986) (24,986) 0 (2,082) (2,082) 0

Interest Receivable 60 60 60 0 5 14 9

Interest Charges (1,189) (1,189) (1,189) 0 (82) (82) 0

Financing Costs (28,166) (28,166) (28,166) 0 (2,350) (2,306) 44

Unwinding Discount (10) (10) (10) 0 (10) (10) 0

PDC Dividend (1,021) (1,021) (1,021) 0 (85) (85) 0

Profit / loss on asset disposals 0 0 4 4 0 4 4

Net Surplus/(Deficit) (9,285) (9,285) (9,285) 0 0.0% (5,871) (5,871) 0 0.0%

EBITDA % 7.1% 7.1% 7.1% (2.5%) (2.6%)

Net Surplus % (1.4%) (1.4%) (1.4%) (11.7%) (11.5%)

Technical Adjustments:

Donated/Government grant assets

adjustment(408) (408) (408) 0 0.0% 23 23 0 0.0%

Trust Position Post Technical

Adjustment (Control total)(9,693) (9,693) (9,693) 0 0.0% (5,848) (5,848) 0 0.0%

1 month ended

30 April 2018

Year to date Variance to planFull Year Variance to plan

19

20

Efficiency Delivery Programme – CIP



Overview The Trust has an annual CIP target of £37.5m

This includes a non recurrent target of £8m

As at April reporting the trust has identified £16.2m of schemes

Forecast delivery is £14.5m at month 1

Quality Impact Assessment

Each scheme, at QIA requires clinical approval from individual

Group‘s Clinical Director (CD) and Modern Matron (MM); and the

Trust‘s Chief Nursing Officer (CNO) and Chief Medical Officer

(CMO). As at month 1, of the documented 121 schemes, 9 have

been fully reviewed by the CMO/CNO

At Operational and Finance sign-off stage, schemes require Chief

Operating Officer (DCOO/COO) and Associate Directors of Finance

(ADoF – Ops/CC). At month 1, all schemes are awaiting full sign off.

Z:\2018-19 CIP\Monthly reporting\Compliance Reports\M1 - April

2018 m1 v1.0.xls

16.2 14.5

37.5

1.8

23.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Identified CIPs Slippage againstIdentified Savings

Forecast CIPdelivery

Forecast CIPsrequired

Target CIPdelivery

Efficiency Savings Slippage

20

Workforce Information | Headlines April 2018

* Headcount - includes ROE (ISS) staff WTE - excludes ROE (ISS) and bank only staff

21

This report provides a summary overview of workforce data. A detailed analysis of this data is provided within

the monthly workforce report presented to the Finance and Performance Committee.

Sickness 4.13%

Training 92.30%

(Substantive

Employees)

HEADCOUNT

8,776 (7,260.90wte)*

Turnover

9.87%

Vacancy

Rate

13.25%

Agency Spend

£2,233,268

90%Target

95%

10%

4%

10%

90%

Medical

88.55%

Non-Medical

85.78%




22

Headcount | WTE Staff Group in Post Monthly Variation

Overall between March 2018 and April 2018

there has been an increase in staff in post of

14.80 WTE.

The staff groups with the biggest increase in

staff numbers are:

• Administration & Clerical (9.32 WTE)

• Additional Clinical Services (4.47 WTE)

• Medical and Dental (2.14 WTE)

The majority decreases of the staff groups in

post are :

• Additional Prof Scientific &Technical (-1.44

WTE)

• Healthcare Scientist (-1.09 WTE)

• Allied Health Professionals (-0.63 WTE)

NB: Staff in Post data reflects new starters,

monthly amendments to the increase and

decrease hours and leavers. Therefore,

whilst a number of staff may have been

recruited in month the overall figure may go

down due to the changes in hours and

leavers.

Total Trust Headcount including ROE (ISS) staff is

8776 a decrease of 20 since March. Bank

headcount has decreased by 27.

Overall, WTE has increased by 14.8 WTE (which

will include existing staff increasing/decreasing

hours)

HEADCOUNT Feb-18 Mar-18 Apr-18

Substantive/Fixed Term

8173 8203 8185

ISS 600 593 591

Totals 8773 8796 8776 Bank only 1804 1783 1756

WTE Feb-18 Mar-18 Apr-18

excluding ROE (ISS) & Bank Workers

7200.29 7246.10 7260.90

Staff Group

Staff in Post

WTE 31st

Mar-18

Staff in Post

WTE 30th

Apr - 18

Variance

(WTE)

%

Variance

Add Prof

Scientific

&Technic

259.23 257.79 -1.44 -0.56%

Additional

Clinical Services1707.19 1711.66 4.47 0.26%

Administrative &

Clerical1245.16 1254.48 9.32 0.75%

Allied Health

Professionals438.75 438.12 -0.63 -0.14%

Estates &

Ancillary2.00 2.00 0.00 0.00%

Healthcare

Scientists339.75 338.66 -1.09 -0.32%

Medical & Dental 983.83 985.97 2.14 0.22%

Nursing &

Midwifery

Registered

2238.84 2240.87 2.03 0.09%

Students 31.35 31.35 0.00 0.00%

Totals 7246.10 7260.90 14.80 0.20%

ISS 457.10 454.60 -2.50 -0.55%



23

Vacancy | by Staff Group

The Trust overall turnover rate (12 months rolling)

has decreased to 9.87% from 10.02%.

The largest numbers of leavers (Headcount) are

within Medical and Dental (51), Nursing and

Midwifery (14), Additional Clinical Services (11) and

Administrative & Clerical (8) staff groups.

A “how to” guide has been developed and is currently

being piloted during April in the Clinical Diagnostics

Group. The guide provides information on the correct

process for leavers and promotes the importance of

consistently asking staff to complete a leavers

questionnaire to enable us to gather meaningful data

for review and action. This guide will ultimately form

part of a managers toolkit.

Turnover | by Staff Group (inc Bank)

The overall vacancy rate is 13.25%. The largest proportion of vacancies are within the Students

(22.48% = 9.09 WTE), Healthcare Scientists (18.24% = 75.57 WTE), Nursing & Midwifery

(18.15% = 496.93 WTE), and the Medical & Dental (13.18% = 149.69 WTE) staff groups.

The forecast new starters for Nursing next month is 19 (Source – Resourcing Department)

It is important to note that Medical and Dental

leavers will be significantly higher within peak

doctor rotation months which include August,

September, December, February, March and April.



24

Pay Costs | Provided by Finance

• The overall pay bill for April 2018 decreased

by £117,608 from March.

• Temporary costs equate to 13.98% of the

Trusts total pay bill (£31,941,978), this is a

decrease of 0.5% from March 2018 which was

14.03%.

• Agency costs against total costs increased

from 6.47% to 6.99% which is an overall

increase in total agency spend by £157,637,

against March 2018.

• Overall bank spend has decreased by

£239,661.

NHSI Rate Caps | Percentage of Shifts Booked Over Cap

• The % of medical shifts above agency cap

rates has remained consistently 100%

throughout the last three months.

• Nursing shifts over cap rates have increased

slightly to between 67.40% – 71.85%.

• A&C workers over cap rates have also

increased to between 42.55% - 61.54%.

• AHP (57.14%- 88.88%) and Healthcare

Scientists (51.85% -62.16%) staff groups have

also continued to fluctuate significantly during

April 2018.

Overall, there has been a significant increase in

agency shifts in month for nursing and medics

which does correlate with service pressures.



25

Absence| by Group

The overall Trust sickness absence rate in April

has increased by 0.4% to 4.13% and is still above

the current Trust 4% target.

In relation to overall time lost due to absence, the

highest reason for absence was Gastrointestinal

problems (16.81%) and not Cold, Cough, Flu –

Influenza which was the highest reason in March.

There are three specialty groups which met the 4%

target during March and April. Ten groups have not

achieved the target in March and April.

Absence | by Month/Year Absence | by Staff Group

The sickness rate for April and is higher on

average in comparison to the same period in

2016 and 2017.

The absence

management team

continue work with

managers to regularly

review all cases with

a focus on high

percentage areas.

There has been a

drive to ensure robust

reporting and

management of

Medical & Dental

sickness which has

had an impact on the

increase in sickness

absence.

Specialty GroupMar % Abs

Rate (WTE)

Apr % Abs

Rate (WTE)

Cardiac & Respiratory (SG01) 3.11% 3.09%

Care of the Elderly (SG13) 6.42% 5.82%

Clinical Diagnostics (SG14) 4.60% 4.29%

Clinical Support Services (SG16) 4.24% 4.19%

Core Services (SG21) 3.36% 2.79%

Emergency Department and Acute Medicine(SG04) 4.25% 4.20%

Neurosciences (SG05) 4.05% 5.10%

Oncology, Haematology & Renal (SG06) 2.25% 2.36%

Specialist Medicine & Ophthalmology(SG10) 4.79% 4.46%

St Cross and Trauma & Orthopaedics (SG08) 4.05% 4.36%

Surgery (SG07) 4.03% 4.65%

Theatres and Anaesthetics (SG11) 4.73% 4.81%

Women & Childrens (SG09) 4.66% 5.24%

Trust Totals 4.09% 4.13%



26

Mandatory Training | by Group

Mandatory Training compliance for substantive staff is currently 92.30%, against a target of 95%, it has remained almost static over the past 3 months. Total compliance, which includes

bank only staff has increased this month by 1.44% to 85.89%.

Clinical Support and Theatres & Anaesthetics remain the only groups to consistently maintain their compliance rates over 95% during the last three months. Care of the Elderly has increased

by 1.98 to bring them over the 95% compliance. However all areas with the exception of TSS are rated amber, providing assurance that majority of our substantive staff are completing

training and are able to work safely when providing care for our patients. We have a specific action plan in place to facilitate improvements in bank staff mandatory training compliance which

is monitored through our Training, Education & Learning Committee.

We continue to focus on making improvements to topics under 90% compliant with targeted actions monitored via our Training, Education & Learning Committee (previously TERC) to ensure

we are providing sufficient capacity and a range of opportunities for staff to undertake their mandatory training. Continued support and challenge is provided to Groups through monthly

accountability meetings to maintain focus on increasing/maintaining their compliance rates.

Appraisals | by Group

Medical appraisal has increased to 88.55% and is aligned to

revalidation dates. We have an agreed process for validating the

information each month between RMS and ESR. The CMO is

contacting individuals who remain non-compliant.

We keep a continued focus on those areas rated red and provide

both support and challenge through the monthly accountability

meetings.

Group Feb-18 Mar-18 Apr-18

Cardiac & Respiratory (SG01) 76.40% 78.35% 83.37%

Care of the Elderly (SG13) 84.04% 83.87% 91.49%

Clinical Diagnostics (SG14) 90.76% 89.52% 88.88%

Clinical Support Services (SG16) 94.38% 95.06% 88.03%

Core Services (SG21) 83.57% 83.33% 82.91%

Emergency Department and Acute Medicine (SG04) 80.73% 79.41% 84.01%

Neurosciences (SG05) 68.81% 70.59% 100.00%

Oncology, Haematology & Renal (SG06) 94.27% 91.65% 72.46%

Specialist Medicine & Ophthalmology (SG10) 84.75% 75.91% 85.20%

St Cross and Trauma & Orthopaedics (SG08) 91.86% 91.72% 70.40%

Surgery (SG07) 91.09% 91.59% 87.21%

Theatres and Anaesthetics (SG11) 94.47% 95.02% 87.30%

Women & Childrens (SG09) 91.68% 90.03% 91.49%

Trust Total 88.39% 87.82% 85.78%

Appraisals -Non Medical Appraisals - Medical

Group Feb-18 Mar-18 Apr-18

Cardiac & Respiratory (SG01) 85.71% 83.33% 87.23%

Care of the Elderly (SG13) 90.00% 100.00% 100.00%

Clinical Diagnostics (SG14) 90.38% 90.38% 88.89%

Clinical Support Services (SG16) N/A N/A N/A

Core Services (SG21) 100.00% 100.00% 88.89%

Emergency Department and Acute Medicine (SG04) 90.32% 90.00% 85.88%

Neurosciences (SG05) 84.21% 97.37% 90.00%

Oncology, Haematology & Renal (SG06) 78.85% 85.19% 89.29%

Specialist Medicine & Ophthalmology (SG10) 80.65% 85.48% 91.18%

St Cross and Trauma & Orthopaedics (SG08) 84.62% 93.88% 96.08%

Surgery (SG07) 82.65% 90.82% 91.26%

Theatres and Anaesthetics (SG11) 87.80% 86.75% 86.52%

Women & Childrens (SG09) 72.92% 87.04% 86.79%

Trust Total 83.14% 87.59% 88.55%

Specialty Group Feb-18 Mar-18 Apr-18

Cardiac & Respiratory (SG01) Total 86.48% 87.15% 90.68%

Care of the Elderly (SG13) Total 91.03% 93.47% 95.45%

Clinical Diagnostics (SG14) Total 93.05% 92.86% 92.30%

Clinical Support Services (SG16) Total 96.31% 96.03% 96.81%

Core Services (SG21) Total 93.04% 93.19% 94.24%

Emergency Department and Acute Medicine (SG04) Total 90.63% 89.13% 90.32%

Neurosciences (SG05) Total 87.14% 86.80% 87.44%

Oncology, Haematology & Renal (SG06) Total 92.35% 92.29% 92.45%

Specialist Medicine & Ophthalmology (SG10) Total 92.64% 92.81% 93.03%

St Cross and Trauma & Orthopaedics (SG08) Total 91.73% 91.68% 91.94%

Surgery (SG07) Total 91.82% 90.91% 91.36%

Temporary Staffing Division Total 46.67% 46.04% 46.67%

Theatres and Anaesthetics (SG11) Total 95.39% 95.04% 95.61%

Women & Childrens (SG09) Total 92.93% 93.09% 93.13%

Grand Totals 84.55% 84.45% 85.89%

Substantive Staff Only Totals 91.95% 92.28% 92.30%

Non-medical appraisal compliance has

decreased from last month and currently stands

at 85.78%, against a target of 90%. Our 2018

appraisal cycle (6 months) commenced on 1

April and we are encouraging alignment of all

non-medical appraisals to this period.


Title Infection Prevention and Control Quarter 4 report

Author Kate Prevc Dr Chris Hastie IPC data Analyst


Nina Fraser, Chief Nursing Officer

Date 31 May 2018

1. Purpose The purpose of this report is to brief the Trust Board on the key infection control metrics and initiatives for quarter 4. Board members are asked to note the contents of the report for assurance purposes. 2. Background and Links to Previous Papers This paper is the quarter four report that feeds into the Trust’s Infection Prevention and Control Annual Report. Progress is monitored against the Infection Prevention and Control annual plan 2017/18. 3. Executive Summary UHCW continues to perform well against Department of Health (DH) targets. Compared to a basket of 33 large teaching NHS Trusts the combined unweighted rank of UHCW for outbreaks of MRSA, MSSA and C. diff is second, reflecting the Trust’s excellent performance in infection prevention and control across the board. This represents an improvement on last year when we achieved third.

Clostridium difficile (C. diff)

UHCW reported 34 cases of C. diff against a DH set aim of having less than 42.

DH Target Internal Target Total cases Trust apportioned

42

37

34

The graph below (Graph 1) shows the improvement in Trust apportioned cases of C. diff since 2009-10. This represents a significant improvement locally and places UHCW amongst the best performing Trusts of its kind. Nationally the rate for Trust apportioned cases of C. diff per 100,000 bed days is 13.63. UHCW had a rate of 8.8. Against a basket of 33 large teaching NHS Trusts UHCW’s rate ranked fourth.

