report prepared by - wales

REPORT PREPARED BY: Anne Biffin, General Manager, Medical Director’s Department Nicola Williams, Associate Nurse Director, Governance & Safeguarding REPORT SPONSORED BY: Bruce Ferguson, Medical Director Victoria Franklin, Nurse Director

TRUST BOARD 10th JUNE 2009

AGENDA ITEM: 6

1000 LIVES CAMPAIGN UPDATE REPORT

1. PURPOSE

This report provides the Trust Board with a summary of how the Trust is implementing the WHO Safer Surgery Checklist (NPSA Safety Notice), taking forward the Patient Identification Project, progress made in rolling out the hospital at night electronic system and SBAR communication tool and to provide a summary of progress made in the roll out of the campaign interventions through the Clinical Directorates.

2. WHO SAFER SURGERY CHECKLIST

2.1 Background

The National Patient Safety Agency (NPSA) produced a safety action notice on the 15th January 2009. The aim of the initiative is to strengthen the commitment of clinical staff to address safety issues within the surgical setting. This includes improving anaesthetic safety practices, ensuring correct site surgery, avoiding surgical site infections and improving communication within the team. The Safety notice identified that organizations are required to have in place:

• An executive and clinical lead to support the implementation of the checklist across the organisation

• Ensure the checklist is completed for every patient undergoing a surgical procedure (including local anaesthesia).

• Ensure each section is signed by a Registered Practitioner involved in that aspect of the patient’s care.

• Ensure a copy of the checklist is retained in the patient’s notes or electronic clinical record. Where the checklist is not completed or is not retained, the reason must be documented by the accountable practitioner.

Organisations have been asked to implement this through the 1,000 lives structure. Action was required to be underway by the 2nd February 2009, an

Action plan was to be agreed and actions started by the 1st June 2009, and all actions to be completed by the 1st February 2010. The 1,000 lives campaign ‘How to Guide’ was launched on the 5th March 2009 and the Trust commenced its ‘Plan Do Study Act’ (PDSA) cycles the following week. 2.2 Implementation to Date The checklist was initially piloted during two surgeons theatre lists at Morriston Hospital during March 2009. Some minor changes were made to the national form (to add a tick box to the 1000 lives intervention and surgical site infection surveillance section) following this. Posters have been erected across all Trust Theatres and staff education and awareness raising is being rapidly rolled out. The checklist was fully implemented across urology and Orthopaedic theatres in Morriston during April 2009 and was rolled out to the neurosurgery theatre during May. It is envisaged that roll out to all Morriston Theatres will be completed by the end of June 2009. The checklist is being used on one surgeons theatre list in Neath Port Talbot currently and a roll out plan for Neath Port Talbot is being established. The checklist was discussed within the Multidisciplinary audit meeting at Princess of Wales Hospital during May 2009, and work to roll out in POW will commence during June. Singleton roll out will commence once Morriston roll out is complete. The Trust is fully on target to meet the NPSA ‘to be fully implemented by’ date of the 1st February 2009. Morriston and Neath Port Talbot theatres are currently setting up systems to capture the mandatory measure data contemporaneously (to negate the need for retrospective audits as the completed checklists are retained in the patients notes as per 1000 lives campaign requirements). Daily data collection commenced during May 2009. The measure that will need to be put in place in relation to this is: ‘% completing the ‘time out’ section using Safer Surgery Checklist with the core team’.

3. DIRECTORATE SPREAD PLANS

As the Trust is now in a period of ‘rapid spread’ it was agreed that it was essential that ownership and responsibility for spreading the 1,000 lives

interventions that have been tested in isolated areas was provided to the Clinical Directorates. Meetings have been held with most Clinical Directorates to develop and take forward their roll out plans. Remaining meetings will be held during June 2009. Roll out of priority areas have already commenced in a number of the directorates as outlined in the summary provided in Appendix 6.1. The initial three priority roll out areas: decontamination of equipment & the commode bundle; patient at risk scoring; and Pressure ulcer reduction have been endorsed by all directorates (or sections of) for which they would be relevant.

4. ROLL OUT OF THE HOSPITAL AT NIGHT ELECTRONIC SYSTEM & SBAR COMMUNICATION TOOL

As reported at the March Operational Board the Trust was planning to roll out the electronic hospital at night system that has been successfully implemented across Bridgend, Neath Port Talbot Hospitals to Swansea Hospitals.

Significant work has been undertaken since March to make this a reality. The initial roll out will be to Morriston Hospital (due to the unavailability of a wireless network across Singleton Site). Ward V commenced this pilot on the 18th May 2009. The Ward Staff and the Hospital at Night team are fully engaged with the project and are extremely excited about its ability to improve patient safety, efficiency and the ability to audit. An evaluation will be undertaken within the first two weeks and if there are no problems the electronic system will then be rolled out – initially to the rest of the medical wards and ward E. The plan for the roll out to all other wards is being developed by the Hospital at Night Team Manager and Senior Nurse for Operations.

Once the system is in place across all wards at Morriston Hospital the cycle will be repeated at Singleton Hospital. A slightly different way of working will need to be developed as there are no immediate plans for wireless to be installed across this hospital.

The measures to support the evaluation of this project across Swansea Hospitals are being developed and will be agreed prior to the initial pilot commencing.

Linked to the roll out of the electronic hospital at night system will be the implementation of the SBAR Communication Tool. SBAR is a structured method of communication of mainly clinical information between health professionals and stands for:

S – Situation: What is happening at the present time?

B – Background: What are the circumstances leading up to this situation?

A – Assessment: What do I think the problem is?

R – Recommendation: What should we do to correct the problem?

SBAR creates a shared mental model for effective information transfer by providing a standardized structure for concise factual communications among clinicians — nurse-to-nurse, doctor-to-doctor, or between nurse and doctor. The SBAR technique provides a framework for communication between members of the health care team about a patient's condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.

5. PATIENT IDENTIFICATION PROJECT

5.1 Background

In November 2005 the National Patient Safety Agency (NPSA) produced a safety action notice ‘wristbands for Hospital Patients Improves Safety’. The notice was produced as a result of the high number of incidents or near misses that were reported to the NPSA relating to wrist bands or wrist bands with incorrect information. The Safety notice identified that by May 2006 all inpatients should have a wrist band that identified them and matched them to their care. In July 2007 the NPSA released a further Safer Practice Notice ‘Standardising Wrist Bands Improves Patient Safety’ as a result of a further escalation in the number of incidents being reported as the result of wrist bands. The notice outlined that:

• Only wrist bands that met the NPSA requirements could be used. • Only five core patient identifiers should be on wrist bands:

o Last name o First name o Date of birth o NHS Number o First line of address

• A Trust wide policy / protocol should be developed outlining process for applying and checking wristbands should be in place

• Only white wrist bands with black writing should be used • By July 2008 wrist bands should be generated and printed from the

hospital administrative system at the patients bedside whenever possible.

Although significant work was undertaken across both predecessor Trusts to work towards meeting these requirements, the Trust is not yet compliant. In order to address this, the 1,000 lives methodology and project is being used as the vehicle for delivery. 5.2 Progress to Date The Trust has been liaising with the 1,000 Lives faculty and has received agreement that the Trust will pilot an ‘Improving Patient Identification’ intervention in order to reduce patient harm as a result of patient identification errors on behalf of the faculty. This work brings together projects that were being undertaken across both predecessor Trusts and includes the following components:

• Reducing duplicate medical records • Increasing the use of the NHS number as the unique patient identifier • Creating a virtual patient record to make available the right information, at

the right time for the right patient. • Implementing fully the NPSA Safer patient initiative – ‘Correct Patient

Identification’ (wrist band project).

A separate project Board has been established consisting of IM&T, Consultant, Nursing representation and the clinical and executive lead identified. The long term project plan is under development and will focus on the delivering of all areas outlined above. The Project Board has agreed that the initial priority will be to implement the NPSA requirements. The other drivers will be rolled out at the same time but will take far longer to achieve. To date the following has been achieved:

• Wrist bands for electronic printing have been agreed and ordered (adult, children & neonatal)

• Mobile carts for printing wrist bands at the patients bedside have been purchased for Princess of Wales (POW), Neath Port Talbot and some of Morriston Hospital

• Training and awareness programme has been successfully piloted • Carts have been piloted and process for Roll Out agreed • Roll out plan for Princess of Wales & Neath Port Talbot Hospitals agreed.

Whilst the printing of wrist bands at the patients bedside is being rolled out across POW work is commencing to ascertain the level of wireless cover at Morriston Hospital and to identify the shortfalls in the number of carts. It is envisaged that main ITU will be the initial roll out area within Morriston Hospital.

Due to the lack of any wireless connection within Singleton Hospital which is essential for the use of carts a ward is being identified to work with the IT Team to identify options for ensuring compliance within NPSA requirements within Singleton Hospital. Measures / Baseline Audits In order for the effectiveness of this intervention to be monitored it is essential that progress is regularly reviewed. The measure that is being introduced to support this work is ‘% of patients with a wrist band on that meets all of the NPSA guidelines’. As the last audit was undertaken over a year ago (identified that 85% of patients had a legible wrist band in place, 84% of which contained all of the other identifiers. The identifiers that were missing in most instances were first line of address and the patients hospital number), a baseline spot audit will be undertaken on each ward prior to the project roll out into this area. Monthly spot audits will be undertaken thereafter until the ward is fully compliant for 3-months, audits will then be repeated after 3- months, 6- months and annually thereafter as long as full compliance continues. The audits will be facilitated by the Clinical Governance Facilitators initially and data will be entered directly onto the 1,000 lives extranet site.

6. CONCLUSION

This report outlines the developments that have been made at both a corporate and a Directorate level in taking forward the saving 1,000 lives campaign as well as outlines how three new interventions are being implemented across the Trust.

7. RECOMMENDATION

The Trust Board is asked to note the contents of the report.

Impact Analysis Criteria Response • Resource impact, including costs, HR,

Capital

Included as part of each individual work stream. The ultimate aim is reduce overall costs through quality improvement

• Benefits in meeting Trust priorities

The implementation of the 1,000 lives campaign is key to meeting Trust Priorities and objectives

• Risks

The current risks are Directorates not engaging and ensuring data collection to measure improvements

• Link to Healthcare Standards

Healthcare Standards – 27,28,11,12,5,7,8

Appendix 6.1Team timeline reportAbertawe Bro Morgannwg University NHS Trust

Interventions covered

Intervention WCH ACCT DS CanS CarS Med ICR MS GS RS P LD MH1 Establish Executive accountability T T T T T T2 Address culture at all levels I I I I I I I I I I I I I3 Demonstrate visible leadership behaviour S S S S S S S S S S4 Use patient stories I I I I I I I5 Monitor aims and measures6 Orientate Board agendas I I I I I I I I I7 Address Board level learning and education8 Implement HCAI strategy I T T T T T T I I I T T I9 Standard precautions

10 Decontamination I I T S I I I11 Isolation precautions I12 Antimicrobial stewardship T I T S13 Management of invasive devices I I I14 Prevention of SSIs S N/A I N/A N/A N/A15 Standardised protocols P P P S P P P P16 Laboratory monitoring17 Using FMEA18 Guided dose algorithms P19 Standard recovery protocols P20 Medicines accuracy P P P21 Hospital use of patient medicines I I I I I I I I I22 Communication with primary care T23 Education S S P24 Self-care management25 Ventilator bundle T S N/A T T N/A N/A N/A26 Central line bundles P S P S I27 Severe sepsis bundle I28 Hand hygiene T S T T T T S S S T I29 Prophylactic antibiotics T I T I I I30 Hair removal methods S S N/A S SI S N/A N/A N/A31 Glycaemic control in diabetics T T N/A T N/A N/A N/A32 Normothermia I S N/A N/A S S S N/A N/A N/A33 List briefings T T N/A T T N/A N/A N/A34 DVT prophylaxis N/A T T T N/A N/A N/A

WHO Safer Surgery Checklist T S N/A I I I N/A N/A N/A35 Beta-blockers N/A T36 Echocardiography T37 ACE-inhibitor at discharge T38 Beta-blocker therapy T39 Discharge planning T I I40 Anticoagulant at discharge T41 Pressure Ulcer Reduction T T T T I T S S S T42 Early warning system T S S43 Structured handover I

Patient Identification I44 SBAR T

War

d C

are

Lead

ersh

ipH

CAI

sM

edic

ines

Mgt

CC

Surg

ical

Com

p

TRUST BOARD 10th June 2009

Agenda item: 7

CHAIRMAN’S ACTIVITY

April 8th Performance Management Trust Board Bridgend Emergency Services Dinner 9th Interviews – CEO for LHB 14th Administration 1,000 Lives Walkabout – Singleton 15th United Kingdom Continence Annual Scientific Conference Meet Staff going out to Sierra Leone 16th Administration Neath Port Talbot LSB 21st Administration Neurosciences Meeting 22nd Louise Joseph – Basic Skills 23rd Administration 24th Vale of Glamorgan LSB Transition Board Prepare for Retirement meeting 27th Administration Meet with David Sissling 29th Executive Short listing Process 30th Administration Cefn Coed Hospital Walkabout TREAT meeting MAY 1st CPPS Seminar 5th Visit to Morriston Hospital 6th Administration 7th IWA Conference 8th Administration Bridgend Mayor Charity Evening 11th Administration 12th Consultant Appointment Panel – Physician in Respiratory medicine 13th Administration Remuneration Committee Meeting with NEDs Trust Board Briefing

Neath GP Forum Meeting with staff going to Sierra Leone 14th Learning Event Trust Board Sub Committee for Mental Health 15th Bridgend LSB Bridgend GP – Dr. John Anthony Neath Port Talbot Mayor’s Inauguration 18th Administration Pennies from Heaven meeting 19th Administration 20th Meet David Sissling CEOs introduction to Health Community Partners CEO tour of Neath Port Talbot Hospital CEO meeting with Clinical Directors 21st CEO tour of Caswell Clinic 22nd Step Change Agenda meeting with NEDs Transition Board Administration 26th RCN – Tina Donnelly Meeting of All Wales Chairmen 27th Administration Joint Governance meeting with Swansea University 28th CEO to Swansea Medical School CEO to Swansea LHB CEO to Neath Port Talbot LHB CEO to Bridgend LHB 29th Administration Meeting with Minister for Health and complainants Non Emergency Transportation Review JUNE 1st Interviews for Executive Directors 2nd Interviews for Executive Directors 3rd Interviews for Executive Directors 4th Interviews for Executive Directors 5th Interviews for Executive Directors 8th Prospective Candidate for Paediatrics Neath Port Talbot LSB 9th Health Challenge Neath Port Talbot Wales for Africa Health Links Annual Report – Senedd 10th Performance Management Committee Trust Board – Annual Accounts

__________________________________________________________________________________________

Chief Executive’s Report Trust Board

10th June 2009

1

REPORT PREPARED BY: Steve Combe, Director of Corporate Affairs REPORT SPONSORED BY: Calum Campbell, Acting Chief Executive TRUST BOARD

10th June 2009

AGENDA ITEM: 8

CHIEF EXECUTIVE’S REPORT 1 PURPOSE To advise Directors of key issues related to the Trust not covered within

reports elsewhere on the Trust Board agenda. 2 KEY ISSUES 2.1 Healing Foundation Directors will be aware of the agreement between the Trust, Swansea

University and Cardiff University to host the Healing Foundation UK Centre for Burns research.

Unfortunately it has not proved possible to appoint the professorial post through Cardiff University. As a result the Healing Foundation has decided not to proceed. The trust is currently in discussions with Swansea University to determine the best usage of the space created at Morriston Hospital to house this service.

2.2 ILS 2 Directors will wish to know that the Assembly is due to make an announcement on 12th June 2009 on the projects that will be granted convergence funding. ILS 2 has submitted a bid for funding and it is hoped this will be looked on favourably.

2.3 Directorate Structures As Directors will be aware work has been ongoing to finalise the management

structures in Clinical Directorates. This has now largely been completed.

2.4 Minor Injuries Unit, Singleton Hospital Directors will recall that the new model for the Minor Injuries Unit (MIU) at Singleton Hospital started operating on 5th January, and was phased in over three weeks. The service is now manned by GPs, in answer to a long-standing and worsening problem of closures due to UK-wide shortages of middle-grade doctors.

__________________________________________________________________________________________


10th June 2009

2

The move has so far gone well, with GPs and Swansea Local Health Board also reporting that the transitional phase has been positive. An interim review of the arrangements has been held with colleagues in the CHC and a copy of the interim report is attached for information. It has been agreed that the full evaluation report will be completed in September following a visit programme by Swansea CHC and the completion of a questionnaire by patients utilising the service. Directors will be kept apprised of progress

2.5 Patient Records & Information Management Accreditation Programme (PRIMAP) The CHKS Healthcare Accreditation and Quality Unit (HAQU) programme provides a quality assurance tool for hospitals by setting out the standards which need to be delivered to ensure high quality Patient Record and Information Management services are in place to support the delivery of safe, effective and efficient healthcare.

The programme enables organisations to critically examine themselves against a nationally recognised framework of organisational standards. The process of self assessment and external peer review highlights areas of good practice, whilst setting an agenda for team development and service improvement for the patient records and information management services.

The Welsh Assembly Government initially funded the Health Records Accreditation programme from October 2000 to 2006 as part of the All Wales Information Quality Programme and the former Bro Morgannwg Trust successfully achieved two years accreditation firstly in June 2002 and again in September 2005.

In November 2006, the former Bro Morgannwg NHS Trust signed a three year agreement with CHKS to participate in PRIMAP, and underwent the external survey in June 2008, covering acute, community and mental health services.

To prepare for the survey, a Project Team was established, involving representation from clinical directorates as well as Health Records and Outpatients. Evidence was collated and presented electronically to the surveyors, and this demonstrated compliance with the criteria within each of the following 9 standards.

• Standard 1 – Management and Organisation • Standard 2 – Physical Facilities and Patient Record Retrieval Systems • Standard 3 – The Health Record • Standard 4 – Policies, Procedures and Working Practices

__________________________________________________________________________________________


10th June 2009

3

• Standard 5 – Clinical Coding • Standard 6 – Communication with Patients, GPS and Others • Standard 7 – Staff Training and Development • Standard 8 – Evaluation and Quality Assurance • Standard 9 – Health Record Content

The final surveyor’s report was received from CHKS in August 2008 and out of a total of 279 criteria, the Trust was non compliant in 5 and partially compliant in 15, (equating to 5%) and standard 8 was found to be fully compliant. The services were commended for: • The health records induction and training programme is very

comprehensive. Training records have been designed on a portfolio basis and record achievements as well as mandatory training (standard 7.2).

• The electronic Transfer of Care form. This record is completed on an incremental basis by junior medical staff from admission through to discharge. The record is approved by consultants prior to sending through electronically to the GP.

• The walkabout information security audits undertaken by the Information Governance, IT Security and Records Programme Managers.

• The Good Practice Guide’ to help reduce DNAs, which has been developed by the Mental Health Directorate focuses on clinical and patient quality aspects in addition to the administration process.

• The ability for medical staff to access the mental health records with appropriate safeguards to provide the medical staff wit a full history of the patient.

Additional evidence was collated and submitted to CHKS in March 2009 to demonstrate compliance with the remaining criteria, and the Accreditation Awards Panel has recently notified the Trust that it has met the required criteria or sufficient progress had been made since the time of the survey and as such, has awarded 3 years accreditation, backdated to June 2008.

To maintain accreditation status, the Trust now has to assure the Accreditation Awards Panel that the PRIMAP standards are being upheld, and that further work is undertaken to fully comply with all standards, as identified in the feedback report. This will be achieved by: • Providing CHKS with an interim report by 12th June 2009, to confirm that

the Trust has taken measures to ensure that ‘nil allergies’ are recorded in casenotes.

• The provision of a satisfactory report from the monitoring process which is part of the Trust’s quality assurance measures, and will need to be submitted to CHKS in December 2009.

__________________________________________________________________________________________


10th June 2009

4

The accreditation report identifies which items will be checked as part of the monitoring process and actions will be put in place to ensure that the Trust is able to meet the deadline. Ongoing compliance with requirements will be monitored through the Outpatient Improvement Group and reported to the Outpatient Improvement Board and Health Records Committee on a regular basis.

Plaques publicising the Award will be displayed in the entrances to all participating hospitals and certificates will also be displayed in the relevant departments across the locality.

2.6 Annual Operating Framework 2009/2010 The Trust Board Briefing of 13th May 2009 was updated on the work ongoing across the Health Community to agree the planning regime required to meet the challenge set out in the 2009/2010 Annual Operating Framework (AOF). As previously advised, the AOF is explicit in terms of its requirements and these are set out in the bullet points below:- • The AOF must be delivered in full. • The delivery of the AOF must be achieved within the content of the

substantial changes that are facing the NHS in Wales. • All of the improvements required must be secured within the resource

available. Through the Transition Board and under the Chairmanship of the Transitional Director, the Abertawe Bro Morgannwg University Health Community response has been constructed. On 1st May 2009 the Health Community responded to the Welsh Assembly Government with a further detailed iteration of it’s AOF position. The Trust Board received a copy of this correspondence at the last briefing. This letter set out that Health Community had fimly identified savings of £29.65m and had outline plans to progress a further £16.25m to meet the National Finance Agreement (NFA) and 2009 Access target pressure of £45.9m. Beyond the NFA and 2009 Access pressures, there remain 12 AOF Local Delivery Plans (LDPs) of which, the Health Community has been able to progress 8 of the plans to delivery within the resource plan set out above. This leaves 4 LDP areas where the Health Community had identified further investment as being required to progress to full delivery, beyond the best endeavours and modernisation work already fully committed to by the Health Community. The four targets where issues remained are set out below:-

__________________________________________________________________________________________


10th June 2009

5

• Chronic Condition Management £0.996m • Mental Health Services £1.600m • Cancer Services £4.652m • Stroke Services £3.700m The Health Community committed to the Welsh Assembly Government that it would continue to work with these four remaining LDP target areas to deliver as much of the targets as possible but without increasing the need for further internal savings to be identified to fund these LDPs in full. However, for both Stroke Services and Cancer Services, the Health Community view is that the complete range of these two targets cannot be achieved without investment from outside of the Health Community. Update Following the Health Community letter of 1st May 2009, a meeting was held between Health Community colleagues and Welsh Assembly Government officials on Thursday 21st May 2009. The discussions at the meeting enabled the Health Community to further develop its position in respect of the AOF for 2009/10 with Welsh Assembly Government colleagues. Set out below is a summary of the discussions with a full copy of the letter referencing the meeting attached at Appendix 8.1. • The Welsh Assembly Government agreed that the Trust had a plan to deliver a balanced AOF but with a £10.9m risk around the four outstanding LDP areas highlighted above. • The risk can be categorised into six areas: 1. Final figures to deliver the Cardiac Total Waiting Times (TWT) target need agreement with Health Commission Wales (HCW). 2. Further work is needed on the Mental Health LDP as it was felt that with some pump prime funding the final risk could be managed out. 3. A discussion with Cwm Taf NHS Trust was required to ascertain the basis of the funding required to address the CAMHS target. 4. Welsh Assembly Government would look at the detail behind the Cancer Services targets. 5. Welsh Assembly Government would review the detail on the Stroke Services target and in particular the requirement to build a service model which meets Royal College of Physician (RCP) standards. 6. Chronic Conditions Management risk would be reconsidered by the Health Community.

__________________________________________________________________________________________


10th June 2009

6

The Health Community feels that this position reflects as pragmatic understanding of the AOF position as possible at this time. The Health Community believes that if a resource neutral solution can be found to agree a planned way forward for both Stroke Services and Cancer Services then a balanced AOF should be possible not withstanding support from both HCW and Cwm Taf NHS Trust for Cardiac and CAMHS respectively. It is important to note however that even with a resource neutral resolution for Stroke and Cancer Services, the challenge to deliver the savings required to meet the £45.9m gap and to deliver the full range of AOF Targets through the transition and the new Health Board remain significant and should not be underestimated.

2.7 Neath Port Talbot Community Health Council Directors will wish to know that Peter Owen has been re instated as the Chief Officer of Neath Port Talbot CHC.

2.8 Neath Port Talbot County Borough Council Directors will wish to note that Tony Clement has taken over the post of Director of Adult Services which includes statutory responsibility for Social Services (Colin Preece has retired). Alun Thomas is now the Leader of Neath Port Talbot County Borough Council with Derek Vaughan having stepped down to stand for the European Parliament.

3 RECOMMENDATION

The Board is asked to note the foregoing.

__________________________________________________________________________________________


10th June 2009

7

Impact Analysis Criteria Response

• Resource impact, including costs, HR, Capital

Increased service pressures and the implications of restructuring will impact on staff and will need careful management

• Benefits in meeting Trust priorities Included in report where necessary

• Risks

Risks associated with increased service pressures are included in the Performance Report. There are risks to business continuity as a result of Transition and these are being project managed.


Healthcare Standards are concentrating on the user experience and this is impacted by several issues raised in the report

• Equality There are no significant issues.

__________________________________________________________________________________________


10th June 2009

8

ABM University NHS Trust

Unscheduled Care and Minor Injuries Unit Interim Report

February – April 2009

A new model of service was designed for the casualty service at Singleton Hospital following sustainability and governance concerns with the service which had first opened in 1985, and in particular the difficulty with the recruitment and retention of medical staff leading to frequent and unplanned closures of the casualty service, often at very short notice. Following discussions between the Trust, the Local Health Board and the Swansea GP out of hours service a new model was developed based upon a closer working partnership between primary and secondary care and the input of local experienced general practitioners and Trust clinicians including the core of the departments nursing staff. The new Minor Injuries Unit service commenced on the 5th January 2009 and during a 3 week transitional period the new service was bedded in with the active support of the Trust, LHB, GP out of hours, NHS Direct and Welsh Ambulance Trust. A multi-agency multi-disciplinary group has met on a regular basis since the change of service to monitor the performance and address any issues.The activity figures have been recorded as follows for the period ending 30 April 2009 Total number of patients attending 4084

Weekly average for April 2009 320

Of the total, aged 0-16 years old 894 or 22% The majority of patients attending are treated by the doctor and/or nurse in the MIU, however approximately a quarter of patients are referred on for a specialist opinion or further treatment at Singleton or Morriston Hospitals. The service is provided on a 24 hour basis and out of hours is co-located with the long standing GP out of hours service. The majority of the patients (84%) attend during the period 9am-9pm. Singleton Assessment Unit (SAU) The SAU was developed as part of the new model of care and building on the experience of the Medical Assessment Unit which had been in place for a number of years to allow for the assessment of patients referred by their GP’s to the on-call medical teams. The changes to the emergency service which accompanied the opening of the MIU required a clinical area to be developed for the assessment of

__________________________________________________________________________________________


10th June 2009

9

patients referred as emergencies to the surgical, ENT and Ophthalmology on-call teams. The SAU has proved to be a very useful albeit very busy element to the unscheduled care service, and it’s workload has been analysed for the first three full months of operation as follows: New referrals Day cases Total activity Feb 09 990 159 1149

Mar 09 1243 269 1512

Apr 09 1059 216 1275 On average 44 patients a day attend the unit requiring assessment. Separate emergency admission arrangements are in place for children and Obstetrics and Gynaecology. The ENT emergency clinic is available during OPD clinic hours on corridor 3 for GPs to refer to, and the emergency eye clinics are run from corridor 7 of the Singleton OPD. Paediatric Assessment Unit (PAU) The Paediatric Assessment Unit was opened on a 24 hour basis to enable 999 ambulances to continue to bring emergency cases to Singleton Hospital as it housed the main Paediatric inpatient base for children in Swansea. The PAU is designed to accept emergency referrals from general practitioners to assess children to determine if they require admission or other forms of therapeutic intervention for non-traumatic conditions. Children who have fractures are recommended to go to the main Accident and Emergency department. The workload figures for the 3 month period are outlined below in both aggregate and daily averages for ease of analysis. PAU Activity February – April 2009 Daily

averageDaily average

Daily average

Feb Mar Apr Total Feb Mar Apr All attendances 611 839 750 2200 22 27 25

New cases 520 717 614 1851 18-19 23 20-21

Admissions 169 187 189 545 6-7 6 6

Discharges 351 530 425 1306 12-13 17 14

Day cases 91 122 136 349 3 4 4-5

999 cases 90 120 96 306 3 4 3

__________________________________________________________________________________________


10th June 2009

10

999 Ambulance workload One of the concerns expressed in advance of the change of service was the impact of diverting 999 emergency ambulances to Morriston. This has been mitigated in part by protocols being developed whereby the ambulance paramedic crews can contact the doctors in Singleton to discuss bringing individual cases to Singleton if the patient profile fits the accepted clinical criteria. The Trust has also carefully monitored the number of 999 ambulances coming to Morriston and there has not been any major discernible increase. The following information on the attendance of 999 vehicles has been recorded: Total Daily average Dec 08 1722 55.5

Jan 09 1723 55.5

Feb 09 1653 59

Mar 09 1755 56.5

Apr 09 1672 55.7 Benefits realised

(i) There has been no closure of the Unit because of shortages of medical staff, nor for any other reason. There is clearly a strong commitment to the new model of service from local doctors on the rota.

(ii) Patients have been seen and treated expeditiously and the 95% target for

completing patient treatment in under 4 hours has been met consistently.

(iii) The redeployment of nursing staff to the Morriston Accident and Emergency department has enabled the children’s section to be opened on a regular basis to match periods of peak demand. This enables younger patients to be treated in a child friendly environment separate from the main department.

(iv) This model has brought primary and secondary care clinicians closer

together through the project management arrangements and this has led to a number of initiatives on joint working including looking at different care pathways for common acute conditions, e.g. DVT, with a view to avoiding unnecessary conditions. Further, hospital consultants have led continuing medical education training sessions with GPs on the management of common emergency conditions in specialist areas such as ENT and Ophthalmology

Appendix 8.1 Cyfarwyddwr Cyflenwi Gwasanaethau a Rheoli Perfformiad, Cyfarwyddiaeth Cyflenwi Gwasanaethau a Rheoli Perfformiad, Adran Iechyd a Gwasanaethau Cymdeithasol. Director of Operations Service Delivery and Performance Management, Department of Health and Social Services.

Parc Cathays Caerdydd CF10 3NQ

Cathays Park Cardiff

CF10 3NQ

Ffôn Tel:029 2082 5850 GTN:1208

Ffacs Fax:029 2082 3907 Ebost Email:[email protected]

Andrew Goodall Transition Director ABMU Health Community 22 May 2009 Dear Andrew Re: ABMU Health Community AOF 2009/10 Thank you for attending the meeting held on 21 May 2009 to discuss the ABMU Health Community AOF for 2009 / 2010. The purpose of the meeting was to seek resolution to the outstanding issues surrounding the AOF 2009/2010. I must be clear that the Minister’s expectations are for all health communities to deliver all the AOF requirements within the budget allocations for 2009/2010. Whereas in the past the Welsh Assembly Government has been able to draw on slippage within its own budget to provide financial flexibilities to organisations, this is not an option for 2009/2010; and I am looking to you and your team to develop a balanced deliverable plan that meets our expectations. I summarise below the main points of the discussion.

1. There is recognition that ABM has robust planning structures and processes in place, and that this provides senior management within the LHB with confidence of delivery. The overall high level summary as at 1st May 2009 sets out the means to present a break-even AOF but on the basis that the gaps and risks associated with the existing LDPs can be managed. If this is not the case, these risks jointly represent a £10.9m deficit.

2. The risks/ gaps are as follows:

• There is a currently a capacity demand gap of 111 patients in respect of cardiac

surgery treatment between HCW and ABM which needs to be addressed. It was agreed that I will discuss this issue further with HCW and feedback to you.

• There is a gap of £1.6m in respect of the Mental Health LDP. This represents significant local service redesign over and above the AOF targets. Access to additional ‘Invest to Save‘ funding from the central WAG initiative, which would provide pump priming monies during 2009/2010 would be helpful. While this would need to be repaid at a later date it would assist in the delivery of the total LDP, and I will ask Steve Elliot to investigate the availability of this funding stream.

• You agreed to pursue the drive for greater service delivery efficiencies from the

CAMHS service with colleagues within Cwm Taf, as the regional providers. The aim being to achieve a £4.6m cost improvement overall and deliver service requirements.

• Compliance with Cancer standards represents a £4.65m risk which currently is

not deliverable across ABM. I appreciate work is ongoing with Jane Hanson and the CSCG network, to produce a report for the Minister and I will discuss this further with WAG colleagues to clarify the expectations for 2009/2010 AOF.

