a g e n d a · jameson added that this was also an area where staff demonstrated commitment and...

TRUST BOARD

DATE: THURSDAY 25 AUGUST 2011, 11.30am VENUE: ROOM 219, TRUST HEADQUARTERS, NORTH

MANCHESTER GENERAL HOSPITAL

A G E N D A

ITEM

1 APOLOGIES FOR ABSENCE

JJ 1130

2 DECLARATION OF INTEREST

GB

3 MINUTE OF MEETING HELD ON 28 JULY 2011

JJ

4 MATTERS ARISING

PATIENT SAFETY

5 PATIENT SAFETY REPORT

RJ 1135

6 PATIENT EXPERIENCE REPORT i) Privacy and Dignity ii) Cleaning

MC JW

1145

7 FRANCIS INQUIRY – ACTIONS FOR THE TRUST

JS 1200

PERFORMANCE

8 CORPORATE PERFORMANCE REPORT HM

1205

STRATEGY, GOVERNANCE AND ASSURANCE

9 SUSTAINABLE DEVELOPMENT MANAGEMENT PLAN – PROGRESS REPORT

JW 1220

10 FOUNDATION TRUST MEMBERSHIP STRATEGY

GB 1225

MINUTES OF BOARD SUB COMMITTEES

11 CLINICAL GOVERNANCE AND QUALITY 15 July 2011

JS 1240

12 RISK MANAGEMENT 12 July

JS

13 DATE AND TIME OF NEXT MEETING Wednesday 28 September 2011, 11.30am

JJ 1245

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1 u:execassts/meetings/trustboard/2011/august

THE PENNINE ACUTE HOSPITALS NHS TRUST Trust Board Part 1

28 July 2011

PRESENT: Mr J Jesky Chairman Mr E Ahmad Non Executive Director Mrs F Burke Non Executive Director Mrs M Carroll Director of Nursing Mr R Chadwick Director of Finance & IM&T Mrs C Guereca Non Executive Director Mr M Holly Non Executive Director Dr R Jameson Medical Director Mrs C Mayer Non Executive Director Mr H Mullen Director of Operations Mr R Pickering Director of Human Resources Mr J Saxby Chief Executive Mr T Wilders Director of Strategic Planning Mr J Wilkes Director of Facilities IN ATTENDANCE: Mr G Barclay Assistant Chief Executive (Board Secretary) Dr S Bradley Deputy Medical Director Dr T Kenny Associate Medical Director APOLOGIES: Mr T Pickstone Non Executive Director 93/2011 MINUTE OF MEETING OF THE PENNINE ACUTE HOSPITALS NHS

TRUST BOARD HELD ON 30 JUNE 2011 The minute of meeting of the Board dated 30 June 2011 was received, approved and signed by the Chairman.

94/2011 MATTERS ARISING 76/2011 Information Leaflets Mr Barclay said that the managers responsible for information leaflets were checking to ensure that they all contained the appropriate information. 77/2011 Releasing Time to Care – Productive Ward Initiative Mrs Carroll reported that the Transforming for Excellence Steering Group was considering how the Productive Ward programme could be mainstreamed and the benefits extended to all other wards. 78/2011 4 Hour Access Target Mr Mullen confirmed that a 4 Hour Access Target recovery trajectory had been prepared.

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85/2011 Security Management Mr Saxby reported that he had met one of the local police superintendants and would meet another two superintendants shortly. 88/2011 Publicity on Annual Reports Mr Barclay confirmed that there had already been significant publicity on the cancer trials and further publicity on other aspects of the annual reports would follow. Mr Saxby added that the staff awards evening had been held at the start of the month. The staff awards recognised the exceptional efforts of staff in a number of categories and he congratulated all the staff who had received an award, and also those who had been nominated. Board members echoed this comment. There had been significant positive publicity on the successful staff. 95/2011 PATIENT SAFETY REPORT Dr Jameson spoke to the report which considered both standardised (risk adjusted) mortality and crude mortality and updated the Board on work being undertaken with respect to safeguarding adults and children. The monthly risk adjusted mortality rates continued to improve and remained significantly below the peer group. The rolling risk adjusted mortality index also continued to show improvement and was now equal to the peer group. Dr Jameson noted the considerable reduction in the rolling risk adjusted mortality index over the previous 12 months. She said this was a significant achievement for the Trust. Dr Jameson said that the Safeguarding Team was now well established, was respected by staff across the Trust and was well used. Mr Holly noted that further work remained to be undertaken to ensure that all appropriate referrals of children attending Accident and Emergency departments were made. Dr Jameson said that the work on the five case notes audit was the most effective way of ensuring that this was drawn to the attention of individual clinicians. Mrs Guereca commented on the work undertaken to integrate community services into the Trust’s safeguarding arrangements. She said this was a good example of cross discipline working. The Chairman commended the Safeguarding Team on the good progress demonstrated and looked forward to continuing to receive quarterly reports on this important area.

The report was noted.

96/2011 PATIENT EXPERIENCE REPORT – HYGIENE CODE / ENVIRONMENT / MATRONS’ REPORT

Mrs Carroll spoke to her report which provided details of performance against the MRSA and CDT trajectories and gave an update on matters relating cleanliness and general infection prevention measures. She said that despite the tough targets imposed on the Trust in both of these areas for 2011/12 the Trust remained below (better than) both of the trajectories. Mrs Carroll drew attention to benchmarking information with other North West Trusts which had been included in the report.

The report was noted.

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97/2011E NON EXECUTIVE DIRECTOR PATIENT EXPERIENCE APRIL – JUNE 2011

Mrs Carroll spoke to the report which informed the Board of the findings of Non Executive Directors whilst sampling patient experiences in the Trust. Mrs Guereca had visited two wards at North Manchester General Hospital and two wards at Fairfield General Hospital. Mrs Guereca and Mr Holly had also attended and supported the launch of the Trust Dignity campaign. Mrs Guereca said that she had found the visits useful and felt that patients were happy to speak to her about their experience. She had also been encouraged to hear staff on wards talking about Trust wide strategies during their day to day work. Mrs Guereca asked whether, following the launch of the Dignity Champions campaign, the Dignity telephone line was being used. Mrs Carroll confirmed that there had been a number of calls and she would provide details in the next routine report covering this area. Mr Saxby asked how patients and staff would know who the Dignity Champions were. Mrs Carroll said that Dignity Champions were named on ward areas and badges were being produced for staff to wear. It was agreed that in addition to providing feedback to individual wards and departments on issues raised it would be helpful to provide wider feedback on a Trust wide basis.

Action: MC The report was noted.

98/2011 MEDICAL EDUCATION STRATEGY Dr Kenny spoke to the Medical Education Strategy for 2011/13 which set out a strategic framework for medical education. Dr Kenny set out the national and regional context within which medical training was provided and said that the Trust was a significant provider of medical training in the North West. She expected the way in which medical education was provided nationally to change in the future and the Trust needed to be in a good position to adapt to this. Mrs Burke said that medical education was at the centre of everything the Trust did and touched on patient safety, patient experience, values and culture and recruitment. Mr Holly welcomed the strategy and urged a resolution to the matters which he knew were being addressed concerning the North West Deanery. Mr Saxby said that the Trust had demonstrated its commitment to medical education by appointing a full time Associate Medical Director to lead this area. He said that the Trust was by far the largest employer of Staff Grade and Associate Specialist doctors in the North West and this important strategy also helped to focus on their training needs. Mr Barclay said that the top risk facing the Trust was more than occasional use of locum staff. He asked how this strategy would help mitigate that risk. Dr Kenny gave an example of training and education in the Anaesthetic department and said that this was one area in the Trust where there were no difficulties in recruiting staff. Dr Jameson added that this was also an area where staff demonstrated commitment and engagement. The Chairman, looking to the future, asked whether the Trust should aspire to become a teaching hospital. Dr Kenny said that North Manchester General Hospital was an associate teaching hospital but the others in the Trust were not. She said that the traditional arrangement of district general hospitals and tertiary teaching centres was

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changing across the country. Locally, this Trust provided some tertiary services in district general hospital settings. She would meet the Dean of the Medical School to confirm the Trust’s continuing role in providing medical education.

Action: TK The strategy was approved.

99/2011 ANNUAL BUSINESS PLAN 2011/12 QUARTERLY REVIEW Mr Wilders spoke to his report which provided an update on progress at quarter one and proposed amendments to the Corporate Objectives. The two proposed amendments were:

Under the Corporate Objective 5 “Environment and Sustainability” to add the estates of Rochdale and Fairfield alongside The Royal Oldham Hospital within the objective to “deliver year on year improvement to estate condition site survey.”

Under Corporate Objective 10 “Equality” to include “ensure that the Trust complies with requirements regarding access to healthcare for people with a learning disability.”

Mr Wilders said that all of the senior managers had their objectives set by the end of June 2011 and trajectories within which all other staff would have their objectives set and a PDR carried out had been provided for all other staff. He therefore expected the objective that 90% of staff would have a performance development review by 31 March to show green/amber by the end of quarter two. He added that following a recent “marathon” mandatory training event, and plans to repeat this later in the year he also expected this objective to be green/amber by the end of quarter two. The amendments to the Corporate Objectives were approved and the report was

noted. 100/2011 JOINT OVERVIEW AND SCRUTINY COMMITTEE REPORT ON

PATIENT COMMUNICATION Mr Wilders spoke to his paper which informed the Board of the recent report by the Joint Health Overview and Scrutiny Committee on patient communication and the Trust’s response to that report. The Trust welcomed the review undertaken by the Joint Health Overview and Scrutiny Committee and the helpful recommendations made. The main issues to be addressed were the development of a policy on communication with patients, determining the Executive leadership of this and putting in place an assurance process. This would be discussed by the Executive Directors.

Action: JS Mr Holly welcomed the recognition within the report that where the Board had taken the lead in other areas there had been significant improvements in performance and he welcomed the suggestion that the Board should provide leadership in the area of patient communication. Mrs Burke agreed with this and added that improving communication was pivotal to the Trust’s strategic direction

The report was noted. 101/2011 CORPORATE PERFORMANCE REPORT Mr Mullen spoke to the report. He said that the 4 Hour Access Target recovery trajectories had been prepared and submitted to the SHA and the Trust was on target against these. Representatives from the SHA had attended a meeting of the Unscheduled Care Group earlier in the week and had been impressed with the amount of work undertaken by the Trust.

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A detailed recovery plan had been submitted to the SHA to eliminate the 18 week backlog. The backlog in Gynaecology had been cleared and work was underway in the remaining specialities. Mr Pickering confirmed the work reported earlier on PDRs and statutory and mandatory training. 2,850 episodes of training had been carried out during the mandatory training “marathon” event. Mr Chadwick said that a recent change to information governance training required all staff to be trained annually rather than bi-annually. Although showing 65% for May 2011, he expected this figure to increase significantly when the June 2011 figures were available. Mrs Guereca asked about the targets for access to services for people with a learning disability. Mr Wilders said that the targets had still to be determined nationally but the Trust would be required to submit a self certification. Mr Wilders would provide details of these to Mrs Guereca once the targets had been agreed.

Action: TW

Mrs Mayer asked what actions had been undertaken to achieve such a significant improvement in the 4 Hour Access target performance. Mr Mullen said that all existing plans had been reviewed and the national ECIST team had visited the Trust again. There had been detailed discussions with individual staff and with staff groups and further work had been undertaken on discharge arrangements also involving Social Services. It was agreed to circulate a copy of the ECIST report to Non Executive Directors.

Action: HM Mrs Mayer asked what accountability was in place if the 90% target for PDPs was not achieved. Mr Saxby said that this would be addressed with managers through the performance management arrangements. Mrs Carroll said that the number of mixed sex accommodation breaches per 1000 finished consultant episodes for the Trust in April had been 0.4 which was better than the North West SHA rate of 2.2 and better than the England rate of 1.9.

The report was noted. 102/2011 AUDIT COMMITTEE ANNUAL REPOT Mr Holly spoke to the annual report which had been considered and agreed by the Audit Committee. He confirmed that the Committee influenced the work of the internal auditors and during the year the Committee had asked for further work to be undertaken on pre-employment checks, safe and secure medicines and cleaning. Mr Holly confirmed that the Audit Committee held a private meeting with the internal and external auditors following every Audit Committee meeting. The Audit Committee had undertaken a self assessment of its own work and had scored 4.2 out of 5. The main issues identified had been the need for induction and ongoing training for Audit Committee members. Mr Holly confirmed that the Chief Executive had attended a meeting of the Audit Committee during the year as required. In general terms, there was prompt follow up of recommendations from internal and external audit although there were a number of recommendations from previous audits which remained outstanding.

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Mr Holly thanked other Non Executive members of the Audit Committee for their support during the year. The Chairman added his thanks to Mr Holly for the efficient way in which the work of the Audit Committee was carried out.

The report was approved. . 103/2011 ELECTRICITY SUPPLY AGREEMENT Revenue costs of £375,000 fixed for four years and variable costs of approximately £13M (including VAT and climate change levy) for four years and the award of the contract to NPower and the services of Energy Management Services were approved.

The electricity supply agreement was approved. 104/2011 MINUTES OF BOARD SUB COMMITTEES The minute of meeting of the Audit Committee dated 12 July 2011 was submitted and noted. Mr Holly said that a report on the Deanery contract would be submitted to the next meeting of the Audit Committee. He also commented on the very positive follow up report by internal audit on the Trust’s response to the Healthcare Commission report on their investigation into Mid Staffordshire NHS Foundation Trust. The follow up report had also included a commentary on the Trust’s response to the recent television documentary. 105/2011 DATE OF NEXT MEETING The next meeting of the Trust Board will be held on Thursday 25 August 2011 in Room 219, Trust HQ, North Manchester General Hospital at 11.30am. Resolved – that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

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Agenda Item: 5

Title of Report Patient Safety Report

Executive Summary

The report considers both standardised (risk adjusted) mortality and crude mortality. The report also provides updates on the North West Reducing Mortality Collaborative Work.

Actions requested

The board is asked to note the report

Corporate Objectives supported by this paper: Objective 1 – Improving Patient Safety - Reduction in standardised mortality

Risks: Board Risk Register: –

- Failure to continue to improve HSMR at a rate that improves the Trust’s National Standing.

Public and/or patient involvement: N/A

Resource implications: N/A

Communication: Through the Governance structures Dedicated section on Trust Internet site

Have all implications been considered? YES NO N/A

Assurance

Contract

Equality and Diversity

Financial / Efficiency

HR

IM&T

Local Delivery Plan / Trust Objectives

National policy / legislation

Sustainability

Name Dr Ruth Jameson

Job Title Executive Medical Director

Date August 2011

Email [email protected]

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INTRODUCTION 1. The Trust is committed to improving patient safety and aims to have no avoidable deaths

and no avoidable harm.

2. This month the report includes current mortality information, and the North West Reducing Mortality Collaborative update.

MORTALITY

3. The Trust uses CHKS as its tool for measuring our Hospital Standardised Mortality Ratio

(HSMR). Standardised mortality is defined as the actual mortality divided by the expected mortality multiplied by 100. This generates a mortality index which is a measurement of standardised mortality. Values above 100 suggest a higher than expected mortality and those below 100 a lower than expected mortality.

4. The monthly Standardised Mortality is shown below using both 2010 and 2011

standardisation methodologies. The 2011 figures have been updated on 8th August to account for increased availability of data.

Report on : TRUST

Apr 2010 / Apr 2011 Inclusive

Indicator May-

10 Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Risk Adjusted Mortality 2010

85 71 79 78 68 75 83 105 87 76 81

Risk Adjusted Mortality 2011

105 94 96 93 92

Peer Group RAMI 2011

102 94 94 105 109

See Appendix 1 for RAG rating. 5. The Trusts rolling Standardised Mortality (2011 methodology) shows the previous twelve

months each month and provides evidence of reduction over the last 12 months avoiding month on month variation.

Rolling Risk Adjusted Mortality Index (RAMI 2011 CHKS Model) ROLLING INDEX

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

TRUST (CHKS 2011)

117 114 112 110 107 104 103 104 101 99 98 97

96

PEER (CHKS 2011)

103 102 100 100 99 97 97 98 96 96 96 96

97

VARIANCE 14 12 12 10 8 7 6 6 5 3 2 1 -1

6. Our CHKS peer rolling standardised mortality is also shown. When comparing the rate of

improvement this demonstrates a reduction in adverse variance from 14 to -1 over the course of the year ie. in a position better than peer.

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7. The Crude Mortality (number of deaths as a percentage of inpatient spells) is shown below.

8. The rolling crude mortality is shown below. This measure does not appear to have changed significantly over the last 12 months.

May- 10

June 10

July- 10

Aug - 10

Sep - 10

Oct - 10

Nov – 10

Dec – 10

Jan - 11

Feb – 11

Mar – 11

Apr - 11

May- 11

1.52 1.50 1.50 1.52 1.51 1.51 1.50 1.53 1.51 1.51 1.51 1.51 1.50

9. These measures will be reported monthly to the Board. Site detail will be discussed and

managed through the Patient Safety and Clinical Governance and Quality Committee structures and reported as necessary to the Board.

PATIENT SAFETY WALKROUNDS

Patient Safety Walk Rounds

0

20

40

60

80

100

120

140

160

Oct-10 Nov-

10

Dec-

10

Jan-

11

Feb-

11

Mar-

11

Apr-11 May-

11

Jun-

11

Jul-11 Aug-

11

Sep-

11

Month

No

Walk

rou

nd

s

Scheduled 0 Actual Trajectory 0

11. Each month members of the executive team conduct a schedule of unannounced ward

visits to discuss issues relating to patient safety using a semi structured questionnaire.

12. The main aim of the walkrounds is to engage staff in the patient safety agenda and enable them to generate solutions. The walkrounds demonstrate the Leadership commitment to the patient safety agenda.

13. The walkrounds are ahead of trajectory. Feedback is being communicated to the

organisation, through the Divisional Structure. “Out of hours” walkrounds are included for completeness.

May- 10

June 10

July- 10

Aug - 10

Sep - 10

Oct - 10

Nov – 10

Dec – 10

Jan – 11

Feb – 11

Mar - 11

Apr - 11

May- 11

1.54 1.21 1.34 1.53 1.33 1.52 1.44 2.11 1.80 1.51 1.47 1.45 1.39

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REDUCING MORTALITY COLLABORATIVE 14. The North West Reducing Mortality Collaborative July 2011 Measurement report is at

Appendix 2. 15. This shows both CHKS and Dr Foster rolling adjusted mortality. The Trust demonstrates

improvement over the year and has improved in relation to this peer group. The Board will note on page 2 the improvement by 17.1 points of our standardised mortality (CHKS Rami 2010). This is the best improvement in the collaborative.