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Graph 1

Graph 2 below illustrates the year’s cumulative figures for hospital acquisition of C. diff, compared to our target ceiling. Acquisition is defined by DH as occurring more than 48 hours after admission. Graph 2

Yearly moving average

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Meticillin Resistant Staphylococcus aureus (MRSA)

UHCW declared one case of MRSA bacteraemia for 2017-18. Nationally the average rate per 100,000 bed days is 0.84. The rate at UHCW is 0.26. The graph below ( Graph 3) shows the cumulative number of MRSA bacteraemia, both assigned to the Trust and not, within the 2017-18 financial year.

Graph 3

Methicillin Sensitive Staphylococcus aureus (MSSA)

The Trust continues to perform well when compared to other Trusts. The national average rate of Trust apportioned MSSA bacteraemia per 100 000 bed days is 9.05. UHCW rate is 8.29. Actual numbers of Trust apportioned MSSA bacteraemia can be seen in graph 4.

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Graph 4

Influenza and Norovirus

During 2017-18 national levels of both influenza and Norovirus were higher than the five year average that they are measured against. UHCW reported high levels of swabbing and positive detection of respiratory virus. Despite this, there was very little disruption to operational work and only a small number of incidents where an organism appears to have spread. This reflects positively on the infection prevention and control practices of staff throughout the Trust.

E Coli During the 2017/18 financial year UHCW had 107 incidences of Trust apportioned E. coli bacteraemia. This equates to a rate of 27.7 per 100,000 bed days (see graph 5). Whilst this is slightly higher than the average rate across teaching trusts (26.5), the difference is not statistically significant. UHCW are part of the national improvement collaborative focusing on reducing on Urinary Tract Infections (UTI) led by NHSI. We continue to work with the regional group and meet regularly.

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Graph 5

Cleaning ISS and the Infection Prevention and Control ( IPC) team have appointed a Matron for ISS who will be professionally managed by the Lead Nurse for IPC .This is an innovative appointment and thought to be the first in this country. Veronica Thompson- Joffe started in post in May 2018. It is anticipated that her remit will be to support the ISS staff with education and provide an evidenced based approach to cleaning. The post will work in conjunction with the Trust IPC team, and provide a point of contact for Matrons and ward staff that will further facilitate collaborative working between ISS and the Trust. Sepsis

During quarter 4, screening compliance for sepsis in the emergency department (ED)

remained at 90% (graph 6) and in-patients increased to 94%.(Graph 7) Treatment time to

IV antibiotics within the crucial first hour from diagnosis of red flag sepsis also

consistently improved to 51% in ED (Graph 8) and 79% for inpatients (Graph 9).

Therefore this has proven to be the most successful quarter so far.

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Graph 6 Shows the improvement in screening compliance within the emergency department.

Graph 7 Shows the improvement in screening within acute inpatients.

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Graph 8 shows compliance (%) with antibiotics administered – Emergency department

Graph 9 Compliance (%) with antibiotics administered - Inpatients.

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The sepsis team have continued to provide training to all staff within the trust including

several ‘what is sepsis?’ sessions, trust induction talks, preceptorship training and

bespoke sessions for individual areas such as AMU, General Critical Care and FY1 Drs.

The team have also trained 17 more sepsis heroes to cascade train their peers in the

recognition and treatment of sepsis.

In the public arena, the team have continued to raise awareness by appearing on BBC

Coventry and Warwickshire radio station alongside a relative of a patient who sadly died

from sepsis at UHCW who, following attendance at our support group, has been inspired

to raise public awareness of sepsis. This coincided with the launch of the ‘#sepsisandme’

campaign in conjunction with Coventry City Council and Public Health, where talking

about sepsis was encouraged through the use of social media with ‘sepsis selfies’.

Decontamination An external report on the endoscopy decontamination service was commissioned from authorising engineer experts from Addenbrooke’s. The report did not identify any safety concerns and is due to be presented to Chief Officers imminently. The department has had two successful accreditation audits and is fully compliant with the highest quality standards. The TSSD team are part of the UHCWi Theatres value stream supported by the KPO. The Theatres teams had been requesting high numbers of instruments with a very short turnaround time. These are cleaned overnight but significantly impact the rest of the service. They are known as ‘fast tracking’ requests and they should only be used in exceptional or emergency scenarios. However, fast tracking had become business as usual for a number of reasons. The improvement work involved both theatres and TSSD staff and was hugely successful. Fast tracking numbers particularly within Urology has reduced from 62% to 47% see Table 1.

Table 1 below shows the decrease in fast tracking requests

Areas of Risk

None noted

4. Link to Trust Objectives and Corporate/Board Assurance Framework Risks Infection Prevention and Control provide assurance to the board as detailed in the infection prevention and Control Assurance framework.

Monthly Totals Jan

2017 Feb

2017 Mar 2017

Apr 2018

Sets Processed 12320 11830 12615 11983

Fastrack Req 7572 7391 6772 5727

% Fastrack of Total Production 61% 62% 53% 47%

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5. Governance Infection Prevention and Control governance framework is mandated within the DH Health Act (2008 revised 2014) UHCW is compliant with these requirements.

6. Responsibility The Chief Nursing Officer (CNO) is also the .Director of Infection Prevention and Control (DIPC) and has a nominated deputy, the Director of Nursing /Deputy Chief Nursing Officer is the deputy DIPC. 8. Recommendations The Board are asked to note the contents of the report for assurance purposes. Kate Prevc. Lead Nurse Infection Prevention and Control, Sepsis and Decontamination. Dr Chris Hastie. Data Analyst Infection Prevention and Control May 2018


Title Quarterly Mortality Performance Report Q4 – May 2018

Author Sharron Oulds- Head of Clinical Effectiveness


Meghana Pandit, Chief Medical and Quality Officer / Deputy CEO

Date 31 May 2018

1. Purpose The purpose of this paper is to provide a quarterly overview of Trust-level mortality data for the time period January 2018 - March 2018, and performance for the time period January 2017 to December 2017 (latest available Dr Foster Intelligence data), providing assurance that any highlighted concerns are investigated thoroughly and appropriate action is taken.

2. Background and Links to Previous Papers Investigating and reporting mortality data enables the Trust to identify ways to improve patient safety and patient outcomes.

3. Narrative

Mortality Review

The completion rate for primary mortality reviews between January 2018- March 2018 is 79.7%.

Between January 2018- March 2018 there has been 0 confirmed NCEPOD E graded death.

87.33% of completed primary reviews between January 2018- March 2018 received an NCEPOD grade A highlighting good standards of patient care. All primary reviews graded B-E have a further secondary mortality review; these are discussed at specialty mortality and patient safety meetings to share the learning and improve patient care. There have been 63 identified opportunities graded B-E for learning from deaths between January 2018- March 2018. During January 2018 - March 2018 there has been 1 death of patients with Learning Disabilities and 4 Deaths of patients with identified Mental Illness during the primary review process. Mortality indicators: HSMR

The Trust HSMR value for the latest available 12 months of data (January 2017- December 2017) is 102.5. This is within the ‘expected’ mortality range.

The Hospital Standardised Mortality Ratio (HSMR) compares all inpatient deaths to expected deaths. HSMR above 100 indicates more deaths than expected, and a HSMR below 100 indicates fewer deaths than expected. The Mortality Review Committee continues to proactively undertake investigations into diagnosis groups with a higher than expected

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number of deaths to identify potential improvements in care. Ongoing actions to reduce HSMR include the development and monitoring of care bundles. Mortality Alerts – Dr Foster Intelligence

Between January 2017- December 2017 the Trust received 214 mortality alerts, 42.% of which were positive alerts.

Each month, diagnosis and procedure groups which have generated negative alerts through Dr Foster Intelligence (significantly more deaths than expected) are discussed at the Mortality Review Committee and appropriate action is agreed to address the alerts. Mortality Indicators: SHMI

The SHMI value (October 2016- September 2017) is 1.093 within the expected mortality range.

The Summary Hospital-Level Mortality Indicator (SHMI) differs from HSMR as it not only includes all inpatient deaths, but also deaths which occur 30 days after discharge. It uses a benchmark of 1 instead of 100. SHMI above 1 indicates more deaths than expected, and a SHMI below 1 indicates fewer deaths than expected. Learning from Deaths Investigation into diagnosis groups as part of the mortality review process has identified areas for improvement in the recording and coding of comorbidities and complications. The clinical coding team is working with specialties to improve the recording of comorbidities for patients including the use of the discharge summary and forms within healthcare records. Improvement in accurate recording of these factors will positively impact on the quality of mortality data. The Emergency Department has improved communication within the team and sharing of learning with the use of newsletters and incorporating a clinical lesson of the week into daily ED handover, safety huddles and junior Doctor teaching. In March 2018 the weekly safety message highlighted cardiac disease as the main cause of maternal death and the importance of patient monitoring during the intrapartum period. 4. Areas of Risk

There are no risks on the risk register.

5. Governance Mortality assurance and reporting is monitored by the Mortality Review Committee chaired by the Deputy Chief Medical Officer (DCMO) and attended by the Chief Medical Officer. The Committee’s actions are monitored through Patient Safety and Clinical Effectiveness Committee, which provides assurance to Quality Governance Committee. Trust Board receives a report on mortality performance every 3 months to meet national expectations. 6. Responsibility The Mortality Review Committee is responsible for assuring the Trust Board that mortality is proactively monitored, reviewed, reported and where necessary, investigated. The

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committee ensures any lessons and actions are implemented and disseminated to improve outcomes. 7. Recommendations [A] The Board is invited to Note the Trust’s mortality performance for the given time periods Author: Sharron Oulds- Head of Clinical Effectiveness 8/5/2018

- 1 -

University Hospitals Coventry and Warwickshire NHS Trust Quarterly Mortality Performance Report Q4– January 2018- March 2018

1.0 Background to Report

UHCW is committed to accurately monitoring and understanding its mortality outcomes. Reviewing patient outcomes such as mortality is important to Trusts as it helps provide assurance and evidence that the quality of care is of a high standard, and to make sure any issues are effectively addressed to improve patient care. Reviewing mortality helps fulfil 2 of the 5 domains set out in the NHS Outcomes Framework:

Preventing people from dying prematurely

Treating and caring for people in a safe environment and protecting them from avoidable harm

The Trust uses mortality indicators such as the Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital Level Mortality Indicator (SHMI) to compare mortality data nationally. This helps the Trust to identify areas for potential improvement. Although these are not a measure of poor care in hospitals, they do provide a ‘warning’ of potential problems and help identify areas for investigation. In addition to this, the Trust has an in-depth mortality review process where each death of an inpatient aged 18 and above is subjected to an initial review of their care and graded according to the standard of care they received. Deaths in patients under 18 years old are reviewed using a separate mortality review process; this incorporates external processes for example, Child Death Overview Panel (CDOP). Further reviews are conducted by an appropriate consultant or team if potential problems in care have been identified. This is to encourage learning from patient outcomes. The Trust mortality review process works to achieve the strategic objective for delivering excellent patient care and experience and the Trust objectives for meeting national performance objectives, for example

‘Achieving a rating of “good” at Trust level in the next CQC inspection’ through sharing and identifying learning from mortality reviews and analysis of mortality indicators

‘Continue to actively participate in system wide working within Coventry and Warwickshire to ensure effective population health’ through collaborative working with the Clinical Commissioning Groups and support of the LeDeR programme for Learning Disability deaths.

All mortality processes are overseen by the Trust’s Mortality Review Committee, chaired by a Deputy Chief Medical Officer and attended by the Chief Medical Officer. The Mortality Review Committee reports into the Trust’s Patient Safety and Clinical Effectiveness Committee each month.

- 2 -

This report provides information to the Trust Board on the performance of UHCW NHS Trust during Q4 January 2018- March 2018, meeting national recommendations.

2.0 Trustwide Mortality Review – Performance for January 2018 – March 2018 Each inpatient aged 18 or above is subjected to a structured primary mortality review by the specialty involved in their care at the time of their death. All patients subjected to a review have their care graded by a Consultant, using the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) Classification of Care grading A-E. During the time period 1 January 2018 – 31 March 2018 there have been 666 inpatient deaths (including ED, and aged under 18) with 661 requested primary mortality reviews for inpatients (and those who died within the Emergency Department), 77% of which have been completed (514/661). Of the 147 reviews still to be completed 10% of these are still within the 30 day time scale for completion (16 reviews as at 8/5/2018). When reviews which are not yet overdue are removed from the analysis, the completion rate for primary mortality reviews is 79.7% (514/645). From April 2017 to March 2018 (YTD) 90.76% of Primary reviews have been completed.

FY and Qtr Completed Save Draft Grand Total

2017/2018 90.76% 9.24% 100.00%

Quarter 1 98.98% 1.02% 100.00%

Quarter 2 96.83% 3.17% 100.00%

Quarter 3 93.12% 6.88% 100.00%

Quarter 4 76.41% 23.59% 100.00% Primary review completion of Inpatient deaths as at 8/5/2018 (excluding ED deaths)

To meet national recommendations, the Trust has moved to a peer review model for assessing primary and secondary reviews. This may impact on the completion rate going forward. Clinicians continue to be supported by the Clinical Effectiveness Team to promote the Trust Wide mortality review process with specialty focused training and frequent updates on the status of any outstanding Primary Mortality Reviews.

The figure below shows the NCEPOD grade of all completed primary reviews between 1 January 2018 and 31 March 2018. It highlights that 87.33% (379/434) of inpatient reviews were graded NCEPOD A for ‘good care’.

- 3 -

Figure 1: NCEPOD Classification Rate (All data extracted 8 May 2018)

2.2 All patients who are graded NCEPOD B-D during primary review, have a

further secondary review completed as the grade highlights that there were aspects of care which could have been improved. The purpose of the secondary review is to identify areas for learning and actions to help improve patient care and avoid similar problems occurring. This is a multi-disciplinary approach and these cases are discussed in specialty meetings to ensure that learning is shared. Theme analyses are conducted from secondary reviews and shared throughout the Trust to promote improvements in patient care. For all deaths between 1 January 2018 and 31 March 2018 which have had a completed primary mortality review, there were 63 requested secondary reviews (cases graded NCEPOD B-D), suggesting an equal number of opportunities for learning. Currently 60.32% of these secondary reviews have been completed (38). Of the incomplete secondary mortality reviews (25), 100% are still within the 2 month allocation for completion (as at 8/5/2018). Of the completed secondary reviews, 29% (11 reviews) have been re-graded to NCEPOD A (good care) following discussions with their specialty’s team members. The Trust is committed to identifying areas for improvement in an open and transparent manner.

2.3 Deaths which are graded NCEPOD E (less than satisfactory care) have an investigation into their death reviewing all aspects of care. This is completed by the Mortality Lead for the specialty involved and reported to the Mortality Review Committee. The Committee then discusses the case and agrees appropriate action including investigation via the serious incident framework. Trend analyses for NCEPOD E deaths are also conducted in the Trust to enable identification for improvement areas and to disseminate learning. For all deaths between 1 January 2018 and 31 March 2018 there has been no case graded NCEPOD E at primary and secondary mortality review. All deaths graded E were investigated via the Serious Incident Framework. The total number of deaths investigated via the Serious Incident Framework for Q4 January 2018- March 2018 is 5.

2.4 The deaths of patients with a learning disability are monitored within the Trust in line with national recommendations and reviewed as part of the Trust wide

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mortality review process. Patients with a learning disability are identified by the learning disability team using an alert on Clinical Results Reporting System (CRRS). Data on the number of patients with a learning disability who have died is received by the Mortality Review Facilitator from Performance and Programme Management Office (PPMO).

The number of deaths of patients with a learning disability between January 2018 - March 2018 is 1. During the financial year April 2017- March 2018 there were 7 deaths with reported learning disabilities. This information along with the learning identified from the mortality review process is reported through the Trust Mortality Review Committee. The national Learning Disabilities Mortality Review Programme LeDeR programme has launched in the West Midlands. The Trust is committed to supporting the review programme as part of the current mortality review process. All patients with learning disabilities who have died at UHCW during Q4 have been referred to the LeDeR programme.