• Compliance with the stroke AOF requirements, to meet RCP guidelines,

represents a £3.7m risk across ABM. I will discuss this further with WAG colleagues to clarify the expectations for 2009/2010 AOF.

• The Chronic Conditions Management risk of £1m will be managed by ABM.

Funding is available through WAG CCM Framework scheme but ABM has further work to complete in order to meet the approval criteria set by WAG.

3. ABM colleagues agreed to provide Tony Hurrell, Regional Office with the detailed plans and profiles associated with the AOF / LDPs, and to provide Heather Giles, WAG with any updated LDPs immediately.

Thank you for the work that has been undertaken to date and I welcome the robustness of your approach. I do appreciate the effort that has been made by ABM colleagues in reaching this position; however, while I will take forward some discussions to clarify the matters detailed above, you and your team must continue to develop a further plan that will cover this £10.9m risk. Yours sincerely

SIMON DEAN Director of Operations cc Paul Williams, Director General, Department for Health & Social Services Steve Elliot, Head of Finance Hospital Care Tony Hurrell, Regional Director, Mid and West Wales Regional Office

REPORT PREPARED BY: Steve Combe, Director of Corporate Affairs REPORT SPONSORED BY: Calum Campbell, Acting Chief Executive TRUST BOARD

10thJune 2009

AGENDA ITEM: 9

TRANSITION PROJECT PROGRESS REPORT 1 PURPOSE

To update the Trust Board on progress on arrangements for transition to the ABM University LHB.

2 INTRODUCTION

Following the establishment of the Transition Board and Executive Team a number of actions have been progressed locally. These are summarised in this report, together with key issues from the national programme.

3 NATIONAL UPDATE 3.1 Critical activities

A number of critical activities have been taken forward since the last meeting. These include: Confirmation of LHB Chief Executive appointments. Mr David

Sissling has been appointed as Chief Executive designate for ABM University LHB and will be working in the LHB area for 2 days a week before taking up post on a full time basis at the end of July 2009;

Confirmation of LHB Vice-Chairs. Dr Ed Roberts, Chairman of Bridgend and Neath Port Talbot LHB has been appointed to this post within ABM University LHB;

Continuation of appointments processes for LHB Executive Directors. The outcome of these interviews will be reported orally to the Board;

Closure of consultation on the proposals for a Unified Public Health Service for Wales; and

Minister’s Plenary Statement on the future of CHCs, following the closure of consultation.

1 Transition Project Progress Report

Trust Board 10th June 2009

3.2 Health Commission Wales (HCW) Consultation on proposed future arrangements for HCW continues. A draft response is being developed and will be circulated for comment prior to submission to the Assembly.

3.6 Shared Services/Business Services Centre (BSC)

A project team has been established to consider all aspects of shared services and will be producing a report for consideration by the National Transition Board

3.7 Next Steps Critical tasks to be taken forward in the next phase include:

Confirmation of NHS Wales Planning Framework; Confirmation of AOF / Performance Management Arrangements; Confirmation of LHB Executive Director appointments; Confirmation of Ministerial announcement on UPHO in Plenary on

6th June 2009; LHB (Functions) (Wales) Regulations 2009 - 19th June 2009; Issuing Model Standing Orders, SFIs & Reservations and

Delegations of Powers for LHBs; Guidance on Corporate Style / Logo issued to the NHS; Guidance on the membership and constitution of the Professional

Forum and the Stakeholder Reference Group. 4 ABM UPDATE 4.1 Project Plan

The Transition Executive Team and Transition Board are keeping the Project Plan under regular review and receives regular reports from Work stream leads.

4.2 Risk Register

The Transition Executive Team and Transition Board are keeping the Transition and Business Continuity Risk Registers under regular review.

4.3 Organisational Development

The Transition Executive Team received reports on the development of the culture and values for the new LHB and the priorities for developing an OD Framework. These are critical areas of work where the views of the incoming Chief Executive Designate will be critical in determining how this work is progressed. As a result it is intended to hold discussions with the Chief Executive Designate at an early stage, prior to proposals being brought to the Transition Board for consideration.



4.4 Locality Planning Following discussion at the Transition Board a discussion paper on locality based management arrangements has been circulated widely within the existing health bodies and with partner organisations for comment. It is intended that the outcome of these discussions will be passed to the Chief Executive Designate to inform consideration of the management arrangements for the new LHB.

4.5 Work streams

Issues considered at the last meeting of the Transition Executive Team, including reports from Work steams included: • The development of legacy statements by the existing organisations

as part of the handover arrangements to the new LHB • The work being undertaken to ensure a standardised approach to

IT support, including network, desktop e mail and printer services. This work is being done in conjunction with the BSC.

• The All Wales agreement that existing ledgers are maintained until 31/3/10. A consolidation team has been established to manage the transition to a single ledger

• The need to establish local arrangements on benefits realisation. Further guidance on this is expected shortly from the Assembly.

4.6 Shadow running

The Transition Board have been considering arrangements for Shadow running, as the new LHB became operational in shadow form from 1st June 2009. As a result of these discussions a draft Memorandum of Understanding has been developed to clarify roles and responsibilities of the existing statutory bodies and the Shadow Board during transition. A copy of the draft Memorandum is attached at Appendix 9.1. This has been forwarded to all local LHB Boards for consideration and needs to be considered by the Board.

5. Reported outcome of Unified Public Health Service Consultation On 2nd June the Minister for Health & Social Services announced that, as proposed in the UPHS consultation document, Public Health Wales will be formed as an NHS Trust in shadow form from 1st August 2009, operational from 1st October. Ms Hart also announced that following a public appointments process, Professor Mansel Aylward, had been appointed as its Chair. In line with many of the views expressed in the consultation, the new organization will incorporate all the organizations and functions proposed with the exception of the Welsh Blood Service which is to remain with Velindre NHS Trust. The only other change reported to date is that, apart from the Chief Executive and Director of Finance, the roles of the remaining three Executive Directors have been left to the discretion of the Board: It was also stated that the two ‘independent’



Non-Executive Directors had been added to the Board (to join NEDS from University, Trades Union and Third Sector backgrounds) to ensure that the needs or the “ordinary person” are factored into its decision making.

6 RECOMMENDATION

The Transition Board is asked to:

• Note progress

• Consider and, subject to comments approve the Memorandum of Understanding.

Impact Analysis Criteria Response


Implications of restructuring will impact on staff and will need careful management

• Benefits in meeting Trust priorities Included in report where necessary

• Risks

There are risks to business continuity as a result of Transition and these are being project managed.


Healthcare Standards are concentrating on the user experience and this is impacted by several issues raised in the report

• Equality There are no significant issues.



Appendix 9.1

DRAFT MEMORANDUM OF UNDERSTANDING BETWEEN THE TRANSITION/SHADOW BOARD OF ABM UNIVERSITY LHB AND ABM UNIVERSITY TRUST, SWANSEA, NEATH PORT TALBOT AND BRIDGEND LHBs Introduction The new LHBs in Wales were established in shadow form on 1st June 2009 with limited functions. The LHBs will be fully operational from 1st October 2009. Up until this date existing Boards remain as the accountable statutory bodies. This Memorandum of Understanding is aimed at clarifying the role of the Shadow Board and its relationship with the existing statutory bodies to ensure that:

• there is effective governance during transition. • Current Boards remain fully engaged • Decisions are not made in isolation and the interests of the ABM

community remain paramount Functions

• Shadow Board During the shadow period the new LHB will have the following limited functions:

(i) Entering into NHS contracts; (ii) Entering into other contracts including contracts of employment;

and (iii) Doing such other things as are reasonably necessary to enable it to

begin to operate satisfactorily from the 1 October 2009.

Where decisions are not made by the Shadow Board they will be made by the chairman and Chief Executive designate and ratified by the Shadow Board. The main focus for the Shadow Board will be forwardly focussed in ensuring that the new LHB is properly constituted and is able to inherit the responsibilities of existing statutory bodies. It will therefore consider issues such as:

. • Developing organisational culture/strategy; • Completing induction for Board Members; • Building the new Board as a cohesive body; • Developing the Governance and Assurance Framework for the new

LHB including: o Considering draft SOs/SFIs and key policies



o Confirming Board Committee arrangements, including joint committees

o Confirming arrangements for the Stakeholder Reference Group, Professional Forum and Local Partnership Forum

• Developing Partnership working arrangements at locality level with Local Authorities, the Third Sector and CHCs;

• Developing management arrangements for the new LHB; • Ensuring effective performance management arrangements are in

place and ensuring business continuity; • Reviewing legacy statements; • Confirming internal and external audit arrangements and arrangements

for the discharge of other key statutory functions; and • Establishing effective communications mechanisms internally and

externally.

• Existing Trust / LHBs The statutory responsibility for the NHS locally is retained by existing bodies until midnight on 30th September 2009. This means they remain statutorily accountable for ensuring: • that there is a financial and service plan that sets out the means by

which it will deliver its financial targets in 2009/10 • effective governance arrangements are in place through the Board and

its committees. • Monthly monitoring is in place against key deliverables, which leads to

remedial corrective action for variances against the plan • Schemes are identified and delivered that sets out the means by which

the organisation intends to stay in recurring financial balance. • Business continues to be conducted in a timely manner • Legacy/handover statements are produced to highlight key

commitments and issues to the incoming LHB Board. In addition:

• Existing Board Committees will be asked to develop handover statements of the key issues considered by the Committee and work that needs to be taken forward

• Existing NOMs/NEDs be asked to contribute to the induction of new Board members and other key areas eg OD.

• Newly appointed Board members be granted observer status at existing Board meetings, where requested.

Business Continuity As the transition is occurring mid year the Shadow Board will have a legitimate interest in monitoring performance and being aware of any key decisions made before 1st October that will impact on the new LHB.



To deal with these matters the following arrangements will be set in place:

• Performance Monitoring Existing Boards will continue to undertake a performance management/monitoring function. Highlight reports will be produced for the Shadow Board so they are able to monitor overall performance. Where the Shadow Board highlights any issues of concern these will be taken up with the relevant Chair/Chief Executive of the statutory body.

• Key Decisions Existing Boards will continue to make decisions to ensure services are maintained and developed. Some of these decisions could have an impact beyond 30th September 2009 eg:

• Consultations on major service changes • Modernising or changing services which have resource consequences.

The Shadow Board needs to be aware of any such proposals before decisions are made by the relevant statutory body. The Chief Executives of existing bodies will be required to produce a regular report on such matters for consideration by the Shadow Board. The views of the Shadow Board will then be made known to the relevant statutory Board so that all decisions are fully informed. Role of Transition Board As shadow running progresses there will be increasing overlap between the work of the Transition Board and Shadow Board. It is anticipated that the first meeting of the Shadow Board will be in July 2009. At this time there will be a formal transfer of responsibility for transition matters from the Transition Board to the Shadow Board. As part of this transfer the Shadow Board should consider what key elements of transition remain to be achieved and the timescale for closing down the project management arrangements and absorbing such work as part of routine business. As part of the transfer the Shadow Board will invite the Chairs and Chief Executives of existing bodies to attend meetings to discuss appropriate agenda items. These individuals will be designated as “in attendance” in line with regulatory requirements. The arrangements for the Transition Executive Team will remain in place and will be subject to regular review as Executive Director appointments are made.



REPORT PREPARED BY: Lindsey Jones and Shan Morgan SPONSORED BY: Paul Stauber Director of Planning


PART A

AGENDA ITEM: 10

ALL WALES CAPITAL PROGRAMME 1. PURPOSE To update the Board on the progress of the schemes approved and seeking approval from the Welsh Assembly Government. 2. SCHEMES 2.1 Morriston Hospital Redevelopment • Phase 1A Good progress has been made on the project which remains on programme with the first phase of the car park (488 car park spaces) and helicopter landing pad are due to be completed on 26th July 2009. When completed phase 2 of the project will start at the rear of the Estates Department which is the construction of the multi storey car park that provides the remaining 818 spaces and completion of the new internal roadway. This phase is due for completion in August 2010. Agreement on the landscaping details along the south and west boundaries adjacent to the resident’s homes have been achieved which will discharge one of the more difficult planning conditions of the project. The liaison meetings continue to be well attended and good progress is being made. A presentation to the group on the plans for Phase 1B has recently been given which was well received. The interim traffic management arrangements at both entrances to the hospital continue to achieve minimum disruptions. The design work associated with the section 278 agreement on the external north entrance to the site has now been agreed with the council and this work which has to be carried out by the Council will commence within the next month and will result in a mini roundabout being installed as part of the works.. • Phase 1B The Strategic Outline Business Case has been completed. The design work on the new entrance, retail space and integrated education centre is well advanced and a late December 2009 construction start date is targeted.

The User Groups for each ‘department’ within Phase 1B continue to meet to agree room details, layouts and functionality with the clinical staff fully engaged as appropriate. 2.2 Modernising Mental Health Services in Swansea • Health Visions – Mental Health The Business Justification Case for the Adult Slow Stream Unit and two 4-bed Step Down Rehabilitation Units at Cefn Coed Hospital was submitted on 27th February 2009 and clarification was sought on a number of points. This has been provided by means of an addendum and the formal approval is eagerly awaited. A detailed planning application was submitted in March 2009 and a number of on site meetings have taken place on site with council officers. The submission is scheduled to be considered at the 2nd June 2009 City & County of Swansea Planning Committee. The enabling works to support the Rehabilitation Units are complete, all of the old dilapidated blocks have been demolished and the site prepared for the construction phase following formal approval of the business case and planning. Phase 1 detailed 1:50 plans are complete and a formal presentation has been given by the Supply Chain Partners to the project group. The design of the 60-bed Older Persons Intermediate Care Beds facility at Cefn Coed Hospital is well advanced and 1:50 scale designs are complete. The planning application is due to be submitted once approval for Adult Slow Stream and Step Down Units has been achieved and the combined Outline/Full Business Case is due for submission in the autumn 2009.

• Co-locations of Adult Community Mental Health Teams & Psychological

Services Progress has been made with the plans to co-locate the CHMT teams and Psychology team. The work will not be undertaken by the Supply Chain from the D4L Building for Wales Framework but by companies selected from the local framework which will provide a better value for money option due to the small scale of each development. The first phase of this works, the re-location of CHMT team 1 and Psychology service into Central Clinic, is targeted for completion by the end of December 2009. An interim solution to allow the co-location of Older Persons CHMT’s 3 and 4 will be provided at Garngoch Hospital by November 2009. The Adult CHMT team 3 at Ty Einion will be relocated to Clydach hospital in the interim which will allow co-location with Adult CMHT team 4 and the redevelopment of the Ty Einion site, subject to local planning and business case approval. Following completion Adult teams 3 and 4 will then return to the Ty Einon Site. • Singleton Hospital – Replacement Linear Accelerator The enabling works to the linear accelerator bunker in preparation for the replacement linac delivery will be completed by February 2010. In addition the new Mosaiq hardware and software

system will be purchased and installed during the year to allow its commissioning and staff training to be carried out prior to the linear accelerator installation in April 2010. 2.3 Modernisation of mental Health Services for Bridgend and Western Vale of

Glamorgan • Day Care Centre – Bridgend Town Centre Work on the new ARC (Assisted Recovery in the Community) Day Centre for Mental Health Services in the centre of Bridgend is proceeding well but unfortunately the Contractors have been unable to recover the time lost at the start of the contract and have now applied for a three week extension of time on the contract period. The Lead Consultant/Architect is presently considering the detail of the application but it is likely that the full claim will be approved. This will extend the contract completion date to the 24th August 2009. A Commissioning Team has been established by the Mental Health Services Directorate with representatives from the Trust and Bridgend County Borough Council and this group will be meeting on a fortnightly basis over the next few months to ensure a seamless transition of services from the existing Ty R’Ardd building on the Sunnyside site. Discussions are already being held with the User Group on the equipment requirements for the building and orders will shortly start to be placed to ensure deliveries start immediately following handover. The Lease Agreement for the land has still not been completed however all the outstanding issues have now been resolved and the finalised documents are being prepared for completion by both parties. • Quarella Road – Rehabilitation Accommodation Construction of the new Rehabilitation Unit at the rear of 71 Quarella Road is progressing very well and in accordance with programme. It is not anticipated that there will be any issues with achieving completion as planned by the 30th October 2009. Meetings are now being held with the Directorate to progress the equipping exercise for this scheme and two of the service users have agreed to represent the patients on the user group. • Glanrhyd Hospital – Enabling Works The bulk of the demolition work on the site has now been completed and the Contractors, Cuddy Demolition Ltd, are engaged in sorting and classifying the materials ready for recycling. The dressed stone from the main buildings has been sold in Northern Ireland but a small percentage is being retained on site to be utilised as a design feature of the new Continuing Care Unit. Care has had to be taken over the demolition of the buildings around the existing tower which is being retained and will form the plant room of the new Unit but so far this work has proceeded without incident. During the course of the works a series of unchartered ducts have been discovered below ground the majority of which are within the footprint of the new building. All of these ducts contained considerable amounts of lagging containing asbestos material which has had to be surveyed and removed by specialist contractors. Due to this additional work the contract period has been extended and it is now anticipated that the demolition contract will complete at the end of June 2009.

• Glanrhyd Hospital – Continuing Care Detailed design of the new Continuing Care scheme has been completed by the Design Team and tender documentation prepared. The Board will recall that expressions of Interest in the Project were invited via an advertisement in the Official Journal of the European Union and following an evaluation of the responses received a draft tender list of six companies agreed. This list was recently vetted by the Finance Department and all of the companies confirmed that they would wish to submit a bid. Tender documentation was therefore issued to the six companies nominated on the 19th May 2009 and bids are to be returned to the Trust on the 23rd June 2009. Assuming that tenders are within the budget cost for the scheme it is anticipated that the contract will be awarded and a start on site made at the end of July 2009. Providing this programme can be achieved the new Unit is scheduled to complete in January 2011. • Old Age Psychiatry Unit Following the agreement of the Project Board for the Modernisation of Mental Health Services to the proposal that this Unit would be sited on the Glanrhyd hospital site further site investigations are to be undertaken to determine the most appropriate location for the building and to determine the extent of the demolition work that will be required. The schedule of accommodation has been reviewed to take account of the close proximity of the scheme with the Continuing Care Unit and the amended schedule has been agreed with the User Group. The budget is currently being to asses the impact of the reduction in space. reviewed • Cimla Hospital – Rehabilitation Accommodation The Main Contractor for the scheme, T. R. Jones Ltd has reported that they have been unable to recoup any of the time lost during the course of the project largely due to the poor weather conditions in the early stages of the contract. The company therefore submitted an extension of time claim which has been assessed by the Lead Consultant/Architect who has granted an eight week extension of time. The impact of this on the scheme is that the completion of phase 1 has been deferred until 3rd August 2009 while phase 2, the completion of the new car park on the site will now commence on the 4th August with completion programmed for 9th November 2009 The equipping exercise has began with existing furniture and equipment being assessed to determine whether there are any items which are suitable for transfer. The colour scheme for the building has been finalised and meetings are being held with Users to agree exact requirements before orders are placed. • Princess of Wales Hospital – Multi Professional Education Centre The construction of the extension of the Post Graduate Centre at the Princess of Wales Hospital to provide a dedicated Multi Professional Education Centre is progressing well and in accordance with programme. The steel structure is almost complete and immediately following Whitsun roof coverings will start to be installed. Phase I of the contract which will transfer the library into the new building is programmed to complete on the 25th September 2009 and, following the transfer of the library, the works to the existing Post Graduate Centre will be completed along with the rest of the new building. Overall completion of the whole project is scheduled for the 9th November 2009. Meetings have been held with Multisense Ltd, a specialist supplier and installer of audio visual equipment, to discuss and agree a specification for such a system for the new Centre.

Representatives of the User Group are to visit similar facilities in Guy’s Hospital in London to see this equipment in use before the specification is finalised and orders placed. Separate meetings are being held to determine other equipment requirements and a Commissioning Group has been established to deal with the operational activities and schedules for the new facility. • Princess of Wales Hospital – Child and Adolescent Mental Health Unit The main construction of the new multi storey car park has been completed and work is proceeding on the installation of the mechanical and electrical services within the building. Cladding of the structure commenced on the 18th May 2009 and is proceeding in accordance with programme as are the groundwork elements such as tarmacing, kerb installations and fencing. Construction of the new access road into the hospital site is well advanced and work is also continuing on the changes to the layout of the A4061 (Bridgend Bypass) that are needed to complete the new access route. The Welsh Assembly Government has granted the Trust a Licence to enter into land it owns on the Brackla Link Road to develop a new cycle path as part of the contract and these works will now be undertaken within the original programme. Both the car park and new access road will be handed over to the Trust at the beginning of September 2009. A “Not To Exceed” cost for the new CAMHS unit has been agreed with the Supply Chain Partner BAM Ltd and on this basis the Full Business Case is being completed ready for submission to the Welsh Assembly Government. Providing approval is received within the approval period of the Designed For Life process construction of the Unit will commence on the 7th September 2009. The length of the construction programme has not yet been fully determined but every effort is being made to achieve completion by the end of December 2010 • Pencoed Primary Care Centre Discussions are still being held with Bridgend County Borough Council on the transfer of ownership of the preferred site for the new Primary Care Centre in Pencoed to the Trust. At the moment no agreement has been reached on the value of the land and it is possible that the Trust may decide to enter into a long lease agreement with the Council for the land rather than purchase it outright. The Council has granted the Trust a Licence to carry out survey work on the site and both topographical and site investigation surveys have been commissioned to inform detailed design. A number of meetings have been held with the Steering Group for the scheme to progress the design of the building. The schedule of accommodation and adjacencies have been agreed and layout plans for the building are presently being reviewed before an AEDET is held involving all the users to get feedback on the proposals before the design is finalised and signed off. Providing the issues of the land ownership, funding and planning approvals can be resolved it is anticipated that tenders could be invited for the scheme in the Autumn of 2009. • Port Talbot Resource Centre The Board will recall that the Trust is presently working with the Neath Port Talbot Local Health Board, local GP Practices and a private development company Haven Health Ltd on the provision of a Resource Centre to provide seamless Primary Care Services in one location to serve the people of Port Talbot and Baglan. The building is being constructed on a site in Moor

Lane, Baglan and is due to be handed over on a two phase basis at the end of August and three weeks later in mid September. The scheme is on programme for completion and a Centre Manager has just been appointed by the Local Health Board to oversee the commissioning of the building and put in place all the operational policies and procedures that will be required to make a successful facility. The Trust is working with the developers, contractors and Centre Manager to ensure this process goes as smoothly as possible. Within the building will be a training centre for dental services to serve the Neath Port Talbot locality. This centre will be a fully equipped, state of the art facility providing nine dental surgeries, x-ray room and sterilising and decontamination services. Three of the surgeries will be dedicated to the Community Dental Service of the Trust. Due to the specialist nature of this area tenders were invited for the fitting out of this area in April 2009 following an OJEU advertisement inviting expressions of interest. Bids have now been received and evaluated and a report is being prepared recommending the award of the contract. RECOMMENDATION Directors are asked to note the foregoing.

REPORT PREPARED BY: Ian Phillips Deputy Director IMT & Performance Improvement REPORT SPONSORED BY: Debbie Morgan Director of IMT & Performance Improvement

TRUST BOARD June 2009

AGENDA ITEM: 11

IM&T STRATEGIC PRIORITIES PURPOSE The purpose of the report is to outline the IM&T strategic objectives and priorities which are presented in the IM&T Clinical Development Strategy (attached at Appendix 11.1) and to gain approval for the principles and approach outlined. IM&T STRATEGIC WAY FORWARD During the last few months, the IMT & PI Directorate has been focussing on developing the strategic way forward and priorities for IM&T for the new Trust. This work has culminated in a draft high level plan which has been shared with Clinical Directors and their senior management teams. The feedback and comments received have been very positive from the eleven meetings already held. The document has been developed in association with the Associate Medical Director for Performance Improvement, Mr Hamish Laing and the Non-Executive Director for IM&T, Mr Barry Goldberg, who has been present at many of the meetings. There has been considerable support so far for the strategic priorities outlined in the document which promotes the vision for using technology to underpin the redesign of care processes and support improvements to patient care. This approach will also improve patient safety (linked to the 1000 lives campaign) and reduce clinical risk by, in the longer term, providing clinical staff with a live patient-centric view of information where ever care is being delivered. The priority for 2009/10 is therefore to create an organisation-wide “gold standard” demographic record to enable consistent and accurate patient identification and provide a link to fragmented patient records currently held on different departmental systems and so provide a virtual patient record for clinicians. One of the major challenges is tackling the historical duplication of records within the two former organisations’ PAS systems, which will require significant additional resources to address. New patient registration processes will also need to be introduced, not just for in patients and out patient but within A&E, pathology, radiology and other departments, in order to stop the creation of more duplicates in the future.

IM&T Clinical Development Strategy Page 1 Trust Board June 2009

Creating and maintaining a live patient record also requires access to IT at the point of care. Funding will, therefore, be required to improve the infrastructure and refresh old technology. NEXT STEPS The Directorate is currently developing the detail of the projects and schemes which need to be established to deliver the strategic objectives. Work has already started on developing the way forward for a single PAS for the Trust in order to support the emerging clinical models which have patient pathways that move across previous organisational boundaries. Planning has also started in other areas which include: • Master Patient Index project in conjunction with Informing Healthcare (IHC)

which is crucial to delivering the unique patient identifier across the Trust • Single Laboratory Information System (LIMS) • E-referrals – working in collaboration with IHC to pilot the use of the Welsh

Clinical Communications Gateway (WCCG) to share information electronically between primary and secondary care

• Technology refresh – a significant level of investment is needed to bring PCs across the Trust up to the minimum standard and to facilitate the ‘work anywhere’ model for clinical staff

Over the next two months a detailed implementation plan will be developed and brought to a future Board meeting for approval. CONCLUSION The IMT & PI Directorate has set out a strategic way forward for IM&T within ABM Trust which will support patient care, improve patient safety and reduce clinical risk. RECOMMENDATION The Trust Board is asked to note:

o the strategic objectives and priorities outlined in the IM&T Clinical Development Strategy, and

o the next steps for the development of an implementation plan to deliver these objectives.


IMPACT ASSESSMENT

Impact Analysis Criteria Response • Resource impact, including costs,

HR, Capital

The Implementation plan will outline the priorities for IM&T discretionary capital funding. Some IM&T schemes will be subject to a separate business case.


Implementation of the IM&T strategy will underpin the redesign of care processes and support improvements in patient care. This approach will also improve patient safety (linked to the 1000 lives campaign) and reduce clinical risk

• Risks

None.


The implementation of the IMT & PI Strategy supports the Corporate and Operational/Clinical Outcomes levels for: Standard 25: Healthcare organisations use effective information systems and integrated information technology to support and enhance patient care, and in commissioning and planning services.

• Equality

There are no significant issues.


Appendix 11.1

Information Management Directorate Page 1 of 5

Information Management & Technology and Performance Improvement (IMT&PI) Directorate

IM&T Clinical Development Strategy 2009-2011

Introduction Abertawe Bro Morgannwg University NHS Trust was formed on 1st April 2008 by the merger of Swansea NHS Trust with Bro Morgannwg NHS Trust. The predecessor organisations had taken very diverse paths in their delivery of IM&T systems to support their respective organisational needs. Therefore, the new Trust must take into account this diversity and provide a prioritised plan which moves the new organisation forward and focuses on improving patient care through better use of information and the widespread application of technology. In parallel, the Trust will continue to work closely with the Informing Healthcare (IHC) Programme in order to plan the convergence of local IM&T services with national products as these become available over coming years. IHC support for local projects continues in order to learn lessons from the operational use of IM&T solutions and inform the requirements for national applications. Ultimately, the IHC vision is to make patient records available to be shared and viewed securely wherever they are required across NHS Wales. Existing links with partner organisations and the Centre for Health Information, Research and Evaluation at Swansea University will need to be developed further in order to maximise the opportunities to share learning, particularly in addressing the significant challenges in sharing information across organisational boundaries.

Strategic objectives The overall aim of the Trust’s IM&T Clinical Development Strategy is to support the delivery of patient care by providing clinical staff with a patient-centric view of information (currently held on numerous non-integrated departmental systems) in order to support high quality care. Clearly, this information needs to be up-to-date, accurate, and available wherever care is being delivered. Making this a practical reality for ABM clinicians is a significant challenge in the light of both the number and variation in IT systems in use across the Trust. Added to this, the key building block for accurately and consistently linking together information held on disparate systems is a unique patient identifier. This is not in place across the Trust. Furthermore, the use of multiple health record numbers and the likely volume of duplicate records provides a weak foundation on which to build the electronic patient-centric record. In addition, there have also been a number of IT systems introduced throughout the Trust which have failed to deliver the expected benefits. There are four key reasons for this:

• Introduction within individual departments without integration with other Trust systems. This results in, not only duplication of data entry, but also introduces the additional risks associated with transcription and further fragmentation of the overall patient record.

• The introduction of non-integrated systems further adds to the burden of integration and works against provision of a holistic electronic patient record.

• Access for staff to all the information they need requires numerous and separate log-ins and patient searches which is not only time consuming but it may also prove difficult to match records in the absence of a unique identifier.

• Multiple identifiers for the same patient compounds all of the above and introduces further risk in not matching important information or, indeed, matching information to the same patient erroneously.

These problems are compounded following the merger of organisations where separate records were held previously, and are intensified by the changing clinical model which is already beginning to move waiting lists and the delivery of care across the previous organisational boundaries.

Principles Following discussions with clinical directorates the IM&T Strategy has been refined. A detailed Implementation Plan is currently being developed and will be finalised following confirmation of the capital resources available. The strategy is built on best practice and is based on a number of key principles which are outlined below:

• Utilising IMT as a critical enabler to support service modernisation • Supporting the redesign administrative and clinical processes to maintain high levels of data quality,

ensure information is accurate and up to date, and help deliver safer patient care

Date: Revised May 2009 Status: Draft version 1.2

Appendix 11.1


• Focus on recording information for clinical purposes (primary use of data) rather than cleansing existing data outputs for secondary purposes

• Automating and streamlining processes wherever possible • Reducing transcription and duplication of data recording • Providing a patient-centric view of information by linking clinical records held on different departmental

systems • Providing a shared view of information across primary and secondary care wherever possible • Investing in a robust, reliable and resilient ICT infrastructure which supports access to information at the

point of care.

Development will be prioritised to provide clinical benefits and reduce clinical risk. The aim is to provide an integrated patient centric record and ensure the enabling systems and technology infrastructure is robust, resilient and available to support care wherever this is delivered. This strategic approach will be delivered in incremental steps and require significant and sustained investment. The IMT&PI Directorate will work closely with clinical directorates to develop a prioritised, annual investment plan.

The ABM Approach

Unique patient ID - In the light of the strategic objectives outlined above, efforts must, therefore, be focussed on supporting improvements in patient safety by delivering an enterprise (Trust-wide) master patient index (EMPI) of demographic information. This will provide the foundation for delivering an integrated patient-centric record as well as begin

to reduce duplication and risk. The key components to this work are outlined below: • Eliminating Current Duplicate Patient IDs - Attacking the historical duplication within the PAS systems

and then incrementally within other systems on a priority basis: Pathology and Radiology being the first priorities. This is a huge undertaking and limited mainly by the number of staff available to work through the potential duplicates held on each system

• Technical build of EMPI software composing of:

o ‘Gold-standard’ demographic record managed in real time with links into clinical systems, PAS systems etc.

o Pre-processing module, which allows records to be matched and cleansed prior to systems being linked up in a live environment.

o Operational management module, which highlights the creation of potential duplicates as they are created, and handles the operational management of records to be matched and merged.

o ‘Signposts’ within the gold-standard record to clinical information held on different departmental IT systems (e.g. PAS events, radiology reports, PACS images, path reports, theatre information etc.) which are matched to the gold-standard record

• Process change - We must ensure that we not only get rid of historical duplication, but also put

sustainable systems in place to ensure duplicates do not continue to be recreated in the future. The good news is that this is possible – currently around seven potential duplicates created each day in the Princess of Wales and Neath Port Talbot hospitals. This is clearly a sustainable number to manage and the Information Department’s data quality processes have been redesigned to manage this in real time (in office hours). This involves forcing registration on departmental systems against the gold-standard demographic record. Delivering this essential component will require a multidisciplinary approach involving commitment at all levels within the clinical directorates, Patient Services and Health Records Departments as well as key IMT&PI Directorate staff.

