trust board meeting to be held on wednesday 24 april … papers... · 2017-09-12 · trust board...

TRUST BOARD MEETING TO BE HELD ON WEDNESDAY 24th

APRIL 2013IN ROOM 20063/64, CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY, CV2 2DX

PUBLIC AGENDA

THE PUBLIC SESSION OF THE TRUST BOARD WILL COMMENCE PROMPTLY AT 1.00PM

P:\Trust Board\Trust Board - Master File\2013\4 - APRIL 2013\PUBLIC\Enc 0 - AGENDA APRIL 2013 final (PUBLIC).doc

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

1 General Business Paper Presenter Category1.1. Apologies for Absence Verbal Chairman N/A

1.2.Minutes of Meeting held on 27

thMarch

2013*Enc 1 Chairman

N/A

1.3. Actions Enc 2 Chairman N/A1.4. Matters Arising Verbal Chairman N/A1.5. Declarations of Interest Verbal Chairman N/A1.6. Chairman’s Report Verbal Chairman N/A

1.7Private Trust Board Meeting Session Report– 27

thMarch 2013*

Enc 3 ChairmanN/A

1.8 Chief Executive’s Report Verbal Chief Executive Officer N/A

1.9 Integrated Performance Report Enc 4 Mrs G Nolan, Chief Finance OfficerQuality &

Safety

1.10 Provider Management Regime Enc 5Mr D Eltringham, Chief OperatingOfficer

Governance

2To Deliver Excellent Patient Care andExperience

Paper Presenter Category

2.1Infection Prevention and Control AnnualReport and Annual Plan

Enc 6Professor M Radford, Chief NursingOfficer

Quality &Safety

2.2 Francis Inquiry: Task & Finish Group Update Enc 7 Mr A Hardy, Chief Executive OfficerQuality &

Safety

3 To Deliver Value for Money Paper Presenter Category3.1 Signings & Sealings* Enc 8 Mr A Hardy, Chief Executive Officer Governance

3.2Finance & Performance Committee MeetingReport – 25

thFebruary 2013

Enc 9Ms S Tubb, Senior IndependentDirector

Governance

4 To be an Employer of Choice Paper Presenter Category4.1 Foundation Trust Application Update* Enc 10 Mr A Hardy, Chief Executive Officer Strategy

5To be a Research Based HealthcareOrganisation

PresenterCategory

No Reports

6To be a Leading Training and EducationCentreNo Reports

7 Administrative Matters7.1 Work Programme* Enc 11 Chairman Governance7.2 Register of Gifts and Interests* Enc 12 Mr A Hardy, Chief Executive Officer Governance7.3 Any Other Business Verbal Chairman

8 Questions from the Public up to 15 minutes

9 Date of Next Meeting:Wednesday 29

thMay 2013 starting at 13.00

Please note: asterisked items (*) are for noting and, in general, do not require discussion.

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

MINUTES OF THE PUBLIC MEETING OF THE UNIVERSITY HOSPITALS COVENTRYAND WARWICKSHIRE NHS TRUST BOARD HELD ON WEDNESDAY 27

thMARCH 2013

AT 1.00PM IN ROOM 20063/64, CLINICAL SCIENCES BUILDING, UNIVERSITYHOSPITAL, COVENTRY, CV2 2DX

1

AGENDA ITEMDISCUSSION ACTION

HTB 13/107PRESENT

Mr A Hardy, Chief Executive OfficerMrs G Nolan, Chief Finance Officer/Deputy Chief Executive OfficerMrs M Pandit, Chief Medical OfficerProfessor Radford, Chief Nursing OfficerMr T Robinson, Non-Executive DirectorMr T Sawdon, Non-Executive DirectorMr N Stokes, Deputy Chair (Chair)Ms S Tubb, Senior Independent DirectorProfessor P Winstanley, Non-Executive Director

HTB 13/108IN ATTENDANCE

Mr I Crich, Chief HR OfficerMrs J Gardiner, Trust Board SecretaryMrs Paula Young, Executive Assistant (note taker)

HTB 13/109APOLOGIES

Mr D Eltringham, Chief Operating OfficerDr P Sabapathy, Non-Executive DirectorMr P Townshend, Chairman

HTB 13/110MINUTES OFMEETING HELD27th FEBRUARY2013*

The Trust Board APPROVED the minutes of the meeting held onWednesday 27th February 2013 as a true record of the meeting.

HTB 13/111ACTIONS

Mrs Pandit advised in respect of item 13/072 (Integrated PerformanceReport) that the narrative provided regarding the HSMR figure wasreported correct at 76. It was noted that the average for 2012 was 94.

Mrs Pandit advised in respect of item 13/019 (Education Report) thatthe Trust had received funding from the Hillier Simulation Centre tosupport the running of the simulation courses.

It was noted that there had been no further media attention in respectof item 12/467 (Any other Business).

Mr Robinson observed that there have been a number of BoardSeminars cancelled recently, for very good reason. However, he notedhis concern that the Board need to consider the implications ofrecommendations contained within the report of the Francis Inquiry.The Chief Executive Officer concurred with this and thanked all thoseBoard members that had attended the presentation sessions deliveredto staff across the organisation. He added that the Government havepublished their initial response and the Executives will be setting upfrom next week a series of task and finish groups to look at groupingthe recommendations and will report back to the public session of theTrust Board in April. He added that Mrs White, Foundation TrustProgramme Director is already working to schedule the Francis Inquiry

Mr Hardy

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



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into the Board Seminar Programme.

In response to a query from the Chair, Mrs Gardiner advised that theChairman has indicated that he does not wish to cancel any furtherBoard Seminars; however, he is unable to commit at this stage to thenext Board Seminar scheduled for 8th May 2013.

The actions completed and actions in progress were NOTED.

HTB 13/112MATTERSARISING

There were no matters arising.

HTB 13/113DECLARATIONSOF INTEREST

There were no declarations of interest.

HTB 13/114CHAIRMAN’SREPORT

The Chair noted that he not been provided with an update from theChairman to report.

HTB 13/115PRIVATE TRUSTBOARD MEETINGSESSIONREPORTS – 27th

FEBRUARY 2013*

The Chairman advised that the purpose of the report is to advise of theprivate Trust Board session meeting agenda held on 30th January 2013and any key decisions or outcomes made by the Trust Board.

The Board NOTED the contents of the report.

HTB 13/116CHIEF EXECUTIVEOFFICERSREPORT

The Chief Executive Officer noted that he, the Chief Medical Officerand Chief Nursing Officer attended the Clinical Summit held on 18th

March 2013, of which the key note speaker was Robert Francis, QC.

The Chief Executive Officer reported that the Trust has experiencedunprecedented emergency care pressures in recent weeks, which hasimpacted on elective care. The Trust hosted a very successfulExpediting Emergency Care Conference on 7th March 2013; credited toMr Eltringham, which was attended by healthcare organisations withinthe region. There were a number of national speakers present at theconference; the aim of which was to bring together organisations toshare ideas and learn from each other. The Trust intends to host otherleadership events and Executives are currently working on puttingtogether a programme of future events.

The Chief Executive Officer provided a brief summary of the nationalfocus on emergency pressures and advised that he would providefurther detail in the private session of the Trust Board.

The Chief Executive Officer was pleased to report that feedback fromthe Royal College of Obstetricians and Gynaecologists following arecent visit is that UHCW NHS Trust is one of the most impressivehospitals visited.



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Ms Tubb queried what big ideas or challenges came out of theExpediting Emergency Care Conference hosted on 7th March 2013.The Chief Executive Officer responded that there were no light bulbmoments but different observations on the emergency pressures thatare affecting the NHS nationally. The Emergency Department modelpresented by UHCW NHS Trust was considered to be exemplar. Thekey message received was that this is a system issue and attentionneeds to be focused on what can be controlled. Mrs Pandit added thatit is acknowledged that the 4-hour A&E target was introduced withoutclinical engagement.

Professor Winstanley suggested that required is a community basedproactive role that interacts between the GP’s and Acute Trusts. Headded that the problem does not sit in A&E but that patient demandshave changed nationally and the NHS is not prepared for this.Professor Winstanley advised that he would provide further comment inthe private session of the Trust Board.

The Trust Board RECEIVED and ACCEPTED the Chief ExecutiveOfficers Report.

HTB 13/117QUALITYSTRATEGY

The purpose of the report is for the Trust Board to consider the revisedQuality Strategy and to approve and support its implementation.

The Quality Strategy has been reviewed and revised to support theTrust’s strategic objective to become a national and international leaderin healthcare. It will support the Trust’s Clinical Strategy by ensuringthat clinical pathways are underpinned by appropriate systems andprocesses for planning, delivery and monitoring of the quality of care inthose pathways It takes account of key national quality drivers.

Mrs Pandit praised Paul Martin, Director of Governance, YvonneGatley and Anita Kane, Associate Directors of Governance and MrsGardiner for their considerable contribution to the document.

Professor Winstanley observed that he has been very impressed withthe patient experience focus of the Trust. Professor Radford confirmedthat work around the patient experience revolution agenda will bepresented to the public session of the Trust Board in May.

In response to a query from Mr Sawdon; Mrs Pandit advised thatimplementation of the quality strategy will be monitored by the QualityGovernance Committee through tracking of the quality metrics, whichare fed into the Integrated Performance Report.

Ms Tubb queried that the document does not provide the finer detail ofwho is responsible and associated deadlines. Mrs Gardiner advisedthat there will be a delivery plan for each of the three themes(effectiveness, safety and experience) underpinning the strategy, whichare currently works in progress.

ProfessorRadford



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Mr Robinson queried that the review date for the strategy (June 2015)seems some distance away. Mrs Pandit responded that when thedocument goes live in June 2013, there will be a huge amount of workto embed which is likely to take two years. Periodically assurance willbe provided at the Quality Governance Committee through the qualitymetrics that feed into the Integrated Performance Report, which will bepresented to both Quality Governance Committee and Finance &Performance Committee from June 2013.

The Trust Board APPROVED the Quality Strategy and NOTED thatdelivery is linked to the Integrated Performance Report.

HTB 13/118ANNUALFINANCIAL PLAN

The purpose of the report is to present the annual financial plan forapproval by the Trust Board.

The plan incorporates both the revenue and capital plans for 2013/14and outline plans for future years.

Revenue PlanThe 2013/14 plan is based on delivering a £5m surplus with a CostImprovement Target of £25m.

Capital PlanCapital expenditure totalling £19.2m is proposed for 2013/14. The planis financed primarily through internally generated funds includingdepreciation charges and a revenue surplus, but also assumes acapital investment loan of £5.1m and a public dividend capital injectionof £1.7m from the Department of Health’s energy efficiency fund.

Negotiations are continuing with the Trust’s main commissioners, andtherefore the commissioner income figure contained within the planreflects an assessment at a point in time.

The financial plan is not predicated on achieving a Monitor FinancialRisk Rating of 3. The current forecast FRR shows a score of 2Liquidity continues to be a concern for the Trust.

Key risks are around the delivery of revenue surpluses and theapproval of the capital investment loan and public dividend capitalinjection which underpin the capital programme. If these risksmaterialise, the capital programme will need to be reviewed andreprioritised accordingly.

Mrs Nolan advised that the plan has been discussed in detail at theFinance & Performance Committee on 25th March 2013, at which it wasagreed that the Finance & Performance Committee would recommendto the Board that the projected surplus for 2013/14 be redefined as£2.5m. The difference between this and the initial surplus of £5m isproposed as a contingency against substantial resources required tosupport the transformation process, and drive efficiencies out of theorganisation whilst ensuring patient quality. In addition, the Finance &Performance Committee recommended that the working capital loan



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that is being applied for is increased by £2.5m and the proposed capitalinvestment plan remains otherwise unchanged.

Ms Tubb urged caution and advised that there are significant risksassociated with the financial plan and that it should not be presentedas a definitive plan, not least because of the ongoing negotiations withCommissioners.

The Chair observed that the underlying issues of liquidity were furtherchallenged when the Trust was unable to secure a loan from theDepartment of Health. Mrs Nolan responded that there will be a newset of negotiations to be had in 2013/14. Long-term affordability will bechallenged; however, the Trust needs to borrow to sustain businessand visa versa. There has been a degree of sympathy received fromthe NHS Trust Development Authority (NTDA), who have offeredslightly different advice to that provided by the Strategic HealthAuthority (SHA).

The Trust Board;

APPROVED the 2013/14 revenue plan and associated costimprovement programme and note the indicative revenue plan for2014/15 and 2015/16.

APPROVED the capital expenditure programme for 2013/14 and notethe indicative programme for 2014/15 to 2017/18.

HTB 13/119INTEGRATEDPERFORMANCEREPORT

The purpose of the report is to inform the Board of the performanceagainst the key agreed dashboard indicators for the month of February2013.

Broadly there has been a month-on-month deterioration in performancein a number of the domains with 30 of the 52 KPIs now breaching thestandard / target in this latest report.

Pressure on the non-elective pathway appears to be having a negativeeffect on a number of wider Trust KPIs. Given the level of operationalpressure on the organisation the primary focus is on ensuring patientsafety.

Excellence in Patient Care

In February there were 8 Clostridium Difficile infections recorded. TheTrust cannot now achieve performance this year against theClostridium Difficile KPI. Year to date there have been 71 cases whichis 6 (9%) above the trajectory of 65 cases and 1 above the yearlytarget. A consolidated action plan has been developed to mitigateagainst further deterioration in readiness for an even more challengingtarget in 2013/14. This includes Professor Radford leading twiceweekly performance meetings, an increase in infection control roundsat ward level, enhanced cleaning program in high risk areas, increasedanti-biotic surveillance and full root cause analysis of all incidences.Professor Radford added that the Trust have received support from the



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SHA to review all cases and indications are that there are 10 caseswhich should not be attributed to the Trust. The Trust will present aclinical case to the Clinical Commissioning Groups to request that thefigure of hospital acquired C-Difficile cases is rebased.

Procedural Note: Professor Winstanley left the meetingThe Chief Executive Officer observed that the Trust is a victim of itsown success; adding that the target is based on the achievements ofthe previous year. Ms Tubb noted that the significant numbers ofpeople waiting in A&E would presumably add to the infection controlchallenge.

Procedural Note: Professor Winstanley re-joined to the meeting.The Trust recorded three instances of grade 3 pressure ulcers duringFebruary 2013, although subsequent root cause analysis has identifiedthat only 1 instance was deemed avoidable. The target is 0.

Excellence in Patient Experience

The Trust has recorded 86% against the A&E 4 hour wait target. Thisis the 5th consecutive month below the 95% standard.

Last minute cancellation of operations remains high for the secondconsecutive month.

The Trust has now seen a significant increase in the number ofbreaches of the 28 day readmission guarantee (up to 8.79%). It wasacknowledged that pressures experienced in ED had contributed to thenumber of patients whose operations were cancelled for non-clinicalreasons on the day, or after admission and who were not treated within28 days.

The Trust has seen a worsening of the successful choose and bookKPI with performance at 12.64%.

The net promoter score has deteriorated in February to 47. The Trustneeds to achieve a score of 54 in March to achieve this KPI. It wasnoted that the Trust is required to sample a minimum 15% of all clinicalareas from 1st April 2013 going forward.

Delivery Value for Money

The Trust is currently reporting a net surplus of £1.5m (Month 10 -£1.9m surplus), which is a £0.4m adverse variance from plan.

The forecast outturn remains at £2.5m surplus for 2012/13.

Employer of Choice

The appraisal completion rate has worsened to its lowest level sinceJuly 2011 with sickness improving to its lowest level in 6 months andtherefore getting closer to the KPI.

Mandatory training performance data is unavailable for the 2ndconsecutive month.



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The Chair observed that the report was disappointing butacknowledged that the Trust is facing some very difficult challengeswith the 4-hour wait A&E target. The Trust’s focus is and will remainpatient safety and quality of care, and if necessary at the cost of notmeeting the performance target. Mr Sawdon added that the challengespresented in A&E have an impact on all of the other performancemetrics.

Ms Tubbs queried that the Acute Medical Unit (AMU) has been in placefor approximately eight weeks; however, during the course of thisperiod the Trust has failed to meet the 4-hour A&E target. The ChiefExecutive Officer responded that upon implementation, the Trustobserved a short period of positive impact which he acknowledged hassince deteriorated. The Chief Executive Officer, Chief Medical Officerand Chief Nursing Officer met with the consultant body today whoconfirmed that they believe that the Trust is following the correct clinicalmodel in ED. However, it is recognised that the model works well whenthe back end flow of the hospital is working.

Ms Tubb reported that nursing staff have advised that the patient flowis obstructed when medical cover is removed from ED. Mrs Panditassured the Board that junior doctors are working in ED supported by24 hour consultant presence, in addition to the doctors working in theAMU.

Mrs Pandit advised that it was helpful to meet with the Physicians todayto explore the views of the wider consultant body. She added that otherorganisations are experiencing the same challenges but many aretaking differing approaches. The Executives at UHCW NHS Trustrecognise the importance of engaging with the consultant body andassessing the skill base to determine the correct clinical model for ED.

Mr Sawdon queried what the overall cost is for cancelling electiveactivity. Mrs Nolan confirmed that the penalty failure for not complyingwith targets is circa £300,000 annually. In addition, the incrementalmeasures to support ED and patient flow in year is £1m, but full year isexpected to be £4m, this is not provided for within the financial plan.

The Chief Executive Officer reported that he and the Chief FinanceOfficer have this morning met with representatives of BMI Hospital andhave successfully managed to negotiate an agreement in relation to acontract issue, which has been ongoing for 10 years. Discussions arecontinuing with BMI to explore the potential for using capacity at BMIon an ongoing basis, which will be based on the national tariff.

Discussion ensued in relation to the arrangements for covering acutemedical admissions on-call. The Chair requested that furtherdiscussion be referred to the private session of the Trust Board.

It was noted that historically there had been seasonal dips in activity(between May – July). However, there is no expectation that activityfigures will change, despite the formation of Clinical Commissioning



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Groups.

The Chair queried why there had been difficulty obtaining informationfor attendance at mandatory training. Mr Crich advised that this hasbeen as a direct result of software system failure.

Ms Tubb queried that there has been a month by month decline in thecompliance figures for completed appraisals. Mrs Pandit acknowledgedthat further analysis by sub-group is required to address this issue. MrCrich advised that he would provide further clarity on this in the privatesession of the Trust Board.

Mr Crich was pleased to report that sickness absence rates haveimproved which is a step in the right direction.

The Trust Board RECEIVED and ACCEPTED the February 2013Integrated Performance Report and NOTED the associated actions.

HTB 13/120PROVIDERMANAGEMENTREGIME

The SHA wide Provider Management Regime (PMR) has been rolledout which each Trust is required to complete on a monthly basis.

The PMR process has been fully operational from April 2012 onwards.This regime was introduced to support Trusts, by working with the SHAin a “Monitor like” way, to help prepare Trusts for their DH and MonitorFoundation Trust assessment and subsequent monitoring postauthorisation under the Monitor Compliance Framework.

The regime provides an opportunity for providers to earn autonomyfrom the SHA. Providers who can demonstrate consistent performanceof governance, finance, quality and contract management will makeless frequent PMR returns and meet with the SHA less often than thoseTrusts that face issues. There is also a clear escalation process forTrusts with persistently poor ratings or other issues. The detailedprocesses and rules by which a Trust can gain autonomy or might faceescalation are outlined within separate SHA guidance.

The Governance Risk Rating of Red (4.0) for February 2013 isbecause the overriding rule was applied by the SHA in January 2013which automatically gave an overall weighting of 4. This hasretrospectively been applied back to October 2012.

The scoring in the revised PMR return has changed so that a GRRweighting of greater than or equal to 1 but less than 2 will give a ratingof Amber/Green (in the previous version used for reportingperformance for July to October 2012 a score of 1 or under gave arating of Green). The SHA clarified this change in January 2013.Furthermore, the SHA are in the process of resolving an error in theGRR section of the PMR template which is incorrectly applying anadditional weighting against the c-diff metric. The Contractual Positionis no longer rated in the PMR return and guidance from the SHA is thatthis should be reported as “Blank”.

Specified areas of insufficient assurance and associated actions are:



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A&E - maximum waiting time of four hours from arrival toadmission/transfer/discharge: ED and CDU were reconfigured to anED/AMU model during February. This included an ambulatoryacute clinic running 7 days a week. The continuation of a GP led‘on site’ Urgent Care Centre running 7 days a week. A daily ‘Healthand Social Care’ economy teleconference to tackle delays insupported discharge. The implementation of a ‘pod’ – site safetyand capacity management – system. The Leadership Team haveconsolidated all actions being taken to address this issue into asingle consolidated action plan which deals with: Reconfiguration ofED and CDU to an ED/AMU model, Prehospital, Arrival at ED,Capacity and flow, Internal discharges, External discharges. Theplan is subject to performance management at Tuesday andThursday meetings with Clinical Directors.

C-diff: A single consolidated action plan has been developed toregain trajectory. This includes: CNO leading - twice weekly C Diffperformance meeting (Executive); DIPC leading actions withclinical and operational teams; Increased Infection control rounds atward level (IPC, 2xPAs Medical, Additional Nursing); AdditionalEnhanced cleaning program in high risk areas (ISS andPerformance team); Increased antibiotic surveillance (Pharmacy);Increased education and awareness program; Full RCA andinformation sharing for C diff cases; Trust initiated external reviewof actions through SHA lead infection nurse and CCG

Financial Risk Rating (FRR) - The Trust is reporting an FRR of 2based on the year-to-date position. The governance declaration isnow based on the year-to-date FRR (forecast outturn in previousmonths) as per a change in the SHA guidance. The year-to-dateposition means an FRR of 2, although this remains the Trust planfor this point in the year. The Trust continues to forecast an FRR 3for the financial year, with the improvement being delivered bydelivery of the forecast surplus position.

Board Statement 4 – The board anticipates the Trust will continueto maintain a financial risk rating of at least 3 over the next 12months. The 2013/14 financial plan is currently forecast to have afinancial risk rating (FRR) of 2. This is due to the liquidity metricbeing less than 10 days. This has been impacted during 12/13 byfailure to secure capital investment borrowing. The route toimproving liquidity is to:

o Target increasing revenue surpluses;o Reduce outstanding debtors;o Ensure capital investment financing does not adversely

impact upon liquidity

It is noted that if the Board does not self-certify against BoardStatement 4, UHCW could be deemed to be in escalation by the SHA.

The Overriding Rule which has been applied by the SHA is:

A&E Clinical Quality Indicator: UHCW did not achieve the 95%, 4-hourA&E target in Q4 2011/12. The target was not achieved in Q1



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2012/13. UHCW has therefore failed to meet the A&E target twice inany two quarters over the last 12 months. UHCW did not achieve thetarget in October, November or December 2012 and January andFebruary 2013 and at the time of writing this report achievement of thetarget for March 2013 was at risk. The SHA have confirmed theoverriding rule has been applied retrospectively from October 2012because this target has been failed in the subsequent nine-monthperiod from Q1 2012/13. This means that UHCW is in escalation.However, the SHA have advised that they will recommend mitigation ofUHCW’s red status due to the overriding rule for A&E if there isevidence of a sustained improvement and delivery against the A&Etarget for a 6-month period.

The Trust Board;

APPROVED the Provider Manager Regime return based on February2013 data for onward submission to the SHA.

CONFIRMED its support for Governance Declaration 2 (for insufficientassurance that all targets are being met) in relation to the FinancialRisk Rating, A&E and C-diff.

AGREED not to self-certify against Board statement 4, in line with thecurrent 2013/14 financial plan.

DELEGATED authority to the Chair to sign the PMR in the absence ofthe Chairman.

