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Trust Board Meeting

The Boardroom, Trust Headquarters, Hereford Thursday 1st October 2015, 10.00 a.m. – 12.00 noon

AGENDA – PART A – (IN PUBLIC) Page No: 10.00 Patient Story 10.20 1. Apologies for Absence CTB

2. Declarations of Interest CTB

3. To approve the minutes of the meeting held on : (i) 27th August 2015 Part A

CTB

3 - 10 4. Matters Arising from the Board Meeting held on 27th August

2015 CTB

11 - 12

Items for Discussion

10.25 5. Chief Executive Update CEO 13 - 14

10.35 6. Chief Inspector of Hospitals High Level Feedback CEO Verbal

10.45 7. Board Assurance Framework CS 15 - 28

10.50 8. Performance and Progress Summary Exception Reports: (a) Key Performance Indicators DFI 29 - 32 (b) Quality & Safety DNQ 33 - 40 (c) Operational Performance COO 41 - 45 (d) Finance DFI 46 - 54 (e) Workforce DPD 55 - 64 11.15 9. Nurse Staffing Monthly Report DNQ 65 - 69

10. Nurse Agency Spend Rules DFI 70 - 72

Items for Approval

11.20 11. Finance & Performance Committee Terms of Reference CFPC 73 - 78

11.25 12. Appointments to Committees CTB 79 - 81

11.30 13. NHS Trust Development Authority Self Certification CS 82 - 89

Items for Information

11.35 14. Committee Meetings:

(a) Quality Committee (b) Finance & Performance Committee (c) Remuneration Committee

CQC CFPC CRTSC

To Follow - 90 To Follow - 91 Verbal

11.45 15. Any Other Business

11.50 16. Questions from Members of the Public arising from the agenda (see Guidance)

17. Date of next meeting in Public: Tuesday 3rd November 2015 at 9.30 am

Exclusion of the Press and Public - Having resolved that representatives of the press and other members of the public be excluded from Part B of the meeting due to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. Section 1(2), Public Bodies (Admission to Meetings) Act 1960. *The Chairman should be advised of any matters to be raised under “Any Other Business” before the meeting.

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FOR INFORMATION ONLY

The following matters are to be considered in Part B of the Board meeting held in private:

• Declarations of Interest to items on the Agenda. • The minutes of the Extraordinary Board Meeting held in private 20th August 2015 • The minutes of the meeting in private of 27th August 2015. • Matters Arising from the meeting in private of 27th August 2015. • Chief Executive Update report • Operational Plan • Confidential matters arising from routine meetings of subcommittees. • Confidential matters arising from routine performance reports and or service delivery. • Confidential report on staff suspensions. • Meeting effectiveness Feedback

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MINUTES OF THE TRUST BOARD MEETING

HELD ON 27 AUGUST 2015 PART A – IN PUBLIC

Present: Mr Museji Takolia, CBE (TC) (Trust Chairman) Mr Jon Barnes (COO) (Chief Operating Officer) Mr Richard Beeken (CEO) (Chief Executive) Ms Michelle Clarke (DNQ) (Director of Nursing & Quality) Mr Andrew Cottom (NED) (Non-Executive Director) Dr Susan Gilby (MD) (Medical Director) Reverend Christobel Hargraves (NED) (Non-Executive Director) Mr Richard Humphries (NED) (Non-Executive Director) Mr Howard Oddy (DFI) (Director of Finance & Information) Mr Mark Waller (NED) (Non-Executive Director) In Attendance:

Mrs Maureen Bignell (DPD) (Director of People & Development) Ms Shirley Collin (ACHS) (Acting Community Hospital Sister) – For the Patient Story Ms Nicola Licence (CS) (Company Secretary) Ms Anna Llewellin (LN) (Lead Nurse) – For the Patient Story Dame Julie Moore (CE UHB) (Chief Executive, UHB) – For Observation Right Honourable Jacqui Smith (C UHB) (Chair, UHB) – For Observation Mrs Val Jones (EA) (Executive Assistant for the minutes)

The Trust Chairman (TC) welcomed and introduced the Right Honourable Jacqui Smith (Chair) and Dame Julie Moore (Chief Executive) from University Hospitals Birmingham NHS Foundation Trust (UHB) to the meeting, who were observing the Trust Board. A001/08.15 PATIENT STORY The TC welcomed Shirley Collin, Acting Community Hospital Sister (ACHS) and Anna Llewellin,

Lead Nurse (LN) for Community Hospitals to the meeting. A presentation was given regarding the end of life care received by a patient who had been admitted to the Emergency Department and subsequently transferred to Leominster Community Hospital, lessons learnt and actions taken were also described within this presentation. In response to a question raised regarding if the patient’s experience represented the Trust’s values, the ACHS advised that it did not as the patient was not in their chosen place to die. The Director of Nursing & Quality (DNQ) noted the challenges faced providing domiciliary packages in rural areas. Actions implemented following this event included a Day Care Room being developed into an “End of Life Room” and having a doctor on the ward for 5 hours a day. The TC thanked the ACHS and LN for their presentation.

A002/08.15 1. APOLOGIES FOR ABSENCE There were no apologies.

A003/08.15 2. DECLARATIONS OF INTEREST AND QUORACY There were no declarations of interest and the meeting was quorate.

A004/08.15 3. MINUTES OF THE MEETING HELD IN PUBLIC ON 30 JULY 2015 The TC noted the constructive feedback given following the attendance at the previous meeting from the Director of Corporate Affairs from UHB.

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RESOLUTION: The minutes of the 30 July 2015 Trust Board meeting held “in public” were APPROVED as an accurate record.

A005/08.15 4. MATTERS ARISING FROM THE BOARD MEETING HELD ON 30 JULY 2015

There were no matters to discuss.

A006/08.15 5. CHIEF EXECUTIVE UPDATE The Chief Executive (CEO) presented his report and the following points were noted: • The CEO highlighted the proposed closure of Bromyard Community Hospital (BCH) inpatient

ward with effect from 11 September; a decision taken purely on patient safety grounds and concerns to safely staff the unit with the required number of staff.

• A meeting would be held with local GPs on 18 September who provided cover for BCH and front line staff to discuss possible changes to the focus of the unit. Discussions would include potentially specialising the unit to encourage more staff to work at BCH.

• Local stakeholders and staff had all been personally contacted by Board Directors regarding the proposed closure prior to the public announcement.

• Proposals made by staff regarding changes in ways of working were being reviewed to prevent the proposed temporary closure.

• The TC noted the public engagement regarding this matter with the number who attended the recent event held at Bromyard.

• Following a question raised regarding the numbers of patients attending BCH, the CEO advised that of the 14 beds, around a ¼ were occupied by residents of Bromyard and surrounding areas.

• A pre-inspection from the Trust Development Authority (TDA) was held on 11 August at the Trust. The subsequent report produced a list of “quick wins” which the Trust could complete prior to full inspection in September.

• The DNQ noted that nursing staff had welcomed the assurance that the review gave alongside the recognition of their efforts to achieve the improvements made.

• Following the “Focus on Flow” (FOF) week, a significant improvement had been noted in three areas which the Chief Operating Officer (COO) would be taking forward: separate management and assessment of GP expected emergency referrals, enhanced clinical pharmacist provision on the wards to process discharge medications and supernumerary ward sisters responsible for the co-ordination of patient discharge.

• In response to a question raised regarding the costs of implementing the areas from the FOF week, the COO advised that the GP referrals would not involve any further costs, the pharmacy changes would carry costs as more staff would be required and the supernumerary ward sisters related to staffing shortages rather than purely a cost issue.

• The COO advised that an element of the outcomes achieved within the FOF week were “artificial” and could not be sustained due to the amount of extra effort given from staff and the different ways of working managed during that week.

• The prioritising of diagnostics was noted as an area that required improvement in the form of requesting tests on patients sooner rather than more tests being requested.

• Discussion was held on monitoring the improvements made to ensure that they were positively impacting on patient care via quality based measures and sustaining the performance to ensure that patients were treated in a timely manner.

A007/08.15 ACTION: Report to the Trust Board on the continued impact of the improvements made following

the “Focus on Flow” week using quality based measures – COO – November 2015 RESOLUTION: The Trust Board NOTED the Chief Executive’s update. A008/08.15 6. PATIENT CARE IMPROVEMENT PLAN (PCIP)

The CEO presented the report and the following key points were noted: • The format of the PCIP would need to be considered by the Trust Board after the feedback was

received from the re-inspection in September. • There were currently 24 outstanding actions, 10 of which would be completed by re-inspection. • There had been some success in recruiting to the vacant middle grade posts to Urgent Care,

noting that this was a national issue.

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• The Medical Director (MD) stated that a competitive package had to be offered to recruit staff to the hospital including highlighting the many benefits of working and living in Herefordshire.

• The Stroke Board had been well attended with a subgroup being set up to consider demand and capacity issues.

• The Director of People & Development (DPD) advised that the recruitment process had been streamlined with the time from appointment to start date reduced to 11 weeks; the target was to achieve 10 weeks.

• The risk of only having one substantive Stroke consultant in post was noted with interviews planned for a further substantive post in the near future.

• A review on improving mortality figures was ongoing with a meeting planned with UHB to consider further options.

• The MD stated that the standardised mortality indicators did not necessarily indicate poor care was being provided to patients and were retrospective figures. It would be several months before an improvement would be seen in the figures from work undertaken within the Trust.

• The Patient Led Assessment of the Care Environment scores for the Trust showed improvement from 2014 in most areas as well as against the average figures.

• In response to a question raised regarding the privacy, dignity and wellbeing score being low, the DNQ advised that the criteria changed each year which meant results could not be compared. Day Rooms for patients in Community Hospitals also being used as meeting rooms had reduced the score results alongside the lack of Day Rooms within the County Hospital.

• The Safety Thermometer figures were 98.1% for July, the best results recorded so far. • Following a question raised regarding patient privacy during consultations on wards, the MD

noted that in clinical situations where a patient could not be moved, clinicians were aware of the lack of sound proofing from curtains, with a letter recently sent to all clinicians reminding them of patient privacy and dignity.

RESOLUTION: The Trust Board NOTED the Patient Care Improvement Plan. A009/08.15 7. RISK MANAGEMENT AND BOARD ASSURANCE FRAMEWORK STRATEGY

The Company Secretary (CS) presented the report and the following key points were noted: • The Strategy and reporting structure had been amended to reflect the recommendations made

from the Governance Review undertaken earlier in the year. • Discussion took place around the Strategy, noting that it needed to clearly define which risks

were overseen by which Committees. • The CEO stated that different ways of working were required to ensure that risk management

did not become risk aversion. • A review of the risk appetite of the Trust was discussed with further discussion of this and the

Strategy at the Board Away Session.

A010/08.15 ACTION: To review the Risk Management and Board Assurance Framework Strategy and the Trust’s risk appetite at the Board Away Session to enable comprehensive discussions – CEO – November 2015

RESOLUTION: The Trust Board APPROVED the Risk Management and Board Assurance

Framework Strategy with the changes discussed. A011/08.15 8. FIT AND PROPER PERSONS TEST POLICY

The DPD presented the report and the following key points were noted: • The policy had been produced following new regulatory standards which came into place from 1

April 2015. • This policy covered Executive Directors (or equivalent) and Non-Executive Directors. • A discussion was held around the policy and a number of changes suggested.

RESOLUTION: The Trust Board APPROVED the Fit and Proper Persons Test Policy with the

changes suggested.

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A012/08.15 9. QUALITY COMMITTEE TERMS OF REFERENCE The Chair of the Quality Committee presented the report and the following key points were noted: • The Terms of Reference had been discussed in detail at the Quality Committee (QC) held in

August, with the updated version presented to the Trust Board. • It was noted that the review of the content and effectiveness of structures, systems and

processes also came under the remit of the Audit Committee. • The Terms of Reference were discussed and minor amendments agreed.

RESOLUTION: The Trust Board APPROVED the Quality Committee Terms or Reference with the

agreed amendments. A013/08.15 10. CAPITAL LOAN – EPR AND GENERAL CAPITAL

The Director of Finance & Information (DFI) presented the report and the following key points were noted: • The terms and conditions of the Capital Loan had been previously presented to the Trust Board

for discussion. • The loan was for £8.289m to fund investment into the Electronic Patient Record system and

financing essential capital schemes.

RESOLUTIONS: i. The Trust Board APPROVED the terms of the interim capital support loan. ii. The Trust Board APPROVED the nomination of the officers to execute and manage the

agreement. iii. The Trust Board APPROVED compliance with additional terms and conditions.

A014/08.15 11. NHS TRUST DEVELOPMENT AUTHORITY SELF CERTIFICATION

The CS presented the report and the following key points were noted: • There had been no changes made to the report from the previous month. • The Trust would declare that it was “at risk” of compliance in four of the Board Statements.

RESOLUTION: The Trust Board APPROVED the NHS Trust Development Authority Self

Certification. A015/08.15 12. PERFORMANCE AND PROGRESS SUMMARY EXCEPTION REPORTS (a) Key Performance Indicators

The DFI presented the report and the following key points were noted: • The DFI noted that a number of key national targets had not been met in July. • The tracker performance had been agreed with the TDA and NHS England. • Due to the delay in figures reported for the SHMI and HSMR, these areas would be removed

from the Effectiveness Domain. A016/08.15 ACTION: To remove the SHMI and HSMR from the Effectiveness Domain due to the delay in the

figures being reported - DFI – September 2015 RESOLUTION: The Trust Board NOTED the Key Performance Indicators report. A017/08.15 (b) Quality & Safety Summary Report

The DNQ presented the report and the following key points were noted: • There had been a reduction in the number of mixed sex breaches. • The number of Clostridium difficile cases had increased. Assurance had been received from the

Clinical Commissioning Group (CCG) that all actions had been taken. • Discussion took place around the benchmarking figures for the Performance Data. • In response to a question regarding the reduction in the Friends & Family (F&F) scores, the

DNQ advised that a detailed discussion took place at the QC regarding the reasons behind this dip.

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• F&F was noted on huddle boards to ensure discussion took place. • Bedside patient folders would be in place shortly which would contain the F&F form for

completion. RESOLUTION: The Trust Board NOTED the Quality & Safety Summary Report. A018/08.15

A019/08.15

(c) Operational Performance Summary Report The COO presented the report and the following key points were noted: • The Accident & Emergency figures were still below target but the COO was planning, with

strategies in place, to achieve the anticipated target for October. • In response to a question raised regarding the additional actions being put into place to improve

the trajectory for the Referral To Treatment Urgent Care pressures, the COO advised that the possibility of accessing providers outside of the Trust was being explored. The lack of theatre capacity was one of the main causes with the option for a temporary additional theatre being investigated.

• The COO confirmed that the work being carried out with the CCG regarding management of the waiting lists was progressing well.

• Discussion took place around the issues surrounding the number of patients attending Accident & Emergency and consequently being admitted to the wards.

• The breast symptomatic performance was still below the 93% standard. There had been no associated patient harm and this was being actively managed to improve the percentage.

• The Trust had achieved the 62 day cancer standard for the second month in a row. Question from member of the public: “Breaches of the 28 day readmission guarantee, (national) standard 5%, WVT actual, July 15%, YTD 27.5%. Can members of the Board explain to members of the public, exactly what this guarantee is, whether the figures for WVT are good or bad and why they have an amber rating?” The COO advised that of the 20 eligible patients, of those 17 were given a future date for their operation within the 28 days with only 3 failing this target which were of low clinical risk. All were offered a date with their preferred surgeon and none requested to be referred to an alternative provider. A red rating would probably have been more appropriate for this month.

RESOLUTION: The Trust Board NOTED the Operational & Performance summary report. A020/08.15 (d) Finance Summary Report

The DFI presented the report and the following key points were noted: • There had been gains on income in the month of July and the cost position has been held to the

in-month plan but the difficulties of achieving the Cost Improvement Plans (CIP) were noted. • An Extra-Ordinary Board meeting had been held to discuss the letter received by the TDA

advising the Trust that a £2.2m saving (to reduce the current deficit) needed to be made. The Trust’s response had noted the huge problems and challenges in achieving this saving with a £500k improvement being offered. A response was awaited.

• In-depth discussions regarding the financial situation had been held at both the Extra-Ordinary Board meeting and the Finance & Performance Committee.

• The CEO stated that following a robust process there were only two options available to the Trust to achieve the savings requested from the TDA: slow down routine activity and therefore reduce the associated outgoing costs (this would be counterproductive with the associated financial loss) or reduce costs to the Trust (eg via reduced nursing staff) which would have an impact on the safety and possibly quality of care provided to patients. The Trust Board were not happy to accept either of these options.

• In response to a question raised regarding the risk of the Capital loan request being refused, the DFI confirmed that the Trust’s bid had already been approved. In relation to the forthcoming bid for cash support, the DFI advised that, in response to the Auditors’ request for confirmation that the Trust were a going concern, the TDA had provided written confirmation to this effect and had encouraged the Trust to apply for such support.

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• The CEO noted the credibility issue if the Trust did not achieve the planned £18.4m deficit, advising that weekly meetings were held with the Executive Directors to review the CIP.

RESOLUTION: The Trust Board NOTED the Finance Summary report. A021/08.15 (e) Workforce Summary Report

The DPD presented the report and the following key points were noted: • The DPD noted that the workforce figures were provided from the Electronic Staff Record which

caused a time lapse in receiving the information. • The turnover of staff this month was slightly lower but was 14% for registered nursing staff which

made the Trust an outlier in this area. • Sickness absence had increased with stress (mainly none work related) the main cause of long

term sickness and gastroenteritis the main cause of short term sickness. • Staff were automatically referred to Health at Work if they were off work with stress. • In response to questions raised regarding how the Trust managed stress, the DPD advised that:

The Trust had signed up to become a Mindful Employer which was a voluntary agreement to support staff working within the Trust which enabled access to further counselling services.

Staff from Health at Work regularly visited areas within the Trust to talk to staff, putting resilience training into place if issues were noted.

Managers needed to highlight any concerns regarding their staff’s health (training was given as part of the Leaders Programme).

Private counselling was available through Staffside and the Health and Wellbeing Strategy.

No indicators for any concern had been raised in the staff survey. • There had been an increase to over 80% of staff completing their mandatory training and

appraisal. • The CEO advised that with a combination of recruitment of overseas nurses already registered

in the UK and overseas staff; this should mitigate some of the recruitment issues for the Trust and would over time reduce the use of agency staff.

RESOLUTION: The Trust Board NOTED the Workforce Summary Report. A022/08.15 13. REVALIDATION ANNUAL REPORT

The MD presented the report and the following key points were noted: • There had been a stepped change with compliance from the report presented the previous year. • It was agreed that the quarterly reporting of appraisal and revalidation issues would be

presented to the QC and updated to the Trust Board via the Chairman’s Summary Report. • Further trained case investigators were required as there was only currently one in post. • 95% of consultants had undergone an appraisal. • In response to a question raised regarding responsibility for locums, the MD advised that the

agency Responsible Officer covered short term locums with the MD covering for long term locums.

