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Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public (Part 1)

to be held on

Wednesday 2nd March 2016

at

9.30am - Conference Room, School of Health

Sciences (South Hospital)

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

Staff and members of the public are welcome to attend the meeting.

Excellent patient care

Our vision and goals guide us; our values underpin everything we do

Quality care for everyone, every time

Our Values

Work with others to keep improving

our services

A positive experience for

patients, service users and staff

Skilled and capable staff

Cost effective, sustainable services

Improve mortality rate Prevent avoidable

harm

Reduce Incidence of Patient Harm

Create and maintain partnerships with other organisations so that we can deliver excellent care Make every service

the best it can be

Improve End of Life Care

Improve what people think of their care Improve how staff

feel about work

Improve the Discharging Planning Process

All staff continue to develop All staff understand

how their contribution helps to achieve our Vision

Design services to deliver best practice within our resources Ensure value for

money for each service

Goa

ls

Prio

ritie

s

QI QI QI

http://intranet/uploads/General/Graphics/Isle%20of%20Wight%20NHS%20TrustCOL.jpg

74

75

71

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DepartmentsAccident and Emergency (Level A) 29Admission & Discharge Lounge 49Allergy Research Centre 58Ambulance HQ 24Ambulance ManagementAmbulance Training 87

42

Ante Natal Clinic 1APCOA Parking Office 79Audiology/ENT 73Bereavement Office 28Breast Care - Applegate 67Breast Screening Unit 47Cardiology Outpatients 72Cardiac Resusitation Training 82Catering (Level B) 38Chapel (Level A) 32Chemotherapy Suite (First Floor) 86Children's Outpatients 68Commisioning Team 84Information Technology 2Computer Training (First Floor) 56Conference Room 39Day Surgery 14Diabetic Service 44Diagnostic Imaging (Level A)District Nursing 82

33

Dieticians 78Education Centre 9Energy Centre (Level B) 40Endoscopy 62Estate Management Department 48Eye Clinic (Ground Floor) 15Finance 52Fracture ClinicGovernance and Assurance Dept 57

30

Sexual Health Service 3Gynae Outpatients 74Hospital Broadcasting Association 21Out of Hours Service 75Information Services 7Intensive Care & High Dependency Unit 36Laidlaw House 23League of Friends Snack Bar (Level A) 50Linen Services 12Maxillofacial Unit (Ground Floor) 46OPARU

Chapel of Rest

6Mortuary 10Occupational Health (Ground Floor) 54Older Persons Mental Health 76Operating Theatres (Level B) 35Orthotics Department 59Outpatients (Level A) 34OT & Wheelchair Services 77PALS and Complaints 71Pathology Laboratories (Level B&C)PCT Headquarters (First Floor) 83

37

Personnel (First Floor) 53Pharmacy (Level A) 27Physiotherapy (Ground Floor) 16Porters 51Post Room 6Pre Assessment Unit 70Printing Department 45Main Reception (Level A) 26Renal Dialysis 60YMCA Creche 69Social Club 25

Social Workers Department (First Floor) 4Southampton School of Health Studies 18Speech & Language Therapy 63Staff Changing 11Staff Residence (Applegate/Cherrygate) 8Support Services 20Surgical Secretaries (Level B) 41Switchboard 5TelephoneTheatres Sterile Supply Unit (Level B) 43Transport 19Vectasearch

Staff ResidencesSolentMedinaWestern House 89Margham 88

MPTT-Orthopaedic TriageAcupuncture Clinic PUVA TreatmentRegistrars Office

216166131

2

8081

WardsNewchurch WardChildren'sCoronary Care UnitRehabilitationLuccombe & Alverstone (Level C)MaternityMedical Assessment (Level A)Mottistone SuiteNeonatal Intensive Care Unit (Ground Floor)Colwell & Appley Wards (Level B)SevenacresStroke UnitSt Helens & Whippingham Ward (Level B)

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44

78

40 36

7613

80

81

Visitor, patient and staff parking

Staff parking

Staff parking

Visitor Parking

Patient Parking

Car ParkingOffice

Staff parking

Staff parking

Visitor Parking


Staff parking

Staff parking


83

82

8442

19

89

87

60

85

8657

51

82

6131 Main Hospital

10Healing Arts 13Respiratory Physio 85

Please note the School of Health Science Building is shown as No. 18 on map

The next meeting in public of the Isle of Wight NHS Trust Board will be held on Wednesday 2nd March 2016 commencing at 9.30am in the Conference Room – School of Health Science Building (South Hospital), St. Mary’s Hospital, Parkhurst Road, Newport, Isle of Wight, PO30 5TG. Staff and members of the public are welcome to attend the meeting. Staff and members of the public are asked to send their questions in advance to [email protected] to ensure that as comprehensive a reply as possible can be given.

AGENDA

Indicative Timing

No. Item Who Purpose Enc, Pres or Verbal

09:30 1 Apologies for Absence, Declarations of Interest and Confirmation that meeting is Quorate

1.1 Apologies for Absence: Shaun Stacey - Chief Operating Officer (Deputy Chief Operating Officer will Deputise) Jessamy Baird - Non Executive Director Nina Moorman - Non Executive Director

Chair Receive Verbal

1.2 Confirmation that meeting is Quorate No business shall be transacted at a meeting of the Board of Directors unless one-third of the whole number is present including: The Chairman; one Executive Director; and two Non-Executive Directors.

Chair Receive Verbal

1.3 Declarations of Interest Chair Receive Verbal

09:35 2 Minutes of Previous Meetings

2.1 To approve the minutes from the meeting of the Isle of Wight NHS Trust Board held on 3rd February 2016 and the Schedule of Actions.

Chair Approve Enc A

2.2 Chairman to sign minutes as true and accurate record

2.3 Review Schedule of Actions Chair Receive Enc B

09:45 3 Chairman’s Update

3.1 The Chairman will make a statement about recent activity Chair Receive Verbal

09:50 4 Chief Executive’s Update

4.1 The Chief Executive will make a statement on recent local, regional and national activity.

CEO Receive Enc C

5 WORKFORCE

5.1 Employee Recognition of Achievement Awards CEO Receive Pres

5.2 Employee of the Month CEO Receive Pres

10:00 6 QUALITY (PATIENT SAFETY, EXPERIENCE & CLINICAL EFFECTIVENESS)

6.1 Presentation of this month's Patient Story CEO Receive Pres

6.2 Quality Governance Committee Chair Report QGC Chair

Receive Enc D

6.3 Quality Improvement Framework Monthly Update EDN Receive Enc E

6.4 Reports from Serious Incidents Requiring Investigation (SIRIs) EDN Receive Enc F

6.5 Safer Staffing Report EDN Receive Enc G

6.6 Mortality & End of Life Report EMD Receive Pres

6.7 Quality Priorities 2016/17 EDN Approve Enc H

7 STRATEGY & PLANNING

7.1 Trust Strategy CEO Receive Verbal 7.2 Principal Risk Register (Board Assurance Framework) CS Approve Enc I

7.3 Foundation Trust Programme CS Approve Enc J 8 PERFORMANCE

8.1 Performance Report EMD Receive Enc K

8.2 Winter Plan Progress Report DCOO Receive Enc L

Meeting in public on 2nd March 2016 Isle of Wight NHS Trust Board – Page 1

mailto:[email protected]

8.3 Finance, Investment, Information & Workforce Committee Chair Report

FIIWC Chair

Receive Enc M

9 GOVERNANCE

9.1 Top Key Issues & Risks arising from Sub Committees for raising at Trust Board. Minutes Included: Minutes of the Quality Governance Committee held on 24th February 2016 Minutes of the Finance, Investment, Information & Workforce Committee held on 23rd February 2016 Minutes of the Audit & Corporate Risk Committee held on 9th February 2016

CS Receive Enc N

9.2 Auditor Panel Terms of Reference and appointment of Chair of Audit Panel

CS Approve Enc O

10 Any Other Business Chair

11 Questions from the Public Chair

12 Issues to be covered in private.

The meeting may need to move into private session to discuss issues which are considered to be ‘commercial in confidence’ or business relating to issues concerning individual people (staff or patients). On this occasion the Chairman will ask the Board to resolve: 'That representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', Section 1(2), Public Bodies (Admission to Meetings) Act l960.

The items which will be discussed and considered for approval in private due to their confidential nature are:

Sustainability Transformation Plan

Procurement Service Business Case

Carbon Energy Fund Update

Operating Plan 2016/17

Informed Client Update

Chief Executive's Update on Hot Topics

Employee Relations Issues

12:00 13 Date of Next Meeting:

The next meeting of the Isle of Wight NHS Trust Board to be held in public is on Wednesday 6th April 2016 at the Earl Mountbatten Hospice, Newport Isle of Wight There will also be a special meeting of the Trust Board on Wednesday 30th March to approve the 2016/17 Annual Plan and Budget.

Meeting in public on 2nd March 2016 Isle of Wight NHS Trust Board – Page 2

IOW NHS Trust Board Meeting Pt 1 3rd February 2016 1

Minutes of the meeting in Public of the Isle of Wight NHS Trust Board held on Wednesday 3rd February 2016

Ryde Health & Wellbeing Centre, 57 Pellhurst Road, Ryde, PO33 3DT PRESENT: Eve Richardson Trust Chair Jessamy Baird Non-Executive Director David King Non-Executive Director Nina Moorman Non-Executive Director Charles Rogers Non-Executive Director (SID) Jane Tabor Non-Executive Director Karen Baker Chief Executive Chris Palmer Executive Director of Financial & Human Resources Mark Pugh Executive Medical Director Alan Sheward Executive Director of Nursing Shaun Stacey Chief Operating Officer In Attendance: Mark Price FT Programme Director & Company Secretary Andy Hollebon Head of Communications & Engagement Lizzie Peers Non-Executive Financial Advisor For item 16/T/005 Debra Hanson Senior District Nurse For item 16/T/ Cllr Steve Stubbings Deputy Leader of IW Council Observers: Chris Orchin Health Watch Mike Carr Patient Council Minuted by: Julie Benson PA to Mark Price/Katie Gray Members of the Public in attendance:

There were no members of the public present

Minute No.

16/T/001 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND CONFIRMATION THAT THE MEETING IS QUORATE

The Chair welcomed the representatives from Healthwatch and the Patient Council. Apologies for absence were received from Katie Gray, Executive Director of Transformation and Integration The Chairman announced that the meeting was quorate. Declarations of Interest were received from Charles Rogers and Karen Baker in their role as Directors of Wightlife Partnership. Nina Moorman declared that she was related to James Seward, recently appointed as the Whole Integrated System Redesign (WISR) Programme Director, part of the My Life a Full Life Programme.

16/T/002 MINUTES OF PREVIOUS MEETING Minutes of the meeting of the Isle of Wight NHS Trust Board held on 15th December

2015 were reviewed.

a) Min No. 15/T/246 - Industrial Action p2: The Chief Executive reported that as a result of the industrial action the number of cancelled operations was 2 and there had been 11 cancelled outpatient appointments.

b) Min No. 15/T/246 – Nursing Homes p2: The Executive Director of Nursing

reported that following the Board Meeting a further review of Nursing homes had taken place and we were not the worst in the country as reported in the Minutes.

c) Min No. 15/T/255 p7: The Executive Director of Financial & Human

Resources highlighted typing errors within the Action should read “cost savings and efficiencies”

Enc A


d) Min No. 15/T/256 p7: The Executive Director of Financial & Human

Resources highlighted typing errors within the first bullet point should read “There was concern about some of the”.

e) Min No. 15/T/256 p7: Jane Tabor questioned if Mark Pugh was the Executive Director Lead to the Board for Discharge Summaries and it was confirmed that this was the case.

Subject to these amendments the Board approved the minutes.

16/T/003 REVIEW OF SCHEDULE OF ACTIONS The Board received the schedule of actions and the following updates were provided:

a) TB/176 – Appraisals: The Executive Director of Financial & Human

Resources conformed that she was now picking this up and seeking a significant improvement by the end of 2015/16.

b) TB/192 – Discharge Summaries: The Executive Medical Director provided

an update and confirmed he was confident that there would be a an improvement in the completion of discharge summaries.

16/T/003 CHAIR’S UPDATE

The Chair confirmed that she continues her visits to our services and often with partners. The Chair advised that she had attended the Dragon’s Den event and was complimentary about it. It was suggested that the successful applicants came back to the Board in approximately 6 months’ time to report on how they got on with their plans. A day was spent with local authority councillors in Shanklin. Older people services and services for the voluntary sector were looked at. Work continues with estates exploring work on Dementia, so estate plans are in some sort of priority. Sam Jones, NHS Director for New Models of Care visited the Island on 25th January 2016. This was on the day of a major fire at Cowes and enabled her to see how the Island worked in a crisis. The Isle of Wight NHS Trust Board received the Chair’s Update

16/T/004 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented the report and highlighted the following:

National:

i. Industrial Action: It is believed at this time that industrial action is due to go ahead next week and that plans are in place in this event.

ii. New Care Models Programme: The Council’s difficult financial position next

year and our own financial position underline the need for the Whole Integrated System Redesign and for the My Life a Full Life Programme to work to create sustainable services for the future. Nicola Longson is the new My Life a Full Life Programme Director starting in March and James Seward has now started as Whole Integrated System Redesign Programme Director.


Local:

iii. System Pressures: These continue as the Trust is back on ‘red’ status at the moment. The stepdown facility at Poppy and Daffodil Unit is still in use.

iv. Stay Well This Winter: There was an update on the number of staff that had

received flu jabs and there is a need for more people to get their flu jabs. Jessamy Baird questioned whether the vaccine incorporated Swine Flu. The Executive Medical Director confirmed that this was not part of the current vaccine but the Chief Operating Officer confirmed that the Business Continuity Plans were in place should there be an outbreak.

v. Quality Account Priorities: The annual consultation on our quality priorities

for 2016/17 has started with more information to be found on the Trust’s website.

vi. Endoscopy Unit: The new Endoscopy Unit is now in operation and this is a

first class facility and there will be a formal opening ceremony later in the year.

vii. Estates: Following the recent workshop with Wightlife Partnership, it is planned to have an Estates Masterplan to support the delivery of clinical care. The plan, with indicative costings, is to be presented to the May Board meeting.

Jane Tabor raised a concern about whether we were clear which junior doctors were working during the strike. The Executive Medical Director explained that the confusion had arisen because of whether doctors were working to the Christmas based rota or an ordinary rota. The Executive Director of Nursing confirmed that there would be no confusion in the future, in the event of industrial action. The Isle of Wight NHS Trust Board received the Chief Executive’s Update

WORKFORCE 16/T/005 EMPLOYEE OF THE MONTH

The Chief Executive presented the Employee of the Month Award: Employee of the Month – December 2015

• Debra Hanson, Senior District Nurse, Sandown District Nursing Team The Isle of Wight NHS Trust Board received the Employee of the Month Award

QUALITY (PATIENT SAFETY, EXPERIENCE & CLINICAL EFFECTIVENESS) 16/T/006 PATIENT STORY The Chief Executive introduced the patient story which focused on the Poppy Unit with

three patients sharing their experience of Poppy Unit. She reported that there had been positive feedback received. She advised that previous concerns had been raised in relation to food/nutrition but that the patients in this story all provide positive feedback on the food overall. The issue raised concerning staff being busy and some delays in care was being looked into but stated that in feedback the patients all praised the staff. The Executive Director of Nursing said that all of the issues with regard to food were now addressed. He stated that it feels more like a stepdown unit now rather than an extension of an Acute ward. One of the concerns is the length of stay. Since October the occupancy rate has been 93% but the average length of stay was 18 days. This


relates to ongoing pathway blocking. Charles Rogers commented that the information was really helpful but is concerned about the length of stay. He asked for assurance that we are making every effort to move patients on. The Chief Operating Officer said that it was a system problem and the System Resilience Group is looking at what interventions it can take to sustain the same bed numbers. It needs to be a system responsibility not the Trust’s responsibility. The Chief Operating Officer said that there is a review happening for the bed requirement on the Isle of Wight. The Chief Executive said that we need to learn from last year and ensure we plan for an improved position. Charles Rogers commented that we now have real time information which is useful. The Executive Director of Financial and Human Resources confirmed that the cost of Poppy was fully funded. The Company Secretary asked, in view of concerns previously expressed, whether the Board was now assured on the quality of care in the Poppy Unit. Following discussion the Chair confirmed that the information received was helpful but that the position should be kept under review via the regular reporting to the Board.

The Isle of Wight NHS Trust Board received the Patient Story

16/T/006 QUALITY GOVERNANCE COMMITTEE CHAIR REPORT

Nina Moorman reported on the Quality Governance Committee (QGC) meetings held on 23rd December 2015 and 27th January 2016. She highlighted: 23rd December 2015

i. Management of Stroke and Transient Ischaemic Attack (TIA) – QGC assured since the recruitment of Stroke Physicians.

ii. Serious Incident Requiring Investigation (SIRI) –

This is being reviewed at the moment due to the length of time that investigations take.

27th January 2016

iii. Mock Care Quality Commission (CQC) Inspection Ambulance, Mental Health and Stroke and Rehab were all compliant but some areas still require improvement. Engagement with the Business Units is ongoing on those areas that require improvement.

The Executive Director of Nursing reported that the new regime for the Care Quality Commission will be in place shortly. This focuses on self-assessment but there may be more unannounced inspections. The ward accreditation programme is built on the fundamental standards of the criteria which will be used.

The Executive Medical Director welcomed the mock inspections and stated that there is a need to continue to do the inspections.

iv. Inpatient Falls Deep Dive

The cost of falls can be quantified and we are not performing as well as we might. What makes the difference is multiple interventions performed by multi-disciplinary teams. Nina Moorman expressed concern that the Falls Co-ordinator is only funded to the end of March.


v. Sepsis Update Our management of sepsis needed improvement and the QGC was assured that the improvement had occurred with a working group being chaired by the Consultant Nurse for Critical Care.

vi. NICE Guidance Implementation The CQC Inspection found the Trust did not have a robust system for ensuring the implementation of NICE guidance but we now have a system in place and the QGC received positive assurance on this.

The Isle of Wight NHS Trust Board received the Quality Governance Committee Chair Report

16/T/007 QUALITY IMPROVEMENT FRAMEWORK MONTHLY UPDATE

The Executive Director of Nursing reported that work still needs to be done around the six domains.

· Leadership visibility

· Reluctance to simplify measurement

· Deference to expertise · Accountability (reward/address bad behaviours)

· Deep engagement of staff/share and learning

· Teamwork.

He highlighted the issue of Pressure Ulcers and one of the risks which is achieving the “buy in” from the staff to take the right actions on a daily basis. There is some commitment from the commissioner to drive the Quality Improvement Framework through the organisation. The Isle of Wight NHS Trust Board received the Quality Improvement Framework Monthly Update.

16/T/008 REPORT FROM SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRIs)

The Executive Director of Nursing reported on the Serious Incidents Requiring Investigation (SIRIs). It was reported that the time for completion of SIRIs is being reviewed. One new SIRI was reported during December. There are 19 open SIRIs, 5 of which were overdue with a further 2 overdue with the CCG for consideration of closure. During December the CCG closed 4 SIRI cases and other 3 were awaiting their decision regarding closure. The Isle of Wight NHS Trust Board received the report from Serious Incidents Requiring Investigation (SIRIs)

16/T/009 TRUST RESPONSE TO MAZARS REPORT ON SOUTHERN HEALTH FT

The Executive Director of Nursing reported that there were 8 key areas of the Mazars report. In response to these findings the Trust has reviewed its current practices. During the time period April 2012 – December 2015 there were 43 unexpected deaths reported of patients known to Mental Health and Learning Disability Services within the Trust. 12 were investigated as SIRIs of the remaining 31 unexpected deaths were subject to a Mental Health and Learning Disability local review. 20 were from natural causes. All unexpected deaths receive a local review, a 48 hour report and/or a Serious Incident Requiring Investigation. The report will be taken back to Quality Governance Committee. David King thanked the Executive Team for the prompt response to the Mazars report and covering all the issues that the Board needs to be assured about. The Isle of Wight NHS Trust Board received the response to Mazars Report on Southern Health FT


STRATEGY & PLANNING 16/T/010 PRINCIPAL RISK REGISTER (BOARD ASSURANCE FRAMEWORK)

The Company Secretary introduced the report and asked the Board to delegate authority to the Audit and Corporate Risk Committee to close down the 2014-15 Board Assurance Framework. Lizzie Peers commented on the principal risk on cost effectiveness and suggested it needed to include some of 2016/17 forward look. The Executive Director of Financial & Human Resources agreed to reflect this next month. Action: The Executive Director of Financial & Human Resources agreed to review

the principal risk on cost effectiveness to include a 2016/17 forward look Action by: EDFHR

Jane Tabor commented that the action plan dates just seem to roll, which does not give assurance and that the capacity and capability risk she had raised is not on the Risk Register. The Company Secretary confirmed that he would respond to Jane Tabor on this risk. Action: The Company Secretary to respond to Jane Tabor on the capacity and

capability risk she has raised.. Action by: CS

The Company Secretary emphasied that periodic reviews designed to give assurance on each of the principal risks are presented to the Audit & Corporate Risk Committee. The Isle of Wight NHS Trust Board approved the Principal Risk Register

16/T/011 TRUST STRATEGY The Chief Executive confirmed the draft strategy had been distributed for comments

and there had been 33 responses. There was a need to include more emphasis on services for younger people as it appeared to be very focused on older people. All comments will be considered and the final Strategy will be brought to the Board in March. The Isle of Wight NHS Trust Board received the Trust Strategy update

16/T/012 STRATEGIC PARTNERSHIP AGREEMENT WITH THE COUNCIL The Company Secretary introduced the Strategic Partnership Agreement which had

been approved by the Council Executive at their meeting last week. There are two integration projects reflected in the schedules but further projects can be progressed without the need to negotiate again all of the issues reflected in the main part of the agreement. Steve Stubbings, Deputy Leader of Isle of Wight Council commended the Strategic Partnership Agreement to the Board. He explained that this was a real strategic partnership and he was grateful for all the hard work undertaken to finalise it. Steve Stubbings said that this would help us to see true integration here on the Island. He also said that he hoped that over time this would enable a pooled budget to deliver care. The Isle of Wight NHS Trust Board approved the Strategic Partnership Agreement with the Council

16/T/013 STATEMENT OF READINESS REPORT – EMERGENCY PLANNING The Executive Director of Nursing reported that the Trust is required to carry out an

assessment against a number of standards and make a public declaration on its


readiness. This has been completed by the Civil Contingencies Manager and Trust Accountable Emergency Officer and out of the 8 standards the Trust is required to self-assess against we are able to declare Full Compliance on 3, Partial Compliance on 4 and there is 1 which is Not Applicable. Jane Tabor questioned how prepared the Trust is in the event that the site was targeted. The Executive Medical Director commented that the Health & Safety & Security team are reviewing site access. As we develop new areas these will be secure however older areas of the site are being looked at to ensure security is effective. The Chief Operating Officer reported that all of our Business Units have a Business Continuity Plan that could be enacted if required. The Isle of Wight NHS Trust Board approved the Statement of Readiness Report – Emergency Planning

PERFORMANCE 16/T/014 PERFORMANCE REPORT The Executive Director of Nursing presented the Performance Report.

Highlights

· 90% of stay on Stroke Unit and High Risk Transient Ischaemic Attack (TIA) fully investigated and treated within 24 hours above target both in month and year to date.

· Ambulance Category A Red 2 calls response time <8 minutes and <19 minutes above target.

· Cancer targets achieved for: Patients seen <14 days after urgent GP referral, Patients receiving subsequent Chemo/Drug <31 days, Patients receiving subsequent surgery <31 days, Cancer diagnosis to treatment <31 days and Patients treated after screening referral <62 days

· % Patients waiting <6 weeks for diagnostics achieving the target

· Mental Health Care Programme Approach (CPA) targets having formal review within last 12 months and Admissions that had access to Crisis Resolution/Home Treatment Teams (HTTs) above target.

· Financial position better than plan in month.

· Slight improvement in Emergency Care Standard

· No Black Alerts or 12 hour trolley breaches.

Lowlights · Second case of the year of MRSA during December

· Referral to Treatment Time - % Incomplete pathways below 92% target

· Staff sickness remains above plan at 4.37%.

· Emergency care 4 hour standard remains below target · Cancer – Symptomatic Breast referrals seen <14 days and Cancer Urgent

referrals to treatment <62 days below target · Theatre utilisation below target

· Ambulance Category A Red 1 calls response time <8 minutes below target

· Financial Position remains a challenge.

· In December there was a Never Event – this related to a retained swab. Assurance was being sought that this could not happen again.

· Safer Staffing – shortfall noticeable compared to last month. Only 50% of wards reporting 90% fill rate. The most vulnerable shifts are being covered.

The Executive Director of Nursing reported that the sale of the Swanmore Road properties are proceeding which will produce a capital receipt.


The Executive Director of Nursing advised that the patient who became our second MRSA case this year had been in the Trust for 4 months, was clinically well but no place had been identified for him to which he could be discharged. The Isle of Wight NHS Trust Board received the Performance Report

16/T/015 WINTER PLAN PROGRESS REPORT The Chief Operating Officer reported that the Trust’s Winter Resilience Programme

continues to enable the delivery of elective activity. The Trust is working hard with partner organisation to move patients through the right pathways. Charles Rogers commented that the report was excellent but asked what happens after the Winter. The Chief Operating Officer confirmed that he was working closely with PGO Team to turn the Business Plans into a Trust Capacity Plan for 2016/17. He agreed to provide an update on this to the next Board meeting. Action: The Chief Operating Officer to report on the Trust Capacity Plan for 2016/17

at the 2nd March Board meeting. Action by: COO.

The Chief Operating Officer reported that we have a better partnership now with the Earl Mountbatten Hospice. Their rapid response team has taken patients out of our beds and more complex needs are now being cared for at home. The Chief Operating Officer acknowledged current problems with calling patients in at short notice and also problems with the Pre-Assessment process. There is a need to look at the long term solution. The Chief Operating Officer confirmed that this was work in progress. The Isle of Wight NHS Trust Board received the Winter Plan Progress Report

16/T/016 FINANCE, INVESTMENT, INFORMATION & WORKFORCE COMMITTEE (FIIWC) CHAIR REPORT

Charles Rogers presented the report from Finance, Investment, Information and Workforce Committee on 6th January 2016 and Jane Tabor reported on the meeting held on 26th January 2016. The Isle of Wight NHS Trust Board received the Finance, Investment, Information and Workforce Committee Chair Report

16/T/016 YEAR END FINANCIAL POSITION The Executive Director of Financial and Human Resources reported on the Year End

Financial Position. A background of the position was given with the Trust agreeing a deficit plan at the beginning of the year of £4.6m. Additional costs of the Winter Plan and CCG fines would give us a £6.4m deficit. In Month 9 we are ahead of our planned deficit position. There is a Cost Improvement Programme gap of £2.67m. Based on Month 9 there is a projected outturn best case (£6.4m), worst case (£9.4m) and most likely (£7.5m). The Executive Director of Financial and Human Resources reported that there is the need to evidence that we have tight cost controls in place and this is done through the Turnaround process. We are required to formally write to the commissioner and confirm the position of the Trust. This was done on 29th January 2016. After a full briefing of the Board on the potential change to the forecast outturn and the repercussions and assuming the Board support then the Chief Executive has to formally write to the TDA confirming any change to the forecast and outline the mitigations and recovery process that has been put in place. The Executive Director of Financial and Human Resources stressed that weekly executive workforce scrutiny continues, fortnightly Turnaround Board/weekly reviews


continue, all efforts are in place to stop discretionary spend (Purchase Orders/Stationery etc), the TDA Turnaround Checklist for short term implementation has been reviewed and commissioner discussions continue. Month 10 position is still awaited but is suggesting a £6.737m deficit which is a deterioration of £2.137m from the original plan and includes the additional £1.8m costs of the Winter Resilience Improvement Plan and CCG fines. There has also been a reduction in anticipated income. Charles Rogers asked from the TDA point of view are we assured that we are doing everything to mitigate the position. The Executive Director of Financial and Human Resources said that all possible actions had been taken but non-recurrent CIPs will be scrutinised and we will seek to ensure as much as possible could be recurrent. The Chair commented that we really needed to work with the CCG to fund all relevant costs. Lizzie Peers asked if we were comfortable that a change to plan of a £6.7m deficit was sufficient. The Executive Director of Financial and Human Resources responded that she believed this was the right figure but we continue to need to look at everything, including minimising expenditure on medical locums and agency staff, to ensure that position is reached. The Isle of Wight NHS Trust Board approved the Year End Financial Position

GOVERNANCE 16/T/017 BOARD SELF CERTIFICATION The Company Secretary presented the monthly report. He confirmed that the Self-

Certification had been approved at the relevant Board sub-committees and sought the Trust Board’s approval. The Isle of Wight NHS Trust Board approved the Board Self Certification

16/T/018 MEMBERSHIP OF WIGHTLIFE PARTNERSHIP BOARD The Chief Executive confirmed that she was stepping down from the Board of

Wightlife Partnership and the Executive Director of Financial and Human Resources will be taking her place. The Isle of Wight NHS Trust Board approved the changes to Wightlife Partnership Board

16/T/019 TOP KEY ISSUES AND RISKS ARISING FROM SUB COMMITTEES FOR RAISING AT TRUST BOARD

The Company Secretary presented the Top Key Issues and Risks report. Jessamy Baird raised the issue of Mental Health Act Hospital Managers training and requested that a time for this training was found that maximised Non-Executive Director attendance. The Company Secretary agreed to discuss this with the Chair. Action: The Company Secretary to agree with the Chair a suitable date for the Mental Health Act Hospital Managers training to be undertaken to ensure

maximum attendance by Non-Executive Directors. Action by: CS

The Isle of Wight NHS Trust Board received the Top Key Issues and Risks arising from Sub-Committees

16/T/020 ANY OTHER BUSINESS There was none. 16/T/021 DATE OF NEXT MEETING The Chair confirmed that the next meeting of the Isle of Wight NHS Trust Board to be


held in public is on Wednesday 2nd March in the Conference Room – School of Health Science Building, St Mary’s Hospital, Newport, IW, PO30 5TG

The meeting closed at 12.30 pm Signed………………………………….Chair Date:…………………………………….

Following the conclusion of the agenda items in Part 1 of the Trust Board, the

Board continued to sit to discuss Charitable Funds. BOARD CONVENED AS CORPORATE TRUSTEE: 16/CT/001 MINUTES OF THE CHARITABLE FUNDS COMMITTEE MEETING HELD ON 15TH

DECEMBER 2015 Nina Moorman, Chair of the Charitable Funds Committee presented the Minutes from

the Charitable Funds Committee held on 15th December 2016. Nina Moorman confirmed that the Annual Accounts & Report of the Isle of Wight NHS Trust Charitable Funds 2014/15 were agreed and recommended for adoption to the Corporate Trustee by the Charitable Funds Committee via e-mail voting in November 2015. The Letter of Representation for auditors Ernst & Young was also signed and approved. She also confirmed that a legacy of £162,000 had been received. The Executive Director of Financial & Human Resources confirmed that the signed annual accounts for 2014/15 had now been uploaded to the Charity Commission website in accordance with the regulations. . The Corporate Trustee received the Minutes of the Charitable Fund Committee

16/CT/002 PROTOCOL FOR STATIC FUNDS The Executive Director of Human and Financial Resources explained that a protocol

had been written to deal with small funds not being spent and it was proposed that these funds are then moved to the General Fund after a set period of time. It was confirmed that fund managers had been approached but without success and this is why the protocol has been written. The Executive Director of Financial & Human Resources assured the Corporate Trustee that any specific wishes requested by the donor would be respected. The Corporate Trustee approved the Protocol for Static Funds

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25/02/20161 of 2

ISLE OF WIGHT TRUST BOARD Pt 1 (Public) - April 15 - March 16ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update Report Author

Further Action by Other

Committee

Due Date Forecast Date

Progress RAG

Date Closed

02-Sep-15 15/T/163vi TB/176 Appraisals: The Chief Executive agreed toensure that TEC is monitoringand seeking improvements inthe level of appraisals.

CEO (EDTI)

28/10/15 - This is scheduled for TEC on 9/11/15 andwill be reported back to the Board at the Decembermeeting.03/12/15 - TEC will be reviewing during December andJanuary and will report back for February Board.15/12/15 - The Executive Director of Transformationand Integration confirmed she was leading on this andwill report back in February.26/01/16 - Due to the sickness of the ExecutiveDirector of Transformation and Integration this hasbeen deferred until March.03/02/16 - The Executive Director of Financial &Human Resources confirmed that she was now pickingthis up and seeking a significant improvement by theend of 2015/16.

TEC 04-Nov-15 31-Mar-16 Progressing

04-Nov-15 15/T/228 TB/188 Older Persons Nurse Fellowship Update

Company Secretary to arrangefor Di Goring to present anupdate at Seminar inapproximately 6 months.

CS On Seminar Forward Plan for May 16 Seminar 17-May-16 17-May-16 Progressing

15-Dec-15 15/T256 TB/192 Finance, Investment, Information and Workforce Chair Report

The Executive Medical Director to ask the Deputy Medical Director for a plan to improve the completion of discharge summaries

EMD 19/01/16 - the Deputy Medical Director has established a group and is planning a change in the process to achieve significant improvement from April 2016.03/02/16 - The Executive Medical Director provided an update and confirmed he was confident that there would be a an improvement in the completion of discharge summaries.23/02/16 - Meetings have been held with key stakeholders; a GP survey has been distributed; work is in progress to review process with key staff; action plan is being developed.

06-Apr-16 06-Apr-16 Progressing

Non Executive Financial Advisor: Lizzie Peers (LP)

Executive Director of Nursing (EDN) Deputy Director of Nursing (DDN) Chief Operating Officer (COO)

Non Executive Directors: Eve Richardson (Chair) Charles Rogers (CR) Nina Moorman (NM) David King (DK) Jane Tabor (JT) Jessamy Baird (JB)

Key to LEAD: Chief Executive (CE) Executive Director of Financial & Human Resources (EDFHR) Executive Director of Transformation & Integration (EDTI) Executive Medical Director (EMD)

Foundation Trust Programme Director/Company Secretary (FTPD/CS) Trust Board Administrator (BA) Head of Communication (HOC)

Head of Corporate Governance (HCG)Business Manager for Patient Safety, Experience & Clinical Effectiveness (BMSEE)Deputy Director of Informatics (DDI)

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25/02/20162 of 2

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update Report Author

Further Action by Other

Committee

Due Date Forecast Date

Progress RAG

Date Closed

15-Dec-15 15/T/255 TB/193 ICT Update - Actions for Task & Finish Group

It was agreed to include cost savings as efficiencies as key goals and the Chair asked that the expertise of primary care and what was emerging in the My Life work be included in the Task & Finish Group

CEO(EDTI)

22/02/16 - The Chief Executive to give an update on the ICT Task & Finish Group at the March Board meeting

Task & Finish Group

02-Mar-16 02-Mar-16 Progressing

03-Feb-16 16/T/010 TB/194 Principal Risk - Cost Effectiveness

The Executive Director of Financial & Human Resources agreed to review the principal risk on cost effectiveness to include a 2016/17 forward look

EDFHR 23/02/16 - The prinicipal risks are currently being reviewed and updated to reflect these aspects.


03-Feb-16 16/T/010 TB/195 Principal Risk - Capacity & Capability

The Company Secretary to respond to Jane Tabor on the capacity and capability risk she has raised..

CS 22/02/16 - Company Secretary confirmed to Jane Tabor that the Executive team have discussed and proposed that this is the subject of another principal risk to place on the Principal Risk Register. This will be included on the Principal Risk Register report for the April Board meeting.


03-Feb-16 16/T/015 TB/196 Trust Capacity Plan The Chief Operating Officer toreport on the Trust Capacity

Plan for 2016/17 at the 2nd

March Board meeting.

COO 23/02/16 - This is included in the Winter Plan report to the March Board meeting. This action is now closed.

02-Mar-16 02-Mar-16 Completed 23/02/2016

03-Feb-16 16/T/19 TB/197 Mental Health Act Hospital Managers Training

The Company Secretary to agree with the Chair a suitable date for the Mental Health Act Hospital Managers training to be undertaken to ensure maximum attendance by Non-Executive Directors.

CS 23/02/16 - The Company Secretary has proposeddates to the Chair of Mental Health Act ScrutinyCommittee

MHASC 02-Mar-16 02-Mar-16 Progressing

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REPORT TO THE TRUST BOARD (Part 1 - Public)

ON 2nd March 2016 Title Chief Executive’s Report Sponsoring Executive Director Karen Baker, Chief Executive Officer

Author(s) Andy Hollebon, Head of Communications and Engagement

Purpose For information Action required by the Board: Receive X Approve

Previously considered by (state date):

Trust Executive Committee Mental Health Act Scrutiny Committee

Audit and Corporate Risk Committee Remuneration & Nominations Committee

Charitable Funds Committee Quality Governance Committee

Finance, Investment, Information & Workforce Committee

Foundation Trust Programme Board

Please add any other committees below as needed

Board Seminar

Other (please state)

Staff, stakeholder, patient and public engagement:

This report is intended to provide information on activities and events that would not normally be covered by the other reports and agenda items. This report covers the period 28th January 2016 to 22nd February 2016. Executive Summary:

This report provides a summary of key successes and issues which have come to the attention of the Chief Executive over the last month. The report covers the following issues: National

· Industrial Action · New Care Models, My Life a Full Life programme Local

· System Pressures and Safer Start Week · Staff Survey · Stay Well This Winter · Listening into Action · Commuting Challenge · Appointments · Endoscopy · Key points arising from the Trust Executive Committee

For following sections – please indicate as appropriate: Trust Goal (see key) All Trust goals Critical Success Factors (see key) All Trust Critical Success Factors

Principal Risks (please enter applicable BAF references – e.g. 1.1; 1.6)

None

Assurance Level (shown on BAF) Red Amber Green Legal implications, regulatory and consultation requirements

None

Date: 22nd February 2015 Completed by: Andy Hollebon, Head of Communications

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Chief Executive’s Report covering the period 27th January to 22nd February 2016

National Industrial Action The Industrial Action by Junior Doctors is continuing and the Secretary of State for Health has announced that the new contract will be imposed on junior doctors in August 2016. The issue has reached a stalemate. We worked closely with the junior doctor body to ensure that the industrial action on Wednesday 10th February did not impact on patient care. We hope that at a time when it is very difficult to recruit doctors and nurses to the Island that the dispute will not lead to significant numbers leaving the profession – a situation which will only make the recruitment position worse. New Care Models, My Life a Full Life programme and the Financial Position During the last month we have met with Sam Jones the NHS England National Programme Director for New Care Models. She was visiting the Island to meet the Trust and other My Life a Full Life programme partners. I have also met with NHS England Chief Executive Simon Stevens. He reiterated the need to make some radical changes across systems and how the Sustainability Transformation Plan (STP), which needs to be submitted in June 2016, is an opportunity for us to do that. Essentially, this is about planning across a system rather than an organisation. We have a one year plan for the Trust and are talking to partners about a five year plan for the system. Over the last month we’ve had a couple of sessions looking at our Estates Strategy and this is being developed into the Estates Master Plan which will support both the Trust’s aspirations and delivery of the My Life a Full Life programme. With the creation of integrated locality working, increased joint working with the Council under the Strategic Partnership Agreement and greater voluntary sector involvement in the delivery of services it is essential that we have a clear plan for the future use of our buildings and land. This can only be achieved through co-production with staff, volunteers, services users, carers and key partners.

Local System Pressures and Safer Start Week We have had some really busy days and the Island wide health and care system has been escalated from amber to red several times. Between 8th and 15th February we were all focused on the Safer Start week’ We had really excellent engagement from everyone. We achieved 94% in the Four Hour Emergency Care Standard which is great when you consider the national average is running at around 91% and some are achieving only 78%. Meetings were cancelled and all areas, including corporate, helped to increase the resources at the front line. We’re grateful to our partners, particularly Age UK IW and the Red Cross for supporting this initiative. All members of the Executive team spent significant amounts of time with the front line patient care services. Safer Start Week has highlighted many examples of what needs to change in order to focus much more on patients and how we can get better flow through the health and care system. You can catch up with what happened on our website at http://www.iow.nhs.uk/getting-involved/safer-start-week.htm.

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Staff Survey The results of the national 2015 Staff Survey are being published on 23rd February. Following last year’s results we invested time in addressing issues raised through dedicated action orientated groups. The work is still underway but in some areas we are making progress and in others we still have work to do. We will be reviewing the results to see where we need to refocus our work. Stay Well This Winter During February and March 2016 we are promoting the 111 service. Some 50,000 business card size reminders of the service have been distributed to public and holiday places across the Island. Advertising of the service has featured on cross Solent operators Red Funnel and Wightlink as well as in bus shelters across the Island and will in March feature on Isle of Wight Radio in the lead up to the Easter holidays. A second phase of the programme will start shortly with a focus on young children. In the face of increasing numbers of children presenting to primary care, pharmacists and emergency departments, a Wessex-wide resource (www.healthiertogetherwessex.nhs.uk) has been developed for parents and healthcare staff (initially focusing on children aged under 5 years), aiming to:-

1) empower parents when faced with an ‘unwell’ child (ideally to empower them to manage children with self-limiting conditions at home)

2) signpost parents to appropriate local services, if indicated 3) promote consistent management strategies and healthcare messages across the urgent

care pathway. These have been developed by professionals (GPs, paediatricians, community nurses) from across Wessex and have been through an extensive Wessex-wide consultation process.

Nationally NHS 111 services have been the focus of negative media attention following the tragic case of William Mead. Our 111 service on the Island is part of our Integrated Care Hub and on 9th February ‘The Sun’ carried a two page feature titled ‘Is this the health centre that could have saved tragic William? We visit state-of-the-art facility that could change healthcare’ about how the system is organised on the Island. NHS England’s medical adviser to NHS 111, Dr Ossie Rawsthorne is quoted as saying: “The Isle of Wight model is how we see the future across the country. It will take some time to roll out across the country but these clinical hubs will make it easier for the public to access a wide range of medical experts in one place.” Listening into Action We held the second Listening into Action ‘Pass It On’ event. There were some great examples of innovative projects and we heard from a service user who talked about the progress being made in mental health services and joint working with My Time. The film made as part of this LiA project and shown to the audience was inspiring. Others exhibiting their progress included projects which have streamlined the meetings in the organisation, improved recruitment arrangements, made enhancements to the way medics interact with Healthroster and produced better information for patients. Ideas are now being sought for a third wave of projects. Commuting Challenge Congratulations to the Workforce Warriors at HR who won 1st Place in the Commuting Challenge. Also well done to the 11 Challenge teams who over January logged 1,819 journeys, saved almost a Tonne of carbon emissions, and burned 790 doughnuts worth of calories!

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Appointments We’re proud of the work of our Patient Council which has been in operation for over 10 years. Patient Council members held the yearly election for the role of Chair earlier this month. The current Chair, Linda Fair, was re-elected and member Doreen Britton was asked to be deputy chair. Alan Sheward has recently been nominated as Executive Director with responsibility for the Patients Council, which means that he will attend all Patient Council meetings to ensure all key issues raised are actioned. Jenni Edgington has been appointed to the role of Head of Nursing and Quality for the Ambulance, Urgent Care and Community Clinical Business Unit. The candidates for the role all demonstrated a high calibre so well done Jenni for shining through. Emergency Department consultant Thomas Lawal-Rieley has been appointed as IW Foundation Programme Director – this is the role that oversees the education of doctors during their first two years. Thomas has an important role to keep us on the map as a major local medical education provider as we run the biggest medical training programme with around 40 trainees. The training of staff is so important and it’s heartening to know that to date 17 young apprentices who have trained with the Trust have gained permanent, part-time or bank work following the completion of their apprenticeship. Several are continuing with the next level whilst employed by the Trust in their new roles, undertaking Apprenticeships in Business and Administration and one has progressed onto a 3 Year Foundation Degree in Business and Management. Apprentices have so much to offer the Trust and we are helping to develop our future workforce. Endoscopy Endoscopy was first offered at St. Mary’s Hospital in 1978 and the service has continued to develop and progress over the past 37 years. The existing accommodation has been far from ideal for some time now but the team have not allowed that to affect the high level of care given to patients; they have continued to deliver a first class service in cramped accommodation. We now have an impressive new facility, as featured in a four page supplement in the County Press on 12th February, which is going to make a huge difference to patients and to the staff who really deserve to work in an environment which is right up to the latest standards. Key Points Arising from the Trust Executive Committee The Trust Executive Committee (TEC) – comprising Executive Directors, and Clinical Business Unit representatives meets every Thursday. The following key issues have been discussed at recent meetings: 28th January 2016

· General Medicine Specialty Registrar (SpR) vacancies and recruitment issue discussed and concerns expressed

· Completion of the sale of the Swanmore Road Properties – TEC approved · Information Governance Toolkit – update received · Emergency Planning Preparedness Response (EPPR) ‘Statement of Readiness’ – TEC

approved

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4th February 2016

· Business Planning Discussed · Winter Resilience Progress Report – system beds and plan for closure of Poppy Unit · Marsipan Policy (to improve the management of patients with severe anorexia nervosa in

general medical and paediatric units) – TEC approved 11th February 2016

· Safer Start Week – No Trust Executive Committee 18th February 2016

· Quality Priorities – TEC approved · IG Toolkit – TEC approved IG Risk Assessment Checklist

Karen Baker Chief Executive Officer 22nd February 2016


ON 2nd March 2016

Title Report from Chair of Quality Governance Committee

Sponsoring Executive Director

Nina Moorman, Chair of Quality Governance Committee

Author(s) Nina Moorman, Chair of Quality Governance Committee

Purpose To receive the report for the Chair of the Quality & Clinical Performance Committee

Action required by the Board:

Receive X Approve

Previously considered by (state date and outcome):

Sub-Committee Dates Discussed Key Issues, Concerns and Recommendations from Sub Committee

Audit and Corporate Risk Committee

Charitable Funds Committee


Mental Health Act Scrutiny Committee

Quality Governance Committee 24/02/16

Remuneration & Nominations Committee


Turnaround Board



Not applicable

Executive Summary:

The Chair of the Quality Governance Committee will report on the following areas as discussed at the meeting held on 24th February 2016.