2.5 In hospital deaths of patients with severe mental illness are monitored as part of the Trust’s current mortality process for all in hospital deaths over the age of 18. During 1 January 2018 and 31 March 2018 there were 4 in-patients that died with an identified mental illness on the Primary Mortality Review form.

3.0 Learning from Deaths

The mortality review process allows specialties to identify areas of learning and improve care for patients. Learning themes identified from the Trust Wide mortality review process are transformed into actions to improve patient care, some through the use of local action plans and fed back through the mortality review committee. Learning is also shared across the wider organisation with weekly safety messages, daily safety huddles, Grand Round presentations and the Mortality Newsletter (appendix 1). Themes identified include communication and handover of information, delays in senior review and problems or delays in patient flow to the most appropriate ward or specialty team.

3.1 Investigation into diagnosis groups as part of the mortality review process has identified areas for improvement in the recording and coding of comorbidities and complications. The clinical coding team is working with specialties to improve the recording of comorbidities for patients including the use of the discharge summary and forms within healthcare records. Improvement in accurate recording of these factors will positively impact on the quality of mortality data.

3.2 The Emergency Department has improved communication within the team

and sharing of learning with the use of newsletters and incorporating a clinical lesson of the week into daily ED handover, safety huddles and junior Doctor teaching.

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3.3 In March 2018 the weekly safety message highlighted cardiac disease as the main cause of maternal death and the importance of patient monitoring during the intrapartum period.

4.0 Mortality Indicators: Hospital Standardised Mortality Ratio (HSMR)

4.1 The HSMR is a mortality indicator (provided monthly), which looks at inpatient deaths in comparison to ‘expected’ deaths. Expected deaths are calculated by assigning each patient a mortality risk, accounting for factors such as age, co-morbidities, diagnosis group, gender, palliative care coding, and many more. The HSMR includes 56 diagnosis groups that contribute to 80% of inpatient hospital mortality (nationally). The HSMR is calculated using the below calculation:

Equation 1: HSMR and Relative Risk Calculation

The national benchmark for mortality performance is 100. If the HSMR value is above 100 it indicates that there has been more deaths than expected. If the HSMR value is below 100 it indicates that there have been fewer deaths than expected. If there is a statistically significant difference between the actual number of deaths and expected number of deaths, either a positive alert or a negative HSMR alert will occur.

4.2 HSMR data is received by the Trust 3 months in arrears. The most recent release of data includes mortality for all deaths prior to and including December 2017. The HSMR for the most recent 12 months of data (January 2017- December 2017) is 102.5. This is within the ‘expected’ mortality range. The HSMR value for December 2017 is 104.4 which is also within the ‘expected’ mortality range. The chart below shows the HSMR trend for UHCW for each month from January 2017- December 2017. It highlights that UHCW is consistently within the ‘expected’ range for these 12 months.

Figure 2: HSMR Trend by Month (January 2017- December 2017)

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5.0 Mortality Alerts

5.1 Each month, diagnosis and procedure groups which have generated negative alerts through Dr Foster (significantly more deaths than expected) are discussed at the Mortality Review Committee. Appropriate action to address the alerts is agreed.

5.2 Between January 2017- December 2017 (latest available Dr Foster Intelligence data), the Trust identified 214 mortality alerts, 42% of which have been positive alerts (90). All negative mortality alerts have been reviewed by the Mortality Review Committee and appropriate actions assigned and monitored for completion. Ongoing actions to reduce HSMR include the development and monitoring of care bundles.

6.0 Mortality Indicators: Summary Hospital-level Mortality Indicator

6.1 The SHMI is a national indicator published by NHS Digital quarterly and is 6

months in arrears. The national benchmark for the SHMI is 1. Similar to the HSMR, a value below the benchmark indicates fewer deaths than expected, while a value above this highlights more deaths than expected. UHCW reports SHMI data to the Mortality Review Committee on a quarterly basis.

6.2 The most recent publication for the SHMI is for October 2016 – September 2017 (published by NHS Digital, in March 2018). The majority of Acute Trusts in this publication were within the ‘expected’ mortality range (78%; 105 Trusts). UHCW is also within the expected range in this publication, as the value is 1.0928. During this time period there were 2,897 deaths recorded compared to 2,651 ‘expected’ deaths. The majority of deaths were inpatient deaths (69.5%), and 30.5% (882) of deaths were within 30 days of discharge.

7.0 Mortality Outlier Alerts 7.1 The Care Quality Commission (CQC) monitors diagnosis groups using

statistical data. Outlier alerts are generated when there have been a significantly higher number of deaths than calculated. 2 CQC outlier letters have been received between January 2018 - March 2018.

In February 2018 CQC sent 2 letters requested information regarding a mortality outlier alert for the diagnosis group Skin and Subcutaneous Tissue Infection. A response was sent updating on actions generated from an initial investigation into clinical coding and case review.

7.2 Other external or national bodies such as Royal Colleges will contact the Trust regarding Mortality Outlier Alerts. In March 2018 Imperial College London contacted the Trust informing of a mortality outlier alert for the diagnosis group Intracranial Injury and Septicaemia (except in labour).

Figure 3: Mortality Alerts received by Month of Alert

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8.0 Additional Developments

8.1 Mortality Focus 2017/2018 The Mortality Review Committee has taken a proactive approach towards

reducing the Trust’s SHMI and has identified key areas of focus for the next 12 months. These include 13 Diagnosis groups with higher crude mortality than expected. An action plan has been developed and progress is reported through the Mortality Review Committee monthly.

Author: Sharron Oulds, Head of Clinical Effectiveness. May 2018

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Appendix 1 Mortality Review Newsletter

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- 11 -

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Title Controlled Drug Accountable Officer Report April 2017 to March 2018

Author Mark Easter & Janette Knight


Meghana Pandit, Chief Medical Officer

Date 31 May 2018

1. Purpose The purpose of this report is to provide an assurance to the Board on the safe and secure management of controlled drugs within the Trust, in accordance with legal and Department of Health requirements. 2. Background A number of drugs used within the Trust, hereafter referred to as “controlled drugs” are governed by the requirements of the Misuse of Drugs Act 1971 (and subsequent amendments). These include opiate analgesics, stimulants (e.g. dexamphetamine), barbiturates and benzodiazepines. The Act imposes strict controls on who can prescribe, supply, be in possession of and administer controlled drugs, and how and where they can be manufactured, prepared, stored, supplied, transported and destroyed. 3. Executive Summary In response to the Shipman Enquiry, the Department of Health (DoH) issued the document Safer Management of Controlled Drugs: Guidance on strengthened governance arrangements, which imposes additional controls on the management of controlled drugs. One of the key requirements of this document is the need for all NHS Trusts to appoint an Accountable Officer (AO) for Controlled Drugs. The AO must ensure the safe and effective use and management of controlled drugs within the organisation, and to monitor the use of controlled drugs and take appropriate action when necessary. Revised regulations were issued in February 2013, to account for the re-organised structure of the NHS from that date. The DoH document also requires each Local Area Team to establish a Local Intelligence Network (LIN), comprising AOs, police, counter-fraud, social services and inspecting bodies. The LIN provides a forum where confidential information relating to controlled drugs incidents can be shared. A subsequent document, Safer Management of Controlled Drugs: ‘A guide to good practice in secondary care’ (England), issued by the DoH in October 2007, provides detailed guidance on the management of controlled drugs in hospitals.

This guidance has been used to compile a detailed Controlled Drugs Policy and supportive Clinical Operating Procedures. The Policy and supportive Clinical Operating Procedures are available on the Trust intranet site and the Pharmacy SOPs upon

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request. Adherence monitoring is undertaken by the Pharmacy team and assurance reported at the Medicines Management Committee.

Updates from National Groups Department of Health - Controlled Drugs (Supervision of Management and Use) Regulations 2013 The Department of Health are continuing to review the Controlled Drugs (Supervision of Management and Use) Regulations 2013. The horizon scanning meeting, held on 17th October, considered the extent to which the Regulations achieved the original policy objectives; whether the objectives remain appropriate; whether there have there been any unintended consequences. Next step is the establishment of a Steering Group to take forward the review, the first meeting was likely to be in the spring. Home Office - The review of the Safe Custody Regulations 1973 The Home Office held the first round of meetings to review the 1973 Regulations in early 2017. Meetings have been held with representatives from both the healthcare and non-healthcare (i.e. museums and universities) sectors. A set of targeted meetings took place in August 2017 to drill down into some of the specific issues such as new technology and exemption certificates and the Home Office are about to send out a questionnaire to form the basis for their impact assessment. Home Office – Misuse of Drugs Act 1971 From 14 December 2017, the 3rd generation synthetic cannabinoids were controlled as Class B drugs under the Misuse of Drugs Act 1971 and as Schedule 1 drugs to the Misuse of Drugs Regulations 2001. On the same day, the anabolic steroid dienedione were be classified as a Class C drug under the Misuse of Drugs Act 1971 and as a Schedule 4 (Part 2) drug to the Misuse of Drugs Regulations 2001. Home Office - Pregabalin and Gabapentin consultation This consultation seeks views on options whether, and how, to schedule pregabalin and gabapentin under the Misuse of Drugs Regulations 2001 following the recommendation by the Advisory Council on the Misuse of Drugs (ACMD) that these 2 drugs should be controlled as Class C drugs under the Misuse of Drugs Act 1971 (‘the 1971 Act’) and placed in Schedule 3 to the Misuse of Drugs Regulations 2001. The consultation was aimed at members of the public, healthcare professionals, institutions, all sectors within the supply chain including the pharmaceutical industry, wholesalers and community pharmacies in the UK. The consultation closed on 22nd January 2018. It is anticipated that the results of the consultation and the Government's response will be published later this year. It is recognized that should the consultation outcome result in both pregabalin and gabapentin requiring safe custody Schedule 3 reclassification then this would have a considerable impact on resource for healthcare professionals to implement. In this event the risk evaluation and risk mitigation monitoring will be undertaken through the Medicines Management Committee.

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CQC Prescribing Sub-Group

The subgroup reviewed the prescribing of Diconal across England and noted this has reduced over the past 12 months and new patients are not being started on it: Dipipanone is a strong opioid analgesic drug, used for very severe pain. The main preparation of the drug commercially available is mixed with cyclizine (Diconal®) which has the advantage of reducing nausea, vomiting and histamine release associated with strong opioid therapy. As of November 2011 Amdipharm stopped making the Diconal brand tablets for the UK due to undisclosed commercial reasons. Prescribing of dipipanone is discouraged apart from in exceptional circumstances, because of the perceived risk of abuse - the BNF marks the substance as "less suitable for prescribing" along with other older compounds such as pethidine and pentazocine with unusual abuse patterns. The combination with cyclizine leads to a very strong "rush" if the drug is injected. During the late 1970s to early 1980s in the UK, many deaths were blamed on misuse of this preparation. Dipipanone is non-formulary and has not prescribed at UHCW NHS Trust. Controlled Drug Accountable Officer The role of the Trust’s Accountable Officer was held by Jenny Gardiner, Director of Quality from 1st April to 20th August 2017. From 21st August 2017, the Trust’s Accountable Officers role has been assigned to Mark Easter, Director of Pharmacy following approval at Quality Star Chamber that the role of Accountable Officer was better suited to a clinically trained professional. This information was communicated Trust wide and included details of a new pharmacy intranet page dedicated to Controlled Drugs and confidential email box for staff to access and report directly to the Accountable Officer should any concerns wish to be disclosed in confidence. Occurrence Reports Quarterly occurrence reports have been prepared by the Trust Medicines Assurance Lead on behalf of the CDAO, presented and approved by the Medicines Optimisation Committee before submission to the NHS Arden & Greater East Midlands Controlled Drug Local Intelligence Network. The format of the reports have been changed to support national reporting and it is anticipated that the data can be evaluated nationally and support future benchmarking initiatives. The reports provide an overview of moderate to high risk CD related incidents as categorized by the LIN risk, type and category breakdown chart found in appendix 1 the status of the investigation at the time the occurrence report was submitted and the learning from these incidents is shared by the Trust CDAO and Medicines Assurance Lead during these quarterly LIN meetings. Overarching Governance The medicines committee structure was reviewed in 2017 that consists of an overarching Medicines Optimisation Committee to which the Drug & Therapeutics Committee, Medicines Safety Committee and Medicines Management Committee report.

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This new structure built on the Trust’s established medicines management systems and processes and aims to ensure that all healthcare professionals work collaboratively to ensure that the right patient receives the right medicine at the right time. This change has bought a single, unified medicines optimisation report to Patient Safety and Clinical Effectiveness committee, clear sign off of medicines related policies (including controlled drugs) policies by senior pharmacy, nursing, medical and quality representatives, and appropriate assurances regarding medicines policies, action plans and risks. Controlled Drugs Governance The Controlled Drug Policy was developed and approved by the newly formed Medicines Management Committee Structure following extensive stakeholder consultation and engagement. This policy was approved in December 2017 and is available on the Trust Intranet. This policy is linked to the Trust’s Medicines Policy and supporting clinical operating procedures that provide in detail the requirements for the storage, prescribing, administration and management of controlled drugs across the Trust. There are currently 109 controlled drug cabinets used for the secure storage of CDs within the Trust. Controlled drug cabinets must comply with BS:2881 standards. Where the fixing of these cabinets do not meet the legislative requirements exemption certificates have been issued following a visit from Warwickshire Police, design out crime officer to St. Cross hospital in October 2017 for the controlled drug cabinets located in the new Cardiac Cath Lab unit, Mulberry ward, Oak ward, Cedar Male and Female wards. CQC Self-Assessment – Annual Review The CQC Self-Assessment Tool is designed to be used by the Accountable Officer as part of an annual review to access their organisation's arrangements for controlled drugs governance and identify areas requiring improvement. The tool covers governance of CDs, including access to these medicines, standard operating procedures, management of CDs in the hospital pharmacy, wards and departments, transport, auditing, reporting of incidents and information sharing.

This annual review was completed in January 2018 and presented at the Medicines Optimisation Committee in February. This review has identified areas for improvement associated with transportation of patients own medicines within the Trust between clinical areas.

NICE medicines practice guideline NG46ICE Baseline – Compliance

In March 2018 a review of the NICE Baseline assessment tool for Controlled drugs: safe use and management (NICE medicines practice guideline NG46) by the Accountable Officer and Medicines Assurance Lead agreed that 60/65 (92%) relevant recommendations were met.

Recommendations not met due to insufficient evidence to provide assurance are scheduled to be discussed and include an action plan to mitigate any risk associated with the guidance not being met at the Medicines Management Committee in May 2018.

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Controlled Drug Audits – Wards & Departments The management of controlled drugs on each ward and department are audited quarterly by a pharmacy staff for regulatory and best practice standards compliance. Compliance with the requirements for the management of controlled drugs has generally been very good. The audits have however identified a few recurrent issues as detailed below on some wards and/or departments although these numbers fluctuate with each quarterly audit. Detail of the compliance for each quarterly audit completed in 2017/18 are provided in appendix 2 The following standards have been consistently difficult for clinical areas to achieve compliance.

The CD cabinet was found to contain other non-CD medicines and objects. It should be noted that 100% compliance was achieved for Q4 2017/18

The CD register error entries had been obliterated, amended or crossed out.