16. Disease specific information is also shown namely:-

COPD – Chronic Obstructive Pulmonary Disease HF – Heart Failure #NOF – Fractured Neck of femur Pneumonia Sepsis All of which show an improved risk adjusted mortality.

CONCLUSION 17. The rolling standardised (risk adjusted) mortality has this month again improved and

shows a value the same as peer. 18. The walkrounds are providing an opportunity to give ward to Board feedback and give

assurance that improvement work being undertaken is appropriate. It provides an opportunity to ensure focus and due attention to the relevant patient safety issues.

17. Although the North West Reducing Mortality Collaborative has finished the work continues

and the progress for these specific conditions will be monitored as an integral part of our patient safety work.

Dr Ruth Jameson Medical Director

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Appendix 1. RAG RATING

Performance vs peer group

All except RAMI/RALI and DQ RAMI/RALI

>=10% worse than Peer Group >=110

<=10% and >=5% worse than Peer Group <110 and >=105

<5% and >=5% better than Peer Group <105 and >=100

>5% better than Peer Group <100 and >=95

>0% and <=5% better than Peer Group <95

No data available/not applicable No data available/not applicable

No peer data No peer data

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Below are the 12-month rolling adjusted mortality data from CHKS and Dr. Foster Intelligence (DFI) through May 2011. DFI data is for all diagnoses (SMR). CHKS data was rebased in February 2010. DFI data was rebased in September 2010. Below the graphs is a table showing DFI data for all diagnoses and comparing the nine Reducing Mortality Collaborative teams with the SHA as a whole. This dated is updated through March 2011. AQuA is working to get updated data.

60.0

70.0

80.0

90.0

100.0

110.0

Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

Adjusted Mortality Rate

12 Month Rolling Adjusted Mortality CHKS (RAMI)

Blackpool Calderdale and HuddersfieldCentral Manchester East LancsMid Cheshire PennineBolton StockportTameside �

60.0

70.0

80.0

90.0

100.0

110.0


Adjusted Mortality Rate

12 Month Rolling Adjusted Mortality (Dr. Foster)

Blackpool Calderdale and HuddersfieldCentral Manchester East LancsMid Cheshire PennineBolton StockportTameside �

Northwest Reducing Mortality Collaborative July 2011 Measurement Report

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2

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Decline

NW Collaborative 92.5 91.2 89.4 87.8 86.2 85.3 84.0 82.7 83.0 82.0 81.0 81.0 11.5

NW Region 87.0 86.0 85.0 84.0 83.0 82.0 81.4 80.7 81.0 80.0 80.0 79.0 8.0

National 85.0 84.0 83.0 82.0 81.0 80.0 79.4 78.5 78.0 77.0 76.0 75.0 10.0

Blackpool 85.6 82.9 81.3 80.3 80.0 81.2 81.5 80.4 82.1 81.2 82.1 82.6 3.0

Calderdale and Huddersfield 81.2 78.5 75.9 73.8 73.5 73.0 72.3 72.5 74.7 75.3 76.0 76.0 5.3

Central Manchester 99.7 98.2 97.6 97.2 95.5 96.1 93.6 91.5 90.3 90.8 89.0 87.8 11.9

East Lancs 102.0 102.0 99.6 98.4 95.8 95.6 95.5 92.7 92.6 92.2 91.2 92.0 10.0

Mid Cheshire 97.9 96.9 95.2 92.5 91.2 89.1 87.7 86.9 87.4 87.4 86.6 84.1 13.8

Pennine 98.5 97.0 94.5 93.0 91.6 89.3 86.9 85.9 86.7 84.4 82.5 81.3 17.1

Bolton 85.1 82.4 80.8 79.9 78.2 76.3 73.3 72.1 70.9 69.5 69.9 70.4 14.7

Stockport 89.0 87.0 86.9 85.8 82.8 82.7 81.6 78.4 77.2 75.9 75.0 74.0 15.0

Tameside 94.0 92.0 89.9 86.4 83.1 82.8 84.2 85.7 85.6 84.9 86.2 87.0 7.0

CHKS RAMI 10 Rolling 12 months

Below are the 12-month rolling adjusted mortality data from CHKS and Dr. Foster Intelligence (DFI). DFI data is for all diagnoses (SMR). CHKS data was rebased in February 2010. DFI data was rebased in September 2010. Below the graphs is a table showing DFI data for all diagnoses and comparing the nine Reducing Mortality Collaborative teams with the SHA as a whole.

92.5

81.0

87.0

79.0

85.0

75.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

105.0

110.0


Adj

uste

d M

orta

lity

(CH

KS R

AM

I 10)

Rolling 12 Months

NW Reducing Mortality Collaborative National Comparison using CHKS RAMI 10

NW Collaborative NW Region National

Collaborative start

�

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3

The tables below show each team’s data for unadjusted mortality (solid lines) and adjusted mortality scores (dashed lines) through May 2011. For teams that do not submit data to CHKS, the source of unadjusted mortality data is DFI. There are small differences in how the two calculate unadjusted mortality so mortality rates should not be compared across the two companies. It is the trends that are important. The legends identify the source of the data.

70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

Ad

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Rolling 12 Months

Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust

Pneumonia (CHKS) Septicemia (CHKS) Unadjusted Mortality (CHKS) SMR (08/09)

RAMI 10 SMR SHA (08/09) SMR Collaborative (08/09)�

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4

70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0


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Rolling 12 Months

Calderdale & Huddersfield NHS Foundation Trust

COPD (CHKS) HF (CHKS) Unadjusted Mortality (CHKS) SMR (08/09)


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5

70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0

32.5

35.0


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Rolling 12 Months

Central Manchester University Hospitals NHS Foundation Trust

Pneumonia (Dr Foster) Unadjusted Mortality (Dr Foster) SMR (08/09)


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75.0

80.0

85.0

90.0

95.0

100.0

105.0

110.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0

32.5

35.0


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Rolling 12 Months

East Lancashire Hospitals NHS Trust

COPD (Dr Foster) #NOF (Dr Foster) Septicemia (Dr Foster)

Unadjusted Mortality (Dr Foster) SMR (08/09) RAMI 10

SMR SHA (08/09) SMR Collaborative (08/09)�

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70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0


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Rolling 12 Months

Mid Cheshire Hospitals NHS Foundation Trust

Septicemia (CHKS) Unadjusted Mortality (CHKS) SMR (08/09)


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70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0

32.5

35.0

37.5

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Pennine Acute Hospitals NHS Trust

HF (CHKS) Septicemia (CHKS) Unadjusted Mortality (CHKS) SMR (08/09)


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65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

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17.5

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ex

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d M

ort

ali

ty R

ate

Rolling 12 Months

Royal Bolton Hospital NHS Foundation Trust

HF (CHKS) Pneumonia (CHKS) Septicemia (CHKS) Unadjusted Mortality (CHKS)

SMR (08/09) RAMI 10 SMR SHA (08/09) SMR Collaborative (08/09)�

Item

5

of 132

10

70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0

32.5

35.0

37.5

40.0


Ad

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Un

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Rolling 12 Months

Stockport NHS Foundation Trust

Pneumonia (Dr Foster) Septicemia (Dr Foster) Unadjusted Mortality (Dr Foster)

SMR (08/09) RAMI 10 SMR SHA (08/09)

SMR Collaborative (08/09)�

of 132

11

70.0

75.0

80.0

85.0

90.0

95.0

100.0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

20.0

22.5

25.0

27.5

30.0

32.5

35.0

37.5

40.0


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d M

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Un

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Rolling 12 Months

Tameside Hospital NHS Foundation Trust

COPD (Dr Foster) #NOF (Dr Foster) Pneumonia (Dr Foster)

Unadjusted Mortality (Dr Foster) SMR (08/09) RAMI 10

SMR SHA (08/09) SMR Collaborative (08/09)�

Item

5

of 132

12

Below are the unadjusted and adjusted mortality figures for all clinical diagnoses chosen by the Reducing Mortality

teams. The graphs on the left show Dr Foster unadjusted mortality data and those on the right show Dr SMR using

2008/09 basing.

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%


Un

ad

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d M

orta

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R

ate

(D

F)

Rolling 12 Months

COPD

Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust Calderdale and Huddersfield NHS Foundation Trust

Central Manchester University Hospitals NHS Foundation Trust East Lancashire Hospitals NHS Trust

Mid Cheshire Hospitals NHS Foundation Trust Pennine Acute Hospitals NHS Trust

Royal Bolton Hospital NHS Foundation Trust Stockport NHS Foundation Trust


45.0

55.0

65.0

75.0

85.0

95.0

105.0

115.0

125.0


Dr. F

oste

r R

R

Rolling 12 Months






0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%


Un

ad

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d M

orta

lity

R

ate

(D

F)

Rolling 12 Months

Heart Failure






60.0

70.0

80.0

90.0

100.0

110.0

120.0

130.0

140.0


Dr. F

oste

r R

R

Rolling 12 Months






of 132

13

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%


Un

ad

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R

ate

(D

F)

Rolling 12 Months

#NOF






40.0

50.0

60.0

70.0

80.0

90.0

100.0

110.0


Dr. F

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r R

R

Rolling 12 Months


Calderdale and Huddersfield NHS Foundation Trust East Lancashire Hospitals NHS Trust




10.0%

15.0%

20.0%

25.0%

30.0%

35.0%


Un

ad

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d M

orta

lity

R

ate

(D

F)

Rolling 12 Months

Pneumonia






60.0

70.0

80.0

90.0

100.0

110.0

120.0


Dr. F

oste

r R

R

Rolling 12 Months






Item

5

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14

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

55.0%


Un

ad

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orta

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R

ate

(D

F)

Rolling 12 Months

Sepsis






40.0

60.0

80.0

100.0

120.0

140.0

160.0


Dr. F

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Rolling 12 Months






of 132

Patient Experience Board Paper 08/11 1

Agenda Item: 6i

Title of Report Patient Experience – Privacy and Dignity August 2011 Report

Executive Summary

The purpose of this report is to inform and update members of the Board on activities and developments across the Trust with regards to privacy and dignity issues.

Actions Requested:

To note.

Corporate objectives supported by this paper: Corporate Objective - 2) Improving the Patient Experience

Risks: Unable to meet government direction and CQUIN targets if survey programme does not continue. Local survey work is also undertaken to meet government guidelines and improve public perceptions and confidence in the Trust.

Public and/or Patient Involvement: As described within the report.

Resource Implications: N/A

Communication: Information in the report is communicated across the Trust to Divisions and Directorates as part of the general performance reporting.


Assurance x

Contract x

Equality and Diversity x

Financial / Efficiency x

HR x

IM&T x

Local Delivery Plan / Trust Objectives x

National policy / legislation x

Sustainability x

Name Marian Carroll

Job Title Director of Nursing

Month and Year August 2011


Item

6i

of 132


Patient Experience – Privacy and Dignity

1. Introduction

The purpose of this report is to inform and update Trust Board members about the activities and developments in dignity and respect issues within the Trust. The Trust has a number of work streams that cover the area and this report aims to give an overall picture of activities and results.

2. Strategic Context

This report directly contributes to 2011/12 Corporate Objective 2 (Improving the Patient Experience). The Trust’s vision and goals are underpinned by the corporate objectives that support patient experience. Identifying the achievement of objectives by identifying surveys and interactions with patients will give added assurance that these are being met.

3. Statistical Report

This report compares national and local patient survey scores on a number of questions identified by the Trust as part of the local survey for CQUIN and performance monitoring requirements.

The national survey is undertaken across all Acute NHS Trusts in the country to identify patients’ experiences and perceptions of care. These results are then analysed and a benchmark score given to allow individual Trusts to compare themselves against others and identify areas for improvement. The results of the 2010 survey were published in April 2011. The Trust local survey has been similarly benchmarked to allow the scores to be compared. The benchmark scores identified are not the direct percentage responses to the questions; they are scores calculated by converting responses to particular questions into scores. For each question in the survey, the individual responses were scored on a scale of 0 to 100, with 100 representing the best possible response. The areas covered by the report are Staff Communication, Treatment and Care, Discharge, Nutrition and Hydration, Noise and Overall Care.

Local Survey N

ati

on

al

Inp

ati

en

t

20

09

Su

rve

y

Na

tio

na

l In

pa

tie

nt

20

10

Su

rve

y

Be

nch

ma

rk S

co

re

Au

g 2

01

0

Be

nch

ma

rk S

co

re

Se

pt

20

10

Be

nch

ma

rk S

co

re

Oct

20

10

Be

nch

ma

rk S

co

re

No

v 2

01

0

Be

nch

ma

rk S

co

re

De

c 2

01

0

Be

nch

ma

rk S

co

re

Ja

n 2

01

1

Be

nch

ma

rk S

co

re

Fe

b 2

01

1

Be

nch

ma

rk S

co

re

ma

rch

20

11

Be

nch

ma

rk S

co

re

Ap

ril 2

01

1

Be

nch

ma

rk S

co

re

Ma

y 2

01

1

Be

nch

ma

rk S

co

re

Ju

ne

20

11

Be

nch

ma

rk S

co

re

Ju

ly 2

01

1

Numbers of usable surveys completed

367

362

265

262

266

256

190

200

331

264

183

259

548

477

of 132


3.1 Staff communication

Local Survey Questions N

ati

on

al

Inp

ati

en

t

20

09

Su

rve

y

Na

tio

na

l In

pa

tie

nt

20

10

Su

rve

y

Be

nch

ma

rk S

co

re

Au

g 2

01

0

Be

nch

ma

rk S

co

re

Se

pt

20

10

Be

nch

ma

rk S

co

re

Oct

20

10

Be

nch

ma

rk S

co

re

Nov 2

01

0

Be

nch

ma

rk S

co

re

De

c 2

01

0

Be

nch

ma

rk S

co

re

Ja

n 2

01

1

Be

nch

ma

rk S

co

re

Fe

b 2

01

1

Be

nch

ma

rk S

co

re

ma

rch

20

11

Be

nch

ma

rk S

co

re

Ap

ril 2

01

1

Be

nch

ma

rk S

co

re

Ma

y 2

01

1

Be

nch

ma

rk S

co

re

Ju

ne

20

11

Be

nch

ma

rk S

co

re

Ju

ly 2

01

1

Did the doctors talk in front of you, as if you were not there?

82

84

85

84

83

84

79

83

86

84

81

87

84

82

When you had a question to ask the nurse, did you get answers you could understand?

76

83

93

93

92

96

88

93

93

95

93

94

92

94

Did a member of staff say one thing and another say something different?

79

81

81

84

81

75

71

80

85

81

81

82

80

82

Did you find someone in the hospital to talk to about your worries and fears?

55

64

65

74

74

80

70

76

80

77

74

69

75

82

3.2 Treatment and care


ati

on

al

Inp

ati

en

t

20

09

Su

rve

y

Na

tio

na

l In

pa

tie

nt

20

10

Su

rve

y

Be

nch

ma

rk S

co

re

Au

g 2

01

0

Be

nch

ma

rk S

co

re

Se

pt

20

10

Be

nch

ma

rk S

co

re

Oct

20

10

Be

nch

ma

rk S

co

re

No

v 2

01

0

Be

nch

ma

rk S

co

re

De

c 2

01

0

Be

nch

ma

rk S

co

re

Ja

n 2

01

1

Be

nch

ma

rk S

co

re

Fe

b 2

01

1

Be

nch

ma

rk S

co

re

ma

rch

20

11

Be

nch

ma

rk S

co

re

Ap

ril 2

01

1

Be

nch

ma

rk S

co

re

Ma

y 2

01

1

Be

nch

ma

rk S

co

re

Ju

ne

20

11

Be

nch

ma

rk S

co

re

Ju

ly 2

01

1

Were you as involved as much as you wanted to be in decisions about your care and treatment?

68

70

82

86

86

86

81

85

85

85

82

82

85

86

Were you given enough privacy when discussing your condition and treatment?

80

83

89

93

94

96

92

91

90

93

92

93

94

93

Did you feel you were treated with respect and dignity while you were in hospital?

84

89

96

97

96

97

93

95

96

95

95

95

96

98

3.3 Discharge information


ati

on

al

Inp

ati

en

t

20

09

Su

rve

y

Na

tio

na

l In

pa

tie

nt

20

10

Su

rve

y

Be

nch

ma

rk S

co

re

Au

g 2

01

0

Be

nch

ma

rk S

co

re

Se

pt

20

10

Be

nch

ma

rk S

co

re

Oct

20

10

Be

nch

ma

rk S

co

re

No

v 2

01

0

Be

nch

ma

rk S

co

re

De

c 2

01

0

Be

nch

ma

rk S

co

re

Ja

n 2

01

1

Be

nch

ma

rk S

co

re

Fe

b 2

01

1

Be

nch

ma

rk S

co

re

ma

rch

20

11

Be

nch

ma

rk S

co

re

Ap

ril 2

01

1

Be

nch

ma

rk S

co

re

Ma

y 2

01

1

Be

nch

ma

rk S

co

re

Ju

ne

20

11

Be

nch

ma

rk S

co

re

Ju

ly 2

01

1

Do you feel you have been involved in decisions about your discharge from hospital?

66

69

85

83

89

91

90

90

85

90

87

87

87

85

Has a member of staff told you about the medication side effects to watch out for when you go home?

43

40

62

56

74

71

66

84

70

76

73

71

61

66

Has a member of staff told you about any danger signals to watch for when you go home?

46

45

60

55

70

72

63

81

64

74

73

64

56

63

The Trust has developed a leaflet to support patients on discharge and the hospital wards have been visited to raise awareness and encourage usage during this quarter.

Item

6i

of 132


3.4 Nutrition and hydration


ati

on

al

Inp

ati

en

t

20

09

Su

rve

y

Na

tio

na

l In

pa

tie

nt

20

10

Su

rve

y

Be

nch

ma

rk S

co

re

Au

g 2

01

0

Be

nch

ma

rk S

co

re

Se

pt

20

10

Be

nch

ma

rk S

co

re

Oct

20

10

Be

nch

ma

rk S

co

re

No

v 2

01

0

Be

nch

ma

rk S

co

re

De

c 2

01

0

Be

nch

ma

rk S

co

re

Ja

n 2

01

1

Be

nch

ma

rk S

co

re

Fe

b 2

01

1

Be

nch

ma

rk S

co

re

ma

rch

20

11

Be

nch

ma

rk S

co

re

Ap

ril 2

01

1

Be

nch

ma

rk S

co

re

Ma

y 2

01

1

Be

nch

ma

rk S

co

re

Ju

ne

20

11

Be

nch

ma

rk S

co

re

Ju

ly 2

01

1

Were you offered a choice of food?

n/a

n/a

91

92

91

94

92

91

94

95

90

91

90

97

Did you get enough help from staff with your meals?

n/a

n/a

96

96

98

98

96

89

97

95

96

96

92

96

The Trust’s nutrition group have been reviewing and examining food provision, in particular soft/pureed diet, during the last few months. The group has recruited patients and interested public members to assist in the tasting and contract placement.