• Live information - Capturing information on all our patients as soon as they come into contact with our

organisation. There is the potential here to use A&E and MAU clerks where there is 24/7 administrative cover to register patients and ‘push’ these to the wards where they appear on the ward for nurses to simply press an ‘admit’ button outside office hours.

Access at the point of care - Creating and maintaining a live patient-centric record will also require

unrestricted access to IT which needs to be provided at the point of care. Significant investment will be required in this area. In addition, the security, confidentiality and integrity of personal identifiable information is paramount and new Trust wide policies and procedures will be introduced to ensure consistency across the organisation. The provision of a comprehensive medical-grade wireless infrastructure for both Morriston and Singleton hospitals will also need to be planned and delivered in due course.


Appendix 11.1


Technology Refresh - With around 8000 PCs across the Trust and a significant number over 5 years old, a

considerable injection of IM&T capital will be required to bring PCs up to minimum standards with £800,000 required annually to maintain this level. Investment in servers for key clinical systems and other key infrastructure components will also be required. Roll-out of laptop computers for consultant staff will also be continued together with replacement PCs being targeted in clinical areas.

Training & Support - A key priority following the introduction of the Trust-wide e-mail system is to ensure

that the opportunities to exploit the benefits of this technology are maximised. In addition to the existing IT systems based training available, a programme of role-based training will be developed, providing staff with the skills to use all appropriate IT tools required to do their job. New IT kit also needs to be set up and users supported to allow new models of working for key clinical staff including remote and home access. The aim is to provide a robust and

user friendly ‘work anywhere’ solution. Work has also commenced on the redesign of the IM&T workforce in order to address the agenda outlined above. An integrated team will provide a more responsive service and support new ways of working across the new Trust. This integrated workforce will allow wider sharing of technical knowledge, greater technical specialisation and expertise, improved succession planning and will be supported by opportunities for training and development. Departmental Systems Replacement PACS - A replacement PACS project is already underway within the Bridgend and Neath Port Talbot locality. The solution will provide access to images across the Trust. Single LIMS - IHC has provided funding to support the rollout of the Masterlab Pathology system already in use at Morriston, Singleton and Neath Port Talbot to the Bridgend site. A single LIMS will provide Pathology with the ability to manage tests seamlessly across ABM. In addition, the migration from Telepath will provide a template for data migration for the rest of NHS Wales following the procurement of an all-Wales LIMS in due course. ABM PAS Strategy Work will commence in 2009 to determine the way forward in implementing a single PAS for the Trust in order to support the emerging clinical models with patient pathways that move across previous organisational boundaries in order to maximise capacity and improve the quality and timeliness of care. Options include either the roll out of one of the existing PAS systems or a new PAS implementation. A business case will therefore need to be developed to consider the options in detail and recommend the preferred options and associated timescales. Work has also commenced to explore the opportunities to consolidate the use of other departmental systems to provide an integrated view of information across the organisation. Timescales to consolidate will be determined by operational priorities, contractual considerations and the resources available and, of course, be subject to the approval of the appropriate business case. Information Reporting & Performance Management The focus on establishing and maintaining high levels of data quality to ensure information is accurate, up to date and supports the delivery of safer patient care, is aligned with the National Data Quality Accountability Framework for Trust data and subsequent data set standards. Site visits undertaken as part of the NHS Wales Data Quality Programme have already identified areas of good practice within the Trust. A Data Quality Policy and Implementation Plan are also currently in development in order to support the work outlined above and provide clear standards for the maintenance of data quality within the Trust. The key focus for Performance and Information reporting is to provide a Trust-wide view of information based on common standards and definitions. Whilst standard ABM reports are now available, work has commenced in order to bring together all relevant information resources and make this available via the Information web page. The Information Page will shortly be available as a tab from the ABMU Trust Intranet Homepage, where the majority of routine information is already published (including referrals, waiting lists, performance, delayed discharges, SITREPs, emergency admissions and A&E trend data, consultant appraisal forms and LTAs). There are also links to additional resources such as Hypercube and CHKS Signpost. The Hypercube product continues to be developed in order to provide a more self service approach to information. This flexible web tool allows users to


Appendix 11.1


query and interrogate summarised information sets directly and allows information to be trended and downloaded to MS Excel. Clinical benchmarking information is also available via the CHKS Signpost product. RTT - The delivery of Referral to Treatment times (RTT) poses a significant organisational service delivery challenge for the Trust with the focus now on the management of the whole pathway of care for patients, as opposed to the current focus on New Outpatient and Inpatient waiting lists. Managing waiting times in this way will require robust system and administrative processes to be in place in order to support the operational management and monitoring of patient pathways and to report RTT waiting times. This requirement has posed a significant challenge for all Trusts across Wales as IT systems and operational processes have been designed to support the delivery of the current component waiting lists. A starting point however must be for the PAS systems to be used consistently and comprehensively as the operational tool for managing waiting lists and patient flow. Monitoring and measuring waiting times for RTT has required these systems and processes to redesigned and redeveloped without compromising the current component waiting times processes. Most merged Trusts have completely separate Patient Administration Systems and no methods in place to join up patient records. At present RTT performance in Wales continues to be reported separately for merged trusts. Until the EMPI project has been implemented to enable safe and consistent patient identification and management of multiple and duplicate records it will not be possible for ABM to manage individual patient pathways seamlessly. In August 2008 the Trust received accreditation of the RTT reporting and data capture processes for the Bridgend and Neath Port Talbot localities of the Trust, where the in-house PAS system has been updated in order to support the live recording and operational monitoring and management of RTT waiting times. In January the reporting processes for the Swansea locality were also accredited. This process, however, is a retrospective approach to provide the information reports as the iPM system does not currently support the live data recording of RTT waiting times. The Trust continues to work with iSOFT to test and implement a new version of the iPM software to support the operational management of RTT. E-Referrals - Key to the efficient management of an RTT pathway is the rapid transfer of referral information. Implementation of electronic referrals between Primary and Secondary care would enable standardisation of referrals received by the Trust and could also provide a record of all the relevant clinical information held at the GP Practice. NHS Scotland has successfully implemented an E-referral solution known as SCI Gateway. IHC are currently finalising an agreement with NHS Scotland to implement this solution across Wales. Work to develop and pilot this solution for electronic referrals in 2009/2010 is already underway. Bringing primary and secondary care sectors together in the formation of the new ABM LHB will facilitate more seamless working in bringing this project to a successful conclusion. Funding Information and communications technology is a critical enabler in service modernisation and stepped change. £1.3 million was previously identified from Trust discretionary capital to support the 2008/2009 IM&T Implementation Plan. Funding was targeted predominately towards replacing the oldest PCs concentrating on clinical areas. Improvements have also been made to the technology infrastructure and commencement of the mobile working project for clinical staff. Investment required to maintain existing levels of the ICT infrastructure is around £1m p.a. Additional and sustained capital investment is key to making progress in providing access at the point of care and developing a robust and resilient ICT infrastructure. The pace at which seamless access to patient-centric electronic information can be provided will be determined primarily by the level of investment available. Investment will also be required to provide wireless access at Singleton and Morriston hospitals in due course. This will require an additional £2million, approximately. Governance & Security In addition to clinical engagement described in the development of annual implementation plans, it is proposed that the Step Change Board will oversee progress against the IM&T development plans. Detailed project management arrangements will be undertaken by the IMT&PI Directorate with regular reports to be provided to the Operations and Trust Boards. As more and more clinical information becomes available electronically, IT security measures will also need to become more sophisticated in order to allow immediate and seamless access whilst maintaining adequate levels of protection for person identifiable information. This work will be lead by the Associate Director of IT Security.


Appendix 11.1


Risks & Challenges Realising the benefits –IM&T is a key enabler in supporting the modernisation agenda. Technology in itself will not, however, deliver service improvement. The IMT&PI Directorate will therefore work closely with the Step Change Team and provide appropriate input at Board level as required. 24/7 support - The increasing use of technology to store clinical information and thus support the clinical process means that there is an increasing need to ensure these systems remain available on a 24/7 basis. Currently, on-call IT services are only in place in the Swansea locality. There will, therefore, be a review of the requirements for on-call in order to provide a comprehensive support service in order to ensure clinical applications are available as close to 24/7 as possible. New ABM LHB – Whilst it is envisaged that the current arrangements for information support to the LHBs provided by the BSC will continue at present, the information requirements of the new organisation are yet to be determined. Support for GP systems will also continue to be provided by the Programme Management Unit (PMU) team. It has been agreed that desktop support for current LHB staff transferring into the new organisation will best be provided by the Trust’s IT Department. This work is being managed as part of the Information Workstream set up as part of the transition arrangements. Revised May 2009


Healthcare Standards Report Trust Board

10th June 2009

1

REPORT PREPARED BY: Hazel Abbott, Associate Director of Corporate Affairs, Risk Management Nicola Williams, Associate Nurse Director, Governance & Safeguarding REPORT SPONSORED BY: Calum Campbell Acting Chief Executive


AGENDA ITEM: 12

HEALTHCARE STANDARDS REPORT

1 PURPOSE

To provide the Trust Board with a report on the progress against the Healthcare Standards Improvement Plan (HCSIP) and final self assessment position of the Standards for the period April 2008 to March 2009.

2 INTRODUCTION

The Trust was required to undertake and complete a self-assessment against the Healthcare Standards by 9th April 2009 although, as a result of the technical difficulties experienced with the tool, the deadline was extended to 15th May 2009. Further technical problems were experienced after the validation work, which the Domain Leads and Internal Audit had, carried out. This resulted in duplication of work in an attempt to update the Standards to the same position at the time of validation in readiness for submission by the deadline. Work was still ongoing on the day of submission and technical problems were experienced up to the time of submission. This report sets out the outcome of the Trusts self assessment against the Healthcare Standards for 08/09; performance against the actions identified within the HCSIP for the period and proposals for the 2009/2010 self assessment of the new LHB.

3. DECLARATION AND SELF ASSESSMENT PROCESS 3.1 Overall score for 2008/2009

Overall the organisation is self assessed as Level 3 (developing), which indicates that steps are being taken to address the key issues with the Board taking steps to address them through the development of strategic plans. Details of the self assessment scores are set out in Appendix 12.1.


10th June 2009

2

There has been a decrease in some level 4 and 5 scores to 3 for 2008/2009 self assessment. This relates to the work which was required to review arrangements in both former organisations and ensure best practice was adopted and implemented. It is anticipated that these scores will increase to level 4 scores in 2009/10 through the development of a robust Healthcare Standards Improvement Plan (HCSIP) for 2009/2010 which will be regularly monitored.

3.2 Core Healthcare Standards The Trust for 2008/2009 has scored level 4 against all of the core Standards, These are regarded as key indicators of organisations’ clinical and corporate governance arrangements by Internal Audit and Healthcare Inspectorate Wales. The core Standards are as follows:

Standard 14 - Risk Management and Health & Safety Standard 16 - Incident reporting and Management Standard 27 - Governance and Risk Management Standard 28 - Healthcare Governance

Achievement of level 4 indicates that there are well developed plans being implemented throughout the organisation and that the strategic agenda is being progressed and monitored by the Board.

3.3 STATEMENT OF INTERNAL CONTROL The Statement of Internal Control (SIC) included in the Manual of Accounts issued by the Welsh Assembly Government indicates that Trusts are required to undertake a self- assessment against the Healthcare Standards and in particular those deemed core to the management of risk as set out in standards 14, 16, 27 and 28 and that a Healthcare Standards Improvement Plan for the year is in place. HIW are aiming to issue their report on the Trusts self assessment, following validation inspections carried out within the Trust in March, in time to inform the SIC for 2009/10.

4. HEALTHCARE STANDARDS QUALITY IMPROVEMENT PLAN (HCSIP) & 2009/2010 SELF ASSESSMENT PROCESS 2008/09 End of Year Position The end of year position against the Trust’s 2008/2009 HCSIP shows that the Trust has made good progress in achieving the actions within the Plan, with a total of 77% of actions being achieved. Those actions that had not been achieved by the 31st March 2009 were in the main as a result of the merger with some policy & strategy development being extended to cover the ABM University LHB. This work is now being progressed through the Transition Board Clinical Governance Work Stream. A full copy of the Plan was considered by the Healthcare Governance Committee and is available on request.


10th June 2009

3

2009/10 HCSIP Development requirements An ABM University LHB HCSIP covering the period 2009/10 is to be developed that will highlight key actions to achieve the cross cutting priorities and risks highlighted by predecessor organisations, which the new LHB will wish to focus on during this year. In order to commence this work a time out session for all four current organisations took place on 1st June 2009 during which the Trust and the LHB’s mapped out the process for completion of the LHB wide HCSIP. All actions have to be implemented and completed by 31st March 2010 and will be monitored internally through the LHB Board or designated Committee. External monitoring of the HCSIP is not clear at this stage and further guidance is expected from the Assembly regarding the process to be adopted.

5. FUTURE DEVELOPMENTS During the period 2009-2010 the Healthcare Standards for Wales framework will be revised, and NHS organisations and other stakeholders will be consulted throughout this process.

6. RECOMMENDATIONS

The Trust Board are asked to note the contents of the report and the end of year position against the HCSIP.


10th June 2009

4

Appendix 12.1

Healthcare Standards Scores for 2007/08 & 2008/09

STD 2007/08 BroMorgannwg

2007/08 Swansea

STANDARD 2008/09 ABMU

Movement on BroMor

Movement on Swansea

1 3 4 1 4 ↑ - 2 4 4 2 4 - - 3 4 4 3 3 ↓ ↓ 4 3 3 4 3 - - 5 3 4 5 3 - ↓ 6 3 4 6 4 ↑ - 7 3 4 7 3 - ↓ 8 3 4 8 3#$ - ↓ 9 3 3 9 3#$ - - 10 3 4 10 3#$ - ↓ 11 3 4 11 3#$ - ↓ 12 3 4 12 3 - ↓ 13 3 4 13 4#$ ↑ - 14 4 4 14 4+ - - 15 4 4 15 3#$ ↓ ↓ 16 4 4 16 4+ - - 17 3 3 17 3#$ - - 18 4 4 18 4#$ - - 19 3 4 19 3#$ - ↓ 20 4 3 20 3#$ ↓ - 21 3 3 21 3 - - 22 3 3 22 3 - - 23 3 3 23 3 - - 24 3 3 24 3 - - 25 5 3 25 3 ↓ - 26 4 3 26 3 ↓ - 27 4 4 27 4+ - - 28 4 4 28 4+ - - 29 4 3 29 4#$ - ↓ 30 3 3 30 3 - - 31 N/A N/A 31 N/A 32 4 4 32 3#$ ↓ ↓

* Core Standards # = Reviewed by Scrutiny Panel + = Reviewed by Internal Audit $ = Internal Audit rechecked these Standards to ensure concern/recommendations of the Scrutiny Panel had been actioned 1 = Aware 2 = Responding 3 = Developing 4 = Practising 5 = Leading

Annual Report of University Non-Executive Director (Professor Julian Hopkin) to ABM University NHS Trust

Year to June 2009 1. Transition to ABM University Local Health Board a] University welcomes this integration of health service governance and function – believing that it creates an outstanding opportunity for transformational change in health service delivery and for advancing collaborative and integrated education and research in health. b] University looks forward in particular to the development of a state-of art Ambulatory Medical Centre (AMC) at the Singleton Hospital campus – seeing the great potential of that to transform clinical care, and to advance education and research, as described in the Concordat between University and Trust in 2007/8. c] School of Medicine has proposed a new formula for integrating university and health service research and development in Wales, to the Minister of Health. The new formula – based on Wales’ new National Institute of Social Care and Health Research (NISCHR) - creates an unique opportunity for promoting outstanding clinically relevant research, through collaboration, and promoting important cost efficiencies at the same time. 2. Education and Training a] Schools of Medicine and Health Science’s degree courses in Medicine, Nursing and other health professions continue to advance – as one vital source of clinical staff at ABM. b] Graduate-Entry MB; School of Medicine has interviewed 200 of 500 applicants for its fully independent, fast-track 4 -year course from September 2009; 130 applicants with high quality first degrees in a broad array of subjects (biological sciences, physical sciences, arts and humanities) have been highly recommended for entry for the 70 places. This course builds on success – including the outstanding clinical teaching performance of School’s Senior Clinical Tutors at Trust and in local general practice. See Appendix for School of Medicine Logo, and its Doctor’s Oath for Graduate-Entry MB.

c] a monthly, tripartite University Health Forum between the Schools of Medicine, Health Science and Human Sciences (including psychology & ageing) explores other educational and research collaborations, and which are of vital importance to ABM d] the Schools of Health Science and Medicine will in 2009/10 session put a proposal to ABM Board on their collaborative engagement in interdisciplinary postgraduate training, and continuing professional development across ABM. 3. Research and Development a] Research Assessment Exercise 2008 represented the latest senior peer-review of the quality of research across Britain’s Universities. Swansea University made serious advance with outstanding performance in particular at Engineering, Computing and the Institute of Life Science – with more than 20% of the work rated as World Leading, and >50% rated as Excellent International Class quality. Strong results were also recorded at School of Health Science and Health Service Research. b] School of Medicine’s Institute of Life Science (£55M value, with its IBM Supercomputing, and Boots Global Centre for Innovation) has fulfilled its targets for the knowledge economy – where the development of medical diagnostics and therapeutics is linked to the creation of intellectual property (IP), spin-out companies, and new jobs. Two spin-out companies at ILS illustrate this well, both supported by direct equity investment and government grants for innovation: – Calon-Cardiotechnology has produced a prototype implantable cardiac assist device, and is developing this micro-pump for the treatment of heart failure; Allerna Therapeutics has created small molecules that specifically block the inflammation that causes asthma, has secured patents on these, and is on the path to develop a new inhaled treatment for asthma. An earlier spin-out company (CyDen) led by Professor Marc Clement of Medicine is already marketing devices on skin care and therapeutics. c] Following the success of the first phase of Institute of Life Science, Schools of Medicine and Engineering have secured funding for a Centre for NanoHealth (£28M value) as part of European Union Convergence funding. Interdisciplinary research between the School of Medicine and Engineering is flourishing – and one Engineering inspired spin-out company (Haemair Ltd) has developed a membrane-device capable of oxygenating blood, and which has the potential for treatment of acute and chronic respiratory failure.

d] School of Medicine is looking to a positive outcome to its bid for Institute of Life Science – Phase 2 with Clinical Research Facility (£29M value) from European Union Convergence Funding, on 12th June. ILS-2 will represent a potent collaboration with ABM – being a 5000m2 build sited on Singleton Hospital ground, and adjacent to the Ambulatory Medical Centre (see 1b above) – and where the ILS-2 Clinical Research Facility will include state of art Health Informatics, comprehensive Clinical Trial capabilities, and investigational modalities with 3T MR and superfast CT imaging. e] Important progress in clinically applicable research continues at the Schools of Health Science and Human Science. In particular there is vibrant research in the areas of developing clinically applicable anti-bacterials from natural sources, of health economics (Health Science), and of the vital social care aspects of ageing (Human Sciences). f] Schools of Medicine and Engineering have together launched a Cardiac Research Forum centred on ABM’s Cardiology Centre (led by Dr Mark Ramsay at Morriston) focusing on modelling the structure and function of the heart and cardiovascular system. This represents a prototype of promoting research in strong clinical units across ABM from East to West. An immediate next project is promoting research at the Regional Burns Unit at Morriston (led by Mr Tom Potokar). An earlier and thriving project (the Sir Gâr Project) focuses on the early recognition of obesity in the Carmarthenshire population (led by Dr Meurig Williams at Hywel Dda Trust and Professor Rhys Williams at School of Medicine) as a basis for intervention to prevent the development of diabetes and cardiovascular disease. Conclusion University and ABM University Trust (and LHB to be) have both seen major progress through 2008/9. Collaboration between the University and Trust is being successfully led at the quarterly Joint Governance Committee (chaired alternately by Chair of ABM Trust and Rector for Medicine & Health at University). JGC thus performs a vital function – not universally present at the major medical centres in Britain and where vital collaborative opportunities have been lost. Hence, 2009/10 and beyond offers great opportunities for us – through close collaboration – to advance both university and health service sectors in South Wales and where we can together deliver major advances in health to our local population and further afield.

Disability Equality Annual Report 2008 1 Trust Board meeting - 12 June 2009

REPORT PREPARED BY: Jane Williams, Assistant HR Manager REPORT SPONSORED BY: Geraint Evans, HR Director


AGENDA ITEM: 14.

DISABILITY EQUALITY ANNUAL REPORT 2008 1. PURPOSE

This paper provides an annual update on progress regarding disability equality within the Trust.

2. BACKGROUND

The Disability Discrimination (Amendment) Act 2005 introduced a new disability equality duty that came into force on 4 December 2006. This requires all public authorities to have due regard to the need to promote disability equality.

As a public authority, the Trust is required to publish a report, on an annual basis, containing a summary of: • the steps that it has taken to fulfil its disability equality duty • what has been done over the past year to eliminate discrimination

and promote equality of opportunity. The publication of this information demonstrates an authority’s commitment to making progress on equality for disabled people. It provides transparency for members of staff and the local community.

3. ANNUAL REPORTING

The Trust has developed a Disability Equality Annual Report, which demonstrates the actions that have been taken to fulfil its disability equality duty (see Appendix 14.1). The Report outlines progress on our journey towards achieving disability equality, provides examples of good practice and highlights where more work needs to be done.


4. CONSULTATION

This Annual Report has been produced in consultation with members of the Disability Equality Forum and staff who served on the Equality and Diversity Steering Groups of the former Bro Morgannwg and Swansea NHS Trusts. Their contributions have been incorporated into the Annual Report.

5. RECOMMENDATION

The Trust Board is asked to approve the Trust’s Disability Equality Annual Report 2008 for publication on our internet site.


Impact Analysis for Disability Equality Annual Report

Impact Analysis Criteria

Response


Adaptations to existing facilities: Any improvements to accessing facilities for disabled people would need to be met from the Capital Programme. Priorities should be identified from the Access Audits previously undertaken across the Trust and the involvement of disabled people. Staff training: The delivery of equality and diversity training has resource implications for the organisation. One of the Trust’s Equality and Diversity Leads currently delivers the training so these costs are met within existing HR resources. To deliver this training across the organisation, the Trust will consider options such as technology based training solutions. The financial implications will be a key part of the evaluation.


The Annual Report highlights those areas where additional work will ensure the organisation continues to progress along the journey towards achieving disability equality.

• Risks

Nominations for the Trust wide Equality and Diversity Steering Group will be secured to establish the Group and avoid the risk of the equality and diversity agenda losing momentum during this period of transition.


Equality and diversity is embedded within many of the Healthcare Standards relating to user experience and healthcare governance.

• Equality

The Disability Equality Annual Report meets the Trust’s requirement to report annually the steps that it has taken to fulfil its disability equality duty.

Appendix 14.1

Disability Equality Annual Report

2008

This report can be made available in alternative formats and other languages, on request,

as is reasonably practicable to do so

Contents

Chapter 1: Introduction 2

Chapter 2: Leadership and Corporate Commitment 4

Chapter 3: Demonstrating Progress with Disability Equality 6

Chapter 4: Involving disabled people 19 Chapter 5: Impact Assessment 24 Chapter 6: Gathering and using information 26 Chapter 7: Conclusion 28

Foreword Abertawe Bro Morgannwg University NHS Trust welcomes the opportunity to produce its first Disability Equality Annual Report. Our Report reviews how effectively the Trust is making progress with implementing the disability equality duty introduced in the Disability Discrimination Act 2005. This requires public bodies to have due regard to the need to promote disability equality. We are encouraged by the disability equality work undertaken within the Trust, particularly the active involvement of disabled people in taking forward the implementation of the Scheme. It is recognised that there are challenges to be tackled to drive forward disability equality. Further work needs to be done and our Report explains how this will be taken forward with top-level leadership, senior management support and commitment. Our challenge is to ensure that disability equality is delivered for patients and staff as an integral part of service improvement and development. The aim is to make a real difference to the day-to-day lives of disabled people.

Win Griffiths Calum Campbell Chairman Acting Chief Executive Abertawe Bro Morgannwg Abertawe Bro Morgannwg University NHS Trust University NHS Trust

1

Chapter 1: Introduction This publication reports on the Trust’s progress towards achieving disability equality in 2008. It identifies and analyses the: • Trust’s good practice • lessons learnt from the development of our Schemes • biggest challenges to the delivery of disability equality • future action to be taken. The timing of this Annual Report coincides with the NHS reconfiguration in Wales. We believe this offers significant opportunities to strengthen the focus on equality and diversity, building on the experience, knowledge and expertise within the existing organisations. Background Abertawe Bro Morgannwg University NHS Trust is the largest hospital Trust in Wales, and one of the largest in the United Kingdom. The Trust was launched on 1 April 2008, following a merger between the former award-winning Swansea and Bro Morgannwg NHS Trusts. The Trust employs around 16,000 staff and has an annual budget of more than £700 million. It manages a comprehensive range of integrated hospital and community services for the 600,000 approximate residents living in the county boroughs of Swansea, Neath Port Talbot, Bridgend and the Western Vale of Glamorgan. We have four major hospitals: Morriston and Singleton in Swansea, the Princess of Wales in Bridgend and Neath and Port Talbot in Baglan. The Trust has, also, 14 community hospitals, clinics and treatment centres with in-patient beds and 46 community clinics and health centres. A range of community health services is provided to the local population. Disabled people particularly value the care and support provided in their homes by community nurses.

2

The Trust offers a comprehensive range of hospital services, including specialist services, such as Cardiac, Neurosurgery and Renal. We are also home to the Welsh Centre for Burns and Plastic Surgery, which covers Wales and the South West of England. The South West UK Burns Network chose the Morriston Centre as the centre for the South West of the UK, covering a population of approximately 10 million people in the delivery of a service for complex burns. The Forensic Mental Health service is provided to a wider community which extends across the whole of South Wales. Learning disability services are provided from Swansea in the west as far as the Cardiff in the east. The Trust manages the Surgical Materials Testing Laboratory, which tests surgical dressings and medical devices on behalf of the NHS in Wales. The Trust also maintains a business interest in ZooBiotic Ltd, which the Trust ‘spun out’ to promote the clinical benefits of maggot therapy. The Trust manages Welsh Health Supplies, which offers a non-profit making procurement service to the NHS in Wales with offices in Bridgend, Cardiff and Denbigh. The Trust is the host organisation for the Welsh Assembly Government’s Informing Healthcare Programme - a National Programme to develop new methods, tools and information technologies to transform health services for the people of Wales. The aim is to modernise health service delivery and promote new ways of working through better access to information and knowledge. The National Leadership and Innovation Agency for Healthcare (NLIAH) continues to be hosted by the Trust. The purpose of the Agency is to provide strategic support to NHS Wales in building leadership capacity and capability to secure continuous service improvement, underpinned by e-technology, innovation, leading-edge thinking and best practice to deliver the service change agenda. 2007/8 saw the Agency complete its third year as a national, strategic resource to support NHS Wales in the delivery of a world class health service.

3

The Trust also hosts the National Delivery and Support Unit. This was established by the Welsh Assembly Government to assist NHS Trusts and Local Health Boards to consistently achieve and sustain national access targets in key priority areas and embed a culture of performance and delivery throughout NHS Wales. The Trust hosts the NHS Centre for Equality and Human Rights (CEHR), which supports the NHS in Wales by building capacity and capability to ensure patients and staff are treated fairly and in accordance with their needs. We are the first Trust in Wales to be granted University title. We work closely with University of Wales, Swansea and its Medical School, along with other university and college partners in South Wales. The Princess of Wales, Neath Port Talbot and Tonna Hospitals hold the prestigious Charter Mark status and accreditation. This is the Government’s award scheme for recognising and encouraging excellence in public service. The former Bro Morgannwg NHS Trust was accredited as an Investor in People organisation. This is the national quality standard for effective investment in the training and development of people to achieve business goals. Chapter 2: Leadership and Corporate Commitment The Disability Discrimination (Amendment) Act 2005 introduced a new disability equality duty that came into force on 4 December 2006. This required all public authorities to have due regard to the need to promote disability equality. The former Swansea and Bro Morgannwg NHS Trusts involved disabled people in the development of their Disability Equality Schemes. The publication of the Schemes made the public and members of staff aware of the Trust Boards’ commitment to the promotion of disability equality.

4

The Chairman of Bro Morgannwg NHS Trust chaired their former Equality and Diversity Steering Group and a Non Executive Director chaired Swansea NHS Trust’s Equality and Diversity Group. It is the intended that the Chairman of the new Local Health Board will be the chair of the Equality and Diversity Strategic Group for the new organisation. This reflects his special interest in promoting equality, diversity and human rights. The Director of Human Resources will be the chair of an Operational Group. It is the role of the Trust’s Equality and Diversity Leads to provide secretariat and technical and legislative expertise to both Groups. There will be senior representatives from the Directorates on the Groups who will act as the leads to take forward equality and diversity in their area of work. Staff side will be represented on the Groups to take forward the equality and diversity agenda in partnership. The Local Access Groups will be asked to nominate representatives to join our Groups as their Members will bring their expertise on disability equality to the discussions. Both Groups will have disability equality as a standing agenda item. The Strategic Group will provide feedback on progress via the designated Executive leads and the Chairman to the Partnership Forum, Executive Team and the Trust Board. The Director of HR currently provides a regular equality and diversity update to the Trust Board and the Executive Team. This includes a disability equality update. An annual self assessment of progress against equality and diversity objectives is undertaken as part of the Healthcare Standards Wales reporting process. Progress on our development towards disability equality is made available to all staff through the Trust Intranet site, updates to Directorate Meetings, Senior HR Development meetings, awareness raising/training events and Corporate Induction Training.

5

Chapter 3: Demonstrating Progress with Disability Equality As one of the largest providers of public services and employer in the local area, the Trust has huge potential to bring about disability equality. One of the key aims of the Disability Equality Schemes is for disability equality to be core business and to be integrated into all aspects of our policy development and implementation, service delivery and employment practice. An update is given below on progress with implementing the Disability Equality Schemes. Service Improvement Lessons Learnt The treatment people with a learning disability receive in primary and secondary care is a major issue that all Trusts face in ensuring equitable services are provided for all. This is highlighted in several national reports including: The Ombudsman’s report into the death of six people with a

learning disability – March 2009 Death By Indifference, Mencap March 2007

Equal Treatment – Closing the Gap, Disability Rights

Commission July 2006 Understanding the Patient Safety Issues for People with

Learning Disabilities, National Patient Safety Agency 2004 Capital funding has been available to improve existing access issues. The involvement of disabled people helped secure the most effective use of the capital allocation.

6

Progress The Trust has appointed a Consultant Nurse, whose focus is on developing the interface between primary, secondary and specialist healthcare services for people with a learning disability. This work includes training for generic healthcare professionals in awareness of learning disabilities, the introduction of a hospital grab sheet to improve information and communication and the development of link hospital nurses within selected departments. Further details are given under the Good Practice section of this Annual Report. The Trust’s Capital Development Team frequently and increasingly look for ways to improve facilities to make life easier and safer for disabled people. Our Team endeavours to comply with the Disability Discrimination Act 2005 (DDA). A number of construction projects were undertaken in 2008 whereby the Disability Discrimination Act was considered and reasonable adjustments applied. Examples are: Critical Care Ward (ITU), Morriston Hospital: This new ward was completed in March 2008. Improved services, communication and toilets were built into the scheme. Burns and Plastics Centre, Morriston Hospital: The Trust opened the extension in the autumn of 2008 to provide a regional burns centre. This has been designed to comply with the regulations and it is fully DDA compliant. Dyfed Road Health Centre, Neath: The upgrading of this health centre has taken account of the requirements of the Disability Discrimination Act to ensure that disabled people benefit from improved access to the building and services. Fire Alarm Systems, Morriston Hospital: The fire alarms systems (main block) were upgraded at a cost of £1.2 million. The work involved installing signalling for disabled patients in the main corridor toilets, plasma information screens at both ends of the corridor and flashing indicating beacons in the main corridor. The ward detection has been upgraded to a far better standard along with other essential work on fire compartmentation.