HTB 13/121FINANCE ANDPERFORMANCECOMMITTEEMEETING REPORT– 28th January2013*

The Trust Board ACCEPTED the contents of the Finance andPerformance Committee Report.

HTB 13/122FINANCE ANDPERFORMANCEToR*

The purpose of the report is to review and approve the Finance andPerformance Committee’s revised Terms of Reference.

Ms Tubb noted that in respect of item 3.2; Mr Robinson as Chair of theAudit Committee cannot hold the position of vice-chair for the Financeand Performance Committee and therefore, discussion will need to beheld on appointment of the new Non-Executive Directors to addressthis.

The Trust Board is REVIEWED and APPROVED the updated terms ofreference for the Finance and Performance Committee.

HTB 13/123AUDITCOMMITTEEMEETING REPORT– 19th NOVEMBER

It was noted that the conclusions of the review of the finance functionhas been deferred for discussion to the April meeting of the Financeand Performance Committee.

The Trust Board ACCEPTED the contents of the Audit Committee



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2012* Report.

HTB 13/124AUDITCOMMITTEE ToR*

The purpose of the report is to review and approve the AuditCommittee’s revised terms of reference.

Audit Committee, after considering its ToR in respect of decisionsrelating to write-offs and special payments, recommended to the TrustBoard that it will no longer receive regular reports on all redundancyand compromise agreements.

Mr Crich expressed concern that referring the approval process to theHR Committee would not be robust enough. The Chief ExecutiveOfficer demonstrated sympathy for Mr Crich’s comments but advisedthat guidance is clear that the Audit Committee must remainindependent and therefore, he must agree with the proposedrecommendation.

Procedural Note: Professor Winstanley left the meetingHTB 13/124AUDITCOMMITTEE ToR*

Mr Robinson suggested that a compromise would be for guidelines tobe clear that the Audit Committee does not have a decision makingrole, but receives assurance from the relevant HR Committees thatapproval via the Quality Governance Committee has been received. Itwas agreed that the Chair of Audit and the Chief HR Officer woulddiscuss how this process would operate.

The Trust Board;

REVIEWED and APPROVED the updated terms of reference for theAudit Committee.

RECOMMENDED that mechanisms are in place to allow for the AuditCommittee to receive assurance from the HR Committees.

Mr Crich

Procedural Note: Professor Winstanley re-joined the meeting.HTB 13/125BOARDASSURANCEFRAMEWORK*

The Board is responsible for identifying its principal objectives, settingannual targets and having systems in place to manage its principalrisks. The Trust Board will undertake an annual risk identification andassessment exercise to identify business critical risks which threatenachievement of the organisation’s strategic priorities and determine thelevel of acceptability of these risks. The output of this assessmentforms the basis of the Trust Board Assurance Framework (BAF).

It is the duty of Trust Board members to ensure that they appropriatelymonitor the BAF and obtain assurances that the controls in place tomanage risks in order to achieve the organisational objectives areeffective and operating as intended. They do this by receiving thepopulated BAF detailing the totality of risks to the strategic objectivesand considering whether risks are being appropriately managed andmitigated by seeking the following assurances;

Do the controls mitigate the risks? Are there areaswhich require further control?

Are the assurances sought adequate? Are there areaswhich require further assurances?

Do resources need allocating to bring controls and



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assurances to the required level? Does the BAF influence the Board agenda?

In addition, the Trust Board will focus on the high risk areas of the BAFby reviewing the red BAF risks as part of monthly risk register report toTrust Board.

Mrs Pandit advised that Mrs White, Foundation Trust ProgrammeDirector is working to schedule a risk mapping process within the BoardSeminar Programme.

Ms Tubb observed that the improvements made demonstrate a clearlink between BAF and corporate risks. The Risk Committee thismorning agreed to dedicate 20-30 minutes of each meeting, in order toidentify early warning indicators/prospective risks, which will addanother link to support the increased robustness of the BAF process.

In response to a query from Mr Sawdon; the Chair advised that theBAF report is presented today for noting only, and assured thatdiscussion and debate takes place in other forums.

Mr Sawdon sought further clarification as to how the detail containedwithin the BAF had been arrived at. Mrs Gardiner responded that theChief Officers have now updated their risks according to the minimumdata fields agreed at the Risk Committee meeting on 28/06/12. Eachrisk requires controls and assurances to be determined and riskassessment in terms of likelihood and consequence. For each gap incontrol, gap in assurance or negative assurance identified, anappropriate action should be defined to address this. Risks should onlybe closed where they are appropriately mitigated i.e. when the currentrisk level and the target risk level are the same (this is the level of riskappetite that the Trust is willing to accept).

The 2012/13 BAF has been considered previously by private TrustBoard and Audit Committee. The 2013/14 BAF will be updatedfollowing a risk mapping session in May/June 2013.

The Trust Board;

ENDORSED the process followed to date to compile the 2012/13 BAF.

REVIEWED and ACCEPTED the Board Assurance Framework for2012/13.

HTB 13/126FOUNDATIONTRUSTAPPLICATION*

The purpose of the report is to provide an update on the progress andtimeline for the Foundation Trust status application and report ondecisions made by the FT Steering Committee.

The FT Steering Committee and the Project Team met on 11th March,2013 to review the Master Action Plan.

UHCW NHS Trust has submitted a revised timeline to the SHA. Thecurrent risks impacting upon achievement of foundation trust status



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are:

The deteriorating performance in A&E The action needed to achieve the financial requirements set out

by Monitor.

It was noted that the Trust had yet to receive written feedback on therevised timeline submission.

The Trust Board RECEIVED and ACCEPTED this report.

HTB 13/127WORKPROGRAMME

The Trust Board NOTED the Work Programme.

HTB 13/128ANY OTHERBUSINESS

There was no other business noted.

HTB 13/129QUESTIONS FROMTHE PUBLIC

There were no questions from the public.

HTB 13/130DATE OF NEXTMEETING

The date of the next meeting is Wednesday 24th April 2013 at 1.00pmin the Clinical Sciences Building, University Hospital, Coventry CV22DX.

HTB 13/131APPROVAL OFMINUTES

These minutes are approved subject to any amendments agreed at thenext Trust Board meeting.

SIGNED……………………………………………..

CHAIRMAN

DATE……………………………………………..

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

24th April 2013

Red = outstandingBlack = in progress not yet dueGreen = complete

Unless a date is specified it will be assumed that the date for completion is the 1st Monday following the next Trust Board.

- 1 -

AGENDA ITEM ACTION LEAD DATE TO BECOMPLETED

COMMENT

ACTIONS IN PROGRESSHTB 13/124 (27.3.13)AUDIT COMMITTEEToR*

RECOMMENDED that mechanics are in place toallow for the Audit Committee to receiveassurance from the HR Committees.

IC 29.4.13

ACTIONS COMPLETEHTB 13/019 (30.1.13)EDUCATION REPORT

The Trust Board RESOLVED to explorealternative sources of funding to supporteducation and training including but not limited toCoventry University, Warwick University and anyappropriate charities.

MP 4.3.13 Mrs Panditadvised atTrust Board on27.3.13 that theTrust hadreceivedfunding fromthe HillierSimulationCentre tosupport therunning of thesimulationcourses.

HTB 13/072 (27.2.13)INTEGRATEDPERFORMANCEREPORT

Mr Stokes noted that the HSMR figures on page11 of the report do not correspond with thatreported on page 7. Mrs Pandit advised that shewould look into this and provide Mr Stokes with anupdate directly.

MP 1.4.13 Mrs Panditconfirmed atTrust Board on27.3.1.3 thatthe narrativeprovidedregarding theHSMR figurewas reportedcorrect at 76.

ACTIONS 13/111(27.3.13)

Mr Robinson observed that there have been anumber of Board Seminars cancelled recently andnoted his concern that the Board need to considerthe implications of recommendations containedwithin the report of the Francis Inquiry. The ChiefExecutive Officer concurred with this and addedthat the Government have published their initialresponse, and Executives will be setting up fromnext week a series of task and finish groups tolook at grouping the recommendations and willreport back to the public session of the TrustBoard in April.

AH 29.4.13 Scheduled forTrust BoardApril

REPORTS SCHEDULED FOR NEXT MEETINGHTB 13/117QUALITY STRATEGY

Professor Winstanley observed that he has beenvery impressed with the patient experience focusof the Trust. Professor Radford confirmed thatwork around the patient experience revolutionagenda will be presented to the public session ofthe Trust Board in May.

MR Scheduled forMay TrustBoard

REPORTS SCHEDULED FOR FUTURE MEETINGSHTB 12/410 (26.9.12)PERFORMANCEREPORT

The Board will look to have more formal periodicalmeetings with the CCG’s to engage with them andbuild up good solid working relationships. TheChairman requested that Mrs Gardiner facilitate a

JG July 2013 Exec to Execmeetings withCCG’s on24.10.12 and

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

24th April 2013

Red = outstandingBlack = in progress not yet dueGreen = complete

Unless a date is specified it will be assumed that the date for completion is the 1st Monday following the next Trust Board.

- 2 -

AGENDA ITEM ACTION LEAD DATE TO BECOMPLETED

COMMENT

HTB 12/460 (31.10.12)SUSTAINABLESPECIALTIES &FRAIL OLDERPEOPLESPROGRAMME

meeting in the next 2-3 months. Mrs Gardineradvised that she will need to take guidance fromthe CCG’s in terms of whether they yet have fullBoard appointments.

Dr Sabapathy suggested that this be the first itemfor discussion on the Board to Board agenda withthe CCG’s as a topic for partnership working.

JG As above

21.11.12 bothcancelled byCCG. CEOconfirmed withCCGAccountableOfficer that theCCG does notrequire Boardto Boardmeetings at thistime. To bereviewed in sixmonths i.e. July2013

ACTIONS REFERRED TO TRUST BOARD SUB-COMMITTEESHTB 13/012 (30.1.13)MORTALITY REPORT

REQUESTED that the Trust Board Secretaryarrange to schedule the Francis Report as an itemon a Board Seminar agenda in March 2013.

REQUESTED that a list be made available to theBoard Seminar in March relating to the level ofcomplaints received regarding to mortality issuesfor three years prior to 31

stMarch 2013.

JG

MP

4.3.13 Scheduled for6.3.13; but B/Scancelled. Tobe rescheduled


REPORT TO THE TRUST BOARD: PUBLIC

24th

April 2013

Enc 3 - Chairman's report March 2013 I/\trust board\templates\revised header public\Version 2\January 2010

Subject: Trust Board Meeting Session Reports of 27th

February 2013Report By: Philip Townshend, ChairmanAuthor: Jenny Gardiner, Trust Board SecretaryAccountable Executive Director: Philip Townshend, Chairman

GLOSSARYAbbreviation In Full

WRITTEN REPORT (provided in addition to cover sheet)? Yes No

POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papers

TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:To advise the Board of the private Trust Board Session meeting agendas for 27

thMarch 2013 and of any key

decisions/outcomes made by the Trust Board.

Chairman’s Report: Mr N Stokes, Deputy ChairThe Trust Board NOTED the Chairman’s report.Chief Executive’s Report: Mr A Hardy, Chief Executive OfficerThe Trust Board RECEIVED and ACCEPTED the Chief Executive Officer’s report.Patient Story: Mrs M Pandit, Chief Medical OfficerThe Trust Board NOTED the patient’s story.Quality Governance Committee Chairs Meeting Report – 12

thMarch 2013: Mr T Sawdon, Non-Executive

DirectorThe Trust Board NOTED the Quality Governance Committee Chairs Report.Quality Governance Committee Draft Minutes of the Meeting – 12

thMarch 2013: Mr T Sawdon, Non-

Executive DirectorThe Trust Board ACCEPTED the Quality Governance Committee meeting report of 12

thMarch 2013.

Nolan Principles/NHS Code of Conduct/UHCW Code of Conduct Policy Statement: Mr I Crich, Chief HROfficerThe Trust Board;

ENDORSED its commitment to the Code of Business Conduct in the form of an annual declaration signed byeach Board Member and retained on file.

NOTED the declarations of eligibility and independence and discussed potential issues highlighted.Integrated Performance Report Issues Escalated from Public Board: Mr N Stokes, Deputy ChairThe Trust Board NOTED the verbal update.IG Toolkit Submission: Mrs M Pandit, Chief Medical OfficerThe Trust Board APPROVED the 2012/13 submission of the IG Toolkit.Annual Plan: Mrs G Nolan, Chief Finance OfficerThe Trust Board;

AGREED the Corporate Annual Plan at the level it is presented today.AGREED the Detailed Financial Plan.

Trust Board received assurance from Finance and Performance Committee to;

AGREE the Annual Plan submission to the NHSTDA.

NOTE the example Delivery Agreement for Trauma & Orthopaedics.



24th

April 2013

Enc 3 - Chairman's report March 2013 I/\trust board\templates\revised header public\Version 2\January 2010

NOTE the latest process/timeline to review the UHCW Planning Framework.Delivery of Action Plan from External Reviews: Mr A Hardy, Chief Executive OfficerThe Trust Board RECEIVED and ACCEPTED the updated FT Master Action Plan.Pathology Stakeholder Agreement: Mr A Hardy, Chief Executive OfficerThe Trust Board;

AGREED to continue with the CWPS governance arrangements for a further year during 2013/14

NOTED that the Stakeholder Board is tasked with ensuring that there is a resourced programme of work todeliver an evaluation of options in a timely way in the form of a Business Case or Options Appraisal Document.

AGREED for a further report to be presented to the Board before March 2014.Clinical Negligence, Personal Injury and ET Claims Report: Mr A Hardy, Chief Executive OfficerThe Trust Board RECEIVED and ACCEPTED the report.Finance and Performance Committee Chairs Meeting Report – 25

thMarch 2013: Ms S Tubb, Senior

Independent DirectorThe Trust Board NOTED the Finance and Performance Committee Chairs Meeting Report of 25

thMarch 2013.

Draft Finance and Performance Committee Meeting Report – 25th

February 2013: Ms S Tubb, SeniorIndependent DirectorThe Trust Board ACCEPTED the Finance & Performance Committee meeting report of 25

thFebruary 2013.

IMRT Consultant Business Case: Mr A Hardy, Chief Executive OfficerThe Trust Board;

APPROVED commencement of the recruitment process.

NOTED that if income is confirmed the £448,000 financial risk will be mitigated.

NOTED that if income is not confirmed, the case will need to be brought back to Planning Unit with the Board’sproposal to mitigate the financial risk.Extension of Lease at the Hospital of St Cross: Mr I Crich, Chief HR OfficerThe Trust Board AGREED to proceed to grant an extension of the lease rooms at Redwood House, Hospital ofSt Cross to Warwickshire County Council for a term expiring 31

stMarch 2015.

SUMMARY OF KEY RISKS:No risks were identified.

RECOMMENDATION / DECISION REQUIRED:For Noting.

IMPLICATIONS:Financial: N/A

HR / Equality & Diversity: N/A

Governance: N/A

Legal: N/A

REVIEW:Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:Data/information Source:Data Quality Controls:Data Limitations:



24 April 2013

Trust board/templates/header sheet (public) version 6 – August 2011

Subject: Integrated Performance Report – Month 12 – 2012/13Report By: Gail Nolan, Chief Finance OfficerAuthor: Jonathan Brotherton, Director of Performance and Programme

ManagementLynda Cockrill, Head of Performance and Programme AnalyticsSarah Oakley, Head of Performance and Programme Finance

Accountable Executive Director: Gail Nolan, Chief Finance Officer

GLOSSARY

Abbreviation In FullA&E Accident and EmergencyALOS Average Length of StayAMU Acute Medical UnitCAB Choose and BookCIP Cost Improvement ProgrammeDNA Did Not AttendEBITDA Earnings Before Interest, Tax, Depreciation and AmortisationED Emergency DepartmentFRR Financial Risk RatingFTE Full Time EquivalentHRED Human Resources Equality and DiversityHSMR Hospital Standardised Mortality RatioKPI Key Performance IndicatorNIHR National Institute for Health and ResearchNPS Net Promoter ScorePMR Provider Management RegimePPMO Performance and Programme Management OfficeQIPP Quality Innovation Productivity and PreventionQPS Quality and Patient SafetyRTT Referral To TreatmentSHMI Standardised Hospital-level Mortality IndicatorVTE Venous ThromboembolismWTE Whole Time EquivalentYTD Year To Date



TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:

To inform the Board of the performance against the key agreed dashboard indicators for the month of March2013



24 April 2013


SUMMARY OF KEY ISSUES:

In this report, 26 of the 52 KPIs reported against (50%) are breaching the standard / target. This compares to30 (58%) in the previous month.

Pressure on the non-elective pathway appears to be having a negative effect on a number of wider Trust KPIs.Given the level of operational pressure on the organisation the primary focus is on ensuring patient safety.

Principal performance exceptions by Domain

Excellence in patient care• In March there were 5 Clostridium Difficile infections recorded. The Trust did not achieve performance

this year against the Clostridium Difficile KPI.

Excellence in patient experience• The Trust has recorded 81.51% against the A&E 4 hour wait target. This is the 6th consecutive month

below the 95% standard and is set against the context of widespread sub-95% performance across allbut one of the West Midlands NHS Trusts during quarter four.

• Last minute cancellation of operations remains high for the third consecutive month.• The Trust has seen a further significant increase in the number of breaches of the 28 day treatment

guarantee following elective cancellation (up to 13.77%)• The net promoter score has deteriorated in March to 44.31. The Trust needed a score of 54 in March to

achieve this KPI and consequently breached the target.

Delivery of Value for Money• The Trust has met its financial performance target as agreed with the SHA for 2012/13. It has recorded

an outturn net surplus of £1.0m, which is £1.5m below internal plan.• The final outturn financial risk rating (FRR) for 2012/13 is 2 against the plan of 3, largely due to poor

liquidity.

Employer of Choice The appraisal completion rate has worsened to its lowest level since July 2011 with sickness improving

to its lowest level in 7 months and therefore getting closer to the KPI.

SUMMARY OF KEY RISKS:

Failure to deliver and sustain the A&E target Difficulties in achieving further reduction of Clostridium Difficile rates which are necessary to achieve

next years more challenging target Further evidence of the impact of emergency pathway pressures on elective pathway KPIs Appraisal rates remain an area of concern Development of CIPs to ensure recurrent savings needs to be accelerated

RECOMMENDATION / DECISION REQUIRED:

The Board are asked to confirm their understanding of the contents of the March 2013 IPRand note the associated actions.



24 April 2013


IMPLICATIONS:

Financial: CIP development and the impact of additional resources to deliver the A&E andwaiting times

HR / Equality & Diversity: Effective management of attendance, mandatory training compliance andappraisal of staff

Governance: None

Legal: None

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:

Data/information Source: VariousData Quality Controls: DQ policies, PPMC and F&PData Limitations:

University Hospitals Coventry andWarwickshire NHS Trust

Integrated Quality, Performance and FinanceReporting Framework

Reporting Period:March 2013

Report Date:18 April 2013

Contents

Section Page

Executive Summary 3

o Summary of performance 4

o Trust Scorecard 7

Domain 1: Excellence in patient care 9

Domain 2: Excellence in patient experience 14

Domain 3: Deliver value for money 32

Domain 4: Employer of choice 43

Domain 5: Leading research based health organisation 48

Appendix 1: Financial Statements 50

2Integrated Quality, Performance and Finance Reporting Framework

Executive Summary


Executive Summary

Summary of performance

Commentary

In this report the Trust has highlighted areas of compliance and underperformance. Areas which are underperforming alsoinclude an exception report and trends/benchmarking where available.

In this report, 26 of the 52 KPIs reported against (50%) are breaching the standard / target. This compares to 30 (58%) in theprevious month. Further detail is contained within the report.

Pressure on the non-elective pathway appears to be having a negative effect on a number of wider Trust KPIs. Given the levelof operational pressure on the organisation the primary focus is on ensuring patient safety.

Principal performance exceptions by Domain

Excellence in patient care

• In March there were 5 Clostridium Difficile infections recorded. The Trust did not achieve performance this year against theClostridium Difficile KPI.

Integrated Quality, Performance and Finance Reporting Framework 4

Excellence in patient experience

• The Trust has recorded 81.51% against the A&E 4 hour wait target. This is the 6th consecutive month below the 95%standard and is set against the context of widespread sub-95% performance across all but one of the West Midlands NHSTrusts during quarter four.

• The Parliamentary Health Select Committee has announced a review driven by national A&E under-performance.

• Last minute cancellation of operations remains high for the third consecutive month.

• The Trust has seen a further significant increase in the number of breaches of the 28 day treatment guarantee followingelective cancellation (up to 13.77%)

• The net promoter score has deteriorated in March to 44.31. The Trust needed a score of 54 in March to achieve this KPIand consequently breached the target.

Delivery of Value for Money

• The Trust has met its financial performance target as agreed with the SHA for 2012/13. It has recorded an outturn netsurplus of £1.0m, which is £1.5m below internal plan.

• The final outturn financial risk rating (FRR) for 2012/13 is 2 against the plan of 3, largely due to poor liquidity.

Executive Summary



Employer of Choice

The appraisal completion rate has worsened to its lowest level since July 2011 with sickness improving to its lowest level in 7months and therefore getting closer to the KPI.

Leading training and education centre

The PPMO is exploring with the education department an indicator that we can conclude in this new section of the IPR frommonth one 2013/14.

PMR

PMR status for March is reported as below:

Executive Summary




Executive SummaryTrust Scorecard – March 2013


Executive Summary

Trust Scorecard – March 2013

Data not yet available

Domain 1:Excellence in patientcare


Domain Summary – Excellence in Patient Care

10

Commentary

In this summary, we have outlined the overall performance for the Trust for all of the Excellence in Patient Care indicators.Where the Trust has achieved the required target for the year to date, there are no areas of concern. It should be noted that theTrusts recorded SHMI score of 103.38 hasn’t changed since the previous month as it is reported quarterly. So whilst thisrepresents a breach of the KPI there is nothing new to report this month.

The following areas are covered in more detail overleaf due to their current performance:

• The Trust has recorded 76 cumulative Clostridium Difficile infections in UHCW, which is 6 above the yearly target, meaning theorganisation has not achieved performance this year against this KPI. In March there were 5 Clostridium Difficile infectionsrecorded. It should be noted that this years performance is significantly improved from last year where there were 90 recordedinfections in 2011/12.

• Patient falls per 1000 occupied bed days resulting in serious harm showed an increase from last month. This measure will needto remain under close scrutiny.

• The Dr Foster Alerts for High Relative Risk that alerted in March was for a clip and coil aneurysm.

Integrated Quality, Performance and Finance Reporting Framework

11

Excellence in patient care – area of underperformance

Clostridium difficile (Trust acquired) - cumulative

Commentary

Applicable Frameworks/Contracts:NHS Performance FrameworkMonitor Compliance FrameworkAcute Contract - Quality Schedule

This indicator reports the number of incidences of Clostridiumdifficile in a calendar month as a cumulative figure per annum.The reporting of Clostridium difficile rates is set by the SHA (as setout in Section B Part 8.5). The organisation has a target of lessthan 70 incidences per annum. By achieving this target, theorganisation can demonstrate its standard of practice in relationto Control of Infection, links to quality of patient care and tomanaging its reputation as a healthcare provider. This can alsoaffect the organisations registration with the Care QualityCommission.

In March 2013 there were 5 recorded clostridium difficileinfections in UHCW. YTD there have been 76 cases which is 6(8.6%) above the yearly target of 70 cases.

UHCW initiated an SHA review of action plans and clinical cases.It was agreed with the SHA that the plans were robust andcomprehensive, with an aim to regain monthly trajectory in year.This was achieved for March. It was highlighted during thisreview that a number of cases were not clinical C Diff disease anda case notes review of 15 cases by the Director of InfectionPrevention and Control has been conducted.