3.5 Noise at night

Local Survey Questions

Score April 2011

Score July 2011

Were you disturbed by noise on the ward during the night?

Yes 31.0% 36.1%

No 69.0% 63.9%

What was the noise that disturbed you? (Choose All That Apply) Score April 2011

Score July 2011

Staff 24.6% 31.4%

Other Patient 61.4% 70.3%

Other 35.0% 25.6%

3.6 Overall


ati

on

al

Inp

ati

en

t

20

09

Su

rve

y

Na

tio

na

l In

pa

tie

nt

20

10

Su

rve

y

Be

nch

ma

rk S

co

re

Au

g 2

01

0

Be

nch

ma

rk S

co

re

Se

pt

20

10

Be

nch

ma

rk S

co

re

Oct

20

10

Be

nch

ma

rk S

co

re

No

v 2

01

0

Be

nch

ma

rk S

co

re

De

c 2

01

0

Be

nch

ma

rk S

co

re

Ja

n 2

01

1

Be

nch

ma

rk S

co

re

Fe

b 2

01

1

Be

nch

ma

rk S

co

re

ma

rch

20

11

Be

nch

ma

rk S

co

re

Ap

ril 2

01

1

Be

nch

ma

rk S

co

re

Ma

y 2

01

1

Be

nch

ma

rk S

co

re

Ju

ne

20

11

Be

nch

ma

rk S

co

re

Ju

ly 2

01

1

As far as you know, did the doctors wash or clean their hands between touching patients?

84

82

93

94

90

93

91

92

93

94

95

94

92

95

As far as you know, did the nurses wash or clean their hands between touching patients?

84

88

93

92

92

95

90

96

93

94

95

97

95

96

How would you rate the overall standard of care you received during your stay?

76

78

79

80

82

80

77

82

79

80

80

81

80

85

Would you recommend this hospital to family and friends?

n/a

n/a

91

93

93

94

87

92

90

92

92

89

87

93

of 132


3.7 Same Sex Accommodation

A monthly survey of patient perceptions is undertaken across the Trust. There have been improvements reported in July of perceptions of patients with regards to same sex accommodation. The planned schedule of LINk visits has commenced with The Royal Oldham visit being undertaken in July. Feedback from the visit was positive and LINk representatives from areas other than Oldham participated in the visit. This cross review will allow all LINks to identify the different provision and challenges in meeting compliance across the sites.

3.8 Non – Executive Director Experience

The Non –Executive Director Programme is progressing and is currently in the fourth quarter of planned activities. Feedback from wards and patients has been positive and reports are submitted to the Trust Board quarterly.

4. Patient Voice/Patient Stories

A total of 41 pieces of patient feedback was left by patients on NHS choices in the reporting period (May – July 2011). 13 people left positive comments, 12 left negative comments and 16 left both positive and negative comments as part of the feedback. The themes identified from the positive feedback related to the quality of care received and staff helpfulness, whilst negative feedback related to issues such as patients smoking outside hospital entrances, parking and Rochdale Infirmary closures. The Trust always responds to the feedback and requests that patients contact the PALS department in cases where further information is required to allow investigation and action to be taken. Feedback is also forwarded on to the department concerned where it is named.

5. Local Department Experience Big Health Event- Manchester June 25th 2011 The Trust supported Manchester Learning Disability Partnership Board to plan and hold an event for people with learning disabilities (PWLD) and their carers during National Learning Disability Week in June. The Trust provided advice and support to the attendees, undertaking blood pressure and pulse checks as part of the wider ‘health check’ available on the day. Over 400 people attended and advice and support was also available from local GPs should the health check results require intervention.

Item

6i

of 132


The Trust used the event as an opportunity to advise carers and the public of the activity in the Trust that is being undertaken to support PWLD. A survey was also undertaken to identify experiences of patients and carers accessing services or barriers that they may feel are present. The event has since enabled the Trust to start working on a project with a community organisation which supports PWLD to identify and resolve issues for PWLD when they are in transition from accessing child to adult services. Smile Week – Medical Assessment Unit (ROH) The Medical Assessment Unit at the Royal Oldham Hospital held a ‘smile week’ initiative in July to encourage staff to greet all visitors to the unit with a smile and focus on their customer care skills. The unit provided a display of information and linked the week into the recruitment of Dignity Champions in the unit, identifying 34 in the initial recruitment drive. Dignity Champions An event was held on 17th May 2011 to celebrate the development of Dignity Champions, as part of the Dignity in Care Campaign, and set out the dignity in care agenda and expectations. Following the launch of the Dignity Campaign in May, the Trust has now recruited 407 champions. These champions are becoming active across the Trust and supporting privacy and dignity in all wards. The Trust dignity breach line has received 5 calls, with staff using it to report how they had dealt with issues of concern; no requests for help in intervening with breaches were made. Issues identified related to how a patient had been spoken to, provision of nightdresses and patient privacy.

6. Lessons Learned

Local survey scores for individual wards are being disseminated via the lead nurses on a monthly basis to allow specific areas to be supported; for example, wards with poor discharge scoring have been visited and supported. Divisional breakdowns against Trust performance have also been provided to allow comparison.

The action plan to support the National Inpatient Survey 2010 has been developed and agreed with identified leads and ratified with the Patient Experience and Equality and Diversity Committee. The plan will be monitored quarterly.

7. Conclusion

Patient experience information and activity continues across the organisation and managers and staff are being encouraged to gather patient and carer experiences and use them to improve service delivery. Advice and guidance to support the

of 132


collection of data and support activity locally is available from the Equality and Engagement Team.

Marian Carroll Executive Director of Nursing August 2011

Item

6i

of 132

of 132

Agenda Item: 6ii

Title of Report Cleaning Report

Executive Summary

Report to update the Trust Board on Cleaning Issues

Actions requested

To note the action

Corporate Objectives supported by this paper: 2) Improving patients experience by improving cleaning standards 3) Care Quality Commission ratings- provide a high quality service for

patients 5) Healthcare Acquired Infections – reduce hospital acquired infection rates

Risks: Failure to meet Trust objectives

Public and/or patient involvement: N/A.

Resource implications: No resource implications.

Communication: There are plans to communicate Trust success internally


Assurance

Contract



HR

IM&T



Sustainability

Name John Wilkes

Job Title Facilities Director

Date August 2011


Item

6ii

of 132

of 132

Trust Cleaning Report 1. Introduction 1.1 The purpose of this paper is to provide an update to the Trust Board on

cleaning issues. 2. Cleaning Spot Checks 2.1 Cleaning spot checks continue to take place on all sites monthly.

Inspections are carried out by the Director of Facilities, Associate Director of Facilities and the Associate Director of Nursing.

2.2 In the last 3 months 20 wards and departments have been visited.

During the spot checks only one ward, F9 at the Royal Oldham Hospital, did not achieve the required score of 90%.

2.3 During the spot checks very high standards were found at Fairfield on

Ward 20 and in the A&E department, on Ward E6, H4 and J6 at NMGH, CAU at Rochdale and F11 and G2 at Royal Oldham.

2.4 The ISS scores continue to exceed the required DOH National

Cleaning Standards and a satisfactory number of audits have been undertaken on all sites each month.

2.5 The graph below shows the ISS scores since April 2010, and that they

are exceeding the required target cleaning score.

2.6 Improvements at North Manchester continue to be sustained. The initial

improvements at Oldham have not been maintained in all areas. This has now been escalated to the Divisional Director of Mediclean who is meeting with the Director and Associate Director of Facilities to agree actions.

Item

6ii

of 132

2.7 Issues are still not being escalated to the Trust team by ward

managers. The Associate Director of Nursing is addressing this with divisional nurse managers.

3. Penalties 3.1 The following financial penalties have been issued to the contractor

Site Financial Penalty May and Area

Financial Penalty June and Area

Financial Penalty July and Area

Royal Oldham

£600 K Block, F9,F8 Path Lab

£300 Physio, C2

£900 CDU,F8,A&E, C2

North Manchester

£621.21 Dental, Pharmacy F6

£358.26 E5, Offices

£955.36 Offices, C5, pharmacy, public areas Park House

Fairfield £400 Lobby by ward 24, GF lift and lobby

No Penalties No Penalties

Rochdale £200 Level D corridor

No Penalties No Penalties

3.2 There has been an increase in the number of penalties issued as a

result of the implementation of an enhanced monitoring protocol, which allows for a spot fine of £200 if a monitored area falls 10% below the required standard.

3.3 It has been identified that 3 areas at Royal Oldham are a concern as

they have received 2 spot fines within the last 3 months. These areas are C2, F8 and A&E. Investigations have identified staffing issues, activity levels and high levels of dust due to the building work as being the main problems. All issues have been rectified and will be closely monitored over the next month.

4. Trust Monitoring Scores 4.1 The average Trust Monitoring scores for the previous 3 month have

been included in this report. The graph below shows the site average scores per month.

4.2 There were only 2 areas across the Trust that were rated red in the last quarter, these were central delivery unit at the Royal Oldham Hospital and Pharmacy at North Manchester. The issues on these areas are being addressed.

of 132

4.3 All sites are exceeding the required target of 88.5% and the cleaning committee continue to closely monitor all scores and report to the Infection Prevention Committee. 4.4 There is a higher proportion of amber rated scores at Oldham than any other site, with some failing by only a very small percentage, this is being actively addressed with ISS. 6. Further Actions 6.1 The facilities directorate will continue to rigorously monitor cleaning

standards and apply penalties where necessary and report to the Board on a quarterly basis.

6.2 The Director of Facilities will continue to meet the Divisional Director for

ISS on a quarterly basis to review progress. 6.3 The infection prevention committee will receive a bi-monthly report from

the Associate Director of Facilities on all cleaning issues. John Wilkes Director of Facilities August 2011

Item

6ii

of 132

Tru

st

Mo

nit

ori

ng

Sco

res M

ay –

Ju

ly 2

011 –

Cle

an

ing

Fair

field

S

co

re %

Ro

ch

dale

S

co

re %

Old

ham

Sco

re %

Man

ch

este

r S

co

re %

21

89.8

8

R

en

al

92.7

2

F

8

80.1

8

P

harm

acy

79.1

9

19

90.1

5

M

arland

93.3

8

A

&E

81.1

7

E

1

88.9

8

29

92.3

7

C

AU

94.6

1

C

2

81.2

5

E

5

90.0

7

9

93.4

5

T

heatr

es

96.2

0

F

10

82.8

1

I5

90.3

7

18

94.5

3

Child

ren’s

96.2

9

T

4

84.8

1

M

axill

ofa

cia

l 91.3

5

6

96.1

2

U

CC

96.3

3

C

DU

84.9

5

J4

91.6

1

1 C

CU

96.1

3

M

ate

rnity

96.9

6

F

1

85.7

1

E

3

91.9

1

3

96.2

6

F

loyd U

nit

97.3

2

F

6

85.8

4

P

ost

nata

l 92.1

7

A&

E

96.7

1

W

ols

tenh

olm

e

98.0

1

F

9

86.0

5

C

4

94.2

4

11a

96.8

0

S

CB

U

99.3

7

S

TU

86.2

4

H

4

94.2

5

24

96.9

0

CC

U

87.7

9

E

6

94.4

3

14

97.4

3

C5

87.8

6

K

oala

94.5

5

25

97.7

2

Oute

r T

heatr

es

88.5

6

B

5

94.5

5

7

97.7

8

T5

88.6

0

F

1

94.5

6

5

98.0

3

F2

88.6

7

J3

94.5

6

23 D

eliv

ery

98.1

3

F5

88.8

1

E

4

94.7

0

12

98.1

5

T3

89.1

4

F

5

94.7

2

2

98.2

0

Theatr

es /

anaes

89.2

2

F

4A

94.7

4

8

98.2

9

F3

89.4

1

H

DU

94.7

8

10 I

CU

98.2

9

G3

89.5

9

Child

ren’s

94.8

1

Obs t

heatr

e

98.5

3

HS

DU

89.8

1

H

3

95.0

7

20

98.5

7

C1

90.4

6

B

1

95.1

0

11b

98.5

8

A1

90.8

5

E

2

95.3

2

22 S

CB

U

98.6

3

G2

91.1

2

D

5

95.3

9

Theatr

es 5

67

98.8

0

F7

91.2

1

F

4

95.4

2

Silv

er

heart

98.9

4

AN

C W

ard

91.2

7

C

6

95.5

9

Theatr

es 1

234

99.3

7

E1

91.3

3

H

SD

U

95.6

6

T6

91.6

7

S

TU

95.8

6

T7

91.9

3

I6

95.9

5

ICU

92.2

0

A

&E

95.9

9

F4

92.3

8

F

6

96.1

0

F11

92.5

8

S

CB

U

96.2

0

G1

92.9

4

J4 R

en

al

96.2

8

D1

93.7

2

D

SU

96.8

2

Mat 2

94.2

5

B

3

96.9

0

SC

BU

94.6

3

D

eliv

ery

96.9

5

E3

94.6

4

G

6 R

enal

97.2

8

A2

94.7

8

D

6

97.3

1

HD

U

95.6

5

A

NC

Ward

97.3

3

Mat 1

96.9

5

F

3

97.3

8

F11

97.2

2

J6

97.4

2

D B

lk theatr

e

98.7

3

N

euro

ph

ysio

log

y

97.5

6

S

tandard

s a

ch

ieved

T

heatr

es 7

-10

98.1

0

M

inor

failu

res,

within

10%

of

the r

eq

uire

d s

tandard

, sm

all

num

ber

of

ele

ments

faili

ng

T

heatr

es 1

-6

98.2

8

S

evera

l ele

me

nts

faili

ng in a

num

ber

of

are

as

G1 I

CU

98.2

8

C

CU

98.5

5

P

aeds T

heatr

e

99.2

5

of 132

Item

6ii

of 132

of 132

Agenda Item: 7

Title of Report Francis Inquiry – Actions for the Trust

Executive Summary

At the April 2010 Trust Board meeting a paper was tabled following receipt of a letter dated 24 February 2010 from Sir David Nicholson, NHS Chief Executive. The paper included an overview of the Francis Inquiry of Mid Staffordshire NHS Foundation Trust and listed 18 actions for the NHS. An update was given to the Board in August 2010. The attached action plan serves to provide a final update to the Board identifying where any ongoing work will be addressed. The Board is asked to note that the recommendations have been reviewed and, where required, subsumed within the Trust’s assurance framework on patient safety – culture and workload.

Actions requested

The Board is asked to note the report

Corporate Objectives supported by this paper: All corporate objectives are supported by addressing this key national high profile report.

Risks: Failure to respond to the recommendations of this national report would place the Trust in a serious position should any similar issues arise within the Trust.

Public and/or patient involvement: Not applicable to this paper.

Resource implications: Not applicable to this paper

Communication: Through line management structures


Assurance √

Contract √

Equality and Diversity √

Financial / Efficiency √

HR √

IM&T √

Local Delivery Plan / Trust Objectives √

National policy / legislation √

Sustainability √

Item

7

of 132

Name John Saxby

Job Title Chief Executive

Date August 2011


of 132

Report to Trust Board 25 August 2011 – Agenda Item Francis Inquiry - Actions for the Trust Introduction At the April 2010 Trust Board meeting a paper was tabled following receipt of a letter dated 24 February 2010 from Sir David Nicolson, NHS Chief Executive. The paper included an overview of the Francis Inquiry of Mid Staffordshire NHS Foundation Trust and listed 18 actions for the NHS. Attached to the paper were a number of actions for the Trust to respond to the recommendations. A progress update was given to the Board in August 2010. This paper serves as a final update to the Board on progress to date. The Board is asked to note that the recommendations have been reviewed and, where required, subsumed within the Trust’s assurance framework on patient safety and culture which has resulted from the recent television documentary featuring the Trust. In addition the Internal Auditors reviewed progress on the actions to date in June 2011 and gave significant assurance. The purpose of the Francis Inquiry 1) Concerns about mortality and the standard of care provided at the Mid Staffordshire Foundation Trust resulted in an investigation by the Healthcare Commission (HCC) which published a highly critical report in March 2009. This was followed by two reviews commissioned by the Department of Health. These investigations gave rise to widespread public concern and a loss of confidence in the Trust, its services and management. 2) The Francis Inquiry was set up by the Rt Hon Andy Burnham MP, Secretary of State for Health, primarily to give those most affected by poor care an opportunity to tell their stories and to ensure that the lessons to be learned from those experiences were fully taken into account in the rebuilding of confidence in the Trust. The period reviewed by the Inquiry was principally January 2005 to March 2009. 3) The terms of reference also allowed the Inquiry to gather the views and experience of the staff at the Trust and to seek explanations from management, including the directors, for what happened. It was not the intention that the Inquiry should be a forum for bringing individuals to account but the opportunity has been taken to examine the processes of accountability.

Item

7

of 132

4) There has been considerable public concern about the significance of the mortality statistics which prompted the HCC’s investigation. The Inquiry undertook a consideration of the significance to be attached to these figures. 5) The Inquiry was urged to investigate the role of a number of external agencies in the failure to detect and act on the deficiencies revealed by the HCC investigation, but the terms of reference set did not permit it to do so. It has however, received a considerable body of opinion on that issue. The Inquiry conclusions and recommendations 1) The deficiencies in staff and governance began before the period under review and were recognised by the management. Any trust where there have been long term serious organisational challenges will be difficult to turn around. However, the action taken by management to address many of the issues they identified was ineffective. Many of the problems found by the Chair on her arrival in 2004 were still present when the current Chair and Chief Executive took over in 2009. 2) A theme of the evidence about the Board has been reliance on the distinction between strategic and operational issues and a disclaimer of responsibility for the latter. The distinction does not justify directors not interesting themselves in operational matters when it is known that governance systems are either not in place or are untested. There was also a lack of clarity about responsibilities for nursing issues. 3) The Board’s approach to some problems such as governance was characterised by a lack of urgency. The issues identified in this report required constant follow up, review and modification. It was unacceptable that the staff review should have been allowed to take so long to complete and implement. 4) A common response to concerns has been to refer to generic data or benchmarks such as star ratings, rather than the experiences of actual patients. While benchmarks and data based assessments are important tools, these should not be allowed to detract attention from the needs and experiences of patients. Benchmarks, ratings and status may not always bring to light serious systemic failings. 5) Among other themes the Inquiry has identified from the evidence are:

a corporate focus on process at the expense of outcomes;

a failure to listen to those who have received care through proper consideration of their complaints;

staff disengaged from the process of management;

insufficient attention to the maintenance of professional standards;

lack of support for staff through appraisal, supervision and professional development;

a weak professional voice in management decisions;

of 132

a failure to meet the challenge of the care of the elderly through provision of an adequate professional resource. Some of the treatment of elderly patients could properly be characterised as abuse of vulnerable persons;

a lack of external and internal transparency

false reassurance taken from external assessments; and

a disregard of the significance of the mortality statistics Progress report Recommendations were reviewed by the Trust Chief Executive and actions identified for the appropriate Executive Directors. Attached at Appendix A is a progress report which identifies which identifies the work stream/responsibility for any continuing actions. Recommendations The Board is asked to note the progress and to confirm that continuing work will now mainstream into the Trust’s work on patient safety, workload and culture. Helen Curtis Governance Director August 2011

Item

7

of 132

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

1

RE

CO

MM

EN

DA

TIO

NS

AC

TIO

NL

EA

DE

XP

EC

TE

D F

RO

MP

RO

GR

ES

SD

EA

DL

INE

1.