Safety

Experience

Effectiveness

Recommendation to the Trust Board:

The Board is recommended to receive the assurance report by the Chair of the Quality Governance Committee

Attached Appendices & Background papers Report

For following sections – please indicate as appropriate:

Trust Goals & Priorities

Principal Risks (BAF)

Legal implications, regulatory and consultation requirements

Date: 24th February 2016 Completed by: Chair of the Quality Governance Committee

Enc D

Quality Governance Committee

Assurance Report for Trust Board

2nd March 2016

Compiled following the QGC meeting on Feb 24th 2016

Patient safety

There has been a reduction in patient safety incidents resulting in major harm over the past 4 months and a corresponding reduction in Serious Incidents Requiring Investigation (SIRIs). However there have been 2 never events and although neither of these caused harm, both were due to failure to comply with standard procedures: relevant staff have been alerted to these and compliance will be audited in 6 months.

Pressure Ulcers

A majority of the incidents were pressure ulcers acquired in the hospital so a hospital led pressure ulcer collaborative is planned for March. The community sector continues to show an improved position.

Assurance negative: Follow up – a rolling programme of all patient safety issues* has been agreed with the EDN so that each is given sufficient scrutiny.

Hospital acquired infections

3 new cases of Clostridium Difficile (CDiff) were reported in January (year total now 20 cases in 13 patients), one case of Methicillin Resistant Staphylococcus Aureus (MRSA) and 4 surgical site infections were reported. A quality improvement approach is being developed by the Infection Control Committee led by the EDN.

Assurance negative

Nutrition

A clinical nurse specialist was appointed in December 2015 to lead this work in the hospital and she provided a briefing on the current situation and the work programme. An audit in January showed that 32% of patients are either malnourished or at risk of developing it, which is in line with National figures for people admitted to acute care. Initial areas for improvement are improving the accuracy of assessment and the focus given to nutrition by medical and nursing staff by education, improving compliance with guidance, and developing pathways and policies for all aspects of nutrition.

Assurance positive

*Pressure ulcers, falls, hospital acquired infections, nutrition including hydration.

Action: All quality improvement methodologies require service specific quality data and the committee urged the development of routinely collected CBU level data.

Patient Experience

Poppy Unit

Concerns were raised about the care and staffing at the temporary step down facility opened at Solent Grange Nursing Home, the Poppy Unit, shortly after it opened. We received a

report and action plan developed following a series of assurance visits which demonstrated that all concerns have now been acted on.

Assurance positive

Action: The Committee would like to know what the plan is for the Poppy Unit, and the patients it cares for, from the end of March.

Bereavement Survey

This was conducted between August and November 2015 to answer questions concerning communication raised by the CQC inspection. The result demonstrated a largely positive response from relatives regarding the care of their relatives.

Assurance positive Follow up – ongoing survey

Clinical effectiveness

Mortality

The Standardised Hospital Mortality Index (SHMI), an NHS comparative Index, currently stands at 1.00 which is the lowest level for the past 4 years. Review of all deaths is carried out and shows a steadily increasing number of patients with a documented do not resuscitate in place and identified as requiring end of life care. The End of Life action plan in response to the CQC inspection still requires greater emphasis on clinical oversight in wards and departments and the EDN is leading a review of these actions.

Assurance limited Follow up year end report due in April 2016

Oncology

Concerns have previously been raised about provision of acute oncology services at the Trust which rely on visiting Consultants from Southampton and Portsmouth. The oncology service is jointly commissioned by the CCG and NHSE who funded a service review which has now reported. A series of recommendations have been made which include a few which are for the Trust to implement, and the rest require joint decisions from commissioners and partner providers. The review commended the work of the Cancer Nurse Specialists at the Trust, for their pivotal role in continuity of care and case management.

Action: The committee requested information on how the review recommendations will be taken forward.

Dr Nina Moorman Chair Quality Governance Committee Feb 25th 2016

REPORT TO THE TRUST BOARD (Part 1 – Public)V10 Page 1

REPORT TO THE ISLE OF WIGHT NHS TRUST BOARD (PART 1 - PUBLIC)

ON 2nd March 2016

Title Quality Improvement Framework (QIF) update February 2016


Alan Sheward, Executive Director of Nursing

Author(s) Deborah Matthews, Lead & Business Manager for the Safety, Experience and Clinical Effectiveness Team.

Purpose Receive for assurance


Receive X Approve


Sub-Committee Dates Discussed

Key Issues, Concerns and Recommendations from Sub Committee

Trust Executive Committee






Quality Governance Committee 24.02.16



Board Seminar


Staff, stakeholder, patient and public engagement: Stakeholder engagement with Falls Lead, Tissue Viability and Nutrition Service, Patient Experience Lead,

Executive Summary & Analysis:

The QIF is an overarching document which draws together all initiatives that are currently underway within the Isle of Wight NHS Trust to improve quality of care; and it provides a framework for delivery of these initiatives that will ultimately result in quality improvements for our patients. This paper provides an update on progress within each of the six domains of the QIF:

· Leadership visibility · Reluctance to simplify · Deference to expertise · Accountability · Deep engagement with staff · Teamwork

It gives specific details of the collaborative work that is underway with pressure ulcers, falls and nutrition.

Enc E


Recommendation to the Board:

The Board is requested to receive the report for assurance of progress with the QIF

Attached Appendices & Background papers



The work underway within the QIF is linked directly to all five of the Trust goals

Principal Risks (BAF) Areas of the BAF affected: Quality, strategy and planning, culture


Date: 23-02-16 Completed by: Deborah Matthews, Lead for SEE; Mandy Blackler, SEE Business Manager

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1. BACKGROUND 1.1 The Quality Improvement Framework (QIF) is an overarching document that draws together all the initiatives that are currently underway to improve quality of care. It provides a framework for delivery of these initiatives that will ultimately result in quality improvements for our patients and describes our approach to quality. The QIF was approved at Trust Board in September and replaces the Long Term Quality Plan. At its core, the QIF describes “the way we do things round here” reflecting the essence of a QI and continuous improvement culture.

1.2 The QIF describes various methodologies for quality improvement; the Plan, Do, Study, Act (PDSA) cycle which will be used for smaller scale projects; and Quality Improvement Collaboratives which still utilise PDSA but will be used for larger scale projects that may take over a year to complete. We are currently fortunate to have a Quality Improvement Practitioner in post until March 2016 who is taking forward some key areas of this work.

1.3 This paper presents updates on progress against the six domains described within the QIF

2. UPDATE ON PROGRESS 2.1 General The QIF has six clearly defined domains for supporting the delivery of quality improvement. These are:

· Leadership visibility · Reluctance to simplify measurement · Deference to expertise · Accountability (reward/address bad behaviours) · Deep engagement of staff/share the learning · Teamwork

Below is a matrix that gives details of how each of the projects underway is performing against the six domains identified above. It identifies for each of the projects which domain is relevant, and a RAG rating as to performance against that domain.

Patient Safety Experience & Clinical Effectiveness Team

Quality Improvement Framework (QIF) Update 19th February 2016

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Project Leadership visibility

Reluctance to simplify

measurement

Deference to expertise Accountability

Deep engagement with

staff Teamwork

Pressure Ulcers ü ü ü ü ü ü

Falls ü ü ü ü ü ü

Nutrition ü ü ü ü ü ü

Listening into Action ü ü ü ü ü

Executive walkabouts ü ü ü ü

Patient Experience Steering Group ü ü ü ü ü The accountability section for falls is listed as red as there is no identified falls lead from within the CBUs after 31st March, when the current falls lead returns to her substantive role following a secondment funded by CQUINS.

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2.2 Pressure Ulcers – Actions



measurement


Deep engagement

with staff Teamwork

Pressure Ulcers ü ü ü ü ü ü

· The CCG has recently supported with non-recurrent funding to the end of March 2016 an additional person into the Nutrition and Tissue Viability Service to help deliver reduction across the Community setting. The Trust have submitted a business case for substantive funding of this post from April 2016 onwards This post is working closely with the Community Clinical Educator and is pivotal in supporting the roll out of the Community SSKIN bundle in the localities, with the aim of eliminating avoidable pressure ulcers. We are still awaiting communication from the CCG to confirm whether this additional post will be substantively funded after April 1st.

· Following Pressure Ulcer Policy updates, clinical updates are being rolled out to team leaders and ward sisters to update their clinical teams. The Nutrition and Tissue Viability Service is working with individual clinical teams in both inpatient and community areas to improve the reporting mechanism and detail provided.

· It is worth noting that the Collaborative work within District Nursing has helped to achieve no avoidable 4 pressure ulcers in the South Wight locality within the last 27 weeks. The Collaborative work is now extending to focus more attention on reducing the occurrence of Grade 2 pressure ulcers. The Nutrition and Tissue Viability Service, along with the Quality Manager for COO, are meeting the ward sisters for inpatient areas on a systematic basis to introduce the practice of cluster review of grade 2 pressure ulcers in the hospital settings.

2.2.1 Pressure Ulcers – Impact:

Pressure Ulcer reporting by geographical location - Data is subjected following review of cases.

· An analysis of the aggregate number of grade 3 or 4 pressure ulcers since April 2015

against the same period last year has shown a significant improvement in this group of the

02468

101214161820

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line

1

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3

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Community

Hospital

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most serious types of pressure ulcer in the community setting. Last year the Trust reported 50 grade 3 and 4 pressure ulcers during the year under community nursing care. To date, the Trust has reported just 17 during 2015-16.

Total avoidable grade 3 and 4 pressure ulcers month by month for 2015-2016 against baseline 2014-2015.

The clustering of grade 2 pressure ulcers to extract learning has raised awareness of this group of pressure ulcers and, as expected, raised reporting in the short term, as opposed to baseline data for 2014-15, although this has dipped below baseline for the first time this month.

0

1

2

3

4

5

6

7

8Community acquired grade 3 and 4 pressure ulcers 2015-16

month on month against 2014-15 baseline Grade 3 and 4pressure ulcers2014-15

Grade 3 and 4pressure ulcers2015-16

Linear (Grade 3and 4 pressureulcers 2014-15)

Linear (Grade 3and 4 pressureulcers 2015-16)

0

5

10

15

20

25

30

Community acquired grade 2 pressure ulcers month on month for 2015-16 against 2014-15 baseline

Grade 2 pressure ulcers 2014-15

Grade 2 pressure ulcers 2015-16

Linear (Grade 2 pressure ulcers2014-15)

Linear (Grade 2 pressure ulcers2015-16)

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Grade 2 pressure ulcers that have developed in the care of IW NHS Trust community nursing service during 2015-2016 against 2014-15 baseline.

Despite this however, this appears to not have resulted in an increase in workload. In fact, a recent review of pressure ulcer related contacts in the community settings has shown that this workload is reducing.

Data for daily contacts specifically related to pressure area care since April 2015.

2.2.2 Pressure Ulcers – Assurance

· The graphs above clearly demonstrate improvements with pressure ulcer prevention · This is monitored weekly and reported to SEE Committee

2.3 Falls



measurement


Deep engagement

with staff Teamwork

Falls ü ü ü ü ü ü 2.3.1 The Quality Improvement Practitioner is currently undertaking the following actions:

· Reviewing all inpatient falls data · Coordinating Falls Cluster meeting reviews for inpatients, reviewing all incidents and

making recommendations for practice improvement. · Organising Falls prevention education via falls prevention “Masterclasses” and Competency

training ( on-going) · Falls risk assessment and care plan being reviewed and will be updated to include current

evidence-based advice and guidance. · Teaching slot booked to speak to Doctors- with associated education material · Discussion has taken place with Medical Consultants and support gained

0

50

100

150

200

250Pressure area related community nursing contacts

per week Pressurearearelatedcommunitynursingcontactsper week

of 10

· MDT approach is vital, Occupational Therapists Physiotherapists and Pharmacists have also been approached to ensure a collaborative team approach to falls prevention. All staff members that have agreed to support the programme have agreed to attend the falls collaborative meeting –last meeting was the 10th February 2016, next meeting booked for the 10th March 2016.

· Currently recruiting “Falls Prevention Champions” to be a point of reference for staff within their departments.

· We will take part in the next national falls audit ( Royal College of Physicians) in September 2016, where improvement will be measured and comparison to last year’s performance will be analysed.

· Falls care plan completion audit commenced February 1st 2016 (report to follow)

2.3.2 Impact – Falls: The graph below demonstrates that the actual number of falls reduced from 84 in November to 60 in December a slight rise in January. ( see graph below) 2.7.6 Assurance – Falls

· Information will be monitored and managed through the Falls Steering Group · Weekly Falls cluster review meetings are now in progress for all falls incidents with

outcome recommendations given and added to Datix reports when necessary. · Reports will go monthly to SEE Committee and be included in the QIF report for QGC

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· Early indications are that falls will be one of the CQUINs for next year which, if proven, will ensure that falls maintains a significant focus to ensure new systems are embedded.

During January 2016 there were 61 Slips, trips and falls. Although 10 of these incidents resulted in harm, there were no cases where the harm met the severity criteria of 4 or 5 indicating serious or catastrophic injury. (see chart below)

3.0 Nutrition



measurement


Deep engagement

with staff Teamwork

Nutrition ü ü ü ü ü ü

The Clinical Nutrition Nurse Specialist is currently under taking the following actions:

- Reviewing all patients receiving enteral feeding through fine bore naso-gastric tubes - A system has been set up to share information about patients receiving enteral feeding

with the dietitians to prevent duplication and ensure there are robust systems. - A teaching programme is in place on the care of naso-gastric and percutaneous endoscopic

gastrostomy tubes (PEG) to date 3 sessions have been held and have been well attended by most areas, these will continue.

- The first link nurse meeting has been undertaken although attendance was poor so there has been further advertising of this prior to the March meeting.

- A Nutrition Steering group is being set up to set the way forward the nutrition agenda - Discussions have already taken place with Gastroenterology Consultants their support has

been gained

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- A pathway has been developed for inpatient referrals for patients where a PEG is being considered. The impact of this on referral times will be audited throughout March and April and compared with previous referral times.

- Working with the hospice to develop competency in the management of patients receiving naso-gastric feeding, as currently this was not a service they provided so precluded those patients from the hospice.

- A recent quarterly audit of the Malnutrition Universal Screening Tool (MUST) we use to assess those patients who are already malnourished or at risk of becoming malnourished was found to be inaccurate in a proportion of cases. CNNS will carry out education to improve knowledge and therefore accuracy of completion.

- To improve the number of patients who are weighed whilst inpatients so it can be determined if patients in our care lose weight whilst within hospital. An audit of this will be undertaken March 2016.

3.1 Impact – Nutrition The table below demonstrates that there has been a significant increase in the use of care plans for patients receiving fine bore naso-gastric feeding. When initially started there was very little knowledge around the correct care of patients receiving this form of enteral feeding however with education this has improved. The standard is for 100% of patients on naso-gastric feeds to have a correctly completed care plan as this shows that patients are being cared for in line with the NPSA alert 2005 & 2011. Although significantly better than previously, there is still room for improvement.

10%

17%

86%

0%

50%

67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec-15 Jan-16 Feb-16

Percentage of patients with a care plan in place

Percentage of those with care plans which are completed

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3.2 Assurance – Nutrition · The Nutrition Nurse Specialist will gain assurance by continuing to monitor the

effectiveness of the above actions through audit to ensure that the principles of safe care are being adhered to.

· Link Nurse Group will monitor. · Reporting will be through SEE Committee via Assurance and mitigation reports and QGC via

the QIF report 4.0 Patient Experience



measurement

Deference to

expertise Accountability

Deep engagement

with staff Teamwork

Patient Experience

Steering Group ü ü ü ü ü

· The Patient Experience Steering Group inaugural meeting is being held on 26th February

2016, chaired by the Deputy Director of Nursing. · As a priority the Patient Experience Steering Group will be reviewing the actions that need

to be taken by the Trust to enable delivery of the Accessible Information Standard which comes into effect on 1st April 2016, and has to be fully implemented by 31 July 2016.

· This group will be key to enabling the Trust to deliver against the Patient Experience Strategy 2014 -2017, and a clear workplan identifying the priorities will be developed, to enable the Trust to deliver the objectives within the strategy.

· Bespoke Patient Experience Surveys, have been disseminated across the Trust to ensure we are capturing a greater depth of patient feedback, Further development of these will occur as we move to ‘I Want Great Care’ to support with patient experience feedback collection.

· The Patient Experience Team are in the process of implementing the clear separation between the complaints and PALS processes. This action has been undertaken following the Healthwatch Isle of Wight review of the complaints process, the new literature will be disseminated by the end of February to inform and support complaints through the Trust processes. The complainant survey that is sent with each final response letter is currently being redesigned and aligned the Parliamentary and Health Service Ombudsman and will recommences by end of February.

4.1 Impact:

· This approach puts patients at the heart of everything we do and gives them a voice as a trusted expert in what they want from our services

· This will enable our staff to fully understand the needs of the patient and align these with their own expertise in developing services

· This will ensure communication requirements for patients is captured and used throughout the patient journey through Trust Services.

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4.2 Assurance:

· Assurance will come through fewer complaints and increased user satisfaction. This will be demonstrable through FFT/I want great care and other local and national survey results.

5.0 Risks to delivery The key risks to delivery are as follows: 5.1 No identified Falls Lead from within the CBUs to take over from 1st April. CBUs need to identify a Falls Lead from within their combined resources in order to mitigate this risk. This role was previously undertaken by a Matron alongside her current role and is currently being covered by the Quality Improvement Practitioner alongside her current role (that is funded by CQUINs) so this doesn’t need to be a stand alone position. 5.2 Executive assurance visits are currently sporadic and would benefit from a defined timetable for assurance. Ownership of this requires clarity. 5.3 The key risks to delivery are if we do not achieve buy in from staff for all six of the domains within the QIF 5.4 Early discussions with Commissioning colleagues have indicated a willingness to continue with the QIP/QIF CQUIN for next year. There will be resourcing implications in delivering this programme if this CQUIN is not rolled forward for another year. 6.0 Monitoring 6.1 Monitoring and challenge will be through the Quality Governance Committee (QGC) via monthly reports 6.2 The Trust Board will receive monthly updates on progress 7.0 Recommendations

7.1 The Trust Board receive this as assurance against the actions being taken to improve the quality of care for patients by completing the actions listed

ALAN SHEWARD EXECUTIVE DIRECTOR OF NURSING 18th February 2016


ON 2nd MARCH 2016

Title Serious Incident Requiring Investigation (SIRI) Activity Report (January 2016 data)



Author(s) Karen Kitcher, Quality Assurance Lead (SEE Team) & Deborah Matthews Lead for Patient Safety, Experience & Clinical Effectiveness (SEE)

Purpose To provide Trust Board with information concerning the number of Serious Incidents that Require Investigation (SIRI) formally reported within January 2016, the ongoing number that are yet to be completed and the lessons learnt from investigations recently closed.


Receive X Approve


Sub-Committee Dates Discussed Key issues, concerns & recommendations from Sub Committees







Quality Governance Committee 24 February 2016


Please add any other committees below as needed:

Board Seminar

Patient Safety, Experience & Clinical Effectiveness Group

17 February 2016


Clinical Business Units (CBU) are required to schedule a table top discussion of SIRI findings at the end of each investigation to inform the final report prior to formal submission of the report to the Isle of Wight Clinical Commissioning Group (CCG) - to ensure lessons learnt are identified and actions for dissemination are agreed. Implementation of this methodology is progressing. To support the scheduling of activities and meetings SEE circulate a timetable of requirements to key stakeholders at the outset of the formal SIRI notification to a service. The investigation commissioning manager is responsible for working with SEE to ensure any required clinical audit is shaped around the outputs from a SIRI and lessons learnt are heard and understood across the wider organisation.

Enc F

2 | S I R I a c t i v i t y r e p o r t ( J a n u a r y 2 0 1 6 d a t a )


This report provides an overview of the Serious Incident Requiring Investigation (SIRI) activity during January 2016. Serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive investigation and response. One SIRI was reported to the Isle of Wight CCG during January 2016.

1. Poppy Unit – Patient Fall (fractured arm) At the time of writing this report there were: 23 open SIRI’s - 7 of which were overdue with a further 3 overdue with the CCG for consideration of closure. During January 2016, and at the time of reporting, the IW CCG had not closed any SIRI cases, there are 3 were awaiting their decision regarding closure. LESSONS LEARNT – As there were no SIRI cases closed by the CCG during January 2016 there are no lessons learnt to be shared this month.

Recommendation to the Board: To receive for information and comment if indicated.

Attached Appendices & Background papers: Nil



Goals · Excellent Patient Care · Working with others to keep improving our services Quality Priorities · Reducing incidents of patient harm

Principal Risks (BAF) 2.6


· The NHS England SIRI Framework and Policy (2015) explains the responsibilities and actions for dealing with Serious Incidents. It outlines the process and procedures to ensure that Serious Incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.

· Timescale – a single timeframe (60 working days) is described for the completion of investigation reports, to allow providers and commissioners to monitor progress in a more consistent way. This also provides clarify for patients and families in relation to completion dates for investigations.

· Timeframes from formal reporting of a SIRI to submission of the finalised report to the CCG are in the majority of cases running outside of the 60 working day standard. Actions are being taken to more formally monitor and manage delays.

Date: 19 February 2016

Completed by:

Karen Kitcher, Quality Assurance Lead (SEE Team) &

Deborah Matthews Lead for Patient Safety, Experience & Clinical Effectiveness (SEE)


Serious Incident Requiring Investigation (SIRI) Activity Report

For Trust Board January 2016 data

(1) NEW INCIDENTS REPORTED AS SIRIs: During January 2016 the Trust reported 1 Serious Incident to the Isle of Wight Clinical Commissioning Group (CCG). Below is a summary of this incident:

Category/ subject

Under whose care

Summary Incident Date

Date reported as a SIRI

Date report due to be sent to Commissioners

Patient fall Poppy Unit Patient fall (fractured arm)

22.11.15 14.01.16 11.04.16

(1a) PRESSURE ULCERS – in line with arrangements under the new SIRI Framework (March 2015), 1 new grade 3 pressure ulcer was identified and reviewed at a table top review during December; this was inconclusive in the last report as further clinical detail was required. Further detail was submitted and whilst there was learning from the incident, it was not deemed to be SIRI reportable. During January 2016, 5 new grade 3 pressure ulcer cases were identified and reviewed at a cluster meeting. The information collated evidenced that these 5 cases were “unavoidable”.

(2) CURRENT POSITION: This table provides the current status of open SIRIs as of 11 January 2016. SIRIs COMMUNITY

& MENTAL HEALTH

OTHER CORPORATE AREAS

CBU 1 CBU 2 CBU 3 CBU 4 CBU 5

CBU = Clinical Business Unit1 Surgery, Women's & Children's Health

· With Coroner 0 0 0 0 0 0 0 0 2 Medicine· With Directorate 1 3 0 0 0 0 0 0 3 Clinical Support, Cancer & Diagnostics· With Quality team 0 0 0 0 0 0 0 0 4 Ambulance, Urgent Care & Community· With Execs 0 3 0 0 0 0 0 0 5 Mental Health & Learning Disabilities· With Commissioner 1 2 0 0 0 0 0 0· Returned from Commissioner - further work

2 2 0 0 0 0 0 0

TOTAL OVERDUE 4 10 0 0 0 0 0 0

· With Coroner 0 0 0 0 0 0 0 0· With Directorate 0 0 0 3 4 0 1 1· With Quality team 0 0 0 0 0 0 0 0· With Execs 0 0 0 0 0 0 0 0· With Commissioner 0 0 0 0 0 0 0 0· Returned from Commissioner - further work

0 0 0 0 0 0 0 0

TOTAL CURRENT 0 0 0 3 4 0 1 1TOTAL NUMBER OF OPEN CASES 4 10 0 3 4 0 1 1 23

how many ongoing SIRIs (auto) 20

HOSPITAL & AMBULANCE

OVERDUE CASES

CURRENT CASES


(2a) Listed below are the SIRI cases that are overdue and their current status: DESCRIPTION Directorate/

Speciality Incident Date

Reported as SIRI

Date to be submitted to CCG (first presentation)

CURRENT STATUS

Unexpected Death

Emergency Dept/Mental Health

06.08.15 12.08.15 04.11.15 17.12.15 – query posed by Medical Director sent to Executive Director of Nursing 21.01.16 – with Executive Director of Nursing for approval 15.02.16 – with Executive Director of Nursing for approval

Patient fall St Helens Ward

20.08.15 (actual) 17.09.15 (review)

17.09.15 11.12.15 05.01.16 – final report received from Directorate; with Execs for approval 12.01.16 – queries from Exec forwarded to Directorate (meeting with family arranged) 21.01.16 – with Exec to add addendum to report

Safeguarding Surgical Ward 14.09.15 06.10.15 31.12.15 (time extension granted by CCG until end January 2016)

09.02.16 – UPDATE: member of staff interviewed; final report currently being reviewed by Council – anticipate completion by end February 2016 (CCG updated)

Delayed Diagnosis

General Surgery 16.09.15 22.10.15 19.01.16 13.01.16 – UPDATE: final report currently being reviewed by Clinical Director prior to submission 17.02.16 – Head of Nursing & Quality meeting with surgeons to draw up action plan

Pressure ulcer Stroke/General Rehab

25.09.15 (actual) 17.11.15 (decision to report as SIRI)

18.11.15 15.02.16 13.01.16 – UPDATE: final report being finalised

(3) CLOSED SIRI CASES During January 2016, and at the time of reporting, the IW Clinical Commissioning Group had not advised us of any closures of SIRI cases submitted. Listed below are the lessons learned from those closed SIRI cases: AREA SUBJECT SUMMARY Lessons Learned In or out of time when

submitted to CCG (first presentation)

None closed this month


(4) OVERVIEW OF SIRI SUBJECTS - logged from April 2012 – to end January 2016

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105

Admission of under 18 to Adult MH WardAllegation against HC professional

Ambulance IssueCritial Care Transfer

Child DeathC diff & Health Acquired InfectionCommunicable Disease / Infection

Confidential Information LeakDeath in Custody

Delayed DiagnosisDrug Incident

EscapeFailure to act upon test results

Hospital Equipment FailureHospital Transfer concerns

major incident/suspension of servicesMRSA Bacteraemia

Never EventOther

Venous Thromboembolism (PE/DVT)Pressure ulcer grade 3Pressure ulcer grade 4Safeguarding Children

Surgical ErrorSub-optimal care of deteriorating patient

Slip, Trip, FallSafeguarding Vulnerable Adult

Unexpected DeathUnexpected Neonatal death

SUBJECTS of SIRIs April 2012 - end January 2016

April 2012-March 2013



April 2015 - March 2016

The next joint Commissioning and Trust bi-monthly SIRI meeting is to take place in February 2016. Prepared by: Reviewed by: Karen Kitcher Deborah Matthews Quality Assurance Lead Lead for Patient Safety, Experience & Clinical Effectiveness 10 February 2016 19 February 2016


ON 2nd March 2016

Title Safer Staffing Report for Nursing and Midwifery for January 2016



Author(s) Sarah Johnston, Deputy Director of Nursing

Purpose For assurance


Receive X Approve













Board Seminar


Staff, stakeholder, patient and public engagement: None


The Trust did not meet its locally set target of 90% average fill rate for nurse staffing for the day shifts. (85.7% for registered nurses in the day and 89.4% for health care assistants in the day). This includes our bank and agency staffing. We are achieving 69% of our registered bank requests, 71% of our HCA bank requests and 89% of our agency requests. For individual wards all our inpatient acute areas are below our 90% target for RN in the day. Mental Health areas are in the main achieving over this. This is due to high levels of sickness in some areas – 5 areas are over 10%. We know safe staffing café’s made an initial impact on sickness and we will review our café’s plan to incorporate areas that are significantly above 3% sickness target. continually There are 82.47 vacancies across the safer staffing areas as at 31st December 2015. Plans in place for recruitment of staff include arrival of our recruited staff from the Philippines which will reduce vacancies by 15 and then 14 as they arrive in March and May. This will make an impact on our safer staffing areas however will not be sufficient, and does not allow for further staff leaving and retiring during the year. Further recruitment plans are under consideration. There has been a recruitment drive for Health Care Assistants during December which has added staff to the nurse bank.

Enc G

Areas under review include Whippingham and Appley; as the contingency areas these wards have difficulty in achieving consistent staffing and are there are concerns about how the areas are managing quality. Matrons are supporting areas intensively and SEE Committee has oversight of quality for these areas.


The Board is recommended to discuss the issues raised in the report and identify whether any further actions are required.

report

Attached Appendices & Background papers: Appendices are provided (referenced in paper)




Skilled and capable staff

Principal Risks (BAF) Risk of significantly inadequate staffing whilst recruitment plans come to fruition. DNT will discuss issues raised on a weekly basis and HoN&Q will ensure good forward planning for bank and agency requests to ensure maximum success.

Risk of inadequate number of care staff. Monthly monitoring of vacancy position and planning occurring at DNT

Risk of not recruiting adequately to RN and Midwife positions to adequately increase workforce. As staff are leaving the current recruitment plan is inadequate to achieve full establishments. A further recruitment plan is under consideration for future sustainability


The National Quality Board guidance sets out requirements of the Board in relation to safe staffing - the Board should receive nurse staffing data on a monthly basis.

Date 19th February 2016 Completed by: Sarah Johnston, Deputy Director of Nursing

MONTHLY SAFE STAFFING REPORT February 2016 Report

JANUARY 2016 POSITION

1. Summary of safer staffing position at January 2016

Day NightRegistered midwives/nurses Care Staff Registered midwives/nurses Care Staff Day Night

Total monthly planned staff

hours

Total monthly actual staff

hours


hours


hours


hours


hours


hours


hours

Average fill rate -

registered nurses/midwiv

es (%)

Average fill rate - care

staff (%)

Average fill rate -

registered nurses/midwi

ves (%)

Average fill rate - care

staff (%)33895 29053.98 22561.2 20179.15 15851.75 15454 10187.75 10140.92 85.7% 89.4% 97.5% 99.5%

· The Trust did not achieve the local 90% average fill rate for planned hours this month: Registered Nurses and Midwives day average fill rate was below target at 85.7% and Health Care Assistant average fill rate was just below our local 90% target at 89.4%

· Night average fill rate was achieved with both RN and Midwives, and HCA being above 90% target

· There are 30 additional beds on Poppy for winter pressures and an additional 11

contingency beds on Whippingham and an additional 6 on Appley. This results in a total of 47 additional beds to be staffed. This is managed by safely moving staff from substantive wards to enable cover where feasible, temporary staff, and bank and agency.

· See Appendix 1 Table 1 - Unify average fill rate data for each ward.

· See Appendix 1 Graph 2, - Safe Staffing average fill rates over time against our locally set target of 90% fill rate.

· See Appendix 1 Graph 2a – 2d to see our average fill rate over the past six months by staff group, and by day and night against our 90% target.

· As of 31st Dec 2015 there are 82.47 vacancies across safer staffing areas and 102 across

the wider areas. This includes registered and non-registered staff. For January we had 69% fill rate for bank requests for registered nurses and 71% for non-registered. Where sifts, if not covered by RN have been able to be supplemented by HCA this is becoming more difficult which can leave ward significantly short at times. Agency staff have been utilised as part of our winter resilience plans and we have a 89% fill rate. See Table 3 for bank and agency data

· Staff sickness is above 3% in 12 out of the 21 Safe staffing areas. Four areas are over 10%. This is adding additional pressure to fill all shifts, particularly sickness on the day, where it is challenging to find any temporary staff for immediate work.

2. Assessment of monthly position

· See Appendix 1 Table 1

· In January all acute areas are below the 90% target for planned hours for registered staff in the day. For areas below 80% this would present a challenge to deliver high quality care particular if HCA are also low.

· Shackleton ward requires adjustments on the rota to account for the removal of staff that were jointly part of the outreach dementia team and also covered the ward. This will happen in March. The Ward Manager has provided assurance of safety and the sickness rate, which contributes to the low number of hours provided will be monitored and managed

· Alverston ward rates red for staffing and sickness however ward indicators are good.. This

concern is being managed through local management. This is a small unit and at times not full to capacity which can mean planned hours are not required.

· Stroke Unit has poor outcomes with a number of falls and pressure ulcers this month. This will be reviewed.

· Appley and Whippingham wards are significantly challenged as they are the contingency

areas. These wards are utilising more temporary staff and are more susceptible to planned hours not being available. Whippingham and Appley are under additional scrutiny by the Safety, Effectiveness and Experience Group for decreased quality outcomes ( i.e. complaints, infections) and both areas are being supported well by Matrons.

· For Colwell and Appley, these two areas have higher percentage vacancy rate and will be

receiving a higher number of the new staff from the Philippines to reduce their vacancy to a more comparable vacancy rate with others. It is anticipated this will help reduce sickness in Colwell caused by staff under work pressures and will enable Appley to achieve a more stable establishment.

· There are no concerns for night fill rates. Night duties are filled first as this is a more risky

time with limited other clinical staff available and in most cases this is achieved.

· The top 5 areas are Shackleton, Stroke, Colwell, Mottistone and Alverston. With the exception of Shackleton the other areas have had safe staffing café’s with the ward manager where sickness has been reviewed using individual sickness reports, particularly those with high Bradford scores, identifying where sickness is long term and short term, where patterns are identifiable, and where sickness management is in place. With the exception of the Stroke Unit it was found that staff were not being adequately managed and HR support is being provided to ward managers to improve this.

· The Safer Staffing Cafés have also identified poor rota management with areas not locking down rota’s for the required 8 month forward looking period. This results in staff not being able to arrange personal lives and commitments and is likely to result in increased sickness. This has been addressed through the Director of Nursing’s (DNT) senior team and the provision of a regular report to identify whether areas are compliant with this rota requirement. Rotas are now being locked down for the future 8 weeks.

· The Safer staffing cafes had an immediate effect on sickness management when started in September 2015. The initial impact has not resulted in all areas being able to bring sickness down and safer staffing café’s will continue to be in pace to provide a focus for management of sickness for high rated areas.

3. Actions in place

· Sickness is being managed through our focussed safe staffing café’s. Areas that have not

been part of a café are being prioritised for the next quarter alongside high sickness areas.

· The second cohort of international staff have completed their exams on 28th January and 7 of 9 passed first time and will move to Band 5 positions. The third cohort of 15 staff will arrive on 27th February 2016.

· New recruitment strategies are being considered, both for management of the bank staff and for the future sustainability of the workforce.

· DNT will discuss issues raised on a weekly basis and HoN&Q will ensure good forward

planning for bank and agency requests. Outcomes are being monitored via the SEE team and discussed directly with ward managers and matrons for actions required.

Appendix 1 Table 1 January 2016 percentage rate and KPI’s for each area, RAG rated

Jan-16

SHACKLETON 72.6% 73.0% 102.2% 101.7% 8% 95% 0 1ALVERSTONE WARD 79.9% 78.8% 87.4% 104.4% 10% 85% 0 0

SEAGROVE 101.5% 111.5% 103.8% 106.3% 6% 85% 0 0OSBORNE 106.1% 92.0% 143.1% 96.0% 4% 90% 0 0

MOTTISTONE 89.6% 94.0% 98.4% - 15% 92% 1 1ST HELENS 82.2% 91.7% 96.8% 90.3% 1% 84% 0 0

STROKE 80.4% 93.2% 96.8% 101.5% 15% 85% 3 2REHAB 84.8% 78.9% 97.9% 96.8% 3% 85% 0 0

WHIPPINGHAM 88.9% 70.3% 98.4% 85.5% 6% 67% 1 0COLWELL 83.9% 84.2% 96.8% 96.6% 12% 72% 0 1

INTENSIVE CARE UNIT 85.4% 110.5% 92.5% 121.8% 5% 90% 0 5CORONARY CARE UNIT 86.7% 87.9% 96.2% 99.8% 3% 84% 0 7NEONATAL INTENSIVE

CARE UNIT74.5% 87.5% 101.9% 93.5% 3% 90% 0 0

MEDICAL ASSESSMENT UNIT

86.5% 80.1% 94.6% 98.4% 5% 87% 1 9AFTON 91.3% 90.1% 109.7% 106.3% 6% 96% 0 0

PAEDIATRIC WARD 77.1% 79.9% 93.5% 100.0% 1% 74% 0 0MATERNITY 99.2% 108.9% 100.2% 100.3% 2% 83% 0 0

WOODLANDS 105.9% 86.5% 100.0% 100.0% 0 0LUCCOMBE WARD 69.1% 143.9% 100.0% 129.4% 4% 68% 1 0

POPPY UNIT 90.0% 84.9% 98.4% 87.6% 2% 61% 0 6APPLEY WARD 74.8% 87.2% 71.4% 94.6% 3% 69% 0 0

95% - 100% fill rate <=3% >75% 0 090% - 94.9% fill rate 4% 70 - 75% 2 2<90% fill rate <4% <70% >2 >2

Pressure Ulcers

Mandatory Training

Day Night

Ward nameAverage fill rate -

registered nurses/midwives (%)

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives

Average fill rate - care staff (%)

Sickness Falls

Table 2 Average percentage fill rate for nursing over time

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%110.0%120.0%130.0%

Average fill rate for Nurses and Midwives Inpatient areas Acute and Mental Health (local target 90%)

Average Fill rate - Registered nurses/midwives (Day) Average Fill rate - Care staff (Day)

Average Fill rate - Registered nurses/midwives (Night) Average Fill rate - Care staff (Night)

Graph 2a Graph 2b Average fill rate for RN & Midwives in the day Average fill rate HCA’s in the day

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Jul-2015 Aug-2015 Sep-2015 Oct-2015 Nov-2015 Dec-2015 Jan-2016

Fil

l ra

te

%

Date

Safer Staffing - All Wards

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%


Fil

l ra

te

%

Date


Graph 2c Graph 2d Average fill rate for RN’s & Midwives at night Average fill rate for HCA’s at night

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%


Fil

l ra

te

%

Date


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%


Fil

l ra

te

%

Date


Changes made to rotas to reflect new establishment

Graph 3 Bank and Agency Fill rates for January 2016

0

500

1000

1500

2000

Registered Non registered Agency registered

556

1591

414383

1136

370

requests

filled

Fill rate for Bank and Agency January 2016



ON 2nd March 2016

Title Quality Priorities 2016/17



Author(s) Mandy Blackler, Business Manager

Purpose To approve the quality priorities for 2016/17


Receive Approve X




Trust Executive Committee 18.02.16 Approved






Quality Governance Committee 24.02.16



Board Seminar


Staff, stakeholder, patient and public engagement: This paper is a direct result of consultation via survey monkey of 78 groups of key stakeholders including staff and public (full list is included as Appendix One).


A Quality Account is a written report that providers of NHS services are required to submit to the Secretary of State and publish on the NHS Choices website each June, summarising the quality of their services during the previous financial year. The legislation governing Quality Accounts is found in the Health Act (2009) and The National Health Service (Quality Accounts) Regulations (2010). These state that local healthcare providers must publish a document each year which sets out information in relation to the quality of their services. The key priority is to deliver standards of care that are safe and compliant with the essential standards of quality and safety that is regulated by the Care Quality Commission (CQC) under the Health and Social Care Act 2008 (Regulated Activities). The quality priorities are identified under the headings in the 3 domains of quality: Safety, Effectiveness and Experience. A wide range of stakeholder consultation has been undertaken prior to the development of the Isle of Wight NHS Trust’s 2015 Quality Account (see Appendix One), including a questionnaire to support the

Enc H


identification of the quality priorities for 2016/17. Following a review of the feedback received, the results of the consultation have revealed the favoured quality priorities, as we move forward to 2016/17. These are outlined below:-

1. PATIENT SAFETY · Implementation and monitoring the effectiveness of the sepsis care bundle · Reduce incidents of patient harm

2. CLINICAL EFFECTIVENESS · Improve the discharge planning process · Improve communication with patients and carers

3. PATIENTS EXPERIENCE

· Improve the culture of the organisation to improve patient experience


It is recommended that the Board approve the quality priorities for 2016/17




Excellent patient care Working with others to keep improving our services A positive experience for patients, service users and staff Skilled and capable staff



Legislation governing Quality Accounts is found in the Health Act (2009) and The National Health Service (Quality Accounts) Regulations (2010).

Date: 18 February 2016 Completed by: Mandy Blackler, Business Manager


Nursing Directorate

Quality Priorities 2016/17

PURPOSE

This paper provides an outline of the quality priorities that have been consulted on and identified for 2016/17, to be included in the Trust’s Quality Account. BACKGROUND In ‘High Quality Care for All’ published in 2008 the Department of Health proposed that all providers of NHS health care should produce annual quality accounts just as they publish financial accounts. The purpose of publishing quality accounts is to support the process for improving the quality of health care services provided. A Quality Account is a written report that providers of NHS services are required to submit to the Secretary of State and publish on the NHS Choices website each June, summarising the quality of their services during the previous financial year. The legislation governing Quality Accounts is found in the Health Act (2009) and The National Health Service (Quality Accounts) Regulations (2010). These state that local healthcare providers must publish a document each year which sets out information in relation to the quality of their services. The key priority is to deliver standards of care that are safe and compliant with the essential standards of quality and safety that is regulated by the Care Quality Commission (CQC) under the Health and Social Care Act 2008 (Regulated Activities). PRIORITY PRIORITIES FOR IMPROVING QUALITY 2015/16 A toolkit for the production of Quality Accounts is provided by the Department of Health. This includes a requirement for each provider organisation to identify its 3-5 quality priorities for the forthcoming year and to describe progress regarding the quality priorities that were identified for the previous year that is being reported. The quality priorities are identified under the headings in the 3 domains of quality: Safety, Effectiveness and Experience. A wide range of stakeholder consultation has been undertaken prior to the development of the Isle of Wight NHS Trust’s 2015 Quality Account (see Appendix One), including a questionnaire to support the identification of the quality priorities for 2016/17. An initial long list of suggested quality priorities was pulled together using information from the CQC Key Lines of Enquiry (KLOEs); themes from complaints and concerns and information provided by Isle of Wight CCG commissioning intentions, Healthwatch, Wessex Patient Safety Collaborative, NHS England (South) commissioning intentions; which provided the basis for consultation with key stakeholders.