Overall Trust position

The Chief Nursing Officer is leading twice weekly performancemeetings of the action plan.

The anticipated loss in income based on current clostridiumdifficile performance is built into the year-end financial position.


12


Falls per 1000 occupied bed days resulting in serious harm

Commentary

This indicator reports patient falls (graded as causing major orcatastrophic injury) per 1000 occupied bed days.

March’s reported position shows an increase from 0.06 to 0.09which has breached the 0.05 threshold. This is marginally abovethe average performance throughout 2012/13.

Other quality and safety indicators regarding patient falls havebeen reviewed and no new concerns are evident at this stage.

The falls action plan that is led by the Chief Nursing Officerremains active and is reviewed monthly at a Trust wide fallsforum.

Recruitment of a falls lead has been agreed.

This indicator will remain under close scrutiny for furtherdeviation.



13


No of Dr Foster High Relative Risks

Commentary

Applicable Frameworks/Contracts:Acute Contract - Quality Schedule

This indicator reports the number of Dr Foster High RelativeRisk alerts per calendar month. The organisation has a target of0. By achieving this target, the organisation can demonstratelinks to quality of care and to managing its reputation as ahealthcare provider.

This indicator is reported 3 months in arrears.

The Dr Foster Alert for High Relative Risk that alerted in Marchwas for a clip and coil aneurysm . This will be presented to theMortality Review Committee on 22nd April 2013.



Domain 2:Excellence in patientexperience


Domain Summary – Excellence in patient experience

15

CommentaryIn this summary, we have outlined the overall performance for the Trust for all of the Excellence in patient experienceindicators. Where the Trust has achieved the required target for the year to date, there are no areas of concern.

In this month’s report the following areas are covered in more detail overleaf:

• The Trust has recorded 81.51% A&E 4 hour wait target. This is the sixth consecutive month below the 95% standard and the yearend target has been breached.

• The Trust has recorded 798 minutes Total time in A&E - admitted patients. This KPI has further deteriorated and represents acontinued breach of the standard. Patient flow and discharge through inpatient wards remains at the crux of this issue.

• The Trust has recorded 341 minutes Total time in A&E – non admitted patients. This KPI has further deteriorated and representsa continued breach of the standard. Congestion in the Emergency Department (largely attributable to the aforementioned patientflow and discharge issue) is the root of this issue.

• Breaches of the 28 day treatment guarantee following elective cancellation has seen a further increase to 13.77% of cancelledpatients not treated within 28 days. This is closely linked to the increased level of last minute non-clinical cancelled operationswhich rose to 2.72%, breaching the KPI for the third consecutive month.

• The Trust has recorded improved theatre efficiency at Rugby but deterioration in both main theatres and most significantly inday surgery. Rugby is the only KPI that is being achieved for theatre efficiency.

• The Trust has recorded 5 days as the Standardised ALOS (non elective) for the second consecutive month. This is marginallyabove the benchmarked target of 4.6 days, though this is not insignificant when related to lost bed days.

• The Trust has seen an improvement of the Successful choose and book KPI since last month with performance at 10.72%,however this still remains significantly above the year end target of 5%.

• The Trust readmission rate has seen another marginal improvement to 7.12% whilst still breaching the KPI.


Domain Summary – Excellence in patient experience

16

Commentary (continued)

Net Promoter Score

• The Trust has recorded 44.31 net promoter score which is a significant way off the score of 54 that was required in March to meet

this KPI. The Trust has therefore breached the target.

• Over the course of the year the Trust has reached 54 intermittently. The current deterioration (or return to previous levels) has

been analysed and there is no apparent reason why the scores have fluctuated so much. Actions to try and deliver the KPI

consistently have been numerous. Further analysis is provided overleaf.

There are three indicators that are in a watching or amber status;

• Referral to Treatment non delivery was recorded at specialty level for General Surgery and Plastic Surgery. No further narrative

is recorded as this is classed as amber performance. However the general deterioration in a number of the referral to treatment

and other elective pathway KPIs is evident.

• The 62 Days urgent referral to treatment cancer target has fallen below the target of 85% to 82.07% in March and is therefore

flagged as an amber performance. The target has been achieved all year with the exception of November 2012 where it fell

marginally below the target.

The number of patients reported as being treated under this target during February was below the average for the year so far .There were more shared breaches with South Warwickshire Foundation Trust than normally expected. This is subject to furtherinvestigation.

The Trust is still compliant against this standard for year to date (85.4%) and it is anticipated that compliance will be achieved forQuarter 4 (Jan-Mar 13).

• Delayed transfers of care decreased from the previous month to 3.76% and are now only marginally above the target of 3.5%.


Excellence in patient experience – area of underperformance

A&E 4 hour waitOverall Trust position

17

Commentary

Applicable Frameworks/Contracts:NHS Performance Framework; Monitor Compliance Framework;Acute Contract - Quality Schedule

This indicator reports the percentage of A&E attendances where thepatient spends four hours or less in A&E from arrival to transfer,admission or discharge. The is a measure against the national waitingtime standard, for which the target is 95%.

4 hour performance continues to be the key challenge facing theorganisation with March’s performance at 81.51%. In terms ofcontext, none of the NHS Acute Trusts within the West Midlandsdelivered 95% in quarter 4, with the exception of BirminghamChildren’s Hospital. Five NHS Acute Trusts in the West Midlandsdelivered the 95% performance for the year.

The improvements implemented through February, specifically therevised AMU model and POD system have continued and have beenconsolidated through March.

Additional pressure, specifically around the Easter period, waschallenging for UHCW and others in the West Midlands.

The Trust has begun additional work with the Intensive Support Teamto ensure all possible actions are being undertaken to improveperformance. A revised action plan and whole system planning eventis in progress.


The Leadership team have consolidated the action planinto the following work streams:•Pre-hospital•Arrival at ED•Capacity and flow•Simple discharges•Complex discharges

This plan is subject to weekly performance monitoringwith Clinical Directors. A revised program management &governance framework will be part of the ECIST supportwork.

A&E 4 hour wait

18

Source: Midlands and East SHA Cluster Performance & Information website19Integrated Quality, Performance and Finance Reporting Framework


A&E Total time in A&E - admitted patients


20

Commentary


This indicator reports in minutes the length of time of the 95thPercentile of admitted patients seen in A&E in a calendar month.This calculation excludes planned follow up attendances andattendances with unknown total times. The organisation's target isless than 240 minutes. By achieving this target, the organisationcan demonstrate that their patient's receive fast access totreatment, which can improve outcomes and reduce anxiety forthe patient.

The Trusts performance against this indicator has deteriorated inline with overall 4 hour performance. This is in spite of thesignificant work and investment that has been committed toimprove patient flow. Furthermore significant reductions ofelective work have been enacted during March in an attempt tostabilise the emergency inpatient pathway.

Validation of actions and further support to improve have beensought from ECIST



A&E Total time in A&E – non admitted patients


21

Commentary


This indicator reports, in minutes, the length of time of the 95thPercentile of non-admitted patients seen in A&E in a calendarmonth. This calculation excludes planned follow up attendancesand attendances with unknown total times. The organisation'starget is less than 240 minutes. By achieving this target, theorganisation can demonstrate their patient's receive fast access totreatment, which can improve outcomes and reduce anxiety forthe patient.

The GP-led Urgent Care Centre was withdrawn following the end ofthe contract on 31 March 2013. However, the level of demand inthe department has not reduced and therefore a service with thePartnership Trust is being reintroduced from the 20 April 2013.Extra staff resource temporarily placed within the EmergencyDepartment (ED) is preventing further deterioration of thisimportant measure. The lack of improvement is symptomatic ofthe sustained high patient numbers within the ED owing to theoutflow issue previously described.



Breaches of the 28 day treatment guarantee following elective cancellation


22

Commentary

This indicator reports the percentage of patients whose operationwas cancelled, by the hospital, for non-clinical reasons, on the dayof or after admission, who were not treated within 28 days. Theorganisation's target is less than 5%. By achieving this target, theorganisation can demonstrate their patient's receive fast accessto treatment where they have not been the cause of delay, whichcan improve outcomes and reduce anxiety for the patient.

Performance has deteriorated further this month with 13.77% ofcancelled patients not treated within 28 days. Over the course ofthis calendar year the Trust has faced continual pressure on itselective admissions due to the resource required (mainly beds) tosupport the emergency pathway. This resource has been divertedfrom the elective pathway at short notice and has caused theTrust to cancel more elective patients on the day of surgery thanhad previously been the case.

Previous good performance against this target has deteriorated asthe clinical priorities on the day have been such that somepatients have had to be cancelled again. Those cases that aremost clinically urgent continue to override those that are deemedmost operationally urgent in terms of priority.



Last minute non-clinical cancelled ops (elective)


23

Commentary


This indicator reports the percentage of Elective Care operationscancelled by the Provider for non-clinical reasons either before orafter patient admission per calendar month. The organisation'sperformance is measured against a target of less than 0.8%. Byachieving this target, the organisation can demonstrate that itoffers accessible and responsive services that are delivered in atimely and efficient manner, which can improve outcomes andreduce anxiety for the patient.

Last minute cancelled operations deteriorated further in March to2.72% (138 cases). The primary reason for the cancellations wasbed availability (sufficient to maintain ED flow & associatedpatient safety). Improvements in timely discharge (i.e. beforemidday) need to be realised to help resolve this issue.



Standardised ALOS (Non-Elective)


24

Commentary


This indicator reports the average length of stay in a calendar monthfor non-elective patients, recorded on completion of their stay. Theorganisation's performance is measured against a target of 4.6. Byachieving this target, the organisation can demonstrate that it offersaccessible and responsive services that are delivered in a timely andefficient manner.

This indicator is reported 3 months in arrears.

This target has been set internally, based on the averageperformance against a benchmark group of ten other largeacute/teaching hospitals in England.

Trust ALOS for non-elective patients has remained the same aspreviously reported and continues to be largely static across the yearat a level slightly above peers.


Excellence in patient experience – area of underperformanceSuccessful Choose and Book


25

Commentary


This indicator reports the percentage of patients who could not bookinto an appointment slot. The organisation’s performance ismeasured against a target of no more than 5%. By achieving thistarget, the organisation can demonstrate its commitment to offeringaccessible and responsive services that are delivered in a timely andeffective manner.

There had been sustained improvement in the Trust ‘s overallposition during 2012-13 when compared to the previous year. Thenumber of patients unable to book has improved in March fromFebruary’s position. Slot availability during March, has partly beenaffected by consultants taking remaining annual leave for the yearand the Easter holiday. However the fundamental issue is capacitywithin certain specialties. This continues to be actively addressedwith these specialities.

Choose and Book referrals only account for a proportion of GPreferrals (about 75%). Manual referrals and other types of referralsuch as tertiary (consultant to consultant either within the Trust orfrom other Trusts) do not come under such scrutiny but have similarperformance issues.


Excellence in patient experience – area of underperformanceReadmission rate


26

Commentary

This indicator reports the percentage of emergency readmissionswithin 28 days of discharge. The organisations performance ismeasured against a target of 7.1%. By achieving this target, theorganisation can demonstrate a commitment to offering effectiveservices which ensure quality patient care.

This indicator is reported 5 months in arrears. No further data wasavailable on Dr Foster.

The Trust position improved marginally on the previous 2 months tojust 0.3% above target whilst remaining well below last yearsreadmission rates.


Excellence in patient experience – standard reporting item

Net Promoter Score

27

Trust wide position


The net promoter score target was to achieve a ten point improvement from the position at the beginning of the 2012/13 yearand therefore a score of 54 was required for the year end. Consequently, the target was not achieved in March 2013.

The CQUIN value for achieving this target is £78,343 which will be withheld due to failure of the target.

UHCW is participating in a path finder project as one of five Trusts in the Midlands and East region to work with TMI incollaboration with the CCGs. The outcome of the project is to improve the net promoter scores in the lower quartile performingorganisations.


Net Promoter Score

28

Specialty position



Net Promoter Score

29

Specialty position (continued)



Net Promoter Score (Breakdown for Text responses)

30

Ward position


Ward/Area breakdown is currently presented as two tables; text message returns and ImpressionsSurvey responses (next slide). Mapping is ongoing between iPM and the Impressions softwarealthough this is limited to the maintenance contract which only allows the Impressions databasestructure to be amended annually.


Net Promoter Score (Breakdown for Survey responses)

31

Ward position


Ward/Area breakdown is currently presented as two tables; text message returns (previous slide) andImpressions Survey responses. Mapping is ongoing between iPM and the Impressions softwarealthough this is limited to the maintenance contract which only allows the Impressions databasestructure to be amended annually.

Domain 3:Deliver value for money


Domain Summary – Value for Money

33

CommentaryIn this summary, we have outlined the overallperformance for the Trust for all of the Value for Moneyindicators. Where the Trust has achieved the requiredtarget for the year to date, there are no areas of concern.

In March the following areas are covered in more detail:

•The Trust has recorded 4.5% YTD variance in Payexpenditure against budget.

•The Trust has recorded 5.5% YTD variance in Non Payexpenditure against plan.

•The Trust has recorded -41.8% YTD variance in CIPdelivery from plan.

•The Trust has recorded a YTD EBITDA Margin of 9.3%.This is below a YTD plan of 10.6%.

•The Trust has recorded a YTD I&E Surplus Margin of0.2%. This is below a YTD plan of 0.5%.

•The Trust has recorded a Liquidity ratio of 5.5 days. Thisis slightly above a YTD plan of 11.2 days.

•The Trust has recorded a score of 2 against the MonitorFinancial Risk Rating. This is below plan.


•The Trust has recorded failure against 5 out of 10Provider Management Regime indices (PMR). Greenrated performance requires failure of no more than 1indicator.

•The Trust has recorded 5.4% YTD variance in Totalincome against budget.

All financial information for Month 12 presented in thisreport reflects the final draft of the 2012/13 financialposition.

It is subject to internal validation as part of the finalaccounts process and will continue to be subject to auditconfirmation.

Value for Money – area of underperformance

Pay expenditure (actual vs plan)



Commentary

This indicator reports the YTD actual pay expenditure as compared to the YTDplanned expenditure (the budget position). The organisation has a target ofa variance of no more than 0.5% above budget per calendar month.Reporting of this target enables the organisation to assess progress onefficiency savings.

• The SOCI identifies that groups have recorded a deficit on operationalexpenditure of £21.4m, £12.2m of which is on pay expenditure.

• YTD pay expenditure is overspent by £12.2m:

• CIP under-delivery £8.7m• ED Pressures £0.8m• Other activity pressures £2.7m

• This metric is non-compliant for 2012/13

Red Amber Green Plan YTD Forecast

> 1% < 1% < 0.5%

> 0.5%CFO COO0.0% 4.5%

Non-compliant for

2012/13

Indicator Range: Performance Timeframe to meetExecutive Lead

Standard


Non pay expenditure (actual vs plan)



Commentary

This indicator reports the total YTD non-pay expenditure as compared to theYTD planned expenditure (the budget position). The organisation has atarget variance of no more than 1% above the budget position per calendarmonth. Reporting of this target enables the organisation to assess progresson efficiency savings.

• The SOCI identifies that groups have recorded a deficit on operationalexpenditure of £21.4m, £9.2m of which is on non-pay expenditure.

YTD non-pay expenditure is overspent by £6.7m:

• CIP under-delivery £3.0m• BMI Activity £1.7m• Other activity pressures £4.5m



> 2% < 2% < 1%

> 1%CFO COO0.0% 5.5%

Non-compliant for

2012/13


Standard


CIP (actual vs plan)


36DRAFT – Integrated Quality, Performance and Finance Reporting Framework

Commentary

This indicator reports the YTD actual CIP delivery as compared to the YTDidentified CIP planned delivery (the budget position). The organisation hasa target of 95%. Reporting on the target enables the organisation to assessthe progress of efficiency savings.

• CIP delivery is showing under-delivery of £12.0m at Month 12.


Red Amber Green In Month YTD Forecast

> -15% > -5% < -5%

of plan < -15% of plan


Standard

COO-40.2% -41.8%Non-compliant for

2012/13


EBITDA margin



Commentary

This indicator reports the actual YTD Earnings before Interest, Tax,Depreciation and Amortisation figure (EBITDA) as a percentage of Income.The organisation has a target of more than 11 %.

• EBITDA performance against plan is being exacerbated by the underperformance against plan year-to-date

• The forecast margin remains below 10% due to a deterioration inoperational performance



< 9% > 9% >=11%

< 11%CFO10.6% 9.3%

Non-compliant for

2012/13


Standard


I&E surplus margin



Commentary

This indicator reports the YTD Income and Expenditure Surplus as apercentage of YTD Trust Income . The organisation has a target ofmore than 1%. Reporting on this target enables the organisation toassess progress on income and efficiency savings.

• The Trust has met its financial performance target as agreed with theSHA for 2012/13. It has recorded an outturn net surplus of £1.0m,which is £1.5m below internal plan.

• The under-performance against plan has been caused by anadditional £1m risk on contract income during M12 and £0.5m ofnon-contract income that has not been recovered in month.

• This metric is non-compliant against internal plan for 2012/13

Red Amber Green In Month YTD Forecast

< 0% > 0% >=1%

< 1%


Standard

CFO-1.3% 0.2%Non-compliant for

2012/13


Liquidity ratio (days)



Commentary

This indicator reports the number of the days the organisation can operate forwith no incoming cash-flow. The organisation has a target of more than 15days.

• The Trust's cash position is a result of its underlying weak balance sheet andpoor liquidity position.

• The under-performance against plan is largely due to failure to secure theCapital Investment Loan that had been planned for

The Trust's quarterly cash balance will be addressed by the following keyactions:

• Target increasing revenue surpluses;

• Reductions in outstanding debtors;

• Ensure capital investment financing does not adversely impact uponliquidity.



< 10 days > 10 days >= 15

< 15days daysCFO11.2 days 5.5 days

Forecast non-

compliant for 2012/13


Standard


Monitor risk rating



Commentary

This indicator is a measure of a combination of:

• EBITDA Margin• EBITDA Achieved• Net Return after Financing• I&E Surplus Margin• Liquidity

• The Trust is reporting an outturn FRR of 2 largely driven by poorliquidity. This has been impacted by failure to secure capitalinvestment borrowing.


PMR indices



Commentary

This indicator reports on the 10 indicators of forward financial risk. Theorganisation has a target of failing to achieve no more than one ofthese indicators.

The indicators that are red reflect four main areas:

• I&E performance below planned levels.

• High Debtor/Creditor balances.

• Low Cash Balances.

• Future years CIP identification

Performance has improved during Month 12 from six indicators to fivedue to significant progress in month in recovering overdue debts


Total income (actual vs plan)



Commentary

This indicator reports the YTD actual income as compared to the YTDplanned income (the budget position). The organisation has a targetof no more than 0.5% either side of the budget position.

• Due to significant over-performance on activity contract income issignificantly over-recovered against plan

• Income from activities is in line with plan for Month 12. There hasbeen no significant over-performance on activity for the month.

• Other income reflects timing differences in ET&R between incomeand expenditure (£3.0m) and over achievement against Groupincome targets (£1.6m)

• At an aggregate level - This metric is non-compliant for 2012/13


> +/-1% < +/-1% < +/-0.5%

of plan > +/-0.5%


Standard

CFO0.0% 5.4%Non-compliant for

2012/13

Domain 4:Employer of choice


Domain Summary – Employer of choice

44

Commentary

In this summary, we have outlined the overall performance for the Trust for all of the Employer of choice indicators.Where the Trust has achieved the required target for the year to date, there are no areas of concern.

In this month’s report the following areas are covered in more detail overleaf:

• The Trust has recorded a 54.55% Appraisal rate. This is considerably below YTD plan and is the lowest level since July2011 since when there has been a general month on month decline to the current position.

• The Trust has recorded a 4.24% Sickness rate. This is above YTD plan although it continues to show an improvingtrajectory and is at its lowest level in 7 months.

• The Trust has recorded a 64.76% attendance at mandatory training. This is consistent with performancethroughout the year. Due to continuing problems with the ESR system, the figure for February remains unavailable atthe current time.


Employer of choice – area of underperformance

Appraisal rate


45

Commentary

Applicable Frameworks/Contracts:Agenda for Change

This indicator reports the percentage of staff recorded as havingreceived an appraisal within the past 12 months. The organisationhas a target of 100%. This indicator demonstrates a commitment todeveloping staff and is linked to evidence required for Investors inPeople/Improving Working Lives. If the majority of staff have had apersonal development review within the past 12 months it showsthat the organisation takes the personal development of itsworkforce very seriously and is endeavouring to develop staff anddeal with any performance issues in a timely manner. In addition itensures staff are competent to deliver their role by equipping themwith the skills needed to perform their job. It should also improvethe outcomes of the annual staff survey.

Appraisal rates are at their lowest level since July 2011 since whenthere has been a general month on month decline to the currentposition. Appraisal rates continue to be robustly tracked through theHRED Committee, with workforce information presented at eachmeeting for review. Individual specialty action plans are also in placefor lowest performing areas, with support provided through the HROperations team where appropriate. In line with the recentannouncements from the National Staff Council, in 2013/2014 theTrust will be reviewing performance management arrangements fornon-compliance with appraisals for managers and staff. This will betaken forward with the HRED Committee and staff-side colleaguesthrough the JNCC.


Staff Experience – area of underperformance

Attendance at mandatory training


46

Commentary

This indicator reports the percentage of staff who are up-to-date withall mandatory training courses on a rolling 12 month basis. Theorganisation has a target of 100% for all mandatory subjects. Incalculating compliance the organisation excludes staff categorised as:on maternity and adoption leave; on external secondment; on careerbreak; Inactive Not Worked; Suspend assignments; terminatedassignment; and widow/widower. The organisation has a target of100%. By achieving this indicator, the organisation can avoid financialpenalties from commissioners and demonstrate that it is meeting itsstatutory legal requirements.

This indicator is reported one month in arrears.

An 11 point action plan, approved through HRED Committee, is inplace. A further end to end review of mandatory training has takenplace following discussion at HRED Committee and QualityGovernance Committee.

The outcomes from this review are currently being implemented anda new mandatory training programme will become effective from 1stJune 2013. This programme radically reduces the number of topicsthat are classified as mandatory and therefore it is expected thatperformance improvements will occur accordingly. This is beingoverseen by Diana Finlayson, Associate Director of HR – Learning andOrganisational Development.


ESR self-service roll-out, which will be completed in 2013,also supports this area by allowing individuals and managerswith direct access to information on compliance levels,reducing a reliance on centralised reporting.

Employer of choice – area of underperformance

Sickness rate


47

Commentary

This indicator reports the percentage of sickness recorded in theorganisation against the overall hours. The organisation has a targetof less than 3.39%. The monitoring of sickness facilitates managers inachieving lower sickness absence levels and encourages tighterregimes around absence management. The figure is reported eachmonth and so will be subject to seasonal variations in staff sickness.Sickness figures may give an indication of quality of care in terms ofconsistency in the workforce without the need for bank/agency coverand possibly staff satisfaction. It also confirms how well theorganisation is managing sickness absence and taking the health andwellbeing of its employees seriously.

March sickness rate has come down to the lowest level in 6 months.A review of the attendance management procedures has commencedand the Trust is about to launch an absence campaign. The fast-trackphysiotherapy scheme for staff has been reintroduced following apilot in 2011/2012. The psychotherapy fast track scheme for staff wasreintroduced in January 2013 following successful appointment of apsychologist. Theatres and St Cross have the highest sickness ratesand these are being reviewed by the HRED.


Domain 5:Leading research basedhealth organisation


Domain Summary – Leading research based health care organisation

49

Commentary

In this summary, we have outlined the overall performance for the Trust for all of the Leading research based health careorganisation indicators. Where the Trust has achieved the required target for the year to date, there are no areas ofconcern.