7

Wards 4, 5 and 6, Princess of Wales Hospital: The upgrading of these wards has addressed the requirements of the Disability Discrimination Act to improve access for disabled patients. The scheme is part of an ongoing refurbishment project at the Hospital which will see the development of single bedrooms rather than multi occupation wards. Ward 4 was completed in December 2008 and Ward 3 is currently being refurbished. Ward 10, Glanrhyd Hospital: The requirements of the Disability Discrimination Act have been taken into account as an integral part of this ward upgrading to ensure that patients benefit from improved access. Diagnostic Equipment: The MRI (Magnetic Resonance Imaging) scanner, CT (Computerised Tomography) Simulator and Double headed gamma camera suites were made accessible for disabled patients at Singleton Hospital. These three capital schemes were installed and available for diagnostic use by mid March 2008. This state-of-the-art, life saving equipment improves cancer services for South West Wales. The investment should speed up and improve the diagnosis of cancer, which would result in better outcomes for patients. A new MRI Scanner was installed in Neath Port Talbot during 2008. At the Princess of Wales Hospital, the CT Scanner has been replaced which included modifications to the entrance to the suite to improve access into the area. Lifts: The lift contract was completed in April 2008. This scheme upgraded 23 of the Trust's main passenger and bed lifts in Morriston and Singleton Hospital and Central Clinic at a cost of £1.7 million. Each lift is fully DDA compliant with repositioned control/selection panels, synthesised voice instructions and internal refurbishment. This is in addition to some major upgrading work to the lifting equipment. All the lifts have been replaced at the Princess of Wales Hospital over the last 18 months on a phased basis. Medical Records Development, Morriston Hospital: The project entails the refurbishment and reconfiguration of an existing building (School of Health Science) to accommodate the Medical Records Department. The value of the scheme is £1.7m and the contract programme is approximately 6 months.

8

The work commenced on 19 January 2009 and handover will take place on 8 June 2009. On completion, the scheme will have: a new lift installed to the first floor

a disabled WC on both ground and first floors

protected wheelchair refuges at existing staircases

accessible WC adjacent to the existing first floor sanitary

accommodation adjustments of ramps at existing fire exits to level landing and

formation of new paths to acceptable gradients new doors into newly formed rooms compliant with Part M of

the building regulations and subsequently the Disability Discrimination Act

disabled parking bays provided within close proximity of the

main entrance. Medical School Library Mezzanine Floor, Morriston Hospital: The Trust is increasing the floor area of the medical library by installing a new mezzanine floor that will be accessible from the first floor via an existing lift. Refurbishment of East and West Wards, Gorseinon Hospital: This scheme will include ensuite facilities for single room cubicles to comply with Part M of the building regulations and subsequently the Disability Discrimination Act. New shower facilities and new chairs will meet DDA requirements. Crush Hall Toilet, Singleton Hospital: The project refurbished existing facilities with a new unisex WC facility replacing the existing male WC. The Secretary of the Local Access Group visited the completed scheme as part of the post project evaluation and was very complimentary about the high standard of DDA compliance.

9

Occupational Health, Morriston Hospital: The project consists of the relocation of the existing Occupational Health Department to the building formerly occupied by the Personnel Department. The project commenced on 6 January 2009. Ramped access has been provided to the building and a new reception counter has been installed. New doors into newly formed rooms will meet DDA standards. A hatched drop off area will be provided to improve access for wheelchair users. Ward 12 Toilet and Shower Facilities, Singleton Hospital: A room has been converted on Ward 12 to provide a disabled WC facility and an assisted shower for cancer patients. The Secretary of the Local Access Group has been involved from the outset of planning this facility to ensure that the Trust meets the DDA requirements. Corridor Upgrade, Morriston Hospital: The Trust is upgrading the main corridor within the main area of the hospital. The work involves new lighting, ceilings, doors, floors and decoration. The Estates Project Manager attended a RNIB course and incorporated the information taken away from the course into the design of the main corridor and stairway upgrades as far as practically possible. This includes careful choice of colours and surface light reflectance contrasts to eliminate perceived obstacles for visually impaired people. A handrail has been fitted where it is sensible to do so as an aid for people who are infirm and ambulant disabled people. The Trust has also commissioned a signage specialist to look at existing corridor, departmental and way finding signage and recommend ways in which it can be improved. Extension of Cimla Hospital: The construction of an extension to Cimla Hospital is presently underway which will provide reablement accommodation in purpose built buildings to assist patients to return to their own homes rather than endure a prolonged stay in hospital. Therapy areas will include physiotherapy and occupational therapy facilities including Aids to Daily Living (ADL) kitchens and bathrooms. The building will also provide a training base for the Manual Handling Team and facilities for Healthy Heart Sessions. A representative from the Local Access Group was involved in the early stages of design and his comments have been incorporated into the plans.

10

Child and Adolescent Mental Health Unit, Princess of Wales Hospital: A new CAMHS Unit is being planned for the Princess of Wales Hospital to replace the Interim Unit presently sited at Glanrhyd Hospital. The design has taken account of the particular problems faced by young people and the need to ensure that their education continues while admitted to hospital. The scheme was presented during the design process to the Disability Equality Forum in October 2008 and the comments fed into the detailed design process. Car Parking, Princess of Wales Hospital: Part of the CAMHS project includes the development of a new multi storey car park and access road into the hospital site and these facilities will be completed at the end of August 2009. The new car park will be dedicated for staff use on the site and there will be a number of disabled car parking spaces provided in the facility. These will be marked in accordance with current guidance to provide appropriate access for wheelchair users. The existing disabled spaces on the hospital site have attracted criticism because of the layout, space availability and location on the site. Following the completion of the multi storey car park, there will be an opportunity for the Trust to look at remaining car parking areas in the light of the criticisms received over previous years from the Community Health Council and other groups and make plans to improve the layout of disabled car parking facilities on the site. Modernisation of Mental Health Services: The Trust has been engaged in a project to modernise the Mental Health Services in Bridgend and the Western Vale of Glamorgan for a number of years and this year will see the first of the new developments being commissioned into use. The buildings have been designed in accordance with the latest guidelines on mental health accommodation and will provide single bed accommodation with disabled access. Access Statements have been developed for each scheme and information on the proposals was presented to the Disability Equality Forum in October 2008.

11

Community Primary Care Centres: The Trust is engaged with Local Health Boards throughout the catchment area in planning for new Primary Care Centres through the Third Party Development Route. These facilities are to be provided by Private Development Companies, then leased to NHS Trusts and other complimentary organisations and are being designed in accordance with the latest DDA standards. The Trust has requested that plans be discussed with Local Access Groups before being finalised. The Trust has identified land within the grounds of Morriston Hospital that could be developed for a rehabilitation facility being pioneered by Treat Trust Wales. This brings the plans for a Centre to aid people recovering from serious accidents and illnesses a step closer to reality. The charity is fund raising to cover the building costs of the new centre. The Trust has started the introduction of leading-edge technology to improve the way chemotherapy is given to patients. The computerised ChemoCare system went live mid-August 2008 and started with lung cancer patients in Swansea. It aids the prescribing of chemotherapy and stores electronic chemotherapy records. The purchase of two specially made chairs has helped to improve the treatment provided to stroke patients at Singleton Hospital. The Hospital’s League of Friends donated funding to buy these chairs for Ward 7 at a total cost of nearly £4,000. The chairs will help decrease recovery time as there is evidence that early seating is vitally important for recovery after a stroke. The chairs give increased postural support so patients can get out of bed sooner and even start their therapy much earlier. The chairs can be adapted, tilted and rotated to the exact needs to the individual to give them the support they need. The Trust has developed a Bed Rail Assessment Tool to ensure patients at risk of falling are assessed appropriately and preventative measures are taken to reduce fractures and injuries to patients.

12

The Trust has recently completed the second phase of the installation of a Patient Safety Alarm System at Tonna Hospital that will assist in the prevention of patient falls. Initial feedback from the first phase showed a substantial reduction in the numbers of accidents and falls recorded at the Hospital. Good Practice Our Trust is the only Trust to have appointed a Nurse Consultant in learning disabilities in Wales. The work of the Nurse Consultant includes: the development of champions in the secondary care sector

which started with the Accident and Emergency Unit in the Princess of Wales Hospital and was positively evaluated

the education of registered and non registered staff in primary

and secondary care to raise their awareness of learning disabilities

the provision of education to General Practitioners as part of

their protected learning time the provision of education in the pre-registered nursing

curriculum the development of the hospital ‘Traffic Light’ system which

supports people with learning disability accessing health services by providing a comprehensive and up to date presentation of their principal needs.

The Trust won the prestigious Building Control Award of the Year for the £10 million extension to the Welsh Centre for Burns and Plastic Surgery. Swansea City Council gave the award in the category for commercial schemes costing over £2 million. Provision to benefit disabled people is one of the criteria on which the judging is based.

13

Challenges • Securing funding from the Trust’s Capital Programme for

Disability Discrimination Act compliance works when there are many competing priorities for capital investment in a large organisation.

Future • Ensure the design of new buildings and adaptations to existing

buildings continue to meet the needs of disabled people. • Ensure continued disability improvements are delivered via the

Trust’s Capital Programme to improve existing access issues. Employment and Training Staff Lessons Learnt • The Trust has recognised the need to improve employment

opportunities for disabled people. • The Trust has recognised that capacity and confidence to

deliver equality and diversity training, amongst staff, needs to be improved to enable all members of staff, at all levels, within the Trust to receive this training.

• A review of existing equality and diversity training has identified that this had not been fully mapped to the ‘Knowledge and Skill Framework’ (KSF). Work is ongoing to wholly address this.

Progress While the Trust has made much progress in improving employment opportunities for disabled people, we recognise more work needs to be undertaken. One way in which we hope to progress our work is by continuing to work in partnership with organisations that represent the interest of disabled people, for example, Remploy and the Shaw Trust.

14

The Trust’s HR Managers have met with representatives from the Shaw Trust to find out up to date information on what help they can offer to retain valued staff who have developed a health problem. The discussions covered advice on ‘Access to Work’ funding and support for workplace modification or equipment. There are a number of robust policies and procedures in place, which support the aims of the Disability Equality Duty, including the Dignity at Work Policy, the Redeployment Policy and the Flexible Working Policy. Raising awareness and understanding of these policies is included within the Trust’s equality and diversity training, which continues to be provided across the Trust. The Trust continues to strive to be a first choice employer, which may be demonstrated by achieving the ‘Two Ticks’ award, which is displayed on all vacancy advertisements. A review of equality and diversity training was undertaken last year. This identified that a more robust and structured training programme was needed to reach all members of staff. The training should be mapped to the Agenda for Change Knowledge and Skills Framework (KSF) to ensure that equality and diversity training becomes a core part of the Trust’s training programme. This training was developed accordingly. The programme commenced with priority given to the delivery of training to Consultants and nursing staff. In addition, the review highlighted that equality and diversity awareness raising needed to feature more strongly within the Corporate Induction Training Programme delivered within the East. The Equality and Diversity Manager, Head of Patient Experience, Chaplain and Assistant Director of Learning and Organisational Development worked together to address this requirement. Equality and diversity awareness raising became a key part of Corporate induction across the Trust in 2008 and has been fully mapped to Level 1 KSF. Equality and diversity is a well-established part of Corporate Induction in the West with the awareness raising being delivered by the BME midwife and a Staff Nurse with a particular interest in equality and diversity.

15

Disability equality was included in recruitment training provided for Managers as part of the introduction of NHS Jobs. The recruitment training covered what our use of the two tick symbol means for Managers when short listing applicants for interview. The Specialist BME Midwife provides equality and diversity training to student nurses and midwives in the University of Wales Swansea and qualified midwives in the hospital and community setting. The Staff Nurse continues to delivers equality and diversity training within her workplace at Hill House Hospital during day and night duty to enable a cross section of staff to attend. Awareness raising and training is fundamental to the Trust’s success in mainstreaming equality and diversity. To assist the Trust in achieving this effectively, the Equality and Diversity Manager continues to work with members of staff, at all levels, across the Trust to identify training and learning opportunities. Examples of these are becoming a member of: • Multi Professional Training and Education Committee • BTEC Generic Core Competency Group • Nurse Management Programme Group • Trust Professional Nurse Forum • Continuing Education Committee As a result of working together more effectively, equality and diversity has become, and will continue to be, integral to developmental programmes within the Trust. Examples of these programmes are: • Senior Medical Staff Training, including Educational

Supervisors and Associated Specialists • Post Graduate Medical Education Training • Managing to Deliver • Directorate Development • Community Nursing • Mental Health Development The Trust has begun delivering a structured equality and diversity educational and training programme for all clinicians, which is competency based, measured and marked and supported by the Deanery.

16

The Trust was a host organisation for the ‘BSL Futures’ Scheme which was a project funded by the Welsh Assembly Government to train individuals to become a professional qualified interpreter. Two Apprentice Interpreter for Deaf People worked within the Trust to develop their BSL skills and assist in communication between deaf and hearing parties. The Apprentices raised awareness of British Sign Language by visiting to wards and departments to speak to staff about their role. Good Practice Following a review of training for Health Care Assistants, the Trust developed the BTEC Principles and Practices in Health Care Delivery, which received BTEC authorisation last year. Integral to this document is Unit 6, ‘Equality and Diversity in Health Care Delivery’. With regards to equality and diversity, the aim of this course is: ‘To gain the necessary knowledge, understanding and skills required to enable individuals to act in ways that support equality and value diversity, with regards to members of staff, patients and visitors.’ To achieve this aim, the following set of objectives was identified: • Describe what is meant by equality and diversity • Identify 3 types of discrimination • Identify 4 areas where discrimination may occur • Describe how discrimination impacts on health care • Demonstrate an awareness and basic understanding of

legislation, policies and procedures, related to equality and diversity

• Explain what is meant by consent and discuss the carer’s role, in relation to advocacy and empowerment

• Reflect on one’s own attitude and behaviour, in relation to equality and diversity.

17

It is understood that several Trusts within Wales have adopted this document as a benchmark, when developing their courses, respectively. Challenges • Overcoming the resourcing and capacity barriers to the delivery

of equality and diversity training in our very large organisation. A particular challenge will be the release of staff from clinical areas to attend training.

• Engaging staff to embed disability equality into the culture of the

organisation and promoting ownership across the whole organisation.

Future The Trust has made much progress but recognises that some work remains to be undertaken to build on recent improvements, in particular, with medical staff. To address this, the Equality and Diversity Manager has been working with the Medical Director and Post Graduate Medical Education Managers to develop a comprehensive, competency based equality and diversity training programme for all levels of medical staff. This programme has been developed to meet the core curriculum criteria laid down by the Deanery and will continue to be delivered throughout 2009. It has been recognised that the Trust will need to build confidence and capacity amongst members of staff to deliver equality and diversity training across all levels of the Trust. The Equality and Diversity Manager will work with the Assistant Director of Learning and Organisational Development and the NHS Centre for Equality and Human Rights to identify ways in which this may be achieved. Consideration will be given to involving service users and user groups in the design and delivery of disability equality training. Following a review of existing equality and diversity training, it has been identified that this had not been fully mapped to the ‘Knowledge and Skill Framework’ (KSF). The KSF provides a common framework on which to base the review and development of staff.

18

Equality and diversity is one of the core competencies of KSF which enables this to be mainstreamed into our training provision. We are aware that our training programme content needs to be more flexible to enable it to be tailored to meet the level appropriate to members of staffs’ roles. Much work has been undertaken in addressing this. This work is ongoing. Chapter 4: Involvement The Disability Rights Commission’s Code of Practice recommends the involvement of disabled people in the implementation of the various aspects of the Scheme and the ongoing monitoring and review of the action planning process. Our Trust strongly supports their involvement as it is crucial to the successful implementation of the disability equality duty. However, it should be recognised that as a consequence of the merger our public groups have not met on a regular basis as their format to meet future need is being considered. Lessons Learnt The former Swansea and Bro Morgannwg NHS Trusts worked collectively with Local Health Boards and other local organisations to facilitate the involvement of disabled people in the development of their Disability Equality Schemes. This worked well as it helped to avoid overloading organisations of disabled people with requests to take part in developing Schemes. We learnt the importance of involving disabled people at an early stage to address their perspectives when developing Schemes and Action Plans. This also applies to service improvement and development. Working in partnership with representative groups provided valuable assistance with the involvement process as their networks ensure focus groups were well attended.

19

Progress Our approach has been to secure the involvement of disabled people to advise on implementing the Scheme. We developed strong links with the Trust’s Clinical Governance Committee and Patient Experience Forum to support the mainstreaming of disability equality. This has been facilitated by the Trust’s Head of Patient Experience. The following range of mechanisms have been used to involve disabled people: Representation on Equality and Diversity Group: Disabled people and carers were members of the Groups because of their expertise in disability equality issues. Consideration was given to the timing, venues and transport arrangements for the meetings to allow full participation. Disability Equality Forum: The Trust’s Head of Patient Experience and a disabled member of the public continue to jointly chair this Forum. Membership includes disabled service users, carers and partner organisations, both statutory and from the voluntary sector. The meetings are held on a bi-monthly basis in a convenient location with good access in the early evening. A wide range of issues are discussed and progress with actions are monitored. The group has received presentations on planned developments and has undertaken walk arounds of units to advise on disability issues and have supported training. Representation on other Trust Groups: Disabled people are represented on our Groups, including the Patient’s Experience Forum. Service users and carers are represented on the Mental Health Directorate Planning Team, the multi-agency planning forums and the Mental Health Modernisation Board. Patient’s Councils and other Groups: In several areas, Patient’s Councils and groups work with service users and local communities. Examples are the Patient’s Council at Cefn Coed Hospital and the friends of Caswell Clinic who review service development proposals. The Trust works closely with the Alzheimers Society in relation to the development of services for older people. The Trust has also worked with a group of patients to develop a Dignity in Care Charter for patients and staff. This reinforces good practice and has been widely circulated.

20

Meetings with the Local Access Group: Representatives from Neath Port Talbot Hospital meet quarterly with the local disabled access group. This is a very well established forum that has been in place for eight years. Existing Structures: Links have been developed with the Trust’s existing public and patient involvement forums to engage disabled people with implementing the Scheme, for example the Cancer Network’s Public Patient Involvement Forum. Focus Groups: The Trust has worked jointly with the Local Health Boards and Local Authorities to gather information from the following involvement events: A Development Day for disabled people was held on 8 October

2008 in Swansea Vale Resource Centre. This was organised by the Joint Planning Group for Disabled People.

A consultation event was held on 20 October 2008 for

Swansea’s Network 50+ Health, Social Care and Well Being Forum in the Grand Theatre, Swansea.

A ‘Have Your Say’ disabled people’s event was held on 25

November 2008 in Bethlehem Church Life Centre, Cefn Cribwr. This was hosted by Bridgend County Borough Council and supported by Bridgend Local Health Board, Bridgend College, Abertawe Bro Morgannwg University NHS Trust and Bridgend Coalition of Disabled People. The Trust’s Chairman showed his support by attending to speak at the event.

These events gave the Trust the opportunity to gather information from focus groups of disabled people on the extent to which our services take account of their needs. The Trust has continued to involve disabled people representing the Local Access Group from the initial planning stage of capital developments. Their advice enables the Trust to ensure that we are taking into consideration the needs of disabled people who access our services. This has led to improved access for disabled people to Trust services and buildings.

21

The Local Access Group gave advice on how the Trust should spend the 2008/2009 capital allocation for Disability Discrimination Act compliance. A review of the recommendations of the access audit of Trust buildings and the issues raised through the involvement of disabled people also helped to inform the prioritisation of schemes. The expertise of the disabled people is crucial to agreeing the most effective ways of spending a limited amount of capital funding. The following improvements were implemented: Car Parking, Chemotherapy Department: Six additional disabled car parking spaces were created close to the Chemotherapy Department at Singleton Hospital to improve access for disabled patients undergoing treatment. Ward G, Neath Port Talbot Hospital: The Trust has worked well with Neath Port Talbot Access Group and undertaken a number of minor schemes annually in response to issues raised at the meetings. One of the main schemes was putting film on the bedroom windows in Ward G of the Mental Health Unit as a result of privacy and dignity issues that had been raised. Crush Hall Car Parking, Singleton Hospital: The spaces adjacent to Crush Hall roundabout were changed to disabled car parking as part of the review of car parking on the Singleton Hospital site last autumn. This development provides disabled people with car parking immediately outside the entrance to Crush Hall from where there is close access to the Outpatient Department and lifts to the hospital wards. The Local Access Group welcomed the improvements. Crush Hall Toilet, Singleton Hospital: The Chair of the Local Access Group advised on the conversion of existing facilities to a unisex disabled toilet. The Group requested a copy of the plans from the Trust to show other organisations how to design and layout disabled toilet facilities. Ward 12, Toilet and Shower Facilities, Singleton Hospital: Capital works have provided an accessible suite (toilet and shower facilities) on the Cancer Ward at Singleton Hospital. An inpatient satisfaction survey highlighted the need for these facilities on the ward and the Trust acted quickly to address the issue.

22

The Local Access Group is involved with post project evaluation where appropriate. Their review of a completed capital project gives the Trust information on the successful and negative aspects of the scheme that can be used to improve future designs for disabled people. A representative from the Local Access Group visited Singleton Hospital on completion of the unisex disabled toilet in Crush Hall and was happy with the work undertaken subject to very minor changes i.e. hanging of a mirror at a lower level. The Local Access Group also lobbied the Local Authority to secure the provision of disabled car parking in the bay outside the front entrance to Central Clinic located in Swansea City Centre. Their support was very much appreciated by the Trust as the disabled car parking improved access to the building for disabled people. Good Practice The Trust works closely with the Local Access Groups to ensure that access for disabled people features strongly in capital developments, for example the redevelopment of Morriston Hospital. The Trust and Local Access Group welcomed the publication of an article in the winter 2008/2009 edition of the national Access Design Journal. This complimented the involvement of the Local Access Group from the start of the redevelopment of Morriston Hospital to ensure access for disabled people is addressed. The Trust has a well-established volunteer program “The Friendly Face at the Bedside”, which as part of its remit promotes the value of ward based disabled volunteers. The project has introduced volunteers alongside nursing and medical staff to support patients, in very practical ways that will enhance patient experience of hospital, provide a worthwhile experience for volunteers and develop the relationship we have with the communities the Trust supports. A significant aspect is developing links with local schools and colleges to develop youth volunteering. By the end of year two, 140 volunteers have been introduced into the Trust on a phased basis to support patients and staff in the following areas:

23

Year 1: Rehabilitation and Medical Wards and Accident and Emergency Unit at the Princess of Wales Hospital Year 2: Wards, Endoscopy Unit and Reception Desk at Neath Port Talbot Hospital Year 3 will have focus on community clinics and will build on years 1 and 2 activities. In recognition, the scheme has been awarded the prestigious Investing in Volunteers Award. At Singleton Hospital, a volunteer program is supporting patients and staff at mealtimes. Challenges • Maintaining the enthusiasm of disabled people to continue their

involvement when limited funding is available for service improvement due to extremely challenging financial pressures.

Future • Consider ways in which disabled people can be involved in how

the new Local Health Board meets its disability equality duty. • Learn from our involvement work to build sustainable networks

to provide advice and information for the new Local Health Board.

Chapter 5: Impact Assessment Lessons Learnt Our staff found the first Equality Impact Assessment Toolkit difficult to understand and use. We received requests from staff for a simplified version of the toolkit to enable them to meet the requirement to undertake the assessments.

24

This is an area where the Trust has work to be done before we can publish the results of assessments. Training is a key priority for designated staff to develop their skills to carry out effective impact assessments. Progress • The Trust developed an Equality Impact Assessment Toolkit,

which has been informed by the former Commission for Racial Equality’s template and the NHS Centre for Equality and Human Rights’ toolkit.

• We amended our policy development guidance to include the

requirement to carry out impact assessment. Divisions and Directorates were asked to identify Leads to be trained on impact assessment to take forward this work across their area.

• Training commenced with the Trust’s HR Development Group

and other key policy makers. An action centred learning approach was used to train representatives from the Equality and Diversity Group and help build their confidence to use the toolkit.

Challenges It is crucial that staff are given the training and support needed to give them the capacity to carry out an assessment of the relevance of functions and policies. It will take time to build the confidence of staff and develop their specialist knowledge to carry out this exercise effectively. A fundamental aspect of achieving disability equality is carrying out effective equality impact assessment. It is a significant challenge to develop the experience within the Trust to ensure that these are undertaken correctly. The mainstreaming of impact assessment is one of the biggest challenges to be addressed by the Trust.

25

Future • Identify staff to be charged with carrying out assessments within

the new organisation. • Continue to provide equality impact assessment training to staff

using an action learning approach. • Undertake an assessment of relevance of the functions and

policies for new Local Health Board. • Consider ways in which disabled people can be involved in

equality impact assessments to share their expertise on disability.

• The results of impact assessments should be published. Chapter 6: Information Gathering Lessons Learnt Information about disabled people’s particular experiences is an important data source to identify ways in which the Trust can improve services. This includes information from patients’ complaints, involvement events and questionnaire surveys. Progress • Disability equality has been built into outpatient satisfaction

surveys. A question asks whether patients have any difficulty accessing the outpatient department. Surveys have been carried out at Parkinson’s Treatment Centre and Burns and Plastics Outpatients.

• An inpatient satisfaction survey was carried out on the Cancer

Wards at Singleton Hospital. This highlighted the need for accessible toilet and shower facilities which has been addressed.

26

• An audit of privacy and dignity has been piloted on hospital

wards at Cefn Coed Hospital and on the Medical Wards at Morriston Hospital. Disability equality has been included within the audit. Specific questions ask whether there is equipment for lifting and moving patients using bathroom facilities and how are immobile patients moved to and from bathroom facilities. The audits identified the need for staff to attend dignity in care training and to provide information in suitable formats.

• A Schizophrenia Integrated Care Pathway Audit has been

undertaken, which identified the need to improve certain aspects of patient documentation.

• The Disability Equality Forum identified the need to provide

dental services locally for people with complex disabilities. This has been raised as difficulties have been experienced getting a service for disabled people who use a very wide wheelchair.

• The Trust introduced a new Patient Administration System in

July 2007 at Singleton and Morriston Hospitals. Our Patient Administration Systems would have to be adapted to collect the all-Wales equality dataset when this is agreed for the NHS Wales Patient Episode Database for Wales (PEDW).

• Our Equality and Diversity Team is advised of any patient

complaints involving discrimination issues. This information is reviewed to ensure that any required remedial action is being taken.

• The Trust implemented the Electronic Staff Record (ESR) in the

autumn of 2006 which improved our ability to collect employment monitoring information for disabled employees.

• The Trust adopted the use of the NHS Jobs service from

January 2007 which is the electronic recruitment (e-recruitment) service for the NHS. An integral part of this recruitment process is the collection of employment monitoring data.

27

• The NHS Jobs on-line application form removes candidates’ personal details from the main part of the application form before consideration by the persons who are short listing for interview. The personal details and diversity monitoring form are retained by our HR Department.

• The Trust advertises using a variety of ways via the intranet,

internet, job centres, staff bulletins and where necessary the press and professional journals. Job adverts are screened by the Recruitment Team before being placed to ensure these avoid any wording that could be considered to be discriminating against people from a particular minority group.

Challenges • Without recording disability data, there is no way of knowing the

patient population that is being served, their diverse needs and how best to meet these needs and ensure they access services. Work is needed to adapt existing information systems to collect disability data and overcome the challenges of acquiring information on patients.

• Effective workforce planning to develop a representative

workforce. Future • Build disability equality into satisfaction surveys administered

for inpatients. Chapter 7: Conclusion Lessons have helped us to make progress towards achieving greater disability equality and develop more effective reporting. It is recognised that challenges remain in the field of equality with the delivery of health services and the employment of staff. The reconfiguration of the NHS in Wales will bring opportunities to share lessons learnt and best practice strengthening the focus on equality and diversity.

28

Report prepared by: Debbie Morgan, Director of IM&T and Performance Improvement Report sponsored by: Calum Campbell, Acting Chief Executive

Trust Board 10 June 2009

Agenda Item: 15

National Performance Exception Report

1. Purpose The purpose of this paper is to brief the Trust Board on key performance issues that relate to national targets and efficiency areas.

2. Introduction The National Performance Report forms part of the Performance Management Framework that the Trust is reviewed against, together with other partners within the health community, on a quarterly basis by the Mid and West Wales WAG Regional Office. ABM University NHS Trust uses this format as its monthly performance report presented to Directorates, Executive and Operational Board and for performance management arrangements.

3. Waiting Times Access 2009 target requires referral to treatment times (RTT) to be a maximum of 32 weeks against the March 2009 interim target and then achieve the 26 weeks target by 31 December 2009. The table below demonstrates that the Trust has achieved two of the four March milestone targets.

Table 1 RTT Performance April 2009 Target >32 wks >26 wks Closed by Admission (CA) (95%, 80%) 94% 88% Closed by Other (CO) (98%, 85%) 96% 94% Pathway Open (PO) (No target) 96% 92%

The Trust achieved 94% against a target of 95% for those patients to be treated within 32 weeks for Closed by Admission (CA) and 96% against a target of 98% for those patients to be treated within 32 weeks for Closed by Other (C0). This is an improvement of 5% and 1% respectively on the performance in March and it is expected that all four targets will be achieved for May data. The lower performance in these two quadrant areas is indicative

Performance Exception Report Trust Board 10 June 2009

1

of legacy patients moving through the system to their treatment phase who will have entered the system when component waiting times were longer than they are currently. Performance against the December 2009 target of 26 weeks has improved by 5% in April for Closed by Admission (CA) and 2% in month for Closed by Other (CO). The Trust gave commitment to holding the component wait targets for April 2009 of 10 weeks for Outpatients (OP), 8 weeks for Diagnostics and 14 weeks for Inpatients/Day cases. At the end of the month the Trust has reported 10 patients waiting over 10 weeks for their first OP appointment and will be reporting 2 cardiac Total Waiting Time patients in excess of 32 weeks. The implications of the new waiting times rules has had a significant impact operationally and in particular for the appointing processes of legacy patients existing in the iPM PAS system. A full awareness programme with all operational managers has taken place together with a review of those patients in iPM that would previously have been entitled to adjustment periods. This will ensure a return to accurate reporting and subsequently avoid a recurrence of component waits booked outside of target. The Access 2009 team within the Delivery & Support Unit has launched a National initiative of three “Focus On“ programmes for the specialties of Orthopaedics, ENT and Ophthalmology. The National programme will be developed and coordinated by the 2009 Access Project team, with clinical leadership provided at a national level by three Consultant and GP advisors for each of the three programmes. In addition:

• A National Performance Improvement Manager will be appointed for each programme, to be responsible for the design, delivery and implementation of each programme.

• Each Health Community will be funded for a local consultant clinical lead and GP lead.

• Local Programme Support Managers will be appointed centrally to work within each designated Health Community to ensure delivery of the programmes locally.

4. A&E Waiting Times The Trust has experienced a very challenging delivery agenda for A&E since the autumn and not dissimilar to other major A&E departments across Wales. Table 1 shows overall performance against targets for each quarter in 2008/09, together with April 2009. The Board will be aware that this has been caused by a combination of issues consistent to both Morriston and Princess of Wales A&E departments, including shortage of middle grade medical cover and access to inpatient beds. This in turn has an impact on ambulance turnaround time.


2

Table 2 A&E Waiting Times Performance

ABM University NHS Trust

Q1 08/09

Q2 08/09

Q3 08/09

Q4

09/10

April 09/10

% New patients (inc paeds) spending less than 4 hours in major A&E

95% 95.90% 91.53% 89.93%

83.84%

83.30%

% All patients spending less than 8 hours in major A&E

100% 99.81% 99.38% 98.24%

Compliance with the A&E access targets is one of the main priorities for the Trust, along side waiting time compliance, meeting the cancer targets and financial performance. Improvement against the current performance is therefore an imperative and the Executive Team now hold weekly meetings led by the Medical Director/Trust Unscheduled Care Lead to agree the weekly actions required. Actions include:

• Implementation of an escalation policy to address potential delays

• Medical staff, working as a part of the Hospital at Night team, have been instructed to base themselves in the A&E department to support timely clinical assessment and treatment of patients.