Th

e T

rust

must

make its

vis

ible

firs

t prio

rity

the d

eliv

ery

of

a h

igh

cla

ss s

tandard

of

care

to a

ll its

patie

nts

by p

utt

ing t

heir n

eeds f

irst.

It s

hould

not

pro

vid

e a

serv

ice in

are

as w

here

it

cannot

achie

ve s

uch

a s

tandard

.

a)

Head o

f C

orp

ora

te D

evelo

pm

ent

to

rein

forc

e T

rust

mis

sio

n s

tate

ment

and

Pennin

e v

alu

es v

ia n

ew

sle

tter

etc

.

Head o

f C

orp

ora

te

Develo

pm

ent

Gavin

Barc

lay

Mis

sio

n s

tate

ment

inclu

ded in

all

Tru

st

public

atio

ns

and p

ress r

ele

ases.

Sta

ff A

ward

s a

ssis

ted w

ith

culture

of

"excelle

nce".

A

rtic

les o

n d

eliv

erin

g t

he 4

hour

access t

arg

et

in J

uly

Pennin

e N

ew

s,

Tru

st

Obje

ctives f

or

2010/1

1 in

July

Pennin

e N

ew

s,

featu

re

on P

erf

orm

ance in

May P

ennin

e N

ew

s,

public

atio

n o

f

Qualit

y A

ccounts

. V

alu

es in

to A

ctio

n la

unched in

April

2011 w

hic

h w

ill e

nsure

that

the V

alu

es b

ecom

e

meanin

ful fo

r sta

ff in

their d

ay t

o d

ay w

ork

and c

ulture

/ behavio

ur

change is a

chie

ved.

Involv

em

ent

of

EC

IST

team

in

deliv

ery

of

4 h

our

targ

et.

In

volv

em

ent

of

Schedule

d C

are

Inte

nsiv

e S

upport

Te

am

to e

nsure

18 w

eek t

arg

ets

achie

ved.

Overn

ight

A&

E s

erv

ice a

t

Rochdale

Infirm

ary

withdra

wn o

n p

atie

nt

safe

ty

gro

unds.

Repla

cem

ent

of

A&

E s

erv

ice w

ith U

CC

and

transfe

r of

inpatie

nt

serv

ices f

rom

Rochdale

Infirm

ary

from

April -

June 2

011 in

ord

er

to m

ain

tain

Patie

nt

Safe

ty.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

b)

Medic

al D

irecto

r to

revie

w a

ll lo

w

volu

me/h

igh r

isk s

pecia

ltie

s/t

hose w

ith s

ingle

handed p

ractice o

r pra

ctitio

ners

and t

o b

ench

mark

all

again

st

best

pra

ctice/s

tandard

s

Medic

al D

irecto

rR

uth

Jam

eson

Paper

pre

sente

d t

o t

he s

trate

gic

managem

ent

gro

up

on lo

w v

olu

me a

nd s

ingle

handed p

ractice.

Div

isio

ns

to e

nsure

all

issues r

esolv

ed.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

Item

7

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

2

2.

Th

e S

ecre

tary

of

Sta

te f

or

Health

should

consid

er

wheth

er

he o

ught

to

request

that

Monitor

- under

the

pro

vis

ions o

f th

e H

ealth A

ct

2009 -

exerc

ise its

pow

er

of

de-

auth

orisatio

n o

ver

the M

id

Sta

fford

shire N

HS

Fo

undatio

n T

rust.

In t

he e

vent

of

his

decid

ing t

hat

contin

uatio

n o

f fo

undatio

n t

rust

sta

tus is a

ppro

pria

te,

the S

ecre

tary

of

Sta

te s

hould

keep t

hat

decis

ion

under

revie

w.

Not

for

Tru

st

actio

nN

/AN

/AN

/AN

/A

3.

Th

e T

rust

togeth

er

with t

he

Prim

ary

Care

Tru

st

should

pro

mote

the d

evelo

pm

ent

of

links w

ith o

ther

NH

S t

rusts

and f

oundatio

n t

rusts

to

enhance its

abili

ty t

o d

eliv

er

up t

o

date

and h

igh c

lass s

tandard

s o

f

serv

ice p

rovis

ion a

nd p

rofe

ssio

nal

leaders

hip

Directo

r of

HR

to a

ppro

ach N

ort

h W

est

Academ

y t

o e

xplo

re 'tw

innin

g' or

'buddyin

g'

arr

angem

ents

with a

hig

h p

erf

orm

ing T

rust

-

possib

ly b

est

done in

anoth

er

SH

A.

Directo

r of

HR

Nic

k H

ayes

Initia

lly u

sin

g d

ata

sourc

es (

CQ

C,

Sta

ff s

urv

eys a

nd

Ivie

w)

targ

et

Tru

sts

were

id

entifie

d a

s p

ote

ntia

l

'buddie

s' and d

iscussed w

ith t

he S

HA

. I

nitia

l

appro

aches t

o T

rusts

were

not

met

with e

nth

usia

sm

;

this

le

d t

o a

revie

w o

f th

e r

ecom

mendatio

n a

nd

rela

ted o

bje

ctive.

Evid

ence s

uggests

that

the d

eliv

ery

of

hig

h s

erv

ice s

tandard

s a

nd im

pro

vem

ents

is lin

ked

to s

trong c

olla

bora

tive r

ela

tio

nship

s a

nd t

hese e

xis

t

thro

ugh t

he c

olla

bora

tive w

ork

successfu

lly c

arr

ied o

ut

thro

ugh A

quA

eg m

ort

alit

y c

olla

bora

tive,

Safe

ty

Th

erm

om

ete

r and S

afe

ty N

odes.

In a

dditio

n

leaders

hip

develo

pm

ent

has b

een d

eliv

ere

d t

hro

ugh

LIP

S,

the A

cadem

ies P

rogra

mm

e a

nd o

ther

OD

initia

tives.

We w

ill c

ontin

ue t

o f

oste

r th

ese

rela

tio

nship

s a

nd le

arn

fro

m o

ther

org

anis

atio

ns w

ho

are

focused o

n a

chie

vin

g s

imila

r goals

and t

his

appro

ach w

ill m

eet

the r

ecom

mendatio

n.

Com

ple

ted in

term

s o

f

the o

rig

inal actio

n.

Ongoin

g w

ork

will

be

part

of

the Q

ualit

y

Impro

vem

ent

Str

ate

gy

and m

onitore

d v

ia t

he

Clin

ical Q

ualit

y a

nd

Govern

ance

Com

mitte

e.

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

3

4.

Th

e T

rust,

in

conju

nctio

n w

ith t

he

Royal colle

ges,

the D

eanery

and t

he

nurs

ing s

chool at

Sta

fford

shire

Univ

ers

ity,

should

revie

w its

tra

inin

g

pro

gra

mm

es f

or

all

sta

ff t

o e

nsure

that

hig

h q

ualit

y p

rofe

ssio

nal

train

ing a

nd d

evelo

pm

ent

is

pro

vid

ed a

t all

levels

and t

hat

hig

h

qualit

y s

erv

ice is r

ecognis

ed a

nd

valu

ed.

Directo

r of

HR

, N

urs

ing a

nd M

edic

al D

irecto

r

to r

evie

w t

rain

ing p

rogra

mm

es w

ith

pro

fessio

nal bodie

s

Directo

r of

HR

,

Directo

r of

Nurs

ing,

Medic

al D

irecto

r

NIc

k H

ayes

Th

e L

ocal E

ducatio

n P

rovid

er

report

subm

itte

d t

o t

he

Deanery

. A

ctio

n p

lan b

ein

g m

onitore

d

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

Ruth

Jam

eson

2)

Th

e L

ocal E

ducatio

n P

rovid

er

report

subm

itte

d t

o

the D

eanery

A

ctio

n p

lan r

evie

wed a

nd m

onitore

d

regula

rly

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

Nic

ola

Nic

holls

Quart

erly m

eetin

gs a

re h

eld

betw

een t

he A

DN

, T

rust's

Pra

ctice E

ducatio

n F

acili

tato

rs a

nd t

he U

niv

ers

ity

links in

ord

er

to a

ddre

ss lo

cal is

sues r

ela

tin

g t

o P

re-

reg n

urs

e e

ducatio

n.

Additio

nally

the T

rust

and

Univ

ers

itie

s a

re s

ubje

ct

to r

evie

ws b

y t

he N

MC

to

assess t

he p

rovis

ion o

f tr

ain

ing a

nd p

lacem

ents

.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

5.

Th

e B

oard

should

in

stitu

te a

pro

gra

mm

e o

f im

pro

vin

g t

he

arr

angem

ents

for

audit in a

ll clin

ical

depart

ments

and m

ake p

art

icip

atio

n

in a

udit p

rocesses in

accord

ance

with c

onte

mpora

ry s

tandard

s o

f

pra

ctice a

requirem

ent

for

all

rele

vant

sta

ff.

Th

e B

oard

should

revie

w a

udit p

rocesses a

nd

outc

om

es o

n a

regula

r basis

.

Th

e M

edic

al D

irecto

r is

undert

akin

g a

revie

w

of

Clin

ical A

udit p

art

icip

atio

n a

nd o

utc

om

es -

KP

MG

is a

lso r

evie

win

g t

his

as p

art

of

its

exte

rnal A

udit r

evie

w o

f C

linic

al G

overn

ance.

Medic

al D

irecto

rH

ele

n C

urt

isA

report

on C

linic

al G

overn

ance a

rrangem

ents

com

mis

sio

ned f

rom

KP

MG

been r

eceiv

ed f

rom

KP

MG

and r

ecom

mendatio

ns im

ple

mente

d -

Qualit

y

Impro

vem

ent

Str

ate

gy im

ple

mente

d,

clin

ical audit

linked t

o s

trate

gic

pla

ns a

nd m

ain

str

eam

ed b

y m

akin

g

sure

clin

ical audit s

taff

have t

he n

ecessary

skill

s t

o

perf

orm

a b

roader

role

(eg im

peovem

ent

work

thro

ugh

Safe

ty E

xpre

ss p

ropgra

mm

e).

K

PM

G c

onfirm

ed

appro

priate

ness o

f T

rust's C

linic

al G

overn

ance a

nd

Qualit

y s

tructu

re.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

Item

7

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

4

6.

Th

e B

oard

should

revie

w t

he

Tru

sts

arr

angem

ents

for

the

managem

ent

of

com

pla

ints

and

incid

ent

report

ing in

the lig

ht

of

the

fin

din

gs o

f th

is r

eport

and e

nsure

that

it:

pro

vid

es r

esponses a

nd

resolu

tio

ns t

o c

om

pla

ints

whic

h

satisfy

com

pla

inants

; ensure

s t

hat

sta

ff a

re e

ngaged in

the p

rocess

from

the in

vestig

atio

n o

f a c

om

pla

int

or

an in

cid

ent

to t

he im

ple

menta

tio

n

of

any le

ssons t

o b

e le

arn

ed;

min

imis

es t

he r

isk o

f deficie

ncie

s

exposed b

y t

he p

roble

ms r

ecurr

ing;

and m

akes a

vaila

ble

full

info

rmatio

n

on t

he m

att

ers

report

ed,

and t

he

actio

n t

o r

esolv

e d

eficie

ncie

s t

o t

he

Board

, th

e g

overn

ors

and t

he p

ublic

a)

Th

e T

rust

has r

ecently a

ppro

ved a

revis

ed

com

pla

ints

polic

y.

Head o

f C

om

pla

ints

,

Head o

f S

afe

guard

ing,

Associa

te D

irecto

r of

Nurs

ing

Gavin

Barc

lay

Revis

ed c

om

pla

ints

report

subm

itte

d t

o T

rust

Board

from

June 2

010 a

nd q

uart

erly t

here

aft

er.

A

nonym

ised

extr

acts

fro

m p

atie

nt

com

pla

ints

in

clu

ded w

ithin

the

report

alo

ng w

ith a

ctio

ns.

Once t

hem

e p

er

quart

er

analy

sed in

depth

. R

eport

s p

resente

d a

t T

rust

Board

and T

rust

and D

ivis

ional G

overn

ance C

om

mitte

es t

o

ensure

that

the p

atie

nt

voic

e is h

eard

. N

on-E

xecutive

Directo

r P

atie

nt

Experie

nce W

alk

rounds

imple

mente

d.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

b)

Th

e C

linic

al G

overn

ance C

om

mitte

e h

as

asked H

ead o

f C

om

pla

ints

, H

ead o

f

Safe

guard

ing a

nd A

ssocia

te D

irecto

r of

Nurs

ing t

o m

ake r

ecom

mendatio

ns o

n h

ow

the B

oard

can p

roperly u

nders

tand 'patie

nt

sto

rie

s' th

at

are

describ

ed in

form

al

com

pla

ints

.

Head o

f C

om

pla

ints

,

Head o

f S

afe

guard

ing,

Associa

te D

irecto

r of

Nurs

ing

Gavin

Barc

lay

Anonym

ised e

xtr

acts

fro

m p

atie

nt

com

pla

ints

in

clu

ded

within

the r

eport

alo

ng w

ith a

ctio

ns.

Once t

hem

e p

er

quart

er

analy

sed in

depth

.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

7.

Tru

st

polic

ies,

pro

cedure

s a

nd

pra

ctice r

egard

ing p

rofe

ssio

nal

overs

ight

and d

iscip

line s

hould

be

revie

wed in

the lig

ht

of

the p

rin

cip

les

describ

ed in

this

report

.

Directo

r of

HR

to le

ad r

evie

w o

f polic

ies,

pro

cedure

s a

nd p

ractice in

rela

tio

n t

o

Pro

fessio

nal overs

ight

and d

iscip

line w

ith

Medic

al D

irecto

r and D

irecto

r of

Nurs

ing

Directo

r of

HR

Nic

k H

ayes

All

HR

polic

ies a

re p

art

of

the p

olic

y g

overn

ance

pro

cess a

nd a

s s

uch a

re t

imeta

ble

d t

o b

e r

evie

wed o

n

a r

egula

r basis

. A

s p

art

of

that

revie

wed it

has b

een

arr

anged t

hat

the r

evie

w w

ill inclu

de a

revie

w a

gain

st

the p

rin

cip

les d

escrib

ed in

the F

rancis

report

.

Confirm

ed w

ith H

R A

dvis

or

that

the a

uth

ors

of

the

rele

vant

polic

ies,

when u

p f

or

revie

w,

will

be a

sked t

o

look a

t th

e F

rancis

Report

.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

5

8.

Th

e B

oard

should

giv

e p

rio

rity

to

ensurin

g t

hat

any m

em

ber

of

sta

ff

who r

ais

es a

n h

onestly h

eld

concern

about

the s

tandard

or

safe

ty o

f th

e

pro

vis

ion o

f serv

ices t

o p

atie

nts

is

support

ed a

nd p

rote

cte

d f

rom

any

advers

e c

onsequences,

and s

hould

foste

r a c

ulture

of

openness a

nd

insig

ht.

Th

e M

edic

al D

rie

cto

r w

ill le

ad a

revie

w o

f

whis

tle

blo

win

g a

rrangem

ents

/polic

ies/

pro

cedure

in

the T

rust

work

ing c

losely

with

Clin

ical P

rofe

ssio

nals

and S

taff

Sid

e

org

anis

atio

ns.

Medic

al D

irecto

rN

ick H

ayes/R

uth

Jam

eson

Th

ecurr

ent

polic

yhas

been

revie

wed

again

st

“Speaking

up

for

ahealthyNHS”

docum

ent

issued

by

the

socia

lpart

ners

hip

foru

mand

public

concern

at

work

.T

he

polic

yw

as

appro

ved

by

the

Centr

al

Polic

y

Gro

up

follo

win

gconsultatio

nw

ith

medic

al

sta

ffand

publis

hed N

ovem

ber

2010.

Com

ple

ted

9.

In t

he lig

ht

of

the f

indin

gs o

f th

is

report

, th

e S

ecre

tary

of

Sta

te a

nd

Monitor

should

revie

w t

he

arr

angem

ents

for

the t

rain

ing,

appoin

tment,

support

and

accounta

bili

ty o

f executive a

nd n

on

executive d

irecto

rs o

f N

HS

tru

sts

and N

HS

foundatio

n t

rusts

, w

ith a

vie

w t

o c

reatin

g a

nd e

nfo

rcin

g

uniform

pro

fessio

nal sta

ndard

s f

or

such p

osts

by m

eans o

f sta

ndard

s

form

ula

ted a

nd o

vers

een b

y a

n

independent

body g

iven p

ow

ers

of

dis

cip

linary

sanctio

n

Not

for

Tru

st

actio

n s

pecific

ally

. H

ow

ever,

Chairm

an a

nd C

hie

f E

xecutive t

o e

nsure

NE

Ds a

nd E

Ds r

eceiv

e n

ecessary

develo

pm

ent

opport

unitie

s t

o d

ischarg

e B

oard

role

s/r

esponsib

ilitie

s a

nd t

hat

these a

re

identifie

d in

PD

Ps.

Charim

an,

Chie

f

Executive

John S

axby

All

Board

Directo

rs h

ave s

pecifie

d d

evelo

pm

ent

pla

ns

inclu

ded in

the a

nnual appra

isal docum

enta

tio

n;

and

that

they a

re e

ncoura

ged t

o a

vail

them

selv

es o

f

develo

pm

ent

opport

unitie

s in

purs

uit o

f th

eir p

ers

onal

obje

ctives.

Board

develo

pm

ent

sessio

ns h

eld

with

Becky M

alb

y.