• The MD confirmed that all doctors working within the Trust were validated as the agency responsible for providing staff to the Trust produced a statement confirming validation for locums supplied.

A023/08.15 ACTIONS: i. The quarterly Revalidation Report would be presented to the Quality Committee for discussion –

MD – November 2015 ii. The Quality Committee Chairman’s Report to the Trust Board would include an update on

discussions held regarding the quarterly Revalidation Report – QCC – November 2015 RESOLUTION: The Trust Board APPROVED the “statement of compliance” within the

Revalidation Report.

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A024/08.15 14. COMPLAINTS ANNUAL REPORT The DNQ presented the report and the following key points were noted:

• A total of 12362 complaints had been received during the year. • There had been a reduction in the number of complaints upheld. • A Complaints Manager was now in post.

RESOLUTION: The Trust Board NOTED the Complaints Annual Report. A025/08.15 15. COMMITTEE MEETINGS (a) Quality Committee

RESOLUTION: The Trust Board NOTED the Quality Committee Report. A026/08.15 (b) Finance & Performance Committee

The Chair of the Finance & Performance Committee highlighted discussions held regarding the scrutiny of theatre support for the temporary mobile unit to augment the Trust’s theatre capacity with the caveats regarding anaesthetic availability.

RESOLUTION: The Trust Board NOTED the Finance & Performance Committee Report. A027/08.15 (c) Charitable Funds Committee

The Chair of the Charitable Funds Committee noted the following: • The number of funds had been consolidated to enable better use of funds. • A Fund Raising Manager was in post. • The Charitable Funds Committee minutes were draft.

RESOLUTION: The Trust Board NOTED the Charitable Funds Committee Report. A028/08.15 16. NURSE STAFFING MONTHLY REPORT

The DNQ presented the report and the following key points were noted: • The number of high dependency and palliative care patients being sent to BCH had been

stopped due to staffing issues. • Following a successful recruitment campaign, Leominster Community Hospital was expected to

have a full complement of qualified staff by September along with Hillside in the next few months.

• In response to a query regarding the nursing figures reported, the DNQ advised that agency nursing figures had to be included within the numbers. A quarterly report went to the QC of nursing numbers without this additional support.

• The Patient Flow Report was monitored by the DNQ with any areas of concern highlighted. • The CEO stated that although the staff fill rate at BCH matched a ward at the County Hospital,

these areas could not be compared as staff within the County Hospital could be moved around wards.

• Discussion took place around the difficulties to recruit to BCH, noting the fragility of a small bedded unit and a rural area. Newly qualified staff were expected to be in post in the next few months with agency and bank staff currently covering these roles.

• The Trust Board acknowledged the dedication and hard work given by nursing staff to ensure a high level of care was provided to patients.

A029/08.15 ACTION: To feedback to the nursing staff the Trust Board’s acknowledgement of their dedication and hard work to ensure a high level of care was provided to patients – DNQ – September 2015

RESOLUTION: The Trust Board NOTED the Nurse Staffing Monthly Report.

A030/08.15 17. Any Other Business

There was no other business raised.

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A031/08.15 18. QUESTIONS FROM MEMBERS OF THE PUBLIC “Regarding the pre-CQC inspection review – General Trust wide issues – concern regarding poor

response times from the Trust’s facilities management contractor under PFI. Can members of the Board please explain to the public, perhaps by giving a few of the more serious examples, these poor response times and the consequent implications for the hospital?” The DFI advised that regarding response times, the portering service was monitored against tight measures. If the question related to minor capital works, the Trust had been in dispute with our Private Finance Initiative (PFI) partners until last October which delayed works being carried out. Monthly liaison meetings took place but progress was slow. The DFI gave examples of these delays noting that the Trust and PFI partners were now working together to bring around improvements.

A032/08.15 “The figures for statutory and mandatory training and appraisal rates, target 90% for both, show a repeated failure to improve or reach targets. This problem has been raised at Public Board meetings previously, as it is a known problem of long standing and the difficulties associated with solving have also been listed before. Can members of the Board explain to the public why no apparent progress has been made in this area?” The DPD advised that the numbers of staff completing their mandatory training and appraisals had increased, noting that the Training Department had been previously outsourced and different computer systems used to record information. It had been found that training had occurred but had not been recorded with systems now in place to ensure that accurate reporting was recorded. The Pay Progression Policy (HR.82) stated that if statutory and mandatory training and an annual appraisal did not take place, staff would not receive their pay progression.

A033/08.15 “Related to the patient story – I am appalled that it was not possible to arrange care for the patient in question due to their rural location. What is the scale of the problem, who is doing something about this and what are the chances that this will be resolved? The CEO advised that due to the complexity of this situation it was very difficult to give an immediate answer. The MD would meet with the member of public to discuss this in more detail to provide reassurance.

A034/08.15 ACTION: To meet with the member of public to discuss and provide reassurance regarding patients’ receiving end of life care in their own home in rural locations – MD – August 2015

A035/08.15 “During the Board meeting in July, it was suggested that efforts should be made to actively “sell” the

hospital and the area to potential recruits to increase the number of applicants for vacant posts. Has any action taken place with regard to this?” The DPD advised of the following actions taken:

• With the assistance of UHB, the Trust was being rebranded. • Work had been carried out regarding Trust values. • The Trust’s website had been updated to include the positive reasons to work and live in

Herefordshire. • Discussions were underway with Staffside regarding offering incentives outside of Agenda

for Change to further encourage applicants.

A036/08.15

19. DATE OF NEXT MEETING – Thursday 1 October.

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Wye Valley NHS Trust

Trust Board Meeting

Action Log for meeting held on 1 October 2015

Part A – Board held in Public

Minute Ref May 2015

Action Deadline per minutes

Action by Outcome

A014/05.15 The Board to receive training in relation to Corporate Parent responsibilities

July 2015 CS Booked for 30 September Board Workshop – the Board Workshop had been cancelled. A new date would be booked.

Minute Ref June 2015


Action by Outcome

A020/06.15 i. The Trust Board to hold a discussion regarding cancelled operations on a quarterly basis.

September 2015 COO Due September

Minute Ref July 2015


Action by Outcome

A002/07.15 To review the procedure for charging patient’s for copies of their medical records as part of the Birth Reflection Service.

September 2015 DNQ There is no charge to review patients’ records with a member of staff. If a patient wanted copies of notes a charge applies up to maximum of £50, however this is usually waived if the patient has made a complaint or is unhappy with the Trust.

A006/07.15 Report on the appointment of a Freedom to Speak Up Guardian for the Trust.

September 2015 DPD Verbal Update

A015/07.15 A formal evaluation of the Focus on Flow week to be presented to the Trust Board.

September 2015 COO Delayed until October.

Minute Ref August 2015


Action by Outcome

A007/08.15 Report to the Trust Board on the continued impact of the improvements made following the “Focus on Flow” week using quality based measures.

November 2015 COO Due November

A010/08.15 To review the Risk Management and Board Assurance Framework Strategy and the Trust’s risk appetite at the Board Away Session to enable comprehensive discussions.

November 2015 CEO Due November

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A016/08.15 To remove the SHMI and HSMR from the Effectiveness Domain due to the delay in the figures being reported.

September 2015 DFI Completed

A023/08.15 i. The quarterly Revalidation Report would be presented to the Quality Committee for discussion.

November 2015 MD Due November

ii. The Quality Committee Chairman’s Report to the Trust Board would include an update on discussions held regarding the quarterly Revalidation Report.

November 2015 QCC Due November

A029/08.15 To feedback to the nursing staff the Trust Board’s acknowledgement of their dedication and hard work to ensure a high level of care was provided to patients.

September 2015 DNQ Completed

A034/08.15 To meet with the member of public to discuss and provide reassurance regarding patients’ receiving end of life care in their own home in rural locations.

August 2015 MD Completed

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TRUST BOARD MEETING

Report to: Trust Board Meeting “in public” Agenda item: 5 Date of Meeting: 1st October 2015 Title of Report: Chief Executive’s Update Report Status of report: (decision and approval, position statement, information, confidential discussion)

For information and discussion

Lead Executive Director: Richard Beeken, Chief Executive Author: Richard Beeken, Chief Executive Appendices:

1. Purpose of the report

To update the Board on the reflections of the CEO on current operational and strategic issues.

2. Recommendations

To note the report and discuss the content.

3. Main Body of Report

3.1 Chief Inspector of Hospitals Inspection of Wye Valley NHS Trust (22nd September – 24th September 2015)

Wye Valley NHS Trust last week welcomed the Chief Inspector of Hospitals team to the Trust to scrutinise the progress the organisation has made on its quality improvement journey since being placed in special measures in October 2014. Over 60 inspection team members were present, leading an intensive review of our acute and community services. The CIH methodology includes a detailed review of a wide variety of data sources, staff focus groups, a public listening event and crucially, detailed direct observation of care being given in a wide variety of clinical environments. The organisation prepared well for the re-inspection, though both a comprehensive patient care improvement plan which has been reviewed on a regular basis over the last 12 months and through a variety of communications and engagement of front-line staff in the inspection methodology and how best to engage with that. I will get the opportunity to feedback on the positives and negatives of the inspection process and methodology at a private event with the CQC Chief Executive held with other NHS providers in London during November 2015.

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3.2 Working together for Herefordshire In response to the challenge laid down by the NHS 5 Year Forward View, the statutory partners in the County (CCG, Local Authority, 2G FT and Wye Valley NHS Trust) together with the GP federation, have further developed the workstreams of our Transformation Programme. In particular:- Acute Hospital Workstream

o Following a review of over 30 services and specialties in the Trust, the Trust Medical Director has agreed with Clinical Commissioners the first 6 specialties for priority development work. These will form the initial phases of the development of the acute hospital-wide clinical services strategy. Key to this process will be the maximisation of potential primary care and community care in delivering care that is currently managed within the acute hospital boundaries

Community Collaborative Workstream o WVT continues to work with 2G FT on the development of a significant change programme in

community services, focussing on improved multi-disciplinary working between primary care and community mental health services in our localities. Key to this process is the appointment of primary care clinicians to Clinical Director roles. The recent productive workshop held by WVT with local GPs and the CCG regarding Bromyard Community Hospital’s future development will feed in neatly to the work that the Community Collaborative Workstream is already developing with respect to the changing shape of services within our community hospitals

3.3 Agency Nursing

The Trust Provider Regulators, Monitor and the TDA have issued detailed and exacting guidance with regard to the reduction in the use of, and the cost of, agency nursing in NHS Trusts and Foundation Trusts. Specifically, there is a deadline of 19th October 2015 with respect to no longer using nursing agencies that are not on the agreed National Framework. WVT is in the process of developing our plans to respond to this challenge and share those with Monitor and the TDA. Clearly, our ability to deliver the guidance issued to Trusts will largely be dependent on our ability to increase the rate of qualified nurse recruitment in the Trust. Our initial plans regarding overseas recruitment have been hampered somewhat by changes visa regulations but the Trust is now seeking alternative routes in our plan, such as return to practice nursing and European recruitment in the short term. Retention of staff is also crucial and our Recruitment and Retention Strategy also sets out how we use staff development, leadership development and skills expansion as core elements of retaining the valued staff we recruit and developing our organisational resilience accordingly.

1. Please confirm, by ticking the box, that you have included or considered the following items in developing your report: Background Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk Register Resource Implications (staffing & financial) Patient, Public and Stakeholder involvement

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TRUST BOARD MEETING Report to: Trust Board Meeting “in public” Agenda item: 7 Date of Meeting: 1st October 2015 Title of Report: Board Assurance Framework Status of report: (decision and approval, position statement, information, confidential discussion)

For discussion

Lead Executive Director: Chief Executive Author: Company Secretary Appendices: Board Assurance Framework & Definitions


1.1 The purpose of the report is to provide Board Members with the opportunity to review and discuss the strategic risks set out within the Board Assurance Framework.

2. Recommendations

2.1 For Board Members to discuss and note the risks to the achievement of the Strategic Objectives as set out

in the attached Board Assurance Framework and the ‘extreme’ operational risks.

3. Summary of Key Issues for discussion

3.1 Attached at the appendix is the Board Assurance Framework which has a ‘risk on page’ and also includes some other additions to provide the Board Members with more assurance and a clearer document to ‘check and challenge’:

• Risk Owner and relevant Committee identified • Assurance ratings added to key controls and assurance on controls as follows:

(1) Management reviewed assurance (2) Board reviewed assurance (3) External reviewed assurance

• Actions clearly allocated to an individual, with date for completion and update. • Risk register definitions document included to promote a common, clear understanding of the

information included within the BAF.

3.2 There are currently six ‘extreme’ strategic risks to the achievement of the Strategic Objectives. Each of the risks have been discussed with the Executive Director Lead to ensure that they accurately reflect the risk, impact/consequence, controls, assurance and actions. These actions are followed up every month with the Executive Director Lead to ensure that the actions in place are undertaken in order to manage / mitigate the risk. Board Members are encouraged to raise any questions they have on the attached with the Executive Lead for that risk.

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3.3 To ensure that clinical risks across the Trust get sufficient review and ensure a more robust risk reporting structure from ‘ward to Board’ a new Executive Clinical Risk Committee has been established the Committee is chaired by the Medical Director and it reports into the Trust Executive Management Meeting. The Committee review all operational risks with a score of 12 and above.

4. Reference to previous reports

4.1 Trust Board report on strategic risks on 27th August 2015.

5. For further information or any enquires relating to this report please contact: Nicola Licence, Company Secretary: [email protected]

6. Please confirm, by ticking the box, that you have included or considered the following items in developing your report:

Background

Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk Register Resource Implications (staffing & financial) Adult and Child Safeguarding Patient, Public and Stakeholder involvement

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mailto:[email protected]

Strategic Objective - Improve the responsiveness of our services for the benefit of our patients and their families

Principle Risk to the Plan Risk Owner & Committee

Key Controls Assurance on controls Current Risk Rating

(399) Risk of continued failure of the Urgent Care Pathway Context The Trust was unable to maintain the Urgent Care pathway & breached 4 hour waits during the year 14-15. This also impacted on Elective Care & on occasions resulted in sub optimal service provision to patients, breaches in 18 week RTT & 2 week waits & exacerbated the Trust's poor financial position. Cause / Source / Event There is a risk that the Trust will fail to maintain the Urgent Care pathway during the year 15-16 due to demand for services potentially being greater than the capacity to supply. Impact / Consequence If the Urgent Care pathway & 4 hour wait are not met, this could lead to; 1) Reduced ability to provide Elective Care services 2) Cancelled procedures / appointments 3) Loss of service provision related income 4) Sub-optimal service provision at certain times 5) Breaches in 18 week RTT & 2 week waits 6) Worsen the Trust's financial position 7) Deteriorating Trust reputation 8) Increased scrutiny from the TDA, NHS England and the CCG

Chief Operating Officer

Finance & Performance Committee

1. Standardised approach to management of acute emergency admissions (1) 2. Clinical Assessment Unit (CAU) in place(2) 3. Emergency Physician of The Day (EPOD) implemented (1) 4. Frailty Pathway & Frailty Assessment Unit (FAU) in place (2) 5. A & E Streaming in place(1) 6. Escalation process in place (1) 7. Site management team & ward trackers in place (1) 8. Recovery trajectory in place - control for reputational damage(2) 9. Increased weekend discharges through implementation of ward discharge team (1) 10. ED Manager in place (1)

Overall level of assurance: 1-management reviewed

1. National Standards (3) 2. Improvements against key performance indicators in Urgent Care (2) 3. Monitoring through KPI Dashboard (2) 4. Triage Time reports (1) 5. Re-admission rates reported (2) 6. Recovery trajectory in place with action plan for achieving trajectory targets(2) 7. Evaluation of FAU undertaken (2) 8. ECIST review (2)

Overall level of assurance: 2 – Board reviewed

5 x 4 =20

Gaps in control Gaps in Assurance

1. Ability to manage / balance capacity & demand over weekend. 2. Insufficient capacity to maintain flow at peak times of activity.

None (Sept 2015)

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Actions By whom By when Update

1. Recruitment of additional medical and extended role of nursing staff in A&E Department.

Service Unit Manager Urgent Care

End Nov 2015

The timescale has slipped from end of September due to problems with the recruitment of international nurses.

2. Transformation of Health and Care in Herefordshire Programme. Chief Executive Ongoing Ongoing for foreseeable future and links to the ‘working together’ proposals presented to the Trust Board.

3. Management of Change process to alter patterns of working hours for nurses and doctors in care co-ordination centre and Emergency Department.

Service Unit Manager Urgent Care

End Nov 2015

Management of change for care co-ordination centre completed and will take effect from 1st October. Management of change in ED taking place from beginning of October 2015.

4. Discharge team extended to 7 day working. Service Unit Manager Urgent Care

End Oct 2015

This will be extended to 6 day working from 7th September and 7 day working from 1st October.

5. Individual ward targets for discharges linked to Trust target of 40% by lunchtime and 65% by 4.30 p.m.


End Oct 2015

Systems are in place to report and monitor on a daily basis and distributed to ward staff. This will be relaunched to ensure more active management in October.

6. Implement ward trackers to proactively manage patient pathways to above standard. Chief Operating Officer

End Sept 2015

Complete

7. Relocate Frailty Unit - to complete by end of Nov 2015. (LK leading). Service Unit Manager Urgent Care

End Nov 2015

This is adding 16 extra beds - addressing gap in control no.2. Currently on target to complete by end of November.

8. Embed escalation process over next 3 months Chief Operating Officer

End Sept 2015

No significant changes required to escalation plan but will be audited for compliance throughout September.

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Strategic Objective - Improve the responsiveness of our services for the benefit of our patients and their families



(400) Risk of the Trust failing to achieve the NHS Constitutional targets Context During 14/15 WVT has failed to achieve the NHS Constitutional targets due to service demand exceeding supply which resulted in the non-achievement of targets in the four areas; Cancer, Diagnostics, A&E and RTT. Cause / Source / Event There is a risk that the Trust will fail to achieve the NHS Constitutional targets in 15/16 due to our capacity & system response to new increased levels of demand not being able to keep pace with the increased levels of demand experienced by the Trust. Impact / Consequence This could lead to; 1 Increased clinical risk to patients & potentially increase exposure to harm 2) Significant negative financial impact in the form of fines from the commissioners for missing targets 3) Failure to manage A&E could lead to cancellation of elective procedures which could worsen the Trust's financial position 4) Increased scrutiny and performance management of individuals from the TDA, NHS England and the CCG 5) Further measures imposed by external bodies 6) Further improvement notices being issued 7) Further improvement plan development & implementation being required 8) Deteriorating Trust reputation 9) Negatively affect staff morale 10) Poor performance in 4 hour target could influence CQC’s view of the organisation

Chief Executive


1. Infrastructure & capacity investment (2) 2. Monitoring of Recovery Plans & action progress on each of the 4 standards via the F&P Committee & the Trust Board (2) 3. Constant monitoring and implementation of actions to improve position of NHS Constitutional targets reported to Trust Board, Quality Committee, Performance and Quality monthly meetings and Service Unit Governance Meetings (3) 4. System Resilience Group (1) 5. Assertive management of cancer PTL (1)

Overall level of assurance: 2 – Board reviewed

1. The Trust does periodically deliver on standards - problem is not consistently. Evidence provided through F&P Committee & Trust Board Reports (3) 2. Monitor against recovery trajectory for each of the 4 standards (although currently not always met - as of May 2015) (2)

Overall level of assurance: 3 – Externally reviewed

4 x 4 = 16


1. Some areas of the Recovery Plans have not yet been rolled out.

1. None achievement of National Standards by the Trust on a consistent basis. 2. Recovery Trajectory was not met last month (3)

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Infrastructure & capacity: 1. Purchase 2nd CT scanner Chief Operating

Officer End Dec 2015

Reconditioned CT scanner now being purchased.