A questionnaire, utilising Survey Monkey® was developed in order to obtain and analyse feedback, which asked stakeholders to rank in order of priority the suggested quality priorities. A question was also included asking for individuals to propose other quality priorities that they felt should be an organisational priority for 2016/17. This questionnaire was circulated to key stakeholders as listed in Appendix One Following a review of the feedback received, the results of the consultation have revealed the quality priorities, as we move forward to 2016/17. These are outlined below:-

1. PATIENT SAFETY · Implementation and monitoring the effectiveness of the sepsis care bundle · Reduce incidents of patient harm

2. CLINICAL EFFECTIVENESS · Improve the discharge planning process · Improve communication with patients and carers

3. PATIENTS EXPERIENCE

· Improve the culture of the organisation to improve patient experience

PUBLICATION OF QUALITY PRIORITIES The quality priorities for 2016/17 will be published in the Trust’s Quality Account; which will form part of the Isle of Wight NHS Trust’s Annual Report and posted on the Trust’s website. The Trust also has a legal duty to send a copy of the final agreed Quality Account to the Secretary of State and make it publically available on the NHS Choices website. The quality priorities will be communicated through the Trust’s management structure to all levels of the organisation so that all staff are aware of these and their responsibility in supporting the plans to achieve the improvements identified. Assurance on progress in achieving the improvements will be reported through the Trust’s sub-committee structure and to the Quality Governance Committee. A summary report will be provided to the Board through the minutes of the Quality Governance Committee. RECOMMENDATIONS The Isle of Wight NHS Trust Board is asked to endorse the quality priorities for 2016/17 to be published in the Trust’s Quality Account. Alan Sheward, Executive Director of Nursing 2nd February 2016

Circulation list for Survey Monkey

1. Academic Health Sciences Network 2. Age Concern 3. All GP Practice Staff 4. All Island media 5. All Trust Staff 6. Alzheimer’s Society 7. Andrew Turner MP 8. British Pregnancy Advisory Service 9. British Red Cross 10. Cardiovascular Disease Network 11. Carers Isle of Wight Young Carers Project 12. Carers UK Isle of Wight branch 13. Caring Cancer Trust 14. Chamber of Commerce 15. Children’s Liver Disease Foundation 16. Children’s Trust 17. Clinical Commissioning Group 18. DIAL 19. Different Strokes 20. Disabled Motorist association 21. Earl Mountbatten Hospice 22. Echotech Ltd 23. Family Information Zone 24. Friends of St Marys 25. Front Line Advice Centre 26. Hampshire Partnership Trust 27. Hampshire Police 28. Hampton Trust 29. Haylands Farm 30. Headway 31. Health & Wellbeing Board 32. Heart Care Club 33. HMSC 34. Home Start 35. Hospital Radio 36. Island Business 37. Island Carers Support 38. Island Stroke Club 39. Isle of Wight Council 40. Isle of Wight Councillors 41. Isle of Wight Dental Committee 42. Isle of Wight Prosthetic Users Group 43. Isle of Wight Rural Community Council 44. Isle of Wight Samaritans 45. Isle of Wight Society for the Blind 46. Isle of Wight Youth Trust 47. Isle of Wight Youth Trust 48. Local Negotiating Committee

Appendix One

49. Local Partnership Forum 50. Local Pharmaceutical Committee 51. Medina Housing Association 52. Multiple Sclerosis Society 53. Not Just Enterprises 54. Nursing homes 55. Older Voices 56. Optio Community Transport 57. Osel Enterprises 58. Parkinsons Disease Society 59. Patient’s Council 60. Patient’s Council 61. People Matter 62. Portsmouth Hospital 63. Riverside Centre 64. Royal National Institute for the Deaf 65. Rural Community Council 66. Salisbury NHS Trust 67. Scio Healthcare 68. St John Ambulance 69. Stoneham Housing Association 70. Stroke Services 71. Support Empower Advocate Promote 72. Supporting People – the Innovation Centre 73. Sure Start Ryde 74. Town and Parish Councils 75. Vectis Housing Association 76. Wessex Cancer Trust 77. Women’s Royal Voluntary Service 78. Young Arthritis Support



ON 2ND MARCH 2016

Title Principal Risk Register (Board Assurance Framework) Report


Mark Price, Company Secretary and Foundation Trust Programme Director

Author(s) Lucie Johnson, Head of Corporate Governance

Purpose 1) To provide an update to the Trust Board in relation to the current Principal risks identified by the Trust.

2) To update the Trust Board in relation to the Trust Self Certification process (Board statements and Licence Conditions) and to put forward a revised process for Board approval, following the TDA notification that the self-assessment process is no longer required.


Receive Approve X




Not applicable


Not applicable.

Staff, stakeholder, patient and public engagement: Not applicable.


Principal Risk Register

As the Trust Board are aware the External Governance Review conducted in the summer of 2015 by Capsticks Governance Consultancy made a number of recommendations in relation to risk, including that the BAF be comprehensively reviewed.

This was achieved in relation to the 2014-15 BAF and 6 new Principal Risks were identified and approved at the Trust Board meeting in October 2015. A further 7th risk was approved at the Trust Board Seminar session on the 10th November 2016.

The 7 Principal Risks are as follows:-

1. Human Resources

2. Financial Resources

3. Strategy and Planning

4. Quality and Harm

5. Culture

6. Local Health and Social Care Economy Resilience

7. Information, Communication, Technology

The attached paper provides an overview of these risks, including the number of actions identified in relation to each risk and any progress made to date.

Enc I


The Head of Corporate Governance wishes to draw the attention of the Board members to the following matters:-

1) Three risks (Culture, Strategy and Planning, and Information Communication Technology) were reassigned on an interim basis on the 22-2-16 due to the long term absence of the current risk owner. Therefore these risks have had limited review.

2) The attached report is the first report that has been produced using the DATIX Web risks module, however, as this system is now in operation; it will be more possible to provide enhanced analysis in relation to the Principal risks moving forwards, for example, changes in risk score, completion of actions and the dates that the risks were last reviewed will be included in future reports. The Head of Corporate Governance can confirm that at this time the risk score in relation to the 7 current Principal risks has not changed.

3) The target scores for the majority of risks have yet to be determined by the risk leads.

4) Not all risks have been reviewed on a monthly basis in line with the Trust Risk Management Strategy and Policy.

5) There are no actions identified in relation to the ICT risk, despite this being one of the highest scoring risks on the risk register.

Board Self Certification Requirement

Since the last Board meeting the Trust Development Authority have written to all Trusts to advise them that it is no longer necessary for Trusts to provide a monthly self-assessment update return in relation to the Board Statements and Licence Conditions. After discussion at the last Board meeting this will be welcomed by the Board.

However, it is acknowledged that a number of risks identified as part of the self-assessment process must not now be lost due to their potential impact on the Trust. Therefore it is proposed that a review be undertaken, by the Head of Corporate Governance to establish which risks embedded within the self-assessment are already registered on the Trusts Risk Management System. Those not registered will be added to the risk register to ensure that they remain visible to the Board and their Assurance Committees, and appropriate actions are taken to mitigate them into the future. The Head of Corporate Governance will include the outcome of this review in the Risk paper for the Board meeting in April 2016.

NB following a discussion at FIIWC and a further discussion during an Executive Governance Review meeting on the 22-2-16 it has been determined that an 8th risk be added to the Principal Risk Register in relation to Board Statement 13 which states that “The board is satisfied all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability”. This new risk is currently being drafted with an action plan for Board approval.


1) Review the 7 risks currently identified on the Principal Risk Register, and seek further assurance from risk owners as deemed appropriate.

2) Identify any further risks and ensure they are flagged for inclusion on the risk register.

3) Approve the proposed approach to the formal closure of the Board Self-Certification requirement in relation to the Board Statements and Licence Conditions.



1) Principal Risk Register report



All

Principal Risks (BAF) All


Date: 22-2-16 Completed by: Lucie Johnson, Head of Corporate Governance

Principal Risk Register report for the Trust Board 2-3-16

Datix Ref Number

Executive Risk Owner Title Description (if and then statement) Opened

Date Rating (current) Target Score

Review date

Last reviewed

Number of actions including completed actions

Anticipated Target/ Completion date

675

Palmer, Chris - Director of Finance

Culture If the Trusts culture does not reflect our core values then we will be unable to deliver our vision and priorities

07/10/2015 16 (Likely x Major) TBD 29/01/2016 Dec-16 2 actions non completed 31/01/2016

676 Baker, Karen - Chief Executive

ICT

If the Trust is unable to deliver against the ICT Strategy, then there will be a negative impact on Quality, Income, Performance, Information Governance Compliance and Staff morale

07/10/2015 20 (Likely x Catastrophic) TBD 29/01/2016

No review undertaken since risk identified (10-11-15)

No actions identified 31/03/2016

672


Financial Resources

If the Trust is unable to manage within the revenue and capital financial resources it receives then it may become financially unsustainable. (working towards the £4.6 million deficit plan)

07/10/2015 16 (Likely x Major) TBD 29/01/2016 Jan 16 (Via

spreadsheet) 4 actions non completed 01/04/2016

673

Price, Mark - FT Programme Director / Company Secretary

Strategy and Planning

If our Trust Strategy is not robust and embedded then staff will be unable to create effective service plans.

07/10/2015 16 (Likely x Major) TBD 29/01/2016 Dec-16 1 action non completed 29/01/2016

677 Baker, Karen - Chief Executive

Local Health and Social Care Economy Resilience

If there is insufficient resilience in the local health and social care economy then we will be unable to deliver safe effective and financially viable care.

07/10/2015 20 (Certain x Major) TBD 22/02/2016 Dec-16 6 actions non completed 31/03/2017

674

Sheward, Alan - Executive Director of Nursing

Quality Governance

If the Trusts quality governance processes are not robust and embedded then the Trust may not be able to maintain adequate patient safety, patient experience and clinical effectiveness.

07/10/2015 12 (Likely x Major)

2 (Rare x Minor) 26/02/2016 08/02/2016 4 actions non completed 31/03/2016

671


Human Resources

If the Trust is unable to attract, recruit and retain sufficient staff of the right quality and skillset then it will be unable to meet demand

07/10/2015 16 (Likely x Major) TBD 26/02/2016 Jan 16 (Via

spreadsheet) 5 actions non completed 02/05/2016



ON 2nd March 2016

Title Foundation Trust Programme


Mark Price, Company Secretary

Author(s) Mark Price, Company Secretary

Purpose For approval


Receive Approve X




Trust Executive Committee 25.02.16









Board Seminar 16.02.16




The establishment of the programme was approved by the Trust Board early in its first year, 2012/13, and featured: · A Foundation Trust Programme Board as a Trust Board Sub-Committee; · The Chief Executive as the Senior Responsible Owner for the programme; · 9 workstreams – Quality and Safety, Leadership, Workforce, Performance, Business

Planning, Finance, Corporate Governance, Communications and Engagement and Programme Governance and Approvals.

The programme underpinned much improvement work in the Trust in its first 18 months and oversaw the creation of key planning documents such as the Integrated Business Plan (5 year strategy) and Long Term Financial Model. A requirement for FT status is an ‘Outstanding’ or ‘Good’ Care Quality Commission rating and following our inspection in June 2014 we achieved “Requires Improvement’.

Enc J


The national position is that the requirement for NHS Trusts to become FTs within a specified timescale was dropped by the previous Coalition Government. This was in recognition of the number of NHS Trusts that have struggled to achieve the authorisation criteria. Membership is perhaps the most successful part of the internal FT programme with around 5400 public members being recruited. There is huge potential for our membership to help the Trust and the wider health and wellbeing system in improving services over the coming years. Although our membership was recruited as it was a requirement for an FT it is proposed to maintain and develop the membership for whatever organisational form is chosen for the services currently provided by Isle of Wight NHS Trust. We will also consider with our partners how we can use our membership to engage with the My Life a Full Life programme. This could be as a membership scheme for the MLaFL programme which draws together service user and carer engagement across a number of areas – secondary and primary care, social care, etc. and provide opportunities for engagement across the whole Island on a variety of health and wellbeing issues. In attracting national Vanguard funding our My Life a Full Life programme with partners has generated a lot of national interest in our integrated working. One of the workstreams of the My Life a Full Life programme is Organisational Form and Governance which is now being established. The national team that support Vanguards will shortly be producing a toolkit for local NHS organisations to use in considering future organisational form. It is proposed that the Trust closes down the FT programme and considers options for future organisational form in conjunction with our partners as part of the My Life a Full Life workstream.


The Board is recommended to approve:

(i) The closure of the FT Programme and removal of the FT Programme Board from the Board Sub-Committee structure;

(ii) The continued development of our public membership as an NHS Trust with the My Life a Full Life programme and for any future organisational form, and the approval of a recurrent budget for this of £36k.

(iii) The need to consider options for future organisational forms to be undertaken with partners as part of the My Life a Full Life Programme/Vanguard programme.




All strategic goals

Principal Risks (BAF) Local Health and Social Care Economy Resilience


To be determined in accordance with any future organisational form.

Date: 23rd February 2016 Completed by: Mark Price, Company Secretary

1

ISLE OF WIGHT NHS TRUST BOARD

WEDNESDAY 2nd MARCH 2016

FOUNDATION TRUST PROGRAMME 1. Introduction

Isle of Wight NHS Trust was established on 1st April 2012. The Trust is one of the last to be created in the NHS in England in the wake of the demise of Primary Care Trusts and the Government policy requirement to separate commissioning and provider functions into separate organisational forms.

At the time of its creation there was also a clear Government policy position that all NHS Trusts were required to become NHS Foundations Trusts (FTs). Indeed the expectation was that NHS Trusts would be abolished so our trajectory to achieve FT status was just two years which had not been achieved anywhere else in the country. The imperative to achieve FT status resulted in the establishment of our own local FT programme led by a Board level Director reporting to the Chief Executive.

The purpose of this paper is to provide an update on future organisational form, how we develop this with our providers within the My Life a Full Life /Vanguard programme and to propose the formal closure of the FT programme.

2. Foundation Trust Programme

The establishment of the programme was approved by the Trust Board early in its first year, 2012/13, and featured:

· A Foundation Trust Programme Board as a Trust Board Sub-Committee; · The Chief Executive as the Senior Responsible Owner for the programme; · 9 workstreams – Quality and Safety, Leadership, Workforce, Performance,

Business Planning, Finance, Corporate Governance, Communications and Engagement and Programme Governance and Approvals.

The programme underpinned much improvement work in the Trust in its first 18 months and oversaw the creation of key planning documents such as the Integrated Business Plan (5 year strategy) and Long Term Financial Model.

A non-recurrent budget has been set for the FT Programme for each of the financial years since 2012/13. In 2015/16 this was set at £170k but will deliver a significant underspend with the principal expenditure incurred being the fees for the External Governance Review. By summer 2014 the Trust Development Authority classified the Isle of Wight NHS Trust as an organisation it expected to achieve FT status but the outcome of the Care Quality Commission (CQC) inspection in June 2014, published in September 2014, stalled the journey to FT status. A requirement for FT status is an ‘Outstanding’ or ‘Good’ rating but the Trust received a ‘Requires Improvement’ rating.

Our CQC status is not the only barrier to progress. In 2014/15 the Trust struggled to identify recurrent Cost Improvement Programmes (CIPs) resulting in a deficit

2

budget (£4.6 million) being set for 2015/16. Our achievement against the scorecard of service targets against Monitor’s Governance Risk Rating (‘GRR’) for many months has not been at a level consistent with FT authorisation such as the Referral to Treatment (FTT) and Cancer waiting targets.

The FT programme has not been active; with the exception of membership development (see Section 4 below) since the end of 2014/15 and the FT Programme Board has not met since November 2014.

3. National Position

The requirement for NHS Trusts to become FTs within a specified timescale was dropped by the previous Coalition Government. This was in recognition of the number of NHS Trusts that have struggled to achieve the authorisation criteria. Today there are over 150 FTs but still around 90 NHS Trusts, a minority of which are likely to achieve FT status in their current form and for at least a third it is recognised that they will not continue in their current form and will be merged/acquired by existing FTs. The Five Year Forward View in November 2014 introduced a “new models of care Programme” and sought bids from local NHS organisations to secure “Vanguard Status”. We have been successful with our partners in the My Life a Full Life Programme in becoming a Primary and Acute Care Services (PACS) Vanguard.

In December 2014 a national paper on organisational models was published

following a review led by Sir David Dalton, Chief Executive of Salford Royal FT. This provided a menu of options including federations, joint ventures, integrated care organisations and multi service chains for NHS organisations to consider locally.

Public statements in late 2015 from both Jeremy Hunt, Secretary of State for Health, and Simon Stevens, Chief Executive of NHS England, demonstrate that there is a recognition at the most senior levels in the service that all NHS Trusts will not be FTs and that some FTs are now struggling with the current staffing and financial challenges creating a greater appetite for different solutions. Jim Mackey, Chief Executive of NHS Improvement, has also described a future system of earned autonomy for NHS Trusts who will not become FTs.

4. Membership

Perhaps the most successful part of the internal FT programme has been the recruitment of a public membership. We have around 5,400 public members at present (total membership of 9,000 with our 2,600 staff members) and a strong cohort of active members who have been prepared to engage with us particularly via:

· Medicine for Members meetings which have been organised bi-monthly since

November 2013. · Patient Council membership – all recent recruitment to the Patient Council has

been from our membership · Providing feedback on specific initiatives e.g. My Life a Full Life events, Trust

Strategy and Plans. · The membership magazine ‘Four’, published three times a year.

3

There is huge potential for our membership to help the Trust and the wider health and wellbeing system in improving services over the coming years. Although our membership was recruited as it was a requirement for an FT it is proposed to maintain and develop the membership for whatever organisational form is chosen for the services currently provided by Isle of Wight NHS Trust. We will also consider with our partners how we can use our membership to engage with the My Life a Full Life programme. This could be as a membership scheme for the MLaFL programme which draws together service user and carer engagement across a number of areas – secondary and primary care, social care, etc. and provide opportunities for engagement across the whole Island on a variety of health and wellbeing issues. To maintain our current membership activities a recurrent budget of £36K will be required.

5. My Life a Full Life Programme

The priorities for the Trust in 2015/16 have been to develop our own service strategy and to improve the quality of our services to patients whilst striving to deliver them within a very challenging financial climate. Organisational form change has the potential to provide an unwelcome distraction to those priorities. It should only be considered if significant service benefits can be secured.

In attracting national Vanguard funding our My Life a Full Life programme with partners has generated a lot of national interest in our integrated working. One of the workstreams of the My Life a Full Life programme is Organisational Form and Governance which is now being established. The national team that support Vanguards will shortly be producing a toolkit for local NHS organisations to use in considering future organisational form.

It is proposed that the Trust closes down the FT programme and considers options for future organisational form in conjunction with our partners as part of the My Life a Full Life workstream.

6. Conclusion

Recent engagement exercises with staff have demonstrated that staff are not clear about the future of the organisation. In 2012/13 and 2013/’14 there was significant engagement with staff on our aspiration for FT status so some staff are confused whether this is still the intended direction. This has been partly addressed by the development of our Trust Strategy, and the engagement exercise in its development, but it would also be appropriate for a clear statement from the Board with regard to FT status. This is important context to the recommendations below.

7. Recommendation




4

(iii) The need to consider options for future organisational forms with partners as part of the My Life a Full Life Programme/Vanguard programme.

Mark Price Company Secretary 23rd February 2016

1

ISLE OF WIGHT NHS TRUST BOARD

WEDNESDAY 2nd MARCH 2016

FOUNDATION TRUST PROGRAMME 1. Introduction

Isle of Wight NHS Trust was established on 1st April 2012. The Trust is one of the last to be created in the NHS in England in the wake of the demise of Primary Care Trusts and the Government policy requirement to separate commissioning and provider functions into separate organisational forms.

At the time of its creation there was also a clear Government policy position that all NHS Trusts were required to become NHS Foundations Trusts (FTs). Indeed the expectation was that NHS Trusts would be abolished so our trajectory to achieve FT status was just two years which had not been achieved anywhere else in the country. The imperative to achieve FT status resulted in the establishment of our own local FT programme led by a Board level Director reporting to the Chief Executive.

The purpose of this paper is to provide an update on future organisational form, how we develop this with our providers within the My Life a Full Life /Vanguard programme and to propose the formal closure of the FT programme.

2. Foundation Trust Programme

The establishment of the programme was approved by the Trust Board early in its first year, 2012/13, and featured:

· A Foundation Trust Programme Board as a Trust Board Sub-Committee; · The Chief Executive as the Senior Responsible Owner for the programme; · 9 workstreams – Quality and Safety, Leadership, Workforce, Performance,

Business Planning, Finance, Corporate Governance, Communications and Engagement and Programme Governance and Approvals.

The programme underpinned much improvement work in the Trust in its first 18 months and oversaw the creation of key planning documents such as the Integrated Business Plan (5 year strategy) and Long Term Financial Model.

A non-recurrent budget has been set for the FT Programme for each of the financial years since 2012/13. In 2015/16 this was set at £170k but will deliver a significant underspend with the principal expenditure incurred being the fees for the External Governance Review. By summer 2014 the Trust Development Authority classified the Isle of Wight NHS Trust as an organisation it expected to achieve FT status but the outcome of the Care Quality Commission (CQC) inspection in June 2014, published in September 2014, stalled the journey to FT status. A requirement for FT status is an ‘Outstanding’ or ‘Good’ rating but the Trust received a ‘Requires Improvement’ rating.

Our CQC status is not the only barrier to progress. In 2014/15 the Trust struggled to identify recurrent Cost Improvement Programmes (CIPs) resulting in a deficit

2

budget (£4.6 million) being set for 2015/16. Our achievement against the scorecard of service targets against Monitor’s Governance Risk Rating (‘GRR’) for many months has not been at a level consistent with FT authorisation such as the Referral to Treatment (FTT) and Cancer waiting targets.

The FT programme has not been active; with the exception of membership development (see Section 4 below) since the end of 2014/15 and the FT Programme Board has not met since November 2014.

3. National Position

The requirement for NHS Trusts to become FTs within a specified timescale was dropped by the previous Coalition Government. This was in recognition of the number of NHS Trusts that have struggled to achieve the authorisation criteria. Today there are over 150 FTs but still around 90 NHS Trusts, a minority of which are likely to achieve FT status in their current form and for at least a third it is recognised that they will not continue in their current form and will be merged/acquired by existing FTs. The Five Year Forward View in November 2014 introduced a “new models of care Programme” and sought bids from local NHS organisations to secure “Vanguard Status”. We have been successful with our partners in the My Life a Full Life Programme in becoming a Primary and Acute Care Services (PACS) Vanguard.

In December 2014 a national paper on organisational models was published

following a review led by Sir David Dalton, Chief Executive of Salford Royal FT. This provided a menu of options including federations, joint ventures, integrated care organisations and multi service chains for NHS organisations to consider locally.

Public statements in late 2015 from both Jeremy Hunt, Secretary of State for Health, and Simon Stevens, Chief Executive of NHS England, demonstrate that there is a recognition at the most senior levels in the service that all NHS Trusts will not be FTs and that some FTs are now struggling with the current staffing and financial challenges creating a greater appetite for different solutions. Jim Mackey, Chief Executive of NHS Improvement, has also described a future system of earned autonomy for NHS Trusts who will not become FTs.

4. Membership

Perhaps the most successful part of the internal FT programme has been the recruitment of a public membership. We have around 5,400 public members at present (total membership of 9,000 with our 2,600 staff members) and a strong cohort of active members who have been prepared to engage with us particularly via:

· Medicine for Members meetings which have been organised bi-monthly since

November 2013. · Patient Council membership – all recent recruitment to the Patient Council has

been from our membership · Providing feedback on specific initiatives e.g. My Life a Full Life events, Trust

Strategy and Plans. · The membership magazine ‘Four’, published three times a year.

3

There is huge potential for our membership to help the Trust and the wider health and wellbeing system in improving services over the coming years. Although our membership was recruited as it was a requirement for an FT it is proposed to maintain and develop the membership for whatever organisational form is chosen for the services currently provided by Isle of Wight NHS Trust. We will also consider with our partners how we can use our membership to engage with the My Life a Full Life programme. This could be as a membership scheme for the MLaFL programme which draws together service user and carer engagement across a number of areas – secondary and primary care, social care, etc. and provide opportunities for engagement across the whole Island on a variety of health and wellbeing issues. To maintain our current membership activities a recurrent budget of £36K will be required.

5. My Life a Full Life Programme

The priorities for the Trust in 2015/16 have been to develop our own service strategy and to improve the quality of our services to patients whilst striving to deliver them within a very challenging financial climate. Organisational form change has the potential to provide an unwelcome distraction to those priorities. It should only be considered if significant service benefits can be secured.

In attracting national Vanguard funding our My Life a Full Life programme with partners has generated a lot of national interest in our integrated working. One of the workstreams of the My Life a Full Life programme is Organisational Form and Governance which is now being established. The national team that support Vanguards will shortly be producing a toolkit for local NHS organisations to use in considering future organisational form.

It is proposed that the Trust closes down the FT programme and considers options for future organisational form in conjunction with our partners as part of the My Life a Full Life workstream.

6. Conclusion

Recent engagement exercises with staff have demonstrated that staff are not clear about the future of the organisation. In 2012/13 and 2013/’14 there was significant engagement with staff on our aspiration for FT status so some staff are confused whether this is still the intended direction. This has been partly addressed by the development of our Trust Strategy, and the engagement exercise in its development, but it would also be appropriate for a clear statement from the Board with regard to FT status. This is important context to the recommendations below.

7. Recommendation




4

(iii) The need to consider options for future organisational forms with partners as part of the My Life a Full Life Programme/Vanguard programme.

Mark Price Company Secretary 23rd February 2016

REPORT TO THE TRUST Board Pt 1 Page 1


ON 2nd MARCH 2016

Title Performance Report Executive Summary


Chris Palmer, Executive Director of Financial & Human Resources

Author(s) Chris Palmer, Executive Director of Financial & Human Resources

Purpose To provide an overarching executive summary of the various Resources utilised by the Trust. To provide a summary analysis of the position, risks, opportunities, mitigating actions and level of assurance to be gained.


Receive X Approve




Trust Executive Committee 25th February 2016

(due to TEC revised meeting dates this will be presented after FIIWC)




23/02/16






Board Seminar


Staff, stakeholder, patient and public engagement: Regular discussions at Finance Meetings, Capital Investment Group Meetings, Scrutiny & Challenge Meetings, Contract Monitoring & Service Reviews, Trust Board and TEC.


Provided in the attached report.

Recommendation to the Committee:

To receive the Executive Summary report and refer to the more detailed reports as required to gain Assurance and oversight of the Resources utilised by the Trust.

Attached Appendices & Background papers Enc K2 – Full Performance Report



To utilise Resources effectively to underpin Quality Care, For Everyone, Everytime

Principal Risks (BAF) Supports mitigation of key risks relating to Cost Effective Sustainable Services (Financial Resources) and Skilled & Capable Staff (Human Resources). Underpins and enables mitigation of risks relating to Strategy & Planning, Culture and

ENC K1


Quality by effective use of Resources and appropriate Planning.


The Trust must ensure compliance with Statutory Financial Duties, Workforce Related Regulations and Consultation with Staff, Service Users and Stakeholders.

Date: 23/02/16 Completed by: Chris Palmer, Executive Director of Financial & Human Resources


PURPOSE OF THE REPORT To provide an overarching executive summary relating to the various Resources utilised by the Trust. To provide a summary analysis of the status, risks, opportunities, mitigating actions and level of assurance to be gained.

External Influences

MLAFL WISR Data Collation

Demand plan Unconfirmed

Tariffs expected 31 March 2016

Human Resources Sickness 4.61% Deep Dive Review

Overpayments increased by £11k

(£23k new in month)

Safe staffing roster compliance 19%

MAPS Healthroster 10 units non

compliant

Medical Workforce Deep Dive

Human Resources cont'd HR Strategy Raising Concerns

(Whistleblowing)

Staff Survey and Culture Appraisals 35.8% Staff Survey

highlights

Estate Resources Strategic Estates Partner Progress

Property Sale Status Swanmore

Road

Carbon Energy Fund

PCMG Audit £108k energy bill recovery

Capital Investment Resources

£79k unallocated - CIG 4th March

Property Sale Proceeds

Capital to Revenue £607k formally

agreed

Performance Information

CCG Under Performance

NCA £597k over plan

Penalties £879k with some fines

TBC

Winter Resilience Improvement Plan

Income below Trust plan £1,349k

Failing EC 4 hour standard and RTT

Incomplete

Data Quality/PbR 5 Red SUS Data Indicators

441 Outstanding Discharge

Summaries

Uncoded activity/staffing

Contracting Lighthouse Medical discussions

OOH and Walk In Service extended to

March 2017

EMH contract review

NHS England over performance £271k

2016/17 Negotiations

Underway

Business Planning Draft Plan submitted

Delivery Schedule In Place (Alan

Sheward Interim Lead)

Capacity & Leadership Risks

CIP development for 16/17 limited

CIP delivery and gap 15/16

Financial Resources

Deficit impact of Income Under Performance

SFI's review In month better

than trajectory to £6.7m deficit

Risk of CCG funding for costs incurred

Procurement service Proposal

Information Governance/Risk

Training compliance IG Toolkit Risk Register Governance review

Action Plan

Isle of Wight NHS Trust Executive Director of Financial & Human Resources

Report to the Trust Board

2nd March 2016

Dashboard of Key Points:


External Influences – The Trust is engaging with KPMG to provide data to underpin the Whole Integrated Systems Redesign. This is currently putting additional pressure on corporate services. Demand Planning and Capacity Planning has commenced however not yet finalised and subject to Commissioning agreement. The delay in tariffs and final documentation for the contract round is of concern so plans are being developed on best known data at this stage. Human Resources –Sickness rates have increased in month to 4.61% with Anxiety/Stress and Depression remaining the highest factor although decreased by 19% from last month in number of days lost. Sickness and Medical Workforce Deep Dive on the agenda. Increased overpayments in month with 16 instances totaling £23k. Late forms continue to be main factor. Continued issues with finalisation of units in Healthroster – 10 removed from the batch list this month resulting in delays in payment of enhancements and variable hours. Safe staffing roster performance – only 4 out of 22 areas achieved an 8 week roster fully approved in advance. HR Strategy in final stage of approval to be taken forward via HR and OD Group. Raising concerns (Whistleblowing) report for the period July to December 2015 indicates 5 concerns raised with 3 of these outside the scope of the policy so dealt with separately. Staff Survey and Culture – Results for the 2015 survey have now been received and Quality Health will present to Board on 2nd March. Summary reports have been shared. Actions arising from the survey will be taken forward with the OD Team. Appraisals are being taken forward with the OD Team with a view to increasing compliance within the organisation. Estate Resources –Swanmore Road sale progressing and documents have been signed by the Trust. Expecting completion in the next few weeks. Strategic Estates Partner – agreed schemes now underway with further Land Development proposals also underway. Successful recovery of £108k following an energy bill review by PCMG. Carbon Energy Fund change of approach to grid connection under consideration. Capital Investment Resources – Committed schemes progressing well and expected to complete within planned timescales. Sevenacres showers commenced. £78k remains unallocated with priority schemes in the pipeline to utilize any underspend. Capital to Revenue Transfer of £607k agreed and actioned in month 10 with identified schemes to slip if required ensuring no breach of Capital Resource Limit. Data Quality/PbR –5 Red rated data indicators have been reviewed and no major concerns to report. Outstanding discharge summaries worsened position from 338 last month to 441. Detail by consultant being shared weekly with CDs and HOO’s to facilitate improvement. Uncoded activity still of concern due to staffing but all being coded by freeze date so no income impact. Performance Information – Activity Under- Performance of which CCG under-performance £1.8m offset by Non Contracted Income £597k over performance; Winter Resilience Improvement Plan Income under-performance £1.349m. Delivery being reviewed for risk to year end position. Penalties currently at £879k and failure of EC 4 hour standard and RTT Incomplete continues with adverse achievement against the agreed Recovery Action Plan. Contracting –Contract negotiation meetings underway although limited by demand plan agreement and tariff unavailability. Discussions underway with Lighthouse Medical as regards continuation of the Beacon contract from September 2016. CCG have confirmed agreement for OOH and Walk-In Centre service to be extended till March 2017. Meetings held with EMH CEO and DOF and SLA being reviewed. NHS England contract is over-performing by £271k year to date with expected continuation to year end. Business Planning – Executive Director of Nursing has taken over the planning process for an interim period and a delivery schedule has been progressed. The draft plan first submission was achieved by 8th February although further work is required to ensure triangulation of all plans. Internal quality assurance process for plans will be complete by 24 February. Risks around capacity highlighted. Gaps remain in identification of CIPs for 2016/17 although proposals with the CEO for how this will be structured have made good progress. CIPs will be strengthened during the quality assurance process with all teams. CIP gap remains for 2015/16 at £2.317m and Finance Deep dives expected to deliver reduction of this gap due to non-recurrent banking of underspends not incorporated to date. Financial Resources – In month deficit of £600k worse than plan by £350k although within the trajectory for the revised £6.737m deficit predicted by year end; Risk of Income delivery as above for WRIP and risk of refusal by CCG to fund costs incurred for system pressures in excess of Poppy and Appley which would worsen the £6.737m deficit forecast. Formal drawdown of Cash Interim Working Capital Facility Loan £2.3m submitted for February. SFI’s reviewed and amendments incorporated with a further review to be undertaken by June 2016 in accordance with the plan. Capital expenditure progressing well and cash management underway to maintain minimum daily balance of £1m. Recommendation to award the procurement service going to


Board for approval on 2nd March. Information Governance/Risk – Communication has been increased to pursue completion of IG training throughout the organisation and therefore support compliance by end of March 2016. All corporate risk owners have been invited to attend risk management training to facilitate updating of risks on the Datix system. Limited assurance is provided for the Governance Review Action Plan due to capacity. Quarterly Information Governance report provided highlighting risks to compliance with the IG Toolkit.

Chris Palmer Executive Director of Financial & Human Resources 23nd February 2016



ON 2nd MARCH 2016

Title Performance Report Executive Summary



Author(s) Alan Sheward, Executive Director of Nursing

Purpose To provide an overarching executive summary of the quality issues raised at the Quality Governance Committee on 24th February 2016


Receive X Approve










Quality Governance Committee 24/02/16



Board Seminar

Other (please state) Staff, stakeholder, patient and public engagement:


Recommendation to the Committee:

To receive the Executive Summary report and refer to the more detailed reports as required to gain Assurance and oversight of the quality issues within the Trust.

Attached Appendices & Background papers Enc K3 – Full Performance Report



ALL

Principal Risks (BAF) ALL


Date: 23/02/16 Completed by: Alan Sheward, Executive Director of Nursing

ENC K2


Isle of Wight NHS Trust Executive Director of Nursing

Report to the Trust Board 2nd March 2016

PURPOSE OF THE REPORT To provide an overarching executive summary of the quality issues raised at the Quality Governance Committee Executive Summary 1. Patient Safety

1.1. Analysis - We have seen an increasing trend in Clinical Incidents resulting in harm

throughout the year. However, the last 4 months have seen a reducing trend. For the 10th Month there is a lower rate of incidents resulting in Major harm. This is the 4th month in a row where we have seen a reduction in the number of Serious Incidents Requiring Investigation (SIRI) There is also a reducing trend of these breaching the time allocated to complete the investigation. Although the rate of Pressure ulcers continues to be high. The level of pressure ulcers causing serious harm has remained the same. There is concern the rate of reduction in the Hospital setting is not reducing at the rate of the community. The rate of HCAI remains higher than the trajectory for January 2016. 20 cases of Clostridium Difficile Infection (CDI) across 13 patients.

The Trust has reported 2 Never events this year. One occurring in December (retained swab) and one in February 2016 (wrong route administration)

1.2. Action – Work continues to develop service specific quality data. The EDON has written to the EDOFHR to request the required support to move this forward. A piece of work is to be undertaken to look in more detail at the levels of incident and where in the organisation these are occurring. A hospital led Pressure Ulcer Collaborative is planned for March 2016 where the clinical business units will support the development of service / CBU level data. A quality improvement approach will be taken to look at Hospital led pressure ulcers and assurance surrounding Hospital Acquired Infections (HCAI). A review of the SIRI process has been undertaken with the support of the Surgical Business Unit. A number of recommendations were agreed as part of this review. They will be factored into the policy for reporting, investigating and learning the lessons of incidents.

1.3. Impact- There has been a clear reduction in the number of harms related to pressure related injury in the community. We need to move this learning from the community into the Main hospital.

1.4. Assurance-The Safety, Experience and Clinical Effectiveness team have been working closely with Quality improvement leads across a number of quality improvement requirements. The Trust has developed a Quality Improvement Plan, and assurance report for each of the key quality improvement requirements. The Quality Governance Committee received this first style of report in January 2016 on the work to reduce harm due to falls. There was a positive response to this style of report. The committee will be advised of future reporting plans.

2. Patient Experience

2.1. Analysis – The number of complaints received in the trust was 21 (20 and 22 in previous

months). However, the total number of complaints year to date remains higher than for the same period last year. The rates of satisfaction regarding the Family and Friends test remains high across all services except for the Ambulance service whose data cannot be used reliably due to such low response rates. Concerns remain over the response rates with


a particular concern in Accident & Emergency and Community Services. During quarter 3 the Trust has received a total of 67 (61) formal complaints and 215 (270) concerns, against 886 (969) compliments. Outpatient cancellations continues to be poor.

2.2. Action – A review of each Clinical Business Units Quality data is being undertaken in March

2016. This is to support the Business Unit to prioritise their quality improvement plans in 2016/17. Following receipt of the Healthwatch report in September 2015 the Patient Experience lead has undertaken a number of actions including:

1. The formation of a Patient Experience Group (PEG) 2. The development of patient complaint posters 3. The development of a new patient complaint leaflet (In conjunction with Healthwatch)

The Deputy head of Operations (Support Services) has been requested to undertake a collaborative on how to reduce the rate of cancelled appointments.

2.3. Impact – Following organisational change, the impact on complaint management is still

settling in. There is a need to confirm the responsibilities of Clinical Business Units and corporate support to ensure patients receive a timely, well-constructed response to this concerns/complaints.

2.4. Assurance – The Quality Governance Committee are asked to receive the Quarter 3

Complaints and Concerns report. 3. Clinical Effectiveness

3.1. Analysis – The latest Standardised Hospital Mortality Rate demonstrated a continued

downward trend. There has been an increasing trend in the number of patients who have a documented Do Not Attempt Resuscitation in place. However, low level use of the Amber Care Bundle and Priorities of care continues to have low uptake. The amount of audit completed in response to the Care Quality commission report action plan Quality improvement Plan (QIP) is currently rated as negative assurance across a number of acute hospital measures. This is largely down to shortfalls in data input which is linked to the recent organisational change.

3.2. Action – A review of the actions arising out of the End of Life Care improvement plan needs

to be concluded with greater emphasis on clinical oversight within the wards and departments of the Trust. The EDON has requested to meet with all QIP improvement leads to ensure the need to provide accurate and contemporaneous data is understood. There is a further need to review the actions assigned to the enforcement actions where practice has now bene in place for 12 months. There will be a renewed focus on assurance against the Quality Improvement Plan Actions.

3.3. Impact - Accurate recoding with the medical notes and improvement in care and treatment

have demonstrated an improvement in the Standardised Hospital Mortality Rate. Although there has been some improvement in the use of the Amber Care Bundle and Priorities of care, it has not been sustained at a level the Trust would like to see.

3.4. Assurance - Following the implementation of the QIP improvement actions reassessed

assurance has been established in areas that include Ambulance and Mental Health. However, there are concerns regarding assurance across a number of other clinical locations. This will be explored further in the month of March with formal board reporting in April as agreed in Nov 2015.

Alan Sheward Executive Director of Nursing 24th February 2016

Isle of Wight NHS Trust Board Performance Report 2015/16

January 16

Title


Author(s)

Purpose

Action required by the Board: X

Audit and Corporate Risk Committee Nominations Committee (Shadow)


Chris Palmer (Executive Director of Financial & Human Resources) Tel: 534462 email: [email protected]

Iain Hendey (Deputy Director of Information) Tel: 822099 ext 5352 email: [email protected]

To update the Trust Board regarding progress against key performance measures and highlight risks and the management of these risks.

Receive Approve


Trust Executive Committee Mental Health Act Scrutiny Committee



Charitable Funds Committee Quality & Clinical Performance Committee 24/02/2016Finance, Information, Investment & Workforce Committee 23/02/2016 Remuneration Committee


Legal implications, regulatory and consultation requirementsNone

Date: Tuesday 22nd February 2016 Completed by: Iain Hendey, Deputy Director of Information

Principal Risks (please enter applicable BAF references – eg 1.1; 1.6)

Assurance Level (shown on BAF) Red Amber Green

Trust Goals:Excellent patient care; Working with others to keep improving our services; A positive experience for patients, service users and staff; Skilled and capable staff; Cost effective, sustainable services



Trust Vision: Quality care for everyone,everytime

Executive Summary:

This paper sets out the key performance indicators by which the Trust is measuring its performance in 2015/16. A more detailed executive summary of this report is set out on page 4.

Page 1

Enc K3


Index

34

5-9567

Ambulance, Urgent Care and Community…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………8Mental Health and Learning Disabilities…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………9

1011

12-18121314

Cancer……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..1516

Theatre Utilisation……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..1718

19-221920212223

24-26242526

27-3031-4331-32

3334-3536-37

3839

40-4142434445

Cost Improvement Programme…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Income………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Operating Costs………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Workforce Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Summary - RAG rated based on Out-Turn position………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Sickness…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Overpayments Summary………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Continuity of Service Risk Rating…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Finance Report………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Summary - RAG Rating based on Out-turn position & CIP graph……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Surplus…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Safe Staffing Report………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Governance Risk Rating…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Glossary of Terms…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Statement of Financial Position………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Capital……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Cash…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Pressure Ulcers……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Patient Safety…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..A&E Performance - Emergency Care 4 hours Standard……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Referral To Treatment Times……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Benchmarking of Key National Performance Indicators……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Summary Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other 'Small Acute Trusts'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other Trusts in the 'Wessex Area'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Ambulance Performance……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Data Quality……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Ambulance……………………………………………………………………………………………………………………………………………………………………………………………………………….

January 16

Balanced Scorecard - Aligned to 'Key Line of Enquiry' (KLOEs)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..Executive Summary…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Performance Summary Pages…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Surgery, Women's and Children's Health…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Exception Reports…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Medicine……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Clinical Support, Cancer and Diagnostics……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Highlights………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Lowlights………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Page 2


January 16Balanced Scorecard - Aligned to Our Goals

Excellent Patient Care AreaAnnual

TargetYTD Month Trend

A positive experience for patients,

service users and staffArea

Annual

TargetYTD Month Trend

Cost effective, sustainable

servicesArea

In

month

plan

Annual

TargetYTD

Month

Trend

Patients that develop a grade 4 pressure ulcer TW 14 3 Jan-16 14 Emergency Care 4 hour Standards AUC 95% 87% Jan-16 89% RTT % of incomplete pathways within 18 weeks - IoW CCG TW 92% 87% Jan-16 92% 91%

Patients that develop an ungraded pressure ulcer TW 8 Jan-16 34 Number of patients who have waited over 12 hours in A&E from decision to admit to admission

AUC 0 0 Jan-16 28 RTT % of incomplete pathways within 18 weeks - NHS England TW 92% 87% Jan-16 92% 91%

VTE (Assessment for risk of) TW >95% 99.6% Jan-16 99.3% Ambulance Category A Calls % < 8 minutes AUC 75% 74% Jan-16 74.8% Zero tolerance RTT waits over 52 weeks (Incomplete Return) TW 0 1 Jan-16 0% 5

MRSA (confirmed MRSA bacteraemia) TW 0 0 Jan-16 2 Ambulance Category A Calls % < 19 minutes AUC 95% 96% Jan-16 95% No. Patients waiting > 6 weeks for diagnostics TW <8 0 Jan-16 <100 50

C.Diff(confirmed Clostridium Difficile infection - stretched target)

TW 7 3 Jan-16 20 Number of Ambulance Handover Delays between 1-2 hours AUC N/A 30 Jan-16 151 % Patients waiting > 6 weeks for diagnostics TW <1% 0.0% Jan-16 <1% 0.5%

Clinical Incidents (Major) resulting in harm(all reported, actual & potential, includes falls & PU G4)

TW 30 0 Jan-16 12 % of CPA patients receiving FU contact within 7 days of discharge

MH 95% 97.9% Jan-16 96.2% New Cases of Psychosis by Early Intervention Team MH 2 3 Jan-16 18 26

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by investigation)

TW 0 Jan-16 2 % of CPA patients having formal review within last 12 months MH 95% 97.8% Jan-16 96.6% Theatre utilisation CWC / CCD 83% 74% Jan-16 83% 76%

Falls - resulting in significant injury TW 5 0 Jan-16 4 % of MH admissions that had access to Crisis Resolution / Home Treatment Teams (HTTs)

MH 95% 95.3% Jan-16 95.0% Total pay costs (inc flexible working) (£000) TW £10,029 £10,232 Jan-16 £95,836 £100,287

Symptomatic Breast Referrals Seen <2 weeks* CCD 93% 93.8% Jan-16 97.4% All Cancelled Operations on/after day of admission SWC / CCD 19 Jan-16 154 Staff in Post (£000) TW £9,259 £9,153 Jan-16 £93,906 £90,758

Cancer patients seen <14 days after urgent GP referral* CCD 93% 95.2% Jan-16 96.0%

Cancelled operations on/after day of admission (not rebooked within 28 days) - including those not rebooked at the time of reporting

SWC / CCD 0 6 Jan-16 30 Variable Hours (£000) TW £770 £1,079 Jan-16 £1,930 £9,529

Cancer Patients receiving subsequent Chemo/Drug <31 days* CCD 98% 97.9% Jan-16 99.5% Patient Satisfaction (Friends & Family test - Total response rate) TW 4% Jan-16 5% Staff sickness absences TW 3% 4.61% Jan-16 3% 4.16%

Cancer Patients receiving subsequent surgery <31 days* CCD 94% 100.0% Jan-16 98.6% Patient Satisfaction (Friends & Family test - A&E response rate) TW 7% Jan-16 10% Staff Turnover TW 5% 0.42% Jan-16 5% 6.38%

Cancer diagnosis to treatment <31 days* CCD 96% 100.0% Jan-16 99.3% Mixed Sex Accommodation Breaches TW 0 0 Jan-16 59 Achievement of financial plan TW N/A (£0.6m) Jan-16 (£4.6m) (£7.0m)

Cancer Patients treated after screening referral <62 days* CCD 90% 100.0% Jan-16 96.5% Formal Complaints TW <168 21 Jan-16 207 Underlying performance TW N/A N/A Jan-16 (£8.3m) (£10.8m)

Cancer Patients treated after consultant upgrade <62 days* CCDNo measured operational standard

No patients

Jan-16 33% Compliments received TW N/A Not yet available

Jan-16 2,771 Liquidity ratio days TW N/A N/A Jan-16 1 1

Cancer urgent referral to treatment <62 days* CCD 85% 79.3% Jan-16 82.5% Capital Servicing Capacity (times) TW N/A N/A Jan-16 2 1

Summary Hospital-level Mortality Indicator (SHMI)Apr-14 - Mar-15

TW 1 1.003 Published Jan 2016 N/A Overall Continuity of Services Risk Rating TW N/A N/A Jan-16 2 1

Never events TW 0 0 Jan-16 1 Capital Expenditure as a % of YTD plan TW N/A N/A Jan-16 =>75% 66%

Stroke patients (90% of stay on Stroke Unit) M 80% 94% Jan-16 86% Quarter end cash balance (days of operating expenses) TW N/A N/A Jan-16 =>10 11

High risk TIA fully investigated & treated within 24 hours (National 60%)

M 60% 81% Jan-16 73% Debtors over 90 days as a % of total debtor balance TW N/A N/A Jan-16 =<5% 5.3%

*Cancer figures for December are provisional.