The only KPI currently in this domain is the number of patients recruited into NIHR portfolio. This indicator has an outturnof 4336, which exceeds the trajectory (YTD plan) of 4250.


Appendix 1:Financial Statements


Month 12 – 2012/13Statement of Comprehensive Income – Primary Statement


All financialstatements for Month12 presented in thisAppendix reflect thefinal draft of the2012/13 financialposition.

They are subject tointernal validation aspart of the finalaccounts process.

They will continue tobe subject to auditconfirmation.

Statement of Comprehensive

IncomePlan Outturn Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000

Income

Income from Activities 411,364 431,353 19,989 33,844 37,568 3,724

Other Operating Income 69,311 73,774 4,463 6,487 5,859 (628)

Corporate Workstreams 169 0 (169) 19 0 (19)

Total Income 480,844 505,127 24,283 40,350 43,427 3,077

Operating Expenses

Pay (269,655) (281,877) (12,222) (22,398) (23,895) (1,497)

Non Pay (167,227) (176,394) (9,167) (13,716) (16,223) (2,507)

Corporate Workstreams 7,956 0 (7,956) 1,298 0 (1,298)

Reserves (890) (124) 766 (6) (729) (723)

Total Operating Expenses (429,816) (458,395) (28,579) (34,822) (40,847) (6,025)

EBITDA 51,028 46,732 (4,296) 5,528 2,580 (2,948)

EBITDA Margin % 10.6% 9.3% 13.7% 5.9%

Non Operating Items

Profit / loss on asset disposals 0 19 19 0 4 4

Fixed Asset Impairments 0 (19,540) (19,540) 0 (19,526) (19,526)

Depreciation (21,079) (19,219) 1,860 (1,757) (932) 825

Interest Receivable 96 80 (16) 8 2 (6)

Interest Charges (462) (386) 76 (39) (26) 13

Financing Costs (23,213) (23,202) 11 (1,934) (1,937) (3)

PDC Dividend (3,870) (3,050) 820 (323) (266) 57

Total Non Operating Items (48,528) (65,298) (16,770) (4,044) (22,681) (18,637)

Net Surplus/(Deficit) 2,500 (18,566) (21,066) 1,484 (20,101) (21,585)

Fixed asset impairment add back 0 19,540 19,540 0 19,526 19,526

Surplus/(Deficit) - excluding

impairment charges 2,500 974 (1,526) 1,484 (575) (2,059)

Net Surplus Margin % 0.5% 0.2% 3.7% -1.3%

2012/13 Month

Month 12 – 2012/13Statement of Financial Position


Prior Year

Outturn Statement of Financial Position Plan Outturn Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000 £000

Non-current assets

379,857 Property, plant and equipment 386,922 345,198 (41,724) 10,814 (29,048) (39,862)

0 Intangible assets 0 113 113 0 113 113

3,511 Investment Property 3,511 3,515 4 0 4 4

32,066 Trade and other receivables 34,333 37,170 2,837 (676) (505) 171

415,434 Total non-current assets 424,766 385,996 (38,770) 10,138 (29,436) (39,574)

Current assets

10,217 Inventories 10,821 9,864 (957) 250 114 (136)

18,158 Trade and other receivables 17,909 15,297 (2,612) (4,989) (24,979) (19,990)

7,459 Cash and cash equivalents 1,764 3,968 2,204 (2,163) 1,848 4,011

35,834 30,494 29,129 (1,365) (6,902) (23,017) (16,115)

124 Non-current assets held for sale 0 453 453 (124) 453 577

35,958 Total current assets 30,494 29,582 (912) (7,026) (22,564) (15,538)

451,392 Total assets 455,260 415,578 (39,682) 3,112 (52,000) (55,112)

Current liabilities

(38,174) Trade and other payables (29,620) (39,523) (9,903) 12,557 18,046 5,490

(2,862) Borrowings (6,246) (6,301) (55) 0 (55) (55)

(2,000) DH Working Capital Loan 0 0 0 1,000 1,000 0

(1,500) DH Capital loan (3,120) (1,500) 1,620 (1,620) 0 1,620

(1,982) Provisions (427) 0 427 150 889 739

(10,560) Net current assets/(liabilities) (8,919) (17,742) (8,823) 5,061 (2,684) (7,745)

404,874 Total assets less current liabilities 415,847 368,254 (47,593) 15,199 (32,120) (47,319)

Non-current liabilities:

Trade and other payables 0 0 0 0 0 0

(284,216) Borrowings (278,778) (279,647) (869) 41 (934) (975)

0 DH Working Capital Loan 0 0 0 0 0 0

(9,750) DH Capital loan (14,730) (8,250) 6,480 (5,730) 750 6,480

(2,247) Provisions (1,956) (3,161) (1,205) 245 (691) (936)

108,661 Total assets employed 120,383 77,196 (43,187) 9,755 (32,995) (42,750)

Financed by taxpayers' equity:

24,124 Public dividend capital 24,124 24,870 746 0 746 746

32,445 Retained earnings 35,019 14,236 (20,783) 607 (19,838) (20,445)

52,092 Revaluation reserve 61,240 38,090 (23,150) 9,148 (13,903) (23,051)

108,661 Total Taxpayers' Equity 120,383 77,196 (43,187) 9,755 (32,995) (42,750)

2012/13 Month

Month 12 – 2012/13Cash Flow


Mar-12 Cash Flow Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

46,883 EBITDA 2,509 2,903 2,297 4,659 5,308 4,142 2,565 4,176 4,282 8,762 2,481 2,648

(78) Donated assets received credited to revenue but non-cash 0 0 0 0 0 (44) 0 0 0 (903) 0 0

(22,601) Interest paid (1,978) (1,964) (2,012) (1,894) (1,983) (1,965) (1,966) (1,965) (1,965) (1,965) (1,967) (1,964)

(4,185) Dividends paid (991) (962)

1,700 Increase/(Decrease) in provisions 0 0 130 0 (46) (1) 0 (48) 0 (1,148) 243 (979)

21,719 Operating cash flows before movements in working capital 531 939 415 2,765 3,279 1,141 599 2,163 2,317 4,746 757 (1,257)

(17,950) Movements in Working Capital (1,881) 6,606 (916) (2,552) (153) (4,480) 3,434 (2,535) 909 (444) (5,854) 6,166

3,769 Net cash inflow/(outflow) from operating activities (1,350) 7,545 (501) 213 3,126 (3,339) 4,033 (372) 3,226 4,302 (5,097) 4,909

(10,165) Capex spend (1,896) (1,170) (1,123) (1,282) (330) (1,769) (1,405) (1,933) (2,343) (501) 1,099 (2,001)

75 Interest received 9 7 6 13 7 5 7 5 4 10 5 5

1,135 Cash receipt from asset sales 115 57

(8,955) Net cash inflow/(outflow) from investing activities (1,887) (1,163) (1,117) (1,269) (208) (1,764) (1,398) (1,928) (2,339) (491) 1,104 (1,939)

(5,186) CF before Financing (3,237) 6,382 (1,618) (1,056) 2,918 (5,103) 2,635 (2,300) 887 3,811 (3,993) 2,970

0 Public Dividend Capital received 746

0 Public Dividend Capital repaid

(3,500) DH loans repaid 0 0 0 0 0 (1,750) 0 0 0 0 0 (1,750)

(1,691) Capital Element of payments in respect of finance leases and PFI (606) (33) (4) (456) (237) (37) (665) (37) (29) (538) (37) (118)

0 Drawdown of loans 0 0 0 0 0 0 0 0 0 0 0 0

(5,191) Net cash inflow/(outflow) from financing (606) (33) (4) (456) (237) (1,787) (665) (37) (29) (538) (37) (1,122)

(10,377) Net cash outflow/inflow (3,843) 6,349 (1,622) (1,512) 2,681 (6,890) 1,970 (2,337) 858 3,273 (4,030) 1,848

17,600 Opening Cash Balance 7,223 3,380 9,729 8,107 6,595 9,276 2,386 4,356 2,019 2,877 6,150 2,120

7,223 Closing Cash Balance 3,380 9,729 8,107 6,595 9,276 2,386 4,356 2,019 2,877 6,150 2,120 3,968

Month 12 – 2012/13Capital Expenditure


PlanForecast

Outturn

Variance

fav/(adv)Plan Actual

Variance

fav/(adv)

£000 £000 £000 £000 £000 £000

Confirmed CRL 2,098 2,844 746 0 0 0

Forecast CRL Adjustments for PFI 9,696 8,547 (1,149) 676 2,320 1,644

Forecast CRL Adjustments for non PFI 8,100 7,665 (435) 1,987 7,665 5,678

0 -1,025 (1,025) 0 -3144 (3,144)

Total Forecast CRL 19,894 18,031 (1,863) 2,663 6,841 4,178

PlanForecast

OutturnVariance Plan Actual Variance

£000 £000 £000 £000 £000 £000

Major Schemes

PFI lifecycle 9,696 7,522 2,174 676 (824) 1,500

New staff car park on land formerly for staff

residences2,000 1,296 704 500 291 209

Lifecycle of Radiotherapy including Linacs 1,200 1,774 (574) (192) 382 (574)

PACS Replacement Project 1,350 722 628 1,225 580 645

Neurosurgical Inst For CJD 1,000 313 687 0 71 (71)

Aggregated Other Schemes 5,629 6,882 (1,253) 1,378 5,116 (3,738)

Total Capital Expenditure 20,875 18,509 2,366 3,587 5,616 (2,029)

Less: Donated/granted Asset Purchases 800 947 147 800 0 (800)

Less: Book value of assets disposed of: 181 322 141 124 0 (124)

Net Charge against CRL 19,894 17,240 2,654 2,663 5,616 -2,953

Under/(Over)Commitment against CRL (total) 0 791 791 0 1,225 1,225

Capital Resource Limit (CRL)

2012/13 Month

Capital Expenditure Programme

2012/13 Month

Month 12 – 2012/13Capital Financing


Capital Cash Funding Sources

2012/13

Budget

£'000

2012/13

Outturn

£'000

Movement

£'000Notes

Internally Generated Funds

Depreciation 23,096 19,219 (3,877) Reduction as a result of the final impact of the year-end revaluation exercise.

Surplus 1,700 26 (1,674) Surplus excludes donations * (shown separately)

Proceeds of Asset Disposals 57 (57)

House Sale 0 57 57

115

External Funds

New Finance Leases (Net) 864 1,824 960

Donations * 800 947 147

Other Capital Contributions Received 700 0 (700) Staff Car Park contribution from PFI partner

New Public Dividend Capital 0 0 0

New Capital Investment Loans 8,100 0 (8,100) loan application declined

Applications

Working Capital Loan Repayment (2,000) (2,000) 0

Capital Investment Loan Repayment (1,500) (1,500) 0

New Capital Investment Loan Repayment 0 0 0

PFI Finance Lease Creditor (2,226) (2,226) 0

Other Finance Lease Repayments (451) (400) 51

Pathology LIMS Finance Lease Repayments 0 (67) (67)

PFI Lifecycling

Lifecycle Payments in Unitary Payment (12,249) (12,194) 55

Net Cash Generated 16,891 3,801 (13,090)

Cash (Applied)/Released to Address Liquidity

Movement in Loan Repayments (< 1 year) 2,000 2,000 0 } Cash released or applied in order to ensure

Movement in New Loan Repayments (< 1 year) (1,620) 0 1,620 } liquidity is unaffected by balance sheet

Movement in PFI Finance Lease Principal Repayments (< 1 year) (3,620) (3,620) 0 } movements

Adjustment 0 0 0

Liquidity (Improvement)/Reduction (1,700) 0 1,700 All revenue surpluses applied to improving liquidity

Net Cash Available for Capital Expenditure 11,951 2,181 (9,770)

Reconciliation to Capital Programme

Capital Funding

Funding Available for non-PFI Capital Expenditure 11,951 2,181 (9,770) Reduction in funding is described above

Add PFI Capital Expenditure 9,696 7,522 (2,174) Capital funding for PFI matches PFI capital expenditureTotal Capital Funding (including PFI Capital) 21,647 9,703 (11,944)

Capital Expenditure

Non-PFI Capital Expenditure 11,179 10,987 (192) Reduction in capital programme as agreed in the mid-year review

PFI Capital expenditure 9,696 7,522 (2,174) Capital funding for PFI matches PFI capital expenditureTotal Capital Expenditure (including PFI Capital) 20,875 18,509 (2,366)

Surplus/(Deficit) of Capital Funding Compared to Expenditure 772 (8,806) (9,578) = Favourable/(Adverse) Impact upon Liquidity


REPORT TO TRUST BOARD: PUBLIC

24th

APRIL 2013

Subject: Provider Management RegimeReport By: David Eltringham, Chief Operating OfficerAuthor: Lynda Cockrill, Head of Performance & Programme AnalyticsAccountable Executive Director: David Eltringham, Chief Operating Officer

GLOSSARYAbbreviation In FullDH Department of HealthUHCW University Hospitals Coventry and WarwickshireSHAs Strategic Health AuthoritiesPCTs Primary Care TrustsPMR Provider Management Regime



TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:The SHA wide Provider Management Regime (PMR) process has been fully operational from April 2012onwards. This regime was introduced to support Trusts, by working with the SHA in a “Monitor like” way, tohelp prepare Trusts for their DH and Monitor Foundation Trust assessment and subsequent monitoring postauthorisation under the Monitor Compliance Framework.

The regime provides an opportunity for providers to earn autonomy from the SHA. Providers who candemonstrate consistent performance of governance, finance, quality and contract management will make lessfrequent PMR returns and meet with the SHA less often than those Trusts that face issues. There is also aclear escalation process for Trusts with persistently poor ratings or other issues. The detailed processes andrules by which a Trust can gain autonomy or might face escalation are outlined within separate SHA guidance.

Each Trust is required to complete a return of the Provider Management Regime template to the SHA on thelast working date of every month. Late submissions are automatically given a red governance risk rating. Theexpectation is that the monthly template returns are signed off by the Trust Board.

The return published by the East and Midlands SHA in 2012/13 includes a new section for Trusts todemonstrate progress against their Tripartite Formal Agreement (TFA) to become a Foundation Trust. TheGovernance Risk Ratings (GRR) section contains a new performance metric (patients on an incomplete, 18-week pathway) and new overriding rules have been applied that will effect performance where these rules arenot being satisfied. In addition a new quality metric has been included in the Quality section (completion ofconsultant personal development plans) and detail must now be submitted regarding financial and contractualperformance. Further amendments have been made in December which includes a revision to the PMRtemplate with changes to the GRR, Financial Trigger and Contractual sections. Errors in the template havebeen identified in the spreadsheet which are being progressed with the SHA. The following metrics have beenremoved from the PMR:

GRR Section - Line 8b: Quality – A&E Financial Risk Triggers Section - Line 3: FRR 2 for any one quarter

The East and Midlands SHA have confirmed that the overriding rules in the Governance Risk Rating Section ofthe PMR will be applied at their discretion. The Overriding Rules are the same as the governance red-ratedoverrides in the 2012/13 Monitor Compliance Framework. Using this framework, Monitor may apply theoverriding rules where Foundation Trusts are not compliant and escalate the Trust for consideration as towhether it is in significant breach. If Monitor is satisfied a Trust is in significant breach they have the discretionto intervene. The SHA have confirmed that they will be taking a similar approach to Monitor and Trust’s whose



24th

APRIL 2013

overriding rules have been applied will be deemed “unauthorisable”.

SUMMARY OF KEY ISSUES:Based on the data provided by the relevant leads the Trust risk ratings are as detailed below:

PERIODGovernanceRisk Rating

FinancialRisk Rating

ContractualPosition

PMRVersion

APR-12Amber/Green

(1.0)Green (3.0) Amber 1

stversion

MAY-12Amber/Green


stversion

JUN-12Amber/Red


stversion

JUL-12 Green (1.0) Red (2.0) Blank 2nd

versionAUG-12 Green (1.0) Red (2.0) Blank 2

ndversion

SEP-12 Green (0.0) Red (2.0) Blank 2nd

versionOCT-12 Red (4.0) Red (2.0) Blank 2

ndversion

NOV-12 Red (4.0) Red (2.0) Blank New versionDEC-12 Red (4.0) Red (2.0) Blank New versionJAN-13 Red (4.0) Red (2.0) Blank New versionFEB-13 Red (4.0) Red (2.0) Blank New versionMAR-13 Red (4.0) Red (2.0) Blank New version

The Governance Risk Rating of Red (4.0) for March 2013 is because of the continuation of the application ofoverriding rule which was first applied by the SHA in January 2013. This automatically gave an overallweighting of 4 and was retrospectively been applied back to October 2012 (see below).

Note: the scoring in the revised PMR return has changed so that a GRR weighting of greater than or equal to 1but less than 2 will give a rating of Amber/Green (in the previous version used for reporting performance forJuly to October 2012 a score of 1 or under gave a rating of Green). The SHA clarified this change in January2013. Furthermore, the SHA are in the process of resolving an error in the GRR section of the PMR templatewhich is incorrectly applying an additional weighting against the c-diff metric for quarter 3. The ContractualPosition is no longer rated in the PMR return and guidance from the SHA is that this should be reported as“Blank”.

Appendix A is UHCW’s proposed submission to the SHA at the end of April 2013.

Specified areas of insufficient assurance and associated actions are:

A&E - maximum waiting time of four hours from arrival to admission/transfer/discharge: With support fromthe Emergency Care Intensive Support Team, existing recovery plans (and the associated governanceframework) are being evaluated and revised to deliver performance improvements throughout Q1 & Q2.The main themes for improvement are developing alternative pathways to ED, improving ED processes,inpatient capacity & capacity management, proactive discharge planning (simple) and improving supporteddischarge (complex).

C-diff: A single consolidated action plan has been developed to regain trajectory. The plan aimed to regainthe monthly target in March and although the overall position for the year was lost, the monthly target wasachieved. As agreed with the SHA, a meeting was planned with CCGs to review case notes since anumber of cases were identified that were found not to be clinical C Diff disease and therefore may not beattributable to UHCW.

Financial Risk Rating (FRR) - The governance declaration is based on the outturn FRR. The Trust hasrecorded an FRR 2 for the financial year, largely as a result of poor liquidity.

Board Statement 4 – The board anticipates the Trust will continue to maintain a financial risk rating of atleast 3 over the next 12 months. The 2013/14 financial plan is currently forecast to have a financial riskrating (FRR) of 2. This is due to the liquidity metric being less than 10 days. This has been impactedduring 12/13 by failure to secure capital investment borrowing. The route to improving liquidity is to:



24th

APRIL 2013

o Target increasing revenue surpluses;o Reduce outstanding debtors;o Ensure capital investment financing does not adversely impact upon liquidity

It is noted that if the Board does not self certify against Board Statement 4, UHCW could be deemed to be inescalation by the SHA.

The Overriding Rule which has been applied by the SHA is:

A&E Clinical Quality Indicator: UHCW did not achieve the 95%, 4-hour A&E target in Q4 2011/12. The targetwas not achieved in Q1 2012/13. UHCW has therefore failed to meet the A&E target twice in any two quartersover the last 12 months. UHCW did not achieve the target in October, November or December 2012 andJanuary and February 2013 and at the time of writing this report achievement of the target for March 2013 wasat risk. The SHA have confirmed the overriding rule has been applied retrospectively from October 2012because this target has been failed in the subsequent nine-month period from Q1 2012/13. This means thatUHCW is in escalation. However, the SHA have advised that they will recommend mitigation of UHCW’s redstatus due to the overriding rule for A&E if there is evidence of a sustained improvement and delivery againstthe A&E target for a 6-month period.


The Governance Risk Rating and Financial Risk Rating are showing as Red The overriding rule against the 95%, 4-hour A&E target has been applied by the SHA for

October, November and December 2012 and January, February and March 2013 In line with the current 2013/14 financial plan, the board do not self-certify against Board

Statement 4.


Trust Board to approve the Provider Manager Regime return based on March 2013 data for onwardsubmission to the SHA.

Trust Board to confirm its support for Governance Declaration 2 (for insufficient assurance that all targetsare being met) in relation to the Financial Risk Rating, A&E and C-diff.

It is recommended that, in line with the current 2013/14 financial plan, the board do not self-certify againstBoard Statement 4.

IMPLICATIONS:Financial: N/A

HR / Equality & Diversity: N/A

Governance: Performance against the PMR submission will impact on the trusts ability tomove forward with its Foundation Trust application

Legal: N/A




24th

APRIL 2013

DATA QUALITY:

Data/information Source:Data Quality Controls:Data Limitations:

SELF-CERTIFICATION RETURNS

Organisation Name:

University Hospitals Coventry & Warwickshire NHS Trust

Monitoring Period:

March 2013

NHS Trust Over-sight self certification template

Returns [email protected] by the

last working day of each month

2012/13 In-Year Reporting

Name of Organisation: Period: March 2013

Organisational risk rating

* Please type in R, AR, AG or G and assign a number for the FRR

Governance Declarations

Supporting detail is required where compliance cannot be confirmed.

Governance declaration 1

Signed by: Print Name:

on behalf of the Trust Board Acting in capacity as:

Signed by: Print Name:

on behalf of the Trust Board Acting in capacity as:

Governance declaration 2

Signed by : Print Name :AndrewHardy

on behalf of the Trust Board Acting in capacity as: Chief Executive Officer

Signed by : Print Name :Philip

Townshend

on behalf of the Trust Board Acting in capacity as: Deputy Chairman

If Declaration 2 has been signed:

Target/Standard:

The Issue :

Action :

Target/Standard:The Issue :

Action :

Target/Standard:The Issue :

Action :

Target/Standard:The Issue :Action :

Target/Standard:The Issue :Action :

Governance Risk Rating (RAG as per SOM guidance) R

NHS Trust Governance Declarations :

University Hospitals Coventry & Warwickshire NHS

Trust

Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to any contractualissues and compliance with CQC essential standards:

Key Area for rating / comment by Provider Score / RAG rating*

At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements of theBoard Statements.

Normalised YTD Financial Risk Rating (Assign number as per SOM guidance) 2

Declaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation.

Please complete sign one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either handwritten or electronic, you are required to print your name.

The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the Board Statements.

The governance declaration is based on the outturn FRR.

The Trust has recorded an FRR 2 for the financial year, largely as a result of poor liquidity. This also results

in Trust being unable to self certify against Board Statement 4 (that he Trust will continue to maintain a

financial risk rating of at least 3 over the next 12 months).

For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain brieflywhat steps are being taken to resolve the issue. Please provide an appropriate level of detail.

A&E: total time in A&E

Continuing winter pressures with a rise in both volume and acuity of medical admissions

With support from the Emergency Care Intensive Support Team, existing recovery plans (and the associated

governance framework) are being evaluated and revised to deliver performance improvements throughout Q1

& Q2. The main themes for improvement are developing alternative pathways to ED, improving ED processes,

inpatient capacity & capacity management, proactive discharge planning (simple) and improving supported

discharge (complex).

Financial Risk RatingThe Trust is reporting an FRR of 2 based on the year-to-date position

C-diffThe Trust is above the trajectory for March 2013

A single consolidated action plan has been developed to regain trajectory. The plan aimed to regain the

monthly target in March and although the overall position for the year was lost, the monthly target was

achieved. As agreed with the SHA, a meeting was planned with CCGs to review case notes since a number of

cases were identified that were found not to be clinical C Diff disease and therefore may not be attributable to

UHCW.

Action plans and their monitoring remain in force and have been shared with SHA.

For each statement, the Board is asked to confirm the following:

For CLINICAL QUALITY, that: Response

1

2 3

For FINANCE, that: Response

4

5 For GOVERNANCE, that: Response

6

7

8

9

10

11

12

13

14

15 Signed on behalf of the Trust: Print name Date

CEO Andrew Hardy

Deput

y

Chair

Philip Townshend

The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver theannual plan; and the management structure in place is adequate to deliver the annual plan.