2. Additional 16 bed capacity Chief Operating Officer

End Nov 2015

Capital bid & Bus case approved. Phase 1 i.e. the additional 16 beds to be in place – on target by end November

3. Implementation of mobile theatre Service Unit Manager Elective Care

End Nov 2015

Business Case presented to TEM and Finance and Performance Committee 25th August.

Recovery Plan Actions: 1. Embed escalation policy & action cards over next 3 months.


End Sept 2015

No significant changes required to escalation plan but will be audited for compliance throughout September.

2. Implement recommendations from 2nd ECIST review, i.e. returning CAU back to its original function


End Sept 2015

Acute medical model agreed and a further pilot to take place on GP assessment which commenced on 1st September

3. Full implementation of Frailty Unit model Chief Operating Officer

End Nov 2015

On target for completion end of November 2015.

4. Implement revised approach to the management of acute medicine as a whole Chief Operating Officer

End Nov 2015

Acute medical model agreed for implementation

5. Full implementation of IST validation recommendations Chief Operating Officer

End Dec 2015

On target for end of Dec 2015.

7. Full implementation of IST patient access recommendations Chief Operating Officer

End March 2016

Underway now with UHB assistance and on target to complete by end March 2016.

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Strategic Objective - Develop a highly skilled, motivated and engaged workforce



(417) Risk to recruitment of new staff and retaining current staff

Context WVT has increasingly experienced difficulty in recruiting & retaining nursing and medical staff for a number of reasons including but not limited to the rural nature of the county, the imposition of special measures on the Trust & the financial difficulties the Trust faces. This has been evidenced by candidates withdrawing from interviews & job offers, reduced applications to advertised vacancies, attrition of existing staff all of which have occurred at greater than expected average rates. Cause / Source / Event There is a risk to the retention of current medical and nursing staff & the successful recruitment of new medical and nursing staff as a result of the Trust being placed in special measures & the increased workloads & pressures on existing staff to cover the staff shortfalls. Impact / Consequence : This could lead to; 1) Further existing staff leaving the Trust 2) Further new candidates withdrawing from interviews / job offers 3) A reduction in applications received in response to job adverts 4) Difficulty in vacancies being substantively recruited to 5) Reduced capacity for service provision / patient care 6) Cancelled procedures / appointments 7) Loss of service provision related income 8) Breaches in national targets, 4hr wait, 18weeks, 2WW etc. 9) Deteriorating Trust reputation 10) Increased costs filling gaps with temporary / bank & agency staff 11) Reduced morale of incumbent staff due to increased work pressures & demands whilst running with less than full complement of staff

Director of People & Development


1. Policy in place covering the conducing of Exit Interviews within two working days to understand why staff leave(1) 2. Follow up phone conversations with applicants who have withdrawn (1) 3. HR.14 Recruitment and Selection Policy (1) 4. HR.19 Salary on Appointment and Reckonable Service Policy (1) 5. Recruitment & Retention task force in place (1) 6. Generic recruitment for HCA's (1) 7. Recruitment & Retention operational group 2015 (1) 8. Reputation Management Programme (1) 9. KPIs in place for recruitment team (1) 10. Recruitment and Retention Strategy(2) 11. Training & Development plan (1) Overall level of assurance: 1-management reviewed

1. National Standards on staffing ratios are reviewed against WVT data (3) 2. Safer staffing levels toolkit is checked against WVT status. A monthly report is provided to the Board (3) 3. Employment checks are in place DBS (prev CBR)(1) 4. Rotas from e rostering 5. Recruitment and retention strategy monitored through action plan


4x4=16


1. Reports / data from exit interviews required. 2. Managers responsiveness to progressing applications, shortlisting, recruiting etc. needs work as some times progress is too slow & applicants can be lost as a result. 3. Medical workforce plan

Inability to achieve staffing ratios.

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1. HCA workforce to be put in place to reduce agency staff use. Head of Resourcing

End March 2016

Generic HCA recruitment happening. Using agency HCAs to cover band 5s.

2. e-Rostering review & rollout to remaining areas to promote efficient use of nursing staff across the Trust

HR Business Systems Manager

End Dec 2015

Review underway and in process of agreeing harmonised shifts.

3. Overseas recruitment has resulted in positions been appointed to which will be phased in from January 2016 onwards subject to immigration checks.

Deputy Director of Nursing

End Jan 2016

Issues regarding immigration rules and nurses passing English exam resulting in reduction in numbers arriving initially. Plans been developed to consider impact.

4. Training & Development to be put in place for staff - through the year Head of Practice Education

End Dec 2015

Plan in place to ensure that capacity is available for training.

5. Act on results from staff survey OD Development Manager

End Sept 2015

Complete – implemented you said we did posters and local plans have been put in place.

6. Recruitment Campaign for Medical Staff. Head of Resourcing

End Dec 2015

Recruitment campaign continues with internal and external networks also been used.

7. Recruitment of Registered Nurses (forms part of Recruitment and Retention Strategy) Head of Resourcing & Director of Nursing & Quality

End March 2016

Recruiting nurses into new roles i.e. Assistant Practitioners. Return to practice courses are being run. Action will be delayed due to issues with recruitment of overseas nurses but have appointed 18 Assistant Practitioners to support band 5s

8. Ensure Exit Interviews are completed within 2 working days of resignation to allow time for employees to be convinced to stay if appropriate.

Director of People and Development

End Nov 2015

Interviews are taking place with report being developed to monitor performance.

10. Options appraisal to be produced for the use of agency & bank staff. Director of People and Development

End Oct 2015

Costings are awaited prior to confirming options.

11. Develop a system to report back KPI performance to the Board. Target completion date Aug 2015

Head of Resourcing

End Aug Complete – KPIs being reported to the Finance and Performance Committee and Trust Board. Also monitored through the Patient Care Improvement Plan.

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Strategic Objective - Develop first class facilities and technology to support the care we provide



(412) Critical Failure in Hutted Ward Environment Context The hutted wards were designed & built in 1943 with an intended life span of 10 - 15 years. They are now 72 years old & are continuing to be used for patient care. However, they are long past their intended useable life span & are no longer adequate. A recent failure of the fabric of one area resulted in the temporary partial loss of beds on Monnow Ward. This resulted in an increased number of complaints, the cancellation of elective surgery & the uncertainty around a total loss of surgical capacity on Monnow & the increased workloads & pressures on existing staff to cover the staff shortfalls. Cause / Source / Event There is a risk of harm to staff and patients & the continued ability to provide inpatient care due to the age and condition of the hutted wards. Impact / Consequence This could lead to; 1) Reduced bed capacity for service provision / patient care 2) Patient harm 3) Patient claims - Financial 4) Staff harm 5) Staff claims - Financial & workforce 6) Cancellation of elective surgery 7) Loss of service provision related income 8) Breaches in national targets, 4hr wait, 18weeks, 2WW etc. 9) Increased costs if further building failures occur 10) Increased numbers complaints 11) Deteriorating Trust reputation

Director of Finance & Information


1. Estates Governance Processes (2)

2. Capital Programme(2) 3. Estates Strategy (2) 4. SOC was agreed by Trust

Board in January 2015(2) Overall level of assurance: 2 – Board reviewed

1. Incident Reports(2) 2. Surveyors Reports (1) 3. Estates Key Performance

Indicators (KPI's)(3) Overall level of assurance: 2 – Board reviewed

5x3=15


No alternative decant space

None Identified.

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1. Business case next stage for replacement of Hutted Wards continues. Head of Estates End March 2016

Outline Business Case being developed for approval in October and the Full Business Case for February 2015.

2. Investigations to take place into protect the wards from inclement weather (allowance in 2015/16 draft capital plan to fund this).

Head of Estates End Dec 2015

There is money within the plan to do works to the roof by the end of 2015.

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Strategic Objective - Improve the quality and safety of care to our patients, their carer’s and families



(302) The published high mortality indices are an alert of possible poor quality of care and therefore of potentially avoidable deaths Context The published Mortality Indices; Summary Hospital level Mortality Index (SHMI) and Hospital Standardised Mortality Ratio (HSMR) have shown that Wye Valley is statistically higher than expected. Cause / Source / Event There is a risk that the published high mortality indices are an alert to poor quality care being provided by Wye Valley Trust to its patients. Impact / Consequence This could lead to; 1. Potentially avoidable deaths occurring at Wye Valley Trust resulting from poor or inadequate care. 2. Nationally published figures causing adverse publicity and reputational damage to the Trust 3. Difficulty in recruitment of staff (links to risk 417) 4. Increased costs filling gaps with temporary / bank & agency staff 5. Increased scrutiny from the TDA, NHS England and the CCG

Medical Director

Quality Committee

1. Review of all in hospital deaths led by Medical Director(1)

2. Escalation process for deaths which raise concerns (1)

3. Implementation of Care Bundles (2)

4. Governance Mortality structure redesigned and implemented(2)

5. Sepsis Screening Tool designed and implemented (1)

6. Action plans in place wher2 mortality higher than expected (1)

7. Review of all unexpected admissions to critical care (1)

8. Review of unexpected cardio-respiratory arrests.

9. Coders involved in mortality reviews (1)


1. Mortality Indices reported to Leadership Team, Quality Committee and Board, compared with National data (3)

2. Mortality Review Group(2)

3. Visit by TDA Deputy Medical Director(3)

4. Regular audit of use of Care Bundles (1)


5x3=15


None Identified.

Standardised Hospital Mortality Indicator (SHMI) is 118.

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1. Identifying patients who were potentially inappropriate admissions at end of life. Medical Director From March 2015

Ongoing

2. Roll out fluid management pack Trust wide Medical Director August 2015 Currently being piloted on Monnow and Arrow Wards 3. Appoint Consultant Lead for Patient Safety Medical Director End Oct

2015 Action in progress

4. Review of 2 months of deaths undertaken by UHB. Medical Director End Aug 2015

Complete – results presented to consultant body

5. Deliver education session on mortality Medical Director End Aug 2015

Complete

6. Review of coding practice Medical Director End Oct 2015

Support being received from UHB to draft and implement new coding policy

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Strategic Objective - Provide more productive and better value care that improves the sustainability of our services



Risk to the financial sustainability of Wye Valley NHS Trust Context The Trust is currently in financial deficit of 19 million as of May 2015. Cause / Source / Event There is a risk that the underlying deficit of the Trust could either remain the same or deteriorate in future years also the TDA have set a control total of £16.75m Impact / Consequence This could lead to; - Negative impact on future sustainability of the Trust & possible future FT status Lack of investment in service development - Difficulty in achieving constitutional targets



1. Cost Improvement Programme (2) 2. Continuous review of pay and non-pay expenditure(1) 3. New agency pay controls from 1.9.2015 (3) 4. High level recovery plan in place(2) 5. Vacancy control panel (1)


1. Reports to Executive (1) 2. Programme Group (1) 3. Monthly monitoring of financial position at Trust Board (2) 4. Monthly reporting to the TDA (3). 5. Service Unit Performance Meetings (1) 6. Corporate Performance Meetings (1) 7. Finance & Performance Committee(2)


5x3=15


1. Lack of a recovery plan 2. Lack of clarity on organisation future

1. Lack of a recovery plan means assurance is unavailable

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1. Continued performance monitoring and challenge at Service Unit level of individual budgets.


Monthly Happening from 2015 onwards

2. Discussions with the TDA regarding corrective actions and potential funding - Director of Finance & Information

Ongoing Ongoing throughout 2015/16.

3. Provide an analysis of the current deficit 'operational & underlying' elements. Director of Finance & Information

End July 2015

Complete - presented to Finance and Performance Committee 28th July.

4. Production of LTFM. Senior Finance Team

End Sept 2015

This will be redrafted by Mid-September for submission to the TDA

5. Seek new sources of additional income Senior Finance Team

End March 2016

Continuing to seek additional sources of income

6. Consider future cost improvement schemes Director of Finance & Information

From Aug This will form 2016/17 CIP schemes.

7. Responding to the TDAs control total. Director of Finance & Information

End October 2015

Taking relevant actions to respond including offering £550k from slippage on overseas recruitment towards total.

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TRUST BOARD MEETING

Report to: Trust Board Meeting “in public” Agenda item: 8a

Date of Meeting: 1st October 2015

Title of Report: Key Performance Indicator (KPI) Performance August 2015/16

Status of report: (decision and approval, position statement, information, confidential discussion)

INFORMATION

Lead Executive Director: HOWARD ODDY – DIRECTOR OF FINANCE & INFORMATION

Author: STEVE POWELL – ASSOCIATE DIRECTOR OF FINANCE

Appendices: KPI schedule (PDF & Excel format)


To inform Board Members of the performance of the Trust on a variety of indicators including operational performance against NHS Constitution targets.

2. Recommendations

For Board Members to consider the KPI performance and to note actions that are being taken to address areas non-compliance documented in the detailed performance reports.


Key Performance Issues

A number of key national targets have not been met in July. These are:-

1. Responsive Domain – A&E 4 Hour Wait, Ambulance Handovers, 28 Day Rebook Standard, 4 of the 7 Cancer access targets, RTT (Admitted Pathways)

2. Caring Domain – Same sex accommodation breaches, A&E Friends and Family Test 3. Finance Domain –CIP variance versus plan and I&E surplus margin, Income and pay actuals versus plan.

NHS Constitution (NHSC) recovery trajectories are in place and measurement against these monitored

internally on a weekly basis and subject to oversight by the NHSTDA on a monthly basis.

Performance has varied across the NHSC standards with a slight deterioration seen in A&E and some cancer indicators (draft) but improved performance against diagnostics. Draft RTT performance remains at a similar level to previous months while the backlog continues to be worked through.

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Summary performance for August was:-


Report produced detailing performance for July 2015

5. For further information or any enquires relating to this report please contact:

[email protected] 01432 364000


Background Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk Register Resource Implications (staffing & financial) Adult and Child Safeguarding Patient, Public and Stakeholder involvement

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StandardTarget

set

Current data

month

Month actual

TrendYTD

(April to March)

Trend (January 2014 to

date)

Referrals (2015/16 v 2014/15) L July -1.9% 4.4% C

Total A&E Attendances (2015/16 v 2014/15) L August 6.5% 0.1% C

Total Inpatient / Daycase Activity (activity v plan) L August -5.5% -2.4% C

Total Outpatient Activity (activity v plan) L August -11.4% -5.3% C

A&E 4 hour wait target 95% N August 89.2% 90.0% C

12 hour trolley waits 0 L August 1 = 4 C

Ambulance handover > 30 minutes 0 N August 150 661 C

Ambulance handover > 60 minutes 0 N August 8 63 C

18 weeks referral to treatment time - admitted 90% N July 63.7% M

% spending >90% of their stay on a stroke unit 80% N July 91.9% 87.2% C

Delayed Transfers of Care (acute only; pts as % of occ beds) <3.5% N July 0.5% M

Diagnostic waiters, 6 weeks and over - DM01 1% N August 1.0% M

Non-clinical ops (elective) cancelled on day 10 per month

L August 13 82 C

% Last minute non-clinical cancelled ops (elective) 0.80% N August 0.79% 0.90% C

Breaches of the 28 day readmission guarantee 5% N August 23.1% 26.8% C

Urgent operations cancelled more than once 0 N August 0 = 0 C

2 week GP referral to 1st outpatient appointment 93% N July 95.1% 92.7% C

31 day diagnosis to treatment 96% N July 96.4% 96.6% C

31 day second or subsequent treatment (drug) 98% N July 100% = 100.0% C

31 day second or subsequent treatment (surgery) 94% N July 100% = 100.0% C

62 days urgent referral to treatment 85% N July 78.9% 83.4% C

62 day referral to treatment from screening 90% N July 85.7% = 89.7% C

Consultant upgrade (62 days decision to upgrade) - July 83.3% 89.7% C

Urgent referrals for breast symptoms 93% N July 84.2% 73.5% C

StandardTarget

set

Current data

month

Month actual

TrendYTD

(April to March)


date)

Quality Deaths in Low Risk Conditions <100 N April 2014 to March 2015 112 C

Emergency readmissions within 30 days of discharge L March 5.7% 6.5% C

Caesarean section - Elective <9% L August 15.8% 15.8% C

Caesarean section - Emergency <14% L August 10.8% 13.0% C

Bed occupancy - G&A Wards (Acute Site) 90% L August 91% = 94% C

Bed occupancy - Community Wards 90% L August 91% 88% C

StandardTarget

set

Current data

month

Month actual

TrendYTD (April to March)


date)

Number of Complaints received 14/15 Comparison L August 20 102 C

Number of Compliments L August 1600 9475 C

Inpatient Scores from Friends and Family Test 95% N August 97% M

A&E Scores from Friends and Family Test 95% N August 75% = M

Community Hospital Scores from Friends and Family Test 95% L August 98% M

Maternity Scores from Friends and Family Test 95% L August 96% = M

Inpatients response rate from Friends and Family Test 30% C August 37.3% M

A&E response rate from Friends and Family Test 25% C August 13.1% M

Community Hospital response from Friends and Family Test 30% L August 94.4% M

Maternity response rate from Friends and Family Test 30% L August 30.6% M

Same Sex Accommodation Standard breaches 0 N August 6 32 C

Wye Valley NHS TrustTrust Key Performance Indicators (KPIs) - 2015/16

Nex

t m

onth

3 m

onth

s

Yea

r en

d

Effectiveness Domain

Caring Domain

Responsiveness Domain

Cancer Targets

Access

Cancelled Ops

Forecast

Type

ForecastTy

peTy

pe

Nex

t m

onth

Nex

t m

onth

3 m

onth

s

Yea

r en

d

3 m

onth

s

Yea

r en

d

Experience

Forecast

G G G

G G G

G G G

R R R

A A A

A A A

R R R

R R R

R R R

Trend Target Type Forecast Type Improvement on last month N National C Cumulative