Working with others to keep

improving our servicesArea

Annual

TargetYTD Month Trend Skilled and capable staff Area

Annual

Target

Annual

TargetYTD Recurring CIP savings achieved TW N/A N/A Jan-16 100% 33.9%

Delayed Transfer of Care (lost bed days) TW N/A 146 Jan-16 2331 Total Workforce (inc flexible working) (FTE's) TW 2608.63 2,816.1 Jan-16 N/A N/A Total CIP savings achieved TW N/A N/A Jan-16 100% 71.5%

Total workforce SIP (FTEs) TW 2496.63 2,669.1 Jan-16 N/A N/A

Variable Hours (FTE) TW 112.0 147.1 Jan-16 1207.5 1,544

Notes

Delivering or exceeding Target

Underachieving Target

Failing Target

Key to Area Code

TW = Trust Wide

SWC = Surgery, Women's and Children's Health

M = Medicine

CCD = Clinical Suppprt, Cancer and Diagnostics

AUC = Ambulance, Urgent Care and Community

MH = Mental Health and Learning Disabilities

Actual

PerformanceActual Performance

Jan-16 =<5%Creditors over 90 days as a % of total creditor balance TW N/A N/A 3.2%

Actual

Performance

QIs to be added in M11 report

Sparkline graphs wil be included in M11

Report to present the trends over time for

Key Performance Indicators

Actual

PerformanceActual Performance

Improvement on previous month

No change to previous month

Deterioration on previous month

Page 3


Executive SummaryJanuary 16

Excellent Patient Care:

Pressure ulcers: The Pressure Ulcer Collaborative has been operating over the past few months to review of all pressure ulcers that occur in the IW NHS care on a weekly basis. This has focussed further attention on this issue and raised awareness in the directorates. Whilst there has been a rise in the overall reporting, this has been mainly in the area of grade 1 and 2 pressure ulcers. There are a number of ungradable pressure ulcers that are still under review. The Pressure Ulcer collaborative is also looking at the community and in this setting only two grade 3 pressure ulcers and 1 grade 4 pressure ulcer have been reported during the review period. The trend overall is encouraging, and the reviews are now focussing on the root cause analysis and cluster review of grade 2 pressure ulcers as the Trust has set itself the target of reducing the occurrence of this grade of pressure ulcers by 50% in the next year. C.diff: there have been 3 further cases during January. We have had 20 cases year to date and our annual target is 7 cases. BioQuell cleaning complete wards by rotation has started and is expected to reduce the number of future cases.

No new cases of MRSA within the Trust during January (two cases year to date).

A positive experience for patients, service users and staff:

The Ambulance Service has failed the Cat A 8 minutes response time (Red 1) target but met Red 2 and 19 minute targets in January 2016. There is a new action plan in progress to address the reporting issues and continuous progress with the Community First Responder project which supports immediately life-threatening calls.

The Emergency Care 4 hours standard - The 95% target was not achieved in January, nor the revised trajectory of 92.5%, due to ongoing system wide pressures impacting upon patient flow and appropriate bed capacity. Alongside the System Resilience Winter Action Plan, an ED action plan has been developed following a review in November by the Emergency Care Intensive Support Team and the Trust Development Authority. The plans are monitored weekly and monthly with the Clinical Commissioning Group.

Mental Health CPA patients receiving FU contact within 7 days of discharge and CPA patients having formal review within last 12 months are above target.

Mixed Sex Accommodation - There were no mixed sex accommodation breaches during January.

The number of complaints increased slightly during January (21) compared to 20 the previous month.

Skilled and capable staff:

SIP increased in month by 10 FTE - from 2659 in December 15. The temporary staffing figure, which increased from 133 FTE in December 15 to 147 in January 16, is representative of the increase in sickness absence.

Trust Headcount at the end of January 16: 3127 (Increase of 13)

Appraisal % at Month 10 is 35.8%, decrease from 41.7% in Month 9, communication has been sent via 10 Minute Team Brief (04-02-16) encouraging Business Units to undertake and log appraisals. Reasons for the 4.9% decrease can be apportioned due to the fact the appraisal % is a rolling %, and that a large number of appraisals undertaken in Jan 15, are not included in the data.

Cost effective, sustainable services:

Performance against the main 'incomplete' 18wks target underperformed against the required 92% standard due to the high backlog of admitted patients waiting more than 18wks for their treatment.

The percentage utilisation of Main Theatre facilities has decreased to 76.4% and is still below the 83% target. Day Surgery Unit utilisation has decreased during January 2016 (70.6%). Overall we have achieved 73.9% against the 83% target. This under performance will have been impacted by reduced elective activity over the Christmas period which traditionally sees a reduction due to bank holidays and patient choice being exercised during this extended holiday period. The system wide winter resilience plan to deliver increased elective activity between October 2015 and March 2016 continues and theatre utilisation will increase during February onwards to facilitate the required level of activity.

The Trust planned for a deficit of £0.250m in January, after adjustments made for normalising items (these include the net costs associated with donated assets).The reported position is a deficit of £0.600m in the month, an adverse variance of £0.350m against plan.The cumulative Trust plan was a deficit of £3.399m, after normalising items. The actual position is a cumulative deficit of £6.972m, an adverse variance of £3.573m.Although a deficit position in month, this is ahead of trajectory towards the revised forecast outturn position.The variance in month includes under performance against the CCG PbR Contract of £0.187m (£1.729m adverse year to date). In addition to this, there is an adverse £0.340m variance (£0.322m year to date) relating to a phasing issue on the CCG SLA Acute Contract, which will reduce to zero by the end of the financial year.Further benefit of £52k (£538k year to date) has also realised following balance sheet reviews. Weekly reviews and scrutiny of each control code are now being undertaken, with the aim to achieve £686k by year end.A benefit of £607k from capital to revenue transfer has also been realised in month. The Trusts planned forecast out-turn deficit has been changed to £6.737m from its original plan of £4.600m. This is due to the implementation of the system resilience improvement plan with its additional net costs, expected CIP non delivery, and unachievement of activity income with fines and penalties. This position is also subject to CCG support of £2.55m, and this has been formally requested.Executive Panel scrutiny review of all recruitment requests continues. Weekly challenge meetings in Clinical Business Units on CIP and budget delivery involving business managers have now been extended to Corporate areas.

The Performance Report has been re-aligned to our Goals and the Clinical Business Unit Structure. Further alignment and refinement will be untertaken in future reports. Qis to be added for the February report.

Page 4


Performance Summary - Surgery, Women's and Children's Health

Target Actual Target Actual Target Actual Target Actual

MRSA (confirmed MRSA bacteraemia) Jan-16 0 0 0 0 Mixed Sex Accommodation Breaches Jan-16 0 0 0 0

C.Diff (confirmed Clostridium Difficile infection) Jan-16 1 1 No. of Complaints Jan-16 7 24

Clinical Incidents (Major) resulting in harm

(all reported, actual & potential, includes falls & PU G4)Jan-16 0 0 No. of Concerns Jan-16

Not yet

available32

Clinical Incidents (Catastrophic) resulting in harm

(actual only - as confirmed by investigation)Jan-16 0 0 No. of Compliments Jan-16

Not yet

available0

Falls - resulting in significant injury Jan-16 0 0 All Cancelled Operations on/after day of admission Jan-16 6 30

Emergency 30 day Readmissions Jan-16 0.7% 2.0%

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at the

time of reporting

Jan-16 0 19 0 154

Never Events Jan-16 0 0 0 1 Theatre utilisation Jan-16 83% 73.9% 83% 75.8%

No. of Reported SIRIs Jan-16 1 3

Physical Assaults against staff Jan-16 4 4

Verbal abuse/threats against staff Jan-16 3 5


Appraisals Jan-16 43.40%

Plan Actual Plan Actual Target Actual Target Actual

Total SLA Value Dec-15 3,419,169£ 3,471,086£ 30,761,861£ 29,556,591£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS

England)Jan-16 92% 85.8% 92%

Not yet

available

Zero tolerance RTT waits over 52 weeks (Incomplete Return) Jan-16 0 1 0 2

% Sickness Absenteeism Jan-16 3% 2.33% 3% 2.94%

*YTD data from November 2015. Full YTD will be available from April 2016

**The Acute Service Level Agreement performance reports a month behind, therefore figures are from December 15.

Income**Latest

data

In Month YTD YTD

YTD


services

Latest

data

In Month

YTDSkilled and capable staff

Latest

data

In Month

Following re-alignment of reporting to the new Clinical Business Unit structure,

●Analysis

●Actions

●Impact and

●Assurance will be included for future reports.

January 16

Balanced Scorecard - Surgery, Women's and Children's Health

Excellent Patient CareLatest

data

In Month YTD* A positive experience for patients,

service users and staff

Latest

data

In Month YTD*


improving our services

Latest

data

In Month

Page 5


Performance Summary - Medicine






Not yet

available30



Not yet

available156

Falls - resulting in significant injury Jan-16 0 0 No. of Reported SIRIs Jan-16 0 2

Emergency 30 day Readmissions Jan-16 5.8% 7.1% Physical Assaults against staff Jan-16 1 9

Stroke patients (90% of stay on Stroke Unit) Jan-16 80% 94.1% 80% 86.2% Verbal abuse/threats against staff Jan-16 0 3

High risk TIA fully investigated & treated within 24 hours (National

60%)Jan-16 60% 81.3% 60% 73.3%

Never Events Jan-16 0 0 0 0





England)Jan-16 92% 85.9% 92%

Not yet

available





Income**Latest

data

In Month YTD YTD

YTD


services

Latest

data

In Month


Latest

data

In Month


●Analysis

●Actions

●Impact and


January 16

Balanced Scorecard - Medicine


data



Latest

data

In Month YTD*



Latest

data

In Month

Page 6


Performance Summary - Clinical Support, Cancer and Diagnostics






Not yet

available36



Not yet

available0

Falls - resulting in significant injury Jan-16 0 0 All Cancelled Operations on/after day of admission Jan-16 6 30

Emergency 30 day Readmissions Jan-16 0.0% 0.6%

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at

the time of reporting

Jan-16 0 19 0 154

Symptomatic Breast Referrals Seen <2 weeks* Jan-16 93% 93.8% 93% 97.4% Theatre utilisation Jan-16 83% 73.9% 83% 75.8%

Cancer patients seen <14 days after urgent GP referral* Jan-16 93% 91.7% 93% 96.0% No. of Reported SIRIs Jan-16 0 0

Cancer Patients receiving subsequent Chemo/Drug <31 days* Jan-16 98% 97.9% 98% 99.5%Physical Assaults against staff

Jan-16 0 0

Cancer Patients receiving subsequent surgery <31 days* Jan-16 94% 100.0% 94% 98.6% Verbal abuse/threats against staff Jan-16 1 1

Cancer diagnosis to treatment <31 days* Jan-16 96% 100.0% 96% 99.3%

Cancer Patients treated after screening referral <62 days* Jan-16 90% 100.0% 90% 96.5%

Cancer Patients treated after consultant upgrade <62 days* Jan-16No measured

operational

standard

No patientsNo measured

operational

standard

33.3%

Cancer urgent referral to treatment <62 days* Jan-16 85% 79.3% 85% 82.5%

Never Events Jan-16 0 0 0 0





England)Jan-16 92% 98.0% 92%

Not yet

available


No. Patients waiting > 6 weeks for diagnostics Jan-16 <8 0 <100 50

% Patients waiting > 6 weeks for diagnostics Jan-16 <1% 0.0% <1% 0.5%




Income**Latest

data

In Month YTD YTD

YTD


services

Latest

data

In Month


Latest

data

In Month


●Analysis

●Actions

●Impact and


January 16

Balanced Scorecard - Clinical Support, Cancer and Diagnostics


data



Latest

data

In Month YTD*



Latest

data

In Month

Page 7


Performance Summary - Ambulance, Urgent Care and Community



C.Diff (confirmed Clostridium Difficile infection - stretched target) Jan-16 0 0 No. of Complaints Jan-16 9 18

Clinical Incidents (Major) resulting in harm (all reported, actual & potential,

includes falls & PU G4)Jan-16 0 1 No. of Concerns Jan-16

Not yet

available17

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by

investigation)Jan-16 0 0 No. of Compliments Jan-16

Not yet

available88

Falls - resulting in significant injury Jan-16 0 0 Emergency Care 4 hour Standards Jan-16 95% 86.8% 95% 89.3%

Never Events Jan-16 0 0 0 0Number of patients who have waited over 12 hours in A&E from decision to admit

to admissionJan-16 0 0 0 28

Category A 8 Minute Response Time (Red 1) Jan-16 75% 60.4% 75% 72.2%

Category A 8 Minute Response Time (Red 2) Jan-16 75% 75.1% 75% 75.0%

Category A 19 Minute Response Time Jan-16 95% 96.1% 95% 95.2%

Number of Ambulance Handover Delays between 1-2 hours Jan-16 30 151







Total SLA Value Dec-15 3,159,587£ 3,220,235£ 28,886,907£ 29,773,045£ % Sickness Absenteeism Jan-16 3% 4.52% 3% 4.14%

Ambulance re-contact rate following discharge from care by telephone Jan-16 3% 10.2% 3% 6.5%

Ambulance re-contact rate following discharge from care at scene Jan-16 2% 2.7% 2% 2.9%

Ambulance time to answer call (in seconds) - median Jan-16 1 1 N/A N/A

Ambulance time to answer call (in seconds) - 95th percentile Jan-16 5 1 N/A N/A

Ambulance time to answer call (in seconds) - 99th percentile Jan-16 14 6 N/A N/A

NHS 111 Call abandoned rate Jan-16 5% 1.9% 5% 1.9%

NHS 111 All calls to be answered within 60 seconds of the end of the introductory

message Jan-16 95% 95.9% 95% 96.3%

NHS 111 Where disposition indicates need to pass call to Clinical Advisor this should

be achieved by ‘Warm Transfer’ Jan-16 95% 97.4% 95% 97.2%

NHS 111 Where the above is not achieved callers should be called back within 10

mins Jan-16 100% 38.1% 100% 37.9%



Income**Latest

data

In Month YTD YTD

YTD

Cost effective, sustainable servicesLatest

data

In Month


Latest

data

In Month


●Analysis

●Actions

●Impact and


January 16

Balanced Scorecard - Ambulance, Urgent Care and Community


data



Latest

data

In Month YTD*



Latest

data

In Month

Page 8


Performance Summary - Mental Health and Learning Disabilities


MRSA (confirmed MRSA bacteraemia) Jan-16 0 0 0 0 FFT - % Response Rate Jan-16 0.5% 0.4%

C.Diff (confirmed Clostridium Difficile infection) Jan-16 0 0 FFT - % Recommending Jan-16 90% 100% 90% 90%


(all reported, actual & potential, includes falls & PU G4)Jan-16 0 1 Mixed Sex Accommodation Breaches Jan-16 0 0 0 0


(actual only - as confirmed by investigation)Jan-16 0 0 No. of Complaints Jan-16 2 4

Falls - resulting in significant injury Jan-16 0 1 No. of Concerns Jan-16Not yet

available4

Never Events Jan-16 0 0 0 0 No. of Compliments Jan-16Not yet

available17




% of CPA patients receiving FU contact within 7 days of discharge Jan-16 95% 97.9% 95% 96.2%

% of CPA patients having formal review within last 12 months Jan-16 95% 97.8% 95% 96.6%

% of MH admissions that had access to Crisis Resolution / Home

Treatment Teams (HTTs)Jan-16 95% 95.3% 95% 95.0%




Total SLA Value Dec-15 -£ 246£ -£ 124,967£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS

England)Jan-16 92% 100.0% 92% 98.9%



New Cases of Psychosis by Early Intervention Team Jan-16 2 3 18 26

IAPT – Proportion of people who have completed treatment and

moving to recoveryJan-16 50% 53.5% 50% 47.8%



Income**Latest

data

In Month YTD YTD

YTD


services

Latest

data

In Month


Latest

data

In Month


●Analysis

●Actions

●Impact and


January 16

Balanced Scorecard - Mental Health and Learning Disabilities


data



Latest

data

In Month YTD*



Latest

data

In Month

Page 9


Highlights

Highlights

January 16

90% of stay on Stroke Unit and High Risk TIA fully investigated & treated within 24

hours above target both in month and year to date

Cancer targets achieved for: Symptomatic Breast Referrals Seen <2 weeks, Patients

receiving subsequent surgery <31 days, Cancer diagnosis to treatment <31 days and

Cancer Patients treated after screening referral <62 days

Ambulance Category A Red 2 calls response time <8 minutes and <19 minutes above target

Mental Health Care Programme Approach targets achieved

Summary Hospital level Mortality Indicator

No new cases of MRSA

% Patients waiting < 6 weeks for diagnostics achieving the target

Page 10


Lowlights

Lowlights

Staff sickness remains above plan

Emergency care 4 hour standard remains below target

Cancer - Patients seen <14 days after urgent GP referral, Urgent referrals to treatment <62 days and Cancer

Patients receiving subsequent Chemo/Drug <31 days below target

January 16

Referral ToTreatment Time - % Incomplete pathways below 92% target

3 new cases of C.Diff in January (20 year to date)

Theatres utilisation below target

3 Grade 4 Pressure Ulcers in January (14 year to date)

1 Zero tolerance 52 week wait (incomplete returm)

21 formal complaints in month (207 year to date)

Workforce pressures + pay costs in excess of plan

6 cancelled operations on/after day of admission (not rebooked within 28 days)

Financial Position impacted by activity and performance

Ambulance Category A Red 1 calls response time <8 minutes below target

Governance Risk Rating of 11 for January 2016

Page 11


January 16Pressure Ulcers

Analysis:

• Trust wide Pressure Ulcer Prevention Group continues to meet. • Deep dives for each directorate going ahead to look at why expected reductions were not achieved last year.• Action plans for pressure ulcer reduction have been reviewed and are being amalgamated into a single master plan for coming year.• Local monthly Tissue Viability and MUST audits are being established by Tissue Viability Service.• Pressure Ulcer Reporting has been handed to Matrons and Locality leads to supervise to develop local ownership of reporting and understanding the scale of the issue.•Work is also ongoing to identify where patients are admitted from their home address who have been receiving non NHS care assistance.

Clinical directorate leads and Tissue Viability Nurse Specialist Jan-16 Ongoing

Commentary:

General: Numbers are reviewed for both the current and previous month and there may be changes to previous figures once validated. Pressure ulcer figures also contribute to the Safety Thermometer and are included within the clinical incident reporting, where any change is also reflected.

Hospital: The Pressure Ulcer Collaborative has been operating over the past few months to review of all pressure ulcers that occur in the IW NHS care on a weekly basis. This has focussed further attention on this issue and raised awareness in the directorates. Whilst there has been a rise in the overall reporting, this has been mainly in the area of grade 1 and 2 pressure ulcers. There are a number of ungradable pressure ulcers that are still under review. Community: Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). The Clinical Directorates took full responsibility for the management of pressure ulcer incidents in June including approval status and checking for duplicates. This is a move away from overall final responsibility for pressure ulcers incidents sitting with the Nutrition and Tissue Viability Service. Increased awareness is continuing to lead to increased numbers being reported. The Pressure Ulcer collaborative is also looking at the community and in this setting only two grade 3 pressure ulcers and 1 grade 4 pressure ulcer have been reported during the review period. The trend overall is encouraging, and the reviews are now focussing on the root cause analysis and cluster review of grade 2 pressure ulcers as the Trust has set itself the target of reducing the occurrence of this grade of pressure ulcers by 50% in the next year.

The report now separates out Ungradable pressure ulcers as a distinct reporting line so that it is clear that these ulcers (which were previously counted as grade 4s) have not yet been assigned a grade and do not automatically mean that this is an incident that has resulted in patient harm.

Level 3/4 pressure ulcers are likely to reduce on validation. Pressure Ulcers benchmark

Action Plan: Person Responsible: Date: Status:

The graph shows improving trend. In December the Trust has been above the national average.

Quality Account Priority 2 & National Safety Thermometer CQUIN schemes

Prevention & Management of Pressure Ulcers

Page 12


Patient Safety

Commentary: Analysis: Clostridium Difficile infections against national and local targets


MRSA Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTDAcute Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0 1 0 1 0 0 0 2

January 16

Status:

Continuing

ContinuingInfection Prevention & Control team / MAAU Team

Continuing

Date:

Feb-16

Feb-16

Feb-16Infection Prevention & Control team / Hotel services

Clostridium difficile

There have been 3 further cases of Healthcare acquired Clostridium Difficile identified in the Trust during November. Our YTD total increased to 20 cases across 13 patients.

Work continues to raise awareness and highlight actions, including intranet and poster campaigns regarding bowel management with action plans for rapid isolation of suspected cases. The reconfigured Medical Assessment Unit is now in use with increased access to isolation facilities for suspected cases although bed pressures continue to present challenges. Specialist 'BioQuell' intensive (gas fogging) system is now used after surface cleansing following an isolation need before the room is available for reuse.

Methicillin-resistant Staphylococcus Aureus (MRSA)

There have been no cases of Healthcare acquired MRSA identified in the Trust during January 2016 (2 cases year to date).

Action Plan:

Use of BioQuell gas fogging intensive cleaning following surface cleaning between patients where isolation has been in place.

Continued increased education regarding timely sampling of loose stool events and isolation

Use of increased isolation facilities in reconfigured & refurbished MAAU

Person Responsible:

Infection Prevention & Control team with Communications

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

Total cases 2 6 7 11 14 14 17 17 17 20 20 20

National Target 1 1 2 2 3 3 4 4 5 6 6 7

0

5

10

15

20

25

Isle of Wight NHS Trust C. Difficile cases (Cumulative)

Page 13


A&E Performance - Emergency Care 4 hours Standard

Commentary: Analysis:

Analysis:

System Resilience Group / Exec on call Jan-16 Ongoing

Daily focus on bed states Matrons Jan-16 Ongoing

Implementation of Safer Start Week recommendations and actions Head of Operations Mar-16 Planned

January 16

Action Plan: Person Responsible:

Emergency Care 4 hours Standard

Date: Status:

The 95% target was not achieved in January, nor the revised trajectory of 92.5%, due to ongoing system wide pressures impacting upon patient flow and appropriate bed capacity. Alongside the System Resilience Winter Action Plan, an ED action plan has been developed following a review in November by the Emergency Care Intensive Support Team and the Trust Development Authority. The plans are monitored weekly and monthly with the Clinical Commissioning Group.

Safer Start week was held in the Trust between 8th and 15th February 2016 with the aim to reset the service, surrounding processes and improve patient flow. The ECS target sustained above 91% through the week and did achieve 95% on Thursday and it is this success that the service will build on during March.

Implement of revised escalation plan Head of Operations for Business Unit Jan-16 Planned

Increase focus on local authority bed situation

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

15

Mar

15

Ap

r 1

5

May

15

Jun

15

Jul 1

5

Au

g 1

5

Sep

15

Oct

15

No

v 1

5

De

c 1

5

Jan

16

Target not achieved Target achieved Target

Page 14



Analysis:

Cancer patients seen <14 days after urgent GP referral – Standard 93% - Performance 91.7%Breach:16 x Patient Led 13 Hospital led (2 x LGI - no clinician available, 11 x urology - equipment failure haematuria

Cancer Urgent referrals to treatment <62 days – Standard 85% - Performance 79.3%6 x Breaches:1 x UGI – Histological diagnosis late in pathway1 x UGI – patient choice 1 x UGI – complex – required tertiary centre investigation2 x Urology – MDT discussion to determine treatment plan did not take place within target time1 x Urology – late change to treatment plan

Cancer Patients receiving subsequent Chemo/Drug <31 days - Standard 98% - Performance 97.9%Breach:1 x Patient choice

All other Cancer Waiting Times standards have been achieving for January.

Status:

• All individual breaches continue to be reviewed. Root Cause Analysis is carried out. Analysis of reasons for breaches identified no specific trend. Complex pathways and patient choice were noted. • Relevant CNSs to be informed by Booking Clerks in OPARU when delay in appointing occurs. This process has been reinforced by the Operational Manager• Close scrutiny of patient pathway with notification by Cancer Pathways Admin Team to Cancer CNS, OPARU, Secretaries and Operational Managers when delays are noted.• Multi Disciplinary Team to continue to facilitate timely discussions and actions recommended to be followed• Continue escalation process to highlight potential breaches for actions to be taken for Operational Managers via twice weekly performance update • Potential shared breaches to be identified and reported to Operational Managers via twice weekly information submitted for Access Meeting.• Outstanding histopathology reports highlighted to Technical Head. Pathology request forms to be marked CaFT (Cancer Fast Track) – This process to be reinforced by the Operational Managers. Future version of request form to include CaFT box. Outstanding imaging reports highlighted to Diagnostic Imaging twice weekly and ad hoc for MDT meetingsEquipment failure relating to 2ww haematuria breaches addressed appropriately and resolved

Continuing

Lead Cancer Nurse/CNSs/Cancer Pathways Manager

Operational Managers/MDT Clinicians Feb-16

January 16

Action Plan: Person Responsible: Date:

Cancer patients seen <14 days after urgent GP referral, Urgent referrals to treatment <62 days and Cancer Patients receiving subsequent Chemo/Drug <31 days

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Cancer patients seen <14 days after urgent GP referral

Target achieved Target not achieved

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Cancer Patients receiving subsequent Chemo/Drug <31 days

Target achieved Target not achieved

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Cancer urgent referral to treatment <62 days

Target achieved Target not achieved Target

Page 15


Ambulance Performance


Analysis:

Documented Performance Review Meetings (PRM) increased from once daily to three times dailyService Delivery Manager, Performance Support

Officers (Operational) & Performance Support Officers (Hub)

Jan-16 Ongoing

Guidance to be developed for ambulance staff to identify recording process, reiterate importance of recording accurate data and confirm clock starts/stops Service Delivery Manager, Performance Support Officers, Clinical Support Officers Jan-16 Ongoing

Introduction of the new CAD has lead to identifying further causes of data anonomolies. Prior to the new CAD it was thought that the data errors were singularly down to technical issues and the new CAD has, together with improved wifi, significantly improved the automation of of arrival and leaving times. This has highlighted that data manually input from crews does at times not enable accurate data. Data validation process to extend beyound the current measure of 120min. This will require a increase in data verification hours.This will be achieved by increasing hours worked from part time to full time. In additon the corporate perfomance team will be trained in the verification process to ensure cover is maintained when absences occur

Continuous monitoring of performance targets, amending REAP (Resourcing Escalatory Action Plans) level as appropriate and sharing status with fellow Senior Managers and increase staffing levels

Service Delivery Manager, Performance Support Officers, Clinical Support Officers Jan-16 Ongoing

OngoingJan-16Lead Clinical Support Officer and Pathway Lead

Status:

January 16

Action Plan: Person Responsible: Date:

The Ambulance Service has failed the Cat A 8 minutes response time (Red 1) target but met Red 2 and 19 minute targets in January 2016. There is a new action plan in progress to address the reporting issues and continuous progress with the Community First Responder project which supports immediately life-threatening calls.

The service continues to work alongside stakeholders from within and outside the Trust and maintains links with our strategic blue light agencies is moving forward and some positive signs are emerging on joint working.

The key issues facing the service is its ability to provide a high quality of care against a back drop of system wide pressures and flow of patients through the hospital setting leading to delays in responding at times. Recruitment to paramedic posts is also a challenge. The Ambulance Service also delivers the quality of care through its innovative Integrated Care Hub. This continues to create efficiencies in delivery of service and patient satisfaction through 999 and 111 are extremely high. The Integrated Care Hub continues to attract media attention due to the joint working approach being promoted through this approach and the many benefits to patients through this system.

All paramedics to have one-to-one session to discuss performance targets and reiterate importance of accurate data recording

Performance reports to be developed to extract handover time data from CAD system.Data validation process to be put in place

Using accurate and validated data monitor performance against national handover standards. If shown to be underperforming develop action plan and trajectory to achieve.

Service Delivery Manager, Performance Support Officers, Clinical Support Officers

Service Delivery Manager, Performance Support Officers (Operational) & Performance Support

Officers (Hub)

Head of Ambulance, HOO

Apr-16 Ongoing

Mar-16 Ongoing

Mar-16 Ongoing

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Cat A 8 minutes response time (Red 1)


Page 16


Theatre Utilisation

Analysis:

The

Head of Performance Jan-16 Ongoing

January 16

Delivering activity' project commenced and being managed until end of March 2016. Project Lead Jan-16 Ongoing

Commentary

The percentage utilisation of Main Theatre facilities has decreased to 76.4% against the 83% target during January 2016, as well as Day Surgery Unit utilisation at 70.6%; overall the performance is at 73.9%. This under performance will have been impacted by reduced elective activity over the Christmas and New Year period as planned due to forecasted non elective increase in activity at this time, as well as the impact of bank holidays and patient choice being exercised during this extended holiday period.

Emergency activity as well as undertaking urgent operations and cancer operations continues to be prioritised.

The system wide winter resilience plan to deliver increased elective activity between October 2015 and March 2016 continues and theatre utilisation will increase during February onwards to facilitate the required level of activity.

Action plan Person Responsible: Date: Status:

Forecast being reviewed with managers to determine trajectory for managing 18 weeks admitted target following impact of previous cancellations. Weekly assurance meeting to monitor RTT. Review of impact of further cancellation on trajectory

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

15

Mar

15

Apr 1

5

May

15

Jun

15

Jul 1

5

Aug

15

Sep

15

Oct

15

Nov

15

Dec

15

Jan

16

Main Theatres

Target failed Target metTarget DSU and Main Total

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

15

Mar

15

Apr 1

5

May

15

Jun

15

Jul 1

5

Aug

15

Sep

15

Oct

15

Nov

15

Dec

15

Jan

16

DSU

Target failed Target metTarget DSU and Main Total

Page 17


Referral to Treatment Times

Analysis:

Development of robust processes and documentation to enable training and awareness of 18 week procedures. Scheduled

PAAU Lead/ Clinical Leads Jan-16 In progress

Head of Performance Mar-16

Rebooking of cancelled operations alongside booking of waiting list backlog

January 16

Status:

Head of PIDS Jan-16 In progress

Person Responsible: Date:

Performance against the 'incomplete' 18wks target continues to underperform at 85.7% against the required 92% standard, and the revised trajectory of 89.9%, due to the high backlog of admitted patients waiting more than 18wks for their treatment.

The agreed system wide winter resilience plan securing non elective and elective capacity ensuring all our patients are treated in the right place at the right time is progressing well. This enabled elective activity to resume normal levels, however, there is a seasonal reduction in elective activity during the Christmas and New Year period. The forecasted impact of non elective has continued longer than planned due to system wide pressures, and plans are in place to mitigate this through increased additional activity until the end of March 2016.

Commentary:

Demand and capacity modelling, revised forecast and weekly plan for General Managers to deliver services

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

15

Mar

15

Ap

r 1

5

May

15

Jun

15

Jul 1

5

Au

g 1

5

Sep

15

Oct

15

No

v 1

5

Dec

15

Jan

16

RTT Incomplete IoW CCG


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Feb

15

Mar

15

Ap

r 1

5

May

15

Jun

15

Jul 1

5

Au

g 1

5

Sep

15

Oct

15

No

v 1

5

Dec

15

Jan

16

RTT Incomplete NHS England


Page 18


Benchmarking of Key National Performance Indicators: Summary ReportJanuary 16

Best Worst Eng

Emergency Care 4 hour Standards 95% 98% 71% 87.4% 81.1% 116 / 138 Red Qtr 3 15/16

RTT % of incomplete pathways within 18 weeks 92% 100% 74% 91.6% 87.2% 170 / 181 Red Dec-15

%. Patients waiting > 6 weeks for diagnostic 1% 0% 13% 2.2% 0.3% 66 / 175 Green Dec-15

Ambulance Category A Calls % < 8 minutes - Red 1 75% 79% 61% 72.6% 70.6% 7 / 11 Amber Red Dec-15

Ambulance Category A Calls % < 8 minutes - Red 2 75% 79% 56% 67.2% 78.5% 1 / 11 Green Dec-15

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 78% 57% 67.4% 78.0% 1 / 11 Green Dec-15

Ambulance Category A Calls % < 19 minutes 95% 97% 86% 92.5% 96.4% 2 / 11 Green Dec-15

Cancer patients seen <14 days after urgent GP referral 93% 100% 74% 94.8% 95.6% 88 / 153 Green Qtr 3 15/16

Cancer diagnosis to treatment <31 days 96% 100% 92% 97.9% 100.0% 1 / 156 Green Qtr 3 15/16

Cancer urgent referral to treatment <62 days 85% 100% 0% 83.5% 80.2% 112 / 155 Amber Red Qtr 3 15/16

Symptomatic Breast Referrals Seen <2 weeks 93% 100% 7% 93.4% 96.8% 42 / 133 Amber Green Qtr 3 15/16

Cancer Patients receiving subsequent surgery <31 days 94% 100% 83% 96.2% 96.2% 111 / 151 Amber Green Qtr 3 15/16

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 100% 96% 99.6% 99.2% 126 / 143 Green Qtr 3 15/16

Cancer Patients treated after consultant upgrade <62 daysNo measured

operat ional standard 100% 0% 90.6% N/A N/A / 148 N/A Qtr 3 15/16

Cancer Patients treated after screening referral <62 days 90% 100% 0% 93.4% 90.2% 114 / 143 Amber Green Qtr 3 15/16

Key: Better than National Target = Green Top Quartile = Green

Worse than National Target = Red Median Range Better than Average = Amber Green

Median Range Worse than Average = Amber Red

Bottom Quartile Red

Data PeriodIW RankNational

Target

National Performance IW

PerformanceIW Status

Page 19


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other 'Small Acute Trusts'January 16

Other Small Acute Trusts

Emergency Care 4 hour Standards 95% 81.1% 23 86.3% 21 92.3% 13 95.4% 1 95.3% 2 88.0% 18 95.2% 4 N/A 94.7% 6 94.6% 7 87.8% 19 91.8% 15 93.0% 12 92.2% 14 N/A 95.1% 5 94.1% 11 N/A 89.2% 17 89.8% 16 81.0% 24 94.1% 8 77.7% 25 84.2% 22 87.8% 20 94.1% 9 94.1% 10 95.3% 3 Qtr 3 15/16

RTT % of incomplete pathways within 18 weeks 92% 87.2%22

97.6%1

90.3%20

93.5%14

94.8%7

94.4%9

95.1%5

N/A 94.1%10

92.1%17

92.0%19

89.3%21

96.1%2

95.1%6

N/A 96.0%3

93.7%12

N/A 95.1%4

92.4%15

N/A 93.6%13

92.2%16

94.7%8

N/A 92.1%18

93.9%11

N/A Dec-15

%. Patients waiting > 6 weeks for diagnostic 1% 0.3%11

0.0%5

7.1%24

1.4%19

0.4%14

0.4%13

0.6%17

N/A 0.1%7

0.0%1

0.5%15

1.9%21

0.0%1

3.8%23

N/A 0.1%6

1.6%20

N/A 0.3%10

0.6%16

0.0%1

1.2%18

0.34%12

0.2%8

N/A 0.0%4

2.2%22

0.3%9

Dec-15

Cancer patients seen <14 days after urgent GP referral 93% 95.6%19

97.2%8

94.2%24

95.9%16

97.2%9

95.3%21

91.1%25

N/A 98.4%2

98.3%3

96.2%14

95.4%20

96.8%10

96.2%13

N/A 98.6%1

95.9%17

N/A 96.3%12

97.9%6

96.4%11

94.9%22

97.3%7

95.8%18

97.9%5

94.7%23

96.2%15

97.9%4

Qtr 3 15/16

Cancer diagnosis to treatment <31 days 96% 100.0%1

99.3%15

98.6%20

99.7%9

99.7%8

97.0%25

99.6%10

N/A 99.0%18

100.0%1

99.0%17

97.4%24

100.0%1

98.4%21

N/A 100.0%1

100.0%1

N/A 99.1%16

100.0%1

97.5%23

99.4%14

99.4%12

97.8%22

99.4%13

98.6%19

99.5%11

100.0%1

Qtr 3 15/16

Cancer urgent referral to treatment <62 days 85% 80.2%21

83.2%18

0.0%26

84.6%17

94.2%1

88.2%10

92.9%5

N/A 93.5%2

91.8%6

89.8%9

81.4%19

90.7%7

87.1%15

50.0%25

87.6%13

80.6%20

N/A 86.5%16

90.4%8

79.7%24

80.0%23

93.5%4

87.5%14

87.9%12

93.5%3

80.2%22

88.0%11

Qtr 3 15/16

Breast Cancer Referrals Seen <2 weeks 93% 96.8%9

92.2%22

95.3%16

96.4%12

96.6%11

94.0%19

85.6%24

N/A 98.2%3

98.0%4

97.7%5

98.6%1

N/A 92.5%20

N/A 96.7%10

96.0%14

N/A 92.4%21

96.2%13

87.9%23

94.7%18

96.9%7

94.8%17

98.3%2

96.0%15

97.5%6

96.9%8

Qtr 3 15/16

Cancer Patients receiving subsequent surgery <31 days 94% 96.2%19

100.0%1

95.7%21

100.0%1

100.0%1

86.1%25

100.0%1

N/A 100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

N/A 100.0%1

93.3%23

N/A 94.1%22

100.0%1

96.2%19

89.5%24

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

Qtr 3 15/16

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 99.2%22

97.2%25

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

99.0%24

99.0%23

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

Qtr 3 15/16

Cancer Patients treated after consultant upgrade <62 daysNo measured

operat ional standard N/A 100.0%1

88.6%19

88.9%16

96.3%13

75.0%22

100.0%1

N/A 100.0%1

100.0%1

75.0%22

100.0% 100.0% 88.9%16

N/A 85.2%21

96.6%12

N/A 88.9%16

100.0% 71.4%24

100.0%1

92.5%15

100.0%1

88.0%20

100.0%1

100.0% 95.6%14

Qtr 3 15/16

Cancer Patients treated after screening referral <62 days 90% 90.2%21

100.0%1

60.0%24

93.3%20

100.0%1

71.4%23

100.0%1

N/A 95.8%14

95.5%15

100.0%1

94.4%18

N/A 95.5%15

N/A 97.1%13

93.9%19

N/A 100.0%1

100.0%1

85.7%22

100.0%1

100.0%1

100.0%1

95.3%17

97.5%12

100.0%1

100.0%1

Qtr 3 15/16

Key: Better than National Target = Green R1F ISLE OF WIGHT NHS TRUST RC3 EALING HOSPITAL NHS TRUST RFW WEST MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST RLT GEORGE ELIOT HOSPITAL NHS TRUSTWorse than National Target = Red RA3 WESTON AREA HEALTH NHS TRUST RCD HARROGATE AND DISTRICT NHS FOUNDATION TRUST RGR WEST SUFFOLK NHS FOUNDATION TRUST RMP TAMESIDE HOSPITAL NHS FOUNDATION TRUST

Target Not Applicable for Trust = N/A RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST RCF AIREDALE NHS FOUNDATION TRUST RJC SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST RN7 DARTFORD AND GRAVESHAM NHS TRUSTRBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST RCX THE QUEEN ELIZABETH HOSPITAL KING'S LYNN NHS TRUSTRJD MID STAFFORDSHIRE NHS FOUNDATION TRUST RNQ KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUSTRBT MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST RD8 MILTON KEYNES HOSPITAL NHS FOUNDATION TRUST RJF BURTON HOSPITALS NHS FOUNDATION TRUST RNZ SALISBURY NHS FOUNDATION TRUST

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RBZ NORTHERN DEVON HEALTHCARE NHS TRUST RE9 SOUTH TYNESIDE NHS FOUNDATION TRUST RJN EAST CHESHIRE NHS TRUST RQQ HINCHINGBROOKE HEALTH CARE NHS TRUST out of the 28 other small acute trusts RC1 BEDFORD HOSPITAL NHS TRUST RFF BARNSLEY HOSPITAL NHS FOUNDATION TRUST RLQ WYE VALLEY NHS TRUST RQX HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

RQXRJNRC3 RCD RCF RCX RD8 RE9IW RBD RBT RBZ RC1RA3 RA4National

TargetData PeriodRLQ RLTRJD RJFRFF RFW RGR RJC RQQRNZRNQRN7RMP

Page 20


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other Trusts in the 'Wessex Area'January 16

Emergency Care 4 hour Standards 95% 81.1% 6 N/A 95.4% 1 91.1% 3 N/A 91.6% 2 85.7% 5 72.4% 7 86.1% 4 N/A Qtr 2 15/16

RTT % of incomplete pathways within 18 weeks 92% 87.2%10

99.5%1

93.5%5

93.4%6

93.7%3

93.7%4

92.1%7

92.0%8

91.5%9

94.0%2

Nov-15

%. Patients waiting > 6 weeks for diagnostic 1% 0.3%3

N/A 1.4%6

1.0%5

0.1%2

6.1%9

0.9%4

1.4%7

2.7%8

0.0%1

Nov-15

Cancer patients seen <14 days after urgent GP referral* 93% 95.6%7

N/A 95.9%5

99.3%1

N/A 97.0%2

95.7%6

96.6%4

96.8%3

N/A Qtr 3 15/16

Cancer diagnosis to treatment <31 days* 96% 100.0%1

N/A 99.7%2

99.1%3

N/A 94.9%7

96.1%6

98.5%5

98.8%4

N/A Qtr 3 15/16

Cancer urgent referral to treatment <62 days* 85% 80.2%7

N/A 84.6%5

85.5%4

N/A 88.8%1

86.7%3

83.8%6

87.1%2

N/A Qtr 3 15/16

Breast Cancer Referrals Seen <2 weeks* 93% 96.8%3

N/A 96.4%4

100.0%1

N/A 100.0%1

91.9%7

94.7%6

96.0%5

N/A Qtr 3 15/16

Cancer Patients receiving subsequent surgery <31 days* 94% 96.2%4

N/A 100.0%1

97.3%3

N/A 94.3%7

94.9%6

95.6%5

99.0%2

N/A Qtr 3 15/16

Cancer Patients receiving subsequent Chemo/Drug <31 days* 98% 99.2%7

N/A 100.0%1

100.0%1

N/A 100.0%1

99.7%5

99.6%6

100.0%1

N/A Qtr 3 15/16

Cancer Patients treated after consultant upgrade <62 days*No measured

operat ional standard N/A1

N/A 88.9%4

100.0%1

N/A 58.3%5

95.3%2

54.5%6

92.0%3

N/A Qtr 3 15/16

Cancer Patients treated after screening referral <62 days* 90% 90.2%7

N/A 93.3%4

92.6%5

N/A 98.1%2

95.2%3

90.3%6

98.3%1

N/A Qtr 3 15/16

Key: Better than National Target = Green R1F Isle Of Wight NHS Trust

Worse than National Target = Red R1C Solent NHS Trust

RBD Dorset County Hospital NHS Foundation Trust

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RD3 Poole Hospital NHS Foundation Trust

out of the 10 other trusts in the Wessex area RDY Dorset Healthcare University NHS Foundation Trust

RDZ The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust

RHM University Hospital Southampton NHS Foundation Trust

RHU Portsmouth Hospitals NHS Trust

RN5 Hampshire Hospitals NHS Foundation Trust

RW1 Southern Health NHS Foundation Trust

Data PeriodRDZ RHM RHU RN5 RW1RDYNational

TargetIW R1C RBD RD3

Page 21


Benchmarking of Key National Performance Indicators: Ambulance PerformanceJanuary 16

Ambulance Category A Calls % < 8 minutes - Red 1 75% 70.6%7

67.7%10

69.6%8

72.8%6

61.5%11

74.9%3

74.3%5

74.5%4

75.3%2

79.0%1

69.0%9

Dec-15

Ambulance Category A Calls % < 8 minutes - Red 2 75% 78.5%1

56.5%11

59.9%10

65.9%7

61.7%9

69.5%6

75.0%3

71.1%4

63.9%8

76.0%2

71.0%5

Dec-15

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 78.0%1

57.0%11

60.4%10

66.1%7

61.7%9

69.8%6

75.0%3

71.3%4

64.5%8

76.2%2

70.9%5

Dec-15

Ambulance Category A Calls % < 19 minutes 95% 96.4%2

86.5%11

90.0%9

93.4%6

88.5%10

92.7%7

95.6%3

95.4%4

90.3%8

97.2%1

93.9%5

Dec-15

Key: Better than National Target = Green

Worse than National Target = Red RX9

RYC

R1F

RRU

RX6

RX7

RYE

RYD

RYF

RYA

RX8

Data PeriodRYARX7 RYE RYD RYF RX8RX6National

Target

IW

PerformanceRX9 RYC RRU

East Midlands Ambulance Service NHS Trust

East of England Ambulance Service NHS Trust


London Ambulance Service NHS Trust

North East Ambulance Service NHS Foundation Trust

Yorkshire Ambulance Service NHS Trust

North West Ambulance Service NHS Trust

South Central Ambulance Service NHS Foundation Trust

South East Coast Ambulance Service NHS Foundation Trust

South Western Ambulance Service NHS Foundation Trust

West Midlands Ambulance Service NHS Foundation Trust

Page 22


Data Quality

Analysis:

January 16

Identfy cause and develop corrective actions for Missing / Invalid Patient Pathway Numbers in the OP Dataset Jan-16 Ongoing

Review of Symphony Data Quality Jan-16 OngoingHead of Information / Deputy Director of Information

Commentary:

Action Plan: Person Responsible: Date: Status:

The information centre carry out an analysis of the quality of provider data submitted to Secondary Uses Service (SUS). They review 3 main data sets - Admitted Patient Care (APC), Outpatients (OP) and Accident & Emergency (A&E).