• On call doctors during the day are required to respond to patients referred by the A&E department within one hour of referral time in line with the escalation policy

• A bed modeling exercise is in progress to understand the requirements in terms of bed numbers for both planned and unscheduled care workload based on the target lengths of stay

• The Medical Director has set up a task and finish group to agree and implement a recruitment plan to cover middle grade medical staff deficits. The plan is in the initial phase of implementation whereby European recruitment has commenced

5. Cancer Waiting Times The Trust is pleased to report achievement of the Non Urgent Suspected Cancers (NUSC) and Urgent Suspected Cancer (USC) Cancer Waiting Times for 2008-2009.The following table demonstrates this cumulative position for 2008/2009 and the in-month position for the month of April 2009:

96.17% 97.18%


3

Table 3 Cancer Waiting Times Performance

Target AOF Target %

Cumulative Achievement

2008/2009

April 2009

USC

95% 95% 95% NUSC 98% 99% 98%

Achievement of the target in April is also noted, although yet to be confirmed. Nevertheless, it is imperative that the performance is sustained and it is noted that in May the main risk areas are within Gynaecology and Urology. Theatre capacity for both sites appears to be insufficient and additional lists are being arranged. 6. Other Targets within National Performance Report In addition to the Waiting Time, A&E, Cancer and Efficiency and Productivity targets the Trust is required to report on performance against a wide range of qualitative clinical and corporate governance objectives included in the Annual Operating Framework (AOF). This is reported with other key AOF targets on a quarterly basis to the Mid & West WAG Regional Office using the National Performance Report as part of the ABM health community’s performance.

The following are some of these areas and performance as at end of March 2009:

Mental Health Action Plans Excellent progress has been made by all localities with Swansea LHB reporting full delivery, including:

• The successful completion of the business justification case for slow stream and step down rehabilitation facilities

• Positive feedback on the assertive outreach service, which is seen as a beneficial and productive addition to the range of services available within Swansea

• The interim Low Secure facility at Cefn Coed Hospital providing a local service for 10 people expanding to 12 in the next 3 months and brought about through partnership agreements of the reinvestment of savings from the local repatriation programme.

Also further expansion of the range of high level community supported accommodation is being progressed in partnership with the Local Authority supporting people team. Stroke Services Co-located stroke beds are available in the Trust which means that patients suspected or confirmed as having a stroke are seen by members of a specialist multi-disciplinary medical and acute rehabilitation stroke team. Also the Trust has implemented forms of multidisciplinary working and is working towards the Royal College of Physicians (RCP) required WTE standards.


4

Co-located beds is a target milestone towards delivering ‘Each patient suspected of, or confirmed as having had a stroke must be admitted to dedicated and co-located acute stroke beds staffed by a specialist multi-disciplinary medical and acute rehabilitation stroke team.’ To enable this a combined stroke steering group has been set up to take forward the stroke action plan. Infection Control The Trust has achieved local infection reduction targets(s), agreed in collaboration with the Welsh Healthcare Associated Infection Programme Team. Delayed Transfers of Care (DToC) Although DToC is a LHB target it is an important measure for the Trust in enabling effective patient flow through our hospital beds. In May, all NHS Chief Executives received correspondence from the Director General, Department for Health & Social Services congratulating the recent progress in managing and reducing delayed transfers of care. Analysis of the census returns over time indicates a clear downward trend on an all Wales basis, particularly encouraging was that both the number of delays and the number of days delayed have significantly reduced. An ABM community-wide DToC plan has been submitted as part of the Health Community 2009/10 AOF response, ensuring this trend continues but recognising that this remains a challenging area of work, requiring continued close attention. Efficiency and Productivity The National Performance Report will be resubmitted to WAG in July 2009 to take account of performance that is dependent on clinical coding and data updates, such as basket day case rates and average length of stay (ALOS). Nevertheless, we can report on a number of targets based on quantitative date where good progress has been made in year, such as:

• 77% of patients with myocardial infarction suitable for thrombolysis had a call to needle (CTN) time of less than 60 minutes

• Achievement of outpatient follow up rates for General Surgery The Outpatient Improvement Project is addressing the inefficiencies currently reported and the rolling out direct booking will see improvements in DNA performance. In addition to this new ways of contacting patients to book follow up appointments will be piloted and it is anticipated that these actions will have a positive effect on follow up DNA rates. Finally, to meet the significant financial and quality challenges in 2009/10 and over the next 5 years a Redesigning Care Programme has been established that incorporates:

• Changing models of care (Step Change Programme)

• Improving efficiency & productivity (Design for Improvement (D4I) Plans)


5

The Programme recognises that current models and processes will need to be challenged and refined to meet the challenges ahead.

8. Consultation The National Performance Report is populated monthly and presented to Directorates, Executive and Operational Board. Progress against the Step Change Projects is managed through a Programme Director and reported monthly to Step Change Board.

9. Action Required The Trust Board is asked to receive this report.


6

Impact Analysis Criteria Criteria Impact


Achieving performance target is a challenging agenda balancing emergency activity and capacity. All of which is being scrutinised to ensure the Trust achieves financial balance at year end.

The benefit in delivery is that patients are treated in a timely manner.


The risks relate to the delivery of good quality care, maximising resources and as an outcome the Trust achieves its key performance targets. However, the ability to improve current performance may at times place at risk other activity.

• Risks

Healthcare Standards are concentrating on the user experience and this is a key area in ensuring the patient experience is improved.


There are no significant issues. • Equality


7

______________________________________________________________________

Director of Finance Report Trust Board 13th May 2009

1

REPORT PREPARED BY: Eifion Williams Director of Finance


AGENDA ITEM: 16

FINANCE REPORT

1. PURPOSE

The Finance Report provides Trust Board colleagues with briefings on the following items:-

(i) Financial Position for April 2009; (ii) Overall updated position on 2009/2010 CIPs; and (iii) Write off of expired stock; and (iv) Standing Orders and Schedule 1 & 4 for 2009/2010

2. INTRODUCTION

Colleagues will be aware of the major challenge facing the Trust to deliver a balanced position in 2009/2010. Due largely to the level of national CIPs set and the need to deliver the R.T.T. Waiting Times targets, the Trust has a shortfall of almost £30m going into the new financial year. This report sets out the financial position of the Trust at the end of April 2009, the first month of the new year. It should be emphasised that producing financial reports for Month 1 is more difficult than normal, due to the complexities arising out of the need to resolve old year balances. In addition, the Trust has now moved over to a new single Financial Ledger and this has provided some teething problems which are gradually being resolved. No major issues remain outstanding in this regard, but there are some minor items which require resolution.

3. FINANCIAL POSITION – APRIL 2009 The Trust has an overspend of some £0.97m in Month 1. In providing this overall assessment of the Trust’s financial position, detailed Directorate positions have not been shown due to the fact that there remains certain outstanding issues to be resolved as a result of the implementation of the new ledger. Therefore, it is inappropriate to detail individual Directorate positions until these have been finalised. It should be emphasised that all these issues will be resolved urgently, so that for future monthly detailed Directorate positions will be available. In the main, the overspend is made up of two areas as follows:- (i) CIPs not yet delivered – at this stage in the year Directorates have not yet

identified savings amounting to £450k in month 1; and (ii) Overspends in Directorate budgets - there are a number of overspent areas,

particularly nursing pay and non-pay budgets. This has amounted to £520k in April.

4. ACTION BEING TAKEN TO ADDRESS THE OVERSPEND A number of key actions are being taken to address the financial position. The key ones

are as follows:-

(i) Executive Directors are meeting with all Directorates to fully explore their financial positions on a monthly basis;

(ii) Those Directorates which have some significant way to go to identify their required

savings schemes have been written to and have been asked to finalise their programmes as a matter of the highest priority;

(iii) Vigorous efforts are being made to reduce the R.T.T. requirement by reviewing

Directorate plans in detail to minimise the need to carrying out extra sessions. In addition, non-IMH LHBs have been written to, outlining that there is a need for financial support from them to support the significant additional activity required to deliver these targets. Requests for financial support are also being made to the Welsh Assembly Government to help partly fund some of this work;

(iv) Devolved Finance Teams are focusing their efforts strongly to deliver increased

savings and also cost avoid/reduce new pressures in the system;

(v) Regular reports reviewing staffing numbers have been initiated and used as a means of pushing Directorates to deliver additional savings. With staff costs representing roughly 75% of the Trust’s budget, it is clear that significant savings are required in this area.

5. CIPS 2009/2010

As identified earlier in this report, the identification and delivery of the Trust’s CIP savings programme is absolutely crucial in helping the Trust try to deliver its breakeven financial target. The position on the various CIPs can be summarised as follows:-

SCHEMES Target Currently Identified Balance Outstanding Housekeeping Step Change

£m 9.630 12.037

Corporate

2.475

£m 9.590 7.472 2.394

£m 0.040 4.565 0.081

% -

38 3

Overall 24.142 19.456 4.686 19

Attached at Appendix 16.1 is a summary schedule showing the position of each Directorate. Those Directorates some way from identifying their full requirement have been pushed to urgently address the outstanding balance. An exercise is now being initiated to ensure the robustness or otherwise of the CIP schemes identified by Directorates.

6. WRITE OFF OF EXPIRED STOCK

At its meeting on 5th May 2009, the Financial Audit Committee received a report regarding the need to write off expired stock. The stock related to an artificial skin product which needs to be written off in accordance with the Welsh Assembly Government guidance on losses and compensation. The loss is

______________________________________________________________________


2

______________________________________________________________________


3

a category 4B loss classified as ‘Damage to buildings, their fittings, furniture and equipment and loss of equipment and property in stores and in use due to other causes’. The value of the stock being written off is £29,161 and is within the Trust Board’s delegated limit of £50,000.

7. STANDING ORDERS Standing Order Paragraph 14.3 states: “Standing Orders shall be reviewed annually by the Audit Committee who shall report any proposed amendments to the Board for consideration. The requirement for the review extends to all documents having the effect as if incorporated in Standing Orders” The Financial Audit Committee completed the review and is proposing amendments to Standing Orders (main) and supporting Schedules 1 and 4 (Standards of Business Conduct for Trust Staff and Contracts Code – Building & Engineering Works) for consideration and approval by the Financial Audit Committee. The changes, which are shown on the Attachments using “track changes” for ease of reference, can be summarised as follows: - Standing Orders (Main) Some minor changes to sections relating to Procurement of Goods & Services (see Appendix 16.2). Schedule 1 (Standards of Business Conduct for Trust Employees) Some minor changes to the section relating to commercial sponsorship for attendance at courses and conferences (see Appendix 16.3) Schedule 4 - Contracts Code – Building & Engineering Works Some minor changes through the Schedule to reflect the local framework agreements and the delegation of some responsibilities to the Assistant Director of Planning (Capital) (see Appendix 16.4).

8. RECOMMENDATIONS

The Trust Board is asked to:-

(i) note the financial position of the Trust at Month 1; (ii) note the current position on the Trust’s CIP programme; (iii) approve the write off of this expired stock; and (iv) approve the changes to Standing Orders and Schedule 1 & 4 for 2009/2010.

Impact Analysis Criteria Response • Resource impact, including costs, HR,

Capital Detail set out in financial report

• Benefits in meeting Trust priorities The Trust has a duty to meet three statutory financial targets

• Risks

The Trust has to live within its means and the report details various plans and actions to deliver this. Not Applicable • Link to Healthcare Standards

• Equality

Any considerations would detail issues within the report.

______________________________________________________________________


4

APPENDIX 16.1

2% Housekeeping 2.5% Stepped Change 5% Corp Dir TotalTarget Actual %ge Identified Target Actual %ge Identified Target Actual %ge Identified Target Actual %ge Identified

£000 £000 £000 £000 £000 £000 £000 £000ANAESTHETICS, CRITICAL CARE & THEATRES 1,137 1,137 100% 1,421 213 15% - - 2,558 1,350 53%CANCER SERVICES 257 257 100% 321 267 83% - - 578 524 91%CARDIAC 432 432 100% 540 460 85% - - 971 892 92%CORPORATE SERVICES - - - 255 255 100% 255 255 100%DIAGNOSTIC 654 654 100% 818 488 60% - - 1,472 1,142 78%DIRECTOR OF FINANCE & PROCUREMENT - - - 277 277 100% 277 277 100%DIRECTOR OF HR - - - 310 310 100% 310 310 100%DIRECTOR OF INFORMATION - - - 358 358 100% 358 358 100%NURSE DIRECTOR - - - 199 199 100% 199 199 100%DIRECTOR OF PLANNING - - - 544 544 100% 544 544 100%FACILITIES - WEST 391 391 100% 489 489 100% - - 879 880 100%GENERAL SURGERY 364 364 100% 454 388 85% - - 818 752 92%INTERMEDIATE CARE 982 982 100% 1,227 389 32% - - 2,209 1,371 62%MEDICAL DIRECTOR - - - 31 31 100% 31 31 100%MEDICINE 1,120 1,078 96% 1,399 758 54% - - 2,519 1,836 73%MENTAL HEALTH DIVISION 1,083 1,083 100% 1,353 1,353 100% - - 2,436 2,436 100%MUSCULO - SKELETAL 429 429 100% 536 483 90% - - 964 912 95%LEARNING DISABILITIES 403 403 100% 504 504 100% - - 907 907 100%PATHOLOGY 318 318 100% 397 289 73% - - 714 607 85%REGIONAL SURGERY 586 586 100% 733 419 57% - - 1,319 1,005 76%SITE MANAGEMENT - WEST 167 167 100% 209 199 95% - - 377 366 97%NEATH GENERAL MANAGER 205 205 100% 256 140 55% - - 461 345 75%POW GENERAL MANAGER 96 96 100% 120 120 100% - - 216 216 100%WOMEN & CHILDREN'S HEALTH DIVISION 1,008 1,008 100% 1,260 513 41% - - 2,268 1,521 67%OTHER CORPORATE - - - 500 420 84% 500 420 84%

Total 9,630 9,590 100% 12,037 7,472 62% 2,475 2,394 97% 24,142 19,456 81%

Cost Improvements 2009‐10

0%

20%

40%

60%

80%

100%

120%

ACT CANCERSERVICES

CARDIAC CORPORATESERVICES

DIAGNOSTIC FINANCE &PROCUREMENT

HUMANRESOURCES

INFORMATION NURSE DIRECTOR PLANNING FACILITIES ‐WEST

GENERALSURGERY

INTERMEDIATECARE

MEDICALDIRECTOR

MEDICINE MENTAL HEALTHDIVISION

MUSCULO ‐SKELETAL

LEARNINGDISABILITIES

PATHOLOGY REGIONALSURGERY

SITEMANAGEMENT ‐

WEST

NEATH GENERALMANAGER

POW GENERALMANAGER

WCH OTHERCORPORATE

Appendix 16.2

Standing Orders 1

STANDING ORDERS 9 PROCUREMENT OF GOODS AND SERVICES

9.5 Invitation to Tender

9.5.7 The party arranging the invitation to tender should provide an official tender

label to be used on the envelope for its return to include tender name, reference number, date and time due. The relevant Divisional Procurement Department will issue tenders which are Division specific and the issuing of trust wide tenders will be shared equitably between the Divisional Procurement Departments. The official tender envelope shall be pre-addressed, shall state the subject matter and the date and time that the tender must be received by the Trust. If the tender envelope is subsequently encased within an additional cover, that packing must identify that a tender envelope is inside. The company submitting the tender should be informed that they must not indicate on the return envelope the originator of the tender. If the sender is subsequently identified then the Director of Finance/Director of Corporate Affairs or in his/her absence an authorised deputy shall have authority to decide whether or not the tender is to be considered invalid. For those paper tenders issued by Welsh Health Supplies, the Director of Welsh Health Supplies, or in his absence, a Contracts Manager shall have this authority.

9.6 Delivery, Receipt and Safe Custody of Tenders 9.6.3 Parties returning tenders by post shall be encouraged to use registered post

or first class recorded delivery. Delivery by hand shall be accepted at the Trust’s reception desk between 8.30am – 5.00pm Monday to Friday. As each tender received between these times shall be receipted, the bearer shall be offered a receipt stating the subject of the tender, the date and time received and the name of the person who has logged receipt of the tender. The party delivering the tender shall not be asked to communicate the identity of the company/party submitting the tender. In the case of Welsh Health Supplies, this shall be undertaken by the Finance Officer, or in their absence, another member of staff so authorised.

Deleted: 15

Deleted: 15

Deleted: Thursday and 8.15am – 4.45pm on a

Appendix 16.3 STANDING ORDERS SCHEDLUE 1 STANDARDS OF BUSINESS CONDUCT FOR TRUST STAFF Commercial Sponsorship for attendance at Courses and Conferences 20. Acceptance by staff of commercial sponsorship for attendance at relevant

Courses or Conferences is acceptable, but only where the employee has obtained permission in advance from the Clinical Director and /or appropriate Director in line with the Study Leave Policy, and the Trust is satisfied that neither the individual nor the Trust is compromised. Applications for study leave by Clinical Directors must be approved by the Deputy Medical Director in line with the Study Leave Policy for Consultants and all other non training grade doctors) before formal approval is granted (see Appendix 2).

Deleted: and the Training Department

Deleted: appropriate Assistant Chief Executive/deputy

Deleted: the Training Department provides

Appendix 16.4

1

SCHEDULE 4

CONTRACTS CODE - BUILDING AND ENGINEERING WORKS

ABERTAWE BRO MORGANNWG UNIVERSITY NHS

TRUST

Approved by Trust Board April 2008

2

TABLE OF CONTENTS CONTRACTS CODE - BUILDING AND ENGINEERING WORKS Page No.

BE1 Introduction 3 BE2 Tenders 3 BE3 Contractor Lists 3 BE4 Estimates 4 BE5 Control of Building and Engineering Schemes 4 BE6 Number of Quotations to be Invited 5 BE7 Number of Tenders to Be Invited 5 BE8 Authority to Invite Tenders 6 BE9 Invitations to Tender - Nominated Sub-Contractors and Nominated Suppliers 6 BE10 Tender Documents 7 BE11 Time Allowed for Tendering 8 BE12 Receipt and Safe Custody of Tenders and Records 8 BE13 Opening and Validity of Tenders 8 BE14 Admissibility of Tenders 8 BE15 Examination of Tenders 8 BE16 Acceptance of Tenders 9 BE17 Forward Ordering and Letters of Intent 10 BE18 Notification of Result of Tenders 10 BE19 Terms and Conditions of Contract 11 BE20 Alternative Procedures 12 BE21 Quotations 13 BE22 Appointment of Nominated Consultants 13 BE23 Technical Brief 14 BE24 Preparation of a Business Case 14

Appendix 16.4

3

BE1 INTRODUCTION

1.1 This Contracts Code - Building and Engineering Works - shall apply to all contracts entered into by the Trust.

1.2 This Contracts Code - Building and Engineering Works - shall have effect as

if incorporated in the Standing Orders of the Trust.

1.3 The appointment of Project Managers and Design Consultants shall be in accordance with BE22.

1.4 Contracts shall be managed in accordance with the guidance contained in the

Capital Investment Manual and Supplementary Guidance about Private Finance Initiatives; the Capital Project Control Manual; Concode; Contracts and Commissions for the NHS Estate, Volumes 1 and 2, and also to the requirements of the EU Procurement Directives relating to Works, Supplies and Services Contracts.

1.5 This schedule should be read in conjunction with Schedule 8, Capital Control

Manual. BE2 TENDERS

2.1 Except as otherwise provided in the Contracts Code competitive tenders shall be obtained and Contracts shall be entered into for all building and engineering works.

2.2 Tenders shall be obtained only from contractors included in the appropriate

lists compiled in accordance with Section BE3 of this Contracts Code. BE3 CONTRACTOR LISTS

3.1 The Director of Planning shall ensure that a Register of Contractors shall be maintained of those companies who may be considered to undertake work for the Trust.

3.2 The Director of Planning shall maintain a bound register of contractors and

consultants, which shall be available to the Director of Finance if required.

3.3 For contracts in excess of £30,000 the Assistant Director of Planning (Capital) acting on behalf of the Director of Planning shall apply for a contractor from the Local Call-off Contractor Framework and prepare a suggested tender list from the register. These companies shall be contacted to ensure that they wish to tender and their response maintained on the scheme file. Those applicants satisfying the Trust's criteria shall then be financially vetted. Professional references shall be sought for any company that has not worked for the Trust in the past 2 years.

Deleted: Nominated Project Manager

4

3.4 Overall monitoring of the contracts shall be the responsibility of the Director of Finance and Chief Executive who shall present a report annually to the Trust showing the number and value of all contracts placed during the year in excess of £30,000 exclusive of VAT, to enable comparisons to be made with previous periods, and the extent to which contracts have been distributed to contractors. A similar schedule should be produced for Consultants appointed under BE22.

3.5 The Chief Executive shall submit a detailed report to the Trust Board of

instances where consultants and contractors go into Receivership/Liquidation whilst undertaking contracts for the Trust.

BE4 ESTIMATES

4.1 Before tenders are invited for the execution of any Building and Engineering work in excess of £30,000 exclusive of VAT the Assistant Director of Plannng (Capital) acting on behalf of the Director of Planning shall ensure that a pre-tender estimate is prepared and this must be within the approved budget cost for the scheme. In the event of the pre-tender estimate being in excess of the approved budget cost, the approval of the Director of Planning must be obtained before tenders are invited, and ratified by the Capital Investment Committee.

4.2 Prior to invitations to tender being made a Certificate of Readiness to Proceed

to Tender shall be completed in accordance with the Capital Projects Control Manual (Schedule 8).

BE5 CONTROL OF BUILDING AND ENGINEERING SCHEMES

5.1 The Trust shall be entirely responsible for the control of all building and engineering schemes under the direction of the Director of Planning.

5.2 All Building and Engineering schemes, irrespective of cost, shall be properly

planned and cost controlled in accordance with the procedures laid down in CONCODE, Estatecode, the Capital Project Control Manual and the Capital Investment Manual except in the preparation of Business Cases which shall be undertaken in accordance with BE24 and in the compilation of contractor lists which shall be undertaken in accordance with BE3.

5.3 The Assistant Director of Plannng (Capital) acting on behalf of the Director of

Planning shall be responsible for ensuring all schemes are planned and controlled in accordance with Construction (Design and Management) Regulations 2007.

5.4 The Assistant Director of Plannng (Capital) acting on behalf of the Director of

Planning and the Director of Finance shall be responsible for the application of liquidated and ascertained damages where deemed appropriate.


Deleted: Capital Investment Committee


Deleted: 1994


5

BE6 NUMBER OF QUOTATIONS TO BE INVITED

6.1 This Standing Order should be read in conjunction with SO 9.3. The number of quotations to be sought is as follows: - 6.1.1 For goods or services estimated to cost less than £5,000 exclusive of

VAT - quotations may be obtained at the discretion of the requisitioning officer.

6.1.2 For goods or services between £5,000 and £30,000 exclusive of VAT a

minimum of three quotations must be sought in accordance with the Trust's Quotation Procedure other than where the goods or services are being procured via the Trust Call-off Framework.

6.1.3 Where the required number of quotations are not available the Chief

Executive or designated deputy in absence, or the Director of Planning or designated deputy in absence, shall be authorised to accept a lower number subject to the principles of fair competition.

6.1.4 Where a staged payment system is intended to be used on a scheme,

those companies invited to submit a quotation must be financially vetted.

6.1.5 Single quotation action shall be the exception and shall only be used

when a single firm or contractor or a proprietary item or service of a special character is required and shall be obtained in accordance with the Trust’s Quotation Procedure. Single quotation action shall only be employed with the express authority of the Chief Executive or designated deputy in absence, and shall be reported to the Trust Board. Those relating to use of funding approved in the Trust’s Capital Programme must also be reported to the Capital Investment Committee

BE7 NUMBER OF TENDERS TO BE INVITED

7.1 The number of tenders to be invited shall be as follows, depending on the estimated value of the works:

7.1.1 Main Contract or Sub-Contract over £75,000 exclusive of VAT - six

tenders or one selected from the Local Contractor or Consultant Call-off Framework.

7.1.2 Main Contractor or Sub-Contractor under £75,000 exclusive of VAT -

four tenders or one selected from the Local Contractor or Consultant Call-off Framework.

7.2 Should the above number of tenderers required not be available due to

professional or financial constraints, then the Chief Executive (or designated

Deleted: .

Deleted: relevant Assistant

Deleted: relevant Assistant

6

deputy in absence) shall be authorised to accept a lower number of tenderers, subject to a minimum of three, on the receipt of a full report detailing the reasons the full tenderers cannot be represented.

7.3 Single tender action shall only be permitted when a single form or contractor

or a proprietary item or service of a special character is required. Single tender action shall only be employed with the express authority of the Chief Executive (or designated deputy in absence) and a detailed record shall be maintained by the Chief Executive. All single tender action procedures and extension of contracts must be reported to the Audit Committee. Those relating to use of funding approved in the Trust’s Capital Programme must also be reported to the Capital Investment Committee Single tender action shall not apply when calling off goods from NHS Contracts.

7.4 Tenders shall not knowingly be invited from companies who are subsidiary

companies of the same Parent Group. Should this limit the eligible companies to such an extent that the competitive exercise would be rendered uncompetitive, the Chief Executive shall be authorised to approve the issue of invitations on receipt of a full report detailing the reasons why the full tenders cannot be represented.

7.5 The selection from the local call off framework or approved lists of

contractors to be invited to tender shall be carried out in such a way that over a period of time all firms are given a reasonable opportunity of tendering for work.

BE8 AUTHORITY TO INVITE TENDERS

8.1 Tenders for all capital schemes shall be invited in the name of the Director of Planning and returned to the Director of Corporate Affairs.

8.2 Tenders for all schemes designed by nominated consultants shall be invited

from contractor tender lists satisfactorily professionally and financially vetted by the Trust.

BE9 INVITATIONS TO TENDER - NOMINATED SUB-CONTRACTORS AND NOMINATED SUPPLIERS

9.1 The practice of naming Domestic or Sub-Contractors and Nominated

Suppliers in Bills of Quantities and Specifications shall be followed whenever possible. As many of the tenders from Nominated Sub-Contractors and Nominated Suppliers as possible and in any case the tenders relating to approximately 90% in value of such sub-contracts shall be invited so that if they are received in time to be considered before or simultaneously with tenders for the Main Contract. If the Director of Planning, Technical Officer or Architects or Engineer, as the case may be, are unable to obtain tenders for the remaining 10% in value until after the Main Contract tenders have been received, the Sub-Contract and Supplies Tenders shall be invited on the basis

Deleted: Nominated

Deleted: , and

7

of prices current at the time of tendering. When this results in the final Design Cost being exceeded, a reduction exercise shall be carried out, taking into account any reserve sums which may be available and any savings which can be achieved in the event of an adequate reduction not being possible as a result of this exercise, this shall be reported to the Chief Executive.

9.2 When it is considered necessary or desirable to establish the name of

Nominated Sub-Contractor or Supplier and enter into a Contractual relationship with him at a date in advance of letting the Main Contract, in order that shop drawings for fabrication and production can begin in good time, the Director of Planning may authorise the invitation of early tenders provided the procedures in Sections BE3 and BE4 are followed.

BE10 TENDER DOCUMENTS

10.1 Tenders for Main Contracts estimated to exceed £75,000 exclusive of VAT

shall be submitted on the Standard Form of Tender and tenders for Nominated Sub-Contracts and Nominated Suppliers shall be submitted on the appropriate Standard Form of Tender for use in connection with the NEC Form of Contrcat or Joint Contractors Tribunal Form of Agreement. Tenders for all Nominated Sub-Contracts shall be accompanied by the Standard Form of Agreement between the Employer and Nominated Sub-Contractor amended as required and tenders for all Nominated Suppliers shall be accompanied by a Standard Form of Warranty amended as required. Tenders for Main Contracts estimated to cost less than £75,000 exclusive of VAT may at the discretion of the Director of Planning be submitted on a tender form based on a simplified form of Agreement prepared by the Director of Planning for small works. 10.1.1 This form of tender shall not be used when nominated Sub-Contract

work is required.

10.2 Every tender for Works where Bills of Quantities or an Activity Schedule do not form part of the Contract Document shall include a Day Work Schedule and a Schedule of Rates. Every tender for an Engineering Main Contract or Sub-Contract shall include the Specification and Priced Activity Schedule or Schedule of Quantities.

10.3 A Declaration of Non-Collusion shall be submitted with every tender.

10.4 Every tender, other than those sourced from the Local call off Framework,

shall be strictly in accordance with the invitation documents and a statement to this effect shall be included in the letter of invitation which shall also specify that a qualified or incomplete tender shall be liable to rejection and that, if in view of this, a Contractor has any doubts about how to proceed, he should clarify the matter with the Director of Planning, Technical Officers or Nominated Consultants as appropriate before submitting his tender.

10.5 Contractors shall be required to take out performance bonds for Works

Contracts as and when required by the Director of Planning. The Director of

8

Planning shall ensure that all consultants and contractors are informed that performance bonds may be required in the tender documentation.

10.6 All tenders shall be enclosed and sealed in the standard envelope provided

which shall be endorsed with the description of the subject of the tender and the date and time for the receipt of such tender and addressed to the Interim Director of Corporate Affairs in all cases. (See SO 9.5)

10.7 The tender envelope should not bear any names or marks indicating the

tenderer.

10.8 The Director of Finance shall be responsible for requesting and verifying any parent company guarantees required.

BE11 TIME ALLOWED FOR TENDERING

11.1 The time allowed for the submission of tenders shall be determined in relation to the scope of the Works Information by the Assistant Director of Plannng (Capital) acting on behalf of the Director of Planning. Should a period in excess of four weeks be recommended the approval of the Director of Planning will be required before tenders are invited. The Assistant Director of Plannng (Capital) acting on behalf of the Director of Planning shall ensure that all companies invited to tender are informed.

11.2 Tenderers shall be instructed to submit their tenders in accordance with SO 9.5.

BE12 RECEIPT AND SAFE CUSTODY OF TENDERS AND RECORDS

12.1 Arrangements for the Receipt and Safe custody of Tenders shall be as those detailed in SO 9.6.

BE13 OPENING AND VALIDITY OF TENDERS

13.1 Arrangements for the opening of tenders shall be as those detailed in SO 9.7.

13.2 After tenders have been opened in accordance with SO 9.7, all documents shall be passed to the Assistant Director of Plannng (Capital), acting on behalf of the Director of Planning as appropriate for report and recommendation.

BE14 ADMISSIBILITY OF TENDERS

14.1 Admissibility of tenders shall be in accordance with SO 9.5.

14.2 If the number of tenders received is insufficient to provide adequate competition, they shall, where necessary or appropriate, be dealt with in accordance with current Welsh Assembly Government Guidance.



9

BE15 EXAMINATION OF TENDERS

15.1 The lowest Tenderer shall submit his priced Bill(s) of Quantities or Activity Schedule, when appropriate as soon as possible after being asked to do so and in any case by not later than four working days after being asked. (Saturday and Sundays are not to be counted as working days for the purpose of this Clause).

15.2 The lowest Tenderer's priced Bills of Quantities or Activity Schedules, or

priced Schedules of Rates shall be checked by Quantity Surveyor, Assistant Director of Plannng (Capital). Priject Offcier or Estates Officer as appropriate.

15.3 All errors discovered or qualifications or alterations to tenders received shall be referred immediately to the Director of Planning or Assistant Director of Planning (Capital) and fully itemised in the tender report, as shall incomplete tenders, that is, those which information necessary for the evaluation of the tender is missing. The procedure for dealing with alterations and/or qualifications shall be as set out in the Code of Procedure for single stage selective tendering.

15.4 Following each tender exercise a report on the results shall be submitted to the

Chief Executive by the Director of Planning, together with recommendations for further action.

BE16 ACCEPTANCE OF TENDERS

16.1 When a lowest tender or only tender is within the Trust's pre-tender estimate it may be accepted immediately and the award of the contract be reported to the Trust Board. In this connection the word "Tender" shall mean the sum total of the Main Contract Tender plus the Sub-Contract Tenders and this shall be regarded as the Approved Contract Sum, which must not be exceeded.

16.1.1 Any additional work considered necessary must be approved by the

Chief Executive.

16.2 Where the lowest acceptable tender sum, adjusted for main sub-tenders, exceeds the pre-tender estimate by not more than 5%, savings should be sought and agreed with the successful tenderer before award of the contract to maintain the integrity of the pre-tender estimate. If the excess is more than 5% a detailed report together with proposals for achieving savings necessary and a note of the effects of such savings must be submitted to the Director of Planning for a decision on whether to proceed and on what basis. If in his opinion it is not practicable to reduce a tender to the approved amount, the Director of Planning shall make a report and recommendation on the matter to the Chief Executive for submission to the Capital Investment Committee.

Deleted: priced

Deleted: Building Officer or Engineer

Deleted: Trust

Deleted: Audit Committee. Those relating to use of funding approved in the Trust’s Capital Programme must also be reported to the Capital Investment Committee

10

16.3 There is no legal requirement for the Trust to accept any tender or award any contract or part of a contract, and the Trust may, if it so adjudges, not proceed further at this stage.