Pro

fessio

nal S

tandard

s f

or

Pennin

e

Board

Directo

rs t

o b

e d

evelo

ped a

risin

g f

rom

the

Valu

es in

to A

ctio

n w

ork

.

Pro

fesio

nal S

tandard

s

for

Tru

st

Board

to b

e

subm

itte

d t

o A

ugust

2011 T

rust

Board

.

10.

Th

e B

oard

should

revie

w t

he

managem

ent

and le

aders

hip

of

the

nurs

ing s

taff

to e

nsure

that

the

prin

cip

les d

escrib

ed in

the r

eport

are

com

plie

d w

ith.

Th

e D

irecto

r of

Nurs

ing w

ith D

irecto

r of

Opera

tio

ns a

nd D

ivis

ional D

irecto

rs t

o r

evie

w

nurs

ing m

anagem

ent

leaders

hip

arr

angem

ents

and p

rocesses

Directo

r of

Nurs

ing,

Directo

r of

Opera

tio

ns,

Div

isio

nal D

irecto

rs

Nic

ola

Nic

holls

Pro

fessio

nal fo

rum

meetin

gs a

re h

eld

bi-m

onth

ly.

Bi-

annual S

enio

r N

urs

e a

way d

ays a

re h

eld

. H

eads o

f

Nurs

ing h

ave b

een in

troduced in

to t

he D

ivis

ions a

nd

Matr

on p

osts

in

troduced in

to t

hre

e D

ivis

ions.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

Item

7

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

6

11.

Th

e B

oard

should

revie

w t

he

managem

ent

str

uctu

re t

o e

nsure

that

clin

ical sta

ff a

nd t

heir v

iew

s a

re

fully

repre

sente

d a

t all

levels

of

the

Tru

st

and t

hat

they a

re a

ware

of

concern

s r

ais

ed b

y c

linic

ians o

n

matt

ers

rela

tin

g t

o t

he s

tandard

and

safe

ty o

f th

e s

erv

ice p

rovid

ed t

o

patie

nts

.

Th

e M

edic

al D

irecto

r to

ensure

the r

evie

w o

f

Recom

mendatio

n 8

in

corp

ora

tes t

his

and t

hat

the C

hairm

en o

f th

e T

rust

Hospital M

edic

al

Sta

ff C

om

mitte

es a

re s

atisfie

d t

hat

the

exis

tin

g a

rrangem

ents

allo

w C

linic

ians t

o

rais

e c

oncern

s w

ithout

hin

dra

nce.

Medic

al D

irecto

rN

ick H

ayes/R

uth

Jam

eson

Lin

ks w

ith r

ecom

mendatio

n 8

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

12.

Th

e T

rust

should

revie

w its

record

keepin

g p

rocedure

s in

consultatio

n w

ith t

he c

linic

al and

nurs

ing s

taff

and r

egula

rly a

udit t

he

sta

ndard

s o

f perf

orm

ance.

Directo

r of

Opera

tio

ns t

o le

ad r

evie

w o

f T

rust

record

keepin

g p

rocedure

s a

nd a

udit

arr

angem

ents

for

these.

Directo

r of

Opera

tio

ns

Hugh M

ulle

nC

QC

Outc

om

e 2

1,

quart

erly r

evie

w f

or

June 2

011

inclu

des e

vid

ence o

f clin

ical and n

urs

ing r

ecord

keepin

g a

udits,

actio

n p

lans t

o im

pro

ve p

ractice,

learn

ing f

rom

com

pla

ints

/in

cid

ents

, advic

e o

n r

ecord

keepin

g s

tandard

s issued t

o r

ecent

inta

ke o

f ju

nio

r

docto

rs.

New

clin

ical com

munic

atio

n p

olic

y b

ein

g

dra

fted,

will

in

clu

de a

public

ity c

am

paig

n t

o r

ais

e

record

keepin

g s

tandard

s.

Th

is w

ill c

ontin

ue a

s

part

of

the C

QC

quart

erly r

evie

w

pro

cess.

13.

All

ward

s a

dm

ittin

g e

lderly,

acute

ly ill

patie

nts

in

sig

nific

ant

num

bers

should

have

multid

iscip

linary

meetin

gs,

with

consultant

medic

al in

put,

on a

weekly

basis

. T

he le

vel of

specia

list

eld

erly c

are

medic

al in

sput

should

als

o b

e r

evie

wed,

and a

ll nurs

ing

sta

ff (

inclu

din

g h

ealthcare

assis

tants

) should

have t

rain

ing in

the d

iagnosis

and m

anagem

ent

of

acute

confu

sio

n.

Directo

r of

Nurs

ing t

o le

ad r

evie

w o

f T

rust

wid

e a

rrangem

ents

for

eld

erly s

erv

ice M

DT

meetin

gs,

an a

ssessm

ent

of

the le

vel of

specia

list

eld

erly c

are

medic

al in

put

and

specific

ele

ments

of

train

ing f

or

nurs

ing s

taff

Directo

r of

Nurs

ing

Paulin

e A

nders

on

A r

evie

w o

f th

e M

DT

pro

cess f

or

the C

are

of

the

eld

erly w

ard

s a

cro

ss t

he t

rust

has b

een u

ndert

aken.

Th

is h

as id

entifie

d t

hat

the 1

5 w

ard

s w

ith id

entifie

d

care

of

the e

lderly b

eds a

nd s

upport

ing c

onsultants

do

undert

ake w

eekly

MD

T m

eetin

gs.

Th

ese in

clu

de m

ulti

pro

fessio

nal att

enders

. A

tra

inin

g n

eeds a

naly

sis

has

been c

om

ple

ted t

o id

entify

the r

equirem

ent

for

specific

sta

ff g

roups t

o b

e t

rain

ed in

managin

g

cognitiv

e im

pairm

ent

and c

onfu

sio

n.

Prin

cip

les o

f care

for

patie

nts

with d

em

entia

have b

een d

evelo

ped.

Th

ere

is a

Tru

st

Lead f

or

dem

entia

and c

linic

al le

ads

have b

een id

entifie

d f

or

each s

ite.

Th

e w

ork

on t

he

Dem

entia

will

contin

ue

thro

ugh t

he C

are

of

the

Eld

erly D

irecto

rate

report

ing t

o t

he

Medic

al D

ivis

ion

14.

Th

e T

rust

should

ensure

that

its

nurs

es w

ork

to a

publis

hed s

et

of

prin

cip

les,

focusin

g o

n s

afe

patie

nt

care

.

Th

e D

irecto

r of

Nurs

ing t

o p

roduce a

Pennin

e

set

of

prin

cip

les f

or

nurs

es,

focusin

g o

n s

afe

patie

nt

care

.

Directo

r of

Nurs

ing

Nic

ola

Nic

holls

Th

is h

as b

een r

evie

wed a

nd in

ste

ad o

f a s

et

of

prin

cip

les,

work

has b

een u

ndert

aken t

o b

uild

upon

the n

urs

e c

are

in

dic

ato

rs.

Additio

nalll

y n

on e

xecutive

walk

abouts

in

clu

de a

sectio

n r

ela

tin

g t

o a

ttitudes.

Com

ple

ted

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

7

15.

In v

iew

of

the u

ncert

ain

tie

s

surr

oundin

g t

he u

se o

f com

para

tive

mort

alit

y s

tatistics in

assessin

g

hospital perf

orm

ance a

nd t

he

unders

tandin

g o

f th

e t

erm

'excess'

death

s,

an in

dependent

work

ing

gro

up s

hould

be s

et

up b

y t

he

Depart

ment

of

Health t

o e

xam

ine

and r

eport

on t

he m

eth

odolo

gie

s in

use.

It

should

make

recom

mendatio

ns a

s t

o h

ow

such

mora

lity s

tatistics s

hould

be

colle

cte

d,

analy

sed a

nd p

ublis

hed,

both

to p

rom

ote

public

confid

ence

and u

nders

tandin

g o

f th

e p

rocess,

and t

o a

ssis

t hospitals

to u

se s

uch

sta

tistics a

s a

pro

mpt

to e

xam

ine

part

icula

r are

as o

f patie

nt

care

.

Th

e T

rust

is a

lrady p

art

of

a N

ort

h W

est

colla

bora

tive W

ork

ing w

ith 7

oth

er

Tru

sts

, D

r

Fo

ste

r and P

rofe

ssor

Bria

n J

arm

an.

Th

e

Medic

al D

irecto

r w

ill e

nsure

this

colla

bora

tive

links in

with a

ny D

oH

consid

era

tio

n o

f

mort

alit

y.

Medic

al D

irecto

rH

ele

n C

urt

isT

he N

ort

h W

est

Mort

alit

y C

olla

bora

tive c

om

es t

o a

form

al end in

April 2011 h

ow

ever

part

icip

atin

g T

rusts

have a

gre

ed t

o c

ontin

ue w

ith d

ata

colle

ctio

n t

hro

ugh

AQ

UA

. D

ata

is r

eport

ed t

o t

he T

rust

Board

and

Clin

ical G

overn

ance a

nd Q

ualit

y C

om

mitte

e o

n a

month

ly b

asis

. T

he t

hre

e w

ork

str

eam

s c

hosen f

or

focus a

re h

eart

failu

re,

sepsis

and V

TE

. W

ork

over

the c

ours

e o

f th

e y

ear

has le

d t

o a

sig

nific

ant

impro

vem

ent

in t

he T

rust

HS

MR

As p

art

of

the c

olla

bora

tive t

he T

rust

has p

art

icip

ate

d

in d

ebate

regard

ing t

he m

eth

odolg

y t

o b

e u

sed

natio

nally

to m

easure

mort

alit

y.

Th

is w

ork

will

contin

ue

as p

art

of

the T

rust's

Qualit

y I

mpro

vem

ent

Str

ate

gy

16.

Th

e D

epart

ment

of

Health

should

consid

er

instig

atin

g a

n

independent

exam

inatio

n o

f th

e

opera

tio

n o

f com

mis

sio

nin

g,

superv

isory

and r

egula

tory

bodie

s in

rela

tio

n t

o t

heir m

onitorin

g r

ole

at

Sta

fford

hospital w

ith t

he o

bje

ctive

of

learn

ing le

ssons a

bout

how

faili

ng

hospitals

are

id

entifie

d.

Not

for

Tru

st

actio

nN

/AN

/AN

/AN

/A

17.

Th

e T

rust

and t

he P

rim

ary

Care

Tru

st

should

consid

er

ste

ps t

o

enhance t

he r

ebuild

ing o

f public

confid

ence in

the T

rust.

Chie

f E

xecutive t

o d

iscuss w

ith P

CT

Chie

f

Executives w

ays in

whic

h t

he lo

cal N

HS

Nort

h

East

Mancheste

r E

conom

y c

an r

eta

in p

ublic

confid

ence.

Chie

f E

xecutive

John S

axby

Tru

st

and P

CT

com

ms h

ave im

ple

mente

d

com

pre

hensiv

e c

om

munic

atio

ns c

am

paig

ns a

s

serv

ices h

ave r

estr

uctu

red a

nd t

ransfe

rred f

rom

site t

o

site.

Engagem

ent

Sem

inar

held

in

August

2011 t

o

develo

p f

urt

her

meth

ods o

f lin

kin

g w

ith lo

cal

com

munitie

s a

nd s

taff

.

Com

ple

ted a

t tim

e o

f

pre

vio

us p

rogre

ss

report

Item

7

of 132

FR

AN

CIS

IN

QU

IRY

- P

EN

NIN

E A

CU

TE

HO

SP

ITA

LS

NH

S T

RU

ST

Pa

ge

8

18.

All

NH

S t

rusts

and f

oundatio

n

trusts

responsib

le f

or

the p

rovis

ions

of

hospital serv

ices s

hould

revie

w

their s

tandard

s,

govern

ance a

nd

perf

orm

ance in

the lig

ht

of

this

report

.

Sta

ndard

s,

govern

ance a

nd p

erf

orm

ance a

re

bein

g r

evie

wed a

nd e

valu

ate

d a

s p

art

of

FT

applic

atio

n p

rocess

Directo

r of

Str

ate

gy

To

m W

ilders

Qualit

y q

overn

ance is n

ow

part

of

the F

T a

ssessm

ent

pro

cess.

Th

is

has a

risen in

part

because o

f th

e

Fra

ncis

report

. T

he T

rust

has a

ssessed its

com

plia

nce w

ith t

he F

T a

ssessm

ent

fram

ew

ork

for

qualit

y g

overn

ance.

Th

e T

rust

has h

ad a

n in

itia

l

meetin

g w

ith t

he S

HA

in

pre

para

tio

n f

or

sig

n o

ff t

he

qualit

y g

overn

ance c

om

ponent

of

the F

T a

pplic

atio

n.

Th

e n

ext

meetin

g w

ithth

e S

HA

is s

chedule

d f

or

Octo

ber

2011.

To

be t

aken f

orw

ard

as

part

of

the F

oundatio

n

Tru

st

applic

atio

n

pro

cess.

of 132

1

Agenda Item: 8

Title of Report The Corporate Performance Report

Executive Summary

The report provides information about the Trust’s performance against national and local indicators.

Actions requested

The Board is asked to note the report.

Corporate Objectives supported by this paper: This paper supports corporate objectives – each KPI is mapped to the corporate objectives in the scorecard.

Risks: The Board Risk Register records 5 risks:

(1) Completing 90% of PDRs; (2) Delivery of 62 day cancer standards; (3) Delivery of 4 hour emergency care standard; (4) Break even; (5) Improvement in HSMR

Public and/or patient involvement: The key performance indicators within this report are derived from the expectations of patients and the public.

Resource implications: Failure to achieve some national indicators could result in loss of income.

Communication: Through management structures


Assurance X

Contract X

Equality and Diversity X

Financial / Efficiency X

HR X

IM&T X

Local Delivery Plan / Trust Objectives X

National policy / legislation X

Sustainability X

Name Hugh Mullen

Job Title Director of Operations

Date August 2011


Item

8

of 132

2

Agenda No. 8

THE PENNINE ACUTE HOSPITALS NHS TRUST

The Corporate Performance Report Introduction

1. This report quantifies:

The Trust’s performance against national indicators used by regulatory agencies (identified in blue font throughout the report)

The Trust’s performance against a range of local indicators (identified in black font)

Strategic context

2. The scorecard included in this report identifies the corporate objective linked to each indicator.

Structure of the corporate performance report

3. The structure of the report is outlined below:-

Section 1 – Performance overview

Performance overview and performance framework ratings used by regulators to assess whether trusts are meeting minimum standards

Section 2 – Performance scorecard

A summary of key performance indicators showing current status, historical trends, and forecasted future performance

Section 3 – The narrative to support the scorecard

A summary of issues and actions for underperforming KPIs for each section of the scorecard

Appendix 1 – Scorecard trends Appendix 2 - RAG rating thresholds applied to the KPIs Appendix 3 – Performance trends for indicators where improvement trajectories have been agreed

of 132

3

Section 1 – Performance overview

4. Overall, the Trust’s performance is as follows:-

Reds include:- NPSA Never events; Cancer standards, RTT, PDRs Mandatory training, and Bullying & harassment indicator

Ambers include:- Stroke care, Cancelled operations, Mixed sex accommodation, Attendance rate, and Staff in post

Regulatory performance assessment frameworks summary 5. The performance assessment frameworks specify the minimum

standards expected of NHS organisations. The NHS Performance Framework applies to trusts that have not attained Foundation status. The headline performance issues are identified in the table below:-

NHS Performance Framework Status Applies to trusts that have not attained Foundation status

Estimated Performance

Summary Q2

Performing Estimated score – July-11 data

RTT, Stroke unit stays, and cancer standards have underperformed. Further details are provided in Sections 2 & 3 of this report. Provisional assessment shows patient experience now meeting specified standards.

Trends Q1 of 2011-12 - The Trust was rated as Performance Under Review. July therefore shows some improvement against the NHS framework

4. As part of the FT application process the Trust are required to establish shadow monitoring processes for Monitor’s governance risk ratings. In preparation for this all of Monitor’s performance indicators are incorporated in the scorecard included in this report.

5. The new A&E clinical quality indicators are included in the scorecard

for the first time this month. Section 3 describes how these new indicators contribute to the Trust’s performance rating.

Section 2 – The corporate performance scorecard RAG rating thresholds used in the scorecard 6. The Trust uses the following traffic light system Table showing the three RAG rating thresholds:-

Performance Performance threshold names and descriptions

Green Achieved - The indicator has been met

Amber Underachieved - The indicator has been narrowly missed

Red Failed - The indicator has been missed by a significant margin

Black Unavailable - The indicator information is unavailable

7. Individual indicator thresholds are described in Appendix 2.

Item

8

of 132

4

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on

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Item

8

of 132

6

Section 3 – The narrative to support the scorecard

6. This section of the report is divided into sub-sections mirroring those used in the scorecard. Details are provided on underperforming indicators.

Clinical Quality, Effectiveness, and Safety A&E clinical quality indicators 7. The new A&E clinical quality indicator performance is reported for the

first time this month. This section of the report outlines the Trust’s performance for July 2011.

8. Trusts are now assessed against the new A&E clinical quality indicators on a quarterly basis at organisational level (Trust level) from July onwards. The Trust has met the specified performance standards outlined in the NHS Performance Assessment Framework in July.

9. Performance is assessed using two clinical quality indicator headings, in addition to which the 4 hour emergency access standard acts as a moderator to the Trust’s overall rating. There are therefore effectively three performance measures:- (1) Patient Impact, (2) Timeliness, and (3) 4 hour emergency access standard:-

Patient Impact includes the following two indicators (passing either one of these two indicators means that the Patient Impact measure has been achieved):-

a. Percentage of unscheduled A&E re-attendances within 7 days (minimum threshold <=5%)

b. Percentage of patients leaving the A&E department without being seen (minimum threshold <5%)

Timeliness includes the following two sub-indicators (passing either one of these indicators means that the Timeliness measure has been achieved):-

a. Time to Assessment (minimum threshold – 95th percentile <=15 minutes)

b. Time to Treatment (minimum threshold – median average <= 60 minutes)

4 hour emergency access measure includes a single indicator (if this indicator is failed the overall rating is failed for the Trust regardless of performance against Patient Impact and Timeliness measurs):-

a. Total time in the department – (minimum threshold is 95% of patients within 4 hours)

10. Given the relative importance of the 4 hour emergency access

standard measure (95% in 4 hours), it will continue to be reported separately from the two new clinical quality performance measures (Patient impact, and Timeliness) in this report’s scorecard. Hence, in July, both of the 2 clinical quality measures were achieved in addition to achieving the 4 hour emergency access standard measure (95.8%).