Deterioration on last month C CQUIN M Monthly

= No change L Local

R R R

A A A

A G G

A A A

R R A

G G G

R A A

G G G

G G G

A A A

R A G

G G A

A A A

R R R

A A A

R A A

G G G

G G G

A A A

A A A

G G G

G G G

R A G

G G G

R A R

R A A

R R R

R G G

A A G

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StandardTarget

set

Current data

month

Month actual

TrendYTD

(April to March)


date)

Never Events 0 N August 0 = 0 C

Number of >AD+1 MRSA Bacteraemia 0 N August 0 = 0 C

Number of >AD+2 clostridium difficile cases 18 N August 0 8 C

Number of E.Coli 0 L August 0 = 3 C

Number of MSSA Bacteraemia 0 L August 0 = 2 C

VTE Risk Assessment 95% N July 95% = M

Safety Thermometer - Harm Free 95% N August 97.8% M

Number of patient falls in inpatient areas 445 L June 16 71 C

Number of patient falls in community hospitals 270 L June 24 86

Number of incidents reported 7839 L August 589 3112 C

Number of SIRIs reported 159 L August 3 = 31 C

Number of reportable acquired category 3 pressure ulcers 72 L August 6 18 C

Number of reportable acquired category 4 pressure ulcers 3 L August 0 = 0 C

% compliance with WHO checklist 100% N August 99.97% M

StandardTarget

set

Current data

month

Month actual



date)

Appraisal rate - consultant 90% L August 83.9% C

Appraisal rate - all 90% L July 69% C

Mandatory Training 90% L July 78% C

Sickness rate 3.4% L August 4.5% C

Staff Friends and Family Test N M

Staff Turnover 10% L August 1.4% 1.0% C

% of complaints responded to within 25 days 90% L August 78% M

Number of complaints reopened 69 L August 1 16 C

Number of complaints referred to Ombudsman 6 L August 0 = 0 C

StandardTarget

set

Current data

month

Month actual (£k)


(£k)


date)

I&E surplus margin Breakeven / Surplus N August -£2,304 -£7,035 C

I&E surplus margin (actuals versus plan) Actual v Plan N August -£598 -£642 C

Total income (actual versus plan) Actual v Plan L August -£400 -£218 C

Pay expenditure (actual versus plan) Actual v Plan L August -£221 -£228 C

Non pay expenditure (actual versus plan) Actual v Plan L August £22 -£197 C

CIP (actual versus plan) Actual v Plan L August -£231 -£600 C

StandardTarget

set

Current data

month

Month actual



date)

Dementia Find 90% C July 92% = M

Dementia Investigate 90% C July 100% = M

Dementia Refer 90% C July 100% = M

Dementia Carers Survey Response Rate C July 26% M

Value for Money

3 m

onth

s

Yea

r en

d

CQUINs

Safety

Safe Domain

3 m

onth

s

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r en

d

Nex

t m

onth

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Type

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r En

d

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Well Led Domain

Nex

t m

onth

Forecast

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Finance Domain Nex

t m

onth

Complaints Management

Nex

t M

onth

3 m

onth

sY

ear

end

3 m

onth

s

Type

Forecast

Type

Forecast

Type

G G G

G G G

G G G

G G G

G G G

G G G

G G G

A A A

G G G

G G G

R R R

G G G

G G G

G G G

G G G

R R A

A A A

G G G

R R R

G G G

A A A

A A A

A G G

A A A

R R A

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TRUST BOARD Report to: Trust Board Meeting “in public” Agenda item: 8b Date of Meeting: 1st October 2015 Title of Report: Quality and Safety Overview Report Status of report: (decision and approval, position statement, information, confidential discussion)

Information

Lead Executive Director: Michelle Clarke, Director of Nursing and Quality Author: Michelle Clarke, Director of Nursing and Quality Appendices: 0 Purpose of the report This report provides an overview of key quality and safety measures across the Trust for July/August 2015. This monthly dashboard identifies any key achievements and challenges that are facing the Trust. Recommendations The Trust Board is asked to;

• Review and note the dashboard report. Summary of Key Issues for discussion Key issues from the KPI dashboard are highlighted within the main body of the report;

• Consultant Lead and Midwife Lead to attend next Quality Committee to provide an update in relation to caesarean section rates.

• The Committee discussed the A&E Friends and Family recommendation and response rates and has agreed a number of actions to be taken;

o Consideration of inclusion of feedback box in Eye Casualty. o Review systems and processes adopted by other Trusts within the West Midlands.

• The Quality Committee highlighted the decrease in incident reporting and were informed that the Quality & Safety Team will continue to monitor this as well as benchmarking the incident reporting level against National Reporting Learning System (NRLS) data due to be published in September 2015.

Reference to previous reports Monthly Quality and Safety Overview Report

For further information or any enquires relating to this report please contact: Michelle Clarke, Director of Nursing and Quality

Please confirm, by ticking the box, that you have included or considered the following items in developing your report:

Background

Care Quality Commission Implications Legal / NHS Constitution considerations

Analysis of Risk including link to the Board Assurance Framework and Risk Register

Resource Implications (staffing & financial) Adult and Child Safeguarding

Patient, Public and Stakeholder involvement

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Exceptions Effectiveness Domain

Subject: Emergency and Elective Caesarean Sections Performance Data: Table 1: Elective Caesarean Section Rates

Target Actual June <9% 16.3%

July <9% 17.8%

August <9% 15.8%

YTD <9% 15.8%

Table 2: Emergency Caesearean Section Rates

Target Actual June <14% 12.1%

July <14% 16.3%

August <14% 10.8%

YTD <14% 13.0%

Issue: Despite a decrease in both the elective and emergency caesarean sections the elective caesarean section rate remains above the 9% tolerance level.

Actions Taken: It appears that the elective caesarean rate is high due to maternal choice to have a repeat caesarean section.

The audit of Robson Group 5 (Women who have had a previous caesarean section) continues to be undertaken.

Action Required:

Quarterly audit of Robson group 5, to be presented at November 2015 Obstetrics & Gynaecology Education and Audit meeting.

It is proposed that the Consultant Lead for Labour Ward be invited to update the Quality Committee on ongoing actions to reduce caesarean section rate.

Related Risks: None.

Expected Outcome:

Reduction in month on month reduction in both emergency and elective caesarean rates. Any failure to achieve this will continue to be reported by exception monthly to the Quality Committee.

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Caring Domain Subject: A&E Friends and Family score and response rate Performance Data:

WVT Scores West Midlands Average

National Average

June 2015 71% 84.9% 88.4% July 2015 75% 85.7% 88.2% August 2015 75% TBC TBC WVT Response

Rate West Midlands Average

National Average

June 2015 9.6% 14.2% 15.1% July 2015 14.4% 13.6% 15.2% August 2015 13.1% TBC TBC

Issue: The A&E Friends and Family score remains below the Trust target.

Actions Taken: In comparing the Trust data with the most recently available national and regional data the Trust has identified that;

• The Trust has the lowest recommendation rate in the West Midlands.

• The Trust is 7th out of 12 Trusts in the West Midlands for the response rate.

As previously reported to the Quality Committee the key themes derived from the comments made shows that waiting times continue to be the primary concern amongst patients.

A long term action plan is in place regarding the urgent care pathway and a key focus for the Trust will be to impact upon the waiting times in A&E.

The Head of Quality & Safety has also asked that the Service Unit provide an update of actions that will be taken to improve both the response rates and scores.

Action Required:

Continued focus on improving response rates and scores for Friends and Family Test in A&E.

In order to increase response rates, A&E are considering moving the electronic kiosk in the reception area to one of the treatment rooms. It is felt that this location would ease the process of staff prompting patients to record their vote.

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These rooms have the highest guaranteed discharge of patients occurring.

In addition, the Quality & Safety Team are currently reviewing the possibility of an incentive scheme to encourage improvement in response rates and scores.

Related Risks: ID 304 - Standards of care and safety when A&E demand is high with increasing emergency admission

Expected Outcome:

Increased Friends and Family response rate.

Subject: Mixed sex accommodation breaches Performance Data:

Issue: 6 mixed sex accommodation breaches were reported in August 2015. 3 of the mixed sex accommodation breaches are attributed to the decamp of ITU.

Actions Taken: The Trust continues to follow the escalation protocol. The Trust is also acquiring screens for key areas. These screens will not prevent the mixed sex accommodation breaches but they will improve privacy and dignity for patients involved.

Action Required:

To encourage continued use of the escalation protocol and monitor daily.

Related Risks: None

Expected Outcome:

Continued decrease in mixed sex breaches.

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Safe Domain Subject: Number of incidents reported Performance Data:

Issue: The Trust has set a target to achieve an increase in the number of incidents reported when compared to 2014/15 whist maintaining a low level of harm. The number of incidents has decreased to below the Trust target for the last 2 months.

Actions Taken: A review of the incidents reported has been undertaken and has identified that the number of incidents is similar to that of the same month in 2014. Summer months are understood to receive a lower number of incident reports.

The graph to the right shows a breakdown of incident reporting by Service Unit. It is clear that there has been a decrease in reporting within the Elective Care and Integrated Family Health Service Units.

However, in order to ensure that staff remain aware of the importance of incident reporting the Patient Safety Lead has;

• Raised awareness through Trust Talk. • Discussed at Service Unit Governance meetings. • See It, Sort It, Report It screensaver to be utilised

again. • Communication as part of the daily Count Down to

Inspection emails sent to all staff.

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Action Required:

Continue to raise awareness of the importance of incident reporting.

Related Risks: None

Expected Outcome:

Continued improvement of the safety culture and incident reporting at Wye Valley NHS Trust.

Subject: WHO Checklist Performance Data:

Theatres Checklist fully completed (%)

Excludes cases with valid exception for not completing checklist Yes No

Obstetric 161 (100%) - Ophthalmic 659 (100%) - General 2356 (99.96%) 1** (0.04%) Podiatric 292 (100%) - Radiology Injections 27 (100%) - Grand Total 3495 (99.97%) 1 (0.03%)

Issue: The Trust monitors compliance against the WHO checklist on a quarterly basis and has achieved a compliance of 99.97% for June to August 2015. This is below the 100% target.

Actions Taken: On review, this equates to one WHO checklist out of 3500 during the reporting period. Details of this case are;

• “Sign Out” not completed. • Reported as incident on Datix. • Band 7 in theatres has spoken to the scrub nurse

involved in the case regarding their responsibility in completing the WHO ‘Sign Out’ and the importance of ensuring this is done.

Action Required:

Continue to monitor the compliance against the WHO checklist.

Related Risks: None

Expected Outcome:

Improved compliance with WHO checklist.

Subject: Other Infection Control Incidents Performance Data: N/A

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Issue: Legionella species has been isolated from water samples taken from the cardiac catheter lab.

Actions Taken: Water incident meetings have been held. Filters have been placed on most outlets in the lab. A Flushing regime of all outlets continues.

Action Required:

A further meeting to be called when the next set of results are known.

Related Risks: ID 203 - Risk of harm to patients and staff due to inadequate assurance around effective water management

Well Led Domain Subject: % of complaints responded to within 25 days Performance Data:

Trust Wide Number of complaints due to be responded to with 25 days

9

Number of complaints not responded to within 25 days

2

% of complaints responded to within 25 days

78%

Urgent

Care Elective Care

Integrated Family Health

Corporate

Number of complaints due to be responded to with 25 days

3 5 0 1

Number of complaints not responded to within 25 days

1 1 N/A 0

% of complaints responded to within 25 days

67% 80% N/A 100%

Issue: The number of complaints responded to within timeframe has improved. However, it still remains below the Trusts target of 90%.

Actions Taken: Each individual case where delays have occurred has been raised with the relevant Service Unit.

A number of actions have been taken;

• The weekly meeting between the Complaints Team, Service Unit links and the Head of Quality & Safety continues to be held to discuss the current position of all complaints.

• The Complaints Team meet with the Head of Quality & Safety on a daily basis to review the current position of all complaints and ensure any issues that arise are dealt with promptly.

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Action Required:

Continue to monitor the timeliness and quality of complaint responses.

Related Risks: None

Expected Outcome:

Improved timeliness of complaint responses whilst maintaining quality of responses.

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TRUST BOARD MEETING Report to: Trust Board Meeting “in public” Agenda item: 8c Date of Meeting: 1st October 2015 Title of Report: Activity/Performance Report to 31st August 2015 (M5) Status of report: (decision and approval, position statement, information, confidential discussion)

Position statement / information

Lead Executive Director: Chief Operating Officer Author: Jon Barnes Appendices: None

1. Purpose of the report To inform the Trust Board of August* performance against key national standards. To highlight areas of compliance and non-compliance To identify actions taken or to be taken to manage risks and ensure delivery *Cancer performance report is for July

2. Recommendations To receive and note the report on the Trust’s Operational Service performance To discuss the planned actions being taken to ensure the Trust performs at or above all service standards

3. Summary of key Issues for discussion Activity Summary for August 2015 Acute

0

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

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Actual Plan

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• During August, A&E attendance were above plan for the first time this financial year at +153 (+3.4%) but activity remains down on plan for the financial year as a whole (-650, -2.8%).

• Emergency Activity was down on plan in the month by 59 attendances (-3.3%) and remains down on plan year to date by 2.5% (-231).

• Elective, and to a lesser extent day-case, activity was affected by the scheduled shutdowns in Theatres 1 –

4 (for planned maintenance) for a week each during August

• Both new and follow up appointments were down on plan in the month, -7.7% (-457 actual) and -12.9% (-1810 actual) respectively, despite planned activity levels being lower for August than the preceding and subsequent two months. Both continue to be down on plan year to date

Community

Community Activity 2015-16

0

1,000

2,000

3,000

4,000

5,000

6,000


Follow Up Outpatient Attendances

Actual 14-15 Outturn

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New Outpatient Attendances


MIU activity decreased compared to previous month and was only slightly down compared to August 2014 (MIUs were open as normal all that month). Key Performance exceptions and remedial actions: A&E, RTT & Diagnostics

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

92.0% 88.7% 90.3% 90.8% 92.2% 94.8% 96.4% 94.2% 90.4% 96.6% 93.6% 95.2%

89.8% 90.0% 90.8% 90.2% 89.2%

69.0% 69.0% 66.9% 69.3% 72.1% 77.5% 79.7% 90.0% 90.9% 94.9% 94.9% 96.0%

62.2% 67.5% 64.1% 64.4% 63.7%

93.1% 95.3% 98.2% 99.0% 99.1% 99.1% 99.1% 99.1% 99.9% 99.9% 99.9% 99.9%

93.1% 96.6% 96.3% 97.6% 99.0%

95%

90%

99%

A&E

RTT - Admitted

Diagnostics

A&E standard. August’s Trust-wide A&E performance dropped from July’s position of 89.2% to 90.2%. Current performance is driven by a lack of available inpatient capacity to accommodate emergency admissions in a timely way or by delays in the ‘system’ resulting from ‘congestion’ as a direct result of poor patient flow.

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A number of recovery actions are being taken to improve patient flow and strengthen performance, these include:

• Improving leadership in the Emergency Department.

• Review of ‘Capacity Management’ processes

• Developing improved ways of clinically managing GP urgent referrals with the introduction of a GP-referred assessment service

• Delivery of the revised Acute Medical model in November

• Increasing the available inpatient capacity at the County Hospital site with the introduction of 16

additional beds by December 2015 There was one 12-hour trolley breach during August, on Tuesday 12th. The total number of 12-hour breaches for the year is now 4. RTT 18 week standards The Trust has failed the English Admitted Pathways target of 90% with performance of 63.7 %. This is also below the Trust’s recovery trajectory of 72.1%. The Trust and CCG (supported by both the TDA and NHSE) continue to meet fortnightly to progress the recovery plan, demand and capacity gap analysis and work to the now agreed 18ww recovery plan, which sees the Trust recover performance in December 2015. Diagnostics Diagnostics performance was achieved in August. The total number of patients seen in the month increased compared to July, and the waiting list has consequently reduced. MRI, CT and non-Obstetric Ultrasound have recovered from their previous challenged positions and now have no patients waiting over six weeks.

There were seven breaches in Adult Audiology and 12 in Paediatric Audiology, due to on-going staffing and capacity issues.

There were four breaches in Urodynamics, due to consultant emergency leave.

The Trust continues to explore plans to make the services more sustainable and to maintain current performance in those areas which have experienced pressures in recent months.

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Cancer standards (July 2015) Indicator Standard Apr May Jun Jul

Cancer Two Week Waits 93% 88.0% 91.3% 95.2% 95.7%

Two Week Waits (Breast Symptomatic) 93% 69.6% 56.6% 81.7% 84.2%

Cancer 31 Days 96% 97.0% 95.3% 98.7% 96.4%

Cancer 31 Days Subsequent Treatments 98% 90.0% 100.0% 100.0% 100.0%

Cancer 62 Days 85% 78.2% 100.0% 86.3% 78.9%Breast 85% 100.0% 100.0% 100.0%Gynaecological 85% 66.7% 50.0% 100.0%Haematological 85% 100.0% 50.0%Head & Neck 85% 100.0% 50.0% 0.0%Lung 85% 83.3% 80.0% 100.0% 68.4%Lower GI 85% 83.3% 50.0% 50.0%Sarcoma 85% 97.1% 0.0%Skin 85% 100.0% 100.0% 100.0% 100.0%Upper GI 85% 87.5% 66.7% 50.0% 0.0%Urological 85% 62.5% 100.0% 71.4% 66.7%Other 85% 79.2% 100.0% 100.0%

Cancer 62 Days Screening 90% 75.0% 100.0% 85.7% 85.7%

Cancer 62 Days Upgrades 85% 80.0% 92.3% 100.0% 83.3%

Cancer 62 Days Rare cancers (31 Days) 85% 100.0% n/a n/a 100.0% The Trust achieved the 2 week wait threshold for the second month in succession (95.7%). There were 30 breaches in total, 29 of which were due to patient choice. Only one patient breached due to lack of capacity, this patient was seen on day 15.

Breast Symptomatic performance continues to improve, however, still stands below the 93% threshold at 84.2%. There were nine breaches in total, all nine were due to patient choice and all patients have been discharged with no cancer diagnosis. There is ongoing work around patient information/GP education. The 62 day cancer standard remains a challenge. Performance for July fell below standard with 13 breaches (see breakdown by tumour site). The issues continue to relate to complex diagnostic pathways and patients transferring to tertiary centres. Cancer pathways will be reviewed by the MDT Teams during September/October and increased patient tracking will be required to improve performance. The 62 day screening standard failed in the month, this related to 1 Breast Screening breach. The patient was difficult to diagnose due to other health issues. Cancelled Operations and Stroke/TIA

Threshold Apr May Jun Jul Aug YTD

Indicator 1 - last minute cancellations 0.8% 0.68% 1.16% 0.87% 1.01% 0.79% 0.90%

Indicator 2 - breach 28 day rebooking 5% 83.3% 0.0% 35.3% 15.0% 23.1% 26.8%

Stroke: patients spending min 90% of time on stroke unit

80% 81.8% 85.0% 89.5% 91.9% 75.0% 84.8%

TIA: high-risk pts scanned & treated within 24 hrs of 1st contact with HCP

60% 5.6% 36.7% 53.1% 58.3% 34.5% 37.4%

Cancelled Operations

Stroke/TIA

Cancelled Operations During the month, there were 13 operations cancelled on day of surgery for non-clinical reasons. The most common cause of cancellations was surgeon unavailability, followed by emergency/trauma taking priority and lack of beds. There were three breaches of the 28-day rebooking standard. An additional 20 procedures were cancelled on day due to clinical reasons and 15 cancelled by patients.