The latest information is up to November 2015. Overall we continue to have 5 red rated indicators. Three of the red indicators are in the Admitted Patient Care (APC) Dataset, one in the Outpatient Dataset and one in the A&E Attendances Dataset. Two of the three red indicators in the APC dataset are Primary Diagnosis and the HRG4 (Healthcare Resource Grouping). These are linked as you need the diagnosis to generate the HRG and we believe the issues has been resolved and has been improving month on month within the data but will take time to appear as amber or green. The third red indicator is the NHS number, we know this relates to prisoners and is not easy to resolve.

In the Outpatient dataset there are a larger than average number of records with an invalid or missing Patient Patway this will be investigated to see if a cause can be identified.

In the A&E dataset the only one red indicator relates to the Departure Time. This relates to patients seen in an A&E clinic and a process has been established to by Information Systems to prompt the department to add the departure time for those patients where it is missing we continue to monitor this closely with a view to this improving in due course.

Page 23


Workforce - Summary - RAG Rating based on Out-turn position

Establishment R Sickness R Turnover & Appraisal R

Plan Actual / Forecast Variance Plan Actual / Forecast Variance

Substantive FTE 2,497 2,669 (172) Year to date 3% 4.16% 1.16% Turnover 0.42%

Temporary Staffing 112 147 (35) In Month 3% 4.61% 1.61% Turnover YTD 6.38%

Total Funded FTE 2,609 2,816 (207) Appraisal 35.80%

Vacancies R Overpayment A Rostering R

Recruitment Activity Plan Actual Adherence to forward rostering policy requirement 19%

Vacancy FTE 281 Current Position £ 000 0 99 Units finalising to payroll deadline 96%

Safe staffing units > 80% staffed (overall) 100%

Summary

SIP increased in month by 10 FTE - from 2659 in December 15. The temporary staffing

figure, which increased from 133 FTE in December 15 to 147 in January 16, is

representative of the increase in sickness absence.

Trust Headcount at the end of January 16: 3127 (Increase of 13)

Summary

Sickness absence has increased from 4.37% in Dec 15 to 4.61% in Jan 16. Trust wide

highest reason for sickness absence remains Anxiety, Stress & Depression although

showing a decrease in month by 19%.

Estimated Cost of Sickness Absence:

Trustwide £309,234

Ambulance, Urgent Care & Community Services (£83,577)

Clinical Support Cancer & Diagnostic Services (£60,759)

Corporate Services (£61,474)

General Medicines (£30,604)

Mental Health & Learning Disabilities Services (£37,497)

Surgery, Women's & Children's Health Services (£34,872)

Summary

280.98 FTE currently in the recruitment process January 16.

High level of activity from managers recruiting in advance for February/March 16 intake

which is best practise, and recent granted permission from Scrutiny panel to process

vacancies has resulted an increase in month. Increased data collection process in HR

will provide more detail in future to identify where posts are generated from ie. "like for

like replacement", "skill mix" etc. along with data by Business Unit.

Summary

Turnover remains low - showing a decrease in month from 0.52% to 0.42% in January

Appraisal % at Month 10 is 35.8%, decrease from 41.7% in Month 9, communication has

been sent via 10 Minute Team Brief (04-02-16) encouraging Business Units to undertake

and log appraisals. Reasons for the 4.9% decrease can be apportioned due to the fact the

appraisal % is a rolling %, and that a large number of appraisals undertaken in Jan 15, are

not included in the data.

Summary

Increase in overpayments due to £23k in new overpayments. Over half of this due to late

forms.

Underlying factors include:

1. Competing Priorities in units.

2. Lack of understanding regarding potential impacts.

3. Duration of process from completing forms to updating ESR.

At time of lockdown, multiple costs centres were not locked down. Substantial effort was

made to contact areas to get this done as outlined in the rostering policy.

This month 10 units were removed from the batch list. These units would not have

received enhancements and overtime pay as a result. A new lockdown guide is now

available and a screen added to the corporate screen saver to raise awareness.

The new organisation build has assisted in targeting appropriate personnel to get locked

down. We are still waiting for final detail from finance to complete this work.

Hospital & Ambulance

January 16

The reasons for recruitment table (left) shows 107.46

FTE in January 16 - this does not match the 280.98

FTE recruitment activity due to the fact the increased

level of information relating to this began recording in

November 15. Moving through the year this will match

total recruitment activity & show exactly what and why

positions are being recruited. Majority of recruitment

remains like for like replacement.

Overpayment information sent to directorates on a monthly basis for review and action.

ESR Employee self service up and running, empowering staff and managers to review and

update their employment records. This will reduce the number of change forms to be

completed by managers for employee personal changes. Drop in sessions have been held

to answer any questions staff may have.

1. Importance of finalising and impacts of not doing so to be re-iterated. This will be

reinforced by staff who will have had pay implications contacting unit managers.

2. System resolution to be implemented by Allocate. Resolution found in other trusts to be

applied here but requires multiple criteria to be adjusted. Allocate are currently

investigating the adjustments required for IOW NHS Trust.

Underlying Causes

The significant majority of overpayments are due to incorrect or late forms. Underlying

factors will include:



3. Duration of process from completing forms to submission.



3. Unit managers timesheets not being finalised by their manager preventing unit

lockdown.

4. Inadequate cover arrangements for finalising during manager absence.

5. System flaw allowing locked units to be unlocked by staff entering web timesheets

Underlying Causes Underlying Causes

Remedies & Actions Remedies & ActionsRemedies & Actions

Active Recruitment by

Stage in Process

Ambulance,

Urgent Care

& Community

Services

Clinical

Support,

Cancer &

Diagnostic

Services

Mental

Health &

Learning

Disabilities

Services

CorporateGeneral

Medicines

Surgery,

Women's

&

Children's

Health

Services

Trustwide

Out to Advert 10.00 10.80 15.00 4.00 9.67 3.60 53.07

LIVE 27.34 20.49 18.28 24.25 33.46 11.32 135.14

Appointed Awaiting Clearances 23.66 9.01 25.57 16.40 7.24 10.89 92.77

Total 61.00 40.30 58.85 44.65 50.37 25.81 280.98

Reasons for Recruitment FTE

Additional Activity 3.10

Additional Funding 3.40

Extension of Fixed Term 0.60

Like for Like Replacement 81.95

New Post 11.53

Organisational Change 5.03

Vacancy 0.85

Winter Resilience 1.00

Grand Total 107.46

Page 24


Workforce - Sickness

R

Trust

The Trust's sickness target is 3%

Currently Sickness Absence rate is 4.61% for January 2016

YTD Sickness Absence is 4.16%.

10 Highest areas within Trust

December 15

Workforce Report Month 10 2015-16 Sickness Summary

Increase in Sickness absence in month from 4.37% to 4.61% - above the 3% target. Anxiety, Stress, Depression remains the main reason for sickness absence despite a 19% decrease in month. Cold,

Cough, Flu showed the largest increase in month by 74%, which is historically representative of January.

Absence Reason Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Variance

S10 Anxiety/stress/depression/other psychiatric illnesses 732.85 841.24 704.58 1044.46 690.25 798.08 1119.58 877.85 1001.37 811.28 -18.98%

S11 Back Problems 337.59 284.48 378.57 390.20 324.69 283.60 295.93 270.26 262.19 272.44 3.91%

S12 Other musculoskeletal problems 302.80 279.37 237.08 317.63 359.69 345.98 539.17 448.90 401.33 462.45 15.23%

S13 Cold, Cough, Flu - Influenza 313.49 251.47 198.45 119.72 133.08 221.25 440.60 346.14 360.91 627.13 73.76%

S25 Gastrointestinal problems 342.90 338.13 485.90 483.44 467.43 428.18 345.06 319.81 278.29 333.09 19.69%

Sum of FTE Days Lost

Organisation

FTE Days

Available

Sickness

FTE Days

Lost

Sickness

% Headcount

Transfer of Care J61300 39.68 19.84 50.00% 2

Specialist CAMHS Medics J61830 52.70 24.80 47.06% 2

Company Secretary J61848 78.12 31.52 40.35% 3

Community Health Management J61422 172.57 53.40 30.94% 7

AUCC Management Team J61011 117.80 31.00 26.32% 4

Laidlaw/Rheumatology Admin J61428 90.11 22.13 24.56% 4

Continuing Healthcare J61241 31.00 7.00 22.58% 1

Communications & Engagement J61732 129.79 28.00 21.57% 5

Mottistone Suite J61090 598.51 91.11 15.22% 25

The Stroke Unit J61221 982.91 146.97 14.95% 38

Page 25


Workforce - Overpayments

Jan-16

Corporate Directorates

Current Employee

Repayments Current Emp

Current

Emp - New Leavers Leavers - New

Allergy & R&D Funded by Income Business Unit £5,020

Nursing Directorate £378

Chief Operating Officer £300 £4,730 £177 £5,885 £848

Trust Administration

Finance & Performance Mgt £45 £336 £1,960 £5,318 £370

Strategic & Commercial Directorate £101 £244 10.70 £686

£446 £5,310 £2,147 £17,287 £1,218

January 16

Summary: Overall overpayments figure increased to £99k. There was £23K in new overpayments in month, £13k of this due to late forms.

Page 26


Safer Staffing Report - Ward Analysis

January 16

Total

monthly

planned

staff hours

Total

monthly

actual staff

hours

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

Total

monthly

planned

staff

hours

Total

monthly

actual

staff

hours

SHACKLETON 855 620.58 1626.5 1187.3 294.5 301 589 599.17 72.6% 73.0% 102.2% 101.7%

ALVERSTONE WARD 1039.5 830.5 644 507.75 620 542 210 219.25 79.9% 78.8% 87.4% 104.4%

SEAGROVE 1276 1295.5 1085 1210 620 643.25 620 659 101.5% 111.5% 103.8% 106.3%

OSBORNE 1492.5 1583 1154.25 1061.75 620 887.5 589 565.5 106.1% 92.0% 143.1% 96.0%

MOTTISTONE 1082 970 388.5 365 620 610 0 0 89.6% 94.0% 98.4% -

ST HELENS 1013.5 832.75 849 778.25 620 600 310 280 82.2% 91.7% 96.8% 90.3%

STROKE 1995.5 1604 1354.75 1263 620 600 620 629 80.4% 93.2% 96.8% 101.5%

REHAB 1762 1494.75 1615.5 1274.5 620 607.25 620 600 84.8% 78.9% 97.9% 96.8%

WHIPPINGHAM 1823.5 1621.3 1484.5 1043.3 620 610 620 530 88.9% 70.3% 98.4% 85.5%

COLWELL 1730 1452.3 1736.7 1461.5 620 600 620 599 83.9% 84.2% 96.8% 96.6%

INTENSIVE CARE UNIT 3426 2925.58 247.5 273.5 2007.25 1857.5 120.25 146.5 85.4% 110.5% 92.5% 121.8%

CORONARY CARE UNIT 2465 2136.8 680.5 598 1550 1491.5 310 309.5 86.7% 87.9% 96.2% 99.8%

NEONATAL INTENSIVE CARE UNIT 1211.5 903 418.5 366 620 631.5 310 290 74.5% 87.5% 101.9% 93.5%

MEDICAL ASSESSMENT UNIT 2468 2136 1377.5 1104 930 880 620 610 86.5% 80.1% 94.6% 98.4%

AFTON 1234.5 1127.5 1162.5 1047.8 310 340 620 659.25 91.3% 90.1% 109.7% 106.3%

PAEDIATRIC WARD 1847 1424 465 371.5 930 870 310 310 77.1% 79.9% 93.5% 100.0%

MATERNITY 1860 1844.5 1147 1249.5 1240 1242.5 620 622 99.2% 108.9% 100.2% 100.3%

WOODLANDS 622.5 659 461.5 399 310 310 310 310 105.9% 86.5% 100.0% 100.0%

LUCCOMBE WARD 1395 964.5 1056 1520 620 620 620 802 69.1% 143.9% 100.0% 129.4%

POPPY UNIT 1077.5 969.75 2030 1723.5 620 610 929.5 814 90.0% 84.9% 98.4% 87.6%

APPLEY WARD 2218.5 1658.67 1576.5 1374 840 600 620 586.75 74.8% 87.2% 71.4% 94.6%

Average

fill rate -

registere

d

nurses/m

idwives

(%)

Average

fill rate -

care staff

(%)

Average

fill rate -

registere

d

nurses/m

idwives

(%)

Average

fill rate -

care staff

(%)

Day Night Day Night

Ward name

Registered

midwives/nursesCare Staff

Registered

midwives/nursesCare Staff

Page 27


Safer Staffing - Full staffing fill rate by shift

Vlook Early

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Afton Ward J61794 150% 150% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 150% 100% 200% 100% 100% 50% 100% 50% 50% 150% 100% 100% 105%

Alverstone Ward J61111 50% 50% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 94%

Colwell Ward J61254 75% 75% 75% 75% 75% 75% 100% 75% 50% 100% 75% 100% 100% 75% 75% 75% 100% 75% 100% 75% 100% 75% 100% 100% 100% 125% 150% 100% 125% 125% 100% 91%

Coronary Care J61190 80% 80% 80% 100% 80% 100% 80% 100% 100% 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 80% 95%

Intensive Care Unit J61120 100% 86% 100% 86% 86% 100% 71% 71% 86% 100% 100% 86% 100% 100% 100% 100% 86% 86% 86% 86% 71% 86% 86% 86% 86% 86% 86% 86% 86% 86% 86% 88%

MAAU J61231 120% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 120% 100% 80% 80% 80% 100% 100% 100% 100% 100% 100% 100% 99%

Maternity Services J61500 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 125% 100% 100% 100% 100% 100% 101%

Mottistone Suite J61090 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Neonatal Intensive Care Unit J61520 67% 67% 67% 67% 33% 67% 67% 33% 67% 67% 67% 67% 67% 33% 100% 33% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 133% 100% 67% 67% 67%

Osborne Ward J61915 150% 150% 150% 150% 100% 100% 100% 150% 100% 100% 150% 150% 100% 100% 100% 150% 150% 150% 50% 100% 100% 150% 150% 100% 100% 150% 100% 100% 150% 150% 100% 123%

Paediatric Ward J61372 75% 100% 100% 75% 100% 75% 100% 100% 100% 100% 100% 75% 75% 75% 75% 100% 100% 75% 75% 75% 75% 75% 100% 100% 100% 75% 75% 75% 75% 100% 100% 86%

Poppy Unit J61235 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Seagrove Ward J61916 100% 100% 150% 200% 200% 200% 250% 100% 100% 100% 100% 150% 150% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 100% 150% 150% 50% 100% 50% 100% 121%

Shackleton J61791 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

St Helens Ward J61102 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Whippingham Ward J61101 75% 75% 50% 75% 75% 100% 75% 100% 75% 75% 100% 75% 75% 75% 75% 100% 75% 100% 100% 100% 100% 125% 100% 100% 100% 100% 100% 125% 100% 100% 100% 90%

Woodlands J61913 100% 100% 100% 100% 200% 200% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 110%

Appley Ward J61250 80% 80% 80% 80% 80% 80% 100% 100% 100% 100% 80% 80% 80% 80% 60% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 100% 120% 100% 80% 85%

Luccombe Ward J61112 67% 67% 100% 100% 100% 100% 67% 33% 67% 67% 67% 100% 67% 67% 33% 100% 100% 67% 100% 100% 100% 67% 100% 67% 100% 100% 100% 100% 100% 100% 100% 84%

The Stroke Unit J61221 100% 100% 75% 75% 75% 100% 75% 75% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95%

General Rehabilitation Unit J61226 125% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100% 75% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100% 125% 75% 98%

Accident & Emergency J61230 83% 83% 67% 83% 117% 83% 83% 117% 100% 83% 100% 100% 100% 100% 100% 67% 83% 67% 100% 83% 100% 100% 100% 67% 67% 83% 67% 117% 133% 100% 100% 91%

Grand Total 93% 90% 89% 93% 95% 97% 93% 93% 92% 96% 95% 96% 95% 91% 91% 93% 95% 89% 92% 95% 93% 93% 96% 90% 92% 99% 95% 97% 105% 99% 93% 94%

Vlook Late

Sum of RN%

Row Labels

01/0

1/2

01

6

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01

6

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1/2

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Afton Ward J61794 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 150% 50% 150% 150% 50% 100% 150% 100% 100% 100% 50% 50% 100% 100% 100% 100% 150% 200% 50% 100% 100% 105%


Colwell Ward J61254 100% 100% 67% 67% 67% 100% 100% 100% 67% 67% 67% 100% 100% 100% 67% 100% 100% 67% 100% 67% 100% 133% 100% 100% 133% 100% 133% 100% 100% 133% 133% 96%

Coronary Care J61190 100% 100% 100% 100% 100% 100% 80% 80% 100% 100% 100% 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 100% 100% 100% 100% 100% 80% 80% 100% 96%


MAAU J61231 120% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 80% 80% 80% 80% 100% 80% 100% 100% 100% 96%




Osborne Ward J61915 150% 100% 100% 150% 100% 150% 100% 100% 150% 100% 100% 100% 100% 150% 200% 150% 100% 100% 100% 100% 150% 100% 100% 150% 100% 100% 50% 100% 100% 100% 150% 116%


Poppy Unit J61235 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98%

Seagrove Ward J61916 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 200% 100% 100% 100% 150% 100% 100% 100% 150% 100% 100% 108%

Shackleton J61791 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 100% 200% 100% 100% 100% 100% 100% 100% 100% 106%

St Helens Ward J61102 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%


Woodlands J61913 100% 100% 200% 100% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 200% 100% 100% 100% 100% 100% 100% 200% 100% 100% 100% 116%

Appley Ward J61250 75% 75% 75% 100% 100% 100% 100% 75% 75% 100% 75% 100% 75% 75% 75% 100% 75% 75% 100% 100% 75% 75% 100% 100% 100% 75% 100% 100% 125% 100% 75% 89%

Luccombe Ward J61112 67% 67% 67% 67% 67% 100% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 67% 100% 67% 67% 67% 69%

The Stroke Unit J61221 100% 100% 75% 100% 75% 100% 100% 75% 75% 75% 100% 75% 100% 100% 100% 100% 75% 75% 100% 100% 100% 75% 100% 75% 75% 75% 100% 75% 75% 100% 100% 89%



Grand Total 97% 93% 90% 93% 90% 97% 90% 92% 93% 91% 94% 92% 96% 100% 94% 96% 93% 90% 92% 93% 96% 92% 94% 93% 96% 90% 94% 101% 99% 97% 94% 94%

January 16

Page 28



January 16

Vlook Night

Sum of RN%

Row Labels 01/0

1/2

01

6

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01

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1/2

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1/2

01

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01

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To

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Afton Ward J61794 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 100% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 110%


Colwell Ward J61254 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% 100% 100% 100% 100% 100% 100% 97%

Coronary Care J61190 100% 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 80% 100% 100% 100% 100% 100% 80% 80% 100% 80% 100% 100% 100% 100% 100% 96%


MAAU J61231 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 67% 100% 67% 100% 100% 100% 100% 100% 100% 67% 100% 100% 100% 100% 100% 67% 100% 95%




Osborne Ward J61915 150% 150% 150% 100% 150% 150% 150% 150% 150% 150% 150% 150% 150% 150% 150% 100% 150% 150% 150% 150% 150% 150% 150% 150% 100% 150% 150% 150% 150% 150% 150% 145%


Poppy Unit J61235 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98%

Seagrove Ward J61916 100% 100% 100% 100% 100% 150% 100% 150% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 105%

Shackleton J61791 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

St Helens Ward J61102 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 97%


Woodlands J61913 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Appley Ward J61250 100% 100% 100% 100% 100% 100% 100% 50% 50% 67% 67% 67% 67% 67% 67% 67% 100% 67% 67% 67% 67% 33% 67% 67% 67% 67% 67% 67% 67% 67% 67% 71%

Luccombe Ward J61112 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

The Stroke Unit J61221 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 50% 100% 100% 100% 100% 97%



Grand Total 100% 96% 100% 100% 96% 98% 98% 100% 100% 98% 96% 100% 98% 98% 98% 95% 96% 96% 96% 95% 96% 96% 95% 89% 93% 98% 95% 98% 98% 96% 100% 97%

Vlook Early

Sum of HCA %

Row Labels 01/0

1/2

01

6

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1/2

01

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1/2

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1/2

01

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Gra

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Afton Ward J61794 50% 50% 100% 100% 100% 100% 100% 50% 100% 150% 150% 100% 100% 150% 100% 100% 100% 150% 100% 50% 50% 0% 100% 100% 100% 50% 100% 100% 100% 100% 150% 95%


Colwell Ward J61254 120% 100% 100% 100% 100% 80% 80% 100% 100% 100% 120% 80% 100% 100% 120% 80% 80% 120% 80% 100% 80% 80% 100% 100% 80% 80% 80% 100% 100% 100% 80% 95%

Coronary Care J61190 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 50% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 92%


MAAU J61231 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 133% 100% 67% 100% 98%




Osborne Ward J61915 50% 50% 50% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 100% 200% 150% 100% 100% 95%


Poppy Unit J61235 75% 100% 100% 125% 125% 100% 100% 100% 100% 125% 100% 100% 125% 125% 125% 100% 100% 100% 100% 100% 125% 100% 100% 75% 100% 100% 100% 125% 100% 100% 100% 105%

Seagrove Ward J61916 50% 100% 50% 100% 50% 100% 100% 100% 100% 100% 50% 100% 100% 150% 50% 50% 100% 100% 100% 50% 100% 150% 100% 100% 100% 150% 150% 100% 200% 150% 100% 100%

Shackleton J61791 100% 67% 100% 100% 67% 67% 100% 100% 67% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 67% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 67% 91%

St Helens Ward J61102 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98%


Woodlands J61913 100% 100% 100% 100% 0% 0% 100% 100% 0% 0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 87%

Appley Ward J61250 100% 100% 125% 100% 100% 125% 125% 100% 100% 100% 100% 125% 75% 100% 75% 100% 75% 100% 100% 100% 75% 75% 75% 100% 75% 100% 100% 100% 100% 100% 100% 98%

Luccombe Ward J61112 133% 133% 133% 133% 133% 133% 133% 200% 167% 167% 167% 100% 133% 100% 167% 133% 133% 100% 133% 100% 133% 133% 100% 167% 133% 100% 67% 167% 100% 167% 133% 133%

The Stroke Unit J61221 75% 100% 75% 75% 125% 75% 150% 100% 75% 125% 100% 100% 100% 100% 100% 125% 100% 100% 75% 75% 100% 75% 100% 100% 75% 100% 100% 100% 100% 100% 100% 97%



Grand Total 90% 96% 100% 98% 100% 94% 104% 98% 92% 110% 100% 96% 94% 102% 100% 100% 94% 98% 92% 88% 98% 87% 96% 106% 94% 96% 94% 108% 104% 104% 104% 98%Page 29



January 16

Vlook Late

Sum of HCA %

Row Labels 01/0

1/2

01

6

02/0

1/2

01

6

03/0

1/2

01

6

04/0

1/2

01

6

05/0

1/2

01

6

06/0

1/2

01

6

07/0

1/2

01

6

08/0

1/2

01

6

09/0

1/2

01

6

10/0

1/2

01

6

11/0

1/2

01

6

12/0

1/2

01

6

13/0

1/2

01

6

14/0

1/2

01

6

15/0

1/2

01

6

16/0

1/2

01

6

17/0

1/2

01

6

18/0

1/2

01

6

19/0

1/2

01

6

20/0

1/2

01

6

21/0

1/2

01

6

22/0

1/2

01

6

23/0

1/2

01

6

24/0

1/2

01

6

25/0

1/2

01

6

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1/2

01

6

27/0

1/2

01

6

28/0

1/2

01

6

29/0

1/2

01

6

30/0

1/2

01

6

31/0

1/2

01

6

Gra

nd

To

tal

Afton Ward J61794 100% 100% 50% 100% 100% 100% 100% 100% 100% 150% 100% 150% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 50% 100% 150% 100% 105%


Colwell Ward J61254 100% 67% 133% 100% 100% 67% 67% 67% 100% 133% 133% 100% 100% 67% 133% 67% 100% 100% 100% 133% 100% 67% 100% 100% 33% 100% 67% 67% 67% 67% 33% 89%

Coronary Care J61190 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 100% 0% 100% 100% 0% 100% 100% 100% 100% 100% 100% 0% 100% 0% 84%


MAAU J61231 67% 133% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 100% 100% 67% 100% 67% 67% 133% 100% 100% 100% 97%




Osborne Ward J61915 50% 100% 100% 50% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 150% 100% 50% 100% 100% 100% 97%


Poppy Unit J61235 60% 80% 80% 100% 80% 80% 80% 80% 100% 120% 100% 100% 100% 100% 80% 100% 100% 80% 100% 80% 60% 100% 60% 60% 80% 40% 80% 100% 80% 60% 80% 84%

Seagrove Ward J61916 150% 100% 100% 100% 150% 50% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 150% 150% 200% 150% 150% 100% 111%

Shackleton J61791 100% 100% 67% 100% 67% 67% 100% 100% 100% 67% 67% 33% 100% 67% 100% 100% 100% 67% 100% 100% 67% 67% 100% 33% 67% 100% 67% 100% 100% 67% 67% 82%

St Helens Ward J61102 100% 100% 100% 100% 100% 100% 50% 150% 100% 100% 100% 100% 50% 100% 100% 50% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 94%


Woodlands J61913 100% 100% 0% 100% 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 0% 100% 100% 100% 100% 0% 100% 0% 100% 100% 100% 81%

Appley Ward J61250 133% 100% 100% 100% 133% 67% 100% 100% 100% 100% 133% 100% 67% 100% 100% 67% 100% 100% 100% 67% 100% 100% 100% 100% 33% 67% 100% 100% 100% 100% 100% 96%

Luccombe Ward J61112 200% 150% 150% 150% 200% 150% 200% 150% 200% 200% 150% 200% 150% 100% 200% 200% 200% 150% 200% 150% 200% 200% 200% 200% 150% 150% 200% 100% 200% 200% 200% 176%

The Stroke Unit J61221 100% 100% 150% 100% 200% 150% 150% 150% 150% 150% 150% 200% 150% 150% 100% 150% 150% 150% 50% 100% 100% 100% 100% 150% 150% 50% 100% 150% 150% 100% 100% 129%



Grand Total 96% 102% 100% 96% 107% 91% 100% 100% 102% 114% 102% 100% 98% 96% 107% 100% 105% 98% 98% 107% 93% 96% 105% 105% 93% 89% 96% 100% 96% 93% 100% 99%

Vlook Night

Sum of HCA %

Row Labels 01/0

1/2

01

6

02/0

1/2

01

6

03/0

1/2

01

6

04/0

1/2

01

6

05/0

1/2

01

6

06/0

1/2

01

6

07/0

1/2

01

6

08/0

1/2

01

6

09/0

1/2

01

6

10/0

1/2

01

6

11/0

1/2

01

6

12/0

1/2

01

6

13/0

1/2

01

6

14/0

1/2

01

6

15/0

1/2

01

6

16/0

1/2

01

6

17/0

1/2

01

6

18/0

1/2

01

6

19/0

1/2

01

6

20/0

1/2

01

6

21/0

1/2

01

6

22/0

1/2

01

6

23/0

1/2

01

6

24/0

1/2

01

6

25/0

1/2

01

6

26/0

1/2

01

6

27/0

1/2

01

6

28/0

1/2

01

6

29/0

1/2

01

6

30/0

1/2

01

6

31/0

1/2

01

6

Gra

nd

To

tal

Afton Ward J61794 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 150% 100% 150% 150% 150% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 108%


Colwell Ward J61254 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 50% 100% 100% 100% 97%

Coronary Care J61190 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%


MAAU J61231 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98%




Osborne Ward J61915 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 95%


Poppy Unit J61235 100% 100% 100% 100% 100% 100% 100% 67% 100% 100% 100% 67% 100% 100% 67% 67% 100% 100% 100% 100% 100% 67% 67% 100% 100% 100% 67% 67% 67% 67% 67% 88%

Seagrove Ward J61916 100% 100% 100% 150% 150% 100% 50% 50% 0% 100% 50% 100% 50% 100% 150% 100% 100% 100% 150% 100% 100% 150% 100% 100% 150% 150% 150% 100% 100% 150% 150% 106%

Shackleton J61791 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98%

St Helens Ward J61102 0% 100% 100% 100% 100% 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 0% 0% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90%


Woodlands J61913 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Appley Ward J61250 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% 100% 100% 100% 100% 50% 100% 150% 100% 100% 150% 97%

Luccombe Ward J61112 100% 150% 100% 100% 100% 150% 150% 100% 100% 100% 150% 100% 150% 150% 150% 100% 150% 150% 150% 100% 150% 100% 150% 150% 150% 150% 150% 150% 150% 150% 100% 131%

The Stroke Unit J61221 100% 100% 100% 150% 100% 100% 150% 150% 100% 100% 150% 100% 100% 150% 100% 100% 100% 100% 100% 0% 50% 100% 100% 100% 100% 150% 100% 100% 50% 100% 100% 103%



Grand Total 88% 103% 97% 103% 94% 100% 100% 94% 94% 106% 100% 94% 100% 100% 103% 87% 100% 103% 106% 91% 100% 94% 97% 103% 106% 100% 103% 100% 91% 106% 110% 99%

Page 30


Summary - RAG Rating based on Out-turn position

Continuity of Service Rating R Surplus R Income G

Plan Actual Plan Actual / Forecast Variance Plan Actual / Forecast Variance

Year to date 2 1 Year to date £k (3,399) (6,972) (3,573) Year to date £k 141,194 141,781 587

Year end forecast £k (4,600) (6,737) (2,137) Year end forecast £k 169,021 172,972 3,951

January 16

Summary

The Trust is reporting a £0.600m deficit for January 2016, which is an adverse variance of £0.350m against plan.

Cumulatively, there is a deficit of £6.972m as at January 2016, an adverse variance of £3.573m against plan.

Although a deficit in month, this is an improvement against the current trajectory to year end forecast position.

The planned Continuity of Service Rating (CoSR) to month 10 was a '2'. As

previously reported, the actual I&E position has deteriorated significantly from

plan and to the end of January, the Trust is reporting an overall Continuity of

Service Rating of '1'. The overall year to date sustainability risk rating still

shows a variance of 1 against plan.

The Trust planned for a deficit of £0.250m in January, after adjustments made for normalising items (these include

the net costs associated with donated assets).

The reported position is a deficit of £0.600m in the month, an adverse variance of £0.350m against plan.

The cumulative Trust plan was a deficit of £3.399m, after normalising items. The actual position is a cumulative

deficit of £6.972m, an adverse variance of £3.573m.

Although a deficit position in month, this is ahead of trajectory towards the revised forecast outturn position.

The variance in month includes under performance against the CCG PbR Contract of £0.187m (£1.729m adverse

year to date). In addition to this, there is an adverse £0.340m variance (£0.322m year to date) relating to a phasing

issue on the CCG SLA Acute Contract, which will reduce to zero by the end of the financial year.

Further benefit of £52k (£538k year to date) has also realised following balance sheet reviews. Weekly reviews

and scrutiny of each control code are now being undertaken, with the aim to achieve £686k by year end.

A benefit of £607k from capital to revenue transfer has also been realised in month.

The Trusts planned forecast out-turn deficit has been changed to £6.737m from its original plan of £4.600m. This is

due to the implementation of the system resilience improvement plan with its additional net costs, expected CIP

non delivery, and unachievement of activity income with fines and penalties. This position is also subject to CCG

support of £2.55m, and this has been formally requested.

Executive Panel scrutiny review of all recruitment requests continues. Weekly challenge meetings in Clinical

Business Units on CIP and budget delivery involving business managers have now been extended to Corporate

areas.

The Trust planned income in January was £15.245m. The actual reported

income is £14.998m in month, an adverse variance of £0.246m.

The cumulative income plan is £141.194m. The actual position is a cumulative

income of £141.781m, a favourable variance of £0.587m.

This position includes £1.729m provision for estimated contract under

performance and penalties (£0.834m activity and £0.886m penalties).

It also includes a capital to revenue transfer of £607k in month.

Page 31


Summary - RAG Rating based on Out-turn position

January 16

Operating Costs (including directorate income) R CIP R Cash A

Plan Actual / Forecast Variance Plan Actual / Forecast Variance Plan Actual / Forecast Variance

Year to date £k (120,478) (123,332) (2,854) Year to date £k 7,026 5,077 (1,949) Year to date £k 4,050 5,253 1,203

Year end forecast £k (143,182) (145,820) (2,638) Year end forecast £k 8,500 6,183 (2,317) Year end forecast £k 1,890 1,715 (175)

Capital G Indicators of Forward Financial Risk A

Plan Actual / Forecast Variance Actual Forecast for quarter

Year to date £k (7,909) (5,209) (2,700) Number of indicators breached 4 4

Year end forecast £k (8,180) (7,070) (1,110) Number of indicators 12 12

Indicators breached are:

i) Trust financial performance is on plan

ii) Capital expenditure <75% of plan for the year

iii) Trusts CIP schemes on plan

iv) Continuity of service rating on plan

Strategic Capital schemes includes the larger capital projects.

The MAU Extension has now been completed and the Endoscopy Relocation

scheme is progressing well and expected to complete within the approved

timescale. The ICU/CCU project from 2014/15 remains on hold and in Assets

Under Construction in 2015/16, no further expenditure on this project has

been agreed as yet. The Ward Reconfiguration of Level C has also been put

on hold for this financial year meaning an additional £103k has been made

available for reallocation. The phasing of the spend of the funding for the

Carbon Energy Fund project has also been changed, the consequence of

which is a transfer of funds back to Operational Capital of £769k this financial

year.

The cash balance held at the end of January is c£5.0m which is c£1.2m more

than expected. The difference in the planned deficit to the actual figure at

month 10 is c£3.6m. This is offset in cash terms by the underspend of £4.9m

on capital expenditure and the variance against the original budgeted

depreciation charges of £254k. Other working capital movements of £119k

account for the other slight difference in the cash balance.

The Trust is reporting a current year overspend against expenditure budget of

£2.854m. Including additional costs relating to the Public Dividend Capital

Charge the adjusted overspend expenditure variance is £2.827m.

The current year net operating costs include £17.294m of directorate income.

Excluding this income source the total costs amount to £140.627m. In addition

to the operating costs, capital charges & finance costs amount to £8.126m.

The in month position for CIP is an achievement of £0.671m against a target of £0.730m, an under achievement of

£0.059m.

Cumulatively there is an achievement of £5.077m with a target of £7.026m. This is an adverse variance of

£1.949m.

The current year forecast is an achievement of £6.183m against a target of £8.500m, a shortfall of £2.317m.

Further plans and budget reviews are being pursued including through the turnaround programme of work to ensure

that this gap is mitigated as far as possible.

Page 32


Continuity of Service Risk Rating

Year To Date Plan

Rating

Actual

Rating Variance

Continuity of Service Risk RatingsLiquidity Ratio 1 1 0

Capital Servicing Capacity (Times) 2 1 (1)

Continuity of Services Risk Rating for Trust 2 1 (1)

Financial Sustainability Risk Ratings from M6 (based on original Plan submission)

I&E Margin Rating 1 1 0

I&E Margin Variance from Plan 3 1 (2)

Overall Financial Sustainability Risk Rating 2 1 (1)

Financial Criteria Weight % Definition Rating categories

4 3 2 1

Liquidity Ratio 1 50% Liquid Ratio (days) Working capital balance x 360 0.0 -7.0 -14.0 <-14

Annual operating expenses

Capital Servicing Capacity Ratio 1 50% Capital servicing capacity (time) Revenue available for capital service

Annual debt service 2.5x 1.75x 1.25x <1.25x

Additional Monitor Risk Ratings

Underlying Performance 1 25% I&E Margin (%) Adjusted Financial Performance Retained Surplus/(Deficit) >1% 0% to 1% 0% to -1% <-1%

Income

Variance from Plan 1 25% Variance in I&E Margin as % of Plan Variance in I&E Margin >0% 0% to -1% -1% to -2% <-2%

Income

The planned Continuity of Service Rating (CoSR) to month 10 was a '2'. As previously reported, the actual I&E position has deteriorated significantly from plan and to the end of January, the Trust is reporting an overall Continuity of Service Rating of '1'. The overall year to date

sustainability risk rating still shows a variance of 1 against plan.

Metric to be scored

January 16

Page 33


Surplus

Base Budget In month Year to date Full Year

Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Surplus / (Deficit) (4,600) (250) (600) (350) (3,399) (6,972) (3,573) (4,600) (6,737) (2,137)

Base Budget In month Year to date Full YearPlan Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Income 166,836 15,245 14,998 (246) 141,194 141,781 587 169,021 172,972 3,951

Pay (114,151) (10,029) (10,232) (203) (95,836) (100,287) (4,452) (114,666) (121,368) (6,702)

Non Pay (47,147) (4,610) (4,550) 61 (40,591) (40,339) 252 (48,947) (48,374) 573

EBITDA 5,538 605 217 (389) 4,768 1,155 (3,613) 5,408 3,231 (2,177)

Depreciation & Amortisation (6,531) (561) (526) 34 (5,219) (5,146) 73 (6,401) (6,328) 73

PDC (3,625) (302) (302) 0 (3,021) (3,021) 0 (3,625) (3,625) 0

Impairment 0 0 0 0 0 0 0 0 0 0

Profit/(Loss) on Asset Disposal 0 0 (13) (13) 0 (45) (45) 0 (45) (45)

Interest Receivable 24 2 3 1 20 23 3 24 27 3

Interest Payable (24) (2) 16 18 (20) (7) 13 (24) (11) 13

Interest Receivable/(Payable) 0 0 18 18 0 16 16 0 16 16

Bank Charges (8) (1) (0) 0 (7) (5) 2 (8) (6) 2

RETAINED SURPLUS / (DEFICIT) (4,626) (258) (607) (349) (3,479) (7,047) (3,568) (4,626) (6,758) (2,132)

Receipt of Charitable Donations for Asset Acquisition (70) 0 0 0 0 0 0 (70) (70) 0

Impairment 0 0 0 0 0 0 0 0 0 0

Depreciation - Donated Assets 96 8 7 (1) 80 75 (5) 96 91 (5)

REVISED RETAINED SURPLUS / (DEFICIT) (4,600) (250) (600) (350) (3,399) (6,972) (3,573) (4,600) (6,737) (2,137)

The Trust planned for a deficit of £0.250m in January, after adjustments made for normalising items (these include the net costs associated with donated assets).

The reported position is a deficit of £0.600m in the month, an adverse variance of £0.350m against plan.

The cumulative Trust plan was a deficit of £3.399m, after normalising items. The actual position is a cumulative deficit of £6.972m, an adverse variance of £3.573m.

Although a deficit position in month, this is ahead of trajectory towards the revised forecast outturn position.

The variance in month includes under performance against the CCG PbR Contract of £0.187m (£1.729m adverse year to date). In addition to this, there is an adverse £0.340m variance (£0.322m year to date) relating to a phasing issue on the CCG

SLA Acute Contract, which will reduce to zero by the end of the financial year.

Further benefit of £52k (£538k year to date) has also realised following balance sheet reviews. Weekly reviews and scrutiny of each control code are now being undertaken, with the aim to achieve £686k by year end.

A benefit of £607k from capital to revenue transfer has also been realised in month.

The Trusts planned forecast out-turn deficit has been changed to £6.737m from its original plan of £4.600m. This is due to the implementation of the system resilience improvement plan with its additional net costs, expected CIP non delivery, and

unachievement of activity income with fines and penalties. This position is also subject to CCG support of £2.55m, and this has been formally requested.

Executive Panel scrutiny review of all recruitment requests continues. Weekly challenge meetings in Clinical Business Units on CIP and budget delivery involving business managers have now been extended to Corporate areas.

The Category A income position includes under performance against CCG PbR contracted activity of £1.729m (£0.843m activity and £0.886m penalties) plus delayed investments and cost per case services that are over or under plan. These delays

are offset by a corresponding balance in reserves of £404k (£127k IoW CCG, £277k NHSE).

Operating costs include considerable over spends in the Clinical Business Units. These relate to unachievement of CIP requirements, and additional costs in respect of operational pressures and black alert status which are being addressed through

contract discussions with commissioners, and formally requested financial support.

The current trajectory year end forecasts from Business Units are a deficit of £8.1m. With further opportunites and support from CCG, this can be reduced to £6.7m.

The current Full Year Plan budgets differ from the Base Budget Plan due to directorates movement of CIP targets between Pay, Non Pay and Income as savings plans are developed.

January 16

Page 34


Surplus

January 16

-1,600

-1,400

-1,200

-1,000

-800

-600

-400

-200

-

200

400


£0

00

s

Surplus / (Deficit) by Month

Plan

Actual

-8,000

-7,000

-6,000

-5,000

-4,000

-3,000

-2,000

-1,000

-


£0

00

s

Cumulative Surplus / (Deficit) by Month

Plan

Actual

Page 35


Income


Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Surplus / (Deficit) 166,836 15,245 14,998 (246) 141,194 141,781 587 169,021 172,972 3,951


Income Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

NHS Isle of Wight CCG 132,668 12,051 11,198 (854) 111,572 110,207 (1,365) 134,066 133,748 (318)

NHS England 11,142 731 817 86 8,486 8,589 102 9,931 9,813 (118)

Isle of Wight Council 1,748 463 464 1 3,420 3,470 50 4,346 4,390 44

Commissioning Support Unit 320 27 25 (2) 267 262 (5) 320 316 (4)

Non Contractual Activity 1,575 87 35 (53) 1,414 1,288 (126) 1,575 1,449 (126)

Southampton University Hospitals FT 105 9 5 (4) 88 65 (23) 105 78 (27)

Capital to Revenue Transfer 0 607 607 0 607 607 0 607 607

Other directorate income - Patient Care Activities 8,686 (597) 1,481 2,078 3,489 6,195 2,706 5,900 4,266 (1,635)

Income from Patient Care Activities 156,244 12,771 14,631 1,860 128,735 130,682 1,947 156,244 154,668 (1,576)

Other directorate income - Other Operating Revenue 10,592 2,474 367 (2,106) 12,460 11,099 (1,360) 12,777 18,304 5,527

TOTAL INCOME 166,836 15,245 14,998 (246) 141,194 141,781 587 169,021 172,972 3,951

The Trust planned income in January was £15.245m. The actual reported income is £14.998m in month, an adverse variance of £0.246m.

The cumulative income plan is £141.194m. The actual position is a cumulative income of £141.781m, a favourable variance of £0.587m.

This position includes £1.729m provision for estimated contract under performance and penalties (£0.834m activity and £0.886m penalties).

It also includes a capital to revenue transfer of £607k in month.

The NHS Isle of Wight CCG position year to date has an estimate of £1.729m for cumulative under performance and penalties against the PbR contract. This is sub divided as £1.925m on Elective and Outpatient activity, and £0.196m favourable

variance on Non Elective activity.

There are also contract services that have yet to commence and cost per case services over and under plan (£127k), but is offset by a corresponding balance in revenue reserves.

The year end position assumes that income will exceed the plan due to for System Resilience Plan, and formally requested support from the CCG.

NHS England variance relates to

i) under performance against Non PbR excluded drugs (£277k), which is offset by a reduction in costs within Clinical Business Units.

ii) over performance against service contract at an estimated £380k to date.

IoW Council variance relates to over performance against the Sexual Health contract.