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The table below describes the Trust performance in more detail:-

Trust A&E Clinical Quality Indicator Performance Summary (July data)

Indicator Rating Sub-indicator Threshold Performance

Overall performance

Achieved All

A rating of Achieved for all 3 performance measures

Achieved

Performance breakdown by indicator group (July data)

Performance measures

Rating Sub-indicator Threshold Actual (July)

Patient impact

Achieved Re-attendance rate <=5% 4.1%

Left without being seen <5% 3.2%

Timeliness Achieved

Time to assessment 95

th percentile <15

minutes 21 minutes

Time to treatment 95

th percentile< 60

minutes 55 minutes

4 hour emergency access standard

Achieved Total time in A&E department

95% within 4 hours 95.8%

11. Whilst trusts are required to meet the minimum standards specified in

the table above, the purpose of the new indicators to provide a springboard for clinical teams to drive continuous improvement in quality of care. I.e., Trusts should not settle for meeting the minimum thresholds, but should strive to improve over time.

12. Clinical staff are leading improvement work on all of the new A&E clinical quality indicators. The site action plans are linked to the new indicators - since these are key drivers in delivering better care to patients including spending less time in A&E departments.

13. The Trust will publish performance information on 26 August. This information includes performance data and a narrative developed with senior clinical staff for each of the A&E clinical quality indicators. Once more national and regional benchmarking information is available these data will be added to the published reports.

4 Hour emergency access (Provider) standard 14. As noted in the preceding section the 4 hour standard has been

retained for 2011-12. In July 2011 the Trust’s performance was 95.8%, which equates to a rating of achieved.

Table showing 4 hour activity Type of Activity Jul-11 Q2 2011-12 Year

No of patients exceeding 4 hours 1,038 1,038 7,194

Total number of Provider attends 24,593 24,593 117,500

National 4 hour % performance 95.8% 95.8% 93.9%

*Performance trends are shown in Appendix 3

15. Implementation of action plans is being managed by the Unscheduled Care Group. ECIST is providing ongoing support to implement agreed improvement action plans for NMGH and ROH.

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16. The following table summarises the underperforming indicators in this section of the scorecard:-

Clinical Quality, Effectiveness, and Safety - indicators Not Met Rating

NPSA 'Never' Events – Jul-11 data Red

Stroke Care - Number of national stroke care standards achieved (best = 2) - Apr-11 to Jul-11 data

Amber

Cancer - Number of national cancer standards being achieved (best possible = 8) – Q1 data

Red

Never events 17. Never events" are serious, largely preventable patient safety incidents

that should not occur if the relevant measures have been put in place. One never event was reported in July 2011. Root cause analysis has been undertaken and actions taken to avoid future incidents.

Stroke care indicators 18. There are 2 nationally monitored indicators of best practice stroke

care:-

80% of stroke patients spending 90% of their hospital stay on a stroke unit (underachieved)

Urgent TIA patients seen within 24 hours of referral (achieved)

19. 42 of the 61 stroke patients (69%) spent 90% of their hospital stay in a stroke unit during July. This equates to a rating of underachieved. The target increased from 70% to 80% from Mar-11 onwards.

20. The Stroke Service’s improvement plan is monitored by the Unscheduled Care Group. Initial work is being undertaken to ensure patients arriving ‘in-hours’ are sent to a stroke unit within the best practice standard of 4 hours from hospital arrival. The ‘out of hours’ arrivals processes will be the next priority.

21. Stroke patients often require complex care packages to support safe and timely discharge from hospital. The Trust’s stroke services team has therefore met with North East Sector commissioners and agreed to develop a joint improvement plan to improve patient flow across community and hospital care services. Progress is being monitored by a monthly conference call meeting and a quarterly review meeting between commissioners and Trust staff.

22. The national standard for treatment of TIA (Transient Ischaemic Attack) patients for 2010/11 is that 60% of high risk TIA patients are treated within 24hrs of first presentation to a healthcare service. Since the introduction of one stop clinics for TIA across the Trust in March 2010 performance has consistently remained better than the 60% target. 22 of the 28 urgent referrals (79%) were seen within 24 hours during July - This equates to a rating of achieved.

23. The Trust improved performance across a range of nationally assessed care quality indicators for stroke in the National Sentinel Stroke Audit carried out every 2 years by the Royal College of Physicians.

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Cancer standards indicator 24. There are 8 cancer standards. This indicator measures the number of

cancer standards achieved. In June 5 of the 8 cancer standards were achieved – This equates to a rating of failed (red) on the dashboard.

25. The national cancer standards and ratings for July are:-

2 weeks from GP referral to attendance (achieved)

2 weeks breast symptomatic – referral to attendance (achieved)

31 day first decision to treat to treatment (achieved)

31 day subsequent decision to treat to treatment – anti cancer drugs (achieved)

31 day subsequent decision to treat to treatment – surgery (achieved)

62 day GP referral to treatment (failed)

62 day screening service referral to treatment (failed) The Trust also has adopted one further local cancer standard (it is not a national standard):-

62 day consultant upgrade referral to treatment (failed) 26. The table below summarises performance against the 62 day cancer

standards using monthly data:-

Standard Threshold Indicator Performance

Apr May Jun

62 day GP referrals 85% % Rate 90.3% 78.2% 76.3%

Breaches 7 18 18

62 day screening referrals 90% % Rate 100% 81.8% 86.7%

Breaches 0 1 1

62 day consultant upgrades 85%

Local target

% Rate 88.5% 88.6% 65.7%

Breaches 1.5 2.5 6

27. The number of 2 week attendances this year has increased relative to

last year from 4597 to 5157 (+560 or +12%) for the period January to June. This has increased demand to specialist cancer services contributing to capacity pressures to meet the 62 day standards. Definitional issues related to the TRUS diagnostic test process have also been identified as a significant factor limiting performance.

28. A performance meeting specifically focussed on cancer standards has

been established to ensure that robust improvement actions are taken. Regional work to improve inter-provider pathways has also started.

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Patient Experience

29. The following table summarises the underperforming indicators:-

Patient Experience - indicators Not Met Rating

Number of national RTT standards being achieved (best possible = 8) – Jul-11 data

Red

Cancelled operations standards achieved (best =2) – Apr-11 to Jul-11 data

Amber

Mixed Sex Accommodation standards achieved (best = 2) – Jul-11 data

Amber

RTT national indicators 30. The Trust is required to achieve 8 national elective RTT access

standards. 5 of the 8 new standards were achieved in Jul- 2011 - This equates to a rating of failed (red). The table below summarises performance against each of the standards:-

Table below showing performance against the Referral To Treatment (RTT) standards for non-Foundation trusts

Pathway Indicator Target Actual – 2011-12

Apr May Jun Jul

Admitted

Median wait (weeks)

<=11.1 10.7 11.3 11.0 11.9

95th percentile

wait (weeks) <=23.0 32.7 33.1 33.0 33.6

% of patients treated in 18 weeks

90% 71.3% 74.9% 76.6% 71.5%

Non-Admitted

Median wait (weeks)

<=6.6 3.0 3.7 4.0 3.6

95th percentile

wait (weeks) <=18.3 16.4 16.5 17.7 17.6

% of patients treated in 18 weeks

95% 96.6% 96.8% 95.4% 95.6%

Incomplete

Median wait (weeks)

<=7.2 8.1 8.1 7.6 7.1

95th percentile

wait (weeks) <=28.0 28.9 29.1 29.5 27.2

No. of standards passed 8 4 3 4 5

*Performance trends against the above indicators are shown in Appendix 3.

31. A detailed recovery plan was submitted to the SHA. Specialty specific

improvement trajectories for reduction of the 18 week backlog were agreed with PCTs.

32. An 18 Week Recovery Group was established to ensure effective implementation of the improvement plan. There are senior operational representatives from all organisations across the North East Sector. The Recovery Group meet weekly, reporting to the North East Sector Commissioning Board (fortnightly) and the Trust’s Performance Management Group (monthly). The 18 Week Recovery Group also

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reports to the PCT Chief Executives monthly through the Director of Operations

33. As advised by the IST, taking the appropriate improvement actions to reduce the 18 week backlog will cause admitted performance deterioration over the next 3 months.

34. As anticipated, reflecting progress made in reducing the backlog, the Incomplete performance data show improvement over the last 3 months. I.e., the median average wait time and the 95th percentile wait time have both reduced. The criteria for a sustainable position will be a backlog equivalent to ½ week of RTT activity i.e. the admitted backlog should contain a maximum of 300 patients. The 10% tolerance in the national target accounts for clinically complex cases.

Cancelled operations indicators 35. There are 2 indicators used to judge the trust’s performance:-

Cancelled operations rate – The Trust’s corporate objectives include the aim that no more than 0.8% of all elective admissions are cancelled for non-clinical reasons. This indicator is no longer part of the national performance assessment framework ratings - (underachieved)

28 day standard – Patients who have their operation cancelled should be offered another operation within 28 days of their original date. The national standard in the DH’s performance assessment framework sets a maximum threshold for trusts that no more than 5% of patients should breach this standard - (achieved)

36. The cancelled operations rate is the best the Trust has achieved since the standard was introduced in 2001. Year to date (Apr to Jun) the Trust cancelled 238 operations in 2011-12 (a rate of 0.81%). This equates to a rating of underachieved against the local 0.80% benchmark adopted by the Trust, or 2 more operations cancelled than meeting the standard would have meant. Improvement actions have led to a significant reduction in cancelled operations. There was a significant reduction (18%) in the number of operations cancelled compared to the same period of 2010-11 when 290 patient operations were cancelled.

37. 28 day standard performance consistently achieves the national threshold of 5% – Year to date (Apr to Jun) 1 patient out of the 238 who had their operation cancelled did not receive their new operation date within 28 days of their original planned operation (a quarterly rate of 0.4%). The Trust therefore met this standard.

38. Improvement actions are monitored by the Scheduled Care Group.

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Mixed sex accommodation indicators 39. There are 2 indicators for national oversight used to judge trust

performance:-

The number of mixed sex accommodation breaches per 1,000 FCEs (achieved)

The number of mixed sex accommodation breaches (failed) 40. The number of mixed sex accommodation breaches per 1,000 FCEs

takes account of the relative size of organisations enabling performance to be benchmarked. The Trust’s July rate was 0.2 breaches per 1,000 FCEs - better than the most recently available NW SHA rate of 0.9, and better than the most recently available England rate of 1.3.

41. In conjunction with commissioners definitions have been agreed with the SHA. Breaches are agreed with Commissioners.

Resources Management 42. The 2 monthly indictors shown in scorecard have been achieved. The

Financial performance score indicator is reported quarterly, and Q1 was achieved.

Workforce 43. The following indicators have not been achieved:-

4. Workforce indicators not met Rating

Attendance Rate – Apr-11 to Jun-11 data Amber

Staff in post versus plan (Full Time Equivalent) – Jul-11 data Amber

PDR completion Rate 90% (rolling year) – Aug-10 to Jul-11 data Red

Mandatory training -12 month rolling compliance for patient handlers (best =3 standards' trajectories met) – Jul-10 to Jun-11 data

Red

Bullying and harassment cases reduced by 10%– Apr-11 to Jul-11 data Red

Attendance rate indicator 44. The attendance rate target was 95.03% last year and is 96% this year.

June 2011 performance was 95.0%, which is 1% below target. An action plan has been developed to enable the trust to meet this target.

45. A meeting was held with the Full Time Officers of the Trades Unions on

5 August and changes to the Sickness Policy were discussed amongst

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other issues. Options for taking this forward are being evaluated and will be discussed and approved by the Executive Directors.

Staff in post indicator 46. The staff in post reduced within month by 44 FTE, but was 126 FTE

behind trajectory. An action plan has been developed to enable the Trust to meet this target. The trend is heading in the right direction. Another round of voluntary severance scheme has also been opened.

PDR completion rate 47. 76% of staff had a PDR in the 12 month period Aug-10 to Jul-11. This

is an improvement on last month when it was 72%, but is below the target of 90%. Trajectories have been produced for non medical staff by the Management Forum members so that the Trust can now manage performance against plans for the rest of the year. Trajectories for medical staff have been produced by the Diagnostic Division but not the remaining Divisions. These are being expedited as a matter of urgency.

Mandatory training for patient handlers indicator 48. This indicator covers 3 types of mandatory training for staff who are

classified as patient handlers. The 3 types of training are:-

Fire Training (year end target = 76%)

Hand Washing (year end target = 70%)

Information Governance (year end target = 95%) Performance against each type of training is measured on a 12 month rolling basis and is summarised in the table below:-

Type of mandatory training Target

trajectory May-11 Actual

Rating

Fire Training >=59% 62% Higher than last month’s

57%

Hand Washing >=55% 56.5% Similar than last month’s

56.1%

Information Governance >=90% 78% Higher than last month’s

65%

Total number of mandatory training standards achieved

3 2 Higher than last month’s

1 standards achieved

49. The Information Governance refresher training period was changed

from two yearly to annual by the Department of Health. A new IG e-learning programme is being developed that is more user-friendly and it is anticipated that this will assist in increasing the compliance rate over the next few months. External benchmarking with other large acute trust has also shown the 78% to be higher than most.

Bullying and harassment cases indicator

50. The corporate objective is to reduce the number of reported cases by 10% compared to 2010-11. Year to date 9 cases have been reported, whereas in the same period last year 7 cases were reported. Also, please note that the previously reported figure for June has increased from 0 to 2 - This is due to late notification of the cases to the corporate HR dept. Diagnostic work has been carried out to better understand

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whether any factors can be linked to the increase in numbers when compared to last year.

Facilities 51. The Director of Facilities is currently developing 3 further new

indicators for inclusion in the scorecard. The indicators are listed below:-

Portering response times in minutes

Statutory PPM completed

Energy consumption per heated volume (2.5% reduction in 2011-12) - GJ / 100m3

52. The Facilities indicators reported in the scorecard have been achieved. Summary

53. This report has quantified:

The Trust’s performance against national indicators used by regulatory bodies (identified in blue font throughout the report)

The Trust’s performance against a range of local indicators (identified in black font)

54. Where performance was below target, a summary of actions being taken has been given.

55. The appendices of the report show:

The performance trends for every indicator

The performance scorecard RAG ratings thresholds and details of the sources of the thresholds

Performance trends for indicators where improvement trajectories have been agreed

Recommendations 56. The Board is asked to note the report Hugh Mullen Director of Operations August 2012

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ve

nts

0 in m

onth

n/a

>0 in m

onth

Locally

agre

ed

VT

E r

isk a

ssessm

ent

>=

90%

cum

ula

tive

n/a

< 9

0%

cum

ula

tive

Vital sig

ns targ

et used

Ho

spita

l a

cq

uire

d I

nfe

ction

- A

ch

ievin

g o

f M

RS

A &

C-D

iff

redu

ction

tra

jecto

rie

s (

Be

st

=2

)<

=cum

ula

tive p

rofile

for

both

sta

ndard

s<

=cum

ula

tive p

rofile

for

both

sta

ndard

s O

R c

urr

ent m

onth

>2

Std

devia

tions

>cum

ula

tive p

rofile

for

either

sta

ndard

OR

curr

ent m

onth

>3

Std

Devia

tions

NH

S P

erf

orm

ance F

ram

ew

ork

thre

shold

s u

sed f

or

traje

cto

ry &

local w

ithin

month

peak indic

ato

r added

4 h

ou

r e

me

rge

ncy a

ccess s

tand

ard

(P

rovid

er)

>=

95%

cum

ula

tive q

uart

er

<95%

And <

=94%

cum

ula

tive q

uart

er

<94%

cum

ula

tive q

uart

er

100%

national sta

ndard

- o

ther

thre

shold

s locally

agre

ed

A&

E C

linic

al q

ualit

y in

dic

ato

r H

ead

line m

easu

res a

chie

ve

d

(ma

xim

um

is 2

)=

2 s

tandard

s a

chie

ved

N/A

<2 s

tandard

s a

chie

ved

Str

oke

Care

- N

um

be

r o

f n

atio

na

l str

oke

ca

re s

tand

ard

s

achie

ve

d (

best

= 2

)T

IA>

=60%

cum

ula

tive Y

TD

And tim

e o

n s

troke u

nit >

=80%

TIA

<60%

and >

=50%

OR

Tim

e o

n s

troke u

nit <

80%

and

>=

60%

- B

oth

Cum

ula

tive Y

TD

TIA

<50%

OR

Tim

e o

n s

troke u

nit <

60%

NH

S P

erf

orm

ance F

ram

ew

ork

thre

shold

s&

Contr

act

targ

et used

Ca

nce

r -

Nu

mb

er

of

natio

na

l ca

nce

r sta

nd

ard

s b

ein

g

achie

ve

d (

best

possib

le =

8)

All

8 c

ancer

sta

ndard

s m

et cum

ula

tive q

uart

er

7, 6, or

5 c

ancer

sta

ndard

s m

et cum

ula

tive q

uart

er

<5 c

ancer

sta

ndard

s m

et cum

ula

tive q

uart

er

NH

S P

erf

orm

ance F

ram

ew

ork

thre

shold

s u

sed

Nu

mb

er

of

CQ

UIN

s o

n t

raje

cto

ry (

Be

st

=7

)C

QU

INs o

n tra

jecto

ry to tota

l valu

eC

QU

INs o

ff tra

jecto

ry to a

fin

ancia

l valu

e <

=5%

of

the tota

l

valu

eC

QU

INs o

ff tra

jecto

ry to a

fin

ancia

l valu

e>

5%

of

the tota

lLocally

agre

ed

2.