The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience andskills to discharge their functions effectively, including setting strategy, monitoring and managing performance andrisks, and ensuring management capacity and capability.

The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accountingstandards in force from time to time.


The necessary planning, performance management and corporate and clinical risk management processes andmitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted bythe board are implemented satisfactorily.

The trust has achieved a minimum of Level 2 performance against the requirements of the Information GovernanceToolkit.

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, orplans are in place to fill any vacancies, and that any elections to the shadow board of governors are held in accordancewith the election rules.

Board Statements

The board will ensure that the trust at all times has regard to the NHS Constitution.

The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,likelihood of occurrence and the plans for mitigation of these risks.

March 2013

An Annual Governance Statement is in place, and the trust is compliant with the risk management and assuranceframework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury(www.hm-treasury.gov.uk).

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after theapplication of thresholds) as set out in the Governance Risk Rating; and a commitment to comply with all commissionedtargets going forward.

The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to theSOM's Oversight Regime (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 itspatients.

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care QualityCommission’s registration requirements.

The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care onbehalf of the trust have met the relevant registration and revalidation requirements.

The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.

All current key risks have been identified (raised either internally or by external audit and assessment bodies) andaddressed – or there are appropriate action plans in place to address the issues – in a timely manner

û

Information to inform the discussion meeting

Unit Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Board Action

1 SHMI - latest data Score 105.3 105.3 105.3 106.1 106.1 106.1 107.4 107.4 107.4 103.4 103.4 103.4

The SHMI is produced and published quarterly by the NHS

IC. 103.4 relates to published data in January. SHMI's first

publication was end of October 2011

2Venous Thromboembolism (VTE)

Screening% 93.4 93.3 92.3 93.1 93.2 92.6 93 93.68 93.66 93.87 95.88 95.73

3a Elective MRSA Screening % 137.96 125.52 136.36 135.22 136.62 137.37 137.6 140.8 129.96 131.39 122.37 125.61266 tests were undertaken on patients needing screening

out of the 1008 total number of admissions.

3b Non Elective MRSA Screening % 65.3 70.0 69.9 70.3 71.1 76.2 70.3 72 69.42 77.21 70.22 68.12

4Single Sex Accommodation

BreachesNumber 0 0 0 0 0 0 0 0 0 0 0 0

5Open Serious Incidents Requiring

Investigation (SIRI)Number

16

7

16

1

22

2

24

6

19

7

21

7

21

5

22

7

28

1

22

2

36

8

30

4

Open SIRIs

Number that were over the 45 day target on the last day of

the month.

NB Sep-Nov 2011 data was not collected. Since the

figures are a snap-shot on the day, this data cannot be

gathered retrospectively.NB -

6 "Never Events" occurring in month Number 0 0 1 0 0 0 0 1 1 0 0 1

Never events - 1. confirmed retained swab post-

operatively

2. Wrong-site surgery (lumbar decompression)

3. Retained foreign object post-op

7 CQC Conditions or Warning Notices Number 0 0 0 0 0 0 0 0 0 0 0 0

8Open Central Alert System (CAS)

AlertsNumber 12 13 13 11

9

2

8

2

8

1

7

2

5

2

3

2

9

0

9

3

9 open CAS alerts. 3

outstanding2

9RED rated areas on your maternity

dashboard?Number 2 2 1 2 3 2 4 3 3 3 3 3

1. C/S Rate - 27.43% - this has come down in month 2.

Breast Feeding - 76.86% - this has come down in month 3. Smoking

at Delivery - 13.12%

10Falls resulting in severe injury or

deathNumber 0 2 3 4 1 2 3 2 4 1 2 3

interpreted as those falls incidents graded as 'major' or

'catastrophic'

11 Grade 3 or 4 pressure ulcers Number 2 1 4 0 3 0 0 2 0 1 1 0Hospital Acquired - avoidable

Note: The RCA for one of the 2 reported for Feb-13 is

pending and may become unavoidable following scrutiny

12100% compliance with WHO

surgical checklistY/N N N N N N N N N N N N N

Dec-11 94.6%, Jan-12 94.8%, Feb-12 94.4%, Mar-12

96.4%, Apr-12 97.7%, May-12 98.4%, Jun-12 98.9%, Jul-

12 99.2%, Aug-12 99.1%, Sep-12 99.6%, Oct 99.2%, Nov

99.5%, Dec 99.7%, Jan 99.4%, Feb 99.7%, Mar 99.7%

13 Formal complaints received Number 41 44 29 48 45 47 40 37 36 38 40 38

14Agency as a % of Employee Benefit

Expenditure% 2.88 3.17 2.94 3.39 4.1 2.84 4.23 3.7 3.17 4 3.86 5.17

Historic and current information changed to reflect the

different definition. Agency costs ONLY as a % of

Employee Benefit Costs - previously Agency & Bank as a %

of Turnover

15 Sickness absence rate % 4.59 4.69 4.73 4.62 4.32 4.56 4.79 5.23 5.00 5.06 4.46 4.24

16Consultants which, at their last

appraisal, had fully completed their

previous years PDP

% 50.6 55.74 53.39 46.23 52.98 55.62 57.49 59.94 63.93 64.35 65.41 63.45

The figure provided here is based on the number of

Consultants whom have completed an appraisal within the

previous rolling 12 months as extracted from ESR. Part of

the appraisal process incorporates a discussion on the

previous year’s objectives and PDP and therefore the

figure provided presumes that all appraisals have included

such discussions


Insert Performance in Month

QUALITY

Criteria

Refresh Data for new Month

Criteria Indicator Weight 5 4 3 2 1Year to

Date

Forecast

Outturn

Year to

Date

Forecast

OutturnBoard Action

Underlying

performanceEBITDA margin % 25% 11 9 5 1 <1 4 4

The Trust has delivered an EBITDA margin of

over 9% YTD

Achievement

of planEBITDA achieved % 10% 100 85 70 50 <50 4 4

The Trust has delivered EBITDA within 85% of

plan YTD

Net return after financing % 20% >3 2 -0.5 -5 <-5 3 3The Trust has delivered a NRaF of over -0.5%

YTD

I&E surplus margin % 20% 3 2 1 -2 <-2 2 2The Trust is delivering an I&E surplus margin of

0.2% YTD

Liquidity Liquid ratio days 25% 60 25 15 10 <10 1 1Forecast liquidity has fallen due to the impact of

failure to secure capital investment borrowing

100% 2.7 0.0 2.7 0.0

2 2

2 0 2 0

Overriding Rules :

Max Rating

3 No3 No2 No2 Unplanned breach of the PBC No2 2 2312

* Trust should detail the normalising adjustments made to calculate this rating within the comments box.

Plan not submitted complete and correct

Reported

Position

Two Financial Criteria at "2"

One Financial Criterion at "1"One Financial Criterion at "2"

PDC dividend not paid in full

Two Financial Criteria at "1"

Plan not submitted on time

FINANCIAL RISK RATING

Financial

efficiency

Rule

Weighted Average

Overriding rules

University Hospitals Coventry &Warwickshire NHS Trust

Risk Ratings

Overall rating

Insert the Score (1-5) Achieved for each

Criteria Per Month

Normalised

Position*

FINANCIAL RISK TRIGGERS

CriteriaQtr to

Jun-12

Qtr to

Sep-12

Qtr to

Dec-12Jan-13 Feb-13 Mar-13

Qtr to

Mar-13Board Action

1Unplanned decrease in EBITDA margin in two consecutivequarters

Yes Yes Yes Yes Yes Yes YesEBITDA performance below trajectory in Q1 of 2012/1, Q2 andQ3 of 2012/13

2Quarterly self-certification by trust that the normalisedfinancial risk rating (FRR) may be less than 3 in the next12 months

No Yes Yes Yes Yes Yes Yes

Due to change in guidance from the SHA as to which FRRshould be used to measure. The Trust was previously usingthe forecast outturn FRR for 2012/13 and 2013/14 to informthis assessment and is now using the YTD position forecast bymonth for the current year.

3Working capital facility (WCF) agreement includes defaultclause

N/a N/a N/a N/a N/a N/a N/a

4Debtors > 90 days past due account for more than 5% oftotal debtor balances

Yes Yes Yes Yes Yes No YesAction - Increased focus on debt recovery

5Creditors > 90 days past due account for more than 5% oftotal creditor balances

Yes Yes Yes Yes Yes Yes YesIssues around large intra-NHS balances

6Two or more changes in Finance Director in a twelvemonth period

No No No No No No No

7Interim Finance Director in place over more than onequarter end

No No No No No No NoSubstantive FD appointed in Jan 2012

8 Quarter end cash balance <10 days of operating expenses Yes Yes Yes Yes Yes Yes YesImprovement requires ongoing increases in liquidity - M112012/13 position also <10 days of operating expenditure

9 Capital expenditure < 75% of plan for the year to date No No No No No No No

10 Yet to identify two years of detailed CIP schemes Yes Yes Yes Yes YesDevelopment of 2 years of CIP schemes is progressing but notyet complete


Insert "Yes" / "No" Assessment for the Month

Historic Data Current Data

Refresh Triggers for New Quarter

See 'Notes' for further detail of each of the below indicators

Area Ref Indicator Sub SectionsThresh-

oldWeight-

ingQtr to Jun-

12Qtr toSep-12

Qtr toDec-12

Jan-13 Feb-13 Mar-13Qtr toMar-13

Board Action

Referral to treatment information 50%

Referral information 50%

Treatment activity information 50%

Patient identifier information 50% N/a N/a N/a N/a N/a N/a N/a

Patients dying at home / carehome

50% N/a N/a N/a N/a N/a N/a N/a

1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a N/a

1cData completeness: outcomes for patientson CPA

50% 0.5 N/a N/a N/a N/a N/a N/a N/a

2aFrom point of referral to treatment inaggregate (RTT) – admitted

Maximum time of 18 weeks 90% 1.0 Yes Yes Yes Yes yes yes Yes

2bFrom point of referral to treatment inaggregate (RTT) – non-admitted

Maximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes yes Yes Yes

2cFrom point of referral to treatment inaggregate (RTT) – patients on anincomplete pathway

Maximum time of 18 weeks 92% 1.0 Yes Yes Yes Yes yes Yes Yes

2d

Certification against compliance withrequirements regarding access tohealthcare for people with a learningdisability

N/A 0.5 Yes Yes Yes Yes Yes Yes Yes

Surgery 94%

Anti cancer drug treatments 98%

Radiotherapy 94%

From urgent GP referral forsuspected cancer

85%

From NHS Cancer ScreeningService referral

90%

3cAll Cancers: 31-day wait from diagnosis tofirst treatment

96% 0.5 Yes Yes Yes Yes yes Yes Yes

all urgent referrals 93%for symptomatic breast patients(cancer not initially suspected)

93%

3eA&E: From arrival toadmission/transfer/discharge

Maximum waiting time of fourhours

95% 1.0 No Yes No No No No No

A&E were seen outside of 4 hours. This means that UHCW’sperformance was at 81.51% or 13.49% below the minimumperformance threshold of 95%. However, this performancethreshold is based on the cumulative position and cumulativelyfor the period April 2012 to March 2013, 14,939 patients out of174,867 attendances at A&E were seen outside of 4 hours.This means that UHCW’s cumulative performance was at91.46% or 3.54% below the minimum performance threshold of95%.ACTIONS:With support from the Emergency Care Intensive SupportTeam, existing recovery plans (and the associated governanceframework) are being evaluated and revised to deliverperformance improvements throughout Q1 & Q2. The mainthemes for improvement are:

• Developing Alternative Pathways to ED• Improving ED Processes• Inpatient capacity & capacity management• Proactive Discharge Planning (simple)• Improving Supported Discharge (complex)

Receiving follow-up contact within7 days of discharge

95%

Having formal reviewwithin 12 months

95%

3gMinimising mental health delayed transfersof care

≤7.5% 1.0 N/a N/a N/a N/a N/a N/a N/a

3hAdmissions to inpatients services hadaccess to Crisis Resolution/HomeTreatment teams


3iMeeting commitment to serve newpsychosis cases by early intervention teams


Red 1 80% 0.5 N/a N/a N/a N/a N/a N/a N/a

Red 2 75% 0.5 N/a N/a N/a N/a N/a N/a N/a

3kCategory A call – ambulance vehicle arriveswithin 19 minutes


Is the Trust below the de minimus 12 No No No No No No No

Is the Trust below the YTD ceiling 70 No Yes Yes No No No No

Is the Trust below the de minimus 6 Yes Yes Yes Yes Yes Yes Yes

Is the Trust below the YTD ceiling 2 Yes Yes Yes Yes Yes Yes Yes

CQC Registration

ANon-Compliance with CQC EssentialStandards resulting in a Major Impact onPatients

0 2.0 No No No No No No No

BNon-Compliance with CQC EssentialStandards resulting in Enforcement Action


C

NHS Litigation Authority – Failure tomaintain, or certify a minimum publishedCNST level of 1.0 or have in placeappropriate alternative arrangements


TOTAL 2.0 1.0 2.0 2.0 2.0 2.0 2.0

Yes

N/a

Yes Yes

Yes

N/a

Yes Yes

Current DataHistoric Data

N/a N/a

Yes

N/aN/a

Yesyes

yes

N/a

Yes

Yes

Yes

Yes

Yes Yes Yes yes Yes

N/a

1.0

N/a

Cancer: 2 week wait from referral to datefirst seen, comprising:

1.0

MRSA

Clostridium Difficile 1.0

Yes

N/aCare Programme Approach (CPA) patients,comprising:

1.0

GOVERNANCE RISK RATINGS

Insert YES, NO or N/A (as appropriate)E

ffe

ctiv

en

ess

N/aData completeness: Community servicescomprising:

University Hospitals Coventry & Warwickshire

NHS Trust

N/a

Pa

tien

tE

xp

eri

en

ce

Qu

alit

y

0.5

1.01a

1bData completeness, community services:(may be introduced later)

3f

3b All cancers: 62-day wait for first treatment:

Sa

fety

1.0

Category A call –emergency responsewithin 8 minutes

3j

4b

4a

In July we had 1 MRSA and March 1 MRSA. YTD there hasbeen 2 MRSA cases so meeting the target of 2 cases.

In March 2013 there were 5 c-diff infections in UHCW. YTDthere have been 76 cases which is 6 (8%) above the trajectoryof 70 cases. The SHA have confirmed the spreadsheet isapplying a weighting of 1 for this metric where Trusts areexceeding the de minimus level but they are within the YTDceiling. Therefore the overall weighting for Qtr to Dec-12should be 1 (Amber/Green) and not 2ACTIONS:A single consolidated action plan has been developed to regaintrajectory.The plan aimed to regain the monthly target in March andalthough the overall position for the year was lost, the monthlytarget was achieved.Actions include:- CNO leading - twice weekly C Diff performance meeting(Executive)- DIPC leading actions with clinical and operational teams- Increased Infection control rounds at ward level (IPC, 2xPAsMedical, Additional Nursing)- Additional Enhanced cleaning program in high risk areas (ISSand Performance team)- Increased antibiotic surveillance (Pharmacy)- Increased education and awareness program- Full RCA and information sharing for C diff cases- Trust initiated external review of actions through SHA lead infection nurse and CCGAs agreed with the SHA, a meeting was planned with CCGs to review case notes since a number of cases were identified that were found not to be clinical C Diff disease and therefore may not be attributable to UHCW.

3a

Yes

N/a

All cancers: 31-day wait for second orsubsequent treatment, comprising:

3d

N/a

Refresh GRR for New Quarter

See 'Notes' for further detail of each of the below indicators Current DataHistoric Data

GOVERNANCE RISK RATINGS

Insert YES, NO or N/A (as appropriate)

University Hospitals Coventry & Warwickshire

NHS Trust

Refresh GRR for New Quarter

RAG RATING : AR AG AR AR AR AR AR

Overriding Rules - Nature and Duration of Override at SHA's Discretion

i) Meeting the MRSA Objective

iv) A&E Clinical Quality Indicator Yes Yes Yes Yes Yes

UHCW did not achieve the 95%, 4-hour A&E target in Q32012/13. The target was not achieved in Q4 2012/13. UHCWhas therefore failed to meet the A&E target twice in any twoquarters over the last 12 months. UHCW did not achieve thetarget in October, November, December 2012 or January,February or March 2013. The SHA advised UHCW in January2013 that the overriding rule will be applied retrospectively fromOctober 2012 because this target has been failed in thesubsequent nine-month period from Q1 2012/13

viii) Any other Indicator weighted 1.0

Adjusted Governance Risk Rating 2.0 1.0 4.0 4.0 4.0 4.0 4.0

AR AG R R R R R

the category A 8-minute response time target for a thirdsuccessive quarter

service referral information for a third successive quarter, or;

treatment activity information for a third successive quarter

vi) Ambulance Response Times

Breaches either:

Breaches the indicator for three successive quarters.

vii) Community Services data completeness

Fails to maintain the threshold for data completeness for:

either Red 1 or Red 2 targets for a third successive quarter

referral to treatment information for a third successivequarter;

the category A 19-minute response time target for a thirdsuccessive quarter

Breaches either:

the 31-day cancer waiting time target for a third successivequarter

the 62-day cancer waiting time target for a third successivequarter

Breaches:

The admitted patients 18 weeks waiting time measure for athird successive quarter

The non-admitted patients 18 weeks waiting time measurefor a third successive quarter

The incomplete pathway 18 weeks waiting time measurefor a third successive quarter

v)

Fails to meet the A&E target twice in any two quarters overa 12-month period and fails the indicator in a quarter duringthe subsequent nine-month period or the full year.

ii)

Greater than six cases in the year to date, and breaches thecumulative year-to-date trajectory for three successivequarters

Cancer Wait Times

Greater than 12 cases in the year to date, and either:

Reports important or signficant outbreaks of C.difficile, asdefined by the Health Protection Agency.

Breaches the cumulative year-to-date trajectory for threesuccessive quarters

iii) RTT Waiting Times

Meeting the C-Diff Objective

RED = Score greater than or equal to 4

GREEN = Score less than 1

AMBER / RED = Score greater than or equal to 2, but less than 4

AMBER/GREEN = Score greater than or equal to 1, but less than 2

Qtr to

Jun-12

Qtr to

Sep-12

Qtr to

Dec-12Jan-13 Feb-13 Mar-13

Qtr to

Mar-13Board Action

1 Are the prior year contracts* closed? Yes Yes Yes Yes Yes Yes Yes

2Are all current year contracts* agreed andsigned?

Yes Yes Yes Yes Yes Yes Yes

3Has the Trust received income support outsideof the NHS standard contract e.g.transformational support?

Yes Yes Yes Yes Yes Yes YesThe Trust has received non-recurrenttransitional support for the achievement ofQIPP and general efficiency metrics

4Are both the NHS Trust and commissionerfulfilling the terms of the contract?

Yes Yes Yes Yes Yes Yes Yes

5Are there any disputes over the terms of thecontract?


6Might the dispute require third party interventionor arbitration?


7 Are the parties already in arbitration? No No No No No No No

8 Have any performance notices been issued? Yes Yes Yes Yes Yes Yes Yes

A contract query has been issued withregard to the Trusts A&E performance inQ3. An excusing notice has been sent bythe Trust 8th January 2013.

9 Have any penalties been applied? Yes Yes No No No No No

*All contracts which represent more than 25% of the Trust's operating revenue.

Current Data

Insert "Yes" / "No" Assessment for the Month


Criteria

CONTRACTUAL DATA

Information to inform the discussion meeting

Historic Data

Refresh Data for new Quarter

TFA Progress

Apr-13

Milestone

DateDue or Delivered

MilestonesFuture Milestones Board Action

1SHA Interviews with the board, SHA initial meeting with thecommissioners

Mar-12 Fully achieved in timeCompleted

2 SHA/UHCW discussion of IBP/LTFM & PMR escalation meeting Mar-12 Fully achieved in timeCompleted

3 Self-assessment completion of BGAF Mar-12 Fully achieved in timeCompleted.

4 Submit 1st draft of IBP/LTFM and authorization for HDD1 refresh Nov-12 Fully achieved in time Completed

5Trust complete self-assessment against quality dashboard and submit tothe SHA

Mar-13Risk to delivery within

timescaleRevised timeline submitted to SHA 25th January 2013.

6 HDD1 Jan-13 Fully achieved in time On track to deliver Final report received and actions incorporated into plan.

7 Submit high quality draft of IBP/LTFM to SHA Jan-13 Not fully achievedRisk to delivery within

timescaleRevised timeline submitted to SHA 25th January 2013

8 Final Draft of the IBP/LTFM to the SHA Feb-13 Not fully achievedRisk to delivery within

timescaleRevised timeline submitted to SHA 25th January 2013

9 CQC Opinion received by SHA (SHA action) Mar-13 Not fully achievedRisk to delivery within

timescale

This is an SHA action - revised timeline submitted to SHA on 25th January

2013

10 HDD 2 Mar-13 Not fully achievedRisk to delivery within

timescaleDelayed due to new timeline

11 Implement recommendations from HDD1 Sep-13 On track to deliver Revised timeline submitted to SHA 25th Janaury 2013 - TBC

On track to deliver

12 IBP to Board for review Sep-13 On track to deliver

13 HDD1 Reassessment Dec-13 On track to deliverAdvised by SHA requirement to reassess HDD1 due to changes in service

strategy model and replacement of Chair/NEDSOn track to deliver

14 FT Readiness review SHA/UHCW including PMR escalation meeting Jan-14 On track to deliver

15 Complete QGAF assessment Mar-14 On track to deliver

16Board seminar BGAF, ICTstrategy, IBP and LTFM prior to submissionto SHA

Mar-14 On track to deliver

17 Final IBP LTFM and supporting appendices to SHA Mar-14 On track to deliver

18 BGAF external validation and CQC opinion Apr-14 On track to deliver

19 Formal 12 weeks public consultation Jun-14 On track to deliver

20 HDD2 assessment Dec-14 On track to deliver

21 Board seminar on HDD2, financial plans and risks and BGAF Mar-15 On track to deliver

22 CCG letter of support Mar-15 On track to deliver

23 NTDA interview with HDD 2 lead and review of self certifications Apr-15 On track to deliver

24 Board seminar on final IBP HDD and BGAF Apr-15 On track to deliver

25 Completed IBP/LTFM to SHA Apr-15 On track to deliver

26NTDA/UHCW Board to Board (Full Voting Board), includes review ofPMR

May-15 On track to deliver

27 Submit FT application to the DH Jun-15 On track to deliver

28

29

30

31

32

33

34

35

36

37

38

39

40

TFA Milestone (All including those delivered)


Select the Performance from the drop-down list

Notes

Ref Indicator Details

Thresholds

1a

DataCompleteness:CommunityServices

Data completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, toconsist of:- Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community;- Community treatment activity – referrals; and- Community treatment activity – care contact activity.

While failure against any threshold will score 1.0, the overall impact will be capped at 1.0. Failure of the same measure for three quarters willresult in a red-rating.

Numerator:

all data in the denominator actually captured by the trust electronically (not solely CIDS-specified systems).

Denominator:

all activity data required by CIDS.

1b DataCompletenessCommunityServices (furtherdata):

The inclusion of this data collection in addition to Monitor's indicators (until the Compliance Framework is changed) is in order for the SHA totrack the Trust's action plan to produce such data.

This data excludes a weighting, and therefore does not currently impact on the Trust's governance risk rating.

1c Mental HealthMDS

Patient identity data completeness metrics (from MHMDS) to consist of:- NHS number;- Date of birth;- Postcode (normal residence);- Current gender;- Registered General Medical Practice organisation code; and- Commissioner organisation code.