Segregation of high strength opiates

Segregation of patients own controlled drugs

The CD cabinet ‘red light’ was not working on opening. It is anticipated that the automated medicines cabinets that are scheduled to commence installment in July 2018 will help to address better compliance with these standards, through the use of electronic CD registers, additional storage facilities to enable the segregation of high strength opiates and Patients Own Controlled Drugs. In January 2018 it was agreed with the Chief Nursing Officer a 95% compliance target would be set for the quarterly controlled drug audit and where this target was not met, the ward/department manager would be asked to provide an action plan to address the deficiency identified. Action plan evidence and feedback discussion has recently been scheduled for inclusion into the controlled drug quarterly audits presentation at the Nursing and Midwifery Quality meetings where concerns in compliance will be escalated if appropriate to the CDAO.

The controlled drugs policy requires wards & departments controlled drug stock balances to be checked twice daily by two healthcare practitioners. A record of the check is maintained in the controlled drug register or a separate controlled drug check log book stored in the controlled drug cabinet. The log is assessed as part of the quarterly audit. Any stock balance discrepancies identified are reported as clinical incidents on Datix and investigated. Email notification of reported incidents involving controlled drugs are sent to the Medicines Assurance Lead and Accountable Officer. A pharmacist is delegated to support the lead investigator with their investigation to establish the cause of the incident. The investigation outcome is added to the Datix incident report. Oversight of the controlled drug incidents reported on Datix are monitored by the Medicines Assurance Lead through a Datix dashboard as part of their interim secondment position established to support the Accountable Officer with their work. Controlled Drugs Audits – Pharmacy The management of controlled drugs in the pharmacy department is assessed by the Senior Technician for Quality and Innovation. The assessment includes an audit undertaken to monitor expired and patients own controlled drugs returned to pharmacy

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for disposal. The audit was last completed in October 2017 and showed some minor non-compliance with documentation on the controlled drugs returns form. The results are shared with the Accountable Officer and the pharmacy team through the Quality Improvement and Patient Safety meetings. There is also a rolling daily controlled drug stock check to reconcile stock levels on the pharmacy JAC stock control system, physical stocks in pharmacy and the controlled drug register. The Pharmacy department at University Hospital was inspected by the Home Office in June 2017 and the appropriate high standards required for the management of controlled drugs were achieved to be granted a Home Office License to enable controlled drugs to be supplied as part of the Pharmacy’s Wholesalers Dealers License (WDL). A planned inspection in 2017 by the General Pharmaceutical Council (GPHC) raised no concerns with the management of Controlled drugs. The Trust is required to ensure medicines waste is stored, transported and disposed of in accordance with the Environmental Act 1990 and Controlled Waste Regulations 2012. An application was made in 2017 to the Environmental Agency for S2 and T28 Waste Exemption Certificates for both St. Cross and University Hospitals for storing, sorting and denaturing controlled drugs for disposal. The current exemption certificates are valid until February 2020. Pharmacy Outpatient – Lloyds The pharmacy outpatient service was contracted out to Lloyds in September 2013. The Accountable Officer for Lloyds is responsible for the governance arrangements for the safe use and management of controlled drugs in this area. There is an agreement within the contract that any concerns regarding the unsafe use or management of medicines would be reported immediately to the Pharmacy Governance & Safety Team and the Trust’s Accountable Officer. Medical Gases

Medical gases are classified as medicines and are subject to the same legislative governance requirements for custody, prescribing and administration.

There has been an increase in the number of thefts of medical gas cylinders containing nitrous oxide (commonly known as laughing gas) from NHS hospitals in England in recent years, due to its popularity for recreational abuse for the purpose of causing euphoria and or hallucinations. In 2017/18 the Trust has reported 2 incidents of thefts of nitrous oxide cylinders.

In October 2017 the theft of eight nitrous oxide cylinders were stolen from the medical gas store at the hospital of St. Cross and in March 2018 four nitrous oxide cylinders were stolen from the gas manifold stores of the Centre of Reproductive Medicine (CRM). Both the Police and British Transport Police were informed of the incidents as this is required when reporting the theft of medical gases.

A clinical review of the use of nitrous oxide in CRM by the clinical leads established that this medical gas is no longer used in clinical practice in this area and following

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consultation with the Chief Medical Officer nitrous oxide has now been removed from the manifolds in CRM, removing the risk of further thefts from this area.

A risk assessment to review the medical gas storage facilities at both the University and St. Cross hospitals has been undertaken by the Health & Safety Officer and local crime prevention officer and additional security measures have been put into place to deter and prevent further thefts of medical gas cylinders from both sites.

Fitness to Practice

The Accountable Officer has not been informed of any registered healthcare professional’s fitness to practice concerns or restrictions to practice relating to medicines during 2017/18.

Training

Medicines management training workshops, that include training for controlled drugs are delivered by the Nurse Practice Facilitator and Medicines Assurance Lead for the nurse preceptorship programme (training for newly qualified nurses), nursing and operating department practitioners (ODPs). See table 1 below for details. The medicines management training workshops continue to receive positive feedback from those who attend and will continue to be delivered monthly in 2018/19.

Table 1:

Type of Training Workshop Delivered 2017/18 No: of

Workshops No: of

Attendees

Medicines Management Workshops 11 139

Preceptorship Medicines Management Workshops 3 91

Total 14 230

4. Areas of Risk

Accountable Officer – Substantive support

The role of the Medicines Assurance Lead is an interim secondment post to support the Accountable Officer in the development and ongoing management of the new Controlled Drugs Policy, the medicines Governance structures and management of CD related incidents. The secondment position will cease from 31st July 2018. A business case has been developed and is scheduled to be submitted to the Strategy Unit meeting for permanent funding to continue to support these roles.

Illicit Substances

The Trust experienced 11 incidents during 2017/18 where suspected illicit substances were brought onto the hospital premises by patients or visitors. It is considered a growing area for concern and further work is required to develop new clinical operating procedures to ensure the governance arrangements for the handling, removal and

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disposal of suspected illicit substances safely by healthcare professionals is imbedded within the Trust and minimize the risks associated with the possession and disposal of these substances.

Training of Medical Staff

Medicines management training workshops are designed to be delivered to nursing and operating department practitioners. There is currently no specific training for controlled drugs practice other than prescribing modules for junior medical staff as part of their FY1 training. Training packages are in development for all trainee doctors and Consultants by Pharmacy and the Associate Medical Director for Education

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks This paper supports the Trust’s corporate agenda to achieve ‘CQC’ good and assurance that the Trust is compliant with the Misuse of Drug Act 1971 and its subsequent amendments. 6. Governance This is the first Accountable Officers report to be presented for Board papers and it is intended that this will be presented annually going forward as part of the regulatory governance assurance for the safe management and use of these medicines. 7. Responsibility The Trust’s Accountable Officer has overall responsibility to ensure that the Trust operates appropriate arrangements for the secure and safe management of CDs and reports to the Chief Medical Officer. 8. Recommendations The Board is invited to note the Trust’s new Accountable Officer, Mark Easter, Director of Pharmacy. The Board is invited accept the Accountable Officer’s annual report. Name and Title of Author: Mark Easter, Clinical Director clinical Support Services, Chief Pharmacist and Controlled drugs Accountable Officer Janette Knight, Trust Medicines Assurance Lead Date: May 2018.

Appendix 1: Breakdown of UHCW NHS Trust LIN incidents reported 2017/2018

Category / Type of incident

Number of occurrences

LIN Risk Rating

Low

Moderate

High

Extreme

Patient Safety Incidents

Prescribing 28 17 11 0 0

Dispensing 39 30 9 0 0

Administration 194 129 55 10 0

Other 145 100 42 3 0

Annual Total 406 276 117 13 0

Unaccounted for losses such as theft and fraud (from the organisation), unexplained stock discrepancies, lost prescriptions / requisitions

72 33 39 0 0

Accounted for losses such as spillages, breakages

93 93 0 0 0

PSI / Patient / public Patient Safety Incidents or incidents relating to the public (this includes 11 incidents for suspected illicit substances)

98 34 51 13 0

Professional individuals of concern These are relevant individuals i.e. people who work in health or social care

0 0 0 0 0

Governance issues such as CD safe custody, staff competence, audit, statutory requirements, SOPs

90 66 24 0 0

Record keeping 53 50 3 0 0

Annual Totals 406 276 117 13 0

Examples of NHS England LIN Occurrence Report Risk, type and category chart.

Risk rating Examples: Type of incident Category

Low Recording errors Record keeping

Low Storage error Governance

Low Dispensing error - before reaching patient Patient related

Moderate Destruction error Unaccounted for losses

Moderate Delivery error Unaccounted for losses

Moderate Lost / Stolen / Missing CDs Unaccounted for losses

High Illicit use by patient Patient related

High Police investigation Patient related

High Discharge procedure error where patient takes drug Patient related

High Prescribing error – patient taken Patient related

High Never event Patient related

Extreme Patient death Death

0

10

20

30

40

50

60

Apr 2017 May2017

Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018

UHCW NHS Trust - Number of Controlled Drug Incidents Reported by Month 2017/18

Appendix 2

Sp

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Q No ENQUIRY

Wa

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Clin

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Wa

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Clin

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/ O

P

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Clin

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/ O

P

OVERALL

COMPLIANCE

1.1Does the CD cabinet comply with B2881 and the requirements of the

Misuse of Drugs Act?100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1.2Confirm that the nurse in charge is in possession of the keys or

knows where they are?100% 100% 100% 100% 100% 100% 98% 100% 100% 100% 100% 100% 99%

1.3Is there a printed list of nursing staff and their signatures, authorised

to order CD's available on the ward?100% 97% 100% 100% 100% 100% 100% 100% 100% 94% 100% 100% 99%

1.4 Was the CD cabinet found locked? 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1.5Is there a CD current stock list, dated within the last 6 months

available on or in the cabinet?100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1.6Is the CD cabinet free from other non CD medicines and objects? IE,

Money, valuables or mobile phones etc.79% 89% 93% 91% 100% 100% 93% 100% 100% 100% 100% 100% 94%

1.7Are registers and order books stored securely and access restricted to

authorised staff?96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99%

1.8Are registers and the requisition book fit for use, i.e.. Covers are

intact and there are no loose pages?89% 100% 100% 91% 100% 100% 95% 100% 100% 76% 85% 100% 97%

1.9Are all CD register entries legible and there are no obliterated

entries? 53% 100% 100% 57% 68% 86% 65% 97% 86% 43% 62% 93% 79%

1.10.Are CD stock checks undertaken twice daily completed and

witnessed by 2 registered individuals?95% 100% 93% 95% 92% 100% 100% 100% 100% 93% 97% 100% 97%

1.11Is there a separate page in the CD register for each drug, formulation

and strength?100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1.12 Are all entries supported by 2 signatories? 96% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 99%

1.13

Are Controlled drug stock and administration records fully

maintained in the ward CD record book and that there is a correct

running balance?

98% 100% 100% 100% 100% 100% 98% 100% 100% 98% 100% 100% 99%

1.14Are part used controlled drug ampoules and accidental breakages /

spillages disposed of in the denaturing kit?87% 100% 100% 98% 100% 100% 100% 100% 100% 98% 97% 100% 98%

1.15Is all waste / spillage recorded, documented and witnessed in the CD

register? 100% 100% 100% 94% 100% 100% 100% 95% 100% 100% 100% 100% 99%

1.16 Are CD registers retained / archived for 7 years? 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1.17Can the nurse provide information on how to report a CD

discrepancy?98% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 99%

94% 99% 99% 96% 98% 99% 97% 99% 99% 94% 97% 99% 98%

2.1 Are the CD keys kept separately from the general keys? 95% 76% 100% 95% 100% 100% 91% 100% 100% 100% 100% 100% 95%

2.2 Does the red light work when the cabinet is open? 64% 47% 94% 65% 38% 92% 71% 39% 100% 70% 37% 100% 68%

2.3Are patients own CD's recorded in a separate Patients Own Drugs

Register?98% 100% 95% 100% 91% 100% 95% 100% 97%

2.4Was the last quarterly CD stock check completed within the last 3

months by pharmacy?100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

2.5Are all balances transferred to either a new page or a new register if

necessary?100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 100% 100% 100%

2.6Are there examples of record keeping in CD registers displayed on the

cabinet?100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

2.7

Are the signatures and dates in the active ward CD order book to

demonstrate receipt of such drugs, not the same as the person who

ordered them?

100% 100% 100% 93% 94% 100% 93% 100% 100% 94% 95% 100% 98%

2.8Are epidural CD's segregated from other injectables? NPSA

alert:039688% 100% 100% 100% 80% 100% 100% 100% 95%

2.9 Are high strength opiates separated from low strength opiates? 36% 44% 100% 44% 100% 44% 100% 65%

2.10.Are patients own CD's segregated from ward stock? IE. In outer CD

cabinet?84% 100% 92% 93% 79% 92%

2.11 Are all stocks within the CD register in date? 96% 100% 100% 98% 100% 100% 98% 100% 100% 98% 100% 100% 99%

2.12 Are the tamper evidence seals still unbroken on full boxes? 80% 100% 100% 88% 95% 100% 94% 100% 100% 83% 100% 100% 95%

91% 91% 99% 92% 92% 99% 91% 95% 100% 91% 92% 99% 94%

93% 95% 99% 94% 96% 99% 95% 97% 99% 93% 95% 99% 96%

Controlled Drug Quarterly Audit Results - Quarterly Comparison 2017/182017/2018 2017/2018 2017/2018 2017/2018

Quarter 1 Quarter 2 Quarter 3 Quarter 4

1.R

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Regulations & Legislation

2.B

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Best Practice Compliance

Overall Compliance:


Title Safe Staffing Report: Acuity and Dependency

Author Rosslyn Young and Mairaide Varney


Nina Fraser: Chief Nursing Officer

Date 31 May 2018

1. Purpose

The purpose of this report is to provide a six-monthly update in relation to the National Quality Board (NQB) 2016 standards for Safer Staffing and to detail the results of a full and comprehensive assessment of nurse staffing and analysis within UHCW on all wards. The report will also describe new methodology used at University Hospitals Coventry and Warwickshire NHS Trust to collect and analyse the data.

2. Background and Links to Previous Papers The National Quality Board (NQB) sets out responsibilities for NHS providers to have the right people, with the right skills, in the right place at the right time to achieve safer nursing and midwifery care staffing. UHCW has had a long term programme in place for understanding and reporting nursing and midwifery staffing. The systems in place are consistent with the national guidance received on safer staffing, including the Safer Nursing Care Tool (SNCT), Care Hours Per Patient Day and use of the ‘SafeCare’ module. The Safer Nursing Care tool (SNCT) is an evidence based tool endorsed by the National Institute for Clinical Excellence (NICE) which enables the measurement of both acuity and dependency which can be applied to patients in a general ward setting. 3. Executive Summary The report describes the way that the safe staffing, acuity, dependency and establishment data are collected and the frequency of that collection. Over the last few months UHCW has moved from collecting Safer Nursing Care Tool (SNCT) data bi-annually to a daily, fully electronic process. This report outlines the six areas of analysis for safe staffing for the period March 2018. Where there is a national or locally set target, this has been identified and rated (red or green) in the summary table 1. The report will explain those areas demonstrating a variance of greater or less than 10% of the Care Hours Per Patient Day (CHPPD) and comment on the compliance of wards inputting data. This report also correlates patient outcome measures (nurse sensitive) indicators such as falls, infection rates and pressure ulcers alongside ward areas’ safer staffing data. Historically Maternity units have been excluded from SNCT as it was designed for adult in-patient areas. Within this report we describe how we currently monitor maternity services and what we will do in the future.