PA

TIE

NT

EX

PE

RIE

NC

E

Nu

mb

er

of

natio

na

l R

TT

sta

nd

ard

s b

ein

g a

chie

ve

d (

best

possib

le =

8)

8 s

tandard

s m

et

All

95th

perc

entile

and 9

0%

and 9

5%

thre

shold

s m

et A

nd a

ny

of

media

n s

tandard

s n

ot m

et

Any

of

the 9

5th

perc

entile

or

the 1

8 w

eeks 9

0%

and 9

5%

thre

shold

s n

ot m

et

NH

S P

erf

orm

ance F

ram

ew

ork

thre

shold

s

Ca

nce

lled o

pe

ratio

ns s

tand

ard

s a

ch

ieve

d (

best

=2

)C

anc o

ps r

ate

<=

0.8

% c

um

ula

tive A

nd 2

8 g

uara

nte

e r

ate

<=

5%

cum

ula

tive

Canc o

ps r

ate

>0.8

% c

um

ula

tive a

nd <

=1.5

% O

R 2

8

guara

nte

e r

ate

>5%

cum

ula

tive a

nd <

=15%

Canc o

ps r

ate

>1.5

% c

um

ula

tive O

R 2

8 d

ay g

uara

nete

e r

ate

>15%

NH

S P

erf

orm

ance F

ram

ew

ork

thre

shold

s &

local

obje

ctive

De

laye

d t

ransfe

rs o

f ca

re<

=3.5

% c

um

ula

tive

>3.5

% a

nd <

=5%

cum

ula

tive

>5%

cum

ula

tive

CQ

C 0

8-0

9 thre

shold

s -

09-1

0 n

ot publis

hed

Mix

ed S

ex A

cco

mm

oda

tion

sta

nd

ard

s a

ch

ieve

d (

best

=2

)N

o o

f M

SA

bre

aches =

0 A

ND

MS

A r

ate

<=

best of

Engla

nd

and N

W S

HA

rate

s

No o

f M

SA

bre

aches >

0 A

ND

MS

A r

ate

<=

best of

Engla

nd

and N

W S

HA

rate

s

No o

f M

SA

bre

aches >

0 A

ND

MS

A r

ate

>=

wors

t of

Engla

nd

and N

W S

HA

rate

s

Based o

n O

pera

ting F

ram

ew

ork

technic

al

specific

ations

Co

mp

lain

ts w

ith

in 2

5 d

ays

>=

90%

cum

ula

tive

75%

to 9

0%

cum

ula

tive

<75%

cum

ula

tive

Locally

agre

ed

Se

lf-c

ert

ific

ation

ag

ain

st

co

mp

liance

with

re

qu

ire

me

nts

reg

ard

ing

access t

o h

ea

lth

care

fo

r p

eo

ple

with

a le

arn

ing

dis

abili

ty

Com

plia

nt w

ith s

tandard

sn/a

Not com

plia

nt w

ith s

tandard

sN

ationally

specifie

d

3.

RE

SO

UR

CE

S M

AN

AG

EM

EN

T

Fin

an

cia

l fo

reca

st

outt

urn

& p

erf

orm

ance

ag

ain

st

pla

nachie

vin

g o

r exceedin

g p

lan f

or

year

to d

ate

and p

lanned

outturn

not achie

vin

g p

lan f

or

year

to d

ate

or

pla

nned o

utturn

by

less

than 1

% o

f tu

rnover

not achie

vin

g p

lan f

or

year

to d

ate

or

pla

nned o

utturn

by

more

than 1

% o

f tu

rnover

NH

S P

erf

orm

ance F

ram

ew

ork

thre

shold

s u

sed

Fin

an

cia

l p

erf

orm

ance

sco

re f

or

Tru

sts

>=

32

1N

HS

Perf

orm

ance F

ram

ew

ork

thre

shold

s u

sed

Pro

gre

ss o

n d

eliv

ery

of

QIP

P s

avin

gs

90%

of

QIP

P targ

et id

entified a

s d

eliv

era

ble

and o

n targ

et to

deliv

er

betw

een 6

0%

and 9

0%

of

QIP

P targ

et id

entified a

s d

eliv

era

ble

and o

n targ

et to

deliv

er

Less than 6

0%

of

QIP

P targ

et id

entified a

s d

eliv

era

ble

and o

n

targ

et to

deliv

er

Local th

reshold

s

AP

PE

ND

IX 2

Item

8

of 132

1

8

So

urc

e o

f T

hre

sh

old

s

PE

RF

OR

MA

NC

E T

HR

ES

HO

LD

S

On

ta

rge

t (A

ch

ievin

g)

PE

RF

OR

MA

NC

E IN

DIC

AT

OR

Wo

rse

th

an

ta

rge

t (F

ail

ing

)B

elo

w t

arg

et

(Un

de

rac

hie

vin

g)

3

. W

OR

KF

OR

CE

Att

end

an

ce R

ate

>=

96%

<96%

AN

D >

=94.6

%<

94.6

%Locally

agre

ed

Tu

rno

ve

r R

ate

>=

7%

>7%

AN

D <

=6.0

%<

6.0

%Locally

agre

ed

Sta

ff in

po

st

ve

rsu

s p

lan (

Full

tim

e e

qu

iva

lent)

>=

83 F

TE

per

month

> 8

3 F

TE

per

month

AN

D <

= p

lan +

42 F

TE

per

month

>42 F

TE

per

month

IBP

pla

n a

s s

traig

ht lin

e tra

jecto

ry

PD

R c

om

ple

tion

Rate

>=

-5%

of

traje

cto

ry<

-5%

of

traje

cto

ry A

ND

>=

-15%

of

traje

cto

ry<

-15%

of

traje

cto

ryLocally

agre

ed

Ma

nd

ato

ry t

rain

ing

12 m

onth

ro

llin

g c

om

plia

nce

fo

r p

atie

nt

han

dle

rs (

best

=3

sta

nd

ard

s' tr

aje

cto

rie

s m

et)

Mandato

ry tra

inin

g o

n tra

jecto

ry f

or

all

3 types

1 o

r 2 m

andato

ry tra

inin

g typ

es r

ate

d a

s a

mber

1 o

r m

ore

mandato

ry tra

inin

g typ

e r

ate

d a

s r

ed O

R 3

rate

d a

s

am

ber

Locally

agre

ed

Ba

nk,

Ag

ency a

nd

Lo

cu

m s

pen

d<

=8%

cum

ula

tive

>8%

AN

D <

=10%

cum

ula

tive

>10%

cum

ula

tive

Locally

agre

ed

Bu

llyin

g a

nd

ha

rassm

en

t ca

ses

<=

last ye

ar's c

um

ula

tive a

ctu

al

n/a

> last ye

ar's c

um

ula

tive a

ctu

al

Locally

agre

ed

% o

f sta

ff r

ecru

ite

d w

ith

in s

tand

ard

tim

es

>=

70%

com

plia

nce w

ith s

tandard

s<

70%

AN

D >

=50%

com

plia

nce w

ith s

tandard

s<

50%

com

plia

nce w

ith s

tandard

sLocally

agre

ed

5.

FA

CIL

ITIE

S

Tru

st

tele

ph

on

e r

espo

nse

tim

es -

exte

rna

l>

=70%

within

20 s

econds c

um

ula

tive

>=

65%

and <

70%

within

20 s

ecs c

um

ula

tive

<65%

within

20 s

econds c

um

ula

tive

Locally

agre

ed

Mo

nth

ly c

lean

ing

sco

res

>=

88.5

% c

um

ula

tive

<88.5

% A

ND

>=

80%

cum

ula

tive

<80%

cum

ula

tive

Locally

agre

ed

Pa

tien

t sa

tisfa

ction

with

fo

od

>=

75%

score

d 3

fro

m 5

cum

ula

tive

<75%

AN

D >

=65%

score

d 3

fro

m 5

cum

ula

tive

<65%

score

d 3

fro

m 5

cum

ula

tive

Locally

agre

ed

Pa

tien

t F

oo

d W

aste

, n

um

ber

of

unto

uch

ed

me

als

wa

ste

d

as a

% o

f to

tal m

eals

se

rve

d<

=7%

cum

ula

tive

>7%

AN

D <

=10%

cum

ula

tive

>10%

cum

ula

tive

Locally

agre

ed

Lau

nd

ry p

rod

uction

- P

ieces p

er

ope

rato

r p

er

hou

r>

=80%

<80%

AN

D >

75%

<75%

Locally

agre

ed

Se

curity

- %

of

deliv

ere

d h

ou

rs a

ga

inst

co

ntr

act

>=

95%

<95%

AN

D >

=90%

<90%

Locally

agre

ed

Occu

pa

tion

al H

ealth

- t

he %

of

app

oin

tme

nts

off

ere

d w

ith

in

10d

ays o

f th

e r

efe

rra

l>

=80%

of

cum

ula

tive r

efe

rrals

<80%

AN

D >

=75%

of

cum

ula

tive r

efe

rrals

<75%

of

refe

rrals

cum

ula

tive

Locally

agre

ed

Po

rte

ring

re

spo

nse

tim

es in m

inute

s<

=15 m

inute

s<

15 m

iniu

tes A

ND

<=

30 m

inute

s>

30 m

inute

sLocally

agre

ed

Co

mp

lete

d

pla

nn

ed

pre

ve

nta

tive

ma

inte

na

nce

Che

cks

ag

ain

st

sch

ed

ule

d>

=70%

cum

ula

tive

<70%

and >

=65%

cum

ula

tive

<60%

cum

ula

tive

Locally

agre

ed

Esta

tes H

elp

de

sk C

alls

att

end

ed

with

in a

llocate

d

tim

efr

am

e>

=80%

cum

ula

tive

<80%

and >

=70%

cum

ula

tive

<70%

cum

ula

tive

Locally

agre

ed

Sta

tuto

ry P

PM

co

mp

lete

d>

=90%

<90%

AN

D >

=80%

<80%

Locally

agre

ed

EB

ME

PP

M o

n h

igh

ris

k e

qu

ipm

en

t>

=80%

<80%

AN

D >

75%

<75%

Locally

agre

ed

No

n-c

om

plia

nt

ste

rile

se

rvic

es instr

um

en

t se

ts>

=0.2

5%

cum

ula

tive

n/a

>0.2

5%

cum

ula

tive

DH

exte

rnal pro

vid

er

sta

ndard

for

join

t ventu

re p

roje

ct

Clin

ica

l w

aste

(kilo

gra

ms p

er

patie

nt)

<=

1.2

Kg / P

atient cum

ula

tive

>1.2

Kg p

er

patient A

ND

<=

1.3

KG

per

patient cum

ula

tive

>1.3

Kg / P

atient cum

ula

tive

Locally

agre

ed

En

erg

y c

onsu

mp

tio

n p

er

hea

ted

vo

lum

e (

2.5

% r

edu

ction

in

201

1-1

2)

- G

J /

100

m3

<=

74.3

GJ

>74.3

GJ A

ND

<=

75 G

J>

75 G

JLocally

agre

ed

of 132

1

9

Ap

pe

nd

ix 3

Pe

rfo

rma

nc

e T

raje

cto

rie

s

Urg

en

t C

are

4 H

ou

r P

erf

orm

an

ce

- T

rus

t

95

.8%

95%

80%

85%

90%

95%

100%

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

% 4 Hour Performance

Actu

al

Nation

al T

arg

et

Urg

en

t C

are

4 H

ou

r P

erf

orm

an

ce

- F

GH

96

.1%

95%

80%

85%

90%

95%

100%

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12


Actu

al

Nation

al T

arg

et

Tra

jecto

ry

Urg

en

t C

are

4 H

ou

r P

erf

orm

an

ce

- N

MG

H

92

.6%

95%

80%

85%

90%

95%

100%

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12


Actu

al

Nation

al T

arg

et

Tra

jecto

ry

Urg

en

t C

are

4 H

ou

r P

erf

orm

an

ce

- R

OH

96

.3%

95%

80%

85%

90%

95%

100%

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12


Actu

al

Nation

al T

arg

et

Tra

jecto

ry

Urg

en

t C

are

4 H

ou

r P

erf

orm

an

ce

- R

I

98

.9%

95%

80%

85%

90%

95%

100%

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12


Actu

al

Nation

al T

arg

et

Urg

en

t C

are

4 h

ou

r p

erf

orm

an

ce

Item

8

of 132

2

0

Re

ferr

al

to T

rea

tme

nt

Pe

rfo

rma

nc

e

95

th P

erc

en

tile

Re

ferr

al

To

Tre

atm

en

t W

ait

s

33.6

Ad

mitte

d T

arg

et

17.6

Non-a

dm

itte

d T

arg

et

27.2

Inco

mp

lete

ta

rge

t

05

10

15

20

25

30

35

40

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

95th Percentile Wait in weeks

Ad

mitte

d A

ctu

al

Ad

mitte

d T

arg

et

No

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of 132

Agenda Item: 9

Title of Report Sustainable Development Management Plan – Progress Report

Executive Summary

This Sustainable Development Management Plan Progress Report has been prepared to inform the Board on the progress being made by the Trust in meeting its objective to provide high quality healthcare that minimises the effects on the environment.

Actions requested

The Board is asked to note this paper.

Corporate Objectives supported by this paper: Objective 5 - Facilities Performance – To improve energy and carbon efficiency.

Risks: Failure to meet carbon reduction targets.

Public and/or patient involvement: This SDMP supports public and patient involvement.

Resource implications: To be implemented using existing resources.

Communication: Communications forms part of the SDMP.


Assurance

Contract



HR

IM&T



Sustainability

Name John Wilkes

Job Title Director of Facilities

Date August 2011


Item

9

of 132

of 132

Sustainable Development Management Plan Progress Report

August 2011

1. Background

1.1 The Trust is committed to supporting the carbon reduction and sustainable development agenda of the NHS and to reducing the Trust’s carbon footprint. The current target of the Carbon Reduction Strategy is to achieve a 10% reduction from the 2007 carbon footprint of the NHS by 2015. Significant progress has already been made in realising these objectives.

The Trust is also registered as a participant in the Governments Carbon Reduction Commitment scheme. By the end of March 2011, the Trust will have established a baseline fuel consumption against which any future targets can be measured.

1.2 The Trust continue to use the good corporate citizenship toolkit for reviewing

our carbon footprint and sustainability. This toolkit enables the Trust to evaluate its progress in improving its sustainability and informing stakeholders.

1.3 Actions to date to implement the strategy are

The Trust Board approved the Sustainable Development Strategy September 2010.

Sustainable Development Management Plan received by the Trust Board in

February 2010.

The Trust Board approval to purchase 100% electricity from renewable sources.

2. Current Position

2.1 The Sustainable Development Management Plan (attached) shows that currently of the original 49 carbon reduction initiatives identified, 23 have been completed. These are programmed to deliver a minimum saving of 171 tonnes of carbon in each full year. Other initiatives such as signing up to good Corporate Citizenship & raising awareness of sustainability issues with staff do not contribute to the Trust’s Net Carbon Reduction at present but will lead to reductions in the longer term.

2.2 There are now 33 initiatives programmed for delivery with identified annual

savings of 279 tonnes of carbon. More carbon savings will be quantified as

Item

9

of 132

appropriate conversion models for estimating carbon emissions savings are made available.

2.3 Several initiatives now showing amber have fallen behind their target delivery

dates these are now being actively progressed to identify any problems.

2.4 The Sustainable Development Management Plan will be reviewed at the next Trust Sustainability Group meeting in September.

3. Recommendation 3.1 The Trust Board is recommended to note the progress on the 56 initiatives. Page 51

of 132

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Sep-1

1P

RO

C5

Intr

oduce e

-sourc

ing

to r

educe p

aperw

ork

and p

osta

l activity

Busin

ess

case t

o b

e

develo

ped

and

subm

itte

d.

Head o

f

Pro

cure

ment

Item

9

of 132

Capital

Costs

Savin

gs

Costs

Com

ple

ted

Com

ple

ted

Capital

Costs

Savin

gs

Costs

30

00

0

Com

ple

ted

Com

ple

ted

PR

OC

3In

clu

de s

usta

inabili

ty

cri

teri

a in t

he t

ender

evalu

ation p

rocess.

Revie

w

cri

teri

a in u

se.

Head o

f

Pro

cure

ment

N/A

N/A

Envir

onm

enta

l

susta

inabili

ty

now

an

evalu

ation

cri

teri

a.

Subm

it f

or

to

Susta

inabili

ty G

roup

20/0

6/2

011 a

nd a

ppro

val

giv

en.

Com

ple

te

PR

OC

2T

enders

to inclu

de

susta

inabili

ty c

lause.

Revie

w o

f

contr

act

term

s a

nd

conditio

ns.

Head o

f

Pro

cure

ment

N/A

N/A

Envir

onm

enta

l

susta

inabili

ty

now

inclu

ded

in t

ender

docum

enta

tion

.

Pro

cu

rem

en

t -

Co

mp

lete

d –

31 M

ay 2

011

Wo

rk S

tream

Ref

Init

iati

ve/M

easu

re

Acti

on

Req

uir

ed

to

Ach

ieve

Resp

on

sib

le

Lead

s

Ind

icati

ve C

osts

& S

avin

gs £

KT

arg

et

Date

for

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mp

leti

on

Sig

nif

ican

t

Mil

esto

nes

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Co

mm

en

ts

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tals

fo

r P

rocu

rem

en

t

Ind

icati

ve C

osts

& S

avin

gs £

K

Revenue p

er

year

N/A

N/A

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Net

Carb

on

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Net

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on

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ucti

on

[to

nn

es]

PR

OC

1D

evelo

p S

usta

inable

Develo

pm

ent

Polic

y

for

pro

cure

ment.

Head o

f

Pro

cure

ment

Com

ple

ted

Dra

ft

Docum

ent

pro

duced f

or

appro

val and

com

ment.