Numerator:

count of valid entries for each data item above.(For details of how data items are classified as VALID please refer to the data quality constructions available on the Information Centre’swebsite: www.ic.nhs.uk/services/mhmds/dq)

Denominator:

total number of entries.1d Mental Health:

CPAOutcomes for patients on Care Programme Approach:

• Employment status:

Numerator:

the number of adults in the denominator whose employment status is known at the time of their most recent assessment, formal review or othermulti-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during thereference period. The reference period is the last 12 months working back from the end of the reported month.

Denominator:

the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during thereported month.

• Accommodation status:

Numerator:

the number of adults in the denominator whose accommodation status (i.e. settled or non-settled accommodation) is known at the time of theirmost recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews werecarried out during the reference period. The reference period is the last 12 months working back from the end of the reported month.

Denominator:

the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the reported month.

• Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:

Numerator:

The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months.

Denominator:

The total number of adults who have received secondary mental health services and who were on the CPA during the reference period.

2a-c RTT

Performance is measured on an aggregate (rather than specialty) basis and trusts are required to meet the threshold on a monthly basis.Consequently, any failure in one month is considered to be a quarterly failure. Failure in any month of a quarter following two quarters’ failure ofthe same measure represents a third successive quarter failure and should be reported via the exception reporting process.

Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any threshold will score 1.0, theoverall impact will be capped at 2.0. The measures apply to acute patients whether in an acute or community setting. Where a trust with existingacute facilities acquires a community hospital, performance will be assessed on a combined basis.

The SHA will take account of breaches of the referral to treatment target in 2011/12 when considering consecutive failures of the referral totreatment target in 2012/13. For example, if a trust fails the 2011/12 admitted patients target at quarter 4 and the 2012/13 admitted patients targetin quarters 1 and 2, it will be considered to have breached for three quarters in a row.

2d LearningDisabilities:Access tohealthcare

Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH,2008):a) Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of careare reasonably adjusted to meet the health needs of these patients?b) Does the trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:- treatment options;- complaints procedures; and- appointments?c) Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?d) Does the trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?e) Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers?f) Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings inroutine public reports?

Note: trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan stage and in each month. Failure to do so will result in the application of the service performance score for this indicator.

3a

Cancer:31 day wait

31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold represents a failure againstthe overall target. The target will not apply to trusts having five cases or less in a quarter. The SHA will not score trusts failing individual cancerthresholds but only reporting a single patient breach over the quarter.. Will apply to any community providers providing the specific cancertreatment pathways

3bCancer:62 day wait

62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and other consultants.Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or less in aquarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply toany community providers providing the specific cancer treatment pathways.

National guidance states that for patients referred from one provider to another, breaches of this target are automatically shared and treated on a50:50 basis. These breaches may be reallocated in full back to the referring organisation(s) provided the SHA receive evidence of writtenagreement to do so between the relevant providers (signed by both Chief Executives) in place at the time the trust makes its monthly declarationto the SHA.

In the absence of any locally-agreed contractual arrangements, the SHA encourages trusts to work with other providers to reach a local system-wide agreement on the allocation of cancer target breaches to ensure that patients are treated in a timely manner. Once an agreement of this nature has been reached, the SHA will consider applying the terms of the agreement to trusts party to the arrangement.

3c CancerMeasured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter. The SHAwill not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any communityproviders providing the specific cancer treatment pathways.

3d Cancer

Measured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary careprofessional).Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases orfewer in a quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter.Will apply to any community providers providing the specific cancer treatment pathways.

Specific guidance and documentation concerning cancer waiting targets can be found at:http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation

The SHA will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing toachieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or notolerance against the target, e.g. those set between 99-100%.

Notes

Ref Indicator Details

3e A&EWaiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour waiting time indicator willapply to minor injury units/walk in centres.

3f Mental 7-day follow up:

Numerator:

the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion)within seven days of discharge from psychiatric inpatient care.

Denominator:

the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care.

All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up withinseven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team.

Exemptions from both the numerator and the denominator of the indicator include:- patients who die within seven days of discharge;- where legal precedence has forced the removal of a patient from the country; or- patients discharged to another NHS psychiatric inpatient ward.

For 12 month review (from Mental Health Minimum Data Set):

Numerator:

the number of adults in the denominator who have had at least one formal review in the last 12 months.

Denominator:

the total number of adults who have received secondary mental health services during the reporting period (month) who had spent at least 12 months on CPA (by the end of the reporting period OR when their time on CPA ended).

For full details of the changes to the CPA process, please see the implementation guidance Refocusing the Care Programme Approach on the Department of Health’s website.

3g Mental Health:DTOC

Numerator:

the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of carewas delayed during the month. For example, one patient delayed for five days counts as five.

Denominator:

the total number of occupied bed days (consultant-led and non-consultant-led) during the month.

Delayed transfers of care attributable to social care services are included.

3h Mental Health: I/Pand CRHT

This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The following cases can be excluded:- planned admissions for psychiatric care from specialist units;- internal transfers of service users between wards in a trust and transfers from other trusts;- patients recalled on Community Treatment Orders; or- patients on leave under Section 17 of the Mental Health Act 1983.

The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolutionteam if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted inadmission.

For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on theDepartment of Health’s website. As set out in this guidance, the crisis resolution home treatment team should:a) provide a mobile 24 hour, seven days a week response to requests for assessments;b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires face-to-face contact unless it can be demonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate, a declaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;c) be notified of all pending Mental Health Act assessments;d) be assessing all these cases before admission happens; ande) be central to the decision making process in conjunction with the rest of the multidisciplinary team.

3i Mental HealthMonthly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance,rounded down.

3j-k

AmbulanceCat A For patients with immediately life-threatening conditions.

The Operating Framework for 2012-13 requires all Ambulance Trusts to reach 75 per cent of urgent cases, Category A patients, within 8 minutes.From 1 June 2012, Category A cases will be split into Red 1 and Red 2 calls:• Red 1 calls are patients who are suffering cardiac arrest, are unconscious or who have stopped breathing.• Red 2 calls are serious cases, but are not ones where up to 60 additional seconds will affect a patient’s outcome, for example diabeticepisodes and fits.Ambulance Trusts will be required to improve their performance to show they can reach 80 per cent of Red 1 calls within 8 minutes by April 2013.

4a C.Diff

Will apply to any inpatient facility with a centrally set C. difficile objective. Where a trust with existing acute facilities acquires a communityhospital, the combined objective will be an aggregate of the two organisations’ separate objectives. Both avoidable and unavoidable cases of C.difficile will be taken into account for regulatory purposes.

Where there is no objective (i.e. if a mental health trust without a C. difficile objective acquires a community provider without an allocated C.difficile objective) we will not apply a C. difficile score to the trust’s governance risk rating.

Monitor’s annual de minimis limit for cases of C. difficile is set at 12. However, Monitor may consider scoring cases of <12 if the HealthProtection Agency indicates multiple outbreaks. Where the number of cases is less than or equal to the de minimis limit, no formal regulatoryaction (including scoring in the governance risk rating) will be taken.

If a trust exceeds the de minimis limit, but remains within the in-year trajectory for the national objective, no score will be applied.If a trust exceeds both the de minimis limit and the in-year trajectory for the national objective, a score will apply.If a trust exceeds its national objective above the de minimis limit, the SHA will apply a red rating and consider the trust for escalation.

If the Health Protection Agency indicates that the C. difficile target is exceeded due to multiple outbreaks, while still below the de minimis, the SHA may apply a score.

4b MRSA

Will apply to any inpatient facility with a centrally set MRSA objective. Where a trust with existing acute facilities acquires a community hospital,the combined objective will be an aggregate of the two organisations’ separate objectives.

Those trusts that are not in the best performing quartile for MRSA should deliver performance that is at least in line with the MRSA objectivetarget figures calculated for them by the Department of Health. We expect those trusts without a centrally calculated MRSA objective as a resultof being in the best performing quartile to agree an MRSA target for 2012/13 that at least maintains existing performance.

Where there is no objective (i.e. if a mental health trust without an MRSA objective acquires a community provider without an allocated MRSAobjective) we will not apply an MRSA score to the trust’s governance risk rating.

Monitor’s annual de minimis limit for cases of MRSA is set at 6. Where the number of cases is less than or equal to the de minimis limit, noformal regulatory action (including scoring in the governance risk rating) will be taken.

If a trust exceeds the de minimis limit, but remains within the in-year trajectory for the national objective, no score will be applied.If a trust exceeds both the de minimis limit and the in-year trajectory for the national objective, a score will apply.If a trust exceeds its national objective above the de minimis limit, the SHA will apply a red rating and consider the trust for escalation



24th

April 2013


Subject: Infection Prevention & Control Annual Report 2012-13Report By: Dr M Weinbren, Director and Kate Prevc, Modern Matron – Infection

Prevention and ControlAuthors: Dr M Weinbren, Director and Kate Prevc, Modern Matron – Infection

Prevention and ControlAccountable Executive Director: Professor Mark Radford, Chief Nursing Officer

GLOSSARY

Abbreviation In FullMRSA Meticillin Resistant StaphylococcusDH Department of HealthC Diff Clostridium difficileMSSA Meticillin Sensitive Staphylococcus AureusSHA Strategic Health AuthorityHCAI Health care associated infectionsDIPC Director of Infection Prevention and ControlRCN Royal College of NursingHCSW Health Care Support WorkerIPC Infection Prevention and ControlPVL Panton-Valentine leukocidinPCT Primary Care TrustHSE Health & Safety Executive



TitleApprox. Length


To present the Infection Prevention and Control Team’s annual report for the year 2012-13 and the Annual Planfor 2013/14 (Appendix 1).


2012/13 and 2013/14 targets for C Diff were/are a significant challenge Delivery of MRSA target 2012/13 Range of additional measures employed to tackle infection control agenda


Potential reputational issues with HCAI Clinical issues with infection risks Potential contractual levers for HCAI in 2012/13



24th

April 2013



Trust Board asked to accept and note the report.

IMPLICATIONS:

Financial: Potential commissioner penalties for not achieving targets

HR / Equality & Diversity: -

Governance: Patient safety

Legal: -

REVIEW:


DATA QUALITY:


April 2012-13Version 1

1


Infection Prevention & Control Report to the Trust Board

Annual Report 2012-13

1. Introduction

Infection Prevention and Control remains a high priority at UHCW NHS Trust. UHCWNHS Trust are fully signed up to the Health Act 2009 and are registered in line withnational requirements.

2. Aim of the report

The purpose of the report is to brief the Trust Board on the progress of the Trust inrelation to the Infection Prevention and Control Annual Plan of Work 2012-2013 includingchallenges encountered and to provide an update on the Trust’s progress against thelocal and National Performance Targets. The report also details the 2013/14 InfectionPrevention and Control Annual Plan (appendix 1).

3. Progress against National Performance Targets

3.1 MRSA Bacteraemias

The Trust continues to perform well against a target of 2 for 2012-2013. Two MRSAbacteraemia were ascribed to the Trust. We are working closely with the IV specialist toidentify any concerns and to address any issues highlighted by the RCA process. Afollow up meeting is held with the CEO and clinical teams to report progress against anyaction plans and to seek any additional assistance if required.

MRSA Bacteraemias Reported by Quarter / Year

Quarter 2008/09 2009/10 2010/11 2011/12 2012/13

1st Quarter 3 3 1 1 0

2nd Quarter 10 2 1 0 1

3rd Quarter 2 2 1 0 0

4th Quarter 2 1 1 1 1Table 1

3.2 Elective and emergency MRSA screening.

The Trust has consistently met the DH requirements for Elective screening and has apositive pick up rate of between 0.3-0.6%. The positive pick up rate for EmergencyScreening is 1.3%. We await the DH guidance around future screening strategy foremergency and elective screening which was due out in June 2012 but is still notavailable. The target for 2012-2013 was a maximum of 2 MRSA Bacteraemia. Thetarget for 2013-14 is 0.

3.3 MSSA Bacteraemias

The upper limit for MSSA for the year 2011-2012 for UHCW NHS Trust was 50. Therewas not a target attributed to MSSA for 2012-13 and the Trust had 47 cases. Wecontinue to monitor our rates and hold RCAs for each MSSA Bacteraemia.


2

Common findings arising from the RCA process

Pie Chart showing MSSA Bacteraemia by associated Clinical Infection

12

8

5

3

2

1

11 1

Sepsis

Skin/soft tissue infection

Line Site

Leg Ulcer

Gastrointestinal

Bone / Joint

LRTI

URTI

UTI

The work of the IV team within the last twelve months has played a pivotal role inreducing the number of bacteraemias associated with cannulation. Further reductionsare achievable through improved training and competency based assessment of medicalstaff who take blood cultures. Ideally education of prospective new doctors before theystart on the wards is required to ensure optimum patient care. The IV team is oneperson who has made huge advances in IV practice and works closely with IPC.However it is concerning to see cases of infections associated with line or cannulae andthis is currently being tackled.

3.4 E Coli

E Coli is the most common blood culture isolate, UHCW reporting 233 cases 2011-12and 294 for 2012-13. There will not be a target attached to this organism next year. Themost common source of infection is the urinary tract. Some work has been done lookingat patients who develop catheter associated urinary tract infections both here and by theSHA lead for HCAI but no link was found in either project. The DH use this data which isa mandatory requirement to monitor antibiotic resistance against 3

rdgeneration

cephalosporin’s. The figures have remained broadly the same since 2009-10.

3.5 Clostridium difficile (Cdiff )

The management of the C diff target has been challenging throughout the country for thisfinancial year. This year saw more stability locally with the testing process but it is unclearwhether all Trusts are monitoring against the same criteria. The DH state all Trustsshould use a 2 stage mechanism but does not mandate which. The DH also state that allToxin positive cases should be reported, whether or not they have active disease or arecolonised.

Since January the Trust had supported a C diff ward round, composed of the DIPC (whois also a Microbiologist and the Infection Control Doctor) and a Gerontologist along withthe F2 for microbiology.

Infection Prevention and Control have introduced a number of strategies to tackle the Cdiff issue. It is our belief that we still have work to do and that we have not achieved ourirreducible minimum. Data collection has informed our strategy and we have developed


3

algorithms to assist staff in correct bowel management and understanding when to sendspecimens. This has been particularly successful and the RCN have adopted it nationallyto teach student nurses good bowel management. Several Trusts have contacted UHCWto adopt the algorithm. We have arranged a series of competitions and activities to raiseawareness, generate enthusiasm and educate staff. These are also proving to besuccessful. One aim was to reduce the number of inappropriate samples being sent andthis has reduced month on month. The initiative started in mid January 2013.

Total

0

100

200

300

400

500

600

700

Jan

Feb

Ma

r

Ap

r

May

Jun

Ju

l

Aug

Sep

Oct

Nov

De

c

Jan

Feb

Ma

r

Ap

r

May

Jun

Ju

l

Aug

Sep

Oct

Nov

De

c

Jan

Feb

Ma

r

Ap

r

May

Jun

Ju

l

Aug

Sep

Oct

Nov

De

c

Jan

Feb

Ma

r

2010 2011 2012 2013

Sum of Requests:

Years Week commencing:

This appears to have had dramatic effect up to week beginning 17th

March, at this timethe Trust saw an increase in Norovirus cases, we had four wards shut. All samples ofdiarrhoea will be tested for C diff. regardless of what is requested. This may account for ahigher number of samples. However despite the number of samples increasing, thenumber of positive cases was 5 for the month which brought us back onto monthlytrajectory.

The table below shows the number of Toxin positive results (76) for 2012-13. This stillrepresents a 16% decrease in cases from the previous year.

C diff Toxin positive results. Reported by Quarter / Year

Quarter 2008/09 2009/10 2010/11 2011/12 2012/13

1st Quarter 50 27 39 22 19

2nd Quarter 32 28 18 22 17

3rd Quarter 36 26 23 36 17

4th Quarter 29 35 24 10 23Table 2

4. Cleaning

Management of the environment is an important factor in the management of C diff withinthe hospital environment. There have been many initiatives developed to improve ourenvironment. The HCSW for IPC undertakes a weekly walk of all Trust areas and is apresence on the wards to enable staff to ask questions and to remind staff of theimportance of environmental cleaning. Issues are tackled immediately and if they are notcompleted within 24 hours the Matron for the area is informed. A report is brought to theOperational Cleaning meeting and trends are discussed and managed. If the problemneeds more senior support it is brought to the Operational Cleaning meeting and


4

discussed further. Bare below the elbows and hand hygiene is tackled through the sameforums.

Infection Prevention and Control are working with the Chief Nursing Officer, Director ofEstates and Soft Services Performance Group to develop an ongoing cleaningprogramme that targets high risk areas more frequently and at a higher level.

The Infection Prevention and Control Team undertook a total of 318 environmental auditsover the year. The overall rate of compliance was 78% minimal compliance. Externalauditors have been invited into the Trust by the Director of Estates and Project Co, weawait their report.

1st Quarter 2nd

Quarter 3rd

Quarter 4th

Quarter Overall yearUHCW2012-13

78%( 45) 74% n(89) 79%n (97) 80% n(87) 78% n (318)

UHCW2011-12

75.5% n (87) 82% n(120) 76.5% n(113)

70% n(106)

77% n( 412)

Table showing the Infection Prevention and Control scores for environment 2011-2012.

5. Saving Lives

Compliance data for Saving lives.2010-11 2011-12 2012-13

C diff compliance 92% 92% 94.% *MRSA screeningcompliance

77% 82.6% 79% *

MRSA Screeningelective

81% 85% 89% Matched.

MRSA Screeningemergency

62% 69% 71%

*. Compliance is monitored against the quick action guide, failures mainly due to medicalstaff not completing their section. This is addressed via the junior doctors inductionprogramme.

6. Annual Audits 2012-2013

Environment Sharps Hand Hygiene IsolationUHCW 78% 88% 89% 89%

7. Surgical Site Infection (SSI) Surveillance

The Trust has signed up to undertake audit on non coronary by pass graft procedures forthe quarter. The initial data has been collected and we are completing the follow upwork which involves post operative discharge surveillance. Over 70 patients have beenincluded in the data.

8. Incidents and Outbreaks

Norovirus was particularly challenging at UHCW this year as it was throughout the county.We are still experiencing issues with Norovirus which is still in the community. To theyear end we had 21 wards confirmed with Norovirus and a total of 60 wards or areas thatwere either affected or closed for observation. In the year 2011-12 we had 7 confirmedcases and 25 wards/ areas closed for observation.

Influenza also posed challenges this year. We had a ward closed as it was a high risk areaand there were significant numbers of patients affected.


5

The Infection Prevention and Control team dealt with:

Chicken Pox 15 Pertussis incidents 12

Nasendoscopedecontamination

1 PVL 1

Influenza 52 Parva virus 4

Multi resistant acinetobactor 3 Coronavirus 2

Mumps 2 Scabies 9

Measles 22 Shingles 15

Meningitis 4 Hepatitis 5

Norovirus (confirmed) 21 Tuberculosis 45

CJD 3

9. Water Quality

9.1 Legionella

There is a rolling programme of testing for the presence of legionella in water samplesthroughout the Trust. No instances of hospital acquired legionella have occurred sincethe new hospital was opened.

The water management group continues to meet.

UHCW site; a minor contamination of the water system was detected in the FM building.Corrective measures have been put in place and the incident is now closed.

Rugby St Cross; progress continues to be made to eliminate the contamination which isthe culmination of a number of factors including closing down services and changing theoccupancy of buildings such that the usage of water is significantly below the deignparameters of the building design.

Stratford haemodialysis unit; after a long period of difficulties with the landlord, privateestates facilities which has required significant and useful input from the HSE significantheadway has been made. The latest results of water testing show the system to be in amanaged state with low counts of 2-14 groups being identified prior to further rectificationwork. In addition a long term plan has been produced which appears to be workable andall parties have signed up to.

10. New appointments

Fiona Wells has been on secondment to the Infection Prevention and Control team forone year to cover adoption leave.

11. Infection Control Link staff training

Infection Prevention and Control works closely with its link workers and we continue tohold two study days per year. In May we held an in house day which covers all aspectsof basic care. This was called “the strongest link”.

In November we held a very successful study day called “Joined up thinking” whichsought to explore the importance of working with external agencies and the PCT. Bothstudy days evaluated extremely well.

12. Recommendations

The Trust Board to accept the report of the Infection Prevention and Control Team 2012-13.

Work plan for year 2013-14

Infection Control work plan 2013-2014April 2013

1

University Hospitals Coventry & Warwickshire NHS TrustInfection Control Work Plan 2013-14

Topic Objective Action By whom By when

Continually review and amend MRSA guidance in linewith local and national guidance

InfectionPrevention andControl Team

March 2015National targets

Meticillin ResistantStaphylococcusAureus ( MRSA)

Ensure sustainableimprovements againstlocally set trajectory

Continue to screen and monitor compliance figuresagainst screening of MRSA elective patients

IPC data analyst March 2014Over 100 % for

elective and approx70% compliancewith emergency.

Still awaitingguidance from DH .

DH proposed 0 MRSABacteraemia

UHCW adopts a zerotolerance to MRSABacteraemia.

Report data:Nationally (monthly)Post infection review process for use in all MRSAbacteraemias. Reporting will be via a new data capturesystem This is intented to replace RCAs . This will becompleted by a multi disciplinary team.

Trust Board (monthly, quarterly, annual report)Divisions), Matrons and Ward staff (daily/monthly)

Modern MatronsDivisional nurse

directors

March 2014

All services to monitor and report on compliance withthe screening component of the MRSA policy anddevelop remedial action plans as required

ModernMatrons/InfectionPrevention andControl Nurses

Monthly

MRSA to be a key element in the Infection Controleducational programme.

Infectionprevention andControl Team

Continuously

Continue to screen and monitor compliance figuresagainst screening of MRSA emergency admissions


Infectionprevention andControl analyst

Head of

Weekly/monthly/quarterly/annuallyAll targets for data

reporting met



2

performance

Monitor and report compliance with the MRSA quickaction guide and develop remedial action plans asrequired with Modern Matrons monitoring through thesaving lives group.

InfectionPrevention andControl Nurses

Monthly.

Support root cause analysis (RCA) at Divisional levelwith Infection control assistance as required andoversee implementation action plans To accompany themedical teams to discuss the outcomes with the CEO

To discuss with the lead for QIPS the PIR process forMRSA.

To work on paperwork for C diff RCA.


Ongoing

Provide trend analysis information to the InfectionPrevention and Control committee, and InfectionPrevention and Control dashboard.

Feedback to DIPC meeting. To continue to work on improving the communication

pathway between IPC and Trust.


Ongoing

Monitor and assist staff to display infection preventionand control information and guidance in a clearstandardised way on the notice boards

InfectionPrevention andControl team.IPC HCSW

Ongoing.Reported biweeklyand monitored by

saving lives .As above

Continue to assist and support root cause analysis(RCA) and oversee action plans through the saving livesgroup. Monitor and amend the RCA process as required.

Infectionprevention andcontrol team

To include aMicrobiologist inRCAs wheneverpossible. .

Clostridium difficile( C diff)

Monitor compliance with the antibiotic policy via C diffPerformance Group- reporting any variances to theInfection Prevention and Control Committee via the

Matt Rogers/Bernie Berretto

Monthly



3

CDT performance group report. To develop a new role within IPC to assist in the

monitoring and surveillance of patients with C diff andto monitor the increase in multi resistant organisms.

Karen Richards April 2013

Investigate all cases of C diff that occur post 48 hoursfrom admission ( slice of PII )

Develop remedial action plans

Infection ControlTeam

Modern Matrons/Ward Managers

OngoingCompliance/ audit

analysis sheetsdeveloped to assist

with this.