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Stroke The Trust failed the Stroke Vital Signs indicator in August (80% of patients spending 90% of their time on a stroke unit): with performance at 75%, which is nine failures from 36 patients. Capacity constraints during the month affected the ability to house all stroke patients on Wye ward. This is the first time since July 14, and only the second since April 2012, that this standard has been breached.

Year to date performance remains above threshold at 84.8%.

TIA performance has dropped during August with performance at 34.5%. The main issues continue to be lack of weekend capacity and clinician availability. A broad range of actions have been, and continue to be, taken to improve clinical and operational performance, which include:

• Advertising the vacant Consultant posts in August

• Confirmation of a plans to develop elements of joint clinical working with Gloucester The Operational Stroke Board, which includes representation from the Trust, Commissioners and Patient Groups, oversees the delivery of the service and its ongoing development.

4. Reference to previous reports None


Jon Barnes THQ ext. 4215 [email protected]


Background Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk Register Resource Implications (staffing & financial) Patient, Public and Stakeholder involvement

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TRUST BOARD MEETING Report to: Trust Board Meeting “in public” Agenda item: 8d Date of Meeting: 1st October 2015 Title of Report: Financial Performance Report (Month 5, 2015/16) Status of report: (decision and approval, position statement, information, confidential discussion)

Information

Lead Executive Director: Howard Oddy, Director of Finance and Information Author: Howard Oddy, Director of Finance and Information Appendices: N/A

• Purpose of the report

To inform Board members of the financial position of the Trust at the end of August 2015 (month 5).

• Recommendations

The Board is asked to note the financial position at the end of August 2015 (month 5) and the risks that have been identified to the delivery of the approved financial plan.

• Summary of Key Issues for discussion

The Trust reported an operational deficit of £7,035k at the end of month 5. This position was £642k worse than the Business Plan.

• Reference to previous reports

Financial Performance report (month 5), 2015

• For further information or any enquires relating to this report please contact:

Howard Oddy, Director of Finance and Information

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• Please confirm, by ticking the box, that you have included or considered the following items in developing your report:


√

√

√

√

√

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I&E Performance against Budget Plan

The Trust Income and Expenditure position at the end of August was a deficit of £7,035k. This was £642k worse than the current budget plan and is a result of an in-month deficit of £2,034k (which was the largest in-month deficit so far this year). The Trust currently has to monitor against two different targets. The budget measured in this report now reflects the target for an additional £500k of improvement from the original planned deficit (a new budget level of £18,431k), whereas the full stretch target applied to the Trust of £2,256K would result in a deficit of £16,675k. In month, financial performance has been particularly poor. Part of this is attributable to the planned theatre maintenance shut down which has caused productivity and income to drop dramatically during the month with the resulting step change to the deficit position. CIP under delivery is also a contributory factor, although, year to date, this has been contained (non-recurrently) by the opportunity to capitalise an element of expenditure, previously provided for within revenue budgets. This current financial position requires the Trust to take corrective action. A series of proposed measures are detailed later in this report and a quantified recovery plan will be presented to next month’s Finance and Performance Committee that outlines how the required financial position will be delivered. Note 1 (in the table to the left) adjust for the phasing difference between the Trusts operational financial plan and the TDA plan (the latter has a locked profile in M1 to M5). The note also adjusts for technical items which are excluded in terms of financial performance monitoring.

STATEMENT OF COMPREHENSIVE INCOME - To Month 5 - 31st August 2015 - 2015/16

ANNUAL CURRENT MOVEMENTFINANCIAL ANNUAL IN

PLAN BUDGET CURRENTAs At PLAN BUDGET ACTUAL VARIANCE MONTH

31/03/2016£000 £000 £000 £000 £000 £000

Contract & PbR Income 151,589 153,150 63,020 62,863 (157) (332)Non Contracted Activity (NCA's) 1,774 1,946 808 842 34 32Other Income for Patient Care 13,015 16,327 7,104 7,119 16 5Donations For Non Current Assets 660 660 275 275 0 (0)Financial Support 0 0 0 0 0 0Other Non Patient Income 4,681 5,521 2,393 2,281 (112) (105)

Total Operating Income 171,719 177,605 73,599 73,381 (218) (400)

Pay Expenditure 121,157 122,020 49,864 50,092 (228) (221)Non Pay Expenditure 59,542 63,645 26,142 26,340 (198) 22

Total Operating Expenditure 180,699 185,665 76,006 76,432 (426) (200)

EBITDA (8,980) (8,060) (2,407) (3,051) (644) (600)

Depreciation 3,581 3,598 1,452 1,452 0 0Gain or loss on asset disposal 0 0 0 0 0 0Interest Receivable 24 24 10 9 (1) 1Interest Payable on Loans 84 449 110 107 3 0Interest Payable on PFI 5,352 5,730 2,388 2,388 (0) (0)Dividends on PDC 454 112 47 47 0 0

Operating Surplus/ (Deficit) (18,427) (17,927) (6,393) (7,035) (642) (598)

Budget phasing diff. (note 1) TFMS & internal plan (1,126) (1,127) (1)

Technical Adjustments

Donated Assets - Additions 660 275 275 0Donated Asset Depreciation (156) (65) (65) 0Donated Assets - Additions less Dep'n 504 210 210 0

Adj. financial performance retained Surplus/ (Deficit) per TFMS (18,427) (18,431) (7,730) (8,372) (642)

YEAR TO DATE

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Income and Expenditure run rate This table shows the detailed month on month forecast which is required in order to deliver the planned deficit of £18,431k (including planned donated asset income). There is no flexibility within this forecast to offset any further deterioration in activity levels, CIP and/or costs. All developments, including the additional 16 beds, are phased into the forecast at their expected implementation dates. Equally, CIP is phased out of expenditure (or added to income) to match the profile of the individual lines in the programme. The impact of the Primecare contract was brought into the position on both the income and cost side in month 2. £77k pay costs have been removed in month 4 to be capitalised as part of the EPR programme. The trend view was distorted due to the favourable one off impact of the review of Balance Sheet provisions in month 2. ‘Excluded Drugs’ expenditure has increased but this is expected to be cost neutral against income.

M1 M2 M3 M4 M5 M5 Variance M6 M7 M8 M9 M10 M11 M12 Outturn Budget Variance

IncomeForecast

@ M4 ActualFrom

Forecast CurrentContract & PbR Income 12,204 12,598 12,590 13,590 12,502 11,881 (621) 13,243 13,451 12,955 13,229 12,920 12,433 12,759 153,853Non Contracted Activity (NCA's) 144 160 154 194 157 190 33 175 176 170 177 169 159 164 2,031Other Income for Patient Care 1,147 1,659 1,425 1,475 1,288 1,413 125 1,334 1,380 1,336 1,385 1,347 1,264 1,188 16,353Income - (Donated Asset Depreciation 55 55 55 55 86 55 (31) 91 91 91 91 91 91 91 910Strategic change 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Other Non Patient Income 451 563 378 544 402 346 (55) 604 410 410 410 410 410 476 5,412

Total Operating Income 14,000 15,035 14,602 15,857 14,435 13,886 (549) 15,447 15,507 14,961 15,292 14,937 14,357 14,679 178,559 177,692 1,007

Pay Directors & Sen. Managers =>Band 8 300 313 306 306 308 298 10 313 313 313 313 313 313 313 3,712Medical & Dental 2,882 3,062 3,077 3,081 3,062 3,088 (26) 3,137 3,138 3,188 3,181 3,181 3,181 3,179 37,373Nurses & Midwives 4,291 3,997 4,191 4,245 4,407 4,468 (61) 4,316 4,313 4,431 4,430 4,430 4,430 4,428 51,971AHPs 751 752 753 750 759 774 (15) 775 778 790 790 790 790 790 9,283Pharmacists 103 106 102 99 108 99 9 117 116 116 116 116 116 116 1,322Professional, Technical, Scientific 448 454 476 464 465 477 (12) 475 475 475 475 475 475 475 5,642Managers/Technical >Band 5 195 236 209 105 180 143 37 182 179 179 179 179 179 181 2,146Clerical <=Band 5 919 913 940 932 980 954 25 946 946 966 966 966 968 966 11,386Other Pay 6 7 6 6 6 6 0 6 6 6 6 6 6 6 74CIP

9,895 9,839 10,060 9,987 10,274 10,307 (33) 10,267 10,264 10,464 10,456 10,456 10,458 10,454 122,909 122,020 (442)

Non Pay Drugs 1,322 1,064 1,332 1,661 1,276 1,193 83 1,272 1,272 1,272 1,272 1,272 1,272 1,277 15,483Med & Surg Supplies 1,117 1,031 1,007 964 999 891 107 994 994 998 996 995 995 998 11,981Implants & Accessories 135 197 187 138 164 155 9 162 162 162 162 162 162 162 1,948Other Clinical Supplies 169 171 217 259 204 148 57 193 193 191 191 191 191 189 2,304Clinical Services contracts 322 951 603 624 633 640 (8) 616 616 616 616 616 616 614 7,448PFI Contract 558 547 572 563 558 562 (4) 640 640 640 640 640 640 641 7,286Transport & Travel 192 116 234 211 205 229 (23) 191 191 216 216 213 214 215 2,442Establishment expenses 327 50 494 386 329 342 (13) 329 329 322 322 322 322 320 3,864I.T. 195 99 111 116 131 107 24 142 139 139 139 139 139 139 1,603Trust Overheads (inc. Insurance) 313 298 319 313 311 312 (1) 311 311 311 311 311 311 310 3,731Other Non Pay 451 303 376 371 493 422 71 453 453 469 479 460 460 460 5,157Hoople Services & Retained IT 71 71 71 71 71 71 (0) 78 78 78 78 78 78 76 898

5,172 4,898 5,523 5,676 5,375 5,073 302 5,382 5,379 5,415 5,423 5,400 5,401 5,402 64,144 63,734 (1,098)

15,068 14,737 15,583 15,663 15,649 15,380 269 15,649 15,643 15,879 15,879 15,856 15,859 15,856 187,054 185,754 1,541

EBITDA (1,068) 298 (981) 194 (1,214) (1,494) (280) (202) (136) (918) (587) (920) (1,503) (1,177) (8,495) (8,062) 533

Depreciation 299 300 270 292 305 292 13 309 306 306 306 306 306 304 3,598(Gain) or loss on asset disposal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Interest Received 0 3 1 1 1 3 (2) 2 2 2 2 2 2 2 21Interest Payable Loans (0) 10 6 55 42 37 5 21 21 21 21 21 21 21 256Interest Payable PFI 478 478 478 478 478 478 0 408 408 408 408 408 408 405 5,237Dividends Payable 36 36 37 (70) 10 8 2 9 9 9 9 9 9 9 112

813 820 789 753 833 810 22 746 743 743 743 743 743 738 9,183 9,865 33

Total Operating Surplus/(Deficit) (1,880) (522) (1,770) (559) (2,046) (2,304) (258) (948) (879) (1,661) (1,330) (1,662) (2,245) (1,915) (17,677) (17,927) 500

Cumulative (7,035)

Donated Assets 910 660 250Donated Asset Depreciation (156) (156) 0

(18,431) (18,431) (0)

Original plan + £500 Board Approved Improvement Target (18,431)

TDA control total (16,675)

(1,756)

Forecast

Total Operating Expenditure

Actual

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Cost Improvement The current outturn forecast variance (£1,267k shortfall) and year to date delivery against plan (£585k shortfall) is resulting in gains on earmarked reserves, mainly achieved from capitalisation of revenue costs associated with EPR and also SIFT (£0.8m in total), being diverted from funding emerging cost pressures or investment requirements.

The graph to the left shows the cumulative outturn trajectory and the lower (purple line) shows a risk adjusted position. This shows the risk identified currently runs between £1.3m and £1.4m within the current forecast outturn; this is however against a forecast outturn which is £1.3m short of the £5.6m target. In response to the full stretch target set by the TDA, the Trust has already scaled back budget for overseas recruitment by £0.5m. The remaining £1.8m of target would have to be addressed through £0.6m of additional income and a further £1.2m of cost reduction. The scale of the challenge of this is further increased by the fact that these values would need to be achieved over a 6 month period. It is only through these additional measures that the stretch target of £16.675m could be achieved and this also assumes no further future deterioration in the current operational position of the Trust.

The graph to the left shows the current risk profile in the (£4.3m) forecast. The table above highlights performance against the CIP element of the Business Plan. The main drivers of the adverse variance of £585k year-to-date are Community Savings, Pay Flexibilities, the additional procurement savings (above £607k) and also slippage in respect of VAT savings on Energy; Productivity and Locum VAT optimisation.

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Current Recovery Plan Actions Given the present position of:

• A significant deterioration in month in the financial position; • The level of financial risk associated with delivering to the partial stretch target agreed by the Board of £0.5m; • The fact that the outturn is currently £1.8m short of delivering to the full stretch target required by the TDA,

the following corrective actions are being proposed to be implemented with immediate effect:

1) CIP Slippage - Performance Management actions to recovery the in-year CIP slippage which has occurred over the last two months through the identification and delivery of substitute schemes at a directorate level.

2) Identification of additional CIP schemes to minimise gap from the Business Plan of £5.6m

3) Implementation of the 'stretch' measures including:

a. Reduction of ACAPs (volume and price)

b. Reduction of agency nursing expenditure (volume and price reduction – reduced non framework use)

4) Increased income (reduction in impact of fines and CQUIN maximisation)

5) Vacancy freeze on all non-medical posts, unless cost neutral

6) End all off-payroll arrangements unless funded through capital (final check but thought now not to exist)

7) End any non-clinical agency contracts unless funded through capital (final check but thought now not to exist)

8) Reviewing all (and potentially end) fixed term contracts

9) Pool all underspending budget resource

10) Block all unbudgeted expenditure

11) Reviewing reserve commitment

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12) Cease any hospitality expenditure post CQC

13) Review Carter report for any further opportunities of Procurement Savings These proposals are being quantified and assessed by the Executive team and are to be built into a recovery plan which will be presented to the October meeting of the Finance and Performance Committee.

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Cashflow

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 TotalACTUAL ACTUAL ACTUAL ACTUAL ACTUAL Forecast Forecast Forecast Forecast Forecast Forecast Forecast Year

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000ReceiptsNHS Contract Income 16,141 9,679 12,625 15,729 16,007 13,651 14,195 14,195 14,195 14,195 14,195 14,195 169,000NHS Contract Performance 0 0 0 0 0 0 0 0 0 0 0 0 0NHS Adult Social Care 0 0 0 0 0 0 0 0 0 0 0 0 0Non NHS Receipts 140 179 129 155 176 184 200 200 200 200 200 200 2,163MacMillan MRU Contract 0 0 0 0 0 0 0 0 0 0 0 0 0Loans - Temporary 0 2,696 2,006 4,498 1,430 890 0 (11,520) 0 0 0 0 0Loans - Permanent 0 0 0 0 0 0 2,320 12,032 1,812 1,639 903 224 18,930Loans - Commissioner Advance 3,000 (1,500) (1,500) 3,000 (1,500) (1,500) 3,000 (1,500) (1,500) 3,000 (1,500) (1,500) 0Loans - New Capital Advance 0 0 0 0 443 0 2,472 2,250 2,300 2,500 1,000 2,230 13,195Permanent PDC Capital 0 0 0 0 495 0 574 0 0 0 0 0 1,069Interest Received 2 0 2 1 2 2 2 2 2 2 2 2 21Charitable Funds 206 0 0 118 416 32 33 33 33 33 33 33 970Sale Of Assets 0 0 0 0 0 0 0 0 0 0 0 0 0VAT Recoverable 178 1,112 277 477 1,185 150 150 1,100 150 150 1,100 150 6,179Other - Financial Support 0 0 0 0 0 0 0 0 0 0 0 0 0Total Receipts 19,668 12,167 13,539 23,977 18,654 13,409 22,946 16,792 17,192 21,719 15,933 15,534 211,527PaymentsSalaries & Wages (5,386) (5,433) (5,467) (5,454) (7,593) (5,420) (5,420) (5,420) (5,350) (5,350) (5,400) (5,400) (67,094)Tax & NI (2,079) (2,144) (2,166) (2,142) 0 (2,095) (2,095) (2,095) (2,095) (2,095) (2,095) (2,095) (23,197)Pension Contributions. (1,460) (1,497) (1,507) (1,515) (1,476) (1,461) (1,461) (1,461) (1,461) (1,461) (1,461) (1,461) (17,679)Accounts Payable (3,493) (6,624) (4,428) (8,349) (7,527) (5,019) (5,294) (5,951) (5,193) (5,966) (5,192) (4,633) (67,670)Atkins Energy 0 0 0 0 0 0 0 0 0 0 0 0 0CNST (240) (240) (240) (240) (240) (240) (240) (240) (240) (240) 0 0 (2,398)Business Rates 124 (79) (79) (79) (79) (81) (81) (81) (81) (81) 0 0 (597)Adult Social Care 0 0 0 0 0 0 0 0 0 0 0 0 0Hoople - Shared Services 0 0 0 0 0 0 0 0 0 0 0 0 0Originating Debt Repayment 0 0 0 0 0 (235) 0 0 0 0 0 (235) (470)Loan Interest 0 0 0 0 0 (26) 0 0 0 0 0 (24) (50)PDC Dividends 0 0 0 0 0 (163) 0 0 0 0 0 (163) (326)Charitable Funds 0 (33) (33) 0 (350) (33) (33) (33) (33) (33) (33) (33) (647)Other / Injury Benefit (0) (0) (1) (10) (0) 0 0 (10) 0 0 (10) 0 (32)PFI Related Payments (5,264) 0 0 (5,277) 0 0 (5,361) 0 0 (5,361) 0 0 (21,262)Capital Items (322) (528) (219) (91) 0 (162) (800) (1,317) (1,338) (1,480) (1,043) (1,267) (8,569)Capital Estates Strategy 0 0 0 (288) 0 (157) (2,315) (307) (286) (144) (581) (357) (4,435)Total Payments (18,120) (16,579) (14,140) (23,446) (17,265) (15,092) (23,099) (16,914) (16,077) (22,211) (15,815) (15,668) (214,426)

Net Cash Inflow/(Outflow) 1,549 (4,413) (601) 532 1,388 (1,683) (154) (123) 1,115 (492) 118 (135) (2,900)Balance B/fwd 3,900 5,449 1,036 435 967 2,355 671 518 395 1,510 1,017 1,135 3,900Balance C/fwd 5,449 1,036 435 967 2,355 671 518 395 1,510 1,017 1,135 1,000 1,000

The cash position of the Trust is entirely dependent on the receipt of £18.9m of financial support in the forms of PDC to cover revenue support and a further £14.2m for capital expenditure in the form of long term loans and PDC. The drawdown against each of the facilities is shown on the cash flow. The cash flow position has been updated to reflect Month 5 receipts and payments and future month’s cash flow assumptions have also been reviewed. The Trust has an agreement with Herefordshire CCG to advance income on a quarterly basis repayable over the following 2 months to assist with the PFI payment. NHS contract income in April and May was skewed by the early payment of approximately £3m of contract income by Herefordshire CCG. This also contributed to the closing cash position being higher. The annual cash-flow points to cash availability being very tight for the year with loans and PDC drawn down to maintain liquidity.