16.4 Tenders shall remain open for acceptance for a period of three calendar

months from the date when tenders are due to be returned. 16.5 Prior to accepting the successful tender, the company shall be subject to a

further financial vet.

16.6 Immediately prior to acceptance of a tender, a check must be undertaken by the Assistant Director of Plannng (Capital) acting on behalf of the Director of Planning to ensure that the period between acceptance of the tender and start on the site as stated in the tender documents is still valid.

BE17 FORWARD ORDERING AND LETTERS OF INTENT

17.1 A Forward Order with a Nominated Sub-Contractor or a Nominated Supplier may be entered into by the Director of Planning as appropriate if considered necessary, following the procedure under Paragraph BE7 subject to the prior approval of the Trust Board. The contractual relationship resulting from this Forward Ordering procedure shall be assigned to the Main Contractor at the time of his Appointment and the Contract with the Nominated Sub-Contractor or Nominated Supplier shall be subject to this condition.

17.2 The Director of Planning as appropriate may use his discretion in issuing letters of intent to Nominated Sub-Contractors or Nominated Suppliers for the sole purpose of reserving capacities and materials, provided he ensures that any such letter does not give rise to any legal relationship or liability.

BE18 NOTIFICATION OF RESULT OF TENDERS

18.1 All Tenderers shall be notified of the result of the competition as soon as possible. The Director of Planning as appropriate shall as soon as possible after the opening of tenders:

18.1.1 Inform the lowest Tenderer that his offer is under consideration and

request submission of his priced Bills of Quantities, Activity Schedules or Schedules of Rates.

18.1.2 Examine the priced Bills of Quantities, Activity Schedules or Schedule

of Rates and, if satisfactory, proceed to 18.1.3. In the event of these documents proving unsatisfactory an approach should be made to the second lowest Tenderer where appropriate.

18.1.3 Inform successful tenderers by letter.

18.1.4 Inform all the other Tenderers that they have not been successful.


Deleted: /

Deleted: /

11

18.2 As soon as the Contract has been let, the Assistant Director of Plannng

(Capital), acting on behalf of the Director of Planning, shall supply each Tenderer, including the successful one, with a list of the tender bids received.

18.3 Where an EU Procurement is involved the notice of the award of the contract

shall be published in next available edition of the Official Journal of the European Union.

Deleted: Nominated

Deleted: Project Manager

12

BE19 TERMS AND CONDITIONS OF CONTRACT

19.1 Every contract for building and engineering works, estimated to exceed £75,000 exclusive of VAT in cost, except measured term contracts where Concode guidance would apply, shall conform to these Standing Orders (SO 9.11). This formal contract document should reflect any change in the terms and conditions of contract agreed following receipt of tenders.

19.2 The form of Contract used for such Works shall be the one selected from the

current suite of NEC Standard Form of Contracts Joint Contracts Tribunal contract as appropriate and applied in accordance with the Trust's Standard Requirements. Contracts are to be completed under Seal, where practicable, and this point to be stated on all tender forms.

19.3 The form of contract for works estimated to cost less than £75,000 exclusive

of VAT shall be at the discretion of the Director of Planning or Assistant Director of Planning (Capital) in his absence, who may use a simplified form of contract or even an exchange of letters in case of small urgent works. This shall not preclude the use of an appropriate form of NEC or JCT Contract if the Director of Planning or Assistant Director of Planning (Capital) decides that this form of Contract is more appropriate for any particular scheme.

19.4 All formal Contracts, where a standard issue by the British Standards

Institution is current at the date of the tender and is appropriate, shall require that goods and materials used in their execution shall be in accordance with that Standard.

19.5 In every Formal Contract a clause shall be included to secure that the Trust

shall be entitled to cancel the contract and to recover from the Contractor the amount of any loss, resulting from such cancellation, if the Contractor shall have prepared his tender in collusion with others or shall have offered or given or agreed to give to any person any gift or consideration of any kind as an inducement or reward for doing or forbearing to do or having done or forborne to do any action in relation to the obtaining or execution of the Contract or any other Contract with the Trust, or if the like acts shall have been done by any person employed by him or acting on his behalf (whether with or without the knowledge of the contractor) or if in relation to any Contract with the Trust the Contractor or any person employed by him or acting on his behalf shall have committed an offence under the Prevention of Corruption Acts 1906 to 1916 and the Public Bodies Practices Act of 1889.

19.6 Every tender for building and engineering works, except any tender for

maintenance work only, including Measured Term contracts where Estatecode guidance should be followed, shall embody or be in the terms of the current Edition of the Standard Form of Building Contract Local Authorities Edition with (or, where appropriate, without) quantities or the Agreement for Minor Building Works issues by the joint Contract Tribunal, as appropriate, or (when the content of the works is primarily engineering) the General Conditions of Contract recommended by the Institution of Mechanical and Electrical

Deleted: edition

Deleted: of the

Deleted: Building

Deleted: as issued by the

Deleted: ,

Deleted: JCT Standard Form of Building Contract if the

Deleted:

13

Engineers and the Association of Consulting and Engineers (Form A) or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institution of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. These base documents should be modified and amplified to accord with current Welsh Assembly Government guidance and in minor respects to cover special features of individual projects. Tendering based on other forms of contract may be used after prior consultation with the Welsh Assembly Government.

19.7 Any Contract for Works estimated to cost under £30,000 exclusive of VAT

may be let by exchange of letters at the discretion of the Director of Planning as appropriate, provided that the following are specified:

19.7.1 The work, materials, matters or things to be furnished or done;

19.7.2 The price to be paid with a statement of discount or other deductions if

any;

19.7.3 If practicable, the time or times within which the contract is to be performed.

19.8 Every Nominated Sub-Contract shall be let subject to the same conditions as

the Main Contract to which it relates.

19.9 The official Contract Document shall be signed by the Chief Executive or another officer duly authorised by him, and where completed under Seal shall be undertaken in accordance with SO 12.

BE20 ALTERNATIVE PROCEDURES

20.1 In accordance with WHC(2006)033, where a contract for construction, engineering works or for professional services relating to such works is being considered, the procedures set out in this Schedule within the Standing Orders need not be followed, where the proposed contract is to be let under a special arrangement negotiated by Welsh Health Estates or the National Assembly for Wales (which terms include any successor bodies exercising its or their functions) in accordance with the terms of such special arrangement.

20.1.1 There shall be no other departure from the procedures specified in this

Contracts Code except:- (a) by direction of the Trust Board; (b) in an emergency; (c) as provided for in the Trust's Standing Orders;

14

(d) when in accordance with a procedure specified in the Department of Health Concode; or

(e) with any other Building or Engineering Works

procedure specified by the Department of Health or the Welsh Assembly Government.

BE21 QUOTATIONS

21.1 This Contracts Code shall not apply to quotations obtained by the Director of Planning, Technical Officers or Nominated Consultants for exploring the market and/or to decide on the Manufacturer to specify in technical specifications that shall themselves be subject to competitive tendering. Such quotations may be invited by the Technical Officers designing the Project and returned to the Director of Planning, Technical Officers or Nominated Consultants as the case may be.

BE22 APPOINTMENT OF CONSULTANTS

22.1 The Director of Planning shall be the Trust's designated officer for managing the appointment of consultants applying to work for the Trust.

22.2 Performance and professional indemnity monitoring of all practices on any

shortlist shall be undertaken by the Assistant Director of Plannng (Capital) acting on behalf of the Director of Planning when the appointment of Consultants is being considered. The method of monitoring shall be in accordance with Concode Part II. Financial vetting of such Consultants being considered shall be carried out whenever possible when accounts have been published. The absence of accounts shall not preclude the consideration of any company. The Assistant Director of Plannng (Capital) acting on behalf of the Director of Planning shall ensure that all Consultants being appointed shall hold appropriate insurances and professional indemnities. The Director of Finance shall present a report annually to the Trust Board, via the Financial Audit Committee, showing the number and value of all commissions placed during the year to enable comparisons to be made with previous periods and the extent of which commissions have been distributed.

22.3 Appointment of Consultants not on the Trust’s Call Off Framework must be approved by the Director of Planning and reported to the Trust Board.

22.4 When the appointment of Consultants is being considered, the Assistant

Director of Plannng (Capital), acting on behalf of the Director of Planning, shall obtain fee bids from the Local Call Off Framework or three practices that have successfully passed the vetting procedures and hold appropriate cover in accordance with the quotation and tendering procedures detailed in Standing Orders. These shall be presented to the Trust Board by the Chief Executive with a recommendation..

Formatted: Bullets andNumbering

Formatted: Outlinenumbered + Level: 2 +Numbering Style: 1, 2, 3, … +Start at: 2 + Alignment: Left +Aligned at: 45 pt + Tab after: 72 pt + Indent at: 72 pt,Tabs: 108 pt, Left + Not at 120.5 pt

Deleted: NOMINATED



Deleted:

Deleted: to various practices

Deleted: ¶

Deleted: ¶

Deleted: For all schemes with a works cost of below £1,000,000 exclusive of VAT, the recommendation of the appointment of the Project Manager and Design Team shall be made by the Director of Planning to the Chief Executive. For all schemes above this threshold, the appointment of a Project Manager shall be considered by a panel comprising a member of the Trust Board, Director of Planning and a Professional Advisor. ¶¶22.3.1 Once appointed, the Project Manager shall co-ordinate the invitation of bids for individual posts on the design team, interview applicants with a member of the User Group and prepare an assessment of bids and interview performance. Based upon this assessment the Director of Planning shall recommend a design team appointment to the Chief Executive.


Deleted:

Deleted: Post approval by the Trust Board, fee negotiations with the chosen firm shall be undertaken by the Nominated Project Manager acting on behalf of the Director of Planning

15

22.5 Competitive fee bids shall not be required where fees are estimated to be below £5,000 for a single commission and where the appointment of the Consultant does not form part of the overall appointment of a design team.

22.6 Any appointment of Design Consultants shall be selected from the Local Call

Off Framework or in accordance with the Capital Investment Manual, Concode Guidance, the Capital Project Control Manual and the requirements of EU Directives.

BE23 DESIGN BRIEF

23.1 When a scheme is designed by Consultants the Design Brief shall be provided by the Director of Planning. In such cases the Tender documents shall bear the name and style of the Director of Planning as being in collaboration with the Designer.

BE24 PREPARATION OF A BUSINESS CASE

24.1 When a scheme is being considered which has a budget cost of £2,000,000 or more exclusive of VAT, a business case shall be prepared. The scope and format of each individual case shall be determined by the Capital Investment Committee as advised by the Chief Executive and the Director of Planning.

Deleted: TECHNICAL

Deleted: Nominated

Deleted: Technical

1

ABERTAWE BRO MORGANNWG UNIVERSITY NHS TRUST

MINUTES OF THE MEETING OF THE PERFORMANCE MANAGEMENT COMMITTEE

Held on 9th February 2009

At 11.30 am in the Boardroom, THQ, Baglan

PRESENT: Win Griffiths, Chairman (in the Chair) Calum Campbell, Acting Chief Executive Bruce Ferguson, Medical Director

Robert Francis-Davies, Non-Executive Directors Vicki Franklin, Nurse Director Debbie Morgan, Director of IM&T and Performance Improvement

Paul Stauber, Director of Planning Walter Thomas, Staff Side Representative Eifion Williams, Director of Finance Michael Williams, Non-Executive Director IN ATTENDANCE: John Collins, Non-Executive Director

Steve Combe, Director of Corporate Affairs (Secretary) Geraint Evans, Director of Human Resources

Julian Hopkin, Non-Executive Director Philippa Rees, Staff Side Representative Christine Thomas, Staff Side Representative Paul Wood, Non-Executive Director Sandra Miller, Staff Side Representative

Randy Guru, RCN Steward (Shadowing Christine Thomas)

Action

1/09 APOLOGIES FOR ABSENCE

Apologies for absence were received from Mr David Davies and Mr Barry Goldberg.

2/09 MINUTES

The Minutes of the meeting held on 3rd December 2008 were received and confirmed as a correct record.

2

3/09 MATTERS ARISING

There were no matters arising.

4/09 DECLARATION OF INTERESTS

No Declaration of Interests were received.

5/09 FINANCE REPORT

A report of the Director of Finance setting out the current financial position was received.

In introducing the report the Director of Finance highlighted the following issues:

− The Trust was overspent by £3.1m as at the end of December 2008.

− The Trust was experiencing increased activity due to the weather conditions.

− The actions being taken to address the overspends, including the support by the Recovery Team.

In discussing the report the Acting Chief Executive confirmed that Staff Side representation on the Recovery Team, Vacancy Board, Step Change Board and Operational Board had been confirmed and that the Recovery Team were providing support in key areas.

In response to an enquiry from Mr Paul Wood, the Director of Finance confirmed that discussions were ongoing with the LHBs in the Hywel Dda area regarding payment for activity above LTA levels.

In response to an enquiry from Professor Julian Hopkin, the Acting Chief Executive confirmed that some areas of the Trust were currently working on a 6-day week basis and this was being extended.

Resolved that the report be noted.

6/09 PERFORMANCE REPORT

(i) Elective & Emergency Activity Impact

The report of the Director of IM&T and Performance Improvement setting out information in relation to activity

3

pressures in December 2008, and the potential impact on delivering key performance areas for the Trust was received.

In introducing the report the Director of IM&T and Performance Improvement highlighted the following issues:

− The increase in emergency admissions in the Trust, especially in patients aged 60 and above.

− The number of cancellations of elective activity due to the increased pressure on emergency admissions.

− The increase in the number of patients with a length of stay of over 30 days and issues with delayed transfers of care.

In discussing the report the Medical Director highlighted the increasing number of elderly patients with co-morbidities that were being dealt with by the Trust. These cases were more complex and had longer lengths of stay.

Mr Paul Wood enquired as to the capacity levels at Morriston A & E. In response, the Medical Director indicated that the key factor was the type of patients being admitted, rather than the number, and that the Trust was admitting more complex cases. He stressed that the Trust was working with Partners in order to streamline services.

The Acting Chief Executive indicated that the Trust was operating at high levels of efficiency but was concerned at the delays in arranging home care for patients to enable speedy discharge.


(ii) A & E Performance against 4 and 8-hour Targets

The report of the Medical Director setting out the Trust performance against the 4 and 8-hour targets was received.

Noted that the Trust performance was not at the target level set by the Assembly. This was due to the increased number of emergency admissions due to the weather condition.


4

((iii) Cancer Service Waiting Times Performance Report

The report of the Acting Chief Executive providing information on performance against the National Cancer Waiting Time targets was received.

Noted that:

− Ongoing discussions were taking place with colleagues in Primary Care to improve referral pathways.

− The Trust was undertaking work for patients within the Hywel Dda area, which impacted upon performance.


(iv) Waiting Times Performance / LDP Delivery

The report of the Director of Planning setting out the current Waiting Times Performance by specialty, including a supplementary paper setting out the position at the end of January 2009 was received.

In introducing the report the Director of Planning highlighted the following issues:

− The position in respect of outpatients where capacity was in place to deliver on target by 31st March 2009.

− The position in respect of day cases where capacity was in place to deliver the targets by 31st March 2009.

− The position in respect of inpatients where there were more significant challenges due to recent elective cancellations because of the increase in emergency admissions. The main risk area was within Orthopaedics.

− He stressed the risks being faced in achieving these targets, which were the financial impact associated with achieving the targets and the availability of beds, where discussions were being held to ring-fence elective bed capacity.

In discussing the report the Chairman asked whether the costs of meeting the Access Targets had been factored into the financial projections. The Director of Finance confirmed

5

that this was the case.

The Acting Chief Executive indicated that work was ongoing to ring-fence elective capacity in order to ensure the Trust met all Access Targets.


(v) Step Change Programme – Redesigning Care, Right Care, Right Time

The report of the Director of IM&T and Performance Improvement advising the Committee of the Trust’s Step Change Programme was received.

In introducing the report the Director of IM&T and Performance Improvement highlighted the following issues:

− The actions being taken to improve performance to deliver the Annual Operating Framework Efficiency and Productivity Targets in line with the 10 High Impact Changes.

− The Step Change Projects agreed with key deliverables, as set out in the report.

In discussing the report Mr Paul Wood enquired whether the Trust could work more effectively with Social Services to reduce Delayed Transfers of Care by, possibly, establishing a Joint Scrutiny Committee.

In response the Chairman indicated that such discussions were taking place currently and that it was anticipated that the Restructuring of the NHS in Wales would help improve the situation further.


7/09 WORKFORCE METRICS

The report of the Director of Human Resources setting out information regarding the Trust Workforce was received.

In discussing the report the following issues were raised:

− Mr John Collins asked for details of the plan to improve ethnicity data. In response the Director of HR confirmed that it was

6

planned to survey staff to obtain more robust information. It was anticipated that this work would be commenced within 6 months.

− The levels of Sickness Absence and the action required to improve performance. The Director of HR confirmed that the Trust was sharing information with neighbouring Trusts and had reviewed the outcomes of an All Wales Audit. The Director of Finance confirmed that, on the basis of days lost, the levels of sickness in the Trust would equate to a financial sum of approximately £3m per annum.

− The need for effective management action to reduce sickness levels and the work of the Sickness Management Group, which was aimed at supporting managers to achieve a sustained improvement in current sickness levels.

− The Medical Director highlighted the current compliance with European Working Time Directive for Junior Doctors, which had been affected by the recent changes in immigration rules. This meant that a number of services were less robust than planned, including such areas as Neurosurgery. This risk was being managed.

The Chairman suggested he discuss this further with the Medical Director to ascertain whether further representations could be made to the Assembly on this matter.

8/09 ANY OTHER BUSINESS

There were no further items raised.

9/09 DATE OF NEXT MEETING

This would take place at 11.00 am on Wednesday 8th April 2009 in the Boardroom, THQ.

Signed: ........................................................... Date: ................................... Win Griffiths, Chairman

1


MINUTES OF THE MEETING OF THE PERFORMANCE MANAGEMENT COMMITTEE

Held on 8th April 2009

At 11.00 am in the Boardroom, SSU, Princess of Wales Hospital

PRESENT: Win Griffiths, Chairman (in the Chair) Calum Campbell, Acting Chief Executive Bruce Ferguson, Medical Director

Robert Francis-Davies, Non-Executive Directors Vicki Franklin, Nurse Director Debbie Morgan, Director of IM&T and Performance Improvement

Paul Stauber, Director of Planning Eifion Williams, Director of Finance Michael Williams, Non-Executive Director IN ATTENDANCE: Steve Combe, Director of Corporate Affairs (Secretary) Geraint Evans, Director of Human Resources

Philippa Rees, Staff Side Representative Barry Goldberg, Non-Executive Director John Collins, Non-Executive Director

Action

10/09 APOLOGIES FOR ABSENCE

Apologies for absence were received from Paul Wood, Sandra Miller, Walter Thomas, David Davies and Prof Julian Hopkin.

11/09 MINUTES

The Minutes of the meeting held on 9th February 2009 were received and confirmed as a correct record.

12/09 MATTERS ARISING

There were no matters arising.

2

13/09 WAITING TIME PERFORMANCE / LDP DELIVERY 2008/09

The report of the Director of Planning setting out the waiting times performance as at the end of March 2009 was received.

In introducing the report the Director of Planning advised Directors that:

− Subject to validation it was anticipated that the Trust had achieved its Access Targets for 2008/09.

− Robust plans were in place to deliver RTT, although there were particular challenges in Orthopaedics, Plastic Surgery and Neurosurgery.


− The Chairman enquired whether profiling work had been undertaken to ensure workload was balanced throughout the year. The Director of Planning indicated that, during the first quarter, priority would be given to patients who had been initially seen during January and March and that capacity has been ring-fenced at an early stage as part of the profiling work.

− The Acting Chief Executive expressed his thanks to all staff for ensuring Access Targets were achieved. He reminded Directors that the Trust was utilising increased capacity for elective work and this meant there was less capacity available for emergency work and this could impact upon the achievement of the A & E Target. The Director of Planning indicated there was a conflict between RTT and component waiting times as both systems were running in parallel in the short term.

− In response to an enquiry regarding Cost Improvement Targets, the Director of Finance reminded Directors that the Trust was the most efficient Trust in Wales but that the achievement of a £30m saving was a huge challenge.

− In response to an enquiry from Mr Goldberg regarding follow-ups and unscheduled care cases, the Medical Director confirmed that the Executive Team were working with Directorates to develop plans based on their Designed for Improvement Plans.

3


14/09 CANCER WAITING TIMES PERFORMANCE REPORT

A report of the Acting Chief Executive was received.

In introducing the report the Acting Chief Executive advised Directors that the Trust was maintaining its performance on non-urgent suspected cancers and there had been a slight improvement in respect of urgent suspected cancers. He reminded Directors that the Trust was undertaking additional work on Urology cases from Hywel Dda Trust which was impacting on the performance.


15/09 A & E PERFORMANCE AGAINST 4 AND 8-HOUR TARGETS

The report of the Medical Director setting out performance against the 4 and 8-hour A & E Targets was received.

In introducing the report the Medical Director highlighted the following issues:

− The fact that this target was the biggest challenge facing the Trust and that the Trust was currently not meeting this target.

− The Unscheduled Care Plan that had recently been sent to the Assembly to improve performance.

− The challenges in maintaining performance which included recruitment and retention, especially of Middle Grade doctors, D & V outbreaks and pressure on beds.

− The additional management capacity that had recently been earmarked, with weekly reports being received by the Executive Team.

In response to an enquiry from Mr Francis-Davies, the Director of I M & T and Performance Improvement confirmed that the peak time of activities at A & E were on Monday. The Acting Chief Executive reminded Directors that trauma outcomes within the Trust were excellent and that high quality care was provided.


16/09 NATIONAL PERFORMANCE REPORT OCTOBER – DECEMBER

4

2008

The report of the Director of I M & T and Performance Improvement setting out the Performance Report for October – December 2008 was received.

In introducing the report the Director of I M & T and Performance Improvement highlighted the following issues:

− The progress in respect of the NSF for Mental Health, where assertive outreach was being established in Swansea.

− The development of ward-based performance indicators.

− The establishment of a Stroke Steering Group to take forward the Stroke Targets following receipt of additional funding from the Assembly.

− The Action Plan in place to develop Sexual Health services.

The Chairman enquired of plans to reduce lengths of stay in line with targets.

The Director of I M & T and Performance Improvement confirmed that this was part of the Step Change Schemes considered later in the agenda.


17/09 STEP CHANGE PROGRAMME – REDESIGNING CARE, RIGHT CARE, RIGHT TIME

The report of the Director of I M & T and Performance Improvement updating the Committee on the Trust’s Step Change Programme was received.

In introducing the report the following issues were raised:

− The detailed Project Plans that had been developed with key areas highlighted in the report.

− The plans to improve productivity and efficiency.

− The need for a Change Management Programme to support the changes, which was being taken forward.


5

Mr Barry Goldberg enquired whether the share-point site was available. The Director of I M & T and Performance Improvement confirmed this was the case and agreed to discuss this further with Mr Goldberg outside the meeting.

The Director of Finance indicated that the Finance Report highlighted the impact of the Step Change Schemes and that these plans were developed by Directorates.


18/09 FINANCE REPORT

The report of the Director of Finance was received.

In introducing the report the Director of Finance highlighted the following issues:

− The Trust was £2.9m overspent at month 11, with an underspend during the month.

− The expectation that the Trust achieve financial balance at the end of the year due to the securing of additional income and improved efficiency.

− The considerable achievement in breaking even when taken alongside the management restructuring and the achievement of Access Targets.

Mr Michael Williams congratulated the Director of Finance and his team for ensuring the Trust would break even and enquired whether the Recovery Team would continue. The Director of Finance confirmed that the Executive Team would need to consider the role of the Recovery Team and the need to embed Directorate structures.

In response to an enquiry from Mr Barry Goldberg the Director of Finance confirmed that there was no Rewards Scheme available from the Assembly during the current year although Bro Morgannwg NHS Trust had received a £2m reward for 2007-08.

(i) Resource Plan

The Resource Plan for 2009-10 was received together with a tabled graph.

The Director of Finance highlighted the following issues:

6

− The £20m shortfall in meeting inflationary pressures.

− The potential £38m shortfall across the Health Community and the additional £10m LDP shortfall.

− Further costs that would be incurred if the Trust developed services in line with other Assembly targets where Directorates had planned to develop these services within existing resources and to use best endeavours to ensure these targets were taken forward.

− The caveats and risks as set out in the report.

The Chairman congratulated the Director of Finance on ensuring that the Trust would break even and advised Directors that the Assembly had asked the Director of Finance to assist in the Assembly on two days a week, which was a reflection on the high regard in which he was held.

In response to an enquiry from Mr Barry Goldberg the Director of Finance confirmed that a Ministerial Letter had been issued confirming the pay award for 2009-10.

Resolved that:

− The report be noted.

− The budgets set out in the Resource Plan be confirmed as a starting base budget for the Trust for 2009-10.

− The current CIP target for 2009-10 should remain as set out in the report.

− All Directorates would manage incremental pay pressures on the allocation set out in Annexe 1 of the report.

− Delivery of AOF targets other than LDP targets be discussed within the ABM community on the basis that the Trust could not contribute financially to the delivery of these targets.

19/09 WORKFORCE METRICS

The report of the Director of Human Resources setting out

7

Workforce Metrics was received.

In introducing the report the Director of Human Resources highlighted the following issues:

− The reduction in the number of staff employed.

− Current turnover rates.

− The increase in sickness absence rates to 5.56%, of which 3.78% related to long term sickness over 28 days. This was an area that was currently being targeted.

In discussing the report the Chairman enquired of the speed in dealing with investigations and hearings. Mrs Christine Thomas expressed concern at the length of time taken to investigate and ensure consistency of investigations and this matter had been considered by the Partnership Forum.

The Acting Chief Executive proposed that dedicated/trained resources would help the investigation process. This was agreed.

Resolved that consideration be given to establishing a group to undertake investigations and hearings for grievance claims.


(i) Neath Port Talbot Staff

Noted that Neath Port Talbot staff had transferred to the employment of the Trust week commencing 1st April 2009.

21/09 NEXT MEETING

This would take place on Wednesday 10th June 2009, time and venue to be advised.


MINUTES OF A MEETING OF THE FINANCIAL AUDIT COMMITTEE

HELD ON TUESDAY 10th MARCH 2009 AT 2.00 pm IN THE BOARDOOM, THQ

Present: Mr M Williams Non-Executive Director (Chair) Mr R Francis-Davies Non-Executive Director Mr D Davies Non-Executive Director Mr P Wood Non-Executive Director (until Minute

15/09(ix)) In Attendance: Mr E Williams Director of Finance Mrs K Jones Associate Director of Finance (Corporate) Mrs P O’Connor Head of Internal Audit Mr N Thomas Internal Audit Office Mr T Roberts Local Counter Fraud Specialist Dr W Thomas Staff Side Representative Mr C Stradling Engagement Partner, Wales Audit Office Mr M Coe Audit Manager, Wales Audit Office (until

Minute 15/09(xv)) Mr C Campbell Acting Chief Executive (from minute

04/09) Mrs W Penrhyn-

Jones Associate Director of Corporate Affairs (Administration)

Mr J Goulding Partner, Grant Thornton (not present for Minute XV)

Ms Angela Ryan Audit Manager, Grant Thornton (not present for Minute XV)

Mr H Richards Capital & PFI Audit Services (For Minute 14/09)

Ms Helena Jarvis Head of Nursing, Musculo Skeletal Directorate (For Minute 12/09 (ix))

Ms Alison McLennan Principal Finance Manager, Musculo Skeletal Directorate (For Minute 12/09 (ix))

Mr Julian Quirk, assoc dir of HR

Associate Director of Human Resources (For Minute 15/09 (i))

09/09 APOLOGIES FOR ABSENCE Action

Apologies for absence were received from Mr G Davies (Partner, Grant Thornton).


Mr R Francis-Davies declared an interest in any items related to the City and County of Swansea.

1

11/09 MINUTES

(i) Financial Audit Committee

The Minutes of the meeting of the Financial Audit Committee held on 20th January 2009 were received and confirmed as a correct record, subject to the following amendment:

Minute 06/09 (i): Capital and PFI Audit Services Progress Report In this respect the Director of Finance requested that Capital and PFI Auditors tested all client projects within the Supply Chain to which Mr Richards agreed to take this view back to Welsh Health Estates.

Matters Arising

(viii) Penultimate Account Audit – Internal Refit

The Director of Finance provided assurance that he had reviewed the necessary documentation with regard to due process being followed. Mr Williams stated that verbal instructions had been given to the Director of Planning from the then Chief Executive to proceed. The relevant documentation followed subsequently with the matter being signed off during June 2008. Therefore, delegated authority had been given and such authority was valid.

Non Executive Directors stated they were content with the oral account set out above.

(x) Internal Audit Matters (x) Private Patients

The Director of Finance confirmed that the administrative service within the Private Patient Unit was not subject to V.A.T.

(ii) Healthcare Governance Committee

The Minutes of the meeting of the Healthcare Governance Committee held on 1st December 2008 were received and noted.

2

It was noted that a Non-Executive Director would need to be nominated as Champion for the Empowering Ward Sisters Action Plan and that this issue was being discussed between the Nurse Director and the Acting Chief Executive.

It was further noted that Mr Michael Williams had become a member of the Medical Education Committee which would report through the Healthcare Governance Committee.

(iii) Delivery & Support Unit Governance Sub Committee

The Minutes of the meeting of the Delivery & Support Unit Governance Sub Committee held on 16th December 2008 were received and noted. Mr David Davies confirmed that this Sub Committee had met again earlier that week

(iv) NLIAH and CEHR Governance Sub Committee

The Minutes of the meeting of the NLIAH AND CEHR Sub Committee held on 16th December 2008 were received and noted. Mr David Davies confirmed that this Sub Committee had met again earlier that week

(v) INFORMING HEALTH CARE Governance Sub Committee

The Minutes of the meeting of the IHC Sub Committee held on 16th December 2008 were received and noted. Mr David Davies confirmed that this Sub Committee had met again earlier that week

12/09 INTERNAL AUDIT MATTERS

(i) Progress Report

The Internal Audit Progress Report against the 2008/09 Plan was received.

The following issues were highlighted by Mrs O’Connor:

- With regard to the annual Healthcare Standards Review conducted through Health Inspectorate Wales (HIW) there had once again been difficulties in terms of the technical functionality of the Electronic Self Assessment Tool which had been found to be not retaining stored data. The

3

Chief Executive had written to Mr Peter Hickson at HIW to highlight the Trust may, as a consequence of these difficulties, fail to meet the required timescale of 9th April 2009 for final submission of evidence. Mr Campbell stated that he had met with Mr Hickson that morning and HIW accepted that the issue was their responsibility to resolve. Health Solutions Wales had therefore been engaged to review the software. The Committee and the Trust Board would be kept involved of developments on this important issue.

- With regard to progress made in relation to Controlled Drug issues Internal Audit were awaiting final information to provide a firm update.

- The Head of Internal Audit was maintaining links with colleagues leading national initiatives on NHS Governance matters such as the Governance in Health Project.

The Committee was assured that Grant Thornton was content that matters were progressing as required and that internal and external audit colleagues met regularly to share information.


(ii) Procurement Strategy

The Internal Audit Review Report regarding the Procurement Strategy was received.

Noted that there was Significant Assurance over the adequacy and application of the Framework of Internal Controls.

(iii) NHS Contract Income

The Internal Audit Review Report regarding NHS Contract Income was received.

Noted that a Significant Level of Assurance had been achieved, indicating the systems of control were operating effectively.

There had been some disputes between Abertawe Bro Morgannwg and Local Health Boards within the Gwent area, all of which were for relatively small amounts. These disputes had arisen due to financial particularities in the ways in which those LHBs operated. Ultimately

4

however, these issues were resolved each year.

(iv) Financial Ledger

The Internal Audit Review Report regarding the Financial Ledger had achieved a Significant Level of Assurance indicating that systems of control were operating effectively.

(v) Budgetary Control & Financial Management

The Internal Audit Review Report regarding Budgetary Control & Financial Management had achieved a Significant Level of Assurance indicating that systems of control were operating effectively.

(vi) Penultimate Account – Cardiology Ward 4 POW

The Internal Audit Report into the Penultimate Account Audit for Cardiology Ward 4 POW was received and noted.