DH set a trajectory of57 for year 2013-14

To continue with the implementation of the C diffaction plan and Stool smart campaign

InfectionPreventionand Controlteam.

C diff to be a key element of infection prevention andcontrol educational programme. To reduce thenumbers of C diff cases in line with the trajectory set bythe DH


January 13 -March14

Review the results of the C Diff and death certificateaudit and distribute findings to the relevantorganisations.

Chief nurseMedical Director

DIPC

May 2013

Provide trend analysis information to the InfectionControl committee, C Diff Performance Group andannual report.


Annually March2013

To continually review and revise policy to reflect nationalguidance and local needs utilising the C diff quick actionguide.

To monitor the effectiveness of this policy monthly andreport variances by auditing Cdiff quick action guides.

C diffPerformance

Group

TBA by DIPC

Monitor and report compliance with the C Diff quickaction guide and develop remedial action plans asrequired with Modern Matrons


Monthlycompliance to

saving lives group

Report data:Nationally (monthly)PCT (monthly and quarterly)


Weekly/monthly/quarterly/annually



4

Trust Board (monthly, quarterly, annual report)Divisions) Matrons and Ward staff (daily/monthly)Monthly dashboard produced.

To ensure compliancewith new DHrequirements

MSSA reporting and RCA To ensure monthly reporting and to undertake post 48Root Cause Analysis

InfectionPrevention andControl team inconjunction with

ClinicalGovernancedepartment

Monthly reportingand RCA to be held

as required.

Reporting of E- Colibacteraemia

To ensure that process are in place to monitor andreport E- Coli bacteraemia occurring post 48 hours ofadmission. To ensure that trends are analysed andactions taken to reduce the numbers by targetingeducation and improving and weaknesses in practice.

To include in new job role to evaluate and monitorincidence of resistant organisms.

Infectionprevention and

Control team anddata analyst.

Head ofperformance.

Monthly reporting

Cleaning Standards To ensure compliance withnational standards

Monitor cleaning standards at bi-weekly OperationalCleaning meeting and agree any remedial action planswith relevant teams


Ongoing

Continue to use the ICNA environmental audit tool.Until the trust is confident that the Maxi miser (ISSquality control tool) is fit for purpose and reflects thegenuine state of the environment.

The ICNA tool should then be used to quality controlon a quarterly basis or in the event of a C diff orother incident.


working with theDirector of

Estates andperformance

team.

Ongoing. .

To widen the role of the HCSW to “ walk the Trust “across a two week period providing feedback and trendanalysis on basic cleaning and infection prevention andcontrol practices.

HCSWFeedback tomatrons via

saving lives andoperational

cleaning group.

Monthly.

Audit To ensure that infectioncontrol is embedded at alllevels of the organisationand to comply with the

Conduct audits as per forward audit plan Include audit of Infection Prevention and Control risk

assessment


OngoingBrought forwardfrom last year.



5

Health Act (DH 2006)

Education forEmployees andContractors at UHCW

To ensure that all staff haveaccess to infection controleducation and mandatorytrainingTo develop the E -learning

for mandatory andInduction. All other learningto be directed directly torelevant areas.

Provide training on induction in conjunction withmandatory training committee process

Provide mandatory training Provide hand decontamination training and develop a

cascade team in clinical areas, Develop DVD and e-learning/self-assessment

packages in accordance with the trust mandatoryprocess.

To provide any additional training sessions whenrequired on: emerging organisms

Outbreak management. New requirements New practices. To develop a working group of junior doctors to foster

better understanding of roles and Infection preventionand control requirements.


OngoingAnnuallyAnnuallyOngoing

As required.

Medical staff TrainingConsultants To ensure all medical staff

receive mandatory trainingannually to include handhygiene which is recordedcentrally

Ensure every consultant within the Trust is trained toperform hand decontamination according to trust policyand this is recorded centrally Via OLM data base

Include mandatory training for all consultants annually

Infection controlteam, link staffand modernmatrons

March 2014Monitored Via OLM

Junior Doctors To ensure all medical staffreceive mandatory trainingannually to include handhygiene which is recordedcentrally

All junior doctors to receive hand hygiene trainingannually. This must be formally assessed and signedoff as part of competencies. All training will be recordedcentrally on the OLM data base


March 2014On junior doctorinductionprogramme



6

To engage Junior medicalstaff in competency basedlearning. Particularly inareas identified by RCA asrecruiting more education.

To ensure engagement with the cannulation trainingprovided by the IV team within four weeks of induction

To ensure engagement with the Blood culture trainingoffered to all staff within four weeks of induction.

To ensure engagement with hand decontaminationand have sign off, within four weeks of induction.

To undertake fit testing as required by all staff usingFFP2/3 masks.

IPC inconjunction withthe IV team.

March 2014

Medical Students To ensure all medicalstudents are safe topractice, Prior tocommencement of clinicalplacement. all medical staffreceive mandatory trainingannually to include handhygiene which is recordedcentrally

All medical students to receive hand hygiene trainingprior to commencement of clinical placement and havea sign off or be on OLM

Medical students to receive mandatory training oninduction to Trust. All training to be recorded on OLMdata base


March 2014

Other training. The Infection Preventionand Control team will workwith the Foundation Trustteam.To develop a trainingpackage for Volunteers whocannot access e learning.

Using social media tocommunicate with the widerlocal community others

To assist in public forum s and sessions for FoundationTrust members.

IPC team with volunteers. To continue with high profile campaign for Hand

Hygiene promoting whenever possible with Patients.Visitors and local schools.

We Have followers both nationally andInternationally, requesting further information andsharing good practice.

InfectionPrevention andControl team

As required.

Aseptic Technique Establish baseline ofcurrent practice andimprove on any poorpractice issues to ensure allclinical staff understandbasic concepts of Asepsis.

Undertake ‘snap shot’ observational audits of practice. Undertake audit of availability and use of equipment Monitor and report on compliance with aseptic and

clean technique guidelines and develop remedial actionplans

To include principles of asepsis on essence of caretraining and Induction for Nursing students.

To ensure that all aspects of aseptic non touchtechnique ( ANTT ) are integrated into practice atUHCW

InfectionPrevention andcontrol team withTissue viabilityteam.

May 2014.



7

Water quality To ensure the safety andquality of water provided toboth patients visitors andstaff

The Water Management Group will monitor waterquality with special reference to legionella andPseudomonas and advise the Trust on appropriateaction plans and monitor compliance on agreed actions

Progress sign off of legionella policy with all partneragencies

To ensure the implementation monitoring and successof the pseudomonas action plan.

Martin Kent

M Weinbren

Continuous

TB Strategy To provide a quality serviceacross the healthcareeconomy region for patientsknown or suspected to haveTB

Participate in networking meetings to Identify ways ofimproving TB services across the region linking withthe regional TB network

InfectionPrevention and

Control team. DrRavi Gowda

Infectiousdiseases

Consultant.

Continuous

Monitor appropriateness and effectiveness of facilitiesto manage all patients with TB provided within the Trust

Participate in the collection of data required in incidentmanagement

Provide timely reports on the progress of the TB forumsto Infection control committee.

Infection Preventionand Control teamtraining.

The infection Preventionand Control team shouldpossess a range of skillsthat ensure the smoothdelivery of an evidencedbased and up to dateinfection control service

To attend appropriate study days To participate in research. To publish work and produce posters for

conferences etc


March 2014

High ImpactInterventions

To comply with SavingLives recommendations

To assist and support GCC to report ventilated carebundles

Modern MatronCritical Care

Monthly

To assist in data collectionand the monitoring of

Central venous catheters Modern MatronCritical Care

Monthly



8

practice in accordance withthe saving lives bundle.

To be part of the working party looking at practicesacross the Trust.

Renal care Modern MatronRenal

Monthly

To assist with themonitoring and reduction ofUrinary tract infectionassociated with catheters

To lead on the work to reduce urinary catheterassociated urinary catheter infections.

To work with the trust urinary catheter group and thecommunity catheter care group to unify andstandardise our practice to reduce the incidence ofcatheter related urinary tract infections.

Modern MatronsSurgery/Medicine

Quarterly

Surgical site .To undertake Surgical site infectionsurveillance with the HPU and to feedback theinformation to the relevant teams.

SSSI Audit andSurveillancenurse.

July 2014

Peripheral venous cannulation To develop a campaign with the IV nurse practitioner

to increase awareness of the management of Centrallines

To develop a campaign with the IV nurse practitioner toincrease awareness of the management of peripherallines and canulae.

IV Team Quarterly

Clostridium difficile; to continue the Stool Smartcampaign.

To continue to work on specimen awareness toimprove our recognition of C diff.

Infection ControlTeam

Monthly

MRSA InfectionPrevention andControl team.

Monthly.

Clean your handscampaign

To ensure that work startedby the clean your handscampaign is sustained bylocally developed strategynow that the national cleanyour hands campaign hasdisbanded.

Hand hygiene stands to be set up at the main entranceto hospital- To engage the public

Ensure posters are delivered and displayed in all areas To maintain and strengthen the link system for hand

hygiene to extend across the spectrum of employees toinclude medical champions.

Deliver education at ward departmental level to ensureall clinical staff are updated at least annually

Assist in the maintenance of training records relating tohand hygiene by putting names onto OLM

Clean hand co-ordinator Monthly

Monthly

Quarterly

March 2012

As requiredAs required



9

Train link staff to help educate new starters toward/department areas

Audit hand hygiene at local level – ICN to auditannually Trust wide and whenever a PII occurs.

To develop a Video which includes all staff to educateand motivate staff to improve hand hygienecompliance.

Bare Below theElbows

To comply with the DoHDirective

To implement Bare Below the Elbows Guidance To work with the Medical Director to ensure compliance

with the code. To readuit following an educational campaign to

improve compliance. Poor compliance score of 50%2013.

Human ResourceDept

IPC Handhygiene lead.

March 2014

Link staff To ensure link staff are welleducated and supported inlink role

Meet with link staff monthly An annual study day is being planned for May 13 ICN’s will work with link staff on an individual basis in

their own work areas to assist in audit and theeducation of staff

To develop an accurate and current database of linkstaff

To continue the BIG 2 initiative which encourages staffto identify two areas of concern each month which theirIPC lead can focus on.


Link Staff andIPC

OngoingMonthly drop in

sessions.

Annual study day To facilitate an infectioncontrol study day acrossthe network free to all NHSStaff

One day study day to be organised during October2014 TBC, to include all staff across the healthcareeconomy

To invite high profile and motivating speakers.

RegionalInfection Control

Committee

October 2014

Ensure the concept ofBoard to ward isestablished inpractice.

Ensuring board to wardresponsibility for theprevention of HCAI

Report all infection control information to Heads ofDivisions for dissemination to clinical teams

Engagement in RCAs and reporting to the ChiefExecutive To include junior medical staff involved in thecare in the RCA process.

Report infection control issues at Group and Executivelevel

Trust Board reports are delivered at public Trust board.


On-going



10

To ensure greaterunderstanding of InfectionPrevention and Control atGroup level.

The Infection Prevention and Control team will attend aselection of Group QUIPs meetings of their areas toensure that the figures presented on behalf of IPC areunderstood and to offer assistance to remedy anyshortfall


Monthly.

Management ofInfluenza

To ensure readiness andcontingency plans are inplace for the managementof suspected/confirmed fluincluding (H1N1) in light ofPCA testing.

Review and revise flu plan/ policy in line with localnational guidance.

A separate plan is available for a single case of avianflu or novel coronavirus.

Test operational management of policy annually All contingency arrangements are in place for business

continuity To continue to offer training and fit testing for staff. To support both the Occupational Health Department in

the flu vaccination campaign within the Trust toincrease the uptake of those vaccinated to protect thetrust from seasonal flu

To ensure our staff are vaccinated.

M WeinbrenDIPC and Flu

lead.

Ongoing

Policy/Guidelines To ensure all policies andguidelines regarding theprevention and control ofinfection are updated in linewith national, localguidelines. New polices willbe generated according toservice needs

All Infection Control policies/guidelines to be reviewed Policies/guidelines to be ratified by the approved trust

process. Policies/guidelines to be disseminated to clinical areas

and all web sites to be updated regularly.


Annually

Surveillance & datacollection

To ensure timely datarelative to alert organism iscollected and disseminatedto wards and departments,to observe trends andidentification of potentialoutbreaks of infection

Improve the accuracy and efficiency of data collection To develop a more user friendly surveillance system

working with the ICT service to replace IC NetAllowing greater transfer of information between the

Infection Prevention and Control team and the clinicalareas. This will also be more cost effective.


IPC team andICT services

MonthlyAnd wheneverincidents occur.

Continue to provide surveillance data to clinicians, divisionsand wards in order to provide timely evidence on theirperformance, which will be overseen by the InfectionControl Operational Group.


Monthly



11

Work with divisions, departments and wards tostandardise, maintain and display relevantinformation on the Infection Prevention and Controldisplay boards.

InfectionPrevention and

Control dataanalysts,Infection

Prevention andControl team andModern Matrons.

Monthly.

Report and act on any information that indicates a risefrom the threshold set for this organism on this location


As required.



25th

April 2013


Subject: Francis Inquiry – Trust Assurance ProcessReport By: Andy Hardy, Chief Executive OfficerAuthor: Paul Martin, Director of GovernanceAccountable Executive Director: Andy Hardy, Chief Executive Officer

GLOSSARY

Abbreviation In Full



TitleApprox. Length


To provide the public with the paper outlining the approved Trust assurance process and timetable,following the release of the Francis report on 6th February 2013.

This report sets out the planned steps, to be taken by the Trust, to consider in detail the findings andrecommendations of the Francis Report. The requirement is for the Trust to have a robust process, inorder to be able to formulate a formal response and plan, as to how the recommendations should beimplemented across the Trust.


National Response to Francis

The recommendations of the report require every part of the healthcare system to respond:

All commissioning , service provision, regulatory and ancillary organisations in healthcare shouldconsider the findings and recommendations of the report and decide how to apply them to theirwork.

Individual organisations should announce at the earliest practicable time its decision on the extentto which it accepts the recommendations and implementation, and on at least an annual basis,report on progress.

Department of Health to publish an annual report on progress collating all the information.

The Health Select Committee to use progress on implementation as part of their performancereviews of organisations.

Trust Response

Following the release of the Francis report, the Chief Executive Officer has completed a series of staffand stakeholder briefings to raise awareness of the report, it’s seriousness, and the future implicationsfor the Trust. The Chief Executive Officer will also continue to lead future work and actions required bythe Trust.



25th

April 2013


The Trust’s Chief Officer’s Group has approved a formal process and timetable (see supporting paper)to consider the findings in detail and to provide assurance to the Trust Board as to where there are gapsand ensure that appropriate actions and performance management arrangements are put in place.

This initial process will involve the following (see Section 4 of report for detail):

1) Identifying which of the 290 recommendations are applicable to UHCW.

2) For those applicable recommendations identify Operational and Executive Lead(s).

3) For each of the applicable recommendations, complete an assurance assessment as to whetherthe Trust has full, some or no assurance for the recommendations (graded via a Green / Yellow /Amber / Red assurance rating).

4) Task and Finish Groups, headed up by an Executive Lead, to be set up for themed areas ofwork, resulting from the assurance process, to ensure that appropriate actions and deadlines areput in place, with regular monitoring and performance reporting.


The Trust’s future strategic and operational direction and planning must take on board relevant learningfrom this review to ensure high quality patient services are delivered in a safe culture of openness.


For information.

IMPLICATIONS:

Financial: There will be possible financial implications as a result of the Francis Reportand the UHCW internal assurance review, and resultant actions required.

HR / Equality & Diversity: There will be possible workforce implications of the Francis Report and theUHCW internal assurance review, and resultant actions required.

Governance: The Francis Report will shape national policy and legislation to ensure highquality of standards for patient care.

Legal: The Trust’s future strategic and operational direction and planning must takeon board relevant learning from this review and subsequent governmentresponses and changes to legislation, to ensure high quality patient servicesare delivered.

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive Meeting 20.3.13Audit Committee

DATA QUALITY:


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Report of the Mid Staffordshire NHS Foundation Trust Public InquiryThe Francis Report (6th February 2013)

UHCW Assurance Process for internal review and action

Report for Chief Officer’s Group

1. Background

The final report of the public inquiry into Mid Staffordshire NHS Foundation Trust was publishedon 6th February 2013 and provides detailed and systematic analysis of what contributed to thefailings in care at that trust. It identifies how the extensive regulatory and oversight infrastructurefailed to detect and act effectively to address the trust's problems for so long, even when theextent of the problems were known.

The report builds on the first independent inquiry, also chaired by Robert Francis QC. Its threevolumes and an executive summary run to 1,782 pages, and is structured around:

• warning signs that existed and could have revealed the issues earlier

• governance and culture

• roles of different organisations and agencies

• present and future.

It recognises that what happened in Mid Staffs was a system failure, as well as a failure of theorganisation itself. Rather than proposing a significant reorganisation of the system, the reportconcludes that a fundamental change in culture is required to prevent this system failure fromhappening again, and that many of the changes can be implemented within the current system. Itstresses the importance of avoiding a blame culture, and proposes that the NHS (collectively andindividually) adopt a learning culture aligned first and foremost with the needs and care ofpatients.

The report makes 290 recommendations, which focus primarily on securing a greater cohesionand culture across the system, which ‘will not be brought about by further “top down”pronouncements, but by the engagement of every single person serving patients’. However, nosingle recommendation should be regarded as the solution to the many concerns identified.

National Response:

The recommendations of the report require every part of the healthcare system to respond asfollows:

All commissioning, service provision, regulatory and ancillary organisations in healthcareshould reflect on the report and its recommendations and decide how to apply them to theirown work.

Each organisation should announce at the earliest opportunity its decision on the extent towhich it accepts the recommendations and what it intends to do to implement them.

Each organisation should publish, at least annually, a report on its progress in achieving itsplanned actions.

The Department of Health should publish a report, at least annually, collating informationabout the decisions, actions and progress reported by other organisations.

The House of Commons Select Committee on Health should incorporate progress onimplementation as part of their reviews of organisations in their normal business.

of 5

2. UHCW responsibilities

UHCW acknowledges the importance of this report and for all parties engaged in NHS servicesto consider the findings / recommendations and decide how to apply them to their own work.

Under the leadership and direction of the Chief Executive Officer, Andy Hardy, UHCW hasalready briefed staff and members around the findings of this report.

Chief Officers Group now require a robust assurance process to help the Trust formulate a formalresponse and plan as to how it should implement the recommendations across the Trust.

This process will then form part of the Trust’s Organisational Development Programme andStrategic direction, with regular, at least annual, progress reports. This will aid the Trust to reportprogress and ensure that patients, and the quality of their care, is at the centre of all futuredecision making and planning.

Staff and public engagement, and involvement to support this process where appropriate, is alsoimperative, and will be built into the remit of this process and the “Task and Finish” Groups.

3. Next steps

Next steps will therefore involve a thorough and detailed review of each of the 290recommendations, identification of those that are relevant to UHCW and a process to identifycurrent practice in relation to each recommendation, where there are gaps / risks / concerns, andthe potential impact for patient care.

Any resultant actions required will need to be graded in terms of their seriousness and impact,and completed in an appropriate and specified timeframe.

The process should also identify and capture areas of good practice where the Trust candemonstrate and provide assurance that it already meets the recommendations (in full or in part).

4. UHCW Assurance Process / Timetable

Under the direction and leadership of the Chief Executive Officer, the following assurance processis proposed (this will be developed and facilitated by the Director of Governance, with the supportof the Trust’s Compliance Manager):

Dates Work to be Completed Responsibilities

February –March 2013

Staff / stakeholder briefings Chief Executive Officer

Early March Trust assurance process and timetable to be proposed Director of Governance/ Compliance Manager

20th March2013

Trust assurance process paper to be reviewed andapproved by Chief Officer’s Group

Chief Officer’s Group

By mid April2013

Detailed review of the 290 recommendations:

Identification of those relevant to UHCW.

Nomination of Trust Leads for each recommendation(both Corporate and Executive).

Development of Trust assurance table and ratingsmodel for each relevant recommendation, toundertake a full gap analysis.

Applicable report recommendations and nominated TrustLeads to be circulated to COG for virtual approval.

Director of Governance/ Compliance Manager

of 5

Dates Work to be Completed Responsibilities

April - May2013

Assurance table to be circulated, by ComplianceManager, to Trust Leads, for review and completion.

Compliance Manager

May – June2013

Trust Leads to complete and return responses toCompliance Manager.

Operational Leads to ensure that responses havebeen reviewed and approved by the relevantExecutive Lead.

Trust Leads

(Operational andExecutive)

June 2013 Compilation of responses and production of gap analysisreport for Chief Officer’s Group / Trust Board.


July 2013 Review and identification of Trust “themes” from thegaps identified.

“Task and Finish” groups to be formulated, to coverthe identified “themes”, headed up by an ExecutiveLead. E.g.

Putting the patient first (CHRO).

Structure for standards and compliance(CMO).

Openness, transparency and candour (CFO).

Nursing (CNO).

Membership, roles/responsibilities and remits ofeach “Task and Finish” group to be confirmed.

Chief Officers Group

July – August2013

“Task and Finish” groups to meet for first time anddevelop detailed action plans, with target dates andresponsible action officers, for each relevant gapidentified from the assurance table.

Action deadlines should be related to theseriousness, impact and assurance grading from thegap analysis / assurance table.

Templates/guidance to be developed by theCompliance Manager, who will co-ordinate and ownthe “master” action plan (on behalf of the Director ofGovernance).

Task and Finish GroupExecutive Leads


August -September2013

“Task and Finish” Groups to provide first progressreports, against identified actions.

Compliance Manager to compile “master” actionplan.

This will feed into the Trust’s performancemanagement framework and reporting to ChiefOfficers Group.

Task and Finish GroupExecutive Leads


Director ofPerformance and PMO

October 2013- March 2014(target enddate)?

On-going assurance models and reportingprocesses to be developed and confirmed.

This should include monthly updates of progressagainst actions to be reported to the ComplianceManager, to feed into the PPMO.

Initial process to be completed and identified actionsimplemented and fully reported by 31st March 2014.

Chief Officer’s Group

Director of Governance/ Compliance manager

Director ofPerformance and PMO

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5. Assurance table and ratings

For each of the recommendations relevant to UHCW, Operational and Executive Leads will haveto review the recommendation, provide a response as to what evidence and assurance the Trustalready has in place, and apply one of the following four ratings.

Grading Assurance Rating Action Timescale*

Red No assurance (i.e. complete gap) Yes – urgent 0 - 1 months

Amber Some assurance, but gaps highlightedindicate that impact on quality of patientcare could be serious.

Yes – urgent 0 - 3 months

Yellow Some assurance, but gaps highlightedindicate that the impact on quality of patientcare is not serious, but requires attention.

Yes – but not urgent 0 - 6 months

Green Full Assurance (i.e. no gaps) None N/A

The assurance rating will also enable the Task and Finish groups to prioritise their actionsand action dates, by seriousness and impact.

The “Task and Finish” group detailed action plans, timescales and reporting requirements will bedeveloped and implemented from the results of the consolidated assurance table.

6. Responsibilities

In order to ensure that the assurance table / process is completed thoroughly, accurately and ontime, the following roles have been specified:

Name Title Role

Andrew Hardy Chief Executive Officer Overall Trust responsibility for Francis reportand Trust’s response.

Meghana Pandit Chief Medical Officer Executive Lead for the “governance” aspect ofthe assurance process.

Paul Martin Director of Governance Lead director for the assurance process andownership of the central, consolidated,resultant action plan.

Chief Officers Group Executive Directors Responsibility for reviewing and approvingresponses for initial gap analysis.

Chief Officers Group Executive Directors Responsibility for leading “Task and Finish”groups for themes and actions resulting fromthe assurance table / gap analysis.