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Table1: Safe staffing analysis summary table Safer Staffing Analysis Target Local or

National March 18

1.Registered Nurse & Registered Midwife fill rate

>95%: Tolerance + or – 10% N Met

2.Health care assistant fill rate >95%: Tolerance + or – 10% N Met

3.Care Hours Per Patient Day (CHPPD) variance

> or less than 10% variance L Met

4. Patient acuity and dependency > or less than 10% variance L Met

5.Safer Nursing Care Tool ward compliance

> 75% by Q4 2017-18 L Met

6. Nurse Sensitive Indicators (NSI) Review the correlation between CHPPD and NSI’s

N/A N/A

4. Areas of Risk

The results may highlight staffing risks in Maternity as our establishment allows us to meet our baseline birth to midwife ratio for 2016/17, and not the most recent results of Birth rate +.

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks Safer Staffing links to our objective to achieve a rating of at least good in the CQC assessment and the corresponding BAF risk (3). 6. Governance In line with the responsibility of the Trust Board for ensuring that services are safe, it is a national requirement that a staffing assessment is submitted in order that the Board is aware of the Trust’s position against national guidance and can take action where appropriate. 7. Responsibility Rosslyn Young is the Senior Lead for Nursing, Midwifery and AHP Workforce and responsible for safe staffing and data validation from Safer Nursing Care Tool (SNCT). Nina Fraser is the Chief Nursing Officer with overall responsibility. 8. Recommendations

The Board is asked to note the contents of this report

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1. Background

Nursing, midwifery and care staff, working as part of wider multidisciplinary teams, play a critical role in securing high quality care and excellent outcomes for patients. There are established and evidenced links between patient outcomes and whether organisations have as advocate. Compassion in Practice (NHSCB 2012) emphasised the importance of getting this right and this led to the development of the Leading Change Adding Value Framework (2016). This was linked to the NHS 5 year forward view focusing on reducing unwarranted variation in workforce. The Carter report (2015) made it clear that workforce and financial plans must be consistent to optimise clinical quality and the use of resources. Lord Carter’s report also recommended a new metric, Care Hours Per Patient Day (CHPPD), as the first step in developing a single consistent way of recording and analysing safe staffing levels.

The National Quality Board (NQB) brings together the different parts of the NHS system with responsibilities for quality and patient care and sets out responsibilities for NHS providers to have the right people, with the right skills, in the right place at the right time to achieve safe nursing and midwifery care staffing. It provides an approach to deciding staffing levels based on patient needs, acuity and risk to enable NHS provider board to make judgments about delivering safe sustainable and productive staffing.

The Safer Nursing Care Tool (SNCT) is one method that can be used to assist in determining optimal nurse staffing levels in adult in-patient areas. It is an evidenced based tool that enables nurses to assess patient acuity and dependency, incorporating a staffing multiplier to ensure that nursing establishments reflect patient needs in acuity/dependency terms. This provides us with richer and more comprehensive data in which to make informed decisions about staffing levels. It also enables us to make assumptions about staffing level requirements on acuity, dependency and skill mix and not simply on the numbers of staff available by shift.

2. Methodology

UHCW have used the Safer Nursing Care Tool (SNCT) to evaluate staffing levels bi-annually since 2008. We have undertaken a review of our methodology to collect and analyse staffing, dependency and acuity data and over the last 6 months have moved to an electronic daily approach. Each day we record the acuity and dependency of every adult inpatient and the bed days. The data is recorded electronically and collated to provide a monthly average of CHPPD, acuity and dependency.

3. Results

The report includes;

Adult inpatient wards and adult acute assessment in-patient areas that collect staff fill rate, SNCT and CHPPD

Note - paediatric, maternity and critical care collect staff fill rate and CHPPD (SNCT is not developed for these areas)

Nursing and Midwifery Committee have agreed six domains for the analysis of safe staffing which are listed below and we will report on these. Outcomes are RAG rated to demonstrate compliance, using only two colours red or green. Amber is excluded because it would add no value and could be ambiguous.

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Safe staffing analysis

1. RN/ M fill rate >95% Tolerance + or – 10%

In March the Registered Midwives/Nurses (RN) fill rate in in-patient areas remained compliant on night shift and continues to improve on day shift to 95.6%, improving from 87.2% in December (target of 95%). A total of 17/44 inpatient areas were non-compliant on day shift in March which has deteriorated from 8/45 in Feb. (24/45 Jan and 32/45 Dec). UHCW site continued to have significant in-patient escalation areas open which impacted on the ability to fill all shifts. Daily staffing meetings continue to support the mitigation of risk to patients by moving staff out of non-clinical shifts or across wards and departments and we have also used off framework agency to fill deficits this month.

Day 95.6%

Night 96.3%

2. HCA (CSW) fill rate >95 %

In March the Care Support Worker (CSW) fill rate was 110.6% on day shift and 117.6% on night shift which is greater than planned. A high volume of these were additional shifts for 1:1 and Cohorts and some were used for opening escalation beds and supporting flow issues in Emergency Care.

Day= 110.6%

Night 117.6%

3. CHPPD variance if > 10% or < 10CHPPD Less than 10% variance + or -

RN CS Overall RN CS OverallOverall

Variance% Variance

Ward S1Actual over

Bed Days

Actual over

Bed Days

Actual over

Bed Days

Required

over Bed

Days

Required

over Bed

Days

Required

over Bed

Days

Required V

Actual

Variance

over

Expected

Ward 24 501 - Obstetrics 3.9 1.5 5.4 5 1.4 6.4 1 -15.63%

Ward 25 501 - Obstetrics 4.3 3.2 7.5 5.5 3.2 8.7 1.2 -13.79%

Ward 16 420 - Paediatrics 4.3 1.8 6.1 5.3 1.7 7 0.9 -12.86%

Ward 22a Vas 100 - General Surgery 3.8 2.5 6.3 4.1 3.1 7.2 0.9 -12.50%

Ward 15 420 - Paediatrics 7.7 2.9 10.6 8.6 3.4 12 1.4 -11.67%

Paediatric HDU 420 - Paediatrics 12.5 0.6 13.1 14.8 0 14.8 1.7 -11.49%

Ward 31 340 - Respiratory

Medicine

2.5 2.5 5 2.4 2.1 4.5 -0.5 11.11%

Ward 21a Med 430 - Geriatric

Medicine

6.4 5.9 12.3 6.6 4.3 10.9 -1.4 12.84%

AMU 3 (Ward 3) 410 - Rheumatology 3.2 3.7 6.9 3.3 2.8 6.1 -0.8 13.11%

Ward 35 800 - Clinical

Oncology

3.5 3 6.5 3.6 2.1 5.7 -0.8 14.04%

Ward 20 430 - Geriatric

Medicine

2.6 4.4 7 2.7 3.4 6.1 -0.9 14.75%

Ward 32 100 - General Surgery 4.7 2.9 7.6 4.6 2 6.6 -1 15.15%

Ward 42 400 - Neurology 2.6 3 5.6 2.7 2 4.7 -0.9 19.15%

Ward 14 420 - Paediatrics 7.6 4 11.6 7.5 2.2 9.7 -1.9 19.59%

Ward 33 Surgery 100 - General Surgery 4.3 3.4 7.7 3.5 2.2 5.7 -2 35.09%

Ward 10 320 - Cardiology 5.3 1.8 7.1 3.6 1.2 4.8 -2.3 47.92%

Care Hours Per Patient Day (CHPPD) CHPPD Variance

Care Hours per Patient Day (CHPPD) is a way of representing staffing data that puts the nursing hours provided to patients in the context of the patient acuity and dependency. Using CHPPD has a number of advantages over other methods of representing this data:

Actual CHPPD are the care hours each patient receives based on real time staffing levels

Required CHPPD is what we should have delivered based on staffing requirements based on what was available versus acuity and dependency for that month.

It gives a single figure that represents, staffing levels (RN and HCA), patient acuity and dependency and bed days and therefore allows comparisons between wards/units.

We are looking for a match between actual and required. We reviewed areas that have a variance of + or – 10% CHPPD and in March 18 there were 16. This is the first time we have undertaken analysis on CHPPD therefore we have no comparative data.

Variance

Wards 10, 14, 24, 32, 33 and 42 are shown to have a variance of + or – 15% CHPPD. We will continue to monitor these areas monthly to determine if there is a trend and review enhanced care spending.

Ward 10: Variance = +47.92%

Regularly opened extra capacity beds on the Cardiology Day unit throughout Feb

Actual 7.8 CHPPD

Expected 7.7 CHPPD

Variance = 1.8%

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requiring an additional RN and CSW


This ward has required extra CSW’s to support young people with mental health needs

Ward 24: Variance = -15.63%

This is due to sickness of 7.5% (Trust target <4.5%) and a vacancy rate of 16%

(Trust target < 10%). Maternity services review staffing on a daily basis and have had safe care training to ensure that this is reflected live on the roster. They move staff across maternity services to minimise risk to patients and when required receive support from the wider organisation. Midwifery have recently recruited to the majority of vacancies and these staff will be in place later this year.


Ward 32 underwent a re-configuration during the data collection period. We were unable

to move staff on e-roster until they were moved on the staff payroll system resulting in additional staff on the roster. In practice the staff were moved on a daily basis to meet

patient demand within surgery. Ward 33: Variance = +35.09%.

This ward has been providing 2:1 care by a RMN and CSW since July 2017 for a patient

who has been sectioned under the metal health act. A discharge plan is currently being developed and we will work with commissioners to recover part of the costs associated with this patient.


Requiring extra CSWs providing enhanced care

4..Acuity and Dependency Less than 10% variance

Jun - 14 Jan-15 Jun-15 Jan -16 June-16 Jan-17 Jun-17 March 18

Bed occupancy

100.76% 101.52% 99.44% 100.76% 100.17% 100.44% 98.50% TBC

Nos. of scores

18,036 17,836 16,825 17,049 16,948 16,394 16,567 21,918

level 0 43% 38% 50% 46% 47% 44% 45% 44%

level 1a 14% 18% 4% 4% 4% 4% 5% 5%

level 1b 43% 43% 45% 49% 49% 52% 49% 50%

level 2 0.22% 0.52% 0.48% 0.32% 0.24% 0.27% 0.37% 0.3%

level 3 0.01% 0.02% 0.01% 0.03% 0.07% 0.00% 0.02% 0.02%

The table above shows the SNCT results for UHCW since we began data collection in 2014. The SNCT provides a method to determine how acute or dependant each patient is. Level 0 is the least acutely unwell or dependant patient moving to level 3 which are patients that have multi-organ failure and require intensive care. We analyse this over time to determine if the mix of patients admitted to each ward has changed over time. There is no statistically significant change in the March 18 data when reviewed against the previous collections. The number of entries (scores) has increased significantly and this is because entry is now collected every day electronically rather than on paper of a 20 day snapshot period.

<10% variance

5.SNCT daily compliance >75% >75%

There are currently 33 areas within the Trust that are inputting their staffing levels and acuity and dependency daily. This system was fully implemented in Q3 2017 and so the target for compliance by Q4 was 75%. Trust compliance was met at 755 for the period.

Of those 33, 16 are consistently compliant >75%. Wards 20, 22SAU, 34, 41, 50 and 52 all achieved compliance >90% for the month. Greater compliance is important as it enables safe

75%

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staffing decisions to be made on the needs of the organisation at that time using acuity and dependency information, rather than ward template and budget.

6.Nurse Sensitive Indicators

Nurse Sensitive Indicators (NSIs) have been identified as quality indicators of care such as the number of falls, pressure ulcers, infection rates and drug administration errors specific to each ward area. They can be used alongside the information captured using the SNCT to develop evidence-based workforce plans to support existing services or the development of new services. In this part of the report we are trying to determine if there is a relationship between the SNCT outcomes and NSIs. We have identified the wards with the greatest variance of CHPPD (+ or – 15%):


Continues to perform very well incurring no episodes of ‘harm’ throughout March, and only 1 pressure ulcer in February

Ward 14: Variance = +19.59% One drug administration error in March, no episodes of ‘harm’ in February

Ward 24: Variance = -15.63%

This ward is one of the top 5 wards in the Trust over the previous 3 months having no episodes of ‘harm’. Ward 24 was identified as having the greatest – variance of >15%

Ward 32: Variance =+15%

There was a slight increase in patient low and no harm falls during the reporting period.

This was due to the increase in the number of medical patients within the department during this period

Ward 33: Variance = +35.09%.

This ward consistently performs well with low ‘harms’ recorded overall. There were no ‘harms’ recorded in March and one pressure ulcer in February

Ward 42: Variance = +19.15% There were two falls recorded in March and one pressure ulcer and one fall identified in February. The criteria of patients nursed on Ward 42 means that some of these patients more vulnerable to falls. There has been significant improvement in the reduction of falls and identifying those patients’ at risk’.

For those wards with an increase in CHPPD of >15%, they have performed well from a safety perspective. One ward was able to provide <15% CHPPD than they required, and this had no negative impact on safety.

4. Midwifery safe staffing levels

Midwifery staffing levels are based on midwife to birth ratio. Following a staffing assessment using the nationally recommended tool, Birthrate plus in 2017, the new Head of Midwifery has reviewed the results and recommends a phased approach to achieve a birth to midwife ratio of 1:28 in the current financial year. This will be followed by a further internal review of safe midwifery staffing indicators, the on-going monthly birth to midwife ratio and fluctuations in the number of births.

5. Proposed recommendations

Trust Board are asked to note and discuss the contents of this report


Title Patient Experience Quarterly Report

Author Paula Lloyd Knight, Associate Director of Quality


Meghana Pandit, Chief Medical and Quality Officer

Date 31 May 2018

1. Purpose

This Quarterly experience report brings together information on Compliments, Complaints, PALS, Patient feedback, patient involvement, Board walk rounds and information from the newly established Involvement Hub 2. Background and Links to Previous Papers

The paper aims to present patient experience and patient Involvement information in an easy to read format, and includes a complaints and PALS performance on a page view.

3. Narrative

In keeping with the Trust’s vision of becoming a national and international leader in healthcare and its values, this report aims to bring together the work of the Patient Experience function of the Quality Department. The complaint response rate for the 25 working day standard indicator across quarter 4 (January to March 2018) was 78%, which is a significant reduction on the previous quarter 3 of 86%. The factors influencing this reduction are two fold, one is around the increased number of complaints month in month ( 180 complaints Q4 compared to 158 complaints Q3) and the increased complexity of cases, along with more complaints being resolved via meetings, which when complex take a significant amount of time to set up and complete within the given period. The second factor contributing to the reduction is the sickness on two members of staff, along with planned annual leave, which left the team operating at 50% capacity. The complaints department have worked extremely hard to ensure the focus is maintained on attaining the 25 working day standard despite the significant challenges in this quarter. Communications with patients, relatives/carers and communications around discharge is the top subject most complained about issue (34). This has changed from previous quarters where communications was 4th Q2 and 3rd Q3 respectively. This is followed by clinical treatment of surgical patient’s (22) and admissions, discharge and transfers (20). There were six new Parliamentary Ombudsmen cases in Q4, with 3 case decisions made, 2 were partially upheld and 1 was not upheld.

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The PALS response rate for the 5 working day response standard for quarter 4 is 92% this represents a slight decrease from quarter 3 (93%). The Trusts received 807 PALS enquiries in quarter 4; this is an increase on the previous quarter (724). 82% of people using the service were extremely likely, or likely to recommend the PALS service to friends and family. Appointments (225) are the top PALS enquiry in Quarter 4 with appointment availability being the largest area with 114 enquiries. Communications is the second most common area of enquiry with (175), and communication with a patient being the most common issue within that category The Impressions surveys are undergoing a refresh and a new system will commence in May 2018, with the current ‘mainly good, mainly bad’ surveys being phased out and replaced with five questions which were co-developed by patients and cover five of the Trusts values: Compassion, Respect, Partnership, Pride and Openness. Therefore ratings received for Q4 should be treated with caution given the low numbers.