(vii) Final Account Audit – Coity EMI Ward, POWH

The internal audit report regarding the final account audit for Coity Clinic’s EMI Ward was received and noted.

(viii) Human Tissue Act Follow Up Report (Limited Assurance)

The follow up review regarding Human Tissue Act issues within Pathology was received. A limited level of assurance had been achieved in respect of the follow up report and Mr M Williams welcomed Mr R Rooke to the committee to discuss the findings. In discussing the findings, the following issues were highlighted: - The follow up review illustrated that there had

been progress in many areas since the original review (undertaken within the former Swansea NHS Trust). However, there remained certain actions that needed to be taken. In particular, there was a need to redesign and implement documentation systems to improve consistency in records management. These issues were inextricably linked to systems used by the Coroner’s Officer. In this respect, a meeting had been arranged for 20th March 2009 and Mr

5

Campbell indicated that he wished a member of the Executive Team be present at the meeting. Mr M Williams also confirmed that he wished to attend if his diary would allow.

Resolved that the report be noted and that the key issues needed to be resolved within the period of the next four weeks and that this matter be put on the agenda for the next meeting to provide an update to the committee regarding compliance within the original sites and on a Trust wide basis. A report would also be submitted to the Operational Board around consent issues in order that Directorates were fully aware of the action that needed to be taken.

RR RR

(ix) Musculo-Skeletal Directorate (Limited Assurance)

The internal audit review report regarding the Musculo-Skeletal Directorate was received.

A limited level of assurance had been achieved. Therefore, Mr M Williams welcomed operational colleagues to the Committee. In discussing the report, the following issues were highlighted:

- It was noted that the KRONOS system had allowed staff to electronically sign off their own attendance and the Committee was reassured that the new iteration of the system would not permit this. Steps had been taken by staff and management to improve systems around procurement and authorisation issues and the operation of the Trust’s Sickness Absence Policy.

Resolved that bearing in mind the reassurances that had been given by operational colleagues, the report would be noted.

(x) Internal Audit Register

A report setting out the summary of the 2008/09 Audit Register was received. The Associate Director of Finance expressed concern that there were a large number of reports not yet finalised that needed to be submitted to the Financial Audit Committee as part of the agreed 2008/09 Internal

6

Audit Plan. Mrs O’Connor advised that whilst a number of draft reports had been issued, the delay in establishing the Directorate management structures had inevitably impacted on the process and this had been highlighted at the previous meeting. Mrs O’Connor confirmed to the Committee that all reports would be finalised and submitted in time for the next meeting in May 2009 Resolved that the Internal Audit Register report be noted.

(xi) Action Plans

A report setting out the Internal Audit Action Plans for the East Division for 2007/08 and 2008/09 for the Trust was received and noted.

13/09 EXTERNAL AUDIT MATTERS

(i) Wales Audit Office Report

The Wales Audit Office Report was received.

Noted that:

- The Accounts Audit had commenced. External Auditors also completed their review of the IFRS balance sheet and preparation and planning of the conversion was being progressed.

- The Wales Audit Office had a different view to the Trust with regard to how the issue of pay accrual should be handled for shift allowances incurred during March be paid in April. Mr E Williams stated that the Trust wished to continue in a consistent manner in terms of the way it dealt with its accounts and therefore would precede as in previous years.

- With regard to the ward staffing benchmarking review, Mr Wood asked how this aligned with budget setting. The Director of Finance advised that budgets would be rolled over initially, but that it would be necessary to recognise that outcome of this significant piece of work in due course, which may indicate the need for resource realignment.

- With regard to further local performance work, as detailed earlier in the agenda, there had been difficulties with regard to the HIW Healthcare

7

Standards evidence tool and Health Solutions Wales had been engaged to review the software. Mr Coe undertook to raise this issue with other Trusts in order that the Wales Audit Office were aware of the issues that this matter had raised across the Principality

- With regard to National Wales Audit Office value for money studies, Mr Michael Williams inquired whether Counter Fraud had been reviewed in terms of value for money issues. Mr Coe advised that the National Fraud Initiative gathered detail regarding amounts recovered.

(ii) External Audit Register 2008/9

The report confirming that an external audit register had been developed to monitor the delivery of external audit operational plans, receipt of draft and final reports and Trust responses to audit reports was received. Mrs K Jones advised at this stage there were no reports issued in draft and therefore no performance information to report to the Committee. Resolved that the report be noted.

(iii) External Audit Action Plan

The report setting out the External Audit Action Plan was received and noted.

14/09 CAPITAL & PFI AUDIT MATTERS

(i) Progress Report The Capital and PFI Audit Plan Progress Report for the

period up to 25th February 2009 was received. Noted that overall, good progress had been made against the plan within the agreed parameters, with all field work due to be completed by the end of June 2009. Resolved that the report be noted.

(ii) Intermediate Care Services at Cimla The Audit report regarding Intermediate Care Services at

Cimla Hospital was received. A significant level of assurance had been achieved. Resolved that this report be noted.

8

(iii) Welsh Centre for Burns & Plastic Surgery Development

The Audit report for the Welsh Centre for Burns & Plastic Surgery Development received. A significant level of assurance had been achieved. Resolved that this report be noted.

(iv) Healthcare Vision Phase 1A – Infrastructure and Enabling

The Audit report regarding Healthcare Vision Phase 1A, Infrastructure and Enabling, was received. A significant level of assurance had been achieved. Resolved that this report be noted.

(v) Capital & PFI Audit Register 2008/09

The report setting out the summary of the 2008/09 Capital & PFI Audit Register was received and noted.

(vi) Capital & PFI Audit Action Plans

The report setting out the current status of the action plans agreed with the Capital & PFI audit for 2007/08 for the East Division and the Capital & PFI for 2008/09 for the Trust was received and noted.

15/09 OTHER STATUTORY MATTERS

(i) Provision of a Single Lease Car Scheme for ABM Trust

The report setting out proposals for the establishment of a common lease car scheme for all staff hosted by the Trust was received.

Mr M Williams welcomed Mr Quirk to the meeting and the following issues were highlighted:

- The former Bro Morgannwg NHS Trust had operated its lease car scheme internally whilst the former Swansea NHS Trust had franchised out this service out to the Ambulance Trust

- The report set out three clear options and details of how the revised lease car scheme could be administered and funded. By creating a single lease car scheme, it was estimated that the Trust could make significant savings per vehicle.

9

- Staff were endeavouring to align insurance provision with those that existed with the scheme that was in place in the East Division and this would bring further benefits in terms of insurance fees, the cost for which would be spread across the pool.

There was some discussion regarding whether if staff did not wish to move to a lease car scheme they would continue to be reimbursed for their expenses at public transport rate. The Director of Finance stated that this was his understanding under NHS rules. Mr Williams invited Dr Thomas on behalf of Staff Side to send him any documentary evidence supporting any contrary interpretation.

Mr Coe suggested that it might be helpful for the Trust to reference a past report undertaken by the Wales Audit Office on Fleet Management issues.

In response to a question posed by Mrs O’Connor, Mr Quirke advised that estate vehicles were to be included in the scheme. Dr Thomas warned that there might be some issues to consider over insurance as certain vehicles carried radioactive materials.

The Report was received and supported in principle on the understanding that there were some further issues to work through.

(ii) Counter Fraud

The report summarising the activities of the local Counter Fraud Specialist during the period of January to March 2009 and progress against the relevant action plan was received.

(iii) Review of Debtor Balances

Schedules setting out the review of debtor balances over 12 weeks old and in excess of £20,000 for NHS balances and £1000 for non NHS balances within East and West Divisions were received and noted.

(iv) Review of Creditor Balances

Schedules setting out the review of creditor balances over 60 days old and in excess of £20,000 for NHS balances and £1000 for non NHS balances for East and

10

West Divisions were received and noted.

(v) Losses and Special payment report

The losses and special payment report for the period 1st December 2008 to 31st January 2009 for East and West Divisions were received and noted.

(vi) Single Tender Actions

The report setting out single tender actions for the period 1st January to 28th February 2009 and a summary report to date were received and noted. The identity of the company involved in the tender to support a software tool around the Equality and Outcomes Framework had been omitted from the report in error. The identity of the company would be sought and reported under matters arising at the next meeting.

KJ

(vii) Single Tender Quotations

The report setting out the single tender quotations for the period 1st January to 29th February 2009 were received and noted.

(vii) Extension to Contract Demolition Works, Glanrhyd Hospital, Bridgend

The report detailing the contract for the demolition of redundant buildings at Glanrhyd Hospital as part of the Modernisation of Mental Health Services Project was received.

In discussing the report it was noted that this provided the detail as to the background to the decision to extend the contract of Cuddy Demolition and the Standing Order provisions followed.


(ix) Hospitality Register 2008/09

As at 28th February 2009, a report setting out the hospitality register for the above period was received.

(x) Annual Accounts Update 2008/09 The report providing an update to the Committee

regarding the Trust’s preparation for the 2008/09 Annual Accounts closure process was received.

11

Resolved that the report was noted.

(xi) Financial Control Procedures 2009/10 The report updating the committee as to progress

against the financial procedure review plan in readiness for the single ledger due to operate on 1st April 2009 was received. Resolved that the report be noted

(xii) Financial Audit Committee Terms of Reference & Workplan 2009/10

The report highlighting the committee’s terms of reference, which were due for annual review was received. In discussing the report it was noted that :

– At a Trust Board meeting in December 2008, the Chairman had presented a report in relation to nominations that had been received from staff side for approval of the Board in terms of increasing the membership of Board Sub Committees.

– In terms of the Financial Audit Committee

workplan for 2009/10 – Item 16, bearing in mind the Trust would cease to exist from September 2009, it was suggested that this issue needed to be brought forward to the May 2009 meeting.

Resolved that the Terms of Reference which would now include Staff Side representation in terms of its membership been approved and that the Financial Audit Committee work plan be amended as suggested.

(xiii) Financial Risk 2009/10

A report advising the Audit Committee of key financial risks for 2009/10 and action being taken to avoid or minimise these risks was received. In discussing the report the following points were raised:

– a detailed review of the 2009/10 key financial risks had been carried out by senior Governance, Planning and Finance colleagues and an appended schedule provided details for Audit Committee members to consider.

12

– – Work had also been carried out to determine the

optimum cost avoidance/minimisation strategies to reduce the financial risk wherever possible.

Resolved that the schedule of key risks for 2009/10 be agreed for submission to the Trust Board for final agreement prior to it being utilised as the initial 2009/10 risk schedule for regular monitoring through the Trust Board and Welsh Assembly Government.

KJ

(xiv) Standing Orders 2009/10 The report outlining the approach for the review of

Standing Orders in readiness for 1st April 2009 was received. Resolved that the Financial Audit Committee approved the proposed approach to review Standing Orders for 2009/10.

(xv) Grant Thornton Internal Audit Contract 2009/10 The letter from Grant Thornton confirming their contract

with the Trust was to cease was received. Mr Williams confirmed that following the usual annual review, Grant Thornton had determined they would not seek an additional year’s internal audit contract with the Trust and would therefore cease to provide such services with effect from 31st March 2009. Representatives from Grant Thornton would attend the next meeting of the Financial Audit Committee to present work completed in the final weeks of their contract. With a view to contingency arrangements, consideration was being given to expanding the Trust’s internal audit team until October 2009. The Committee was asked to indicate support in principle for this in order that a formal report could be compiled for the next meeting setting out how this proposal would work. Resolved that the Financial Audit Committee supported this proposal in principle with a view submission of a detailed proposal paper being put forward at the next meeting.

PO’C


Oral Report

13

The Acting Chief Executive reported that the Palestinian Society for South Wales had contacted the Welsh Assembly Government regarding the issue of fees for NHS treatment. The Welsh Assembly Government had indicated it wished to encourage Trusts to apply NHS rates. Resolved that the oral report be noted and that this matter would be the subject of further discussion between the Chief Executive and the Director of Finance.

Mr Goulding advised that whilst he or his partner Geraint Davies would attend the next meeting, this was the final attendance of Ms Angela Ryan. The Committee took the opportunity to wish Ms Ryan well and Mr E Williams conveyed his personal thanks for her assistance over the years.

Congratulations were offered on behalf of the Financial Audit Committee to Win Griffiths on becoming Chairman of the new organisation.

17/09 DATE & TIME OF NEXT MEETING

The next meeting will be held on Friday 5th June 2009 in the Boardroom, THQ commencing at 10am.

14


MINUTES OF A MEETING OF THE FINANCIAL AUDIT COMMITTEE

HELD ON TUESDAY 5th MAY 2009 AT 1.30 pm IN THE BOARDOOM, THQ

Present: Mr M Williams Non-Executive Director (Chair) Mr R Francis-Davies Non-Executive Director Mr P Wood Non-Executive Director In Attendance:

Mrs K Jones

Associate Director of Finance (Corporate)

Mrs P O’Connor Head of Internal Audit Mr N Thomas Internal Audit Office Mr T Roberts Local Counter Fraud Specialist Dr W Thomas Staff Side Representative Mr C Stradling Engagement Partner, Wales Audit Office Mr M Coe Audit Manager, Wales Audit Office Mrs W Penrhyn-

Jones Associate Director of Corporate Affairs (Administration)

Mr G Davies Partner, Grant Thornton Mr H Richards Capital & PFI Audit Services Mr I Phillips Associate Director, I M & T (for minute 21/09 iv) Mr M Turner Financial Resources Manager (for minute 21/09 iv) Mrs C Moseley Performance Project Manager, WAO (from minute 21/09 iv) Mr H Richards Senior Audit Manager, Capital & PFI (from minute 23/09)

18/09 APOLOGIES FOR ABSENCE Action

Apologies for absence were received from Mr D Davies, Non-Executive Director, Mr E Williams, Finance Director, and Mr C Campbell, Acting Chief Executive


Mr R Francis-Davies declared an interest in any items related to the City and County of Swansea.

20/09 MINUTES

a) Financial Audit Committee

The Minutes of the meeting of the Financial Audit Committee held on 10th March 2009 were received and confirmed as a correct record, subject to the following amendment:

Minute 11/09 (i): Financial Audit Committee

“The minutes of the meeting of the Financial Audit Committee held on 20th January 2009” (rather than 10th March 2009).....

1

12/09 Internal Audit Matters

(i) Progress Report

“...The Chief Executive had written to Mr Peter Higson (as opposed to Hickson) at HIW ...”

Matters Arising

12/09 Internal Audit Matters

(viii) Human Tissue Act Follow Up Report

Internal Audit Services was asked to undertake a review of Pathology Services in relation to the Human Tissue Act, and bring the report back to a future meeting when completed. The Chief Executive would be asked to provide an update to the Financial Audit Committee at its next meeting, regarding the meeting that had taken place on 20th March

2009 with the Coroner’s Office.

PO’C/NT

CC

13/09 External Audit Matters

(i) Wales Audit Office Report

With reference to the difficulties experienced with the software provided for the purpose of HIW Healthcare Standards annual process, Mr Coe advised that WAO Auditors in Wales were aware of this issue and that other organisations had also experienced problems with the system. A remedy was being sourced via Health Solutions Wales.

(vi) Single Tender Action

The identity of the company involved in the tender to support a software tool around the Equality and Outcomes Framework, which had been omitted the paper submitted to the previous meeting of the Committee was noted to be “NSD Informatics”.

(xiii) Financial Risk 2009/10

Mrs K Jones confirmed that a schedule of key risks for 2009/10 had been submitted to the April 2009 Trust Board meeting for final agreement.

16/09 Any Other Business

In the absence of the Acting Chief Executive and the Director of Finance it was not possible to provide an update regarding the issue of fees for NHS treatment. The Director of Finance would update the Committee in June EW

2

2009.

b) Healthcare Governance Committee

The Minutes of the meeting of the Healthcare Governance Committee held on 2nd February 2009 were received and noted.

The Committee had requested a further paper be submitted on the issue of Criminal Records Bureau Checks. The 1000 Lives Campaign was continuing to make excellent progress. Mr M Williams commented that he had recently been present at a celebratory with clinical staff on Anglesey Ward, Morriston Hospital, where they had been able to demonstrate the benefits of their work around the prevention of pressure sores.

c) Capital Investment Committee

The Minutes of the Capital Investment Committee held on 25th March 2009 were received and noted.

The extensive capital value of the ABM Capital Programme was noted to be delivering significant benefits to the Welsh economy.

d) Hosted Agencies Governance Sub Committees (DSU, NLIAH/CEHR/IHC)

The Minutes of the meeting of the Hosted Agencies Governance Sub Committee held on 5th March 2009 were received and noted.

OTHER STATUTORY MATTERS

(i) Counter Fraud work within ABM University NHS Trust

The report to advise the Committee of activities undertaken by the Local Counter Fraud Specialist for the financial year ended 31st March 2009 was received.

Mr Roberts reminded the Committee that regular progress reports had been submitted during the financial year. This information had now been brought together to form the 2008/09 Annual Report.

(ii) Counter Fraud Work Plan 2009-10

The report regarding the proposed Counter Fraud Work Plan for the year commencing 1st April 2009 and the Local Counter Fraud Specialist response to instructions from the Counter Fraud & Security Management Service Quality Assurance Directorate with regard to the implementation of the Work Plan was received.

In introducing the report Mr Roberts commented that, whilst Abertawe Bro Morgannwg University NHS Trust would remain a statutory body until September 2009 and the Work Plan covered the period 2009-10, there was a need for it to remain flexible to

3

take account of the new LHB organisation post-October 2009. Counter Fraud issues were currently serviced via the Business Service Centre in respect of the LHBs and would need to be consolidated to meet the needs of the new ABM University LHB. Within the Work Plan, the Committee noted that there were areas that would be subject to LCFS review within the initial months of the financial year and again post-October 2009.

Resolved that:

− The Local Counter Fraud Specialist Annual Report 2008-09 for ABM University NHS Trust be noted.

− The content of the Work Plan be approved and guidance issued by the CFSMS supporting the LCFS recommendation to standardise Trust claim forms be noted.

21/09 INTERNAL AUDIT MATTERS

a) Internal Audit Annual Report 2008-09

The report produced by the part-provider of the Trust’s Internal Audit Service (Grant Thornton) summarising the outcome of the Internal Audit Reviews for the period 1st April 2008 – 31st March 2009 was received.

In introducing the report Mr Davies advised that the Annual Report would support the Trust’s Statement of Internal Control. Based on the split of Internal Audit work, Grant Thornton had focussed on reviewing financial systems, and the in-house Internal Audit team had reviewed operational processes. The Annual Audit Plan had been kept flexible in order that audit resources could be directed to specific areas of work as risks and priorities changed during the year.

The most recent changes to the 2008-09 Plan were set out within the Annual Report and the Committee was asked to ratify these.

Mr Davies advised the Committee that, based upon the findings of work undertaken during the year and acknowledging the context in which the Trust had operated during this 12-month period, the Risk Management, Control and Governance processes covered by the various reviews had been adequate, effective and sufficient to enable the Board and the Accountable Officer to rely on the Internal Control System. Mrs O’Connor advised that the Accountable Officer was currently seeking assurance via individual Directorates regarding the development of the governance mechanisms throughout the organisation.

Resolved that the final changes to the 2008-09 Plan be ratified.

b) Internal Audit Service

The report setting out details of existing arrangements for Internal Audit Services, the anticipated shortfall in available audit days to

4

deliver the proposed Audit Plan for 2009-10 and recommendations to resolve this was received.

Mrs O’Connor highlighted the following key points:

− The Trust already had an established Internal Audit Service.

− The three LHBs commissioned their Internal Audit Service via this department and had done so since 2003.

− The political expectation via the Welsh Assembly Government was that all NHS Internal Audit Services should be provided within the NHS itself rather than through contracts with external private providers.

In discussing the report it was noted that there were a number of possible solutions. Bearing in mind the costs associated with the Grant Thornton contract would be re-invested into the Trust it would be possible to look to recruit additional staff to support the existing Internal Audit team on a fixed-term basis. Mrs O’Connor advised that a separate paper on this matter was due to be submitted to the Financial Governance Work Stream.

Resolved that approval be given for the opportunity to externally recruit be explored whilst also given the opportunity for internal employees to express and declare an interest in two fixed-term appointments.

c) Internal Audit Strategy 2009-10

The paper setting out progress with regard to the development of a Model Internal Audit Strategy for NHS Wales outlining proposals for ABMU NHS Trust was received.

There was a requirement to standardise assurance ratings on individual audits and an approach was emerging reflecting the system in use by the Welsh Assembly Government. This corresponded closely with the one in use by ABMU NHS Trust. The only term which would change would be that reflecting the current ABMU Assurance of “Significant” which would change to “Adequate”.

Resolved that the Committee noted ongoing work on the financial aspects of governance project work, approved the continuation of the current Terms of Reference and Strategy for the provision of Internal Audit Services by ABMU Internal Audit for 2009-10 and agreed the adoption of Audit Assurance Terminology as proposed in the paper for all work undertaken under the 2009-10 Plan.

d) Telecommunications : Mobile Phones (Limited Assurance)

The Internal Audit Review Report regarding Telecommunications (Mobile Phones) was received. A Limited Level of Assurance had been achieved, therefore, Mr M Williams welcomed Mr Ian Phillips, Associate Director of I M & T and Mr Malcolm Turner,

5

Financial Resources Manager to the Committee.

In discussing the report the following issues were discussed:

− Mr Phillips gave assurances that the Directorate of I M & T and Performance were in the process of implementing a single process around the issue of mobile phones and were engaging with financial colleagues over the necessary resource controls. The document would detail all relevant issues including reimbursement of personal calls by staff.

− Itemised billing was already available for matters relating to the former East Division and, once this had been standardised across the Swansea locality, costs associated with calls could be handed over to Directorates to manage locally. I M & T and Performance would retain responsibility for managing tariff issues.

− The Trust currently had more than one provider due to variations in reception across the locality.

In discussing the report there was reference to the possible commercial benefits of aerial masts being sited on the Trust’s grounds. Mr W Thomas reminded colleagues of the alleged risks associated with such masts.

Mr M Williams commented that he would be interested to see the outcome of a review into the use of Blackberry technology within ABM. It was further suggested by Mr Wood that consideration should be given to the issue of telecommunications being a subject that needed to be considered as part of the Transitional work in preparation to moving towards establishing ABMU LHB.

Resolved that, bearing in mind the reassurances that had been received from Directorate colleagues, and the robust nature of the proposed action plan, the report be noted.

e) Pathology Directorate (Limited Assurance)

The Internal Audit Review Report on the Pathology Directorate was received. A Limited Level of Assurance had been achieved; therefore, Mr M Williams welcomed Mrs Sally Buckland-Jones, Directorate General Manager and Mr Richard Bowmer, Financial Resources Manager, to the Committee.


− With regard to the coding issues identified, a plan was being developed to review the source coding and a member of staff had been identified to take this piece of work forward.

− The issue around completion of salary cards and hours worked had occurred in one department and this had been dealt with immediately with a new authorisation process being put in place.

6

− The Directorate took on board the issues identified around management of annual leave and sickness absence leave. Mrs Buckland-Jones advised that, whilst the Directorate maintained it had been following due process, it had not been able to substantiate this by means of documentary evidence. Appropriate action had been taken to address this.

Resolved, bearing in mind the reassurances that had been given by colleagues the report and action plan were noted.

f) Directorate Reviews, Cancer, Mental Health, Anaesthetics & Critical Care, General Surgery and Renal Surgery (Limited Assurance)

The Internal Audit Review Report regarding the above Directorates was received. A Limited Level of Assurance had been achieved and therefore Mr M Williams welcomed Sian Passey, Paul Sussex, Paul Baker and Linda Bevan to the meeting.

In discussing the report the following issues were highlighted:

− Directorates expressed disappointment at the outcome of the Internal Audit findings, however, they planned to use the report findings to reinforce the systems that were already in place to address the various issues.

− Mr Wood questioned whether the issue of staff building up time in lieu was widespread. It was acknowledged that such issues needed to be managed robustly and that appropriate audit trails needed to be in place.

− With regard to the payments made to staff involved in waiting list initiative clinics, it was noted that the Trust was currently negotiating an ABM level payment with staff.

Resolved that, bearing in mind the reassurances that had been offered by operational colleagues and the content of the proposed action plans, be noted.

g) Learning Disabilities Directorate (Significant Assurance)

The Internal Audit Review Report regarding the Learning Disabilities Directorate was received.


h) Transport : Private Ambulances & Taxis (Significant Assurance)

The Internal Audit Review Report regarding Transport issues was received.

In discussing the report, Mr Wood sought clarity around the rationale for the difference in use of the vehicles. Mrs O’Connor

7

advised that this was primarily due to the nature of the regional services provided within the Swansea locality. Mr Wood requested that further detail be provided on this issue at the next meeting of the Committee in June 2009. PO’C

i) Final Account Audit : Refurbishment of Physiotherapy Department, Princess of Wales Hospital

The Internal Audit Review Report on the above Final Account of the Refurbishment of the Physiotherapy Department at Princess of Wales Hospital was received and noted.

j) Claims Management WRMS Internal Audit Review (Significant Assurance)

The Internal Audit Review Report regarding Claims Management (WRMS) was received.

The report noted that Internal Audit had not reviewed the self-assessment to avoid duplication of work, but that the WRP had confirmed the assessment scored Claims Management at 75%.


k) I M & T Directorate (Significant Assurance)

The Internal Audit Review Report regarding I M & T Directorate was received and noted.

l) NLIAH Funded Student Allowances (Limited Assurance)

The Internal Audit Review Report regarding Review of controls and systems in place within Universities to administer NLIAH funded student allowances was received. A Limited Level of Assurance had been achieved and therefore Mr M Williams welcomed Mr A Butler, Director of Finance, NLIAH, and his colleague Mr A Lewis, Acting Chief Executive, to the meeting.

In discussing the report the following issues were highlighted:

− Mr Butler advised the Committee that the review had been undertaking at the request of NLIAH and had been restricted to reviewing and assessing the controls and procedures in operation at 3 of the 6 Universities used by NLIAH.

− There had only been two minor findings in respect of NLIAH’s responsibilities.

− NLIAH had responsibility for the management of the non-medical education budget used to support more than 6,000 students within the NHS and this was primarily used to pay Universities for student fees and the salaries of staff, as well as bursaries. During the past month, NLIAH representatives had met with each of the Universities included in the audit to share the findings and had received a commitment from the

8

respective Deans to improve systems.

− NLIAH would be seeking the approval of WAG in order to obtain Ministerial approval to re-issue current HEIs as well as to request a fundamental review of systems to give assurance they were fit for purpose. A Stakeholder Group would be overseeing this work.

In discussing the report Mr Wood questioned the student drop-out rate. Mr Butler advised that within Wales it was expected that some 15% of students would cease to complete their course by the third year. This percentage was higher within England.


m) WHS Contract Monitoring Report (Full Assurance)

The Internal Audit Review Report regarding WHS Contract Monitoring was received and noted.

n) Duplicate Payments (Full Assurance)

The Internal Audit Review Report regarding Duplicate Payments was received and noted.

o) Consolidation Process – 2nd Review (Full Assurance)

The Internal Audit Review Report regarding the Second Process Review – Consolidation Process was received and noted.

p) Asset Management (Full Assurance)

The Internal Audit Review Report regarding Asset Management was received and noted.

q) Debtors Management (Significant Assurance)

The Internal Audit Review Report regarding Debtors Management was received and noted.

r) Consultant Contract Follow up (Significant Assurance)

The Internal Audit Review Report regarding Consultant Contract Follow up was received and noted.

s) Payroll and Expenses (Significant Assurance)

The Internal Audit Review Report regarding Payroll and Expenses was received and noted.

t) Final Account Audit : Fire Alarm Installation – Tonna Hospital

The Internal Audit Review Report regarding the Final Account Audit : Fire Alarm Installation – Tonna Hospital was received and noted.

9

u) Penultimate Account Audit : Electric Installation including Patient Cameras / Safety System – Tonna Hospital

The Internal Audit Review Report regarding the above system was received and noted.

v) Final Account Audit : Gamma Camera – Princess of Wales Hospital

The Internal Audit Review Report regarding the above Final Account Audit was received and noted.

w) Final Account Audit : Boiler and Plate Exchanger Installation – Tonna Hospital

The Internal Audit Review Report regarding the above Final Account Audit was received and noted.

x) Internal Audit Register

A report setting out a summary of the 2008-09 Audit Register was received.

It was noted that the majority of reports had been received within the required timescale.

Resolved that the Internal Audit Register Report was noted.

y) Internal Audit Action Plans

A report setting out the Internal Audit Action Plans for the former East Division was received and noted.

22/09 EXTERNAL AUDIT MATTERS

a) Wales Audit Office Report

The Wales Audit Office Report was received.

Noted that:

− The report contained a record of progress in concluding the agreed programmes of work in 2008-09 Abertawe Bro Morgannwg University NHS Trust and also tracked the completion of Performance Reviews coming to a close from previous years’ plans and provided an update on National Welsh Audit Office Value for Money studies.

− The Internal Audit Review was nearing completion.

− External Audit intended to bring a strategy to the next meeting of the Committee regarding the first six months Audit Plan for 2009-10 for ABM.

MC

− The final page of the report provided a summary of reports

10

that had been recently published.

In discussing the report Mr Ceri Stradling advised that Wales Audit Office had produced a guide covering all the relevant themes in terms of the NHS Reorganisation and it would be for Auditors to work with the Transitional Boards to ensure that all the necessary issues were covered and to re-visit such issues after the new LHBs had been developed.

With reference to the issue of Pay Modernisation, Mr Wood questioned the wording contained within this particular topic.

Mr Wood suggested that the wording should not have hypothesised that there would be intended benefits. This was taken on board.


b) Performance Audit

The paper identifying a number of areas which the Wales Audit Office had agreed with the Director of Finance they could now proceed with in terms of local performance projects was received and noted.

c) External Audit Action Plans

The report advising the Committee of the status of each of the Action Plans agreed with External Audit for 2005-06 and 2006-07 for the former East Division and for 2007-08 for ABM Trust was received and noted.

23/09 CAPITAL & PFI AUDIT MATTERS

a) Audit Plan Progress Report

The Capital & PFI Audit Plan Progress Report for the period up to 22nd April 2009 was received.

In introducing the report Mr Richards advised that work was due to commence imminently on the Mental Health Modernisation Project and Capital Systems. A full update would be provided to the next meeting of the Committee with regard to the Caswell Clinic Project.

HR

Overall, good progress had been made against the plan within agreed parameters.


b) Capital & PFI Audit Annual Report 2008-09

The above Annual Report had allowed Capital & PFI Audit Services to give Significant Assurance on the design adequacy and effectiveness of the system of Internal Control of the areas

11

tested at the Annual Plan.

Resolved that the Annual Report be received.

c) Designed for Life: Building for Wales – Central Audit Management Protocol

The Central Audit Management Protocol which aimed to complement specific audit risk assessments was received.

d) Capital & PFI Audit Register 2008-09

The report providing the summary extract of the 2008-09 of the Capital & PFI Audit Register as at 23rd April 2009 was received.

Resolved that the status of the Capital & PFI Audit Register be noted.

e) Capital & PFI Audit Action Plans

The report setting out the current status of the Action Plans agreed with Capital & PFI Audit for 2007-08 for the former East Division and Capital & PFI for 2008-09 for the Trust was received and noted.

24/09 OTHER STATUTORY MATTERS

a) Review of Debtors Balances as at 31st March 2009

A schedule setting out a Review of Debtors Balances over 12 weeks old and in excess of £20,000 for NHS balances and £1,000 for non-NHS balances within the former East and West Divisions were received and noted.

b) Losses & Special Payments

The Losses & Special Payments Report for the period 1st February to 31st March 2009 for the former East and West Divisions was received and noted.

Mr Thomas noted that the report referenced damage having occurred to a Linear Accelerator at Singleton Hospital. Mrs Jones undertook to bring further details back to the next meeting. KJ

Resolved the report was noted.

c) Losses – Write-off of Expired Stock

The report providing details of expired stock, which needed to be written off in accordance with the Welsh Assembly Government Guidance on Losses and Compensation, was received.

It was noted that the category of loss had a delegated limit of £50,000, whereas the specific stock item was valued at £29,161.

12

Resolved that the Committee noted the actions being taken by the Trust’s write-off the cost of this expired stock in the financial year ending March 2009.

d) Single Tender Action

The report setting out Single Tender Actions for the period 1st March – 31st March 2009 and a Summary Report to date were received and noted.

e) Single Tender Quotation

The report setting out Single Tender Quotations for the period 1st March – 31st March 2009 was received and noted.

f) Hospitality Register 2008-09

As at 20th April 2009 a report setting out the Hospitality Register for the above period was received.

g) Standing Order Review 2009-10

The report setting out the proposed amendments to the Standing Orders and supporting schedules was received.