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Capital Position

Loan

Internally Generated

Funds PDC Funded Charitable TotalM5 YTD Actual

Full Year Forecast

£K £K £K £K £K £K £K

General Schemes

EstatesBacklog Schemes 300 300 79 300Provision of additional Lucentis Procedure Facility 187 187 11 187Endoscopy washers/Drying Cabinets 180 180 5 180Contingency 142 142 0 31Ross Endoscopy Compliance works & Washer 120 120 0 60Phase 2 Theatres TDSI Access Control System 40 40 0 40Digital Mammography Phase 2 3 24 27 0 27SIFT Skills lab 0 0 150Estates - Other 32 32 12 32Sub Total - Estates 1,004 24 0 0 1,028 106 1,007

Clinical EquipmentPower Tools x6 64 64 65 65Eq Slippage HASU Qube monitors 39 39 35 39Cardiac Output Monitors 19 19 0 19Second CT Scanner 500 500 0 500Equipment - Other 40 40 24 40Sub Total - Equipment 0 662 0 0 662 124 663

ICTPathology System 170 170 0 190Windows server 2003 replacement 70 70 0 70Various infrastructure requests 70 70 59 70Sub Total - ICT 310 0 0 0 310 59 330Total General Schemes 1,314 686 0 0 2,000 290 2,000

Estates Strategy (Phase 1)

Additional bed capacity works (16 Beds Single Storey) 2,401 2,401 87 2,748All Other phase 1 items 2,564 2,564 428 2,217Total Estates Strategy (Phase 1) 4,965 0 0 0 4,965 515 4,965

EPR Y1

EPR Tech Fund element 1,069 1,069 441 1,069EPR balance 6,975 6,975 0 6,975Total EPR (Year 1) 6,975 0 1,069 0 8,044 441 8,044

Donated

Midwifery Led Unit (£660k + £100k addn fundraising for equip + £45k fees foregone by PFI partner) 660 660 0 805Second CT Scanner (donated element) 250 250 0 250Total Donated Assets 0 0 0 910 910 0 1,055

Total 13,254 686 1,069 910 15,919 1,246 16,064

Funding Source and budget Financial Position

To date, the Trust has spent £1,246k against a capital plan of £15,919k for the year. The forecast has increased to £16,024k due to an increase in planned charitable donations for the Midwifery Led Unit. The forecast for all other schemes remains broadly as plan. Total spend during August was £550k which included:

• £15k on preliminary work for the new 16 bedded ward,

• £112k on professional fees relating to the preparation of the business case for the next phase of the Estates Strategy,

• £42k on estates schemes, primarily backlog maintenance,

• £59k on ICT infrastructure works • £316k on EPR (detailed overleaf)

The expenditure trend is beginning to increase as the EPR project has commenced and the new 16 bedded ward is well underway.

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TRUST BOARD MEETING

Report to: Trust Board Meeting “in public” Agenda item: 8e Date of Meeting: 1 October 2015 Title of Report: Workforce Report – August 2015 Status of report: (decision and approval, position statement, information, confidential discussion)

Information

Lead Executive Director: Maureen Bignell, Director of People & Development

Author: Andrea Jones, Workforce Planning Manager Appendices: Appendix 1


This report provides an analysis of workforce information and issues covering: • HR Key Performance Indicators (KPIs) 2. Recommendations

The Board are invited to note the contents of the report and actions underway to improve performance efficiency and productivity.

3. Summary of Key Issues for discussion There continues to be significant nursing recruitment challenges in Hospital posts on the Medical and Surgical wards, and in Stroke. Currently there are 328 fte posts going through the recruitment process. Sickness Absence is up this month to 4.45%. Long term sickness numbers are up. Substantive workforce numbers are up this month. The total pay bill has increased this month. Budget Establishment is included. This shows the Trust overall is under establishment. Turnover in month shows no change with 12 month rolling figure also up this month.


• Monthly Workforce Reports

5. For further information or any enquires relating to this report please contact: Maureen Bignell, Director of People and Development Andrea Jones, Workforce Planning Manager

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Background Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk

Register Resource Implications (staffing & financial) Patient, Public and Stakeholder involvement

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1.0 MAIN BODY OF REPORT 1.1 KEY PERFORMANCE INDICATORS

Category Performance Indicator Target 2013/14 2014/15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Trend

Progress V's workforce Plan Total Staffing WTE 2736.24 2379 2474.89 2463.29 2483.1649 2496.49 2500.34 2508.85

Headcount Total Staffing 2947 3051 3034 3056 3072 3080 3094 Vacancy %

% of FTE vacant to total workforce 9.92% 9.94% 9.34% 9.37% 9.42%

% Temporary (B&A)Staff to

permanent staff5% 8% 6.50% 6.60% 7.11% 7.4% 8.3%

Sickness Absence (YTD) % of FTE lost to sickness 3.69% 4.20% 4.33% 4.33% 4.39% 4.30% 4.29% 4.42%

Sickness Absence (Mthly) % of FTE lost to sickness

3.49% 3.94% 3.68% 3.59% 3.84% 4.45%

Long Term Sickness % (mthly) % of FTE lost to sickness

1.69% 1.98% 1.76% 1.73% 1.96% 2.57%

Medium Term Sickness % (mthly) 4 -

12 wks % of FTE lost to sickness2.63% 2.42% 2.26% 2.16% 2.68%

Short Term Sickness % (Mthly) % of FTE lost to sickness

1.80% 1.96% 1.92% 1.86% 1.88% 1.88%

Sickness Calendar Days lost (mthly) Calendar Days

3710 3642 3377 3945 4176

Cost of Sickness £2,442,883 (YTD)

£2,649,618 (YTD)

£214,601 £218,569 £200,707 £220,780 £244,618 Turnover % (YTD exc.

Jr Drs) % of Contracted Headcount 10% 12% 12% 12.24% 12.23% 11.92% 11.44% 11.70%

Mandatory Training% of staff completed

Mandatory training in last 12 months

90% 81% 78% 80% 79% 78% 85%

Appraisal% of staff appraised in last 12

months 90% 76% 68% 69% 68% 66% 69% 72% Consultant Appraisal

% of staff appraised in last 12 months 90% 89% 92% 89.4% 87.7% 87.1% 85.9% 83.9%

Human Resources Key Indicators Scorecard

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Summary of Key Issues

1. Total Staffing In July, there was an increase of 8.55 WTE in the substantive workforce. There was an overall increase in Bank and Agency workers of 24.98 WTE this month. Temporary staffing comprised of 8.26% of the total workforce July 2015, an increase against previous month (7.44% last month).

2. Sickness Absence The August Sickness absence rate increased to 4.45% (3.84% last month) with one Service unit above the Trust target. The Trust’s sickness rate is average compared to other Trusts. Long term sickness has increased to 78 staff (61 last month). The absence rate increased to 2.57% from 1.96% last month. All cases are being actively managed as per policy with 17 of the 78 having return to work dates planned. Short term absence has remained the same this month at 1.88%. The main reason for sickness absence this month remains Stress & Anxiety. There was a total of 333 staff absent from work during August 2015, a decrease from last month (353). August has seen an increase in seven out of the eight staff groups for sickness absence The highest group is Estates and Ancillary at 10.08% (an increase on last month), followed by Additional Clinical Services staff at 6.08% (an increase on last month).

3. Turnover 12 month turnover up to August 2015 has increased from 11.4% to 11.7%. Turnover by Staff Group – 12 Month Cumulative Data The highest percentage staff group this month is Nursing & Midwifery at 14.41 (a decrease from last month). This is followed by Additional Scientific & Technical staff group at tist at 14.28% (same as last month). During August there was a total of 43 (34.35 fte) leavers. The highest number were in Nursing and Midwifery staff group with 18 (14.47 fte).

4. Education & Training Mandatory training is showing an increase in August from 78% to 85%. (below Trust target of 90%). Appraisal completion is currently at 72% up on last month (69%). (below Trust target of 90%).

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5. Recruitment

There are currently 328 FTE posts going through the recruitment process. This equates to approximately 13.10% of the workforce. The Bank recruitment is in additional to these numbers.

5.1 Medical Challenges

The Trust is still experiencing recruitment issues to Consultants posts. There continues to be a high use of agency locums to cover ongoing vacancies. Actions The Trust continues to use BMJ to advertise and promote consultant posts through a marketing campaign in liaison with the Medical Director. Actions to mitigate risks include:-

• Early decision making in relation to managed service provider contracts and/or the implementation of VAT relief schemes

• Recruitment strategy and action plan – medical recruitment strategy to be developed by July with the Medical Director/Director of P&D/Workforce Lead

• Review of Fixed term (non- training) posts with a view to becoming substantive • Review of Medical Recruitment processes with Clinical Directors • Review of alternative options to agency doctors • Explore the use of International Medical Trainees (IMT) doctors – the Trauma &

Orthopaedic department are exploring the appointment of an ST1/2 IMT • Continue to provide agency staff with appropriate induction material. • Use of Recruitment & Retention premia.

5.2 Nursing Challenges Update on Philippines Recruitment – No change The Trust is now expecting only 10 Filipino nurses between now and April 2016. This has been reduced due to a high number of candidates failing the 1st attempt at LETS and the increasing difficulties to secure the visas. Therefore the Trust has decided to only support a maximum number of 10 for this financial year. However we will still be supporting nurses going the ILETS and CBT processes in the Philippines over the next 6 months in preparation for bringing them over in the next financial year. The process they have to go through are as follows:

• ILETS (International Language English Tests) • NMC give authorisation to go to next stage of tests • CBT (computer based tests) on line tests – Tests of Competence • NMC approval to go to next stage • Apply for Visa (few weeks) • Arrive in UK (take up HCA role) • NMC test for registration

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EU Recruitment Trust staff will be going out to Italy in October to recruit between 20-30 nurses who should be ready to practice by January 2016. We have already interviewed 7 nurses, they will be arriving in November ready to practice in December. Health Education West Midlands (HEWM) HEWM are also organising an EU recruitment programme for hospitals in the West Midlands. We will be going to Athens, Greece in September and Spain in October. From these trips we are hoping to recruit between 10-15 nurses. Overseas Registered Nurse - Assessment Day From our first overseas recruitment day the Trust has employed 12 at Band 3 level and a further 2 will be starting in September. These staff will now commence a 12 week skills/competency based course to become an Assistant Practitioner, supported then by the Trust through a programme to meet the requirements to be NMC registered. Another assessment day is being held on 12 September. 6. FTE vs Establishment Budget Establishment against Staff in Post (assignment) data. Payroll and Finance departments are working together to reconcile the Financial budget data to the HR Electronic Staff Record (ESR) system data. The table below shows in detail what the differences are by staff group, ie. Vacancies

Staff GroupFTE

EstablishmentAssignment (actual) FTE Variance

Over/Under Establishment

Add trof Scienti fi c and Technica l 86.69 79.14 -7.55 UnderAdditional /l inica l Services 582.34 545.57 -36.77 UnderAdminis trative and /lerica l 547.29 532.65 -14.64 UnderAl l ied Heal th trofess ionals 197.67 188.76 -8.91 Under9states and Anci l lary 35.55 34.43 -1.12 UnderHealthcare Scientis ts 66.16 62.43 -3.73 Underaedica l and Denta l 302.38 261.05 -41.33 Underburs ing and aidwifery Regis tered 943.48 797.14 -146.34 UnderStudents 3.60 3.60 0.00 Under

Total 2765.16 2504.76 -260.40 Under

The Trust is overall under establishment by 260.40 fte.

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Summary data – by Month

MonthFTE

EstablishmentAssignment (actual) FTE Variance

Over/Under Establishment

January'15 2690.31 2461.16 -229.15 UnderFebruary 2691.54 2462.53 -229.01 Underaarch 2690.12 2474.02 -216.10 UnderApril'15 (new Financial year) 2736.24 2464.80 -271.44 Underaay 2754.57 2480.75 -273.82 UnderJune 2755.31 2497.80 -257.51 UnderJuly 2757.69 2499.10 -258.59 UnderAugust 2765.16 2504.76 -260.40 Under Note: ESR Data v Financial Data There are instances whereby there will be small differences between the ESR data and the Financial data due to:

• Long Term Sick/Maternity/Career Break/ Dual UIM roles where staff have special roles for rights within the PAS SYSTEM – these will remain as they are in ESR and are not adjusted in any way if the staff member goes into a “no pay situation” – this may not be the case in relation to the Financial systems data.

• Split Cost Coded Posts – i.e staff members have 1 ESR post – but budget sits across several cost centres.

• Bank Budget – no budget set in ESR for Bank posts - these sit in a segregated area in ESR – a very small number of manual notes may be required to allow budget establishment to be matched where this takes place.

• Visiting Consultants – are not substantive staff but budget is allocated to the role they do.

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Author: Maureen Bignell – Director of People and Development Lead: Sarah Price – Head of Education and Development Strategic ambition : Effective and engaged workforce with skills in place to perform requirements of role

Specific objective: To ensure statutory and mandatory training meets overall compliance target of 90% by 31 December 2015 High Level Action Specific Measurable Actions Timescale/progress

RAG RATING Ensure capacity and capability is present for staff to access statutory and mandatory training to meet the needs of the service

Provide a combination of face to face and e-learning modules for all staff to access to achieve compliance Ensure training delivered matches core skills training framework Implement the recommendations and best practice from the West Midlands Streamlining group

Number of sessions face to face delivered to meet needs of service including bespoke and extra sessions Number of e-modules developed Training reports to F&P committee demonstrating attendance and compliance Feedback from staff survey on E&D questions No complaints that access to training is difficult Best practice is shared

Review capacity and capability with ED team to deliver Review methods of learning and delivery Align training to West Midlands streamlining group

completed

Improvement in areas of low compliance in subjects and staff groups

To increase compliance rates of equality and diversity and safeguarding level 2 to 75% by 31 December 2015 To increase compliance of specific groups with low compliance rates e.g. medical workforce

Increased compliance Increased compliance Staff survey results for specific groups Reports to board

Review compliance on monthly basis Deliver a blended learning approach e.g. access to e-learning from home, e-readers Include targeted discussion at performance meetings Deliver bespoke training for medical staff

Slipped but recoverable (3/4

actions complete)

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High Level Action Specific Measurable Actions Timescale/progress RAG RATING

Ensure all employees including managers understand the requirements for their role through the training matrix.

To provide the most up to date information on training through a training matrix that reflects current legislation and alignment with west midlands streamlining group.

Training matrix reflects legislative requirements Training matrix is easily accessed and understood by different staff groups Feedback from appraisal Compliance reports

Review requirements on a monthly basis (complete) Upload most up to date to the intranet (complete) Include in team brief every time matrix is updated (complete) Production of compliance reports (complete)

Complete

Ensure data accuracy in reporting

Ensure ESR data is accurate and timely for reporting. Ensure managers are competent in reviewing their local data on ESR Ensure reports are provided in timely way for: performance meeting/F&P/Board Managers understand their responsibility to validate the data at a local level via ESR Having one system in place to eradicate use of attendance reporting

No local database used No inconsistency in reporting verbally from managers at performance meetings 90% data uploaded by EDC within 48 hours to ensure reports issued are up to date.

Ensure all staff/educators within operational services understand that ESR is the only definitive source of data for reporting Ensure information from local registers are received and inputted onto ESR via EDC team Continue to provide training for managers to access training compliance reports from ESR/OLM

On plan – validating of local records in

progress

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High Level Action Specific Measurable Actions Timescale/progress RAG RATING

Ensure all staff are able to access ESR/OLM to undertake training and review training compliance

All staff have access to ESR/OLM through issuing smart cards and/or passwords Review OLM to ensure fit for purpose in 2016

Number of staff accessing and completing e-learning 90% of staff have been issued with access Increased compliance

To review current access to ESR/OLM and identify those staff without access To signpost staff without access to alternative methods Communication on how and where support is available to access ESR/OLM

On plan to achieve by end of December

Individuals are held to account for their responsibility to undertake responsibility

Pay progression is withheld for non-compliance Managers are held to account to ensure staff are released to attend training Staff are reminded of pay progression policy and contractual obligation to undertake training and failure may result in disciplinary and/or pay progression Pay progression policy in place with agreed criteria for pay progression relating to training compliance. Increase capacity for training to enable demand resulting from flyer

Number of people where pay progression has been withheld Compliance reports 20% increased compliance in response to reminder Number of bookings onto face to face learning

Run exception reports Records to be sent to individuals via pay slip in October to confirm/challenge and validate record. Timescale to respond by 30 November Responses from individuals recorded onto ESR/OLM by EDC within 48 hours If no response pay progression and/or disciplinary action will be invoked by 31 December Issue notification of above action in October via team brief

On plan – pay policy agreed.

Amnesty agreed for 3

months to validate records

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Report to: Trust Board Meeting “in public” Agenda item: 9 Date of Meeting: 1st October 2015 Title of Report: Exception Report for Expected and Actual Staffing for

Nursing, Midwifery and Care Staffing (Ward Areas) Status of report: (decision and approval, position statement, information, confidential discussion)

Information

Lead Executive Director: Michelle Clarke, Director of Nursing & Quality Author: Paul Hooton, Deputy Director of Nursing Appendices: Appendix A - Fill Rate Indicator Return Staffing: Nursing,

midwifery and care staff –August 2015 Appendix B – Nurse Sensitive Indicators August 2015


To inform the Trust Board of the ward areas that didn’t meet the expected staffing requirements in August 2015. This relates to Board Assurance Risk Number 417. Risk to recruitment of new staff and retaining current staff.

2. Recommendations The Quality Committee are asked to note the content of the report.

3. Summary of Key Issues for discussion The majority of shift fill rates were between 90 and 100%. There were however a number of overfill shifts predominantly within the HCA workforce; however this is down on last month (from 150% to 125%). Again the main reason for overfill was to cover the shortfall in RGNs in those areas but also due to an increased need for high dependency care largely due to confused patients . An audit was undertaken by Heads of Nursing in Urgent care which found that an additional 176 shifts were requested to support high dependency patients. Going forward both the Director of Nursing and Quality and the Deputy Director of Nursing will explore this further during the 6 month safer staffing acuity review to determine if the additional shifts should be built into the nursing establishment .