The highest performing KPIs on Impressions, which rated mainly good are: staff professionalism n=5 (100%), Impression of unit n=5 (100%), environment of unit n=5 (100%), management of pain n=5 (100%), involvement in baby’s care n=9 (100%) visiting times n=5 (100%), politeness and respect n=985 (99%), medical care n=754 (99%),feeling safe n=757 (99%). The lowest are with a mainly bad experience are: Comfort and facilities n=5 (20%) and parking n=645 (32%).

In February a new involvement Hub was installed in the main entrance of the UH site, and was officially launched on the March. Three feedback kiosks are part of the hub and ran the five values based co-developed questions, feedback between 16th February to the 31st March identified the following: being treated with compassion n=3004 (64.9%), being involved in care (partnership) n=1675 (73.5%), being treated with respect n=1638 76.3%, staff open and honest (openness) n=1385 (77.3%) and staff passionate about high quality care (pride) n=1389 77.4%. The NHS Choices rating for University Hospital, Coventry remains unchanged from quarter 1 at 4 out of 5 stars, while the Hospital of St Cross has maintained 5 stars. Board Walk rounds continue on a monthly basis with departments sharing their ideas for positive change with senior colleagues and actions have been followed up from Q1 visits. 4. Areas of Risk The resilience of complaints process – If there is insufficient capacity within the complaints team or in specialty groups to progress complaints in line with the agreed complaints management plan, performance against the 25 working day standard will be significantly affected.

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5. Governance NHS Constitution Principle 4 – The NHS aspires to put patients at the heart of everything it does NHS services must reflect and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers.

Principle 7 - The NHS is accountable to the public, communities and patients that it serves. 6. Responsibility Meghana Pandit, Chief Medical Officer and Deputy Chief Officer 7. Recommendations [A] The Board is invited to note: The Patient Experience Quarterly Report Name and Title of Author: Paula Lloyd Knight, Associate Director of Quality Date: 11th May 2018

1

We Care Patient Experience Report Quarter 4 2018-2019 31st May 2018

2

Contents

1. Patient Relations………………………………….. 3 -14 2a. Involvement…………………………………………. 14-15 2b. Insight…………………………………………………… 15-20 3. Board Walk Arounds………………………………. 21-23 Comment of the Quarter: “Thank you so much for the amazing care you have given to my baby and I. From the minute we came onto the ward we were made to feel welcome, supported and part of a family. You have all been so genuine and compassionate. The level of care that we have received has been the best on offer.”

3

3

15 (8%)

Total number returned for further local resolution (FLR)

The age of oldest complaint at end

of quarter

Of the 3 cases decided by the PHSO in Q4, 0 were fully upheld, 2 partly upheld and 1 were not upheld

266

Compliments and Thanks reported about numerous services across the Trust

180 Actions recorded

resulting from complaints within Q4

Total number of complaints received

No of complaints with previous PALS involvement

Q4 26

(15%)

Complaints Performance

39% 25% 26%

Satisfied Neither satisfied nor dissatisfied Dissatisfied

Complaints satisfaction survey – Satisfaction rates with the way their complaint was handled.

180

99WD

Performance against 25 working day target in July and August

78%

4

Quarter 1 2016-17

Quarter 2 2017-18

Quarter 3 2017-18

January 2018

February 2018

March 2018

Total number of formal complaints received

147 164 158 58 60 63

180

Average monthly number of formal complaints received

49 55 53 58 60 62

60

% of complaints acknowledged within 3 days

126 (86%) 157(96%) 153(97%) 49(84%) 56(93%) 54(89%)

162(90%)

% of complaints responded to in 25 working days

137 (92%) 91(88%) 136(86%) 54(94%) 53 (90%) 33(52%)

140(78%)

Oldest open complaint at end of month

New indicator

New indicator

146WD 112WD 104WD 99WD

Total number returned for further local resolution (FLR)*

25 (17%) 17 (10%) 16(10%) 3 6 10

15 (8%)

Total number of new PHSO cases

6 5 4

1 4 1

6

No of complaints with previous PALS involvement

26(18%) 17(10%) 21(13%) 7 10 9

26

Complaints Activity & Performance

* This is the number of complaints returned for Further Local Resolution. These do not necessarily relate to the complaints received that month as complaints can be returned for further local resolution up to a year after the complaint was responded to.

5

Parliamentary and Health Service Ombudsman (PHSO) Quarter 3 January 2018 February 2018 March 2018 Quarter 4 Total

Number of new PHSO cases 4 1 4 1 6

Number of PHSO decisions 5 2 0 1 3

Number of PHSO cases fully or partly upheld

Upheld 0 Partly Upheld 2 Not upheld 3 Withdrawn 0





Decided Quarter 3 (2017-18)

Quarter 4 (2017-18)

Complaint outcomes Not upheld 41 Partially upheld 93 Upheld 32 Withdrawn 1 Out of time 1 Linked cases with Patient Safety 13 Referred to patient safety 1

Not upheld 36 Partially upheld 78 Upheld 34 Withdrawn 0 Out of time 0 Linked cases with Patient Safety 16 Referred to patient safety 1

Complaints by level of harm (post investigation)

No harm 132 Low 28 Moderate 5 Severe 0 Death 0

No harm 105 Low 38 Moderate 4 Severe 0 Death 0

Complaints Activity & Performance

6

Top 5 Complaint Subjects Top 5 Primary Subjects Top 3 themes

1st: Communications

34

Communication with patient 15

Communication with relatives/carers 6

Discharged too early 4

2nd: Clinical Treatment - Surgical Group

22

Delay or failure to diagnose (inc e.g. missed fracture) 4

Post-treatment complications 4


3rd: Admissions, Discharges & Transfers (excl delayed discharge due to absence of care package – see Integrated care)

20


Discharge Arrangements (inc lack of or poor planning) 6


4th: Appointments

15

Appointment delay (inc length of wait) 4

Appointment Cancellations 3


5th: Clinical Treatment - Accident & Emergency

13



Lack of clinical assessment 2

7

Learning and improving from complaints Datix ID Main Issues of Complaint Outcome Actions Taken

17444 Whilst being moved between the bed and a wheelchair the patient began to fall. Attempts to move the patient were made using a slide sheet which resulted in them being lowered to the floor in a controlled manner.

Apologies for the incident offered, reassuring family that the patient did not fall but was lowered to the floor and further clarified that a hoist was used. The correct procedure however, was not followed when trying to reposition the patient in the wheelchair and it was acknowledged that it was not appropriate to have used a slide sheet in these circumstances.

The nurse concerned has attended further Moving and Handling Training in relation to the correct procedure for repositioning patients in a wheelchair.

17091 Complainant is unhappy with the care provided to her husband on Ward 22 ECU. Patient was on a liquid only diet but was inappropriately given dinner. The complainant believes this led to the patient’s subsequent admission to the General Critical Care Unit.

The complaint response confirmed that the patient was inappropriately offered and ate food. The Consultant believes that this contributed to the patient aspirating which led to the admission to the General Critical Care Unit. Apologises offered for the incident and for the distress caused, further detailing the actions that have been taken by Ward 22 ECU to prevent this type of incident occurring in the future.

Incident discussed at QIPS, including emphasis for staff to be more aware of postoperative care pathways. Nutrition status boards have also been implemented on Ward 22 ECU.

17656 Complainant’s son has complex needs and required an oxygen supply whilst on Ward 16. Whilst the walled oxygen was being serviced, the supply was changed to a cylinder. When complainant returned to her son she noticed that his SATS were at 74% and he was not being monitored.

The oxygen cylinders were noted to be full when initially changed and the investigation was therefore unable to determine how this incident occurred, in terms of low oxygen. A new process however will be put in place to prevent a similar situation happening again.

If temporary oxygen cylinders need to be used, this will only be when the ward is fully staffed. The Paediatrics Team have also designed a prompt form, which is kept with the portable oxygen cylinders. This requires a signature to confirm that the oxygen cylinder is over half full and further checks every 5 minutes that the child is receiving the correct oxygen. The incident will also be presented as a patient story at the Paediatric Grand Huddle.

17364 Patient underwent breast surgery but following the operation she was not given any post-operative physiotherapy instructions. Patient subsequently suffered frozen shoulder and the scar tissue was knotted. This delayed the planned radiotherapy treatment.

It was clarified with regards to the specific operation, at the time it was routine to provide advice around wound care, rest and general exercise, but not specific shoulder exercises.

Following discussion at QIPS it was agreed that all patients who were to undergo any form of breast reconstruction will be sent information leaflets with exercises prior to their surgery. In addition, the discharging doctor and the Plastic Surgery Specialist Nurse, will re-emphasise the advice regarding post-operative physiotherapy and a referral to the Physiotherapy Team will be arranged if needed.

17403 Patient raised concerns that Consultant Dermatologist did not offer appropriate medical advice on how to treat their condition. Furthermore, according to the GP, the medications prescribed had been 'black listed' and could not be provided.

Apologies offered for patient's experience and reassured that the Consultant Dermatologist made a clinical diagnosis and prescribed the relevant medications. Further clarified that one of the medications had no prescribing restrictions so should have been prescribed by the GP. The second item is a licensed medication but is subject to local prescribing restrictions. It was acknowledged that the patient should have been informed that they may experience difficulties in obtaining part of their prescription.

Complaint discussed at Dermatology QIPS. The emphasis was to take time to ensure that patients have an understanding of their condition and to try to address their expectations as best as possible.

8

Complainant Satisfaction Survey

How did you find out how to make a complaint?

Was it easy to find information on how to make a complaint or raise a concern?

Do you feel that your complaint was responded to within a reasonable amount of time?

Did we provide you with a clear and understandable response?

Do you feel that we fully addressed your complaint?

Do you feel that your concerns were treated seriously and with sensitivity?

Did you feel that we understood your complaint?

Overall, how satisfied are you with the way your complaint was handled?

4% 13% 25% 13%

A member of staff Leaflet Internet The Patient Advice and Liaison Service Another organisation

32% 56% 12%

Very easy Easy Not easy

24% 48% 28%

Yes completely Yes to some extent No

32% 48% 20%

23% 42% 35%

48% 36% 16%

48% 43% 9%

39% 25% 26%

Satisfied Neither satisfied nor dissatisfied Dissatisfied

8

Below you will see the results of the Complaints Satisfaction Survey for Quarter 4; the results of this are reported into the Patient Experience and Engagement Committee. There was a total of 27 responses in Quarter 4.

9

5 working day

performance

Total number of PALS enquiries

received

50 Working

Days

The age of oldest PALS

enquiry at end of quarter

PALS Performance for Quarter 4

807 93%

807

42% 50%

Extremely likely Likely Neither likely nor unlikely Unlikely Extremely unlikely Don't know

How likely are you to recommend PALS to friends and family?

8%

93%

10

PALS Activity and Performance

Quarter 3 2017-18

January 2018

February 2018

March 2018

Quarter 4 Total

PALS Enquires 724 265 244 298 807

Signposting 32 4 6 9 19

Immediate Response 451 170 136 145 451

Liaise and Respond 192 84 82 109 275

Refer to Specialty 19 1 15 28 44

On-going support 15 6 5 7 18

Oldest open enquiry at end of Q4 - 50WD 27WD 8WD 50WD

90% of enquires resolved or referred in 5 working days

674 (93%) 228 (86%) 226 (92%) 294 (98%) 748(93%)

• Work streams : The work streams allows PALS to triage enquiries appropriately which enables effective management and reporting of the PALS caseload and enhances PALS ability to perform trend analysis. Each work stream will be analysed to provide information on a monthly and quarterly basis. The work streams are as follows:

• Signposting: PALS receive enquiries that do not relate to UHCW. In these cases the PALS will be as helpful as possible and where they are able to they will signpost the

enquirer to the relevant organisation. • Immediate Response: where possible the PALS provide an immediate response to enquiries raised.

• Liaise and Respond: in these cases the PALS will raise the enquiry with the relevant service(s) to obtain a response that they will relay to the enquirer on the service(s)

behalf.

• Refer to Specialty: in some cases the PALS will identify that the enquiry needs to me managed directly by the service(s) and they will therefore refer the enquiry to the relevant services(s) to respond to directly. They will advise the enquirer of the timeframe in which they can expect to receive a response and the enquirer will be invited to contact the PALS again should they not receive a response from the service or if they require any further support.

• Ongoing support: in some cases patients or their family, friends or carers require ongoing support through a period of care. For example the PALS may support patient’s through the Patient Safety Investigation Process.

11

PALS Top 5 Subjects

Neonatal: “This is just a quick email to say that the staff of University hospital in neonatal care and transitional care were amazing. My baby was born 10 weeks premature and stayed there for about 7 weeks. He was born at 960 grams. The care he received was amazing. The nurses and doctors kept us up to date. I would not have had it any other way. 6months on he is doing really well.”

“To all staff on ward 1 (area 1) Unfortunately I had to spend a total of 8 days on the ward and the staff could not of done any more for me if they tried, from the cleaners to the consultants treat me with the highest of care. I believed this helped me recover a lot quicker. I have stayed on many wards in my time and I can honestly say this has been the best ward by far.”

Top 5 Primary Subjects Top 3 Themes

1st : Appointments

225

Appointment - availability (inc urgent) 114

Appointment delay (inc length of wait) 36

Other - Appointments incl delays / cancellations 28

2nd: Communications

175


Communication with relatives/carers 50

Other - Communications 15

3rd: Trust Admin / Policies / Procedures incl Pt record management

76

Complaint handling - all aspects 30

Access to health records 23

Other - Trust Admin issues 11

4th: Admissions, Discharges & transfers (excl delayed discharge due to absence of care package - see Integrated care)

61

Other - Admissions, Discharges & Transfers 14

Discharge Arrangements (inc lack of or poor planning) 13


5th: Waiting Times

54

Wait for operation/procedure 36

Emergency Department/MAU waiting time 6

Waiting for Appointment / Length of Waiting List 5

12

Below you will see a series of examples of PALS enquiries received throughout Quarter 4; the examples below represent the variety of concerns and enquiries that the PALS deal with daily under each work stream, and provide examples of the outcomes achieved.

Actions taken as a result of PALS Enquiries

Datix ID Main Issues of Complaint Action Taken Outcome

16797 Immediate Response

Delay in receiving MRI scan results.

PALS spoke with the Operational Manager and Performance Manager for Radiology who confirmed that the Royal College of Radiology (RCR) in its submission of ‘information submitted to Health Education England Workforce planning and education commissioning 2015/16’ noted that there is a national shortage of Consultant Radiologists’. It also pointed out that Coventry was one of the ‘hotspots’ for unfilled posts is the West Midlands.

Apologised for the delay in reporting results and explained the reasons behind this.

16441 Refer to Specialty

Patient was handed a questionnaire in clinic 3, respiratory medicine - she is unhappy with 2 of the questions 1. Do you have a partner? 2. If yes, do you share a bedroom?

PALS spoke with the Group Manager who advised that she will speak to the team and ask them to telephone the patient.

The team telephoned the patient and addressed her concerns.

17585 Ongoing Support

Patient admitted to ward and waiting for a bed at the Caludon Centre. Patient has discussed personal problems and would like support once transferred.

PALS supported the patient whilst on the ward and continued to support once transferred to the Caluden Centre.

Patient thanked PALS for supporting her and her family.

16882 Signposting

Mother of patient having concerns over Autism Diagnosis and visit from the District Nursing Team.

PALS contacted the Coventry and Warwickshire Partnership NHS Trust relaying the information to their PALS team

CWPT contacted the relative and resolved their concerns.

16884 Liaise and Respond

Patient has been waiting 24 weeks for hip operation; he is aware that "legal requirements are to have procedure in 18 weeks“.

PALS contacted the Group Manager for Hospital of St Cross, Rugby to progress this matter.

The patient had his surgery in November 2017.