Resolved that the proposed amendments be recommended to the Trust Board for approval.

h) Any Other Business

There was no other business.

i) Date and time of next meeting

The next meeting would take place at 10.00 am on 5th June 2009.

13

ABM UNIVERSITY TRUST

HEALTHCARE GOVERNANCE COMMITTEE

Minutes of the Meeting of the Healthcare Governance Committee held on Monday 6th April 2009 at 0900 hours in the Board Room,

Trust Headquarters

Present: Robert Francis-Davies, Non-Executive Director (RFD) (Chair) John Collins, Non –Executive Director (JC) Paul Wood, Non-Executive Director (PW)

Barry Goldberg, Non-Executive Director (BG) In Attendance: Dr. Bruce Ferguson, Medical Director (BF) Victoria Franklin, Nurse Director (VF) Debbie Morgan, Director of IM & T and Performance Improvement

(DM) Mrs Liz Rix, Acting Director of Risk Management (LR) Dr. Sharon Evans, Associate Medical Director – Clinical Audit (SE) Dr Barry Statham, Associate Medical Director, Patient Safety (BS)

Paula O’Connor, Head of internal Audit (POC) Phil Spivey, Deputy Director of HR (PS) Dr Geoffrey Carroll, Medical Director, Health Commission Wales (GC) Mrs Gillian Davies, Bridgend CHC (GD) Mrs Mary Watkins, Neath & Port Talbot CHC (MW) Nicola Williams, Associate Nurse Director, Governance & Safeguarding (NW) Stephen Wade, Clinical Director, Learning Disabilities Directorate (SW) Linda Davies, POVA Facilitator (LD) Chris Jones, Associate Medical Director – Operational, Cardiology (CJ) Kathryn Lewis, Head of Safeguarding Children (KL) Lesley Bevan, Associate Nurse Director, Workforce Modernisation & Re-design (LB) Dawn Davies, Associate Director of Corporate Services, Redress (DD) Philippa Rees, RCN, Lead Steward and Staff-Side Chair – East Paul Sussex, Head of Nursing, Mental Health Directorate (PS) Chris Jones, Directorate Manager, Mental Health (CJ)

AGENDA ITEM

ACTION

18/09 APOLOGIES FOR ABSENCE Apologies for absence were received from Calum Campbell, Geraint

1

Evans, Steve Combe, and Professor Stephen Bain.

19/09

MINUTES OF THE LAST MEETING HELD ON THE 2ND

FEBRUARY 2009 Accuracy – The Committee agreed that the minutes were an accurate reflection of the meeting that had been held on the 2nd February 2009. Matters Arising- 17/09: VF reported that Wyn Griffiths confirmed that David Davies has been identified as the NED Lead for the Empowering Ward Manager Programme.

20/09 PATIENT STORY – SETTING THE SCENE BF introduced an audio-taped patient story that is intrinsically linked with a number of the agenda items. The patient had been within an HDU area and how the noise and environment had affected him.

21/09 1000 LIVES CAMPAIGN The Saving 1,000 Lives Campaign Update Paper was received. The paper provided an update of progress made in the development of Directorate Saving 1,000 Lives spread plans and summarised the progress made in taking forward three new interventions launched by the Campaign/Trust:

• Surgical Glycaemia Control • Improving Patient Identification • WHO Safer Surgery Checklist

SE identified that all interventions required adequate nursing levels. VF advised that action was actively being taken in relation to alignment of Nurse Staffing levels across ABM University Trust. Appendix 1 to the report was missing. NW to email out. PW requested to know the national guidelines regarding baby tags. BF to ascertain and feedback at the next meeting. A Trust-wide policy regarding the use of baby tags was required. VF to discuss with Head of Midwifery. Discussion ensued regarding the use of the NHS number. BG requested to be involved in future patient safety walkrounds.

NW

BF

VF

NW

2

The Committee noted the paper and requested feedback on the above items at the next meeting.

22/09 MENTAL HEALTH DIRECTORATE CLINICAL GOVERNANCE ASSURANCE PRESENTATION The Mental Health Directorate Clinical Governance Assurance paper was received. Paul Sussex, Head of Nursing and Chris Jones, General Manager, Mental Health Services Directorate provided the Committee with a PowerPoint presentation highlighting the key components of the clinical governance arrangements that have been put in place within the Mental Health Directorate and each of the individual Service Groups. It was identified that within Mental Health the Patient Experience was central to what they do – it was acknowledged that the ethos across mental health was to ‘do simple things better’. The following key points were raised:

• Directorate Healthcare Clinical Governance Structure outlined with six sub-groups to address all relevant clinical governance components.

• Harmonisation of policy and procedures across Mental Health

Services is being undertaken on a risk basis.

• Detailed information in relation to the Audit Sub-Group was provided.

• Dementia Services were discussed and the increasing

demand that was being put onto them. The professional plan to address this was shared with the Committee.

• Innovative practice outlined: o shared care ward - crisis resolution has recently won

awards • Areas needing improvement:

o Eating Disorder Services o Early Intervention Service

BS raised concerns regarding the difference in environment between units identified during 1000 Lives Walkrounds. Particularly concerns regarding mental health areas. CJ provided assurance that the Action Plan is being developed within the area of concern and there are new premises being built.

3

The Committee:

• Thanked the Directorate Team for the Presentation • Noted that the Mental Health Directorate is as big, if not

bigger, than some Mental Health Trusts in England. • Thanked the Directorate for the report and presentation.

23/09 PROTECTION OF VULNERABLE ADULTS – AN OVERVIEW

Linda Davies, POVA Facilitator, provided the Committee with a PowerPoint presentation overview of POVA requirements. Safeguarding Adults. The presentation outlined:

• An overview of the SWAP Forum • Safeguarding Adults Team • DLM Structure • Training • Who a vulnerable adult is • Categories of abuse – financial abuse being the largest area

– above 50% • All Wales percentage figure above 37%. Increased across

Wales and reflected in Trust with referrals up by the same amount

• Training Compliance The Committee expressed Concerns regarding number of staff who have received the mandatory training and the resources for POVA – paper outlining number of staff trained and plan for rolling out training and resources required requested at the next meeting. A copy of the presentation to be provided. LD was thanked for her presentation. Links with University for training to be fully explored.

VF

NW

24/09 HEALTHCARE STANDARDS SELF-ASSESSMENT REPORT The Healthcare Standards Self-Assessment Report was received. The report outlined to the Committee the current position in relation to the 2008/2009 HIW Self-Assessment. The significant problems the Trust had in relation to the tool were discussed.

4

The Committee noted the report.

25/09 HEALTHCARE INSPECTORATE WALES REVIEW UPDATE REPORT The HIW Review Update Report was received. The report provided a summary of:

• The unannounced visits undertaken since the last meeting • Summary of key findings and action plan developed following

the Substance Misuse inspection • Status report against the Infection Prevention and Control

action plan provided at the last meeting. POC advised the Committee that following spot checks will link into the Healthcare Standards. Delays in the reports coming from HIW was discussed. NW to Write to HIW formally to HIW regarding these reports. The Committee noted the report.

NW

26/09 HUMAN TISSUE ACT INTERNAL AUDIT REPORT The Human Tissue Act Internal Audit Report was received. The report outlined the key findings of the Internal Audit Human Tissue Act follow-up audit undertaken by Internal Audit and compliance to date with the action plan. The Committee noted the report.

27/09 SAFEGUARDING UPDATE REPORT The Safeguarding Children Update Report was received. The report outlined a summary of a serious case review report that had been received. The current status of all ‘open’ serious case reviews position in relation to School Nursing identified issues for health in Lord Lamings review (March 2009). The Committee noted the paper.

NW

28/09 LEARNING DISABILITIES FOLLOW-UP REPORT The Learning Disabilities Follow-up Report was received. SW presented the paper providing an update since the last meeting and advised that an update had been provided to HIW on behalf of

5

all partner organisations with no response to date. The major issues were:

• Lack of access to CHAMS – refusing to see children with learning disabilities

• Children with complex needs with significant learning disabilities

The Committee suggested the involvement of the Children’s Commissioner.

29/09 CRB CHECK UPDATE PAPER The CRB Check Update Paper was tabled at the meeting. The paper outlined the current statistics and categories of CRB checks. The concern was that staff in post before 2002 had not had a CRB check. The new legislation due in November 2009 was outlined. PS reported that the process for Independent Safeguarding Authority checks is still being worked through. The risk of not undertaking the CRB checks on existing staff was discussed. Concerns were expressed that the Trust is not compliant with WAO recommendations. The Committee:

• Noted the paper but did not accept the recommendation • Requested that all maternity CRB checks are undertaken

immediately and other staff checks through a phased approach/rolling. Report back to Trust Board.

• Acknowledged the financial implication.

PS

30/09 NURSING WORK FORCE PLAN The Draft Briefing Report into the Nursing Resource was received. The Committee were advised that a review nurse staffing levels had been undertaken in December 2008 and an action plan developed to realign staffing areas in five quality areas was discussed. The five directorates have been meeting with the Executive Board recently to develop plans to raise staffing levels. The Committee were advised that there was no national guidance in relation to the number of nursing staff on ‘normal wards’, only the

6

following specialist areas: ITU/Burns/Paediatrics/Midwifery. The Committee were advised that the priority is to identify where we are, what has been achieved, that priority areas are identified and that these are addressed as a matter of urgency. The Committee noted that the use of bank and agency staff very high and that it is envisaged that these actions will lower considerably this bank and agency spend.

VF

VF

31/09

CLINICAL EFFECTIVENESS STEERING GROUP The Clinical Effectiveness Steering Group paper was received. The paper advised the Committee of the establishment of a Trust Clinical Effectiveness Steering Group, which would advise of the clinical governance arrangements in relation to new interventional procedures. The prepared new interventional procedure in relation to Percutaneous Aortic Valve Replacement – the first procedure being to take place at the end of April 2009. The Committee noted the paper.

32/09 LOCAL SUPERVISION MIDWIVES REPORT The Local Supervision Midwives Report was received. The report outlined on how ABMU Trust is doing against the All Wales position. The Committee noted the paper.

33/09 NURSING CLINICAL SUPERVISION The Nursing Clinical Supervision paper was received. The paper provided a summary of the current status of nursing clinical supervision across the Trust. The Committee noted the paper.

34/09 DONATION COMMITTEE REPORT The Donation Committee Report was received. The Committee noted the paper.

35/09 SIGNIFICANT DEVELOPMENTS IN ON-GOING CLAIMS The Significant Developments in On-going Claims paper was

7

received. The Committee:

• Noted the paper • Identified concerns regarding the detail within the paper and

confidentiality of this stressed. DD to clarify this further. • To look at how such sensitive information is provided in the

future. JC offered to support. The Committee noted the paper.

36/09 CHKS REPORT A verbal report outlining what action the Trust is taking in relation to reviewing clinical patient outcome data was received. The current trend graphs were presented to the Committee via a PowerPoint Presentation. Group set up to analyse. Further report to be provided at the next meeting and then at future meetings on a regular basis.

BF

37/09 MEDICINES MANAGEMENT AND CONTROL DRUG ACTION PLAN UPDATE REPORT The Medicines Management and Control Drug Action Plan Update Report was received. The Committee noted the report and action plan.

38/09 HEALTHCARE PREMISES ENVIRONMENT REPORT The Healthcare Premises Environment Report was received. The paper provided actions agreed following the HPE inspections undertaken in 2008. An audit report regarding nursing linen to be presented at future meeting. The Committee noted the report.

NW

39/09 DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS) The Deprivation of Liberty Safeguards paper outlining how the Trust meeting the DOLS legislation was received. The key issue in relation to training and specific actions outlined.

8

The Committee noted the report.

40/09 RESEARCH AND DEVELOPMENT POLICIES The amalgamated Research and Development Policies in relation to:

• Intellectual Property • R&D Adverse Events Policy • Financial Policy and Procedure

were received by the Committee. The Committee endorsed the policies.

41/09 SAFEGUARDING CHILDREN POLICIES AND STRATEGIES The Committee received the:

• Safeguarding Children Training Strategy • Safeguarding Children Training Policy • Safeguarding Children Strategy • Safeguarding Children Guidance • Safeguarding Children Support Policy • Safeguarding Children Information Sharing Policy • Resolution of Professional Differences Procedure

The Committee:

• Commended the information sharing components of the policy

• Ratified the endorsed policies & procedures

42/09 ANY OTHER BUSINESS Directorate Presentations The paper outlining proposed timing of Directorate Presentations was received and ratified.

43/09 NEXT MEETING The next meeting will be held on Monday 1st June 2009, 0900-1200 in the Boardroom at Trust Headquarters.

9

1

Report Prepared by: Nicola Williams, Associate Nurse Director, Governance & Safeguarding Hazel Abbott, Associate Director of Corporate Affairs, Risk Management Report Sponsored by: Steve Combe, Director of Corporate Affairs Victoria Franklin, Nurse Director Bruce Ferguson, Medical Director

TRUST BOARD 10th JUNE 2009

Agenda Item: 18

HEALTHCARE GOVERNANCE COMMITTEE REPORT

1. PURPOSE The purpose of this report is to provide the Trust Board with a summary of key Governance and quality outcomes as reported to the Healthcare Governance Committee on the 1st June 2009. This report provides information on the following areas:

• Risk Management; • Infection Prevention & Control; • Assurance presentations from the Women & Child Health and Muscular Skeletal

Directorates; • Safeguarding; • Quality Standards; • Sub-Committee Updates; • Professional Registration; • Clinical Audit & Effectiveness Plan; • Policy & Procedure ratification;

2. INTRODUCTION

The Healthcare Governance Committee has devolved responsibility for providing assurance in relation to the quality and safety of care provided across the Trust. This paper summarises the key Governance and Quality outcomes provided to the Healthcare Governance Committee. In addition to the items included in this paper the Healthcare Governance Committee also received assurance reports in relation to the Saving 1,000 Lives Campaign, the 2008/2009 Healthcare Standards submission and the end of year position against the Healthcare Standards Quality Improvement Plan which are being reported to the Board separately and are therefore not included in this paper.

3. RISK MANAGEMENT

Risk Management Report The Risk Management report outlined delivery to date against the Trust Risk Management Strategy that since its ratification had been circulated to Directors (Clinical and Non-Clinical) and made available to staff via the intranet. A template Directorate Risk Management Strategy and Template Business Continuity Plan had been distributed and Directorates, via the quarterly risk management update, will be required to report on progress against the development and implementation of these documents.

2

The Risk Management Report provided the Committee with the present position in

relation to the Corporate Risk Register outlining key risks facing the organisation in 2009/2010. The Corporate Risk Register will be further developed following feedback from Executive Directors and as risks are escalated from the Clinical Directorates for initial discussion and assessment at the Trust Risk Management Group.

The new Trustwide Datix system has been installed and is being used in a pilot to manage the Corporate and Directorate Risk Registers and will be subject to formal evaluation prior to being rolled out Trust wide. Core Training A paper outlining proposals following a review of statutory and mandatory training across the Trust was received and endorsed.

4. INFECTION PREVENTION & CONTROL The Committee received a comprehensive report outlining a summary of key activity and outcomes in relation to infection prevention and control for the period January – March 2009. The key elements of the report are summarised below:

1000 Lives Campaign

Significant work has been undertaken to progress the Reducing Healthcare Associated Infection (HCAI) content areas of the campaign.

Hospital Infection Surveillance Programmes

The report outlined the Trust’s participation in a number of National Infection Control Surveillance Programmes:

Mandatory Surveillance Programmes

• Surveillance of Clostridium difficile associated diarrhoea- For the first time, the National Public Health Service of Wales report in April 2008 presented the incidence of C. difficile in patients > 65 years per 1000 admissions for ABM during the period 10/01/2008 to 31/12/2008 was 11.94. This is below the All-Wales incidence of 17.05 per 1000 admissions.

• Surveillance of Staphylococcus aureus bacteraemia - the 30th Report from the NPHS was published in February 2009. The incidence for ABM Trust, as a whole, was benchmarked with other Welsh Trusts and shows that the incidence of total Staph. aureus bacteraemia within ABM Trust between October 2007 and September 2008 had reduced to 22/100,000 bed days, which is below the All Wales rate (25/100,000 bed days). The incidence of MRSA bacteraemia within ABM Trust is the same as the All Wales rate at 9/100,000 bed days.

Mandatory Infection Reduction Programme Trusts were required to identify their local infection reduction targets in January 2008, when ABM remained two separate Trusts. A summary of progress against each area was provided to the Committee.

3

Mandatory Surgical Site Infection (SSI) Surveillance

• Caesarean Section- The recent NPHS report, for the period 01/01/08 to 31/12/08 (compliance data 01/01/08 to 30/09/08), identified that average compliance with the surveillance in ABM Trust during this period was 76% to maintain compliance with surveillance and to decrease infection rates through the implementation of a number of the 1,000 lives reducing surgical complications interventions.

• Orthopaedic SSI (Joint replacement surgery) - The recent NPHS report, for the period 01/01/08 to 31/12/08 (compliance data from 10/01/08 to 30/09/08), identified that compliance with the surveillance in ABM Trust was 35.53% (69.40% All-Wales compliance). The overall Trust compliance is affected by the non-compliance with the surveillance within Morriston Hospital. Measures have been put in place by the Musculo-Skeletal Directorate to fully meet the requirements. Some improvement has been noted compared to previous years. This is being closely monitored through performance review.

• Bacteraemia in Intensive Care - In the recently published report on this

surveillance scheme, results between 01/01/2008 to 31/12/2008 show the Trust is performing significantly better than the Welsh National average.

• Critical Care Ventilator Associated Pneumonia- In the recently published report on this surveillance scheme, results between 01/09/2008 to 31/01/2009 show the Trust has had zero infections of this nature compared with a Welsh average of 1.2 per 1000 ventilated days.

Localised Surveillance of “Alert Organisms”

Work to align alert organism surveillance across ABM is almost complete. All Localised “Alert Organism” Surveillance data was provided to the Committee. The key areas to highlight are summarised below: • Although the quarterly totals for new MRSA isolates fluctuate, there has been a

steady downward trend within Bridgend and Neath & Port Talbot Hospitals. • The incidence of “alert organisms” within Morriston Hospital has shown a

relatively steady decline. Outbreaks of Infection

Between January and March 2009, there were 49 outbreaks of infection within the Trust, involving 503 patients and 160 staff. All were enteric (gastro-intestinal illness, e.g. diarrhoea and/or vomiting) outbreaks. All outbreaks would have involved bed closures. During all outbreaks there is close collaboration with the Bed Management Teams, to ensure that service provision is maintained, utilizing risk assessment and management processes. Education in Infection Prevention & Control for all Healthcare Staff The delivery of Infection Prevention and Control Mandatory Education Programmes continued across the Trust.

4

Mandatory training is being reviewed Trust-wide. Consequently, a review of Infection Prevention and Control training is being undertaken. Hand Hygiene Trainers Initiative Between April 2007 and December 2008, the Infection Prevention and Control Nurses have trained more than 171 Hand Hygiene Trainers (HHTs) from all Directorates. Between them, these HHTs have trained more than 770 staff in the correct technique for hand hygiene. Decontamination of Medical Devices The Decontamination of Medical Devices sub group of the Infection Control Committee has met. The aim of the group is to ensure on behalf of the Infection Control Committee that the Trust is fully meeting its duty in relation to ensuring appropriate decontamination of equipment.

5. DIRECTORATE ASSURANCE PRESENTATIONS / REPORTS

The Committee received a report and presentation from the Senior Directorate Teams within the Women & Child Health and Muscular Skeletal Directorates. The reports / presentations provided the Committee with assurance in relation to the Healthcare Governance infrastructures and reporting mechanisms that had been put in place within the Directorates as well as an overview of the key Directorate risks and action being taken to address them and some key Governance outcome data.

6. SAFEGUARDING

Safeguarding Adults Training The Safeguarding Adults Training update report was provided to the Committee which mapped out the level of compliance against each level of training and the action being taken to enhance compliance. The Committee acknowledged the work that was being undertaken across the Trust in this respect and endorsed the prioritisation model proposed. Serious Case Review Update Report The Committee received a summary of the recent serious case review reports that had been received from across the ABM locality. Care Quality Commission Review into Baby P The Committee received for information the key points arising from the Care Commission review of the involvement and action taken by health bodies in relation to the case of baby P” in May 2009. The Committee were advised that the Trust’s Named Professionals were undertaking a full internal review of this which would be reported back to the Committee once completed.

7. QUALITY STANDARDS

Clinical Outcomes A report outlining the proposals for monitoring benchmarked clinical outcome data across the Trust was received and endorsed.

5

Nursing Metrics The Nursing Metrics report provided the Healthcare Governance Committee with a summary of progress made to date in implementing the Ward – Board Nursing Metrics. This is the subject of a separate report to the Performance Management Committee.

8. SUB COMMITTEE UPDATES

The Committee received an update report from a number of its sub-committees which are outlined below: Thromboprophylaxis & Anticoagulation Committee This was the second Thromboprophylaxis Committee report received which outlined action taken to date to ensure compliance with best practice / national guidance in anticoagulation and prevention of venous embolism such that published by the National Patient Safety Agency and the National Institute for Health and Clinical Excellence. The report outlined that the Committee also serves as the steering group for two elements of the 1000 Lives Campaign; Deep Vein Thrombosis (DVT) Prophylaxis in surgical patients and the safe use of Warfarin.

Critical Care Delivery Group

• This inaugural paper advised the Committee of the establishment of the Trust Critical Care Delivery Group, and outlined the purpose and objectives of the Group. The Quality Requirements for Adult Critical Care in Wales, issued by the Welsh Assembly Government in 2006, include as a core requirement for achievement that every Trust must form a multi-disciplinary “Critical Care Delivery Group” that has patient representation and a clear reporting mechanism to the Trust Board.

Transfusion Committee This inaugural report advised the Committee of the proposals to establish a Trust wide Transfusion Committee

9. PROFESSIONAL REGISTRATION

A paper was provided to give assurance to the Healthcare Governance Committee that there are robust processes in place to ensure that all Professional Staff (Nursing, Medical & Allied Health Professional) are registered with the appropriate professional body. The paper outlined that it is the primary responsibility of individual professional staff members to ensure that they maintain up to date registration with the relevant professional body. However, the Trust has a responsibility to ensure that staff employed has a current and valid professional registration. The process for ensuring that staff within each professional group is registered with the appropriate professional body was outlined. The Committee also received and endorsed the General Medical Council (GMC) Registration Policy.

10. 2009 / 2010 CLINICAL AUDIT & EFFECTIVENESS PLAN

The 2009 / 2010 Clinical Audit & Effectiveness Plan is an essential part of the Trusts internal assurance framework. The Plan meets the Trust’s objectives as outlined within the Clinical Audit & Effectiveness Strategy (participation in National Audits, audits of compliance against national guidance and assurance of compliance with legal and best practice standards) as well as reflecting directorate risk based priorities. The plan was

6

endorsed by the Healthcare Governance Committee. A copy of the Plan is available on request.

11. POLICY AND STRATEGY RATIFICATION

The Healthcare Governance Committee received and ratified the following Trust wide policies and strategies:

• Consent Policy • Resuscitation Policy • Health Records Strategy

12. OTHER REPORTS / INFORMATION RECIEVED

The Committee also received the following papers:

• Proposed Professional Structure of Psychological Services – outlining a proposed professional framework for the delivery of Psychological services across ABM Trust which was endorsed.

• Patient Stories- outlining how the Trust is, in conjunction with the 1000 Lives Campaign driving forward the use of patient stories as a key mechanism for capturing the experiences of those using our services, relatives, partners and carers who support them. The stories have been used to date to open each Healthcare Governance Committee, for internal conferences, to drive forward the work of each of the 1,000 lives project boards and as part of staff induction training.

• Nursing Work force plan- a progress status report was provided outlining action that had been undertaken to realign nurse staffing levels across the Trust. The Committee noted that a significant number of posts had been recruited to within the Directorates of Medicine, Cancer, Muscular Skeletal and General Surgery.

13. CONCLUSION

This is the formal Healthcare Governance report provided to the Trust Board. It is envisaged that this will be an evolving paper that will brief the Board on the key outcomes from a quality and governance perspective that are reported through and monitored by the Healthcare Governance Committee.

14. RECOMMENDATIONS The Trust Board is asked to note the foregoing.

REPORT PREPARED BY: Mrs Lucy Thomas Consultant Recruitment Officer REPORT SPONSORED BY: Dr Bruce Ferguson - Medical Director


AGENDA ITEM: 19

APPOINTMENT OF CONSULTANT MEDICAL STAFF 1. INTRODUCTION

The appointment of consultant medical staff to the Trust is a responsibility of an Appointments Committee, under the chairmanship of a lay member of the Trust Board.

2. ADVISORY APPOINTMENTS COMMITTEES 2.1 Consultant Physician in Respiratory Medicine

Funding stream: (Replacement post)

An Appointment Committee met on 12th May 2009, under the Chairmanship of Mr Win Griffiths, Chairman, to consider the appointment of a Consultant Physician in Respiratory Medicine.

The Committee recommended the appointment of Dr Martin Sevenoaks with effect from a date to be confirmed.

3.0 RECOMMENDATION

The Trust Board is asked to confirm the appointment of Dr Martin Sevenoaks The Following Locum Consultants have also been appointed: Locum Consultant Physician in Diabetes and Endocrinology

Locum Consultant Anaesthetist

Locum Consultant Cardiologist

Locum Physician in Elderly Care

Appointment of Consultant Medical Staff Executive Board Meeting – February 2009 1

Report Prepared by: Liz Rix Director of Patient Safety Report Sponsored by: Steve Combe Director of Corporate Affairs


Agenda Item: 20

CLAIMS MANAGEMENT

1. PURPOSE

To set out proposals to establish a Claims Management Sub Committee to allow the Board to discharge its responsibilities with regard to Claims Management.

2. INTRODUCTION

At the last Board meeting the most appropriate mechanism for ensuring the Claims process within the Trust was monitored effectively was discussed. This report sets out proposals for the arrangements, following further discussions between Mr John Collins Non Executive Director, Liz Rix, Director of Patient Safety and Steve Combe, Director of Corporate Affairs.

3. PROPOSALS It is proposed that a Sub Committee of the Healthcare Governance Committee is established to carry out this function. The proposed membership and terms of reference are attached at Appendix 20.1.

4. RECOMMENDATION

Directors are asked to: • consider and, subject to amendment approve the terms of

reference of the Claims Management Sub Committee, • confirm the Non Executive membership of the Sub Committee

Claims Management Trust Board 10th June 2009

1

APPENDIX 20.1 Membership and Terms of Reference – Claims Management Sub Committee INTRODUCTION

The Welsh Risk Pool standard for Claims Management is audited annually. The purpose of this standard is to ensure that the organisation has an effective process for managing claims made by patients and staff, which is linked, to both the complaints and incident reporting system and that the conditions for the operation of the delegated authority for settlement of claims to a limit of £1million are met by NHS organisations. Efficient and early handling of claims can have a significant positive effect on the financial, professional and reputational well-being of organisations and the physical and emotional well-being of their patients.

REQUIREMENTS

The standard requires the organisation to demonstrate that it has a designated Executive Board member with responsibility for Claims Management issues, who keeps the Board informed of all significant issues pertaining to the Trust’s claims profile and claims handling record. This can be achieved where an Executive Board member can demonstrate the delivery of a reporting specification to the Board or a duly authorised delegated committee, demonstrated via the Trust’s scheme of delegation. There must be reports on claims to this duly authorised committee by the designated Board member, advising of key issues and/or major issues or developments affecting the organisation. TERMS OF REFERENCE

The Sub Committee will:

• Receive and analyse reports at a level which will enable the Committee to form a view of emerging trends and the organisation’s claims profile generally.

• Ensure an identification and analysis report of patterns and trends

in all reported claims is produced for the Risk Management Committee and Board on a regular basis (e.g. quarterly).


2

• Ensure there are appropriate linkages between directorates to ensure lessons are learned and that claims management is viewed as part of a wider governance approach including, complaints management, risk management, clinical audit and incident reporting

• Ensure relevant information and feedback on reports is circulated at

all management levels within the organisation. Such feedback should include information on the actions taken to reduce or eliminate reported claims, and any changes in working practices.

• Review individual high cost claims to provide appropriate advice to

the Healthcare Governance Committee and trust Board. MEMBERSHIP The Sub Committee will comprise of:

• 2 Non Executive Directors, one of whom should Chair the Sub Committee and should also be a member of the healthcare governance Committee.

• The Director of Corporate Affairs as the Executive Board member responsible for Claims management

• The Director of Patient Safety • The Medical Director or nominated deputy • The Nurse Director or nominated deputy

REPORTING The Sub Committee will report to the Healthcare Governance Committee. Where appropriate the Chair of the Committee will bring matters to the attention of the Board directly. MEETING ARRANGEMENTS The Sub Committee will meet on a quarterly basis as a minimum. It will be supported by the Associate Director of Corporate Affairs – Redress.


3

____________________________________________________________________________________________________________ Ministerial Letters 1


REPORT PREPARED BY: Steve Combe, Director of Corporate Affairs REPORT SPONSORED BY: Steve Combe, Director of Corporate Affairs


AGENDA ITEM: 21

MINISTERIAL LETTERS ISSUED APRIL – MAY 2009

Number Title Date of Letter

021/08 Assessment Unit Activity 15/05/09

003/09 National Performance Report 2009/2010 08/05/09

006/09 Emergency Department Data Set (EDDS) 03/04/09

007/09 Human papillomavirus (HPV) vaccination catch-up campaign 05/05/09

010/09 Welsh Guidelines for the Transfer of the Critically Ill Adult 08/04/09 (Received 07/05/09)

014/09 Revised Cross Border Protocol 01/04/09

Affixing of the Common Seal 1


REPORT PREPARED BY: Steve Combe Director of Corporate Affairs REPORT SPONSORED BY: Steve Combe Director of Corporate Affairs


AGENDA ITEM: 22

AFFIXING OF THE COMMON SEAL 1. PURPOSE

To report on documents to which the Common Seal has been affixed since April 2009.

2. INTRODUCTION

In line with Standing Orders a routine report on documents to which the Common Seal has been affixed is required.

3. REGISTER OF SEALINGS

Attached at Appendix 22.1 are details taken from the Seal Register. All documents have been signed by the Chairman, or Vice Chairman, and an Executive Director, in line with the requirements of Standing Orders.

4. RECOMMENDATION The Board is asked to note the foregoing.



Appendix 22.1

REGISTER OF SEALINGS

Register No Date Name of Document

504 3/4/09 Baglanmoor Healthcare Plc – Amended and Restated Agreement Collateral / Supplemental Agreement Deed of Novation

505 7/4/09 Alterations to Ward 3, Princess of Wales Hospital

506 15/4/09 Lease Rental YMCA office, Barry

507 16/4/09 Clydach Primary Care Centre Lease

508 16/4/09 Morriston Hospital Medical School Library Mezzanine – M & E Consultants

509 16/4/09 Singleton Hospital – Additional Car Parking Area 3 – Contractor

510 16/4/09 Cefn Coed Hospital – OT Department Alterations - Contractor

511 21/4/09 Cwmbwrla Clinic – Methadone Dispensing Facilities – Contractor

512 21/4/09 Singleton Hospital – Day Surgery Gutter Repairs – Contractor

513 21/4/09 Transfer of Land at Baglan Way, Neath Port Talbot Hospital

514 21/4/09 Disposal of Clydach Health Centre

515 21/4/09 Morriston Hospital – New Fire Alarm System – Phase 3 – Contractors

516 29/4/09 Supplemental Sub Lease – Baglan Moor Hospital

517 29/4/09 Collateral Deed – Laundry & Linen Service Agreement for Neath Port Talbot Hospital

518 29/4/09 Deed of Amendment and Novation

519 29/4/09 Clydach Primary Care Centre Lease 21st April 2009 – Stamp Duty Land Tax Return



520 14/5/09 Morriston Hospital – Medical Records Development – Services Engineer

521 19/5/09 Singleton Hospital – 4th LINAC – Architect / Lead Consultant

522 19/5/09 Morriston Hospital – Alterations to Jubilee Suite – Contractor

523 19/5/09 Reshaping Mental Health Services for Swansea