January 16

Page 36


Income

January 16

11,500

12,000

12,500

13,000

13,500

14,000

14,500

15,000

15,500


£0

00

s

Monthly Income

Plan

Actual

95,000

100,000

105,000

110,000

115,000

120,000

125,000

130,000

135,000

140,000

145,000

Oct Nov Dec Jan

£0

00

s

Cumulative income by month

Plan

Actual

Page 37


Operating Costs

Surgery, Womens & Children's Health Medicine Clinical Support, Cancer & DiagnosticsIn month Year to date Forecast In month Year to date Forecast In month Year to date Forecast

Plan Actual Variance Plan Actual Variance Variance Plan Actual Variance Plan Actual Variance Variance Plan Actual Variance Plan Actual Variance Variance£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Income 74 80 6 769 842 73 88 Income 64 95 32 638 793 156 183 Income 232 277 45 2,620 2,961 341 352

Pay (1,496) (1,523) (27) (15,784) (16,424) (640) (765) Pay (879) (922) (43) (8,466) (8,766) (300) (229) Pay (1,813) (1,956) (142) (18,171) (20,001) (1,830) (2,147)

Non Pay (259) (276) (17) (2,325) (2,292) 33 (16) Non Pay (197) (208) (11) (1,655) (1,581) 74 63 Non Pay (1,427) (1,531) (104) (13,977) (14,518) (541) (1,122)

TOTAL (1,681) (1,720) (39) (17,340) (17,873) (534) (694) TOTAL (1,012) (1,035) (22) (9,483) (9,553) (70) 17 TOTAL (3,008) (3,209) (201) (29,528) (31,558) (2,030) (2,916)

Ambulance, Urgent Care & Emergency Mental Health & Learning Disabilities Chief Operating OfficerIn month Year to date Forecast In month Year to date Forecast In month Year to date Forecast


Income 215 248 33 2,106 2,160 54 40 Income 28 46 18 344 447 103 132 Income 435 584 149 4,270 5,066 797 969

Pay (2,128) (2,124) 4 (20,834) (21,485) (651) (751) Pay (1,285) (1,335) (50) (12,011) (12,136) (126) (6) Pay (1,054) (1,092) (38) (6,799) (8,865) (2,066) (2,501)

Non Pay (473) (445) 28 (4,542) (4,507) 35 (85) Non Pay (98) (93) 5 (958) (958) 0 (73) Non Pay (526) (457) 69 (2,606) (2,919) (313) (533)

TOTAL (2,386) (2,322) 65 (23,270) (23,832) (562) (797) TOTAL (1,355) (1,382) (27) (12,625) (12,647) (22) 52 TOTAL (1,145) (965) 180 (5,135) (6,717) (1,582) (2,065)

Corporate Research & Development ReservesIn month Year to date Forecast In month Year to date Forecast In month Year to date Forecast


Income 449 473 25 4,476 4,532 56 (18) Income 37 46 9 368 492 124 124 Income 343 0 (343) 358 0 (358) (43)

Pay (1,292) (1,237) 55 (12,293) (12,156) 137 115 Pay (37) (43) (7) (366) (455) (89) (89) Pay (44) 0 44 (1,112) 0 1,112 (330)

Non Pay (1,390) (1,285) 105 (13,317) (12,855) 461 568 Non Pay (0) (1) (1) (1) (36) (34) (34) Non Pay (241) (254) (13) (1,210) (674) 536 1,806

TOTAL (2,234) (2,049) 185 (21,134) (20,479) 654 665 TOTAL 0 2 1 1 2 1 1 TOTAL 58 (254) (312) (1,965) (674) 1,291 1,433

January 16

The overall forecast position for the Corporate business units has improved from £469k in Mth 9 to £665k,

this is due to continued spending restraint, plus are a number of staff seconded to support various other

initiatives, with only limited backfill to their substantive roles. Although this financially beneficial, it is not

sustainable in the longer term. It is important to note that the profit forecast for NHS Creative has been

improved from £9.7k in mth 9 to £48.3k, however this continues to be a substantive shortfall against the

original £91.5k presented to TEC in April 2015. This reduction is due to adverse trading conditions throughout

the NHS, which are forecast to continue for sometime. On a positive note the donated asset income forecast

remains at £70k in line with the annual budget.

This budget will report a break even position as all costs are offset by income. The variance to date relates to:

i) commissioners contract variations on delayed investments and cost per case services that are over or under

plan, but is offset by a corresponding balance in income (£404k favourable)

ii) slippage on reserves for which funding had been committed (£543k favourable)

iii) impact of changed CCG SLA Contract activity phasing to date (£322k adverse)

iv) review of Trust reserves requirements and available as CIP (£665k favourable)

The Trust is reporting a current year overspend against expenditure budget of £2.854m. Including additional costs relating to the Public Dividend Capital Charge the adjusted overspend expenditure variance is £2.827m.

The current year net operating costs include £17.294m of directorate income. Excluding this income source the total costs amount to £140.627m. In addition to the operating costs, capital charges & finance costs amount to £8.126m.

The business unit is reporting an overspend in month and YTD due to the unachievement of CIP (£989k YTD)

This is offset by vacancies (YTD £349k) and further underspends against non pay and non recurrent

overachievement of income (over seas, private patients)

In month pay overspend due to reallocation of contingency bed costs. YTD is overspent as a result of

agency and locum medics costs, which are set to continue for the remiander of the financial year.

Non pay is underspent due to stock adjustment for pacemakers.

Ambulance and Urgent Care are underspent in the month by £40k. This £123k was due a transfer from

Mental Health for Paris costs/CIP. The year to date overspend of £626k is mainly due to agency staff

including medical staff plus unachieved CIP. Two business cases are underway for approval via the Trust

approval route to the CCG to fund pressures in Continence (£195k full year) and MPTT (£89k full year) This

will address £284k of the ytd total overspend of £626k

Mental Health overspent in month 9 by £46k. The overspend is due to Paris transfer cost and CIP to

AUC in December. Ytd, the Business Unit is underspent by £5k. The business unit is closely monitoring

the use of agency staff in key areas, including Medics plus inpatient unit cover to ensure the business

unit's budget remains balanced.

The COO division is mainly overspent in month due to the winter resilliance expenditure, this will be funded in

future months. The main cost pressures are Beacon CIP allocation and Mottistone NHS activity charged to

COO.

The overachievement on income relates mainly to pharmacy and costs are reflected in the non-pay position.

The Business unit has the majority allocation of CIP from the previous HAD directorate and this is reflected in

their monthly performance and year-end forecast.

Page 38


Cost Improvement Programme

January 16

The in month position for CIP is an achievement of £0.671m against a target of £0.730m, an under achievement of £0.059m.

Cumulatively there is an achievement of £5.077m with a target of £7.026m. This is an adverse variance of £1.949m.

The current year forecast is an achievement of £6.183m against a target of £8.500m, a shortfall of £2.317m. Further plans and budget reviews are being pursued including through the turnaround programme of work to ensure that this gap is mitigated

as far as possible.

Directorate

CIP Target

year to date

£'000

Recurrent

achieved year

to date

Non Recurrent

achieved year

to date

CIP achieved

year to date

£'000

Over / (Under)

Target

year to date

£'000Chief Operating Officer 132 0 0 0 (132)

Community and Mental Health 1,005 465 642 1,107 102

Ambulance & Community 611 214 2 215 (395)

Clinical Support 3,243 920 231 1,151 (2,091)

Surgery 907 58 123 181 (726)

Finance and Performance 207 234 1,266 1,499 1,293

Nursing and Workforce 181 77 75 152 (29)

Strategic and Commercial 583 282 331 613 30

Trust Administration 159 102 56 158 (0)

Grand Total 7,026 2,352 2,725 5,077 (1,949)

Directorate

CIP Target

2015/16

£'000

Recurrent

achieved

forecast year

end

Non Recurrent

achieved

forecast year

end

CIP achieved

year end

forecast

£'000

Over / (Under)

Target

forecast

£'000Chief Operating Officer 160 0 0 0 (160)

Community and Mental Health 1,216 592 757 1,350 134

Ambulance & Community 908 248 2 249 (659)

Clinical Support 3,744 1,279 235 1,514 (2,229)

Surgery 1,105 70 123 193 (912)

Finance and Performance 250 281 1,559 1,840 1,590

Nursing and Workforce 219 103 86 189 (30)

Strategic and Commercial 706 325 331 656 (50)

Trust Administration 192 136 56 192 0

Grand Total 8,500 3,035 3,149 6,183 (2,317)

Page 39


Cash

Plan

Year to date

Actual Variance Plan

Full Year

Forecast Variance

£000s £000s £000s £000s £000s £000s

Cash Balance 4,050 5,253 1,203 Cash Balance 1,890 1,715 (175)

Plan

Year to date

Actual Variance Plan

Full Year

Forecast

Actual Variance

£000s £000s £000s £000s £000s £000s

Operating Surplus/(Deficit) (459) (4,036) (3,577) Operating Surplus/(Deficit) (1,001) (3,136) (2,135)Depreciation and Amortisation 5,400 5,146 (254) Depreciation and Amortisation 6,531 6,363 (168)Impairments and Reversals 0 0 0 Impairments and Reversals 0 0 0Gains /(Losses) on foreign exchange 0 0 0 Gains /(Losses) on foreign exchange 0 0 0Donated Assets - non-cash 0 0 0 Donated Assets - non-cash (70) (70) 0Government Granted Assets received, credited to revenue but non-cash 0 0 0 Government Granted Assets received, credited to revenue but non-cash 0 0 0PFI/Finance Lease Interest Paid 0 0 0 PFI/Finance Lease Interest Paid 0 0 0Interest Paid (21) (7) 14 Interest Paid (27) (25) 2Dividend (Paid)/Refunded (1,813) (1,834) (21) Dividend (Paid)/Refunded (3,625) (3,646) (21)Release of PFI/Deferred Credit 0 0 0 Release of PFI/Deferred Credit 0 0 0Movement in Inventories 0 218 218 Movement in Inventories (228) 303 531Movement in Receivables 800 (3,054) (3,854) Movement in Receivables 1,000 (256) (1,256)Movement in Other Current Assets 0 0 0 Movement in Other Current Assets 0 0 0Movement in Trade and Other Payables 3,396 7,256 3,860 Movement in Trade and Other Payables 2,997 1,121 (1,876)Movement in Other Current Liabilities 0 0 0 Movement in Other Current Liabilities 0 0 0Provisions Utilised (185) (121) 64 Provisions Utilised (330) (405) (75)Movement in Non Cash Provisions 0 (203) (203) Movement in Non Cash Provisions 0 0 0

Cashflow from Operating Activities 7,118 3,365 (3,753) Cashflow from Operating Activities 5,247 249 (4,998)

Cashflow from Investing Activities Cashflow from Investing ActivitiesInterest Received 20 23 3 Interest Received 24 27 3Capital Expenditure - PPE (11,060) (6,802) 4,258 Capital Expenditure (11,244) (7,958) 3,286Capital Expenditure - Intangibles (750) (96) 654 Capital Expenditure - Intangibles (837) (494) 343

Cashflow from Investing Activities (11,790) (6,872) 4,918 Cashflow from Investing Activities (12,057) (8,422) 3,635

Cash Flows from Financing Activities (4,672) (3,507) (1,165) Cash Flows from Financing Activities (6,810) (8,173) (1,363)Revolving Working Capital Support Facility Accessed 0 0 0 Revolving Working Capital Support Facility Accessed 0 0 0Revolving Working Capital Support Facility Repaid 0 0 0 Revolving Working Capital Support Facility Repaid 0 0 0Capital Element of Finance Leases (77) (39) 38 Capital Element of Finance Leases (99) (39) (60)

0 0 0 0 0 0

Cashflow from Financing Activities (77) (39) 38 Cashflow from Financing Activities (99) 1,089 (1,188)

Net increase/decrease in cash (4,749) (3,546) (1,127) Net increase/decrease in cash (6,909) (7,084) (2,551)Opening Cash Balance 8,799 8,799 0 Opening Cash Balance 8,799 8,799 0Opening Balance Adjustment 0 0 0 Opening Balance Adjustment 0 0 0

8,799 8,799 0 8,799 8,799 0

0 0 0 0 0 0

Closing Cash Balance 4,050 5,253 1,203 Closing Cash Balance 1,890 1,715 (175)

January 16

The cash balance of c£5m held at the end of January is £1,203k more than planned. Primarily, this is because the increase in the

reported deficit of £3.6m is offset by the reduced cash spent on capital £4.9m (£6.9m against the original planned spend of £11.8m). The

variation in the cash balance can therefore be attributable to the net movement in other working capital.

The table above shows the forecast cash balance at 31st March 2016 will be £1,715. This will require careful monitoring of our cash

between now and the year-end. This is now based on the latest estimate of all known cash related items in 2015/16 including the draw

down of the £1.73m interim working capital support (the original agreed support loan of £2.3m has been reduced by the capital to

revenue transfer), the repayment to the IWCCG of the cash advanced in October and November and the expected recovery for the under-

performance in the acute SLA. The 2016/17 initial finance plan has not yet been built into the cash forecast assumptions and therefore

the forecast cash flow shown in the graph below still indicates that it may be necessary to continue with the revolving capital support

facility or apply for a further loan.

The cash balance held at the end of January is c£5.0m which is c£1.2m more than expected. The difference in the planned deficit to the actual figure at month 10 is c£3.6m. This is offset in cash terms by the underspend of £4.9m on capital expenditure and the variance against the

original budgeted depreciation charges of £254k. Other working capital movements of £119k account for the other slight difference in the cash balance.

Restated Cash and Cash Equivalents (and Bank Overdraft) at Beginning of the Period

Effect of Exchange Rate Changes in the Balance of Cash Held in Foreign Currencies

Restated Cash and Cash Equivalents (and Bank Overdraft) at Beginning of the Period

Effect of Exchange Rate Changes in the Balance of Cash Held in Foreign Currencies

Capital grants and other capital receipts (excluding donated/government granted cash

receipts)

Capital grants and other capital receipts (excluding donated/government granted cash

receipts)

Page 40


Cash

January 16

-20000000

-15000000

-10000000

-5000000

0

5000000

10000000

15000000

20000000

Jan

-16

Feb

-16

Mar

-16

Ap

r 1

6

May

16

Jun

16

Jul 1

6

Au

g 1

6

Sep

16

Oct

16

No

v 1

6

De

c 1

6

Jan

17

Feb

17

Mar

17

Ap

r 1

7

May

17

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

No

v 1

7

De

c 1

7

Jan

18

£

Cash flow - Forecast to January 2018

Payroll

Capital

NON NHS expenditure

NHS expenditure

Interim Revolving Working Capital Support - RECEIVED

Recharges to IOW CCG

SLA with IOW CCG

Other income

Month end bank balance as per GL

Page 41


Statement of Financial Position

1st April 2015

Plan Actual Variance Notes Plan Forecast Variance Notes

£k £k £k £k £k £k £k

Property, Plant and Equipment 107,504 110,177 107,786 (2,391) Property, Plant and Equipment 114,042 108,750 (5,292)

Intangible Assets 3,495 2,609 2,492 (117) Intangible Assets 2,451 2,697 246

Investment Property 0 0 0 0 Investment Property 0 0 0

Other Financial Assets 0 0 0 0 Other Financial Assets 0 0 0

Trade and Other Receivables 340 224 174 (50) Trade and Other Receivables 150 200 50

Non Current Assets 111,339 113,010 110,452 (2,558) Non Current Assets 116,643 111,647 (4,996)

Inventories 2,303 1,728 2,085 357 Inventories 1,500 2,000 500

Trade and Other Receivables 7,604 6,948 10,840 3,892 Trade and Other Receivables 6,930 8,000 1,070

Other Financial Assets 0 0 0 0 Other Financial Assets 0 0 0

Other Current Assets 0 0 0 0 Other Current Assets 0 0 0

Cash and Cash Equivalents 8,799 4,050 5,253 1,203 Cash and Cash Equivalents 1,890 1,715 (175)

Sub Total Current Assets 18,706 12,726 18,178 5,452 Sub Total Current Assets 10,320 11,715 1,395

Non-Current Assets Held For Sale 0 0 497 497 Non-Current Assets Held For Sale 0 0 0

Current Assets 18,706 12,726 18,675 5,949 Current Assets 10,320 11,715 1,395

Trade and Other Payables (18,694) (20,081) (24,661) (4,580) Trade and Other Payables (17,993) (14,105) 3,888

Other Liabilities 0 0 0 0 Other Liabilities 0 0 0

Provisions (643) (334) (319) 15 Provisions (448) (337) 111

Borrowings (incl. Working Capital Support Facility) 0 0 0 0 Borrowings (incl. Working Capital Support Facility) 0 0 0

Other Financial Liabilities 0 0 0 0 Other Financial Liabilities 0 0 0

Liabilities arising from PFIs / Finance Leases 0 (38) (16) 22 Liabilities arising from PFIs / Finance Leases 0 0 0

DH Working Capital Loan - FT Liquidity 0 0 0 0 DH Working Capital Loan - FT Liquidity 0 0 0

DH Working Capital Loan - Revenue Support 0 0 0 0 DH Working Capital Loan - Revenue Support 0 (1,735) (1,735)

DH Capital Loan 0 0 0 0 DH Capital Loan 0 0 0

Current Liabilities (19,337) (20,453) (24,996) (4,543) Current Liabilities (18,441) (16,177) 2,264

Trade and Other Payables 0 0 0 0 Trade and Other Payables 0 0 0

Other Liabilities 0 0 0 0 Other Liabilities 0 0 0

Provisions 0 0 0 0 Provisions 0 0 0

Borrowings 0 0 0 0 Borrowings 0 0 0

Other Financial Liabilities 0 0 0 0 Other Financial Liabilities 0 0 0

Liabilities arising from PFIs/Finance Leases 0 (933) (739) 194 Liabilities arising from PFIs/Finance Leases (933) (739) 194

DH Working Capital Loan - FT Liquidity 0 0 0 0 DH Working Capital Loan - FT Liquidity 0 0 0

DH Working Capital Loan - Revenue Support 0 0 0 0 DH Working Capital Loan - Revenue Support 0 0 0

DH Capital Loan 0 0 0 0 DH Capital Loan 0 0 0

Non-Current Liabilities 0 (933) (739) 194 Non-Current Liabilities (933) (739) 194

TOTAL ASSETS EMPLOYED 110,708 104,350 103,392 (958) TOTAL ASSETS EMPLOYED 107,589 106,446 (1,143)

FINANCED BY: FINANCED BY:

Public Dividend Capital 6,762 6,762 6,762 0 Public Dividend Capital 6,762 6,155 (607)

Retained Earnings Reserve 69,520 63,699 62,708 (991) Retained Earnings Reserve 62,406 62,994 588

Revaluation Reserve 34,426 33,889 33,922 33 Revaluation Reserve 38,421 37,297 (1,124)

Other Reserves 0 0 0 0 Other Reserves 0 0 0

TOTAL TAXPAYERS EQUITY 110,708 104,350 103,392 (958) TOTAL TAXPAYERS EQUITY 107,589 106,446 (1,143)

January 15

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in asset values, as well as other movements in working capital.

Year to Date Full Year

The reduced asset values of c£2.4m are attributable to the less than planned year-to-date spend on capital items. The movement in working

capital, mainly the increase in receivables offset by the increase in payables, is more than the planned level at month 10. As previously reported

this is mainly because the plan was based on figures before the final outturn for 2014/15 were confirmed. Assets Held for Sale relates to the

properties in Swanmore Road the sale of which is now likely to complete before the year-end. The receivables figure includes the £607k cap-to-

rev transfer pending receipt of a purchase order against which to raise the invoice to the DH and payables include significant accruals relating to

winter resilience costs. The short and long term liabilities shown on the balance sheet relate to the new finance lease in respect of the MRI

scanner which came into use during November.

The planned asset values included an estimated price increase of 5% and this has now been updated in line with the latest information

received from the DV during their initial review of the estate. The revenue support loan of £1,735m is now included and other assets and

liabilities are based on the best available current information. The PDC included in Taxpayers Equity has been reduced by the £697k capital to

revune transfer.

Page 42


Capital

Year to Date Year End Forecast

Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k

Strategic Capital 4,234 3,225 1,009 Strategic Capital 4,233 3,362 871

Operational Capital 3,675 1,983 1,692 Operational Capital 3,947 3,708 239

Total 7,909 5,209 2,700 Total 8,180 7,070 1,110

Strategic Capital Year to Date Full Year Operational Capital Year to Date Full Year

Plan Actual Variance Plan Forecast Plan Actual Variance Plan Forecast

Source of Funds £k £k £k £k £k Source of Funds £k £k £k £k £k

Strategic Funds C/F 0

External Funding 0 Initial Capital Resource Limit (based on Depn) 4,115 4,115 0 6,134 6,134

Finance Lease (MRI) 1,057 778 0 1,057 778

Capital Investment Loans 0 Capital to Revenue Transfer 0 0 0 0 (607)

Operational Capital 0 0 0 4,233 4,233 5,172 4,893 0 7,191 6,305

Donated Capital 0 Property Sales 750 526

0 0 0 4,233 4,233 Donated Funds 70 0 70 70 70

Other 169 0 169 169 169

Transfer to Strategic Capital (4,234) (4,234) 0 (4,233) (4,233)

1,177 659 239 3,947 2,837

Year to Date Full Year

Application of Funds Plan Actual Variance Plan Forecast Variance Risk Application of Funds Plan Actual Variance Plan ForecastVariance Risk

Strategic Capital Schemes £k £k £k £k £k £k Rating Operational Schemes £k £k £k £k £k £k Rating

MAU Extension 588 649 61 588 588 0 G Estates Schemes 449 334 115 534 673 (139) G

Ward Reconfiguration Level C 103 0 103 103 0 103 R IM&T RRP 500 96 404 500 273 227 G

Endoscopy Relocation 2,774 2,577 197 2,774 2,774 0 G MRI Upgrade - Finance Lease 1,057 778 279 1,057 778 279 G

Carbon Energy Fund 769 0 769 769 0 769 A Equipment RRP 838 521 317 882 996 (114) G

ICU/CCU 0 0 0 0 0 0 G Estates Staff Capitalisation 150 132 18 180 180 0 G

Contingency/Unallocated 555 0 555 555 186 369 G

Donated Assets 0 0 0 70 70 0 G

PARIS Implementation 126 42 84 169 169 0 G

Other (Non RRP, Equipment) 0 80 (80) 0 383 (383) G

4,234 3,225 1,009 4,233 3,362 871 3,675 1,983 1,692 3,947 3,708 239

NB - Please note the Year to Date and Full Year Plan figures are as per FIMS Return and not Capital Plan

The initial source of funds for 2015/16 was £8.18M, this included expected property sales of £750k which were delayed from 2014/15. We have now received and accepted an offer of £526k for the Swanmore Road properties and if the cash is received before year

end as expected it will go towards the £607k capital to revenue transfer shown in the figures below. The Gables is not expected to be sold within this financial year. The Finance Lease has now been finalised and the increase to the CRL to cover this is £778k as

opposed to the original plan of £1.057m, this is now reflected in the forecast outturn for the year.

Strategic Capital schemes includes the larger capital projects.

The MAU Extension has now been completed and the Endoscopy Relocation scheme is progressing well and expected to

complete within the approved timescale. The ICU/CCU project from 2014/15 remains on hold and in Assets Under

Construction in 2015/16, no further expenditure on this project has been agreed as yet. The Ward Reconfiguration of

Level C has also been put on hold for this financial year meaning an additional £103k has been made available for

reallocation. The phasing of the spend of the funding for the Carbon Energy Fund project has also been changed, the

consequence of which is a transfer of funds back to Operational Capital of £769k this financial year.

Operational Capital - Projects from 2014/15 carried forward into 2015/16 are the Ambulance CAD Upgrade (Equipment RRP) and the

Sevenacres AntiClimb Roofing Installation (Estates Scheme), the latter of which is now complete.

The Upgrade to the MRI (Equipment RRP) has now been completed. Following the finalisation of the lease the MRI has been added to the

Trust's asset register at £778k, the net present value of the lease payments over the seven year lease term. This has produced a variance

against the plan of £1.057m of £249k which is not available for cash spend as this was an increase to our CRL at the start of the financial

year and so the CRL will be adjusted to reflect this variance.

In line with the recent request from the Trust Development Authority that we review our Capital spend it has been decided that, in addition

to the £178k agreed in December, a further £429k will not be spent on capital this year but will be transferred to revenue to support our

year end position.

January 16

Page 43


Governance Risk Rating

With effect from the September report, the GRR has been realigned to match the Risk Assessment Framework as required by 'Monitor'.

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

Ref Indicator Sub SectionsThresh-

old

Weight-

ing

Q1

2015/16

Q2

2015/16

Q3

2015/16Jan Feb Mar

Q4

2015/16Notes

1 90% 1.0 No No No No No


3 92% 1.0 Yes No No No No


Urgent GP referral for suspected cancer 85%

NHS Cancer Screening Service referral 90%

surgery 94%anti-cancer drug treatments 98%

radiotherapy 94%

7 96% 1.0 Yes Yes Yes Yes Yes

All urgent referrals (cancer suspected) 93%For symptomatic breast patients (cancer

not initially suspected) 93%

Receiving follow-up contact within seven days of discharge 95%

Having formal review within 12 months 95%

10 95% 1.0 No No No Yes Yes


Red 1 calls 75% 1.0 No No No No No

Red 2 calls 75% 1.0 No No Yes Yes Yes

13 95% 1.0 No No Yes Yes Yes

14Early intervention in Psychosis (EIP): People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral

50% 1.0 - - - - -

People with common mental health conditions referred to the IAPT programme

will be treated within 6 weeks of referral75% 1.0 No No No No No

People with common mental health conditions referred to the IAPT programme

will be treated within 18 weeks of referral95% 1.0 Yes Yes Yes Yes Yes

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

Is the Trust below the YTD ceiling 1 No No No No No

17 ≤7.5% 1.0 No No No No No



20 N/A 1.0 Yes Yes Yes Yes Yes

Referral to treatment information 50%Referral information 50%

Treatment activity information 50%

TOTAL 11.0 12.0 12.0 11.0 0.0 0.0 11.0

R R R R R R R

January

Yes

No

GOVERNANCE RISK RATINGSInsert YES (target met in month), NO (not met in month) or N/A (as appropriate)

See separate rule for A&E

Historic Data Current Data

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway

A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge

5 No


1.0

No Yes

1.0 Yes

1.0 Yes Yes

1.0

NoNo

No

NoNo

No

Yes

No

YesYes Yes

Yes Yes

Yes

No

No

No

1.0

Certification against compliance with requirements regarding access to health care for people with a learning disability

Clostridium difficile – meeting the C. difficile objective

12

Minimising mental health delayed transfers of care

Mental health data completeness: identifiers

Mental health data completeness: outcomes for patients on CPA

1.0

15

Category A call – emergency response within 8 minutes, comprising:

Category A call – ambulance vehicle arrives within 19 minutes

Data completeness: community services, comprising:

Care Programme Approach (CPA) patients, comprising:

8

Meeting commitment to serve new psychosis cases by early intervention teams

All cancers: 62-day wait for first treatment from:

Improving access to psychological therapies (IAPT)

6

Admissions to inpatients services had access to Crisis Resolution/Home Treatment teams

All cancers: 31-day wait from diagnosis to first treatment

Cancer: two week wait from referral to date first seen, comprising:

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

Out

com

es

16

21

Acc

ess

9

Page 44

Isle of Wight NHS Trust Board Performance Report 2015/16January

Glossary of Terms

Terms and abbreviations used in this performance report

Quality & Performance and General terms QCE Quality Clinical ExcellenceAmbulance category A Immediately life threatening calls requiring ambulance attendance RCA Route Cause AnalysisBAF Board Assurance Framework RTT Referral to Treatment TimeCAHMS Child & Adolescent Mental Health Services SUS Secondary Uses ServiceCDS Commissioning Data Sets TIA Transient Ischaemic Attack (also known as 'mini-stroke')CDI Clostridium Difficile Infection (Policy - part 13 of Infection Control booklet) TDA Trust Development AuthorityCQC Care Quality Commission VTE Venous Thrombo-Embolism CQUIN Commissioning for Quality & Innovation YTD Year To Date - the cumulative total for the financial year so farDNA Did Not AttendDIPC Director of Infection Prevention and ControlEMH Earl Mountbatten HospiceFNOF Fractured Neck of Femur Workforce and Finance termsGI Gastro-Intestinal CIP Cost Improvement ProgrammeGOVCOM Governance Compliance CoSRR Continuity of Service Risk RatingHCAI Health Care Acquired Infection (used with regard to MRSA etc) CYE Current Year EffectHoNOS Health of the Nation Outcome Scales EBITDA Earnings Before Interest, Taxes, Depreciation, AmortisationHRG4 Healthcare Resource Grouping used in SUS ESR Electronic Staff RosterHV Health Visitor FTE Full Time EquivalentIP In Patient (An admitted patient, overnight or daycase) HR Human Resources (department)JAC The specialist computerised prescription system used on the wards I&E Income and ExpenditureKLOE Key Line of Enquiry NCA Non Contact ActivityKPI Key Performance Indicator RRP Rolling Replacement ProgrammeLOS Length of stay PDC Public Dividend CapitalMRI Magnetic Resonance Imaging PPE Property, Plant & EquipmentMRSA Methicillin-resistant Staphylococcus Aureus (bacterium) R&D Research & DevelopmentNG Nasogastric (tube from nose into stomach usually for feeding) SIP Staff in PostOP Out Patient (A patient attending for a scheduled appointment) SLA Service Level AgreementOPARU Out Patient Appointments & Records UnitPAAU Pre-Assessment UnitPAS Patient Administration System - the main computer recording system usedPALS Patient Advice & Liaison Service now renamed but still dealing with complaints/concernsPATEXP Patient Experience PATSAF Patient SafetyPEO Patient Experience Officer - updated name for PALS officerPPIs Proton Pump Inhibitors (Pharmacy term)PIDS Performance Information Decision Support (team)Provisional Raw data not yet validated to remove permitted exclusions (such as patient choice to delay)

Page 45



ON 2nd March 2016

Title Winter Resilience Monthly Update February 2016


Shaun Stacey, Chief Operating Officer

Author(s) Sarah Hayward, Head of Performance

Purpose To receive the monthly update on delivery against the Winter Resilience Plan


Receive X Approve




Trust Executive Committee 18-02-16









Board Seminar


Staff, stakeholder, patient and public engagement: None due to regular monthly update


The Trust’s Winter Resilience Programme is currently delivering interdependent system wide capacity and activity to improve patient flow for our non elective and elective patients to enable them to receive their treatment in the right place at the right time. This improved patient flow will also contribute to the achievement of key national performance standards including ambulance, emergency care and referral to treatment. Delivery of this Programme is monitored weekly against activity and financial plans both internally within the Trust and jointly through the System Resilience Group (SRG) structure. Two monthly updates have been previously provided to Trust Board in December 2015 and January 2016, and this report is a further regular update on progress for Trust Board’s information.


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The Board is recommended to receive this update for information.

Attached Appendices & Background papers None




Working with others to keep improving our services

A positive experience for patients, service users and staff



Date: 23 February 2016 Completed by: Sarah Hayward, Head of Performance

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TRUST BOARD REPORT WINTER RESILIENCE MONTHLY UPDATE

February 2016 1. SITUATION

The Trust’s Winter Resilience Programme is currently delivering interdependent system wide capacity and activity to improve patient flow for our non elective and elective patients to enable them to receive their treatment in the right place at the right time. This improved patient flow will also contribute to the achievement of key national performance standards including ambulance, emergency care and referral to treatment. Delivery of this Programme is monitored weekly against activity and financial plans both internally within the Trust and jointly through the System Resilience Group (SRG) structure. Two monthly updates have been previously provided to Trust Board in December 2015 and February 2016, and this report is a further regular update on progress for Trust Board’s information.

2. BACKGROUND

On 7 October 2015 the Trust Board approved the recommended preferred option to provide additional non elective and elective capacity required to deliver performance for the remainder of the year in emergency and elective care, whilst acknowledging a financial risk of £1.5m.

3. ASSESSMENT

Non Elective and Elective Capacity

The Winter Resilience Programme includes the following provision, with the current status reported against each: · acute medical capacity – Appley Ward opened in October 2015 providing 21 beds. 6

contingency beds opened following the Christmas and New Year period due to an increase in medical activity and these are still required. Actions in place to increase medical reviews and discharges to return to normal bed capacity levels continue and this is monitored within the daily patient flow meetings;

· reinstatement of non elective surgical capacity – Whippingham Ward has returned to its intended use, however, medical activity within this capacity has continued to be present, with an increase in January with contingency beds being opened. Increased reviews and discharges are also in place to reduce the contingency capacity required and return the ward to delivering its intended surgical activity;

· ringfencing elective capacity – both ring fenced elective wards continue to see non elective patients on the Wards; similarly, actions are in place to review these patients ensuring timely discharges to enable this capacity to be solely dedicated to elective activity in order to deliver the Trust’s activity plan;

· opening step down medical capacity off site (including ‘safe haven beds’) – The average bed occupancy for Poppy Unit since 11 October 2015 to 22 February is 94%; further quality performance information is shown below; and,

· additional flexible capacity to enable unexpected events to be managed as required – identified contingency beds are currently in use.

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Progress against the above key objectives within the Winter Resilience Programme continues to be monitored regularly through the SRG structure and reported in the regular updates of the joint Isle of Wight System Resilience Improvement Plan 2015/2016. Longer term resilience post March 2016 is being prioritised by the SRG to ensure appropriate and timely focus; as detail is developed it will be shared with Trust Board. As stated above, quality performance information is available for Poppy Unit and some of this is provided here. This information is monitored within the Medicine Clinical Business Unit as well as reported weekly within the Winter Resilience reporting and discussed within the weekly SRG sub group meetings with the Clinical Commissioning Group (CCG). Poppy Unit – Daily bed occupancy as at 22 February 2016:

Alongside monitoring the quality performance information of Appley and Poppy Wards, patient satisfaction surveys continued to be undertaken in addition to the existing national Friends and Family Test to ensure further monitoring of patients’ experience during this period of concentrated elective activity. Unfortunately, the response rate remains very low at approximately 9%, however, the detail within is reassuring. This information is currently being shared with our clinical wards teams for review and agreeing actions in response for implementation.

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Patient Satisfaction Surveys – Elective Wards, week ending 21 February 2016

Delivery of the Winter Resilience Programme is detailed against the following key milestones including those identified and prioritised from the recommendations following the Trust Development Authority (TDA) and Emergency Care Intensive Support Team (ECIST) stocktake in the Trust in November 2015. These are also monitored and discussed within the Trust’s Programme Governance Office framework, as well as the SRG’s weekly sub group meeting with the CCG. Progress against the key milestones as at 21 February 2016 is reported below.

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Winter Resilience Programme - Progress against key milestones as at 21 February 2016:

Non Elective Activity

Ambulance - Ambulance performance had achieved against the three key national targets (Red 1 and Red 2, both within 8mins, and 19mins) since September 2015, following three months of under achievement following the implementation of the ambulance front loaded model. It was anticipated this level of performance would continue, however, has been dependent on patient flow within the Accident & Emergency Department, and is subject to frailty in the low volume call numbers. In January, despite best efforts and plans, the Trust failed to achieve the Red 1 target of 75%, reaching 60.4% due to the statistical challenge around low volume call numbers. Assurance has been provided to the TDA that, whilst challenging, the Ambulance Service is focused on achieving all targets and continues to grow its first responder community scheme to enable sufficient resources going forward to meet this challenge. The Service will continue to closely

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monitor the figures in line with performance on a daily basis and additional resources will be applied to each day where need is identified to ensure we meet the standards required. The Service still aims to achieve the year end target of 75%.

Ambulance 3 Main Performance Targets – as at week ending 21 February 2016

A contract performance notice has been issued by the Clinical Commissioning Group (CCG) regarding the provision of ambulance handover performance information. A remedial action plan is being developed in agreement with the CCG to improve this provision, focusing on the accuracy and reporting of data to enable robust performance monitoring going forward.

Emergency Care 4hr Standard – Performance against the Emergency Care 4hr Standard (ECS) showed an initial improvement following the implementation of the Winter Resilience Programme in November 2015, however, not to the level planned, nor was it sustained. This was due to an inappropriate admission model, not implementing the previous ECIST 2012 recommendations, lack of required clinician and nursing complement and skill mix, and, continuing length of stay on medical wards impacting patient flow. As previously reported, in January 2016, two emergency care pathway managers commenced in ED to provide seven day operational management support to the Urgent Care teams and focus on preventing breaches and streamlining processes to support flow. Their impact against the performance of the ECS in January can be seen below however, unfortunately, it was not sustained. Patient groups’ length of stay is now longer than anticipated due to a combination of issues surrounding patient flow into the community and internal pathway management supporting discharge. These issues and delay reasons are currently being analysed within the Trust and findings will be shared and discussed with our partner organisations as appropriate. This will continue to be monitored closely both within the ED management structure, as well as through the SRG sub group weekly meetings with the CCG, alongside the delivery against the actions in the current ED action plan. Due to this, the revised trajectory to achieve the standard at 95% from the end of February 2016 is felt not to be achievable as demonstrated below (actual performance year to date is

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shown as the light blue line and the rolling 21day average shown as the dark blue line.) It is anticipated that improved performance will be achieved through the implementation of the ED action plan, in particular the implementation of the ambulatory care model, however, it continues to be subject to patient flow within the hospital and into the community and, as part of the performance monitoring may require further revision. Work is currently underway to review the trajectory going into next year in readiness for planning submissions; once confirmed, this revised trajectory will be shared with Trust Board.

Emergency Care 4hr Standard – Actual vs. Trajectory as at 21 February 2016:

Safer Start week was held in the Trust between 8th and 15th February 2016 with the aim to reset the service, surrounding processes and improve patient flow. It involved Safer Start debrief and lessons learned into a revised ED action plan which will inform the revised ECS trajectory. The ECS target sustained above 91% through the week and did achieve 95% on Thursday and it is tis success that the service will build on during March.

Elective Activity

The Trust Plan to deliver elective admitted activity, following the Summer period where this

was very limited due to system wide pressures, commenced on 19 October 2015. The Plan aimed to treat the increasing backlog of patients who had been waiting longer than 18weeks for their operation by the end of March 2016.

The impact of this inpatient and day case activity is measured by our performance against the ‘admitted’ part of the national ‘incomplete’ standard; the ‘non admitted’ part measures the outpatient part of the patient’s pathway. It is currently planned for the total incomplete target (non admitted plus admitted) to achieve from the end of March 2016. Total incomplete performance is 87.3% as at week ending 21 February 2016 against a trajectory of 90.79%. Work is currently underway to review the trajectory going into next year in readiness for planning submissions; once confirmed, this revised trajectory will be shared with Trust Board. Following analysis of the reasons for previous under performance, the actions required to support achieving this trajectory included recruitment of clinical and non clinical staff to the

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admitted booking team to increase pre assessment and booking capacity, as well as additional theatre staff to support further weekend activity. Interim booking capacity has been provided however not to the level required and thereby constraining the intended impact on performance. Theatre staff have been engaged and additional weekend lists are scheduled till the end of March 2016.

Progress against this performance forms part of the monitoring in the weekly SRG sub group with the CCG, the Trust’s weekly patient access meeting and the ‘Delivering Activity’ project governance framework.

The information graph below shows our performance for non-admitted patients against our recovery trajectory as at week ending 21 February 2016. The non-admitted incomplete is 93.1% against a trajectory of 97.7%, impacted by current under delivery within the gastroenterology specialty; discussions are currently being held and actions developed to address this position and outcomes will be shared within the SRG structure.

Non Admitted Incomplete Performance against Revised Trajectory as at w/e 21 February 2016

The next graph below shows our performance for admitted patients against recovery trajectory as at 21 February 2016. The admitted incomplete is 72.2%, just below trajectory of 72.9%. Admitted Incomplete Performance against Revised Trajectory as at w/e 21 February 2016

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Treatment provided at specialty level within the Trust Plan and the assumed income from this activity is shown below, split out into inpatient and day case activity. Whilst this performance is below Trust plan activity levels, it is good progress for our patients to be able to treated through the ring fencing of the elective capacity.

Delivering Admitted Activity Trust Plan (19/10/15-21/02/16)

The operational actions required to mitigate against this under delivery of the Trust Plan between now and the end of March 2016 are currently in place and their impact on performance is being monitored. However, there continue to be infrastructure constraints, including elective bed and pre assessment clinical capacity and staffing shortfall, as well as theatre utilisation. The calendar timing of Easter long weekend and patients extending choice also limit the impact of developing actions on performance. It is anticipated that activity level gains are likely to be marginal due to the volume of activity to be recovered equating to approximately 50% additional between now and 31 March 2016. Therefore, during this time the priorities will continue to be treating patients in turn thereby reducing our long waiting patients and improving performance against the incomplete target. Cancer 62day target – Urgent and suspected cancer activity has increased in Urology and, combined with the clinician vacancy issues, has continued to impact upon this specialty’s contribution to the Trust’s ability to achieve the cancer 62day target. Work is currently

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underway to review the trajectory going into next year in readiness for planning submissions; once confirmed, this revised trajectory will be shared with Trust Board.

Below is the cancer performance position as at 21 February 2016; key points are discussed within the Trust Board ‘Performance Report’ being presented to the 2nd March 2016 meeting. Cancer Performance against national targets, as at 21 February 2016

Actions to improve performance are Policy approval including timed pathway agreement, revised urology pathway management including increased outpatient and diagnostics capacity, and improved weekly monitoring in patient access meeting (including weekly PTL submission). Demand and Capacity Planning As part of both national and the Trust’s own business planning cycle, work is currently underway on developing the demand and capacity plans for 2016/17. Working with the CCG, initial demand plan forecasts for 2016/17 have been developed at point of delivery by specialty level equating to over 1,000 forecasts. When setting the forecasts, activity trend data back to Apr 2012 has been examined; trends have also been overlaid with known service changes and growth due to population changes have been applied. Work is also taking place internally on the subsequent capacity required to deliver that activity at staffing, bed and theatre levels, as well as the performance trajectories to be set throughout next year. Regular discussions will continue throughout March and the final agreed plans will be reported to Board. Financial Plan Formal approval has been sought from the CCG for the winter costs incurred in total and the majority of contract variations have been issued. Further negotiations are taking place regarding the cost of contingency beds which have been opened throughout the financial year due to bed pressures (approx. £844k Oct to Mar forecast & £269k for April to Sept). Poppy Unit After 21 weeks, the variance against approved spend is £33k underspent, with a breakeven forecast at 31st March 2016. This current position does not take into account the use of contingency beds or the potential 17 patients in Acute beds at the start of the project when Poppy first opened at 13 beds (approx. £138k).

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Appley Ward The position is reflecting an underspend in 21 weeks and forecast outturn. However, the contingency bed costs has not been taken into account against this spend, and the 2 together result in a forecast overspend of £146k. Theatres The project is currently £283k underspent against the plan in 21 weeks, with a forecast of £742k underspent at the end of the financial year, based upon the same trajectory. However, plans are being drawn up this week to increase the activity levels till the end of March 2016. The forecast takes all scrutiny requests into account, on top of the extrapolated forecast, therefore, assumes worst case.

4. RECOMMENDATION

The Board is asked to receive this update for information. 23 February 2016

REPORT TO THE TRUST BOARD (Part 1 – Public) Page 1


ON 2nd March 2016

Title Report from Chair of Finance, Investment, Information & Workforce Committee


Charles Rogers, Chair of Finance, Investment, Information & Workforce Committee

Author(s) Charles Rogers, Chair of Finance, Investment, Information & Workforce Committee

Purpose To receive the report on the Finance, Investment, Information & Workforce Committee


Receive X Approve

Previously considered by (state date and outcome):

Sub-Committee Dates Discussed Key Issues, Concerns and Recommendations from Sub Committee




23/02/16





Turnaround Board

Please add any other committees below as needed Staff, stakeholder, patient and public engagement: Not applicable

Executive Summary:

The Chair of Finance, Investment, Information & Workforce Committee will report on the following areas as discussed at the meeting held on 23rd February 2016. Human Resources:

· Safer Staffing · Sickness Absence · Medical Staffing · Raising Concerns at Work (Whistle Blowing) Policy

Financial:

· Financial Performance Report 2015/16 · Business Planning · Procurement Service Contract

Recommendation to the Trust Board: The Board is recommended to receive the report by the Chair of Finance, Investment, Information & Workforce Committee


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REPORT TO THE TRUST BOARD (Part 1 – Public) Page 2

None


Trust Goals & Priorities Cost Effective, Sustainable Services; Skilled and Capable Staff

Principal Risks (BAF) Finance, Workforce, Strategy & Planning


Date: 24th February 2016 Completed by: Chair of Finance, Investment, Information & Workforce Committee

FINANCE, INVESTMENT, INFORMATION AND WORKFORCE COMMITTEE MONTHLY ASSURANCE REPORT TO ISLE OF WIGHT NHS TRUST BOARD: FEBRUARY 2016

This report to the Trust Board follows from the February meeting of the Finance, Investment, Information and Workforce Committee (FIIWC) held on 23rd February 2016. The meeting was not quorate. Non-Executive Directors who were unable to attend provided comments prior to the meeting and agreement was sought from them after the meeting in terms of actions and recommendations arising. 1. Human Resources

1.1. Safer Staffing. Rostering in Safe Staffing areas has decreased in compliance (eight weeks in advance approved rosters) to nineteen percent in January from twenty four percent in December. This has an impact on staff planning and the resultant higher use of Agency and Bank personnel.

Limited Assurance.