13

Below you will see the results of the PALS Satisfaction Survey for Quarter 4; the results of this are reported into the Patient Experience and Engagement Committee. There was a total of 12 responses in Quarter 4.

PALS Satisfaction Survey

How did you hear about PALS?

How did you contact PALS?

Do you feel you were kept reasonably informed of progress during the handling of your enquiry?

Were you happy with the speed in which PALS responded to your enquiry?

Did PALS do what they said they would do?

Did PALS clearly explain how they could help you?

Do you feel that PALS understood your enquiry?

Did you find the PALS staff approachable and supportive?

How likely are you to recommend PALS to friends and family?

42% 8% 25% 8% 17%

Member of staff Internet Leaflet Poster Other (please state below)

25% 50% 25% 0%

Telephone Email Met with a PALS member of staff in person Letter

75%

Yes completely Yes to some extent No

83%

67% 17% 17%

83% 0% 17%

83% 17% 0%

67% 17% 17%

42% 50%

Extremely likely Likely Neither likely nor unlikely Unlikely Extremely unlikely Don't know

17%

17% 8%

8%

14

2a- Involvement activity 1) Kitchen Table Event , Main Outpatient Department, University Hospital: 23rd January 2018 The following key messages can be taken from the Event: • Access to the Site: distance from the car parks to the hospital is too far, access and egress to the site is extremely problematic, waits for patients who

use non emergency transport are too long. • Car Parking: Not enough spaces, charges are far too expensive, payment machines are often out of order, weekly or monthly car parking passes

should be introduced. • Environment, General: the ambience is good, the chairs are comfortable, good refreshments available but wider choice needed, need for

entertainment materials such as magazines and TV screens. • Miscellaneous: mixed views on new Phlebotomy appointment system, mixed views on waiting times in the department, satisfaction levels with staff

are extremely high; text appointment reminders are very helpful. The Outpatient Management Team are currently action planning to address areas identified for improvement.

2) Stakeholder Management visits-(Awareness Raising re New Patient Involvement Programme) - Alzheimer’s Society, Age UK, Heart of England Carers Trust and the Milan Group (a support group for Asian carers).

4) Patient Experience and Engagement Delivery Plan 2018-2021 published - the plan outlines the Quality Strategy PE objectives 5) Patient Involvement Week - The Trust’s first Patient Involvement Week took place during 12th March 2018 – 16th March 2018

6) The Trust’s new Involvement Hub – was officially launched by the CEO on the 12th March and is available for staff to book for Awareness Raising Events/Service Improvements/Surveying Patients/Advertising new procedures/any other events which require engaging with patients, relatives, carers and/or members of the public

7) Recruitment to Patient Partners’ Programme & Patient & Public Involvement Panel – recruitment is underway for the Trust’s first cohort of its new Patient Partners, interview are scheduled for April and May.

8) We Care Newspaper launched - In March the first quarterly We Care newspaper was published. For both staff and patients, the newspaper features articles on how the Trust is improving patient experience as well as involvement opportunities.

9) We Care Delivery Plan 2018-2021 – was published in February and contains the Trust commitment's for delivering its Patient Experience and Engagement Programme

15

2b Insight - Patient Insight and Impressions

Quarter 4 2016/17 Quarter 4 2017/18

Bottom 3 areas

Food & Drink: Two new

menus have been

launched onto the wards

for patients the Main Menu

& Special Diet Menu and

the Low Potassium Menu

these were launched on

the 19th March and have

been a success with both

patients and staff.

Doing things on Time:

new training is being rolled

out to new starters,

processes are being

embedded and

engagement with

specialties has

commenced. Reporting

levels of compliance are

currently limited because

the training is not role

specific or renewable in

ESR. The Mandatory

Training Committee need

to review (Sarah Slack,

Service Development

Lead– April 2018).

Car Parking: negotiations

continue for increased

parking

16

Friends and Family Test - Activity and Performance The Friends and Family Test (FFT) is a national initiative overseen by NHS England. It is an initial single question, which asks patients whether they would recommend the NHS service they have received to family and friends if they need similar care or treatment, plus a supplementary question asking why the patient has responded how they have. The FFT question is incorporated into Impressions. The results are presented as a percentage of recommenders and non-recommenders. The tables below show UHCW’s figures against our internal targets and also the national average for the previous Quarter.

January '18

Recommender %

February '18

Recommender %

March ’18

Recommender %

Internal Target

Recommender %

National Average

for Q2 17/18

Inpatients 92% 92% 89% 95% 95%

A&E 82% 77% 81% 87% 86%

Antenatal (after 36 weeks) Experience 94% 98% 95% 97% 95%

Birth/Labour Experience 96% 99% 100% 98% 96%

Postnatal (hospital) Experience 96% 92% 99% 93% 98%

Postnatal (community) Experience 100% 98% 99% 97% 93%

January'18

Response Rate %

February'18

Response Rate %

March'18 Response

Rate %

Internal Target

Response Rate %

National Average

for Q2 17/18

Inpatients 21% 22% 20% 26% 25%

A&E 12% 12% 13% 15% 13%

Antenatal (after 36 weeks) Experience 25% 22% 27% 15% N/A

Birth/Labour Experience 16% 16% 19% 15% 23%

Postnatal (hospital) Experience 26% 27% 21% 15% N/A

Postnatal (community) Experience 16% 22% 19% 15% N/A

NHS Choices Ratings: University Hospitals 4 stars, Hospital of St Cross 5 stars.

Over all rating for University Hospitals Coventry and Warwickshire 4 stars

17

Feedback from Involvement Hub Kiosks

16 Feb-31 March

17

On the 16th February three feedback kiosks were installed as part of

the Involvement Hub in the main entrance of University Hospital to

support greater insight and engagement. The first survey looked at

five value based questions, which were co-developed by patients,

from Sept 2018 these questions will form part of the new Trust FFT

survey for all adult inpatient and outpatient contacts. The questions

developed cover five of the seven trust values:

• Were you treated as an individual with care and kindness?

(compassion)

• Did staff involve you in there care? (Involve)

• Did staff treat you with dignity and respect? (Respect)

• Were staff open and honest with you at all times? (Openness)

• Were staff passionate about delivering high standards of care?

(Pride)

Data Summary for 16th Feb to 31st March (3004 responses

for Q4 )

• 3004 relied to Compassion question – 64.9% always /very often

• 1675 replied to Involve – 73.5% always /very often

• 1638 relied to Respect – 76.3% always /very often

• 1385 relied to openness – 77.3% always /very often

• 1389 relied to pride – 77.4% always /very often

In addition to the five questions respondents also had the

opportunity to provide verbatim comments. These comments from

Q2 will be fully Intergrated into the impressions system.

18

Feedback from Involvement Hub

16 Feb-31 March

18

19

Feedback from Involvement Hub

16 Feb-31 March

19

20

Insight actions – Responding to feedback & surveys The Action Log captures “extremely unlikely” and negative feedback from the FFT questionnaire (and feed back kiosks from May 2018) in addition to National Survey Programme actions. This new system began in September 2017 and the data below covers September to March. Further work to revised the log is being carried out by the supplier, which will allow for more detailed reporting.

20

Number of Actions Group with highest number of actions

Number of closed Actions Number of open Actions Top Three Themes from Action Log

Womens and

Childrens

67 10 Functionality

not yet

developed-

due by

September

2018

National Survey Programme 2018

• Inpatient survey - I inpatient Survey 2017 will be published in May/June • Children and Young people - Fieldwork is underway for the 2018 Children and Young People’s survey. • Maternity - Fieldwork for the Maternity Survey 2018 will take place between April- August 2018. • Cancer survey - The Cancer Patient Experience Survey report for 2017 will be published in July 2018, fieldwork for the 2018 survey will

commence in October 2018

21

Board Walk Rounds

Quality Walk Rounds are a way of ensuring that Board members are informed first hand regarding any safety concerns of frontline staff. They are also a way of demonstrating visible commitment by listening to and supporting frontline staff when issues of safety are raised. They were recommended by the National Patient Safety Agency (NPSA) as part of their “Patient Safety First” campaign. Walk Rounds are also support the drive for culture change as identified in the Francis report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013) and the Berwick review (A promise to learn– a commitment to act, 2013) where it was strongly recognised that leaders have a crucial part to play in shaping a positive culture and that the voices of our staff are amongst the most valuable for learning about patient safety. The outcomes of each Walk Round are recorded and the areas are asked to provide an update on the action taken to deliver the improvements identified. Some of the actions are medium to long term developments and the action will therefore be ongoing. The volume of outcomes resulting from Board Walk Rounds mean that full details cannot be provided within the report but an overview of the outcomes and resulting actions is provided. Quarter 4 Board Walk Rounds Board Walk Rounds continued in Quarter 4. Four areas were visited in total across four Specialty Groups. A wide range of positive practices were identified and rich conversation took place with regards to the improvements that could be made in each area to continue to deliver on our commitment to provide world class patient care and experience. Below is a summary of the outcomes of each Board Walk Round within each Specialty Group. Oncology

Ward 35: The ward was observed to have a very good and stable team, with only one vacancy and little use of agency staff. Staff reported that the Group Manager was very supportive and it was highlighted that the Ward Pharmacist was extremely diligent in identifying drug errors. It was recognised that the early morning patient safety huddles were working well however it would be beneficial if more doctors attended. Some opportunities for improvements were identified including exploring the possibility of a fire alarm on the lift doors and reducing the number of bed management meetings per day to free up the Ward Managers time to increase their presence on the ward. Following the Board Walk Around the ward have reported that the bed management meetings are now co-ordinated and representation shared between different Wards and staff members on that ward thus reducing the impact on the Ward Manager’s availability. While there is no change in doctor attendance at the Ward Safety Huddle any pertinent issues are shared with the doctors when the Ward Round commences at 0900.

22

22 Surgery Ward 33: It was observed that the ward had a stable team with strong teamwork being observed across the team, including ISS. There were low vacancies and therefore a low use of bank and agency staff. The staff confirmed that they were able to raise and escalate any concerns they had through the team meetings. In terms of positive change, it was raised that it was necessary for doctors to be reminded to prepare TTOs the day before discharge to support patient flow. The ward has confirmed that the doctors now attend the board rounds at which point it is highlighted which TTOs are a priority for the medical team to support flow. Other areas for change related to working in partnership with other teams, such as the support received from mental health teams, greater use of SODA for straightforward treatments that do not require a bed and working in partnership with community colleagues particularly with regards to patients undergoing detox who could be discharged earlier if effective handover could take place with the community team. The ward will continue to explore ways in which these teams can better work together to ensure the best possible care is provided as efficiently as possible. Renal Ward 50: A large number of positive observations were made; the team were observed to manage their staffing challenges well and they demonstrated resilience and effective team working. Positive relationships with ISS were observed and the staff provided positive feedback about the quality of their cleaning services. It was recognised that renal outliers are well managed with a renal consultant being identified to support in this area. It was confirmed that safety huddles took place each morning with multi-disciplinary attendance. Further training for HCAs working in renal was considered to be required and since the Board Walk Around a training day has taken place with another one being scheduled in. Nursing staffing was recognised to be below what was required but the ward were able to confirm that two new registered nurses were due to start in September. To assist in the short term the ward have now managed to recruit three more HCAs and a nursing associate has also been recruited to Ward 50. A number of suggestions for positive change were made including making their trained nurse co-ordinator supernumerary as other wards have done, allocating time to a trained member of staff to lead local renal training and delivering more sessions to support staff with the forthcoming CQC inspection. The Ward have confirmed that daily huddles have taken place in respect of the CQC inspection where information has been provided and staff have been updated on Trust wide communication in this regard.

23

Orthopaedics

Ward 53: A number of positive observations were made at the Board Walk Around including good multi-disciplinary working with visitors being well received to the department. The enhanced recovery process programme was recognised to support patients with a pathway to a rehab bed after they have received their surgery. Good adoption of the Red to Green as SAFER principles were observed and it was pleasing to see Associate Nurse Practitioners running their own clinics. A number of observations for positive change were made including how having more ortho-geriatricians would deliver better management of this particular group of patients. The ward has confirmed that recruitment to this role is an ongoing challenge but that the Group Manager is currently working on a business case that will include a plan to have an additional ANP to be shared with Trauma and Orthopaedics and Gerontology. Medical Outliers were raised as adversely affecting the elective lists and the ward recognise that this is an ongoing challenge which is a Trust level issue. They have however taken a number of steps to better manage the issue locally including a daily morning meeting to identify what action is required and to better plan the bed capacity. TTOs being completed in advance was seen as an area that would support patient flow and the ward has confirmed that the importance of this is now included in the new Junior Doctors Induction Programme. Appropriate and safe discharge of patients to other more suitable centres or rehabilitation beds was raised as an opportunity for improvement and this is something that has since been raised and discussed at the Department Meeting and a repatriation list has now been introduced to aid escalation.

23

24

PATIENT EXPERIENCE TEAM QUALITY DEPARTMENT

3RD FLOOR CENTRAL EXT 25166

@nhsuhcw https://www.facebook.com/NHSUHCW/ @nhsuhcw


Title Safeguarding Adults and Children report

Author Lisa Pratley, Lead Professional for Safeguarding


Nina Fraser, Chief Nursing Officer

Date 31 May 2018

1. Purpose To update the Board on Safeguarding activity, issues and risks for both children and adults throughout 2017-18.

2. Background and Links to Previous Papers The Safeguarding Team provides a regular update for the Trust Board. This paper is an annual report for 2017-18.

3. Executive Summary The report provides information on the following areas:

Referrals to Social Care

Training compliance

Audit

Serious Case Reviews

Deprivation of Liberties safeguards

4. Areas of Risk

The overall training compliance for safeguarding is a risk for the trust as it could impact on quality of care and reputation with the CCG and external agencies, and this does sit on the risk register. The safeguarding team are targeting individuals who have not yet had their training. The team will continue with delivering training in various formats to support individual learning styles.

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks By ensuring that we are able to safeguard the wellbeing of children and adults in our care will support the trust to achieve a rating of at least “good” in the next CQC inspection, The Safeguarding Team will continue to actively participate in system wide working within Coventry and Warwickshire to ensure effective population health, working collaboratively with partner agencies to ensure statutory safeguarding arrangements are met.

of 2

6. Governance The Trust is committed to its’ contractual obligations and complying with legislation including the Care Act (2014) and the Children Act (1989). There is monthly safeguarding vulnerable adults and children committee chaired by the chief nursing officer. This committee then feeds into patient’s safety committee and the nursing and midwifery committee. 7. Responsibility Nina Fraser, Chief Nursing Officer, is the chief officer with the responsibility for Safeguarding. 8. Recommendations The Board is invited to note the Safeguarding report. Name and Title of Author: Lisa Pratley (Lead Professional for Safeguarding) Date: 23.05.18

1

Safeguarding Adults & Children’s Report

This is an annual report to update the Trust Board on safeguarding activity, issues

and risks for both adults and children in relation to the financial year of 2017-18.

UHCW continues to work collaboratively with partner agencies in order to ensure

statutory safeguarding arrangements are met within children and adult services.

UHCW NHS Trust is represented at both the Local Safeguarding Children Board and

the Safeguarding Adult Board by the Associate Director of Nursing for Women,

Children and Safeguarding. The Lead Professional for Safeguarding, the Named

Nurse for Safeguarding Adults or the Named Doctor represent the Trust on all

Safeguarding Board Subcommittees. The Serious Case Review Subcommittee is

chaired by UHCW’s Named Doctor for Child Protection and the Workforce and

Development sub group by the Named Nurse for Safeguarding Adults.

1. Referrals to Social Care

The two graphs below summarise the referrals made by UHCW to both Children’s

Social Care and Adult’s Social Care throughout the year of 2017-18.