Fill rates in some clinical areas for registered staff have been below 90 %( on 8 occasions in total). This is mainly due to vacancies and high sickness rates and inability to provide bank and agency back fill. The Trust still has a high vacancy rate but the measures that have been put in place to mitigate against this are beginning to take effect. Although there has been some improvement on last month both Hillside and Leominster continue to report low fill rates for band 5 registered staff (74.4% and 65% respectively). Following the recent successful recruitment campaign the nurses should start to arrive over the next 4 to 6 weeks Teme ward shows a significant under fill for the month of August. This is because the ward ran at reduced capacity due to theatre maintenance resulting in elective capacity reducing to 50% its usual volume of work and therefore requiring less staff to support the service.

Bromyard had 1 band 5 at night due to vacancies and sickness. The planned staffing hours had been altered to reflect this.

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Nurse sensitive Indicators (NSI) The majority of the indicators are green reporting zero incidents, however there has been an increase in complaints and slips , trips and falls in some ward areas . The report also shows an overall decrease in drug errors. The Trust continues to be MRSA free. Pressure Ulcers

There has been no reported incidence of level 3 and 4 pressure ulcers this month.

Slips Trips and Falls. Although the majority of wards in the inpatient areas have seen a significant reduction in the number of reported falls, the overall reported incidences remains the same as last month from 56 falls, (It is important to note that one clinical area had an exceptionally high fall rate going from 1 last month to 9 this month and therefore has skewed the overall reported numbers). Community hospitals fall rates on average remain the same; however Bromyard has seen a reduction from 11 last month to 3 falls this month. This on part may be due to the recent standard operating procedure restricting high dependency patients being admitted.

Lugg ward also shows a significant improvement with their slip trips and falls down from 11 falls last month to 5 this month. Redbrook ward has shown a significant increase in falls. On further exploration the ward sister reported that the falls that have occurred have been some patients that were independent so no one could have predicted the occurrence. They also said that post op delirium has been an issue when patients were satisfactory pre operatively and then altered post operatively. The ward sister said they will raise awareness with the team to be vigilant regarding falls in all our patients as potentially all patients are at risk of falls.

Other areas that have shown a slight increase are, Arrow ward (+3) Wye ward (+3) and Hillside (+3). All wards implemented robust action plans which include sensory mats and pads, intentional rounding and 1 to 1 care of high risk patients. Some wards reported difficulties in obtaining one to one specialing of the high risk patients due to staff shortages. It is important to note that no harm was caused to any patient.

In last month’s report the Nursing Director informed the committee that they had asked that the data collection tool used on datix is updated to capture more details about incidents of falls which will include location , if a risk assessment was undertaken , what measures have been put in place including specialing and intentional rounding . These amendments have been added and currently this section of the electronic incident report form is under testing in conjunction with medicines reflective log section. It is hoped that these sections will be fully operational by mid October 2015.

Drug Errors There has been a slight increase in reported drug errors (+1) on the previous the month. On further exploration of the data, it shows that two clinical areas account for the bulk of the drug errors (Frome 3 and Lugg 4). Women’s Health reported 2 drug errors. Both Wye ward and Leominster Community Hospital reporting 1 each. All drug errors have been investigated and all staff involved has been requested to write a reflective practice log and the matrix will not be signed off until the reflective practice is complete and returned to EDC. None of the drug errors resulted in significant harm to the patients involved. The remaining clinical areas report no drug errors.

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Infection Control

There have been no reportable clostridium difficle cases in August.

Lugg has been on an extended review period since the 1st June 2015. This has now become a period of increased infection (more than one PCR EIA positive CDI within a 28 day period). Lugg have now had three assurance audits that have been passed and only require one more audit next week.

Friends and Family test

The majority of clinical areas are in the green percentile in the response rate to the Friends and Family test. However all areas in Integrated Family Health Services showing red due to a low response rate. Over 96.4% of respondents would recommend us to their friends and family which is an improvement on last month.

Action from Quality Committee

Director of Nursing & Quality to provide assurance that Hillside and Leominster Community Hospital have adequate staffing levels at the next Quality Committee.

4. For further information or any enquires relating to this report please contact: Michelle Clarke, Director of Nursing & Quality, [email protected] Or Paul Hooton Deputy Director of Nursing [email protected]



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WVT NSTFfil Return - August 15

Total monthly planned staff

hours

Total monthly actual staff

hours


hours

Total monthly actual staff

hours


hours

Total monthly

actual staff hours

Total monthly planned

staff hours

Total monthly

actual staff hours

Women's Health 697.5 677.5 465 422 294.5 308.25 589 503.5 97.1% 90.8% 104.7% 85.5% CS over due to RGN undfill

Maternity Ward 775 775 762.5 737.5 775 775 450 450 100.0% 96.7% 100.0% 100.0%

Childrens Ward 1867.5 1635 465 435 589 589 294.5 294.5 87.6% 93.5% 100.0% 100.0% RCN under due to vacancy rate

Lugg Ward 1860 1557 2557.5 2774.5 883.5 854.25 883.5 1097 83.7% 108.5% 96.7% 124.2% RN under due to vacancy rate. CS over due to RGN undfill and

Arrow Ward 1627.5 1551.75 1395 1370 883.5 779.5 551.5 589 95.3% 98.2% 88.2% 106.8% RN under due to vacancy rate CS over due to HDP

Wye Ward 2092.5 1670 2325 2440.75 1178 1143.5 883.5 1034.5 79.8% 105.0% 97.1% 117.1% RN under due to vacancy CS over due to HDP and acuity

Acute Admissions Ward

3720 3059.25 1860 2133.5 2356 2441.5 883.5 969 82.2% 114.7% 103.6% 109.7% RN under due to vacancy rate CS over due to HDP

Cardiac Care Unit 930 951.5 589 587.5 102.3% 99.7%

Hillside Intermediate Care

1395 1038.5 1800 1979 589 579 883.5 807.5 74.4% 109.9% 98.3% 91.4% RN under due to vacancy rate cause by change in skill mix

Leominster Community Hospital

1395 908.25 2325 2043 589 619 883.5 807.5 65.1% 87.9% 105.1% 91.4% RN under due tovacancy and sickness

Bromyard Community Hospital

930 926.5 1395 1481.5 456 427.5 722 741 99.6% 106.2% 93.8% 102.6% CS over due to HDPRoss Community

Hospital 1395 1408.5 2325 2705.25 589 598.5 1178 1475.75 101.0% 116.4% 101.6% 125.3% Overfill on both groups due to

high level of HCPs

Leadon Ward 1395 1178.25 1162.5 1373.25 589 579.5 589 579.5 84.5% 118.1% 98.4% 98.4% RN under due to vacancy .CS over due to HDP CS over due to

Teme Ward 1395 958.25 1162.5 1143.5 589 477.75 589 68.7% 98.4% 81.1% 38.4% reduced capacity due to Theatre maintenance-elective capacity

Monnow Ward 1395 1247.75 1162.5 1146.25 589 588.5 589 588.5 89.4% 98.6% 99.9% 99.9%

Redbrook Ward 1627.5 1482.75 1627.5 1618.75 883.5 785 589 664.5 91.1% 99.5% 88.9% 112.8% RN under due to vacancy .CS over due to HDP CS over due to

Special Baby Care Unit

1162.5 1213 1162.5 1089.75 104.3% 93.7%

Intensive Care Unit 2244 2221.25 2148 2128.25 99.0% 99.1%

Totals 27904 24460 22790 23804 15732.5 15351 10558.5 10602 76985 74216.8

Fill rate 88% 104% 98% 100% 96%

Comments

Average fill rate -

registered nurses/

midwives (%)

Average fill rate - care staff (%)

Average fill rate -

registered nurses/

midwives (%)

Average fill rate - care staff (%)

Ward name

Day Night Day Night

Registered midwives/nurses Care Staff Registered midwives/nurses Care Staff

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Urgent Care

NumberPer 1000 bed days





Key

Complaints - Communication with Nursing staff

0 0.0 0 0 0 0.0 0 0.0 0 0.0 Colour Colour %

Complaints - Clinical care 0 0.0 0 0 1 1.0 0 0.0 1 1.3 Over 40%Complaints - Attitude of Nursing staff 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 30-40%Compliments 0 n/a 24 n/a 0 n/a 11 n/a 0 n/a Under 30%Friends and Family Test Response Rate 60.3% n/a 67% n/a 25% n/a 71.7% n/a 64% n/aFriends and Family Test Recommendation Precentage

94% n/a 100% n/a 95% n/a 95% n/a 83% n/a

MRSA Bacteramia 0 0.0 0 0 0 0.0 0 0.0 0 0.0 Colour %Clostridium Difficle (post) 0 0.0 0 0 0 0.0 0 0.0 0 0.0 100-95%Drug Errors 0 0.0 0 0.0 3 3.0 4 4.5 1 1.3 90-94%Slips, trips and falls 6 8.4 0 0.0 4 3.9 5 5.6 7 8.9 0-89%Patient falls - Moderate harm or above (SIRI) 0 0.0 0 0 0 0.0 0 0.0 0 0.0

Pressure Ulcers (3&4) 0 0.0 0 0 0 0.0 0 0.0 0 0.0Bed Days 715 n/a 132 n/a 1016 n/a 891 n/a 784 n/aSickness

Community Hospitals





Complaints - Communication with Nursing 0 0.0 0 0.0 0 0.0 0 0.0Complaints - Clinical care 0 0.0 0 0.0 0 0.0 0 0.0Complaints - Attitude of Nursing staff 0 0.0 0 0.0 0 0.0 0 0.0Compliments 11 n/a 23 n/a 16 n/a 18 n/aFriends and Family Test Response Rate 88.6% n/a 97% n/a 88.9% n/a 100% n/aFriends and Family Test Recommendation 94% n/a 100% n/a 100% n/a 100% n/aMRSA Bacteramia 0 0.0 0 0.0 0 0.0 0 0.0Clostridium Difficle (post) 0 0.0 0 0.0 0 0.0 0 0.0Drug Errors 0 0.0 1 1.3 0 0.0 0 0.0Slips, trips and falls 7 8.4 5 6.5 3 8.1 8 12.2Patient falls - Moderate harm or above (SIRI) 0 0.0 0 0.0 0 0.0 0 0.0Pressure Ulcers (3&4) 0 0.0 0 0.0 0 0.0 0 0.0Bed Days 838 n/a 773 n/a 369 n/a 658 n/aSickness

Elective Care Discharge Lounge







Number

Complaints - Communication with Nursing 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Complaints - Clinical care 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Complaints - Attitude of Nursing staff 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Compliments 27 n/a 12 n/a 31 n/a 0 n/a 0 n/a 10 n/a 0Friends and Family Test Response Rate 42.6% n/a n/a n/a 74.2% n/a 76.5% n/a 69.2% n/a 33% n/a n/a

Friends and Family Test Recommendation Precentage

100% n/a n/a n/a 100% n/a 95% n/a 99% n/a 98% n/a n/a

MRSA Bacteramia 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Clostridium Difficle (post) 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Drug Errors 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1Slips, trips and falls 0 0.0 0 0.0 2 3.8 9 12.8 0 0.0 1 4.3 0Patient falls - Moderate harm or above (SIRI) 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Pressure Ulcers (3&4) 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0Bed Days 595 n/a 119 n/a 521 n/a 703 n/a 300 n/a 232 n/a n/aSickness

Integrated Family Health Services






Complaints - Communication with Nursing staff

0 0 0 0 0 0 0 0 0 0

Complaints - Clinical care 0 0 0 0 0 0 0 0 0 0Complaints - Attitude of Nursing staff 0 0 0 0 0 0 0 0 0 0Compliments 22 n/a 23 n/a 10 n/a 12 n/a 13 n/aFriends and Family Test Response Rate 8.2% n/a 39.4% n/a 39.4% n/a n/a n/a 38.7% n/aFriends and Family Test Recommendation Precentage

100% n/a 92% n/a 97% n/a n/a n/a 94% n/a

MRSA Bacteramia 0 0 0 0 0 0 0 0 0 0Clostridium Difficle (post) 0 0 0 0 0 0 0 0 0 0Drug Errors 0 0.0 0 0 2 10.4167 0 0 0 0Slips, trips and falls 0 0 0 0.0 0 0 0 0 0 0Patient falls - Moderate harm or above (SIRI) 0 0 0 0 0 0 0 0 0 0

Pressure Ulcers (3&4) 0 0 0 0 0 0 0 0 0 0Bed Days 207 n/a 281 n/a 192 n/a 169 n/a * n/aSickness

This information includes data for August 2015

Arrow Ward CCU Frome AAU/SSU/FAU Lugg Ward Wye Ward

FFT Response rate key

FFT Score key

Ross CH Leominster CH Bromyard CH Hillside

Leadon Ward ITU Monnow Ward Redbrook Ward Teme WardDaycase

Unit/Endoscopy

*Discharge figures are unavaliable from this area as they can have multiple bed occupancies a day

Childrens Ward Maternity WardWomens Health

WardSCBU Delivery Suite

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TRUST BOARD MEETING Report to: Trust Board Meeting “in public” Agenda item: 10 Date of Meeting: 1st October 2015 Title of Report: Nursing Agency spend rules Status of report: (decision and approval, position statement, information, confidential discussion)

For information

Lead Executive Director: Howard Oddy, DoF Author: Howard Oddy, DoF Appendices:


To brief the Board on the new rules being introduced by the TDA in relation to Nursing Agency spend and the Trust’s response to the rules.

2. Recommendations

To note the new rules being introduced by the TDA in relation to Nursing Agency spend and the Trust’s response to the rules.


In 2014/15, NHS providers spent £3.3billion on temporary nursing staff. (This Trust spent £5.1m on agency nursing during the last year.) In response to this level of spend, a national programme of rules has been introduced, the first elements of which can be summarised as follows: -an annual ceiling for total nursing agency spending for each Trust -the mandatory use of approved frameworks for procuring agency staff A further rule, i.e. price caps on rates of pay for agency staff, is due to be introduced later in 2015. Annual ceiling The annual ceiling for agency nursing expenditure is being presented as a percentage of total nursing spend (excluding health care assistants). Whilst the ceiling takes effect from 1st October, providers have had an opportunity to apply for an adjustment to the ceiling, though it was stated that a change would only be made in exceptional circumstances. Applications had to be made by 14th September.

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The ceiling for this Trust has initially been set as follows: -10% for the second half of 2015/16, -8% for 2016/17, -6% for 2017/18, -4% for 2018/19. As the Trust’s expenditure on nursing agency has continued to increase in 2015/16 (nb the first five months have seen expenditure level s rising to £669k in August, making a monthly average of £517k compared to an average of £423k in 2014/15), the Trust decided to submit a request for our ceiling to be increased to 12% for the last six months of the current year. We have thus submitted a profile reflecting the 12% ceiling, but understand that we will have to resubmit the profile showing 10% delivery if our application is rejected. Use of frameworks From 19th October, all procurement of nursing agency staff is expected to take place through approved frameworks, unless otherwise authorised by the TDA. The TDA published a list of approved frameworks on 17th September, which gives providers one month to make the necessary arrangements for complying with this rule. It is expected that Trusts take the necessary steps to procure all of their agency staff through approved frameworks. Trusts have an opportunity to apply to use an agency that is not on an approved framework and this has to be done by 1st October. It is expected that any approvals would only be in exceptional circumstances, which means a superior quality of service and good value for money. Trusts will be informed of the decision whether or not approval has been granted by 15th October. In August, at least 49% of this Trust’s agency nursing expenditure was on two agencies which are not on frameworks. Executives are thus currently determining whether or not we should apply for approval to use these two or any other agencies that do not appear on the frameworks. However, it is highly likely that we would struggle to demonstrate that these agencies (most notably Thornbury) offer good value for money. Compliance In relation to the ceiling, Trusts will be monitored through the monthly returns and will be held to account on a quarterly basis. Trust’s performance against the approved frameworks will also be reported through their monthly returns. Where Trusts are not compliant, they will be required to submit shift-level detail and explanations for the reason behind this. It is stated that the TDA will take ‘appropriate and proportionate action’ in cases of non-compliance but they have also indicated that they will work with Trusts which are struggling to comply with the controls. The TDA has published a graduated plan setting out how they intend to approach non-compliance in a way that supports Trusts in articulating the issues and developing solutions. However, if the TDA thinks that Trusts are not doing all they can to carry out the steps to meet the agency controls in a timely manner, the TDA has indicated that it may need to resort to the use of formal powers. Task and Finish Group In order to identify the actions that we need to take in order to comply with these rules, a task and finish group, comprising the Directors of Nursing, Finance and People and Development, plus the Deputy Director of Nursing and the three Heads of Nursing, has been formed and has already met twice.

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The Trust has clearly been attempting to recruit more nursing over recent months via a variety of methods, but the need to reduce agency spend in the next six months intensifies the need for more urgent action. In view of this, one of the initial actions being given serious consideration is to pay improved rates of pay in order to encourage substantive nurses to do additional hours (up to the maximum allowed by the European Directive) for the next six months, whilst our recruitment work progresses. It is believed that this will have a material impact on nurses willing to do additional work and thus reduce our reliance on agencies. Decisions are due to be taken at a forthcoming Executives meeting. An update on the Trust’s plan for implementing the rules will be presented to next month’s F&PC and Board meetings.

4. Reference to previous reports n/a

5. For further information or any enquires relating to this report please contact: Howard Oddy, Director of Finance



y

y

y

y

y

y

y

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TRUST BOARD MEETING Report to: Trust Board Meeting ‘in public’ Agenda item: 11 Date of Meeting: 1st October 2015 Title of Report: Finance and Performance Committee Terms of Reference Status of report: (decision and approval, position statement, information, confidential discussion)

To review

Lead Executive Director: Chair of Finance & Performance Committee Author: Company Secretary Appendices: 1


1.1 The purpose of the report is to provide members of the Trust Board with the opportunity to review and approve the attached Finance and Performance Committee Terms of Reference.

2. Recommendations

2.1 For Members of the Trust Board to approve the Finance and Performance Committee Terms of Reference for incorporation into the Trust’s Standing Orders.


3.1 It is good practice for all Terms of Reference of Committees of the Board to be reviewed on an annual basis.

3.2 The attached draft Terms of Reference have been reviewed to take into account the changes recommended by the Governance Review but also changes required for good ‘housekeeping’ to ensure they remain up to date and relevant.

3.3 These Terms of Reference were discussed and recommended for approval by the Finance and

Performance Committee on 25th August 2015. All changes suggested at the Finance & Performance Meeting have been incorporated into the revised Terms of Reference.


4.1 Governance Review presented to the Trust Board April 2015. 4.2 Terms of Reference report to Finance and Performance Committee on 25th August 2015.