1.2. Sickness Absence. The Committee has received a detailed review and analysis of Trust staff sickness. The paper that has been presented includes information from the recently concluded Internal Audit and new initiatives that are being introduced to improve sickness absence management. Comparative information for sickness in other organisations and also nationally has led the Committee to question whether the present sickness absence targets continue to be appropriate. Given the significant annual financial cost of sickness to the Trust, the Committee consider that this important piece of work should be discussed by the Trust Board at seminar.

Positive Assurance.

1.3. Medical Staffing. The committee has been provided with a detailed summary of the service provided by the Medical HR function. In particular, the number of outstanding vacancies, the challenges and actions that are being created in an effort to improve recruitment in the future.

Positive Assurance.

1.4. Raising Concerns at Work (Whistle Blowing) Policy. FIIWC received a half yearly report summarising concerns that have been raised using the dedicated and confidential e-mail address. For the six month period to the end of 2015, five concerns were received. Three of the concerns related to individuals own employment which fell outside of the policy. The two remaining concerns have been investigated. The cumulative total of concerns received using this e-mail address since 1st. April 2014 has been fourteen. The Committee have asked for a more detailed report in future, in particular to ensure that the Investigating Director for any case is appropriate and in all ways impartial. Finally it is noted that the Trust will respond to the outcome of the Freedom to Speak Up Review when the new policy is published.

Positive Assurance.

2. Financial

2.1. Financial Performance Report 2015/16. At month ten the Trust Forecast Outcome is

currently estimated as: · Best Case £6.4m deficit · Most Likely £6.7m deficit · Worst Case £9.4m deficit

The Cost Improvement Plan (CIP) gap forecast is £2.317m and therefore a significant risk of achievement remains. It is also noted that the request to the CCG for the funding of additional costs for the opening of contingency beds has not yet been supported. The Committee have been advised that due to the current level of activity performance against plan and risks to forecast achievement there is a negative level of assurance at present.

Negative Assurance

2.2. Business Planning. The Trust’s initial draft plan for 2016/17 identifies a CIP requirement of 6.7% (£10.65m) to break even. Identified schemes detailed within the Draft Plans total 177, indicating savings of £3.9m although validation is required. Whilst there has been some improvement in savings, plans remain significantly off trajectory and the Committee remains of the opinion that far more needs to be done.

Negative Assurance.

2.3. Procurement Service Contract. The Committee received the Procurement Business Case. The proposal is to go forward to the Trust Board Part 2 for a decision.

Positive Assurance.

Charles Rogers

Chair, FIIWC

23rd February 2016

Top Key Issues & Risks for Raising at Board – 2nd March 2016 Page 1 of 2

Top Key Issues and Risks arising from Sub Committees for raising at Trust Board

Quality Governance Committee Meeting held on 24TH February 2016

Minute no: Risks 16/Q/028 Data information and need for service level data required – details within Chair report

to Board 16/Q/052 Sepsis CQUIN – urgent review being undertaken Highlights 16/Q/035 Nutrition improvement progress made to date 16/Q/036 Poppy Unit assurance and progress made

Finance, Investment, Information & Workforce Committee held on 23rd February 2016

Min. No. Top Key Issues & Risks for Raising at TEC & Trust Board 16/F/069 Human Resources Report – Safer Staffing: Rostering in Safe Staffing areas has

decreased in compliance (8 weeks in advance approved rosters) to 19% in January from 23% in December. This has an impact on staff planning and the resultant higher use of Agency and Bank personnel.

16/F/070 Review of Sickness Absence: The Committee has received a detailed review and analysis of Trust staff sickness. Comparative information for sickness in other organisations and also nationally has led the Committee to question whether the present sickness absence targets continue to be appropriate. Given the significant annual financial cost of sickness to the Trust, the Committee consider that this important piece of work should be discussed by the Trust Board at Seminar.

16/F/071 Review of Medical Staffing: The Committee has been provided with a detailed summary of the service provided by the Medical HR function. In particular, the number of outstanding vacancies, the challenges and actions that are being created in an effort to improve recruitment in the future.

16/F/072 Raising Concerns (Whistleblowing) Report: FIIWC received a half yearly report summarising concerns that have been raised using the dedicated and confidential email address. For the 6 month period to the end of 2015, 5 concerns were received. Three of the concerns related to individuals own employment which fell outside of the policy. The 2 remaining concerns have been investigated. The cumulative total of concerns received using this email address since 1st April 2014 has been 14. The Committee has asked for a more detailed report in future, in particular to ensure that the investigating Director for any case is appropriate and in all ways impartial. Finally, it is noted that the Trust will respond to the outcome of the ‘Freedom to Speak Up’ Review when the new policy will be published.

16/F/074 Human Resources Strategy: The Committee agreed the updated Human Resource Strategy for presentation to the Trust Board for approval.

16/F/087 CIP Plan 2016/17: The Trust’s initial draft plan for 2016/17 identifies a CIP requirement of 6.7% (£10.65m) to break even. Identified schemes detailed within the draft plans total 177, indicating savings of £3.9m although validation is required. Whilst there has been some improvement in savings, plans remain significantly off trajectory and the Committee remains of the opinion that far more needs to be done.

16/F/088 Financial Performance: The Trust is currently forecasting a £6.7m deficit at year end but there is a risk to this due to Winter Resilience Improvement Plan and the remaining CIP gap of £2.3m. Cash is being managed. Therefore there is a significant risk to

FOR PRESENTATION TO TRUST BOARD ON 2nd MARCH 2016

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Top Key Issues & Risks for Raising at Board – 2nd March 2016 Page 2 of 2

achievement. It is also noted that the request to the CCG for the funding of additional costs for the opening of contingency beds has not yet been supported. Due to the current level of activity performance against plan and risks to forecast achievement there is a negative level of assurance at present.

16/F/093 Turnaround Report – Clinical Job Planning: The Committee is concerned that clinical job planning has not been taken forward and was disappointed in terms of missed opportunities for CIPs.

16/F/095 Procurement Service Contract (Commercial in Confidence): The Committee agreed the option proposal be submitted to the Trust Board in private for approval.

Audit & Corporate Risk Committee held on 9th February 2016

Min. No. Top Key Issues/Risk 16/A/005 Appraisal Process: The Committee opined that the organisation’s Goals and Priorities

should be agreed by April in order that these can be cascaded down to individuals in the organisation, via the appraisal process, to deliver those Goals and Priorities, with support to enable staff to do that. This should take place in the first quarter of the year otherwise the Trust is not delivering the Goals and Priorities for that year.

16/A/006 Principal Risk - Financial Resilience: The Committee was concerned and acknowledged that the Trust’s finances are difficult. The need for the organisation to have the right skills and capacity, to be strategically focused, and for lessons to be learnt in order to deliver CIPs was highlighted and emphasised. In addition, the challenge is to have an overall process that drives forward to provide sustainability for the organisation.

16/A/008 Operating Plan Development 2016/17: The Committee was concerned at the lateness in producing the Operating Plan and felt that culture and prioritisation need to be addressed and considered alongside operational pressures within the organisation. The Trust needs to ensure that those managers who do not have the requisite skills are given the necessary training to acquire those skills. It would be untenable to have the same debate next year.

16/A/009 Principal Risk Register (BAF) 2015/16: The Committee considered that there should be triangulation of the Principal Risk Register with the CCG, GPs and local authority to obtain feedback on whether this resonates with our customers.

16/A/016 Internal Audit Plan 2016/17: The Committee agreed the Internal Audit Plan for 2016/17 subject to requested amendments.

16/A/019 External Audit Plan 2015/16: The Plan for the 2015/16 audit was agreed. The indicative fee for the Trust’s audit is £67,000 excluding VAT.

16/A/023 Draft Security Strategy: The draft Strategy was agreed subject to agreed amendments for presentation to TEC. The Committee considered that the raising of awareness security management at Board level should be on an annual basis as this links in with Emergency Preparedness.

16/A/026 Auditor Panel: The draft terms of reference were agreed for presentation to the Trust Board for approval. The inaugural meeting of the Auditor Panel to be held on the 10th May 2016 immediately following the ACRC meeting.

Full Minutes of Meetings

Please note that the full minutes of these meetings are available electronically and have been previously circulated to members. Mark Price Company Secretary 29th February 2016



ON 2 MARCH 2016

Title Auditor Panel


Executive Director of Financial & Human Resources

Author(s) Healthcare Financial Management Association (HFMA) Example Terms of Reference

Purpose To recommend to the Trust Board:

· approval of the terms of reference for the Auditor Panel

· appointment of the Chair of the Auditor Panel from within the membership of the Audit & Corporate Risk Committee.


Receive Approve X





Audit and Corporate Risk Committee 09/02/16 Agreed draft terms of reference for the Auditor Panel








Board Seminar


Staff, stakeholder, patient and public engagement: N/A


The draft terms of reference are taken from the example terms of reference produced by the Department of Health and HFMA. The Board is asked to appoint a Chair of the Auditor Panel from within the membership of the Audit & Corporate Risk Committee. The Auditor Panel will meet separately from the Audit & Corporate Risk Committee and the minutes of the meetings will be submitted to the Trust Board. The inaugural meeting of the Auditor Panel is on the 10th May 2016 immediately following the ACRC meeting, at which the terms of reference will be adopted,


The Trust Board is asked to:

· Approved the draft Auditor Panel terms of reference

· Appoint a Chair from within the membership of the Audit & Corporate Risk Committee

Enc O


TT


Draft terms of reference



All Goals and Priorities

Principal Risks (BAF) All Principal Risks


Compliance with the Department of Health Guidance for Health Bodies to meet their Statutory Duties –September 2015

Date: 22 February 2016 Completed by: Corporate Governance Officer

Auditor Panel Terms of Reference 1 January 2016

Draft terms of reference for an auditor panel

Background

The Local Audit and Accountability Act 2014 (the Act) requires every ‘relevant authority’ to appoint an auditor panel to exercise functions set out in the Act (part 3, section 9). In the NHS, relevant authorities are NHS trusts and clinical commissioning groups (CCGs).

Schedule 4 paragraph 1 of the Act states that:

• The auditor panel MUST be appointed either by the organisation OR by the

organisation and one or more other relevant authority1 • The auditor panel MUST be either a specially established panel OR an existing

committee, sub-committee or panel.

It is for the organisation’s board/ governing body to decide how it appoints its auditor panel.

The auditor panel must be in place in time to advise on the appointment of external auditors for 2017/18. In practice this means that the panel needs to be established early in 2016.

These terms of reference assume that an NHS trust board or CCG governing body has decided to nominate its existing audit committee to act as its auditor panel. No other relevant authorities are involved.

It is important to remember that even when this approach is followed (i.e. the existing audit committee is nominated as the auditor panel), the statutory requirements set for auditor panels must be followed. This means that the panel must have its own terms of reference and discharge its duties separately from the audit committee.

This briefing has been produced by the HFMA’s Governance and Audit Committee and is designed to help NHS trusts and CCGs as they set up their auditor panels. The terms of reference set out in the briefing are provided as an example only and reflect the requirements of the Act. They do not go into detail about how the auditor panel should function or fulfil its role. The HFMA, working alongside the Department of Health, has issued a separate briefing that provides practical guidance – Auditor Panels: guidance to help health bodies meet their statutory duties – is available via the HFMA and gov.uk websites.

1 For example, two CCGs may decide to appoint a single joint auditor panel to achieve economies of scale.


Terms of Reference Constitution

The Trust Board hereby resolves to nominate its Audit &Corporate Risk Committee to

act as its Auditor Panel in line with schedule 4, paragraph 1 of the 2014 Act2. The Auditor Panel is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these terms of reference.

Membership

The Auditor Panel shall comprise the entire membership of the Audit & Corporate Risk

Committee with no additional appointees3. This means that all members of the Auditor

Panel are independent, non-executives4. This satisfies the requirement that an Auditor Panel must have at least three members with a majority who are independent and non-executive members of the Board.

In line with the requirements of the Local Audit (Health Service Bodies Auditor Panel and Independence) Regulations 2015 (regulation 6) each member’s independence must be

reviewed against the criteria laid down in the regulations5. Chairperson

Either the Audit & Corporate Risk Committee chairperson will be appointed by the Board to chair the Auditor Panel OR one of the Auditor Panel’s members shall be appointed chairperson of the Auditor Panel by the Board6.

Removal/ resignation

The Auditor Panel chairperson and/ or members of the panel can be removed in line with rules agreed by the Board.

Quorum

To be quorate, independent members of the Auditor Panel must be in the majority AND there must be at least two independent members present or 50% of the Auditor Panel’s total

membership, whichever is the highest7.

2 Boards/ governing bodies can – if they choose – nominate a ‘sub-set’ of the audit committee to act as the auditor panel. If a sub-set is used, there must be at least 3 members with a majority who are independent and non-executive members of the board/ governing body. 3 If a ‘sub-set’ of the audit committee is nominated to be the auditor panel the membership should be specified. 4 Regulation 2 of the Local Audit (Health Service Bodies Auditor Panel and Independence) Regulations 2015 allows for instances where a member of the board/ governing body may not satisfy the independence criteria and still be a member of the auditor panel. Such instances are likely to be rare. If there are non-independent members they must be in the minority. 5 If a specially established panel is nominated with new members (i.e. not from the existing audit committee) a full recruitment process must be followed in line with regulation 3. This means that any prospective members who are not on the board/ governing body must be appointed in response to an advertised vacancy and after submitting an application. 6 Key issues to bear in mind are that the chairperson must be independent and a non-executive member of the board/ governing body AND the chairperson of the organisation


itself must not be a member of the auditor panel. 7 This rule should also be adhered to if the auditor panel is a sub-set of the audit committee


Attendance at meetings The Auditor Panel’s chairperson may invite executive directors and others to attend depending on the requirements of each meeting’s agenda. These invitees are not members of the auditor panel.

Frequency of meetings

The Auditor Panel shall consider the frequency and timing of meetings needed to allow it to discharge its responsibilities but, as a general rule, will meet on the same day as the Audit & Corporate Risk Committee.

Auditor Panel business shall be identified clearly and separately on the agenda and Audit & Corporate Risk Committee members shall deal with these matters as Auditor Panel members NOT as Audit & Corporate Risk Committee members.

The Auditor Panel’s chairperson shall formally state at the start of each meeting that the Auditor Panel is meeting in that capacity and NOT as the Audit & Corporate Risk Committee.

Conflicts of interest

Conflicts of interests must be declared and recorded at the start of each meeting of the Auditor Panel.

A register of Auditor Panel members’ interests must be maintained by the Panel’s chairperson and submitted to the Board in accordance with the organisation’s existing Conflicts of Interest Policy.

If a conflict of interest arises, the chairperson may require the affected Auditor Panel member to withdraw at the relevant discussion or voting point.

Authority

The Auditor Panel is authorised by the Board to carry out the functions specified below and can seek any information it requires from any employees/ relevant third parties. All employees are directed to co-operate with any request made by the Auditor Panel.

The Auditor Panel is authorised by the Board to obtain outside legal or other independent professional advice (for example, from procurement specialists) and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. Any such ‘outside advice’ must be obtained in line with the organisation’s existing rules.

Functions

The Auditor Panel’s functions8 are to:

• Advise the organisation’s Board on the selection and appointment of the external auditor. This includes: - agreeing and overseeing a robust process for selecting the external auditors in line with the organisation’s normal procurement rules - making a recommendation to the Board as to who should be appointed

8 Practical guidance on how to fulfil these functions is set out in the HFMA’s September 2015 briefing,

Auditor Panels: guidance to help health bodies meet their statutory duties


- ensuring that any conflicts of interest are dealt with effectively

• Advise the organisation’s Board on the maintenance of an independent relationship with the appointed external auditor

• Advise (if asked) the organisation’s Board on whether or not any proposal from the external auditor to enter into a liability limitation agreement as part of the procurement process is fair and reasonable

• Advise on (and approve) the contents of the organisation’s policy on the purchase of non-audit services from the appointed external auditor

• Advise the organisation’s Board on any decision about the removal or resignation of the external auditor.

Reporting

The chairperson of the Auditor Panel must report to the Board on how the Auditor Panel discharges its responsibilities9.

The minutes of the Panel’s meetings must be formally recorded and submitted to the Board by the Panel’s chairperson. The chairperson of the Auditor Panel must draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action.

Remuneration

Payments to Auditor Panel members shall be in line with the organisation’s existing approach to remuneration and allowances.

Administrative support

The organisation’s Company Secretary (or governance lead) shall be responsible for organising effective administrative support to the Auditor Panel. The duties of the person appointed to fulfil this role shall include:

• Agreement of agendas with the chairperson • Preparation, collation a nd circulation of papers in good time • Ensuring that those invited to each meeting attend • Taking the minutes and helping the chairperson to prepare reports to the Board • Keeping a record of matters arising and issues to be carried forward • Arranging meetings for the chairperson • Maintaining records of members’ appointments and renewal dates etc • Advising the Auditor Panel on pertinent issues/areas of interest/ policy

developments • Ensuring that Panel members receive the development and training they need • Providing appropriate support to the chairperson and Panel members.

9 If the auditor panel is a sub-set of the audit committee, this report should be separate from the report/ minutes of the audit committee so that it is clear that the auditor panel is fulfilling a distinctive role.

FOR PRESENTATION TO PUBLIC BOARD ON 2nd MARCH 2016

QUALITY GOVERNANCE COMMITTEE Held on Wednesday 24th February 2016

Present: Dr Nina Moorman Non-Executive Director - Chair Jessamy Baird Non-Executive Director- Deputy Chair David King Non-Executive Director Alan Sheward Executive Director of Nursing (EDN) Dr Mark Pugh Executive Medical Director Deborah Matthews Lead for Patient Safety, Experience & Clinical

Effectiveness & Deputy DIPC (LSEE) Chris Orchin

Chair, Healthwatch IW (HIW)

In Attendance: Mandy Blacker SEE Business Manager (SEEBM) Vanessa Flower Patient Experience Lead (PEL) For item 16/Q/035 Tracy Cloke Nutrition Nurse For item 16/Q/036 Pieter Joubert Head of Nursing & Quality for Medicine (HNQM) Minuted by: Jo Ferguson Quality Governance Committee Administrator (CA) Observing: Jo Winch Quality Governance Committee Administrator from

7/3/2016

Key Points from Minutes to be reported to the Trust Board Minute no: Risks 16/Q/028 Data information and need for service level data required – details within Chair report

to Board 16/Q/052 Sepsis CQUIN – urgent review being undertaken Highlights 16/Q/035 Nutrition improvement progress made to date 16/Q/036 Poppy Unit assurance and progress made Minute No.

16/Q/023 APOLOGIES FOR ABSENCE

Apologies were received from: John Doherty, Clinical Director Mental Health and Learning Disabilities Dr Sandya Theminimulle, Clinical Director, Clinical Support Services, Cancer & Diagnostics Chris Smith, Clinical Director, Ambulance Urgent Care & Community

16/Q/024 CONFIRMATION OF QUORACY The Chair confirmed the meeting was quorate.

16/Q/025 DECLARATIONS OF INTEREST There were no declarations of interest.

16/Q/026 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 27th January 2016 were agreed as an accurate

record with no amendments.

16/Q/027 REVIEW OF ACTION TRACKER The Committee reviewed the Action Tracker and updated the following:

a) QGC/0431 -"National Hip Audit”: To be presented at the March meeting and

SEEBM to establish who would present b) QGC/0486 – Consultant/Hospital LED cancelled appointments and

operations: Service area to be invited to March SEE committee to provide more detailed assurance report and this would then be reported within the SEE report to the Committee

c) QGC/0450 - Mandatory Training results for Ward areas: The Chair confirmed this was referred to the Finance, Investment, Information and

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Quality Governance Committee 24th February 2016 Page 1 of 7

Workforce Committee in February and awaiting response. d) QGC/0453 Venous Thromboprophylaxis (VTE) Prescription: The

Committee noted the recommendations for improvement and advised that a detailed report be presented to the April meeting.

All other actions were forward dated for completion from March 2016.

QUALITY 16/Q/028 REPORT FROM SAFETY, EFFECTIVENESS & EXPERIENCE COMMITTEE The Lead for SEE advised the Committee the paper provides a summary update to

the Quality Governance Committee (QGC) and the Trust Executive Committee (TEC) from the Patient Safety, Experience & Clinical Effectiveness Sub-Committee Meeting on 17th February 2016. The report details exceptions from the January Quality Report. The EDN advised the Committee that an Executive summary based on the highlights from this report and the quality aspects of the organisation would also now be produced and provided for further assurance to the Board. The EDN highlighted the following areas of particular note for the Committee:

i. Safety Grade 4 pressure ulcers in the Trust continues to be high. However, the level of pressure ulcers causing serious harm has remained the same. There is concern the rate of reduction in the Hospital setting is not reducing at the rate of the community. A hospital led Pressure Ulcer Collaborative is planned for March 2016. The rate of HCAI remains higher than the trajectory for January 2016. Action being taken includes work to develop service specific quality data to ensure that reporting is accurate. A piece of work is to be undertaken to look in more detail at the levels of incident and where in the organisation these are occurring.

The EDN also advised that the Trust has signed up to and will be attending a national Health Care Aquired Infections (HCAI) initiative that is being run. This is a 90 Day improvement programme to support 30 NHS Trusts and FTs to deliver improvements in infection prevention control (IPC). The specific aim of the programme is to deliver an improved experience and clinical outcome for patients through the delivery of best practice pathways in IPC, whilst also seeking to measure, monitor and reduce the cost of care by having a zero tolerance to avoidable infections.

ii. Experience

EDN advised the Committee that the rates of satisfaction regarding the Family and Friends test remains high across all services except for the Ambulance service whose data cannot be used reliably due to such low response rates. Concerns remain over the response rates with a particular concern in Emergency Department and Community Services. Outcomes will be reported through the Quality Report. A more detailed response has been requested from the Clinical Business Units on their improvement plans in response to assurance against the response rate.

iii. Effectiveness

The latest Standardised Hospital Mortality Index (SHMI) rate has demonstrated a continued downward trend. There is low level use of the Amber Care Bundle and Priorities of care continues to have low uptake. The amount of audit completed in response to the Quality Improvement Plan (QIP) is currently rated as negative assurance across a number of acute hospital


measures. A review of the actions arising out of the End of Life Care improvement plan needs to be concluded with greater emphasis on clinical oversight within the wards and departments of the Trust. The EDN has requested to meet with all QIP improvement leads to ensure the need to provide accurate and contemporaneous data is understood. There is a further need to review the actions in response to the CQC enforcement actions where practice has now been in place for 12 months. There will be a renewed focus on assurance against the Quality Improvement Plan Actions. This will be explored further in the month of March with formal Board reporting in April as agreed in November 2015

The key issue of concern is data in regard to performance and quality to allow monitoring and assurance provision. All quality improvement methodologies require service specific quality data and the Committee urged the development of data aligned to service areas within Clinical Business Units to allow more detailed deep dive into the data. The Committee agreed to raise this as an issue to Trust Board.

Action: Chair

Delayed Discharges in care was raised as this had been referred by the Audit Committee as an item for discussion. The Committee agreed that a report regarding the actions being taken and assurances would be required to be presented.

Action: CA

The Committee also received an update regarding the current business planning process and to support the Clinical Business Units to ensure Quality Improvement Measures are included with the business planning process a Quality improvement template and guidance document would be provided by the SEEBM.

Action: SEEBM

16/Q/029 CONSULTANT LED CANCELLATIONS The Committee noted that an assurance mitigation report had been provided by the

Clinical Business Unit and requested that this is re-presented to the Safety, Experience and Effectiveness meeting in March and the Operational Manager for the area attends to present and provide the required assurances.

Action: SEE

16/Q/030 MORTALITY/SUMMARY HOSPITAL-LED MORTALITY INDICATOR (SHMI) EMD presented the current status and it was noted that the Standardised Hospital

Mortality Index (SHMI), which is an NHS comparative Index, currently stands at 1.00 which is the lowest level for the past 4 years. Review of all deaths is carried out and shows a steadily increasing number of patients with a documented do not resuscitate plan in place and identified as requiring end of life care. The End of Life action plan in response to the CQC inspection still requires greater emphasis on clinical oversight in wards and departments and the EDN is leading a review of these actions. The Committee will be updated via the year-end report due in April 2016. A Bereavement Survey conducted between August and November 2015 to answer questions concerning communication raised by the CQC inspection. The result demonstrated a largely positive response from relatives regarding the care of their relatives. The Committee was assured from this and noted this will be continued to be monitored through an ongoing survey.

16/Q/031 QUALITY INITIATIVES FROM CLINICAL BUSINESS UNITS The Committee requested this item be carried forward to the March meeting when

Clinical Directors would be in attendance.


The Quality Improvement Framework (QIF) assurance report was discussed under this item. The Committee requested that the report be presented in a different style including the patient safety items and remove the Listening into Action, Executive Walkabouts and Patient Experience Group sections as it was felt these were not projects that needed to be reported on within this report as all of these areas related to Leadership Visibility. SEEBM to amend report and share with the Committee.

Action: SEEBM

16/Q/032 QUALITY PRIORITIES 2016/17

The SEE Business Manager presented a paper which provided an outline of the quality priorities that have been consulted on and identified for 2016/17, to be included in the Trust’s Quality Account. Following review of the feedback received, the results of the consultation have revealed the quality priorities, as we move forward to 2016/17. These are outlined below:-

1. PATIENT SAFETY • Implementation and monitoring the effectiveness of the sepsis care

bundle • Reduce incidents of patient harm

2. CLINICAL EFFECTIVENESS • Improve the discharge planning process • Improve communication with patients and carers

3. PATIENT EXPERIENCE

• Improve the culture of the organisation to improve patient experience

The Committee was informed that the Clinical Business Units would be consulted on how they will be able to meet these locally and a report advising on how these priorities will be measured will be presented to SEE Committee, then Quality Governance Committee and will be presented to Trust Board for information.

Action: SEEBM

PATIENT SAFETY 16/Q/033 SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRIs) This report provides an overview of the Serious Incident Requiring Investigation (SIRI)

activity during January 2016. During January 2016 the Trust reported 1 Serious Incident to the Isle of Wight Clinical Commissioning Group (CCG). The Committee confirmed receipt of the report and had no further questions.

16/Q/034 SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRIs) New Draft Proposal Lead for SEE advised the Committee that an initial meeting with the Surgery, Women

and Children’s Business Unit, EDN, Clinical Director and Head of Nursing and Quality had been undertaken. The outcomes from the meeting clearly highlighted the need for a much improved process that focusses on the lessons to be learnt and more robust reports. A new policy and process will be implemented that would support a more streamlined process that focusses on the priorities and it was also suggested that patient and/or relative feedback is sought on the content of the report before being closed by the Clinical Commissioning Group. The Lead for SEE would provide an updated status report on progress at the April meeting.

Action: Lead SEE

16/Q/035 NUTRITION NURSE SPECIALIST REPORT Tracy Cloke, Clinical Nurse Specialist was appointed in December 2015 to lead on

this work and presented to the Committee an update report on actions to date and future plans.


An audit in January showed that 32% of patients are either malnourished or at risk of developing it, which is in line with national figures for people admitted to acute care. Initial areas for improvement are improving the accuracy of assessment and the focus given to nutrition by medical and nursing staff by education, improving compliance with guidance, and developing pathways and policies for all aspects of nutrition. Plans for a monthly Link nurse group that would review nutrition and hydration within the Trust including out of hours provision and the availability of snacks throughout the day. Longer term the group would look at the Mental Health and Community areas. A suggestion was to include a key performance indicator that measured numbers of malnourished patients admitted to see if they are readmitted and the status of their nutrition. The Committee thanked Tracy Cloke for all the improvement measures put in place to date and would like to receive future updates as plans progress.

16/Q/036 POPPY UNIT ASSURANCE REPORT Pieter Joubert, Head of Nursing and Quality for Medicine (HNQM) presented the

Poppy Unit Assurance Report. This had been requested as concerns were raised about the care and staffing at the temporary step down facility opened at Solent Grange Nursing Home, the Poppy Unit, shortly after it opened. An assurance report was received by the Committee and an action plan developed following a series of assurance visits. The Committee was assured that all necessary actions had been undertaken. Length of Stay on the unit was raised and the HNQM confirmed that much work was underway with the Clinical Commissioning Group (CCG) to ensure links with care providers are improved in order to ensure care packages are available to allow discharges from the unit in a timely way. The Committee requested to know the future plans for the Poppy Unit, and the patients it cares for, from the end of March. The EDN confirmed that the CCG are currently awaiting capacity plans from the Trust to ensure that any ongoing support will meet activity targets. It has been suggested that a phased reduction could be a potential solution. An update would be provided at the April meeting.

Action: HNQM

PATIENT EXPERIENCE 16/Q/037 PATIENT STORY This was presented to the Committee in video format and related to discharge

planning and contained feedback from a volunteer, patient and member of staff from the discharge lounge. The query of medications being available in a timely manner for discharge would be raised with the Chief Pharmacist to respond to.

16/Q/038 PATIENT STORY ACTION TRACKER

The Patient Experience Lead advised the Committee that the report shows that since March 2013, the Trust has recorded a total of 47 stories. During the quarter 2 stories were seen at Quality Governance Committee and Trust Board. The two films related to Urology Services and MAAU. Only 2 actions remain outstanding from the total of 22 actions identified from all 47 stories that have been captured since March 2013, and these are progressing well. The patient story process continues to be reviewed and refined regularly to ensure that the patient’s voice is heard at Board and aligns to key issues within the Trust. The Committee recommended that as a Trust Board meeting would be taking place at the Earl Mountbatten Hospice in future that patient story feedback from a palliative care patient should be considered. The Chair requested that suggestions for areas to be included would be useful and it was noted that mental health and community areas should also be included.


Action: PEL 16/Q/039 COMPLAINTS QUARTERLY REVIEW The report identifies that the quarter has again seen a rise in complaints, but a

decrease in the number of concerns. This reflects to some extent the change in process, and the improvements made in response to the Healthwatch report on the complaints management process. Delays in responding to concerns are still occurring, and there was a slight decrease in the achievement of the 3 day acknowledgement standard this month. The key subject of complaints remain as clinical treatment and communication and from complaints and concerns the area with the highest area was the Emergency Department. The Committee was asked to note the improving trend in relation to the complaints / concerns received regarding OPARU1. Since putting in extra staffing the concerns raised about unanswered calls has seen a significant decline, although there was a slight increase in December 2015. This report shows that the Trust welcomes complaints / concerns as a valuable form of feedback, and that we are aligning our process to that of the Parliamentary & Health Service Ombudsman Vision and recommendations of Healthwatch. The Committee was advised that the Patient Experience Group would be reviewing complaints and the process as part of its remit.

16/Q/049 PATIENT EXPERIENCE QUARTERLY REPORT Patient Experience Lead advised that overall, patients/carers provide positive

feedback of the services in the Trust. As a Trust we are still receiving high levels of feedback, and our response rates for national surveys sits in the higher quartile. Patients continue to provide feedback via national forums including NHS Choices, and at the time of writing we have seen an increase in this for quarter 4. Complaints have increased, and we receive 14 compliments for each complaint received. During the Quarter we have seen a decrease in local feedback from Friend and Family Tests, and some areas are still not reporting patient feedback. These areas have been contacted directly to be offered support. There has been an increase in responses in some areas which were previously struggling. 50% of patients praised the Trust in general, however, 30% reported negatively on waiting times during the quarter. The Trust continues to achieve 4 out of a 5 star rating on NHS Choices. The next quarter will see the launch of the Patient Experience Steering Group, launch of bespoke surveys improving on the current Friends and Family Test process, and improved complaints literature being disseminated across the Trust.

CLINICAL EFFECTIVENESS 16/Q/050 ONCOLOGY SERVICE REVIEW UPDATE

The EDN advised that Vanessa Arnell-Cullen, Project Manager at the Clinical Commissioning Group, had provided the full written report and the Committee had received the Executive Summary. The oncology service for the Isle of Wight population was reviewed by an independent management consultant. The review was conducted over 4 months and evidence was gathered from perspectives of key individuals and stakeholders working and supporting the oncology services on the Isle of Wight, and cross referenced with data from local and national data bases.

1 Outpatient Patients & Records Unit


The Committee confirmed that the recommendations needed further detail and the EDN advised that as a result of the report a Consortium Board was being arranged and would include key stakeholders from each of the Trusts. The first meeting of the group would be held in early March. The Committee requested that the recommended actions and a progress report would be provided at the May meeting following the initial Cancer Board Consortium.

Action: EDN

CORPORATE PERFORMANCE & RISK 16/Q/051 BOARD SELF CERTIFICATION The Committee was informed that this is no longer a requirement to be undertaken

and would be removed from the Agenda for future meetings.

16/Q/052 ANY OTHER BUSINESS a) Sepsis CQUIN: The EDN highlighted for the Committee an issue in regard to

the Sepsis CQUIN. A review as to why this is being reported as not achieved would be undertaken as the Trust are meeting the nationally agreed targets but locally the targets met need to be validated to ensure this is just a reporting error.

b) Change of Day for QGC meetings: The Committee agreed to move the date for future QGC meeting to Tuesday mornings prior to the FIIWC meetings which occur the week before the Board meeting. This would be with effect from the March 2016 meeting.

Action: CA

16/Q/053 TOP ISSUES FOR TRUST EXECUTIVE COMMITTEE & TRUST BOARD To be provided in the form of a report from the Chair to the Trust Board and would

include the positive assurance received for Nutrition and Bereavement.

16/Q/054 ITEMS TO BE RECOMMENDED TO OTHER SUB-COMMITTEES There were no items to be referred to other Sub-Committees. The following items

were noted from the Finance Investment, Information and Workforce Committee;

a) Sustainability of Urology Service: The Committee confirmed this would be included as part of the March report that would be presented to QGC.

b) Confidence in trajectory to achieve key performance indicators by year-

end and start 2016/17 ‘on-track’ e.g. Emergency care, RTT: The Committee confirmed this should be referred to the Trust Executive Committee and Operational Management Group

Action: CA

c) Delayed Discharges: Item referred from Audit Committee in regard to delayed discharges and impact on the patient experience. Discussed under item minute no.16/Q/028 above.

16/Q/055 DATE OF NEXT MEETING The next full Committee meeting will be held on Tuesday 29th March 2016

Time: 9 am to 12 Noon Venue: Conference Room – School of Health Sciences Please note change of day for these meetings (see min.no. 16/Q/052b).

Signed: ______________________________ Chair (Dr Nina Moorman) Date: ________________________________


AUDIT AND CORPORATE RISK COMMITTEE Minutes of the meeting of the Audit & Corporate Risk Committee held on Tuesday, 9th February 2016 at 9.30 a.m. in the Conference Room, School of Health Sciences, St. Mary’s Hospital, Newport. PRESENT David King Chairman Nina Moorman

Lizzie Peers Non Executive Director Non Executive Financial Advisor to Trust Board

Charles Rogers Non Executive Director (Vice Chairman)

In Attendance Chris Palmer Executive Director of Financial & Human Resources (EDFHR)

Mark Price Company Secretary (CS) Ian Young External Audit Manager (EAM) Items 16/A/006/7&8

Mark Stabb Karen Baker

Director of Audit (TIAA) (DIA) Chief Executive Officer (CEO)

Items 16/A Lucie Johnson Head of Corporate Governance (HCG) Item 16/A Item 16/A Item 16/A Item 16/A

Andy Hollebon Andrew Shorkey Barry Eadle Connie Wendes

Head of Communications & Engagement (HCG) Business Planning Manager (BPM) Local Counter Fraud Specialist (LCFS) Assistant Director Health & Safety and Security (ADHSS)

Minuted by Linda Mowle Corporate Governance Officer

Min. No. Top Key Issues/Risk 16/A/005 Appraisal Process: The Committee opined that the organisation’s Goals and

Priorities should be agreed by April in order that these can be cascaded down to individuals in the organisation, via the appraisal process, to deliver those Goals and Priorities, with support to enable staff to do that. This should take place in the first quarter of the year otherwise the Trust is not delivering the Goals and Priorities for that year.

16/A/006 Principal Risk - Financial Resilience: The Committee was concerned and acknowledged that the Trust’s finances are difficult. The need for the organisation to have the right skills and capacity, to be strategically focused, and for lessons to be learnt in order to deliver CIPs was highlighted and emphasised. In addition, the challenge is to have an overall process that drives forward to provide sustainability for the organisation.

16/A/008 Operating Plan Development 2016/17: The Committee was concerned at the lateness in producing the Operating Plan and felt that culture and prioritisation need to be addressed and considered alongside operational pressures within the organisation. The Trust needs to ensure that those managers who do not have the requisite skills are given the necessary training to acquire those skills. It would be untenable to have the same debate next year.

16/A/009 Principal Risk Register (BAF) 2015/16: The Committee considered that there should be triangulation of the Principal Risk Register with the CCG, GPs and local authority to obtain feedback on whether this resonates with our customers.

16/A/016 Internal Audit Plan 2016/17: The Committee agreed the Internal Audit Plan for

FOR PRESENTATION TO TRUST BOARD ON 2 MARCH 2016

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Audit & Corporate Risk Committee 1 9 February 2016

2016/17 subject to requested amendments. 16/A/019 External Audit Plan 2015/16: The Plan for the 2015/16 audit was agreed. The

indicative fee for the Trust’s audit is £67,000 excluding VAT. 16/A/023 Draft Security Strategy: The draft Strategy was agreed subject to agreed

amendments for presentation to TEC. The Committee considered that the raising of awareness of security management at Board level should be on an annual basis as this links in with Emergency Preparedness.

16/A/026 Auditor Panel: The draft terms of reference were agreed for presentation to the Trust Board for approval. The inaugural meeting of the Auditor Panel to be held on the 10th May 2016 immediately following the ACRC meeting.

16/A/001 APOLOGIES Received from Paul King, External Audit Director

16/A/002 QUORACY The Chairman confirmed that the meeting was quorate.

16/A/003 DECLARATIONS OF INTEREST Charles Rogers and the Executive Director of Financial & Human Resources

declared an interest as Directors of Wightlife Partnership.

16/A/004 MINUTES The minutes of the meeting held on the 10th November 2015 were agreed and

signed by the Chairman as a true record.

16/A/005 MATTERS ARISING FROM PREVIOUS MINUTES The schedule of progress on actions arising was noted with the following

comments: a) Min. No. 15/A/057 Counter Fraud Training – Appraisal Process: In

response to Lizzie Peers’ query on the low rates of appraisals and whether reflecting counter fraud training within the appraisal process would boost numbers, the EDFHR confirmed counter fraud training is being taken forward. In addition, as an interim arrangement whilst the EDTI is absent on sick leave, the EDFHR now has responsibility for appraisals and that the process is being reviewed and will be picked up as part of the revised directorate performance reviews.

Nina Moorman asked for clarity on what is required to be included within mandatory training as part of the appraisal process. The EDFHR confirmed that mandatory training is being reviewed as part of an OD group and appraisals compliance is being taken forward through the Finance, Investment, Information & Workforce Committee (FIIWC) and will be reported to the Committee through the FIIWC report. A deep dive into appraisals will be undertaken in the coming months by FIIWC and it is hoped that there will be a change in the rate of compliance by the end of Quarter one 2016/17

Action: EDFHR on behalf of EDTI The EDFHR commented that the organisation’s Goals and Priorities should be agreed by April in order that these can be cascaded down to individuals in the organisation, via the appraisal process, to deliver those Goals and Priorities, with support to enable staff to do that. This should take place in the first quarter of the year otherwise the Trust is not


delivering the Goals and Priorities for that year. The Committee acknowledged that a good appraisal system was not only good for employees but managers as well. An update on appraisals and mandatory training to be included within the FIIWC report to the Committee at its next meeting. Action: CR

16/A/006 PRINCIPAL RISK - FINANCIAL RESILIENCE The Chief Executive (CEO) outlined the background to the Trust’s current

worsening financial position which was originally a planned deficit in 2015/16 of £4.6m but now the most likely outturn for yearend is a £6.7m deficit, although this very much depends on the Trust receiving funding for some of the additional costs incurred to cope with the system pressures. In addition, in order to secure Sustainability and Transformation funding for 2016/17, the Trust has been advised it needs to be in a breakeven position or a surplus of £5.7m for 2016/17. Given the current financial position and the CIPs gap, it is very doubtful that a surplus of £5.7m in 2016/17 can be achieved. However, the Trust is responding to how it might be possible to achieve a surplus. The submission in June 2016 of the Sustainability Transformation Plan (STP) if successful will enable the Trust to make radical changes across systems. In response to the Chairman’s query on how the Trust would achieve a surplus of £5.7m, the EDFHR highlighted that the following actions are being undertaken as part of Business Planning which will contribute to this but is unlikely to achieve that result.

• Cost base review of services – mismatch between income and expenditure

• Whole Integrated Service Redesign (WISR) • Advance Budget setting • Downside scenario modelling and opportunities to mitigate • Wightlife Partnership – savings maximised • E-Rostering and Clinical Job Planning • Carter Review response • LEAN ways of working

The Committee noted that contract negotiations for 2016/17 with the Clinical Commissioning Group (CCG) will commence on Thursday, 11th February 2016. However, the CCG’s indicative stated position for next year is a deficit position of £3.5m which will impact on the Trust with no growth funding nor Island Premium. The Chairman queried whether external advice should be sought to assist with the cost savings. The CEO advised that KPMG is currently assisting with WISR and that the output of that should be substantial savings across the system. In addition, KPMG will be assisting with the development of the 5 Year STP. In reply to Nina Moorman’s enquiry regarding Lord Carter’s letter dated 18th September 2015 on the NHS drive on productivity and efficiency improvements, the EDFHR confirmed that the Trust through South of England Procurement (SoEPS) was taking every opportunity to maximise savings wherever possible in terms of economy of scale in line with Portsmouth Hospitals and that this will continue through cash releasing and cost avoidance savings.


Lizzie Peers highlighted again the need for the organisation to have the right skills and capacity, to be strategically focused, and to embed lessons learnt, in order to deliver CIPs. The CEO expressed confidence in the new Clinical Business Unit leaders but the organisation needs to identify and describe really big cost improvement programmes and this is currently being taken forward. The Committee requested that the CEO provides an update on the outcome of this work, particularly on the review of PMO and Turnaround. Action: CEO The Chairman summarised the concerns of the Committee in that the Trust’s finances are difficult and that the challenge is to have an overall process that drives forward to provide sustainability for the organisation. In addition, clarity on the financial support to be provided by the CCG needs to be confirmed.

16/A/007 PRINCIPAL RISK: LOCAL HEALTH AND SOCIAL CARE ECONOMY

RESILIENCE The CEO updated the Committee on the ‘whole Island approach’ through a

landmark strategic partnership agreement with the IW Council for the integration of health and wellbeing services on the Island, which will come into effect from the 15th February 2016. The partnership will seek to develop integration through a focused partnership Health & Wellbeing Board to achieve effective and efficient early help and prevention and better integrated working practices among professionals. The Committee also noted that integrated teams will also be working more closely with the third sector and developing an increasing number of self-management plans to enable more people to remain in the community, supported by their community and reducing the need for hospital admissions. Charles Rogers queried how the ‘whole Island approach’ can be included within the Trust’s 5 Year Forward Plan, together with how, as an organisation, we gain the flexibility to adapt quickly to change and to flourish. The CEO considered that through the Health & Wellbeing Board, as the overarching Board of the Island, the impetus can be provided to influence governance and be a platform over the next 6 months to obtain resolution and understanding of the choices to be made and their impact. There is a need to have an ‘open book’ approach and for the finance teams of the member organisations to work together to understand what is possible and not possible. The CEO stated that the driving force to make this happen will have to come from the Trust.

16/A/008` BUSINESS PLANNING REPORT – OPERATING PLAN DEVELOPMENT 2016/17

The CEO and Business Planning Manager (BPM) presented the update on the Operating Plan development for 2016/17 which outlined the background, requirements, process and milestones for delivering the Operating Plan. The Committee noted that to date 55 service level plans have been developed across the Clinical Business Units and 12 service level plans have been developed across the Corporate Support Services with the following key risks to delivery:

• Impact of organisational change on operational capacity and service knowledge

• Impact of operational pressures on capacity • Impact of reduction in central workforce planning capacity • Development of operational plan in isolation from agreed corporate and


locality strategy • Continuity of executive leadership

The CEO advised the draft Operating Plan was submitted to the Trust Development Authority (TDA) on the 8th February 2016 with a deadline for re-submitting of the 18th March 2016. The CEO further advised that, for the interim during the absence of the EDTI, Business Planning has been added to the portfolio of the Executive Director of Nursing and, in order to ensure that the final submission in April is right, the governance structure for Business Planning will be reviewed in the next few weeks under the management of the Executives. Charles Rogers acknowledged the change of managers within the CBUs may have added to the lateness of producing the Operating Plan but felt that culture and prioritisation need to be addressed and considered alongside operational pressures. At the same time, the Trust needs to ensure that those managers who do not have the requisite skills are given the necessary training to acquire those skills and that it would be untenable to have the same debate next year. The CEO concurred that once the submission in April has been achieved, the Executive Team will be scrutinising the business planning process to introduce a process which is fundamentally different but which supports the cycle of business planning for next year. The CEO agreed to provide an update to the Committee on achieving a quality and deliverable business planning process.