Children

As this graph below demonstrates the predominant reason for UHCW referring to

Childrens Social Care is due to their behavioural issues which would be placed

under the category of emotional abuse. This relates primarily to the large number of

children and young people who are admitted to the paediatric wards following self-

harm or suicidal ideation. Many of these children and young people are repeat

attenders and often remain as an inpatient for a prolonged period due to specialist

support being required such as tier 4 placements. The safeguarding team regularly

liaise with the lead nurse for paediatrics and the child and adolescent mental health

service to review this cohort of patients and ensure that they are in the right place

receiving the right care.

2

Adults

12

30

3

46

22

82

40

22

3 9

0102030405060708090

No

. Of

Ref

erra

ls

Catergory

Referrals - Safeguarding Children 1st April 2017 - 31st March 2018

4 9

0 0

34

16

87 82

25

43

0

10

20

30

40

50

60

70

80

90

100

No

. of

Ref

erra

ls

Category

Referrals - Safeguarding Adults 1st April 2017 - 31st March 2018

3

The safeguarding team have raised awareness around Self- Neglect in its various

forms throughout the year and this has been reflected in the high number of referrals

to adult’s social care for this reason. There are a number of strategy’s within the

hospital to support this cohorts patients including, referral to the fire service, Age UK,

alcohol liaison with the aim of providing a personalised care plan. Neglect was the

predominant reason for referral. Within an acute hospital the staff will often see an

unwell patient whereby neglect is suspected due to the nature of their presentation.

Many of the concerns however are not substantiated following further investigation.

2. Training

Training figures for April 2018

Compliant Non- Compliant

Target % Compliant

Safeguarding Children level 1 1770 183 1953 90.63%



Safeguarding Adults level 1 7877 1196 9073 86.82%

Safeguarding Adults level 2 505 75 580 87.07%

To increase compliance the safeguarding team are trying to meet the needs of the

staff by offering a variety of learning opportunities; which include face to face

sessions, E-learning modules, and work books. There is also a 2 for 1 offer whereby

staff can attend a face to face session for one hour and obtain both safeguarding

adults level one and safeguarding children level two competencies. Individuals who

are non-compliant have been informed of the upcoming training opportunities via

email.

The safeguarding team continue to work with the Temporary Staffing Service to

identify staff that may no longer be active members of our work force so they can be

removed from the data. Temporary staffing are the group which negatively affects

4

the overall compliance of the trust. There is a separate work stream being led by the

trust to address this group of staff.

Specialty Group

Safeguarding Adults Level 1 -

3 Yearly

Safeguarding Adults Level 2 - 3 Yearly

Safeguarding Children Level

1 - 3 Yearly

Safeguarding Children Level 2

- 3 Yearly

Safeguarding Children Level 3

- 3 Years

Cardiac & Respiratory 93.54% 89.13% 95.56% 90.41%

Care of the Elderly 96.50% 95.00% 92.31% 96.09%

Clinical Diagnostics 94.66% 89.19% 94.55% 93.01% 100.00%

Clinical Support Services 97.79% 90.00% 93.42% 98.60% 100.00%

Core Services 94.00% 100.00% 95.10% 93.72% 92.86%

Emergency Department and Acute Medicine 90.17% 89.87% 91.94% 97.25% 70.78%

Neurosciences 86.18% 75.86% 84.21% 90.69%

Oncology, Haematology & Renal 94.36% 79.17% 94.25% 95.93%

Specialist Medicine & Ophthalmology 94.08% 90.91% 87.72% 95.54% 100.00%

St Cross and Trauma & Orthopaedics 95.83% 88.89% 94.62% 93.48% 75.00%

Surgery 92.74% 82.19% 95.70% 93.78%

Temporary Staffing Division 48.43% 16.67% 57.58% 55.08% 60.00%

Theatres and Anaesthetics 97.81% 90.79% 92.68% 97.80%

Women & Childrens 96.02% 89.66% 98.67% 96.37% 93.28%

Grand Total 86.82% 87.07% 90.63% 86.94% 86.80%

PREVENT Training

Prevent is one of the arms of the government’s anti-terrorism strategy, it addresses

the need for staff to raise their concerns about individuals being drawn towards

radicalisation. Prevent training at UHCW forms part of the wider safeguarding

agenda and encourages staff to view an individual’s vulnerability as they would any

other safeguarding issue. The training has been developed in accordance with the

Prevent Training and Competencies Framework (2015). All staff groups require basic

Prevent and all clinical staff are required to attend Workshops to Raise Awareness of

Prevent (WRAP). This has been undertaken in a phased approach.

April 18

PREVENT Awareness 98.54%

PREVENT WRAP 94.4%

5

3. Audit

UHCW have completed a number of audits throughout the year which have been

reported to the safeguarding committee upon completion. In addition the team

contributes to both the Adults and Children Safeguarding Board audits.

Below is a summary of the internal audits undertaken in 2017-18.

Safeguarding Children Audits

Hidden Harm (quarter 1 and 4)

The experience of children and young people living with parents who abuse alcohol,

misuse substances and/or self-harm has become known as Hidden Harm. The

impact can have devastating effects on these children and young people and can

affect them for the rest of their lives – they need access to support and advice.

An internal audit has been undertaken by the Safeguarding Team investigating if

UHCW are responding appropriately when parents present to the Emergency

Department following self-harm, intoxication or substance misuse. This is a repeat

audit from June 2017.

The audit reviewed the 10% of attendances to the Emergency Department with

intoxication/self-harm/overdose during a month. The results show that practice is

improving with asking patients if they have children and the sharing of relevant

information with Childrens Social Care however the child’s welfare at the present

time was not always captured.

No

. Standard

Current

Compliance

(January 18)

Previous

Compliance

(June 17)

1. Patient asked if they have children 59.4% 33.3%

2. Documented where children were 55.6% 83.3%

3. Information shared with Children’s

Social Care 77.8% 50%

6

An action plan was been developed to share these findings with the Emergency

Department and to work closely with them to improve the results. Plan to re-audit

June 2018.

Notification to the Local Authority Children’s Services of Children in Hospital for 3

Months (quarter 1 and quarter 3)

An internal audit was performed to ensure staff are adhering to the trust guideline

which reflects the statutory guidance by notifying the local authority of any children

who are inpatients for 3 months / 90 consecutive days or above. The audit was

completed by reviewing the documentation in the medical notes.

No. Standard

Compliance

(November

17)

Compliance

(April 17)

1 Notification Form completed in full 9 /11 – 81.8% 5 / 8 - 62.5%

2

Notification forwarded to

Safeguarding Team

8 / 9 – 88.8% 3 / 5 – 60%

3

Notification forwarded to Local

Authority

8/ 9 – 88.8% 4 / 5– 80%

The audit highlights that, overall, compliance with this policy is satisfactory however

there are some improvements that could be made to ensure 100% compliance.

Following the audit the safeguarding team have introduce a tracking system for all

notifications as there was no evidence that the notifications were forwarded to the

relevant local authority.

7

Female Genital Mutilation (FGM) Risk Assessment and Information Sharing (quarter

2)

A repeat single agency audit was undertaken to ensure that the maternity service is

completing appropriate risk assessments on mothers whom are identified as having

FGM, and sharing this information as appropriate with Childrens Social Care and the

health visiting service.

No. Standard Compliance

1. FGM identified in the antenatal period. 4 / 4 – 100%

2. FGM risk assessment completed 4 /4 – 100%

3. Appropriate referral to Children’s Social Care 1/1- 100%

4.

FGM documented on the triplicate back page

of postnatal notes in order to share

information with the health visiting service?

3 /4 – 75%

The questioning and recording of FGM during the antenatal period remained 100%

compliant and it was reassuring to note that when identifying FGM a risk assessment

is always being completed. The early identification is beneficial in terms of planning

the health care and also in raising any potential safeguarding concerns. This was

demonstrated within one case that warranted referral to Childrens Social Care.

It is unfortunate that due to the small numbers of ladies who had given birth over this

time period one lady did not have information shared with the health visiting service

meaning compliance was only 75%. However this is an improvement on the previous

audit.

Recommendations from the audit were shared with maternity staff and the

importance of documentation and information sharing was expressed. This audit will

be repeated in 12 months.

Child Protection Supervision (quarter 4).

When the CQC last inspected UHCW in 2015 they highlighted that all community

midwives should be supported by regular child protection supervision as this was not

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happening. In 2016 the safeguarding team reviewed the trust policy and began to

implement quarterly supervision for all community midwives with the understanding

that they are required to attend a minimum of two sessions per year. A review of the

attendance at supervision has highlighted that the supervision has been well

attended and only 3 members of staff have not achieved the expectation that they

will attend 2 within 12 months. These names have been shared with the relevant

modern matron

Safeguarding Adults Audits

Deprivation of Liberty Safeguards Authorisation (quarter 1)

The safeguarding team undertook an audit to review the use of Deprivation of Liberty

Safeguards (DoLS) and timeliness of assessment to ensure that UHCW staff are

appropriately applying for Deprivation of Liberty Safeguards and that the subsequent

assessment process by the local authority is timely. All DoLS submissions completed

by UHCW NHS Trust during a 3month period were audited. This totalled 73 cases.

The audit demonstrated a considerable increase in the number of DoLS applications

by UHCW over this period. This is attributable to an increase in staff awareness due

to an increased presence on board rounds in the same time period by the

safeguarding team. Alongside the increase in DoLS applications, there was a

noticeable decrease in the percentage of patients being assessed and authorised by

the Local Authority in a timely manner which may indicate that the local authorities

were not prepared for this increase in applications on top of an existing backlog. It

was disappointing to note that none of the cases met the urgent authorisation time

frame, (14 days) and only one application in met the time frame for standard

authorisation, (28 Days).

Recommendations from the audit was to share the findings with the local authorities

involved. This was completed and in recognition of the increased demand for

assessments from UHCW and other sources, the one Local Authority is employing

more ‘best interest’ assessors and hopes to have a number of these based in

UHCW.

Completion of capacity assessments (quarter 4).

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An audit was undertaken to determine whether the process of decision making

around ReSPECT followed the Mental Capacity Act (MCA) Principles. On a single

day a snapshot was taken from CRRS of all inpatients who had a ReSPECT form

and were identified on the form as lacking capacity. A member of the safeguarding

team then went and reviewed the patient’s notes to examine if there was evidence of

the mental capacity act principles being adhered to.

12 patients were identified and each of their medical records were reviewed.

Unfortunately none of the patients had a capacity assessment documented in

relation to the ReSPECT decision in their medical records. It was evident that all of

the patients had family and friend but only 7 of the 12 (58%) had a documented best

interests meeting whereby the patient was represented d by these family and friends.

However there was documentation to state that all of the other families had been

informed of the ReSPECT decision for their relative.

The audit has highlighted that documentation surrounding MCA and the ReSPECT

form needs to be improved. Therefore the ongoing work by the safeguarding team to

raise awareness of Mental Capacity assessments needs to continue and be

supported by the resuscitation department. The resuscitation department are happy

to work with the safeguarding team and will discuss Mental Capacity when educating

staff in relation to ReSPECT. The audit findings will be incorporated into the

upcoming training facilitated by the safeguarding team.

Since the audit the safeguarding team have increased visibility at board rounds and

supported staff to ask the question of every patient – does this patient have

impairment to mind or brain? And if yes – are they undergoing any treatment or

procedures today? It is hoped that this will encourage staff to consider capacity

assessments and document where required. The team have also distributed

proformas for recording capacity assessments to all clinical areas.

Weekly audits have now begun to monitor compliance with capacity assessment as

a whole and not just in conjunction with ReSPECT forms. The latest audit was

undertaken across the medical wards. In total 19 patients were reviewed who had

impairment or disturbance of mind including learning disability, dementia, delirium,

sepsis, stroke or head injury. The medical notes of these patients were reviewed and

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capacity assessments were looked for in connection with each decision. Overall

there were 27 decisions that would require a capacity assessment to be undertaken,

however there were only 14 (52%) documented assessments. This was more

reassuring and the audit findings were shared with the relevant matrons. The

safeguarding team are currently working with ward 30 and ward 31 utilising UHCWi

methodology to understand how as a trust we can improve documentation in relation

to capacity assessments.

4. Serious Case Reviews (SCRs)

Adults

Throughout the year UHCW have submitted scoping as requested for two serious

adult reviews. The individual management review request is awaited for one and the

other is not being taken any further. Therefore the trust has no outstanding actions.

Children

Throughout the year UHCW have submitted scoping as requested for two serious

case reviews. One of which was in relation to a complex sexual abuse case which

involved a number of children, the individual management review has also been

submitted for this and the final report is expected in the summer of 2018.

Throughout the year there have been two domestic homicide reviews which UHCW

have contributed to. Neither of the reviews are yet published however it is not

anticipated that there will be any agency specific actions for UHCW.

5. CQC ‘Should Do’ Recommendations

Following the CQC inspection in March 2015 a ‘should do’ recommendation was

made in relation to improving staff members understanding of the Mental Capacity

Act (MCA) and Deprivation of Liberties Safeguards (DoLS) and how to apply them in

practice. There is an action plan in progress which has been updated with the chief

nurses approval in April 2018.

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The number of DoLS applications made by the trust has increased over the last 12

months which is reflective of the visibility and training provided by the safeguarding

team.

The safeguarding team continue to have a presence within the clinical areas to

engage staff and promote the use of the Mental Capacity Act and DoLS and have

launched a campaign ‘Act on the Act’ whereby staff from within clinical areas are

delivering power training to their colleagues.

6. I.T Systems

Throughout the year the safeguarding team have facilitated the implementation of

two I.T systems which will enhance safeguarding.

The Child Protection – Information Sharing (CP-IS) system is an NHS England

sponsored information sharing solution that will deliver a higher level of protection to

children who visit NHS unscheduled care settings. It does so by connecting local

authorities’ Childrens Social Care IT systems with those used by staff in NHS

unscheduled care settings. The information sharing focuses on three specific

categories of child:

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Those with a child protection plan

Those with looked after child status (children with full and interim care orders

and voluntary care agreements)

Pregnant women whose unborn child has a pre-birth child protection plan.

UHCW have been utilising this system within the Childrens Emergency Department

since October 2016 and have subsequently throughout 2017-18 implemented this

system to the trusts remaining unscheduled care settings, Clinic 9 Eye Casualty,

Maternity and Emergency Gynaecology, Rugby Urgent Care and the Emergency

Department.

The second system implemented is the Female Genital Mutilation (FGM) Risk

Indicator system. The FGM Risk Indicator System (RIS) allows authorised healthcare

professionals and administrative staff throughout England to view information about

girls at risk of FGM, regardless of location (e.g. midwives, GP’s, health visitors).

Seeing a risk indicator should prompt a care team looking after a girl to consider

whether it needs to take further action to safeguard her. The actions that are taken

after seeing the risk indicator will vary according to individual circumstances. A family

history of FGM is very important when assessing potential risk to a girl undergoing

FGM as this is the most significant risk factor. Risk of harm can and does change at

different times, depending on varying factors in the girl’s life.

Within UHCW there are a small number of midwives who have the responsibility of

adding the FGM risk indicator to a girl’s record. The safeguarding team will also have

access to support with this.

7. Conclusion

Overall the safeguarding team have had a productive year and worked with many

clinical areas on specific tasks such as the implementation of IT systems or bespoke

training sessions. However it is recognised that all elements of safeguarding training

compliance can be improved in order to reach the trust target of 95% compliance.

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The team are aiming to improve this by offering an increase in face to face training

as well as ensuring the right cohort of staff sit within each level of training.

There has been a positive change in practice reflected by the increased number of

requests for DoLS applications throughout the year, but it is acknowledged that

further work is required around demonstrating the use of the Mental Capacity Act is

practice such as documenting assessments of capacity. There is a detailed action

plan to address this.

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