5.1 Nicola Licence, Company Secretary at [email protected]

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WYE VALLEY NHS TRUST

FINANCE AND PERFORMANCE COMMITTEE

TERMS OF REFERENCE

1. Purpose

The Finance and Performance Committee is a Committee of the Trust Board and has no Executive powers other than those specifically delegated in these Terms of Reference. The overall purpose of the Committee is to scrutinise the Trusts performance, together with TDA accountability performance framework and oversee the development of mitigating actions associated with the delivery of each. In addition, the committee will scrutinise financial control, future investment plans, business cases, monitor that decisions involving finance are properly made and promote good financial practice throughout the Trust. 2. Membership The Committee will be appointed by the Board and will comprise the following core members:

• Chair of the Trust Board • Three Non-Executive Directors • Chief Executive • Director of Finance and Information • Chief Operating Officer • Director of People and Development

All Board members outside the core membership have an open invitation to attend any meeting if he/she wishes. 3. Attendance Other Board Members may attend the meeting at the invitation of the Committee Chair or where a nominated Board Member has arranged for another Board Member to attend on their behalf.

4. Chair

The Chair of the Committee will be a Non-Executive Director appointed by the Trust Board.

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5. Secretary

The Secretary to the Committee will be the Company Secretary whose duties will include: • Agreement of agenda with the Committee Chair and the nominated lead

Executive Director • Ensuring the taking of the minutes and keeping a record of matters arising

and issues to be carried forward • Ensuring that the agenda, reports and corresponding minutes reflect

confidential items. 6. Quorum

A quorum shall be 50% (four Members) of which two (of the four stated in the Membership) shall be Non-Executive Directors. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. 7. Frequency of Meetings Meetings shall be held monthly with additional meetings if necessary. 8. Notice of Meetings Meetings of the Finance and Performance Committee, other than those regularly scheduled as above, shall be summoned by the Secretary to the Finance and Performance Committee at the request of the Chair of the Finance and Performance Committee.

Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed and supporting papers, shall be forwarded to each member of Committee, any other person invited to attend, no later than 5 working days before the date of the meeting.

9. Minutes of Meetings

The minutes of Committee meetings shall be formally recorded and circulated to the Board.

10. Duties

The duties of the Finance and Performance Committee are as follows:

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Finance

• To review the financial performance of the Trust and assess adequacy of proposed recovery plans to bring performance in line with plan.

• To review the in year delivery of the annual cost improvement plan (CIP). • To review projected financial performance with particular reference to

reviewing sustainability against Board objectives on risk ratings and liquidity. • To review budget control framework, including budget setting and guidelines. • To review proposed budgets and integrated business plans and recommend

adoption of these to Trust Board. • To review the development of the medium and long-term financial models in

the context of the wider strategy. • To review proposed business cases for both capital and revenue investment,

to test assumptions and to assess whether such investment will assist the delivery of the strategy.

• To review delivery against the annual capital programme. • To understand the implications of financial policies including service line

reporting and associated costing. • To review implications of national financial policies, and changes therein, on

the Trust.

Operational Performance

• To review performance against National Trust Development Agency (NTDA) accountability framework standards and targets and assess the adequacy of exception reports and recovery plans for these where required.

• To review accountability framework performance with particular reference to sustainability against strategic objectives and risk ratings.

• To regularly assess the adequacy of performance reporting to Service Units, the Committee and the Trust Board.

• To annually assess the adequacy of performance review systems deployed by the Executive to hold Service Units to account for delivery.

• Undertake any other responsibilities as delegated by the Trust Board.

• To receive regular updates on the management of the Private Finance Initiative (PFI) Contract.

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Workforce

• To review performance against Key HR Performance Indicators.

• To monitor total staffing levels against budget, turnover and the talent pipeline

• To monitor payroll and agency costs.

To fulfil these duties the Committee is authorised to seek the information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

11. Reporting Responsibilities The Committee Chair shall draw to the attention of the Board any issues that require disclosure or require Executive action. The Chair is required to inform the Board on any exceptions to the annual work plan or strategy. The Committee will report to the Board monthly highlighting discussions, which have taken place. The Committee will also report annually on its work in support of the Governance Statement and by exception as and when necessary.

The Groups/ Committees stated below report directly to the Finance and Performance Committee on a monthly basis. Reports will be received by the Committee from the designated responsible Executive Director:

• Capital Planning and Equipment Committee • Executive Performance Meeting

12. Review

These Terms of Reference will be reviewed annually or sooner if required and recommendations made to the Trust Board for approval.

At least once a year the Committee shall undertake a self-assessment of its effectiveness, and the outcome of this assessment shall be reported to the Committee and the Trust Board.

13. Approval

Date Approved: Approving Body: Wye Valley NHS Trust Board

Next Review Date:

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TRUST BOARD MEETING Report to: Trust Board Meeting ‘in public’ Agenda item: 12 Date of Meeting: 1st October 2015 Title of Report: Appointments to Committees Status of report: (decision and approval, position statement, information, confidential discussion)

For Approval

Lead Executive Director/Non-Executive Director: Chairman Author: Company Secretary Appendices: 1


1.1 The purpose of the report is to approve the appointment of Non-Executive Directors to the current vacancies within the membership of the Committees of the Trust Board.

2. Recommendations

2.1 For Members of the Board to approve the following:

• Christobel Hargraves to be appointed to the Audit Committee and the Remuneration and Terms of Service

Committee. • Frank Myers to be appointed to the Finance and Performance Committee and to step down from the

Audit Committee • Mark Waller to be appointed to the Remuneration Committee and step down from the Quality

Committee.


3.1 These changes have been discussed and agreed with the Chairman and Non-Executive Directors and now required formal Board approval prior to serving on the above Committees.

3.2 The attached schedule shows which Non-Executive Directors are appointed to the Committees of the Trust Board.


4.1 Not applicable.


[email protected]

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Background Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk Register Resource Implications (staffing & financial) Patient, Public and Stakeholder involvement

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NOMINATED COMMITTEE ROLES OF NON-EXECUTIVE DIRECTORS NON-EXECUTIVE

DIRECTOR BOARD AUDIT

COMMITTEE

QUALITY COMMITTEE

FINANCE & PERFORMANCE

COMMITTEE

REMUNERATION COMMITTEE

CHARITABLE FUNDS

COMMITTEE (Corporate

Trustee)

OTHER ROLES

Museji Takolia (01.06.15 – 31.05.16)

CHAIR X X X X Stakeholder Group

Mark Waller (03.08.15)

Deputy Chair/ Senior

Independent Director

X CHAIR X X

Frank Myers (31.03.16)

X CHAIR X CHAIR

Richard Humphries (09.11.2016)

X X CHAIR X

Andrew Cottom (09.11.2016)

X CHAIR X X Hoople Ltd

Christobel Hargraves (01.07.2015 –

30.6.2017)

X X X X X Stakeholder Group

Cancer Board

1. Each Committee features at least 3 nominated NEDs (including the Chair)

2. Chair of the Board may be invited by the AC Chair to attend AC

3. AC Chair may be invited by QC Chair to attend QC

4. A “non-member” NED can be invited to attend any Committee by the Committee Chair

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TRUST BOARD MEETING Report to: Trust Board Meeting “in public” Agenda item: 13 Date of Meeting: 1st October 2015 Title of Report: NHS Trust Development Authority – Self Certification Status of report: (decision and approval, position statement, information, confidential discussion)

For Approval

Lead Executive Director: Chief Executive Author: Company Secretary Appendices: 1 & 2


To provide the Board with the opportunity to review the monthly self-certifications as attached to this report prior to approval and submission to the NHS Trust Development Authority (NHSTDA). As part of the NHSTDA oversight and escalation, process (detailed within the Accountability Framework for NHS Boards) each Trust is required to self-report monthly against a number of requirements. These form part of the conversation with NHS Trusts in relation to on-going oversight as well as each organisation’s journey towards a sustainable organisational form. These cover: • Monitoring progress against the Trust’s timeline to sustainable organisational form • Compliance against Monitor Licencing Requirements • Self-assessment against Board Statements. The Act requires Monitor to introduce a licence for all providers of NHS services. The Act also requires everyone who provides an NHS health care service to hold a licence. The standard licence conditions are grouped into seven sections. Section 1 – General Conditions, sets out standard requirements and rules for all licence holders. Sections 2 to 5 of the licence are about new functions, Section 6 is about translating the core of the current oversight of NHS foundation trust governance into the new licence based system of regulation. Section 7 contains definitions and notes. There are 12 Conditions, which apply to Wye Valley NHS Trust. We are required to assess whether we are compliant, not compliant or at risk of compliance. If we are not compliant or at risk of compliance we are required to comment and give a timescale as to when the Trust will be compliant.

2. Recommendations To approve the attached self-certifications to be submitted to the NHSTDA on 2nd October 2015.

3. Summary of Key Issues for discussion The Board should note that it is currently declaring that it is ‘at risk’ of compliance in four of the Board Statements. These are statements 1, 6, 8 and 10. In addition to this the Board considers that the Trust is ‘not compliant’ with statement 5. Details of what will be submitted, in the form of a comment, to the TDA in relation to those areas ‘at risk’ and ‘not compliant’ are set out in Appendix 2.

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4. Reference to previous reports This report should reflect what is presented in the monthly Performance Reports to Board in addition to the Board Assurance Framework.


Nicola Licence, Company Secretary at [email protected] or Extension 5210


Background Care Quality Commission Implications Legal / NHS Constitution considerations Analysis of Risk including link to the Board Assurance Framework and Risk Register Adult & Child Safeguarding Resource Implications (staffing & financial) Patient, Public and Stakeholder involvement

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Appendix 1

Compliance with Monitor licence requirements Submission Date: 2nd October 2015 Reporting Year: 2015/16 Month: August 2015 1. Condition G4 Fit and proper persons as Governors and Directors Compliant

2. Condition G5 Having regard to Monitor Guidance Compliant

3. Condition G7 Registration with Care Quality Commission Compliant

4. Condition G8 Patient eligibility and selection criteria Compliant

5. Condition P1 Recording of information Compliant

6. Condition P2 Provision of information Compliant

7. Condition P3 Assurance report on submissions to Monitor N/A

8. Condition P4 Compliance with National Tariff Compliant

9. Condition P5 Constructive engagement concerning local tariff Modifications

Compliant

10. Condition C1 The right of patients to make choices Compliant

11. Condition C2 Competition oversight Compliant

12. Condition IC1 Provision of integrated care Compliant

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Compliance with Board Statements Submission Date: 2nd October 2015 Reporting Year: 2015/16 Month: August 2015 Declaration Compliance

(Yes, No, At Risk)

Timescale for compliance

1. Clinical Quality

The Board is satisfied to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the Trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

At Risk December 2015

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

Yes

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

Yes

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

Yes

5. Governance The Board shall ensure that the Trust remains at all times compliant with the NTDA Accountability Framework and shows regard to the NHS Constitution at all times.

No March 2016

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

At Risk January 2016

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

Yes

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

At Risk October 2015

9. An Annual Governance Statement is in place, and the Trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from H M Treasury.

Yes

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

At Risk March 2016

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

Yes

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

Yes

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

Yes

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

Yes

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Appendix 2

Declaration Compliance (Y - yes, AR – At Risk, N - No)

Evidence / Assurance / Comment where at risk of non-compliance

1. The Board is satisfied to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the Trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

AR The Trust’s CQC report indicated that the quality of its healthcare was inadequate and as a result the Trust was placed in Special Measures in October 2014. A robust Patient Care Improvement Plan has been developed to address the concerns highlighted in the report and robust reporting arrangements are in place to the Trust Board and Quality Committee. The Trust has an Improvement Director in place and is ‘buddying up’ with UHB. A work programme to support the Trust has been agreed with UHB. The PCIP is regularly monitored by the Executive Directors, Quality Committee (monthly) and the Trust Board (monthly). The Local PCIP is monitored by the Executive Directors in the form of ‘check and challenge’ sessions with the Service Unit Leads. A mock inspection took place on 11th August 2015 and feedback and ‘quick wins’ are currently being implemented. Peer Reviews and fresh eyes reviews continue to be undertaken. In addition to the above the Director of Nursing & Quality presents a Quality and Safety Overview Report from the Quality Committee to the Trust Board on a monthly basis. This report is also discussed at the monthly Service Unit Governance Meetings and challenged by the Executive at the monthly Service Unit Performance Meetings. The Trust is within the top five of all small acute Trusts for the levels of incident reporting with no increase in harm per 1000 bed days.

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

Y On-going compliance is assured through the Quality and Safety Overview report which is presented to the Quality Committee by the Director of Nursing and Quality. Compliance is also checked through patient safety walk rounds. The Quality and Safety Overview report contains a KPI to monitor CQC compliance with registration requirements.

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

Y The Medical Director has completed the Responsible Officer Training. The Revalidation Officer roles have been clarified.

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

Y Assurance is received via the Audit Committee as part of the Annual Accountability process. Assurance is also received from External Auditors via the Value for Money report and overall Value for Money Conclusion. Letter from the TDA states that the Trust is a going concern from April 2015-June 2016.

5. The Board shall ensure that the Trust remains at all times compliant with the NTDA Accountability Framework and shows regard to the NHS Constitution at all times.

N The Trust has not consistently delivered on the targets set out within the NHS Accountability Framework which relate to Quality, Performance and Finance and is therefore not compliant .

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

AR The Trust has identified the current key risks to compliance with the Accountability Framework and has trajectories in place for 4 hour wait, 18 RTT, diagnostic and cancer and a financial recovery plan is was developed and considered by the Finance and Performance Committee in August. However, the trajectories will not be delivered upon until January 2016 and the financial recovery plan will be beyond this date.

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

Y The Trust has identified the future key risks to compliance with the Accountability Framework and has trajectories in place for 4 hour wait, 18 RTT, diagnostic and cancer and a financial recovery plan has been developed. However, the trajectories will not be delivered upon until January 2016 and the financial recovery plan will be beyond this date.

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

AR An annual operating plan is in place has been formally approved by the Trust Board. A Governance Review has been undertaken and all actions within the action plan have been completed. Service Unit Governance arrangements are currently under review and an Executive Clinical Risk Committee is in place to review all risks with a rating of 12 and above. Audit recommendations continue to be tracked through the Audit Committee and Executive Directors.

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9. An Annual Governance Statement is in place, and the Trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from H M Treasury.

y The 2014/15 Annual Governance Statement was developed as part of the Annual Accounts approved by the Trust Board. The statement was developed in line with latest DH guidance. Prior to submission the Trust Executive Management Meeting reviewed the Governance Statement. The Audit Committee noted the process for the development of the Governance Statement. The Governance Statement was also reviewed by External Audit to ensure it was reflective of what had happened in the preceding year.

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

AR

Plans are in place to achieve compliance with the Accountability Framework and trajectories have been developed for 4 hour wait, 18 RTT, diagnostic and cancer and a financial recovery plan has been developed. However, the trajectories will not be delivered upon until January 2016 and the financial recovery plan will be beyond this date.

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

Y The Trust is compliant with level 2 on the IG toolkit. Compliance is monitored through the Information and IT Group, Chaired by the Director of Finance & Information.

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

Y The Company Secretary keeps and maintains the Register of Interests which was reviewed by external audit as part of the end of year processes. The Audit Committee monitors compliance of the process for registering and reviewing declarations of interests every six months. A report was made to the June Audit Committee with some further recommendations made to strengthen the process. The Trust Executive Management Meeting reviews the Register every six months. All Board positions are filled.

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

Y All Executive Director posts are filled and all have appropriate qualifications, experience and skills to discharge their functions effectively. A capacity and capability review of the Trust was undertaken on 10th and 11th March 2015, by Sir Ian Carruthers from the NHS TDA and a paper in response to the review was presented to the Trust Board Meeting ‘in private’ on 4th June 2015.

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

Y The Medical Director and Chief Operating Officer are currently undertaking a review of the structures, processes, reporting arrangements and capability of the Service Units.

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BLANK SHEET FOR ENCLOSURE 14a

QUALITY COMMITTEE REPORT

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BLANK SHEET FOR ENCLOSURE 14b

FINANCE & PERFORMANCE

COMMITTEE REPORT

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Acronym

AAU Acute Admissions Unit ACE Active Care for Everyone AKI Acute Kidney Injury A&E Accident & Emergency Department BAF Board Assurance Framework BGAF Board Governance Assurance Framework CAMHS Child and Adolescent Mental Health Services CAU Clinical Assessment Unit C. Diff Clostridium Difficile CCG Clinical Commissioning Group CIP Cost Improvement Plan CNST Clinical Negligence Scheme for Trusts COPD Chronic Obstructive Pulmonary Disease CQC Care Quality Commission CQUIN Commissioning for Quality & Innovation DCU Day Case Unit DNA Did Not Attend DNACPR Do Not Attempt Cardiopulmonary Resuscitation ECIST Emergency Care Intensive Support Team ED Emergency Department EDS Electronic Discharge Summary EPR Electronic Patient Record ESR Electronic Staff Record FAU Frailty Assessment Unit FOI Freedom of Information F&F Friends & Family FTE Full Time Equivalent GMC General Medical Council HCA Healthcare Assistant HSE Health & Safety Executive HSMR Hospital Standardised Mortality Ratio IHA Initial Health Assessment IMC Inpatient Medication Chart IPC Infection Prevention Control ITFF Independent Trust Financing Facility IV Intravenous KPIs Key Performance Indicators MRSA Methicillin-Resistant Staphylococcus Aureus MSSA Methicillin-Sensitive Staphylococcus Aureus NEWS National Early Warning Scores NHSH NHS Herefordshire NHSLA NHS Litigation Authority NICE National Institute for Health & Clinical Excellence NICETAG National Institute for Health & Clinical Excellence Technical Assurance Guidance NIV Non-invasive ventilation OBC Outline Business Case OOC Out Of County PALS Patient Advice & Liaison Service

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PAS Patient Administration System PCIP Patient Care Improvement Plan PFI Private Finance Initiative PLACE Patient Led Assessment of the Care Environment PHE Public Health England PROMs Patient Reported Outcome Measures QGAF Quality Governance Assurance Framework QIA Quality Impact Assessment RRR Rapid Responsive Review RCA Root Cause Analysis RHA Review Health Assessment RIDDOR Reporting of Injuries, Diseases & Dangerous Occurrences Regulations RO Responsible Officer RTT Referral to Treatment SDQ Strengths and Difficulties Questionnaire SOP Standard Operating Procedures SOC Strategic Outline Case SHA Statutory Health Assessment SHMI Summary Hospital Level Mortality Indicator SI Serious Incident SIRI Serious Incident Requiring Investigation SOP Standard Operating Procedure TEM Trust Executive Management TIA Transient Ischemic Attack TTO To Take Out TVN Tissue Viability Nurse TDA Trust Development Authority UHB University Hospitals Birmingham NHS Foundation Trust UTI Urinary Tract Infection VTE Venous Thromboembolism WHO World Health Organisation WMQRS West Midlands Quality Review Service WTE Whole Time Equivalent WVT Wye Valley NHS Trust YTD Year To Date 2g 2gether NHS Foundation Trust #NOF Fractured Neck of Femur

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