Action: CEO

16/A/009 BOARD ASSURANCE FRAMEWORK (PRINCIPAL RISK REGISTER) 2015/16

The HCG presented the update on work relating to the Risk Management Framework and the recommendations made by Capsticks Governance Consultancy in the External Governance Review in relation to Risk Management. The Committee noted the following:

• 8 recommendations by Capsticks and RAG rated • Risk reconciliation exercise resulting in 7 risks identified for inclusion in

the Principal Risk Register and 23 risks for inclusion in the Corporate Risk Register

The HCG advised that there is mis-understanding across the Trust regarding what should be included on the Risk Register but that through the training programme there will, in the future, be a better understanding of the way in which risks are described. The Chairman asked whether there had been triangulation of the Principal Risk Register with the CCG, GPs and the local authority to obtain feedback on whether this resonates with our customers. The Committee agreed that, once the reconciliation exercise has been completed, triangulation with stakeholders be undertaken with feedback being provided at the August 2016 meeting.

Action: HCG 16/A/010 EXTERNAL GOVERNANCE REVIEW – ACTION PLAN The Committee received the detailed update report on the progress made in

relation to the Governance Review Action Plan prepared by HCG, noting that


of the 70 actions, 32 have been concluded. The HCG explained that the next steps are to prioritise the remaining 38 actions in conjunction with the Executive Team, rather than trying to manage all at the same time. An update on this process will be provided to the Committee at its next meeting in May.

Action: HCG The Company Secretary (CS) advised that discussions are to be held with the Trust Development Authority (TDA) on this process and that their response will be included within the next update. In addition, Governance is to be included on the next Board Seminar agenda.

16/A/011 TIMETABLE FOR ANNUAL GOVERNANCE STATEMENT (AGS) 2015/16 The HCG reported that due to the tight timescales for the production of the

AGS that a first draft of the report will be circulated to ACRC members by the 1st April 2016 for comments. Action: HCG The deadlines for the submission of the AGS are as follows:

• 22nd April 2016: AGS to be provided to auditors and the TDA • 2nd June 2016: auditors to send a signed original copy of the AGS to the

Department of Health as part of the accounts submission process. The Trust is also required to send a final copy to the TDA

The Committee noted that the full report will be made available to ACRC members on the 15th April 2016 for comments by close of play on the 19th April 2016, in order that the report can be finalised for submission on the 22nd April 2016. Action: HCG

16/A/012 ANNUAL REPORT 2015/16 TIMETABLE The Head of Communications & Engagement (HCE) provided a verbal update

on the high level timetable to meet the deadlines for the submission of the 2015/16 Annual Report. The Committee noted that the content of the report is drawn from the Manual for Accounts. In response to the expressed view of the HCE that someone will be sought in February/March 2016 to help with the report, the Committee was of the opinion that this resource should be internal. The HCE agreed to circulate the timetable to ACRC members for feedback.

Action: HCE

16/A/013 DECISIONS TO SUSPEND STANDING ORDERS None to date.

16/A/014

FINANCE, INFORMATION, INVESTMENT & WORKFORCE COMMITTEE QUARTERLY ASSURANCE REPORT

The Chairman of FIIWC, Charles Rogers, presented the report on the work of FIIWC during the last quarter, advising that this is the first written report from FIIWC since the Committee adopted a redesigned agenda. The agenda is now constructed following a Resources Flowchart model suggested by the EDFHR and covers both operational and strategic matters. An Executive Summary at the start of the Agenda, written by EDFHR, includes a dashboard of key points and allows a summary analysis of the main issues covered by the agenda. In addition, there is an agenda item on the progress and development of My Life a Full Life (MLAFL) programme which is designed


to ensure that any developments on the MLAFL agenda that relate to the Committee’s work are captured and taken into account. The following items were highlighted:

• Human Resources Workforce Performance Information – Limited Assurance Resourcing – Limited Assurance Workforce Strategy – Positive Assurance Staff Survey – Limited Assurance

• Estate Resources Informed Client Group – Positive Assurance Property Sales – Positive Assurance

• Capital Investment Capital Plan – Positive Assurance

• Data Quality /PbR Discharge Summaries – Limited Assurance

• Performance Information Winter Resilience Improvement Plan (WRIP) – Limited Assurance Business Planning – Limited Assurance

• Contracting Contract Status Report – Positive Assurance

• Financial Actual and Forecast Revenue – Limited Assurance CIP 2015/16 – Limited Assurance CIP Plan 2016/17 – Negative Assurance PMO/Turnaround – Limited Assurance Government Banking Services – transition to RBS – Positive Assurance

• Audit & Governance Board Self Certification – Limited Assurance Corporate Risk Register – Limited Assurance

. 16/A/015 NON CONSOLIDATION OF CHARITABLE FUNDS 2015/16 ACCOUNTS The Committee agreed to recommend to the Trust Board that the 2015/16

Charitable Funds Accounts are not consolidated within the 2015/16 IOW NHS Trust Annual Accounts due to the level of materiality

16/A/016 INTERNAL AUDIT PLAN 2016/17 Mark Stabb, Director of Internal Audit, presented the Internal Audit Plan which

summarises the proposed programme of internal audit coverage to be undertaken during 2016/17. The Committee noted that the varied programme of ‘risk-based’ audits has been developed through a detailed audit needs assessment, taking into account the Trust’s BAF and risk register, and from their own knowledge and experience from work at other organisations and from emerging local and national issues. A rolling Strategic Plan is included in the Plan to provide the Committee with the proposed level of coverage through to 2016/17 for assurance purposes. Lizzie Peers asked whether Patient Pathways in Quarter 3 could be brought forward and whether an audit around partnership risk could be undertaken on Local Health Economy Resilience in regard to governance for MLAFL and


Vanguard in terms of capacity and capability. The EDFHR confirmed that once the Internal Plan had been updated and revised, this would be presented to TEC for approval. The updated Internal Audit Plan 2016/17 to be circulated to ACRC members and onwards to TEC for approval.

Action: DIA Action: EDFHR

16/A/017 INTERNAL AUDIT PROGRESS REPORT The Committee received the summary report which provides an update on the

progress of work as at 22nd January 2016. The report is based on work carried out by TIAA and management representations that have been received since the last report.

The Committee noted the following reports:

• Clinical Audit – Reasonable Assurance • Sickness Absence Reporting – Reasonable Assurance • Financial Accounting – Substantial Assurance • PBR including Mental Health Clusters (Mazars Report) – Limited

Assurance

16/A/018 INTERNAL AUDIT RECOMMENDATIONS The DIA advised that of the completed audits there are a total of 50 agreed

actions/management responses, 35 of which are overdue implementation dates and 15 not yet due for implementation. 23 of the 35 overdue agreed actions relate to audits completed in 2014/15 and prior years, with the remaining 12 relating to 2015/16 audits. All overdue agreed actions are now being actively followed up by TIAA with the managers concerned and a more detailed report will be brought to the next ACRC.

16/A/019 EXTERNAL AUDIT PLAN 2015/16

Ian Young, the External Audit Manager (EAM), presented the Plan for the 2015/16 audit. The Plan summarises the initial assessment of the key risks driving the development of an effective audit and outlines the planned audit strategy in response to those risks. The EAM highlighted the following:

• Value for money conclusion report will be by exception • Financial statements risks (including fraud risks) • Value for money risks – delivering financial sustainability

The Committee noted that the indicative fee scale for the Trust’s audit is £67,500, excluding VAT, which is a reduction on the 2014/15 fee. The Committee further noted that in 2015/16 external audit undertook additional work outside the scope of the scale fee by reviewing the Trust’s proposals for the Carbon Energy Fund Project. The additional fee for this work will be discussed with the EDFHR and reported to the Committee in June 2016 as part of the Audit Results Report.

16/A/020 EXTERNAL AUDIT HEALTH SECTOR BRIEFING


The Committee received the Health Sector Audit Committee Briefing covering: • Government land economic news • Accounting, auditing and governance • Regulation news • Key questions for the Audit Committee

16/A/021 QUALITY AND CLINICAL PERFORMANCE COMMITTEE – QUARTERLY ASSURANCE REPORT

The Chair of QCPC, Nina Moorman, presented the quarterly report covering the period November 2015 to January 2016 together with the minutes of the meetings, highlighting:

• Mock Care Quality Commission (CQC) Inspection – Limited Assurance • Deep Dive into In-patient Falls – Limited Assurance • Sepsis update – Positive Assurance • NICE Guidance Implementation – Positive Assurance

The Chairman asked for details on how delayed discharges were reported as this must be detrimental to the quality of the patient experience. Nina Moorman advised that this subject was to be an agenda item for the next Quality Governance Committee, following which an update will be provided to the Committee. Action: NM The Committee received and noted the Internal Audit report on the review of Clinical Audit and the action plan to progress recommendations.

16/A/022 COUNTER FRAUD PROGRESS REPORT The LCFS introduced the report highlighting:

• Fraud Awareness tasks undertaken • Work Plan allocated days – 78: total remaining days 20.25 • Fraud Survey – including awareness of the Whistleblowing Procedure

and Code of Conduct • Investigations – new and closed • Proactive review - Consultants Private Work: The Committee was

extremely concerned at the outcome of this proactive review and felt that this required a firm clinical leadership stance by the Executive Medical Director. The EDFHR advised that the findings and recommendations of the report will be taken forward, in the first instance, from a clinical job planning perspective. The Committee noted that 5 recommendations had been made. The EDFHR to discuss with the LCFS how implementation of these will be followed up. An update on the recommendations to be provided to the May 2016 meeting of the Committee. Action: EDFHR/LCFS The Committee agreed that the Executive Medical Director attend the next meeting in May 2016 to provide a report on actions taken.

Action: CA/CS

16/A/023 DRAFT SECURITY STRATEGY The ADHSS presented the draft Security Strategy advising that the overriding

principle for security management is to support the Trust in providing high quality healthcare through a safe and secure environment that protects patients, staff and visitors, their property and the physical assets of the


organisation. The key aims of the Security Strategy are to: • Comply with new and existing DH directions and guidance including the

requirements outlined by NHS Protect • Promote a culture in which all staff, patients and visitors take

responsibility for the safety of people and property • Reduce the incidence of security related incidents (e.g. violence and

aggression/theft) and to seek sanctions and redress where incidents do occur

• Ensure staff are trained to the appropriate level in security, personal safety and managing incidents of violence and aggression

• Achieve the requirements within CQC Regulation 15, Outcome 10 • Develop and maintain an effective collaborative working relationship

with local stakeholders, NHS Protect and other local agencies • Protect the assets of the Trust against fraud, dishonesty, vandalism,

damage and any potential litigation. The ADHSS advised that following the consultation process the VIP Protocol, a section on Rigour, access to the hospital via the Beacon, together with a cross-reference to Cyber Security need to be included within the Strategy which will then be presented to TEC for agreement. Action: ADDHSS With regard to raising the awareness of security management at Board level, the Committee considered that the security profile should be discussed on an annual basis, possibly at a Seminar, as this also links in with Emergency Preparedness. The Company Secretary to discuss the timetabling with the Executive Medical Director. Action: CS The Committee agreed the draft Security Strategy, subject to the inclusion of the above additions, for presentation to TEC for agreement and that the Executive Medical Director should take forward and monitor the Workplan and Strategy. The Company Secretary to advise the Executive Medical Director accordingly. Action: CS

16/A/024 NATIONAL FRAUD INITIATIVE 2014/15 The Committee received the progress report noting that 1460 of the total

matches identified in the 2014/15 exercise have now been investigated. No fraudulent activity has been identified. Of the total 28 payroll to payroll matches identified, 27 have been investigated and closed with no issues. Despite several attempts to reach a suitable conclusion with the counterpart organisation for the outstanding match, it has proved unsuccessful to reach a suitable conclusion and the Trust has now closed this matter with the outcome being shown on the record. The Committee noted the completion of the 2014/15 NFI exercise and that no fraud was evident.

16/A/025 ITEMS FOR NOTING (Previously Circulated) • TIAA – Comparison of Provider Trust 2015/16 Internal Audit Plans

• NFI AppCheck • EY Health Insight: Survive, strive or thrive? The financial sustainability

of England’s small hospitals.

16/A/026 AUDITOR PANEL – APPOINTMENT OF EXTERNAL AUDITORS The Committee received the following reports:


• Draft Terms of Reference: agreed for presentation to Trust Board for approval

• Auditor Panels’ Guidance to help Health Bodies meet their Statutory Duties – September 2015

• Procurement Timetable update • Register of Auditor Panel Members/ Interests

The Committee agreed that the inaugural meeting of the Auditor Panel be held on the 10th May 2016, immediately following the ACRC meeting.

16/A/027 DATE OF NEXT MEETING • Tuesday, 10 May 2016 at 9.30 – 11.30 a.m.

Signed: ………………………………………………… Dated: …………………………………… CHAIRMAN.


FINANCE, INVESTMENT, INFORMATION & WORKFORCE COMMITTEE

Minutes of the meeting of the Finance, Investment, Information & Workforce Committee held on Tuesday, 23rd February 2016 at 1.00 p.m. in the Large Meeting Room, St. Mary’s Hospital, Newport. PRESENT Charles Rogers Non Executive Director (Chairman) Chris Palmer Executive Director of Financial & Human

Resources (EDFHR) In Attendance Items 16/F/096-99

Lucie Johnson

Head of Corporate Governance (HCG)

Minuted by Linda Mowle Corporate Governance Officer Min. No. Top Key Issues & Risks for Raising at TEC & Trust Board 16/F/069 Human Resources Report – Safer Staffing: Rostering in Safe Staffing areas has

decreased in compliance (8 weeks in advance approved rosters) to 19% in January from 23% in December. This has an impact on staff planning and the resultant higher use of Agency and Bank personnel.

16/F/070 Review of Sickness Absence: The Committee has received a detailed review and analysis of Trust staff sickness. Comparative information for sickness in other organisations and also nationally has led the Committee to question whether the present sickness absence targets continue to be appropriate. Given the significant annual financial cost of sickness to the Trust, the Committee consider that this important piece of work should be discussed by the Trust Board at Seminar.

16/F/071 Review of Medical Staffing: The Committee has been provided with a detailed summary of the service provided by the Medical HR function. In particular, the number of outstanding vacancies, the challenges and actions that are being created in an effort to improve recruitment in the future.

16/F/072 Raising Concerns (Whistleblowing) Report: FIIWC received a half yearly report summarising concerns that have been raised using the dedicated and confidential email address. For the 6 month period to the end of 2015, 5 concerns were received. Three of the concerns related to individuals own employment which fell outside of the policy. The 2 remaining concerns have been investigated. The cumulative total of concerns received using this email address since 1st April 2014 has been 14. The Committee has asked for a more detailed report in future, in particular to ensure that the investigating Director for any case is appropriate and in all ways impartial. Finally, it is noted that the Trust will respond to the outcome of the ‘Freedom to Speak Up’ Review when the new policy will be published.

16/F/074 Human Resources Strategy: The Committee agreed the updated Human Resource Strategy for presentation to the Trust Board for approval.

16/F/087 CIP Plan 2016/17: The Trust’s initial draft plan for 2016/17 identifies a CIP requirement of 6.7% (£10.65m) to break even. Identified schemes detailed within the draft plans total 177, indicating savings of £3.9m although validation is required. Whilst there has been some improvement in savings, plans remain significantly off trajectory and the Committee remains of the opinion that far more needs to be done.

16/F/088 Financial Performance: The Trust is currently forecasting a £6.7m deficit at year end but there is a risk to this due to Winter Resilience Improvement Plan and the remaining CIP gap of £2.3m. Cash is being managed. Therefore there is a significant risk to achievement. It is also noted that the request to the CCG for the funding of additional costs for the opening of contingency beds has not yet been supported. Due to the current level of activity performance against plan and risks to forecast achievement there is a negative level of assurance at present.

16/F/093 Turnaround Report – Clinical Job Planning: The Committee is concerned that clinical job planning has not been taken forward and was disappointed in terms of missed opportunities for CIPs.

FOR PRESENTATION TO TRUST BOARD ON 2 MARCH 2016

Enc N2

Minutes of the Finance, Investment, Information & Workforce Committee – 23 February 2016 Page 1 of 12

16/F/095 Procurement Service Contract (Commercial in Confidence): The Committee agreed the option proposal be submitted to the Trust Board in private for approval.

16/F/062 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND

CONFIRMATION THAT THE MEETING IS QUORATE Apologies for absence were received from Katie Gray, Executive Director for

Transformation & Integration (EDTI), Lizzie Peers Non Executive Financial Advisor, and Jane Tabor Non Executive Director. The Chairman confirmed that the meeting was not quorate. Concern was expressed at the limited membership of the Committee and the Chairman asked that this be reviewed.

Action: CS The minutes to be circulated to members to seek agreement to the actions and recommendations made. Lizzie Peers had provided comments on the reports by email. Charles Rogers and Chris Palmer declared an interest as Directors of Wight Life Partnership.

16/F/063 MINUTES OF PREVIOUS MEETINGS The minutes of the meeting held on the 26th January 2016 were agreed subject to email

agreement by Lizzie Peers and Jane Tabor. 16/F/064 SCHEDULE OF ACTIONS The schedule of progress on actions arising from previous minutes was noted with the

following comments: a) Min. No. 15/F/283 Informed Client Group Report: Update provided to meeting. Status – closed. b) Min. No. 15/F/294 – CIPS 2015/16 PMO Review: The EDFHR tabled a flow chart on PMO Intelligence, Planning & Delivery Process Overview which included the intelligence, planning and delivery function, together with the structure and roles of the PMO. The EDFHR explained that this was an initial proposal and outlines what might need to change going forward, as the PMO staff have been approaching CIPs from a service improving perspective. It was noted that there is to be an internal audit of the work of the PMO and this will help inform how the PMO is developed. Status – closed. c) Min. No. 15/F/294 – CIPs 2015/16 Linked to Corporate Goals & Priorities: Included with the PMO proposed flow chart. Status – closed. d) Min. No. 15/F/302 Corporate Goals & Priorities 2015/16: EDFHR advised that the 2015/16 Goals & Priorities will be the same for 2016/17 with the ‘House’ being expanded. Monitoring achievement of the Goals & Priorities throughout the year needs to be established. The topic to remain an agenda item. Status – closed. e) Min. No. 16/F/010 Staff Survey & Culture – Achievement of Targets: Summary report to be presented to Trust Board on 2nd March 2016. Status – closed. f) Min. No. 16/F/010 Appraisals – Clinical Business Unit: A Deep dive is to be undertaken at the April Committee meeting. Status – progressing. g) Min. No. 16/F/023 Board Self Certification – Statement 13 Capacity & Capability of the Executive Team due to demands of MLAFL: EDFHR confirmed how the Executive Team were managing capacity in terms of MLAFL. Status – closed. h) Min. No. 16/F/024 Corporate Risk Register – IT Risks: Noted that the CEO in the interim, is taking forward the IT part of the EDTI’s portfolio with Paul Dubery. i) Min. No. 16/F/049 CIP Plan 2016/17 – Limited Identification of CIPs: EDFHR reported that she had attended a planning meeting on Monday, 22nd February 2016 at which she was not fully reassured as £3.9m CIPs had only been identified for next year. A meeting has been arranged with the Hotel Services Manager to move forward the Hotel Services action plan to deliver the savings highlighted by the Strategic Estates Partnership but these will not be delivered this year. Other opportunities will be identified such as outputs from the Carter Review and the Strategic Estates Partnership as well as the establishment of CIP focused groups which will enable delivery from the 1st April 2016. Status – closed.


j) Min. No. 16/F/052 Turnaround Report – Clinical Job Planning: EDFHR advised that although the Turnaround Board had requested information on clinical job planning, this had not been forthcoming and was very disappointing in terms of missed opportunities for CIPs. Status - open k) Min. No. 16/F/055 Corporate Risk Register – Corporate Risk – Capacity & Capability of Executive Team: EDFHR confirmed that this risk is to be included on the Risk Register. Status – closed. l) Min. No. 16/F/055 Corporate Risk Register – Shackleton Ward Windows: An email from FIIWC to be sent to the Associate Director of Estates seeking confirmation that the work to Shackleton windows has been completed. Action: CA (Post meeting note: email sent to the ADE on 24 February 2016. ADE confirmed on 01/03/16 that the outstanding work to replace a cracked window has been completed.) Status – closed. m) Min. No. 16/F/056 External Governance Review – FIIWC Actions Executive Summary: To be provided to the Committee meeting in March 2016.

16/F/065 OVERARCHING EXECUTIVE SUMMARY OF HIGHLIGHTS AND LOWLIGHTS

The EDFHR presented the overarching executive summary which provided an analysis of the current position, risks, opportunities, mitigating actions and level of assurance to be gained, as well as outlining the impact on Quality, Performance and Finance contained within the Trust’s Goals and Priorities. The narrative has been expanded to include External Influences, Staff Survey & Culture and Business Planning. Triangulation with the Quality Governance Committee on how items of joint interest are shared needs to be explored. The EDFHR advised that the Trust is engaging with KPMG to provide data to underpin the Whole Integrated System Redesign. This is currently putting additional pressure on corporate services. Demand Planning and Capacity Planning has commenced however it is not yet finalised and subject to Commissioning agreement. The delay in tariffs and final documentation for the contract round is of concern so plans are being developed on best known data at this stage. The Committee was concerned by the lack of recognition for resource support and this has been flagged with MLAFL and the Programme Director of WISR. With regard to Business Planning, the Executive Director of Nursing has taken over the planning process for an interim period and a delivery schedule has been progressed. The draft plan first submission was achieved by 8th February although further work is required to ensure triangulation of all plans. The Chair congratulated the EDFHR on an excellent paper which provided an in depth understanding of the overall current Trust performance.

EXTERNAL INFLUENCES 16/F/066 MY LIFE A FULL LIFE (MLAFL) REPORT The EDFHR provided a verbal update on MLAFL highlighting the following:

• WISR Workshop on 18th February 2016 first indication of data covering activity by service and workforce by profession, service and finance

• 25th February 2016 first cut of the modelling forecasts • Recognition of significant resource pressures on PIDs, Finance and HR • Overview of the activity forecasting approach • Presentation of 10 year activity forecast across primary care, secondary care,

social care and the third sector • Trust Secondment Policy in place and reiterated through TEC for managers to

adhere to when staff are seconded to MLAFL • Governance structure to be put into place • Hilary Salisbury has now joined the HR Programme

16/F/067 COMMISSIONING INTENTIONS The EDFHR reported that there had been no changes since the last meeting. Any


changes are being picked up in the contract negotiation meetings. The planning guidance detail which impacts on commissioning intentions for next year is being followed through.

The Committee noted that discussions have been held at the contract review meeting concerning the cost of the Urology Service which will be underfunded at year end and the possibility of a contract notice from the Trust.

16/F/068 INVESTMENT/DIS-INVESTMENT NHS Creative Trading Account: The month 10 Trading Account providing negative

assurance due to the current position of a loss of £17k, was received and discussed. With regard to overheads, the Chairman considered that a clear policy on the allocation of overheads needs to be established which will provide a framework of all the component parts which need to be considered in any overhead charge. EDFHR to take forward and present a draft policy to a future meeting of the Committee. Action: EDFHR

The Committee agreed that the Trading Account and a long term Business Plan be presented on a quarterly basis in order to inform any future decision on the continuity of the service. The next Trading Account to be present to the May 2016 meeting. Action: EDFHR

Beacon Trading Account as at 31st December 2015.: A Beacon Contract Review meeting has taken place. The Committee noted:

• Walk-in Centre: currently forecasting a loss against income. Income is based on activity. The Trust is seeking support from the CCG to bring income back on line with the previous block contract. Cost pressure with GP costs is an on-going problem and the Trust is working with Lighthouse to develop options to minimise costs. The recent agreement to employ a further Advanced Nurse Practitioner (ANP) will reduce the requirement to fill shifts by the GPs therefore reducing GP costs. Lizzie Peers had asked whether this posed a risk to our year end outturn and if so, how much of a risk and asked what the likelihood was of the CCG funding part of the forecast loss. EDFHR reported that no overheads have been included and this will be flagged through the contract negotiations.

• Dermatology: The assumption is that Dermatology will achieve the total SLA activity and anticipating making a profit at year end of £87k in total. Pathology recharges have been incorrectly charged during the year and work is underway to correct the charges which are based on direct access.

• GP Pilot: The pilot is currently making a profit and this is expected to continue to year end.

• Clinical Co-ordinator post charged to Trading Account excluded in budget setting. Lizzie Peers had queried why this was not budgeted for and identified the need for lessons to be learnt for future budget setting. EDFHR agreed to look into why the post had not been budgeted for and report back. Action: EDFHR

• All trading accounts are comparison on actual income and expenditure and do not include budgeted plan

The Committee agreed to have a more regular Trading Account report with the next report being presented to the April 2016 meeting. Action: EDFHR

HUMAN RESOURCES 16/F/069 HUMAN RESOURCES REPORT The EDFHR introduced the HR report for Month 10 (January) 2016 covering:

• Sickness absence: decreased to 4.37% from 4.56% in month against a 3% target

• Temporary staffing: decreased to 133 FTE in December from 147 FTE in November


• Overpayments: outstanding overall balance has maintained in month at £88k • MAPs Healthroster: 8 Units were removed from the batch list for payment of

enhancements and variable hours due to rosters not being finalised by the deadline, an increase of 4 from previous month

• Rostering in safe staffing areas: increased in compliance to 24% in December from 23% in November. Rostering in safe staffing areas has decreased in compliance (8 weeks in advance approved rosters) to 19% in January from 23% in December. This has an impact on staff planning and the resultant higher use of agency and bank personnel.

• Establishment Figures: Budget setting is still taking place within Finance. Once completed accurate budgets will be uploaded into ESR for reporting

• Bank and Agency Usage & Recruitment: Recruitment activity has decrease in month to 231.81 FTE from 279.88 FTE in November.

• Identified key risks • The next group of overseas nurses (15) are due to arrive in the UK on Saturday,

27th February 2016. Induction will commence on Monday, 29th February. 16/F/070 REVIEW OF SICKNESS ABSENCE- DEEP DIVE The Committee received and discussed the following reports outlining a range of options

into the future approach for sickness absence monitoring and the current approach to employee wellbeing, prevention and assurance in relation to attendance management:

• Monthly sickness absence performance report • Sickness absence deep dive discussion paper • National Benchmarking report • Internal Audit Sickness Absence Audit report

The Committee congratulated the Senior HR Manager on the extensive report which enabled the Committee to have a better understanding of the management of sickness within the Trust. Comparative information for sickness in other organisations and also nationally has led the Committee to question whether the present sickness absence targets continue to be appropriate. Given the significant annual financial cost of sickness to the Trust, the Committee considers that this important piece of work should be discussed by the Trust Board at Seminar. The Committee considered that the strategic direction in relation to future sickness absence targets for Acute Trust, Community, Ambulance and Mental Health should be discussed at Trust Board either in Seminar or private session. Action: EDFHR

16/F/071 REVIEW OF MEDICAL STAFFING – DEEP DIVE The EDFHR introduced the discussion document prepared by the Senior HR Manager

which provided a summary of the services provided by the Medical HR function and highlighting some of the challenges and achievements to date. The Committee acknowledged that one of the biggest risks to the organisation is medical vacancies and recognised the actions that are underway to improve the position. The Committee queried whether the clinical job plans reflected the delivery and demand plans to be achieved. Lizzie Peers had queried whether there was robust clinical job planning in place and whether the job plans would be ready by 1st April so as to inform the business planning process. The Committee agreed that an update on medical staffing be presented to the Committee on a 2 monthly basis for assurance and oversight on how medical vacancies are being overcome. The next report to be presented to the April 2016 meeting of the Committee. Action: EDFHR The Committee congratulated the Senior HR Manager on the excellent report on medical


staffing which enabled the Committee to have a better understanding of the recruitment difficulties and challenges to fill medical vacancies.

16/F/072 RAISING CONCERNS (WHISTLEBLOWING) REPORT The Committee received the confidential report covering the period 1 July – 31

December 2015 noting that 5 concerns were raised. Three of the concerns related to individuals own employment which fell outside of the policy. The 2 remaining concerns have been investigated. The Committee noted that Monitor, NHS TDA and NHS England are proposing to introduce a national whilstleblowing policy arising from the ‘Freedom to Speak Up’ review. The review of the Trust’s policy is on hold until the outcome of the consultation on the national policy is known. Lizzie Peers asked that any material whistle-blower issues are reported to the Committee on an exceptional basis as and when these arise rather than waiting for the 6 monthly report. The Committee agreed with this request and for the EDFGR to take this forward. Action: EDFHR With regard to the 2 cases which have been investigated, the Committee requested more detail on the actions being taken and on the independence of the investigating officers. A confidential report to be provided to the Committee at its next meeting.

Action: EDFHR 16/F/073 SAFER STAFFING REPORT AND AGENCY NURSE USAGE Deferred to April 2016 meeting. 16/F/074 HUMAN RESOURCE STRATEGY The EDFHR presented the updated Human Resource Strategy which is Appendix 6 of

the Trust’s Integrated Business Plan, advising that amendments have been made following feedback together with the inclusion of the Strategic Intent. The EDFHR further advised that an Organisational Development Strategy is to be developed which will link into the Human Resource Strategy in order to develop closer links between the two departments. The Committee agreed the updated Human Resource Strategy for presentation to the Trust Board for approval. Action: EDFHR

STAFF SURVEY & CULTURE 16/F/075 STAFF SURVEY AND ORGANISATIONAL DEVELOPMENT REPORT The Committee received and noted the contents of the report which is to be presented to

the Trust Board on 2nd March 2016. 16/F/076 STAFF EXPERIENCE GROUP UPDATE . EDFHR highlighted:

• Human Resources (HR) and Occupational Health (OH) in dialogue with Workplace Options to plan launch during March for new Employee Assistance Programme (EAP) service from 1st April 2016

• OH Helpline for managers: new way of working since 1st January 2016 where managers must ring OH before submitting a referral

• Workplace Wellbeing Charter – weakest areas are physical activity and healthy eating

• Repeat stress audit in CCU and ICU • Chamber Health checks for staff

ESTATE RESOURCES 16/F/077 INFORMED CLIENT GROUP REPORT Deferred to March 2016 meeting as no report available due to sick leave. 16/F/078 ISLAND-WIDE ESTATES STRATEGY Deferred to March 2016 meeting as no report available due to sick leave. 16/F/079 PROPERTY SALES REPORT Swanmore Road Properties: Preparation of the contracts for sale. It is expected that

exchange and completion will be at the same time with a target date of the end of February 2015.


The Gables, Fairlee Road: since the last update in November 2015 when the Hospice stated that they wanted to have a structural survey carried out of the building they have not contacted the Trust further.

CAPITAL INVESTMENT 16/F/080 CAPITAL INVESTMENT GROUP REPORT The EDFHR presented the updated Capital Investment report advising that the majority

of the allocation has been committed and highlighting the following: • Capital to revenue transfer has been agreed with the TDA of £607k • Depending upon receipt of property sales, identification of schemes which could

be delayed until 2016/17 16/F/081 CARBON ENERGY FUND The Committee received and discussed the project update including the impacts of the

project slippage, namely: • Slippage on delivery of CIPs • Impact of RPI on capital costs. General inflation having remained at a historic

low over the last 12 months, the impact of RPI is negligible. The Committee was concerned that the financial impact of the CEF slippage was not clear and requested assurance on the management oversight for the operational delivery of the project. The EDFHR to take this forward through TEC and an update to be provided to the Committee. Action: EDFHR

DATA QUALITY/PAYMENT BY RESULTS (PbR) 16/F/082 DATA QUALITY REPORT The Committee received and noted the Data Quality Report covering:

• SUS Data Quality – 5 red rated indicators in the SUS data sets national benchmarking for admitted patient care, outpatients and A&E

• Outstanding Discharge Summaries – as at 15th February 2016 there were 441 discharge summaries outstanding. The Deputy Medical Director is developing a plan to improve both the timeliness and quality of the discharge summaries. To do this he is seeking: - Feedback from GPs on what they expect in a discharge summary - Identifying problems and obstacles to timely completion of summaries with

consultant colleagues The aim is to develop a plan that ensures no patient leaves hospital without a summary of acceptable quality and how to monitor this process.

• Uncoded Activity at Flex Date – constant in month 9 to 42% from 41% in month 8. All activity has been coded by Freeze date so there has been no instances of lost income to date.

PERFORMANCE INFORMATION 16/F/083 ACTIVITY PERFORMANCE The Activity and Performance Report for Month 9 details the Trust’s performance against

the Service Level Agreement requirements, as follows: • Month 9 Flex SLA income is £1,123.5k below plan, constituting an increase in

the underperformance by £157k from Month 8. • Point of Delivery (POD) analysis shows that Planned inpatients is £1.435m

below plan. • At a Specialty/POD level, Emergency Non Elective General Medicine has the

largest cost variance above plan of £639k and 188 spells • Elective Inpatient Trauma & Orthopaedics (T&O) has the largest cost variance

below plan of £915k and 138 spells • Contract penalties amount to approximately £879k to December

The Committee considered that a challenge as to why the provider is the prime organisation which is being penalised for system issues should be raised by the CEO and COO through the Systems Resilience Group. Action: EDFHR

16/F/084 WINTER SYSTEM RESILIENCE PLAN The update report on the Trust’s performance against the Winter System Resilience Plan

was received with the following key points noted:


• Currently behind schedule on actions to develop Surgical Assessment Unit and 2 of the 4 actions on the Oncology Bed Base

• Development of ongoing performance measures for Urgent Care Capacity has not yet started

• The status of all other programme milestones is ‘completed’ or ‘on target’ • Currently 250 inpatient spells and 632 day case spells behind the Trust activity

plan and in financial terms this is estimated to equate to a shortfall of £1.349m • Emergency care 4 hour performance is currently behind the recovery trajectory

Lizzie Peers had asked, given that most of the milestone actions are green but the recovery plan is behind target, what else needs to be done and what is not working. The Committee agreed that the Chief Operating Officer be invited to the March 2016 meeting of the Committee to provide a report on the actions being taken to deliver the Winter Resilience Plan. Action: CA

CONTRACTING 16/F/085 CONTRACT STATUS REPORT 2015/16 The Report for 23rd February 2016 outlined the following position:

• The Trust has received approximately £879k worth of penalties to end of December 2015. The Trust is working with the CCG through the System Resilience Group to re-invest these penalties into the Health Economy in line with national guidelines.

• 9 C-Diff breaches in year to date which have had lapses of care. There will be a financial sanction of confirmed breaches over the annual target of 7

• The acute element of the CCG contract has under-performed by approximately £1.5m as at end of month 8 which means a reduction of approximately £200k compared to the last month.

• The NHS England contract shows an over-performance of approximately £271k as at end of month 9 (flex position) mainly relating to Breast Screening and Chemotherapy delivery

• The CCG has proposed to extend the Out of House and Walk In services contract to March 2017 and to extend the Dermatology service contract to end of December 2017

• Working to finalise the Earl Mountbatten Hospice 2015/16 contract. 2016/17 Contracting: The Trust’s contracting strategy for 2016/17 and beyond was updated and approved by the Trust Board in September 2015. Following approval of the updated strategy, the following have been implemented:

• As part of the annual contracting cycle a stakeholder workshop was held in September 2015 to determine what could be improved upon in terms of 2016/17 negotiations

• The outcomes of the workshop fed into the contracting timetable with progress being monitored against the timetable

• The Trust’s intentions, including coding and counting intentions, were collated and shared with both the CCG and NHS England in September 2015

• The Executive Negotiation meetings with the CCG have been progressing well, discussing terms of reference, contract format and structure, CCG allocation, opening envelope, interim support, Better Care Fund, demand and capacity planning and quality and CQUIN

• Publication of the NHS Standard Contract and national CQUIN guidance awaited.

BUSINESS PLANNING 16/F/086 BUSINESS PLANNING REPORT 2016/17 The Business Planning update for 2016/17 Operating Plan development prepared by

Andrew Shorkey, Business Planning Manager, was received by the Committee highlighting:

• The Trust’s initial draft operating plan was submitted to the TDA on 8th February 2016 in line with the required schedule which included


• One year plan narrative summary • Financial plan • Activity plan • Workforce plan

16/F/087 CIP PLAN 2016/17 The Committee noted that to date CIPs detailed within the Business Plans for 2016/17

total 177 draft schemes against identified savings of £3.9m which require validation, which is significantly off trajectory. An initial assessment of plans indicates that approximately £1.99m is identifiable as income, vacancy factor or other un-specified budget management activity rather than CIP. Lizzie Peers was concerned that, although there was some new schemes since the last meeting, there is still a big gap remaining and the risk still remains high as previously raised at the last meeting. The Committee considered that whilst there has been some improvement in savings, plans remain significantly off trajectory and the Committee remains of the opinion that far more needs to be done.

FINANCIAL RESOURCES 16/F/088 FINANCIAL PERFORMANCE REPORT The EDFHR presented the report and advised that in month the financial position is a

deficit of £600k behind plan by £350k. The year to date financial position is a deficit of £6.972m which is worse than plan by £3.573m. Income is ahead of plan by £587k year to date. The Trust Board at its meeting on the 3rd February 2016 formally agreed the year end position as a deficit of £6.7m (Minute No. 16/T/016). The Trust Forecast outturn is currently estimated as:

• Best case £6.4m deficit • Most Likely £6.7m deficit • Worst Case £9.4m deficit

The Committee noted:

• Cash is being managed and forecast is £1.7m at year end (based on continuation of current levels of spend)

• Revolving Working Capital Support Facility (£1.7m) drawn down in February • No further support from the DH to be requested in 2015/16 • Capital to revenue transfer £607k approved and benefit taken in January • The CIP gap forecast £2.317m. Significant risk to achievement remains • Formal agreement sought from CCG for extra costs incurred relating to

contingency beds/black alert costs/restructuring • Waivers Agreed – Nos. 147 - 157 dated 21/01/16 – 09/02/16 totalling £1,175k

The Committee was extremely concerned that the CIP gap forecast is £2.317m and, therefore, remains a significant risk of achievement. It was also noted that the request to the CCG for the funding of additional costs for the opening of contingency beds has not yet been supported. The Committee has been advised that due to the current level of activity performance against plan and risks to forecast achievement, there is a negative level of assurance at present.

16/F/089 ANNUAL REVIEW OF STANDING FINANCIAL INSTRUCTIONS (SFIs) The Committee received and agreed the minor amendments made to the SFIs, noting

that the annual review of SFIs is due in June 2016. The amendments include: • Preferred title of Chair and other job titles • Increased delegated limit under Losses and Compensation for the EDFHR to

£5,000 from £1,000 to ease the process of small claims/payments 16/F/090 ANNUAL ACCOUNTS 2015/16 TIMETABLE


The draft Annual Accounts Timetable for 2015/16 was received which detailed all known key milestones. It has been circulated to all necessary staff for review and feedback pending the issue of the final document.

16/F/091 PROCEDURE PACKS RATIFICATION Deferred to March 2016 meeting as no report available. 16/F/092 COST IMPROVEMENT PROGRAMME (CIPs) 2015/16 The Committee noted with concern that although there has been an increase of £353k in

CIP delivery, there was still a CIP Plan variance of £2.224m. The Committee acknowledged that changes are being made to the report and that work is underway on separating the portfolio into the Clinical Business Units and the review of the PMO in terms of documentation. In order to scrutinise the effectiveness and efficiency of the CIPs programme for 2015/16 and to establish any trends, the Committee requested that a comparison between the CIP report for June 2015 and the report presented to the February meeting be undertaken as a priority action for the next meeting in March 2016. Action: EDFHR

16/F/093 TURNAROUND REPORT – CLINICAL JOB PLANNING The EDFHR advised that although the Turnaround Board had requested information on

clinical job planning, this had not been forthcoming and was very disappointing in terms of missed opportunities for CIPs. Currently, approval to the job planning letter by the Clinical Directors is awaited. The EDFHR provided the Committee with an update on the Trust’s current status in relation to Turnaround progress, highlighting the following key points:

• Carter Review: work is underway in anticipation of the response required to the report

• Stationery Project now implemented and amnesty continuing. First indicators are that approximately £4-5k savings have been achieved within the first month

• Resource support for the Turnaround Board has been raised as a concern and is to be reviewed by CEO/COO

• Turnaround Board terms of reference to be reviewed to ensure focus is correct FINANCIAL PLANNING 2016/17 16/F/094 FINANCIAL PLAN 2016/17 The Committee received the update on planning process for the Financial Plan for

2016/17 which outlined the following: • Trust’s draft Financial Plan for 2016/17 was submitted to the TDA on 8th

February 2016 in line with the deadline • A forecast outturn of £2.152m deficit as agreed at Trust Board on 3rd February

2016 • Achievement of £8.5m Cost Improvement Plans • Submission is subject to TDA review and approval with the final planning

submission due on 8th April 2016 16/F/095 PROCUREMENT SERVICE CONTRACT (COMMERCIAL IN CONFIDENCE) The Procurement Business Case 2015 and recommendation was received. The

Committee noted that the recommendation has been made after review of options and in answer to questions raised at TEC on 14th December 2015. The Committee agreed that the option proposal be submitted to the Trust Board in private for approval. Action: EDFHR

AUDIT & GOVERNANCE 16/F/096 BOARD SELF CERTIFICATION UPDATE The Committee noted that the TDA has advised that the Self Certification is now no

longer required. The HCG confirmed that the risks highlighted previously in the Board Statements will be included on the Risk Register at the appropriate level. The subject of Board Statement 13 is to be proposed to the Trust Board for inclusion on the Principal Risk Register at Board level.

16/F/097 REVIEW OF CORPORATE RISK REGISTER – FIIWC RISKS The HCG presented the suite of papers which provide an update on FIIWC relevant risks

currently logged on the Corporate Risk Register prepared by the Head of Corporate


Governance. The Committee noted that the reconciliation exercise is continuing and further training sessions are being planned through March. As the ICT Task & Finish Group is not yet operational, the Committee agreed that the IT risks would be removed from the report at the point that the Group goes live.

16/F/098 EXTERNAL GOVERNANCE REVIEW – FIIWC ACTIONS The Committee received the action plan update on the progress made in relation to the

External Governance Review recommendations. Overall, 70 actions were determined from the 48 recommendations made by Capsticks. The Committee noted that of the 70 actions, 38 are not yet completed. Of the 32 actions completed, evidence is required from action owners in relation to a number of these actions. The HCG advised that the Audit & Corporate Risk Committee at its meeting on the 9th February 2016 asked that a review be undertaken by the Executive Team to prioritise and RAG rate the actions. Once this has been completed, the outcome will be presented to the Committee. The HCG proposed that this can also be submitted to FIIWC in order to focus the attention of the Committee. Action: HCG/CS

16/F/099 INFORMATION GOVERNANCE QUARTERLY REPORT The HCG presented the Quarterly Information Governance Report which provides a

summary of the current position on the 4 key functions of the IG Department, namely:

• Compliance wth the IG Toolkit 2015/16: Internal Auditors will be undertaking an audit of the level of compliance during the week commencing 22nd February 2016

The Committee was concerned at the current lack of compliance to the Toolkit and considered that should be highlighted to the Trust Board by the Company Secretary.

Action: HCG/CS

• Freedom of Information requests and performance against requirements: performance continues to drop due to staffing issues

The Committee considered that the large number of FOIs, our current performance and the impact this has upon the organisation needs to be highlighted to the Trust Board.

Action: HCG/CS • Information Governance Incidents reported via DATIX: increased number of

records being lost or unavailable from 4 last quarter to 13

• Subject Access Requests and performance against requirements: Increased scrutiny from the Information Commissioners Office due to continued failure to meet deadlines. An action plan has been requested by the ICO to demonstrate how this will be addressed

Lizzie Peers was concerned that with the significant number of records that are unavailable or lost, it would appear to demonstrate that as a Trust we have an increasing issue with records management and queried whether this impacted on quality and safety. The Committee concurred with Lizzie Peers and asked that the action plan to address the ICO concerns is presented to the March meeting of the Committee.

Action: HCG/CS 16/F/100 CORPORATE GOALS & PRIORITIES 2015/16 – FIIWC GOALS & PRIORITIES Deferred to March 2016 meeting as no report available due to sick leave. 16/F/101 INTERNAL AUDIT REPORTS The following internal audit reports were received and noted:

• Compliance Review of Financial Accounting – Substantial Assurance The Committee congratulated the Financial Accounts Team on the excellent work undertaken to achieve this result.


• Review of Estates – Reasonable Assurance 16/F/102 DRAFT TERMS OF REFERENCE Deferred to March 2016 as no report available. 16/F/103 COMMITTEES PROVIDING ASSURANCE The notes and minutes of the following committees were received and noted by the

Committee: • Quality Governance Committee Minutes – January 2016 • Risk Management Committee Minutes – January 2016

Information items previously circulated: 2015/16 Annual Report Timetable

16/F/104 ANY OTHER BUSINESS Deep Dives on Mandatory Training and Appraisals to be undertaken at the April 2016

meeting. 16/F/105 DATE OF NEXT MEETING • Tuesday, 29th March 2016

• 1.00pm – 4.00 p.m. • Large Meeting Room – South Block, St Marys

The meeting closed at 4.05 p.m. Signed: …………………………………………………. Date: ………………………………… CHAIR


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