Jonathan Brotherton Director ofPerformance andPPMO

Lead director to build action plans into Trust’sperformance monitoring and reportingframework, to report delivery and status.

Operational Leads To Be Confirmed To review relevant recommendations andidentify Trust position for initial gap analysisand implementation of resultant actions.

Paula Moody Compliance Manager Assurance process development andfacilitation.

Ownership of central, consolidated, action plan,from “Task and Finish” groups, to feed intoPPMO reporting structures.

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7. Summary

The Final Report of Robert Francis QC detailing the findings of the public inquiry into MidStaffordshire NHS Foundation Trust was published on 6th February 2013. This report has majorimplication for all those involved in delivering and commissioning patient care or regulating theNHS.

The purpose of this paper is to set out the Trust’s initial assurance process as to how it willundertake a detailed review of the reports findings and act on any necessary recommendations.

Also so that the Trust can provide all stakeholders (internal and external) with the necessaryassurances and progress reports, as required.

This process will also need to take account of the governments response to this report and anyother national guidance issued.

Paul Martin,Director of Governance

March 2013



24th April 2013


Subject: Register of SealingsReport By: Andrew Hardy, Chief Executive OfficerAuthor: Jenny Gardiner, Trust Board SecretaryAccountable Executive Director: Andrew Hardy, Chief Executive Officer

GLOSSARY




TitleApprox. Length


To provide an overview of the documents sealed since by Trust Board during 2012/13.


In order to comply with the Trust’s Standing Orders, a Register of Sealings is maintained by the Trust BoardSecretary and a summary report provided Trust Board at the start of each financial year detailing all sealsissued during the previous financial year. The report contains the full list of seals issued during 2012/13.


None


Trust Board to RECEIVE and ACCEPT the report of seals issued by the Trust during 2012/13.

IMPLICATIONS:

Financial: NA

HR / Equality & Diversity: NA

Governance: NA

Legal: NA



24th April 2013


REVIEW:


DATA QUALITY:


Register of Sealings 2012/13

Consecutive

Number

Date of

Sealing

Date of Trust

Board Authority

Description of document

sealed

Names and titles of

persons attesting

sealing

No of

documents

sealed

No of seals

issued (per

document)

Dissemination

of Document:

Name of Solicitor Comments

263 27/06/2012 25/11/2009 Land Registry Transfer of

whole of registered titles

for 128 Blandford Drive,

Walsgrave, Coventry, CV2

2NE

Mr Philip

Townshend,

Chairman and Mr

Andrew Hardy,

Chief Executive

Officer

1 1+1 Steve Noon Field Overell Solicitors

42 Warwick Street,

Leamington Spa, CV32 5JS

Original documents mislaid in

transit to solicitors. Further

copy required for re-sealing -

Datix web number 32526.

264 14/11/12 31/10/2012

University Hospitals

Coventry and

Warwickshire NHS Trust,

and Coventry and

Warwickshire Patnership

NHS Trust, and the

Coventry and Rugby

Hospital Company PLC

and Vinci Construction UK

Limited Hard Services

Management Overview

Agreement.

Mr Philip

Townshend,

Chairman and Mr

Andrew Hardy,

Chief Executive

Officer

5 1 Lincoln Dawkin Clyde and Co

265 30/01/2013 30/01/2013

University Hospitals

Coventry and

Warwickshire NHS Trust,

Myton Hamlet Hospice

Development Limited, The

Myton Hospices Liceience

to Assign - for premises:

Ryton Myton Day Hospice

of St Cross, Barby Road,

Rugby, CV22 5PX

Mr Philip

Townshend,

Chairman and Mr

Andrew Hardy,

Chief Executive

Officer

2 1

Paul Wilding

Davies Pinsent Masons

266 30/01/2013 30/01/2013

Design and Build Contract

2011 JCT. University

Hospitals Coventry and

Warwickshire NHS Trust

and Skanska Rashleigh

Weatherfoil LTD.

Mr Philip

Townshend,

Chairman and Mr

Andrew Hardy,

Chief Executive

Officer2 1 Lincoln Dawkin

Joint Contracts Tribunal

Limited



24 April 2013


Subject: Finance and Performance Meeting Report – 25 February 2013Report By: Ms S Tubb, Non-Executive DirectorAuthor: Mrs G Nolan, Chief Finance OfficerAccountable Executive Director: Mrs G Nolan, Chief Finance Officer

GLOSSARY

Abbreviation In FullBMI BMI Healthcare LimitedC.diff Clostridium difficileSHMI Summary Hospital Mortality Indicator



TitleApprox. Length


To advise the Board of the Finance and Performance Committee meeting agenda for 25 February 2013 and ofany key decisions/outcomes made by the Finance and Performance Committee.


DEVELOPMENT REPORTS – TRANSFORMATION PROJECTA report was presented on proposals to develop a transformation programme which will strive to improveclinical quality and productivity, reduce variation and remove unnecessary costs to support the Trust indelivering performance financial targets over the next three years. The Committee asked for a further report tobe submitted to the March meeting of the Committee.DEVELOPMENT REPORTS – BMI OPERATIONAL REPORTA draft presentation on the work currently being undertaken was received with issues relating to the scope ofthe programme highlighted. The Committee agreed for plans to be developed and implemented as set out inthe report.PLANNING REPORTS – DRAFT ANNUAL PLANAn update on the preparation of plans for 2013/14 and beyond, together with the review of the Trust’s PlanningFramework/Processes was presented. It was agreed that a further update would be provided at the Marchmeeting.PLANNING REPORTS – FINANCIAL PLANThe report presented an update on the Trust’s financial plan for 2013/14 and the likely level of savings requiredto achieve a surplus. The plan continued to reflect the Month 9 forecast outturn. Further updates will be givenat future meetings.PERFORMANCE REPORTS – INTEGRATED PERFORMANCE REPORT (INCLUDING ESCALATIONREPORTS)The Integrated Performance Report was presented to the Committee with key issues being highlighted. TheCommittee was informed that a new model of care for emergency care had been implemented. An analysis ofthe figures both pre and post implementation of the new model of care was presented. The latest figures forC.diff were discussed and it was noted that a comprehensive action plan has been put in place to address theissues. An improvement in the SHMI score was noted.



24 April 2013


FINANCE REPORTS – INTEGRATED FINANCE REPORTThe Integrated Finance Report was received by the Committee and attention was drawn to salient points withinthe report.FINANCE REPORTS – FINANCE RISK REGISTERThe Risk Register was presented to the Committee.REPORTING SUB COMMITTEES – SUSTAINABLE DEVELOPMENT GROUPA report from the Sustainable Development Management Group was presented and provided an update on theGroup and its subordinate groups. Key issues from the report were highlighted and it was noted that a newsustainable development strategy has been released.


No key risks were identified.


The Board is asked to review and note the report of the Finance and Performance Committee meeting held on25 February 2013.

IMPLICATIONS:

Financial:

HR / Equality & Diversity:

Governance:

Legal:

REVIEW:


DATA QUALITY:




24th

April 2013

Subject: Foundation Trust ProjectReport By: Andrew Hardy Chief Executive OfficerAuthor: Christine Emerton Foundation Trust Programme DirectorAccountable Executive Director: Andrew Hardy Chief Executive Officer

GLOSSARYAbbreviation In FullBAF Board Assurance FrameworkBGAF Board Governance Assurance FrameworkFT SC Foundation Trust Steering CommitteeHDD Historic Due DiligenceIBP Integrated Business planLTFM Long Term Financial ModelNTDA NHS Trust Development AuthorityNED Non-Executive DirectorPWC Price Waterhouse CooperSHA Strategic Health AuthorityQGAF Quality Governance Assessment FrameworkPPMO Performance and Programme Management


POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papersTitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:To provide an update on the progress and timeline for the Foundation Trust status application and report ondecisions made by the FT Steering Committee.

SUMMARY OF KEY ISSUES:The FT Steering Committee and the Project Team met on 8

thApril, 2013 to review the Master Action

Plan. A summary of the actions completed since the last report to the Board is included in the attachedException Report.

SUMMARY OF KEY RISKS:UHCW NHS Trust has submitted a revised timeline for achieving foundation status to the SHA.. The currentrisks impacting upon achievement of foundation trust status are:

The deteriorating performance in A&E The action needed to achieve the financial requirements set out by Monitor.

RECOMMENDATION / DECISION REQUIRED:The Trust Board are asked to RECEIVE and ACCEPT this report.

IMPLICATIONS:Financial: Financial performance this year. Importance of achievement of CIPs, work to

increase predicted surplus and achieve financial assumptions for down-sidescenarios.

HR / Equality & Diversity: Recruitment and maintenance of a representative and diverse membership.

Governance: Date for achieving Foundation Trust status.

Legal: Legal constitution and completion of necessary assessment phases.



24th

April 2013


DATA QUALITY:

Data/information Source:Data Quality Controls: FT Steering Committee reviewData Limitations:

ENC FOUNDATION TRUST PROJECT TEAM EXCEPTION REPORT

P:\Trust Board\Trust Board - Master File\2013\4 - APRIL 2013\PUBLIC\Enc 10.1 - FT Project Excpetion Report toTrust Board April 2013.doc

11th

April for April 2013 Trust Board

Actions since last month:

Decision made by the FT Steering Committee 11th

March 2013:

1. Board Visibility Programme - The FT Steering Committee discussed proposals for increasing thevisibility of all Board members both within the organisation and across the community. This is required aspart of addressing the Board Governance Assurance Framework recommendations and builds uponactions and good practice already in place such as the Chat with the Chief and Patient SafetyWalkarounds. The FT Steering Group agreed that:

A process is to be established for recording all visits by Board members (both formal and informal)to operational and non operational areas within the Trust.

A rolling programme of visits is to be developed to ensure there is coordination of activities andduplication or overload to any one area is avoided.

Other actions: Planning and IBP – The Francis Report has been reviewed and areas for strengthening the Board

Development Programme to reflect the recommendations have been included in the Board VisibilityProgramme. Members of the FT Project Team attend the FT Network meeting with the SHA 14

thMarch.

This included a sharing and learning session from the West Midlands Ambulance Service NHS FoundationTrust who recently went through the Monitor process.

Finance/LTFM – Work continues with modelling scenario’s to quantify the strategic model. Membership – FT Road shows were held in Coventry Orchard Centre between 25

thFebruary and 3

rd

March and 60 new members were recruited. The CEO met with members of the Youth Council LeadershipTeam on 19

thMarch. Membership road shows now completed.

BGAF – Updated action plan and monitored for any new requirements. Completed proposals paper toinform sign up to Coventry Champions Scheme. FTN strategy consultation response completed andsubmitted.

Board Development – Rescheduled board development sessions to coincide with new nonexecutive/chair appointments (likely to be June 2013). Collated and reported back on good practice fromFT Network session on Robust Quality Governance 7

thMarch and post Francis Governance 20

thMarch.

Senior Leadership Development – Further actions on hold. Strategic Membership and Governor Development – Collated and reported back good practice from FT

Network session on Governors and elections. Planning commenced to implement communications aroundnew FT timeline, once formal notification received from NHS TDA.

Activities for coming month:

Planning and IBP – continue with further updates on strategy following review with CEO. Finance/LTFM – commence work with divisions, finance and planning to quantify scenarios for 14/15 and

15/16. Membership – Commence planning for the Give and Gain Day scheduled for 17

thMay.

BGAF – Populate Board visibility programme with details of visits already undertaken and thosescheduled.

Board Development – Confirm content for Board seminars for May and June. Re-plan work for period upto new Board members being in post. Meet with new NTDA Relationship Manager.

Senior Leadership Development – Establish small group involved in OD to review leadershipdevelopment. Undertake presentations to Grade 5’s on leadership development training.

Strategic Membership and Governor Development. – Undertake presentations to Coventry OlderPeoples Partnership Board and Coventry Carers Forum. Plan sessions for HOSC and LINks to becompleted in May 2013.

Risks:

FT R 31 Current rate of FT authorisations low

ENC FOUNDATION TRUST PROJECT TEAM EXCEPTION REPORT

P:\Trust Board\Trust Board - Master File\2013\4 - APRIL 2013\PUBLIC\Enc 10.1 - FT Project Excpetion Report toTrust Board April 2013.doc

FT R 12 Financial compliance and failure to demonstrate stable financial footing for FT authorisation

FT R 11 National targets and deterioration in A&E performance.

FT R 47 Quality Governance Framework assessment score of 3.5 well above Monitor QGAFthreshold.

Mitigations:

Revised timeline submitted to SHA.

The achievement of the 4 hour target continues to be a challenge and is receiving the full attention ofthe Executive and the Leadership Team. The capacity management position has now been escalatedto black alert by the Chief Operating Officer and all elective surgery has been cancelled for the weekcommencing 8

thApril.

A detailed review of the Quality Governance Framework is underway with external support to identifyareas of weakness and actions required.

PPMO process established to ensure Quality Impact Assessments are incorporated into costimprovement programmes.

Additional resources are being secured to provide more capacity in the governance team. The CEO isto review the situation with the Director of Governance.

Trust Board Work Programme (Public Session)

Report Public Exec

Lead

Lead Manager Frequency No. Set date for in-year report? Report for Noting /

Approval

AHSN Public AH Amanda Royston Annual 1 Oct Approval

Calendar of Meetings Public AH Jenny Gardiner Annual 1 Nov Approval

Foundation Trust Application Update Public AH Chirstine Emerton Monthly 10 Monthly Noting

Register of Gifts Public AH Jenny Gardiner Annual 1 Apr Noting

Register of Interests Public AH Jenny Gardiner Annual 1 Apr Noting

Work Programme Public AH Jenny Gardiner Monthly 10 Monthly Noting

Signings and Sealing's Public AH Jenny Gardiner Annual 1 April Noting

Provider Management Regime Public DE Simon Reed Monthly 10 Jan, Feb, Mar, Apr, May, Jun, Jul, Sep, Oct, Nov Approval

Integrated Performance Report and Dashboard Public DE/GN Jonathon Lloyd Monthly 10 Jan, Feb, Mar, Apr, May, Jun, Jul, Sep, Oct, Nov Approval

Annual Plan Public DE John Amphlett/ Sarah Phipps Annual 1 May Noting

Infection Prevention and Control Annual Report and Annual Plan Public MR Mike Weinbren Annual 1 Apr Noting

Infection Prevention and Control Report including Joint Cleaning Update with ISS Mediclean Public MR Mike Weinbren Annual 1 Oct Noting

ICT Report Public DE Robin Arnold Annual 1 May Approval

PR Report Public IC Kerry Beadling Annual 1 January Approval

Annual Financial Plan (Revenue and Capital) including Health Care Contracts with Commissioners Public GN Antony Hobbs / A Jones Annual 1 Mar Approval

Annual Report and Accounts (including Statement of Internal Control and Quality Account) Public GN Alan Jones Annual 1 July (AGM by 30th Sept) Noting

Equality and diversity report Public IC Barbara Hay Annual 1 May Approval

Risk Management (inc H&S & Radiation Protection) Annual Report Public IC Dipak Chauhan Annual 1 Sept Noting

Nolan Principles/NHS Code of Conduct/UHCW Code of Conduct Policy Statement Public IC Jenny Gardiner Annual 1 February Approval

PEAT Report Public IC David Powell Annual 1 May Approval

Audit Committee Meeting Report Public NED Alan Jones 6 times per

year

6 As required Approval

Audit Committee TOR Public NED Alan Jones Annual 1 Mar Approval

Finance & Performance Meeting Report Public NED Alan Jones 8 times per

year

8 As required Approval

Finance and Performance Committee TOR Public NED Alan Jones Annual 1 July Approval

Quality Governance Committee TOR Public NED Paul Martin Annual 1 Nov Approval

Quality Governance Meeting Report Public NED Paul Martin 10 times per

year

10 Monthly Approval

Remuneration Committee TOR Public NED Jenny Gardiner Annual 1 Sept Approval

Trust Board Terms of Reference Public NED Jenny Gardiner Annual 1 November Approval

Trust Board meeting report Public NED Jenny Gardiner Monthly 10 monthly Noting

Patient Experience and Engagement Report Public MP Paul Martin Annual 1 Sept Noting

Patient and Staff Story Public MP Paul Martin Bi-monthly 6 Jan, Mar, May, July, Sept, Nov Approval

Board Assurance Framework Public MP Jenny Gardiner Bi-annual 2 Mar, Sep Noting

Education Report Public MP Maggie Allen Annual 1 January Noting

SIG Report Public MP Paul Martin Bi-annual 2 January and June Approval

Mortality Report Public MP Paul Martin Bi-annual 2 January and June Approval

Research and Development Annual Report Public MP Ceri Jones Annual 1 May Noting

Page 1 Enc 11 - Work Programme (public)

Trust Board Work Programme (Public Session)

Number of Reports 109

Page 2 Enc 11 - Work Programme (public)



24th

April 2013


Subject: Register of Interests and Declaration of Gifts, Benefits and Hospitality2012/13

Report By: Jenny Gardiner, Trust Board SecretaryAuthor: Jenny Gardiner, Trust Board SecretaryAccountable Executive Director: Andrew Hardy, Chief Executive Officer

GLOSSARY




TitleApprox. Length


The purpose of this report is to provide the Board with an update on the information currently held on theRegister of Interests/Declaration of Gifts, pertaining to Trust Board members for the financial year 2012/13.


In accordance with the Department of Health’s Code of Conduct and Code of Accountability and the Trust’sStanding Orders, the Trust is required to hold a number of Registers and to make them available for publicinspection.

A review of the details held in the “Register of Interests” and “Register of Gifts” has taken place. Declarationshave been requested from members of the Trust Board and an all user message has been issued to all Truststaff.

The Register has been updated accordingly. Hard and soft copies of all declarations received are available forinspection from the Trust Board Secretary. However, only the declarations for Trust Board members aresummarised here. The full register will be considered by the Audit Committee annually.

Directors are reminded of their responsibility to advise the Trust Board Secretary promptly on any changes totheir Register of Interests.


N/A


Trust Board is asked to RECEIVE and NOTE the Register of Directors’ interests and gifts.



24th

April 2013


IMPLICATIONS:

Financial: The register of interests details financial interests of members including paidemployment

HR / Equality & Diversity: Annual declaration by Trust Board members are made in accordance with thecode of conduct and code of accountability

Governance: Formal returned received from all voting members of the Trust BoardStatutory requirement in line with Standing Orders.

Legal: The register of interests, and register of gifts and hospitality are a statutoryrequirement

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Perfomance Committee Executive MeetingAudit Committee

DATA QUALITY:


Name Job Title Date gift/benefit rec'd Source of Gift or benefit Nature of gift/benefit start/end date

of visit

Destination Event details Purpose of visit Annual leave taken for

visit (Y/N/NA)

Study leave taken for

visit (Y/N/NA)

Crich I Chief HR Officer NA NA NA NA NA NA NA NA NA

Eltringham D Chief Operating Officer 07/03/2013 Unipart Dinner at Coombe Abbey 07/03/2012 Coombe Abbey, Coventry na na na na

Gardiner J Trust Board Secertary NA NA NA NA NA NA NA NA NA

Hardy A Chief Executive Officer NA NA NA NA NA NA NA NA NA

Nolan G Chief Finance Officer NA NA NA NA NA NA NA NA NA

Pandit M Chief Medical Officer 01/07/2012 Silverstone Two tickets to F1 British Grand Prix at

Silverstone

2 hours on

07/07/12

Silverstone F1 Event No No

Radford M Chief Nursing Officer NA NA NA NA NA NA NA NA NA

Robinson T Non-Executive Director NA NA NA NA NA NA NA NA NA

Sabapathy P Non-Executive Director NA NA NA NA NA NA NA NA NA

Sawdon T Non-Executive Director NA NA NA NA NA NA NA NA NA

Stokes N Non-Executive Director NA NA NA NA NA NA NA NA NA

Townshend P Chairman NA NA NA NA NA NA NA NA NA

Tubb S Non-Executive Director NA NA NA NA NA NA NA NA NA

Winstanley P Non-Executive Director NA NA NA NA NA NA NA NA NA

Declaration of Gifts April 2012 - March 2013

Page 1 of 2I:\corporate governance\ declaration of gifts

Name Job Title Directorships Ownership Shareholdings Charity or Voluntary

Organisations

NHS Service Contracts: Research Funding Pooled Funds Paid employment, office, profession:

Crich I Chief HR Officer Foundtaion Trust, Director at Foxford

School, Coventry

NA NA NA NA NA NA NA

Eltringham D Chief Operating Officer N/A N/A N/A N/A N/A N/A N/A N/A

Gardiner J Trust Board Secretary N/A N/A N/A N/A N/A N/A N/A N/A

Hardy A Chief Executive Officer NA NA NA Trustee Health Link Malawi Trustee Healthcare Financial Management

Association

Trustee Coventry, Soliull and Warwickshire

Partnership

NA NA NA

Nolan G Chief Finance Officer NA NA NA NA NA NA NA NA

Pandit, Dr Meghana J Chief Medical Officer Nominal 'Director' of JJ & MJ Pandit

Ltd a company registered to receive

any private practice income.

n/a n/a n/a n/a n/a n/a n/a

Radford, M Chief Nurse Peak-XV Healthcare Consulting

(Dormant Company)

Holly Medical Services Limited (GP

Surgery (Bham))

Peak-XV Healthcare

Consulting (Dormant

Company)

Holly Medical Services

Limited (GP Surgery

(Bham))

n/a Parent Governor - Sutton Coldfield

GirLs Grammer School

n/a RAAK international Collaborative Research

funding (with Enschude University, Holland)

Visiting Professor of Nursing at Birmingham City University

Association of Advanced Practice Educators (Executive

Committee)

Healthcare Consultant with System C

Robinson T Non-Executive Director Member of Audit and Risk

Committee of OFQUAL

(Examinations Regulator) - unpaid

NA NA NA NA NA NA In reciept of pension from Local Government Pension

Scheme

Sabapathy, P Non-Executive Director NA NA NA Patron Heart of England

Community Foundation Charity

Patron Medical Life Sciences

Research Fund Charity

NA NA NA NA

Sawdon T Mastgrove LTD Director,

Optitians.

NA NA NA NA Provider of G.O.S to Coventry PCT NA NA Occasional remuneration to Mastgrove Ltd re the supply of

spectacles to HES prescriptions. Councillor Coventry City

Council.

Stokes N Non-Executive Director Director of Marketing and

Communications at Coventry

Univeristy (until end July 2012)

NA NA NA NA NA NA NA

Townshend P Chairman Designated member of the Law

Partnership Solicitors LLP

NA NA Trustee Bond's Hospital Estate

Charity

Trustee of the Elizabeth Swillington

Trust

NA NA NA Partner / Solicitor Advocate in the Law Partnership

Solicitors LLP

Councillor - Cabinet member Community Safety Coventry

City Council.

Tubb S Non-Executive Director Director of St Petrox LLP Holiday

Auction Business.

Director 65 Finsbury Park Road

Limited individual property

management of 3 flats.

St Petrox LLP holiday auction business. Rental income

from privately owned property.

Winstanley Prof. P Dean of Medicine President of the Royal Society of

Tropical Medicine & Hygiene for next

12 months.

n/a n/a Trustee of the UHCW 'Malawi'

Charity.

Member of the Research Committee of Heart of

England Foundation Trust

No Grants Operational n/a Paid an Honourariam for work on the 2014 Research

Excellence Framework (HEFCE)

Member of sub-panel A1 of Research Excellence

Framework 2014

Dean of Medicine, University of Warwick

Member of the Wellcome Trust PHATIC Panel

Register of Interests April 2012 - March 2013

*NB All voting Trust Board members are corporate Trustees of the UHCW Charity

Page 2 of 2 I:\ corporate governance\register of interests

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