N/A

of 132

Capital

Costs

Savin

gs

Costs

CA

T3

Reduce t

he u

se o

f all

dis

posable

cro

ckery

and c

utlery

and

exam

ine a

ltern

ative

Work

with

supplie

rs,

educate

sta

ff

Head o

f

Cate

ring /

Head

of

Pro

cure

ment

Dec-1

1U

nable

to

assess a

t

pre

sent

CA

T5

Purc

hase %

of

fresh

fruit a

nd v

egeta

ble

s

from

local supplie

r

Calc

ula

te %

purc

hased

Head o

f

Cate

ring

Dec-1

1U

nable

to

assess a

t

pre

sent

57%

of

Fru

it &

Veg is

curr

ently p

urc

hased f

rom

GB

pro

ducers

CA

T6

Purc

hase B

read a

nd

morn

ing g

oods f

rom

supplie

rs w

ith 3

0 m

ile

radiu

s o

f th

e T

rust

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f

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ring

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1U

nable

to

assess a

t

pre

sent

CA

T9

Rationalis

e s

tock

hold

ing a

nd r

educe

supplie

rs

Head o

f

Cate

ring

Dec-1

1U

nable

to

assess a

t

pre

sent

Capital

Costs

Savin

gs

Costs

40

00

0

Sig

nif

ican

t

Mil

esto

nes

Met

Net

Carb

on

Reduction

To

tals

fo

r C

ate

rin

g

Ind

icati

ve C

osts

& S

avin

gs £

K

Revenue p

er

year

Net

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on

Red

ucti

on

[to

nn

es]

Co

mm

en

ts

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

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rin

g -

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po

sed

– 3

1 M

ay 2

011

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rk S

tream

Ref

Init

iati

ve/M

easu

re

Acti

on

Req

uir

ed

to

Ach

ieve

Resp

on

sib

le

Lead

s

Ind

icati

ve C

osts

& S

avin

gs £

KT

arg

et

Date

for

Co

mp

leti

on

Item

9

of 132

Capital

Costs

Savin

gs

Costs

CA

T1

85%

of

meat

purc

hased f

rom

Bri

tish m

eat

supplie

rs

Achie

ved

Head o

f

Cate

ring

Com

ple

teU

nable

to

assess a

t

pre

sent

Com

ple

ted

CA

T4

Pro

cure

ment

of

milk

and m

ilk p

roducts

from

supplie

rs w

ithin

a 4

0 m

ile r

adiu

s

Achie

ved

Head o

f

Cate

ring

Com

ple

teU

nable

to

assess a

t

pre

sent

CA

T7

Purc

hase p

re p

acked

sandw

iches f

rom

supplie

rs w

ith 3

0 m

ile

radiu

s o

f th

e T

rust

Achie

ved

Head o

f

Cate

ring

Com

ple

teU

nable

to

assess a

t

pre

sent

CA

T8

Purc

hase S

ausage

and b

acon p

roducts

from

supplie

rs w

ithin

30 m

ile r

adiu

s o

f th

e

Tru

st

Achie

ved

Head o

f

Cate

ring

Com

ple

teU

nable

to

assess a

t

pre

sent

Capital

Costs

Savin

gs

Costs

50

00

0

Cate

rin

g -

Co

mp

lete

d –

31 M

ay 2

011

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rk S

tream

Ref

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iati

ve/M

easu

re

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on

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uir

ed

to

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ieve

Resp

on

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le

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s

Ind

icati

ve C

osts

& S

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gs £

KT

arg

et

Date

for

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mp

leti

on

Sig

nif

ican

t

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esto

nes

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Net

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on

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ucti

on

[to

nn

es]

Co

mm

en

ts

Card

board

recycle

d o

n a

ll

sites

To

tals

fo

r C

ate

rin

g

Ind

icati

ve C

osts

& S

avin

gs £

K

Revenue p

er

year

Intr

oduce

waste

str

eam

on a

ll sites

Head o

f

Cate

ring

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Net

Carb

on

Reduction

Unable

to

assess a

t

pre

sent

CA

T2

Recycle

all

depart

menta

l

Card

board

of 132

Cap

ita

l

Co

sts

Sa

vin

gs

Co

sts

Revie

w

exis

tin

g p

lan

s

an

d

do

cu

me

nts

.

Fa

cili

tie

s

Dir

ecto

r

Esta

blis

h

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st

aim

s.

Tra

ve

l a

nd

Acce

ss

Co

ord

ina

tor

Lia

ise

with

Lo

ca

l

Au

tho

rity

.

Lia

ise

with

Lo

ca

l

Au

tho

ritie

s

an

d t

ran

sp

ort

pro

vid

ers

.

Se

ek

ap

pro

va

l o

f

cu

rre

nt

dra

ft

do

cu

me

nts

.

TR

V3

Cre

ate

tra

nsp

ort

wo

rkin

g g

rou

p t

o

assis

t in

imp

lem

en

tatio

n a

nd

futu

re d

eve

lop

me

nt

of

su

sta

ina

ble

tra

ve

l

pla

ns.

Pu

blic

ise

an

d

se

ek t

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ecru

it

me

mb

ers

.

Tra

ve

l a

nd

Acce

ss

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ord

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De

c-1

1A

wa

it f

urt

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r

pro

gre

ss o

n

TR

V1

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CB

arr

y W

ate

rho

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cili

tie

s

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ecto

r

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ve

l a

nd

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ss

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ord

ina

tor

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ita

l

Co

sts

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vin

gs

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sts

30

00

0

To

tal N

o o

f

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tive

s

Re

ve

nu

e p

er

ye

ar

Ne

t C

arb

on

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du

ctio

n

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CT

RV

4Im

ple

me

nt

actio

n

pla

ns w

ith

in e

ach

of

the

su

sta

ina

ble

tra

ve

l

pla

ns.

So

me

pro

gre

ss

ma

de

with

39

ou

t o

f 1

33

actio

ns

ach

ieve

d.

To

tals

fo

r T

rave

l &

Tra

ns

po

rt

Ind

ica

tive

Co

sts

& S

avin

gs

£K

TB

CB

arr

y W

ate

rho

use

to

pro

gre

ss

As d

eta

iled

in

dra

ft

su

sta

ina

ble

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ve

l p

lan

s

for

the

fo

ur

TB

CM

ajo

rity

of

me

asu

res b

y

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c 2

01

1

N/A

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c-1

1D

raft

do

cu

me

nts

pro

du

ce

d f

or

ap

pro

va

l a

nd

su

pp

lied

fo

r

co

mm

en

ts t

o

loca

l

au

tho

ritie

s.

Sig

nif

ica

nt

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es

ton

es

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t

TR

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tify

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ve

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nd

acce

ss s

tra

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tra

ve

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at

wo

rk p

olic

y a

nd

su

sta

ina

ble

tra

ve

l

pla

ns f

or

ea

ch

site

.

N/A

N/A

Ne

t C

arb

on

Re

du

cti

on

[to

nn

es

]C

om

me

nts

Re

ve

nu

e p

er

ye

ar

Tra

vel &

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nsp

ort

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rop

osed

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1 M

ay 2

011

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rk S

tre

am

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fIn

itia

tive

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as

ure

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tio

n

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qu

ire

d t

o

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hie

ve

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sp

on

sib

le

Le

ad

s

Ind

ica

tive

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sts

& S

avin

gs

£K

Ta

rge

t D

ate

for

Co

mp

leti

on

Item

9

of 132

Capital

Costs

Savin

gs

Costs

Develo

p

pro

motional

dis

pla

ys

inclu

din

g

Leaflet/

info

rm

ation

dis

trib

ution.

Com

ple

te

Capital

Costs

Savin

gs

Costs

15

00

0

Tra

vel

& T

ran

sp

ort

- C

om

ple

ted

– 3

1 M

ay 2

011

Wo

rk S

tream

Ref

Init

iati

ve/M

easu

re

Acti

on

Req

uir

ed

to

Ach

ieve

Resp

on

sib

le

Lead

s

Ind

icati

ve C

osts

& S

avin

gs £

KT

arg

et

Date

for

Co

mp

leti

on

Sig

nif

ican

t

Mil

esto

nes

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Net

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on

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ucti

on

[to

nn

es]

Co

mm

en

ts

TR

V2

Public

ise c

urr

ent

Tra

vel C

hoic

es

initia

tives

Tra

vel and

Access

Coord

inato

r

5N

/AN

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form

ation

now

availa

ble

on intr

anet

and

update

d

regula

rly.

TB

C

To

tals

fo

r T

ravel

& T

ran

sp

ort

Ind

icati

ve C

osts

& S

avin

gs £

K

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Revenue p

er

year

Net

Carb

on

Reduction

of 132

Capital

Costs

Savin

gs

Costs

WA

T1

Reduce t

he t

ota

l

square

mete

rage o

f

imperv

ious s

urf

ace

are

a o

n a

ll sites.

Reduction in

hard

sta

ndin

gs b

y

incorp

ora

ting

Head o

f E

sta

te

Develo

pm

ent

N/A

Inclu

ded in

majo

r new

develo

pm

ent

work

.

2020

Incorp

ora

te

low

flo

w

models

into

new

develo

pm

ents

.

Head o

f E

sta

te

Develo

pm

ent

Modify/r

epla

c

e e

xis

ting

insta

llations.

Head o

f E

sta

te

Opera

tions

WA

T3

Dis

trib

ute

info

rmation

to s

taff

that

encoura

ges e

ffic

ient

wate

r usage o

n a

ll

sites.

Develo

p

pro

motional

dis

pla

ys

inclu

din

g

intr

anet

and

inte

rnet.

Envir

onm

ent

/

Ris

k M

anager

1A

ug-1

1T

he M

arc

h 2

011 t

arg

et

could

not

be m

et

as n

o

Energ

y M

anager

in p

lace.

Intr

anet

dis

trib

ution

undert

aken A

ug 2

011.

WA

T4

Insta

ll w

ate

r re

cyclin

g

syste

m o

n b

atc

h

washer

Confirm

pro

ject

with

Chri

ste

yns

Sanoxy

Nig

el W

ylie

pro

ject

manager

30

20.4

Oct-

11

100

Ord

er

pla

ced P

lanned

Sta

rt o

n S

ite A

ugust

2011

Capital

Costs

Savin

gs

Costs

41

30

20.4

100

Repla

cem

ent

of

toile

ts

and u

rinals

will

be o

n a

n

as a

nd w

hen n

ecessary

basis

.

To

tals

fo

r W

ate

r

N/A

Inclu

ded in

majo

r new

develo

pm

ent

work

.

2020

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r -

Pro

po

sed

– 3

1 M

ay 2

011

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rk S

tream

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iati

ve/M

easu

re

Acti

on

Req

uir

ed

to

Ach

ieve

Resp

on

sib

le

Lead

s

Ind

icati

ve C

osts

& S

avin

gs £

KT

arg

et

Date

for

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mp

leti

on

Sig

nif

ican

t

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esto

nes

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Net

Carb

on

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ucti

on

[to

nn

es]

Co

mm

en

ts

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Net

Carb

on

Reduction

Revenue p

er

year

WA

T2

Upgra

de t

oile

ts a

nd

uri

nals

to low

flo

w

models

on a

ll sites.

Ind

icati

ve C

osts

& S

avin

gs £

K

Item

9

of 132

Capital

Costs

Savin

gs

Costs

Capital

Costs

Savin

gs

Costs

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Net

Carb

on

Reduction

Revenue p

er

year

Ind

icati

ve C

osts

& S

avin

gs £

K

To

tals

fo

r W

ate

r

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r – 3

1 M

ay 2

011

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rk S

tream

Ref

Init

iati

ve/M

easu

re

Acti

on

Req

uir

ed

to

Ach

ieve

Resp

on

sib

le

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s

Ind

icati

ve C

osts

& S

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gs £

KT

arg

et

Date

for

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mp

leti

on

Sig

nif

ican

t

Mil

esto

nes

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Net

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on

Red

ucti

on

[to

nn

es]

Co

mm

en

ts

of 132

Capital

Costs

Savin

gs

Costs

WA

S3

Investigate

ways o

f

segre

gating c

linic

al

waste

to c

om

ply

with

HT

M 0

7-0

1

Benchm

ark

with o

ther

trusts

. T

ask &

Fin

ish g

roup

esta

blis

hed

Phil

Chalo

ner

Oct-

11

N/A

80%

com

ple

te

Capital

Costs

Savin

gs

Costs

10

00

0

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Waste

- C

om

ple

ted

– 3

1 M

ay 2

011

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rk S

tream

Ref

Init

iati

ve/M

easu

re

Acti

on

Req

uir

ed

to

Ach

ieve

Resp

on

sib

le

Lead

s

Ind

icati

ve C

osts

& S

avin

gs £

KT

arg

et

Date

for

Co

mp

leti

on

Sig

nif

ican

t

Mil

esto

nes

Met

Net

Carb

on

Red

ucti

on

[to

nn

es]

Co

mm

en

ts

Net

Carb

on

Reduction

Revenue p

er

year

To

tals

fo

r W

aste

Ind

icati

ve C

osts

& S

avin

gs £

K

Item

9

of 132

Capital

Costs

Savin

gs

Costs

WA

S1

Card

board

recyclin

g –

rem

ove c

ard

board

waste

fro

m t

he

dom

estic w

aste

for

recyclin

g

Insta

ll

card

board

com

pacto

rs

on t

he

NM

GH

,

TR

OH

and

Fair

field

sites

Phil

Chalo

ner

TB

Ccom

ple

te

WA

S2

Dom

estic w

aste

contr

act

inclu

des

waste

segre

gation

and r

ecyclin

g a

cro

ss

the T

rust.

Contr

act

in

pla

ce

Phil

Chalo

ner

10

New

contr

act

in p

lace

N/A

New

contr

act

achie

ves

100%

recyclin

g o

f

dom

estic w

aste

.

Com

ple

te

Capital

Costs

Savin

gs

Costs

20

10

00

Net

Carb

on

Red

ucti

on

[to

nn

es]

Co

mm

en

ts

Net

Carb

on

Reduction

Revenue p

er

year

To

tals

fo

r W

aste

Ind

icati

ve C

osts

& S

avin

gs £

K

Tota

l N

o o

f

Initia

tives

Revenue p

er

year

Waste

– 3

1 M

ay 2

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rk S

tream

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Init

iati

ve/M

easu

re

Acti

on

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ed

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ieve

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on

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le

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s

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icati

ve C

osts

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gs £

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et

Date

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mp

leti

on

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nif

ican

t

Mil

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of 132

Agenda Item: 10

Title of Report Foundation Trust Membership Strategy

Executive Summary

This paper outlines the Trust’s proposed membership recruitment and engagement strategy for Foundation Trust status over the next 18 months from July 2011 to December 2012. The strategy describes the activity and progress to date since the Trust formally consulted on its proposals to become an NHS Foundation Trust. It also outlines plans to recruit more members and future marketing and engagement. The strategy will build on the recruitment of FT members so far along with details of how the membership will be actively involved in the work of the Trust. The strategy draws on the recent Board seminar on engagement. Preparation of an FT Membership Strategy is one of the milestones in the Accountability Agreement signed with the SHA. The strategy forms an appendix to the Integrated Business Plan.

Actions requested

The Board is asked to consider the strategy, offer a view on whether if is comprehensive, consider whether there are any risks that need to be addressed at Board level and offer comment or amendments. Having done so, the Board is then asked to approve the strategy.

Corporate Objectives supported by this paper: Objective 7 – Foundation Trust Status

Risks: The strategy offers mitigation against Board Risk 924 – Reputation - by further developing methods of engaging with the local community. The strategy offers mitigation against Board Risk 921 – FT Status – by ensuring that a milestone is achieved.

Public and/or patient involvement: Draws on comments during the consultation process, from existing FT members and staff following the first FT newsletter and from the Board seminar on engagement.

Resource implications: A budget to implement the strategy needs to be identified.

Communication: Wide communication outlined in the paper.

Item

10

of 132


Assurance X

Contract X

Equality and Diversity X

Financial / Efficiency X

HR X

IM&T X

Local Delivery Plan / Trust Objectives X

National policy / legislation X

Sustainability X

Name Gavin R Barclay

Job Title Assistant Chief Executive

Date August 2011


of 132

FT Membership & Engagement Strategy_19 August2011 1

Foundation Trust

Membership Recruitment & Engagement Strategy

July 2011 – December 2012 Introduction This paper outlines the Trust‟s proposed membership recruitment and engagement strategy for Foundation Trust status over the next 18 months from July 2011 to December 2012. The strategy describes the activity and progress to date since the Trust formally consulted on its proposals to become an NHS Foundation Trust. It also outlines plans to recruit more members and future marketing and engagement. The strategy will build on the recruitment of FT members so far along with details of how the membership will be actively involved in the work of the Trust. Phased Approach The Trust‟s FT membership strategy has adopted a phased approach in its delivery, as follows: Phase 1 - Consultation Phase 2 – Recruitment Phase 3 – Retention and growth Phase 4 – Influencing / Interactivity

So far the Trust has successfully implemented phases 1 and 2 of the strategy. Phase 1 – Consultation

Aim – To raise awareness of becoming an NHS Foundation Trust among staff, the public, patients, and key stakeholders. As part of our FT application, the Trust carried out a formal 12 week consultation. The consultation document (newspaper) called „Your Hospitals, Your Choice – Your Voice‟, was officially launched on 3 November 2009 at the November Trust Board meeting. A series of public meetings, information stands and publicity supported the consultation exercise. The consultation closed on 29 January 2010. The Trust Board considered and made a number of amendments to the FT governance arrangements as a result of issues raised during the consultation.

Phase 2 – Recruitment

Aim – To build membership; develop an active and participative membership. Since the FT consultation, the Trust has received a positive response from our public and patients. To date, the Trust has recruited over 4,600 public members, in addition to our staff members. The makeup of the Trust‟s public membership is shown in the graph below.

Item

10

of 132


FT Public Members

1062

261

1243 1538

502

4606

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Bu

ry

No

rth

Man

ch

este

r

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ham

Heyw

oo

d,

Mid

dle

ton

&

Ro

ch

dale

Oth

er

part

s

of

en

gla

nd

To

tal

Area

mem

bers

Recruitment to date has been achieved through a combination of broad general marketing communications, member recruitment and community relations/PPI activity. Many public joined as members up at our stands in the Arndale shopping centre in Manchester city centre and in the Spindles town shopping centre in Oldham towards the end of last year. The Trust‟s FT promotional video has received over one thousand views on YouTube and the Trust‟s FT web pages regularly receive over 100 unique visits per month. A number of Trust volunteers have been instrumental in signing up public members on wards and in out-patient departments across all sites. Their involvement is essential for future ongoing membership recruitment. Patients and members of the Pennine Cancer Patient User Partnership (PPUP) have signed up to support and become Foundation Trust members. The PPUP has a membership of 72 patients, carers and healthcare professionals. The Trust has been working with a number of suppliers and contractors to encourage their employees who work at the Trust to sign up as members. This has included over 30 staff who work for Securitas and we expect a number of staff at ISS Healthcare Services Ltd to join. The Trust is looking to recruit a further 5,500 public members over the next 18 months through targeted marketing communications, aiming at specific age groups and localities (e.g. North Manchester and young people), whilst retaining and effectively engaging with existing members. Phase 3 – Retention and growth

Aim – To retain and build the FT membership.

The target is to reach a total public membership of 10,000 by the end of December 2012. This is a trajectory of 350 per month or 1050 per quarter, in addition to current staff members. See graph below.

August 2011

of 132


In line with experience from other NHS Foundation Trusts, it is projected that the Trust may lose approximately 10% of its membership every six months. This loss of membership is due to people moving home and mail being returned, older members passing on and some people simply no longer wishing to be involved. The Trust will work hard to minimize the latter by having a meaningful range of engagement and involvement. For this reason, a revised trajectory for the recruitment of members should take this into account and therefore is 385 new members per month or 1155 per quarter.

FT public membership trajectory

4000

5000

6000

7000

8000

9000

10000

July - Sept

2011

Oct-Dec

2011

Jan-Mar

2012

April - Jun

2012

July-Sept

2012

Oct-Dec

2012

Month/Quarter

FT

pu

bli

c m

em

bers

In August 2011, the Trust published the second edition of its Foundation Trust Membership Magazine, called Your Hospitals, Your Pennine. The first edition was published in August 2010. Our public members will have received this magazine by post. In future we aim to send as many magazines as possible by email. For our staff members, following feedback from the last magazine, this latest edition is now being sent by email and is being made available in staff rooms and on wards alongside the monthly Trust staff magazine, Pennine News, and on the Trust intranet.

This level of recruitment poses a growing demand on the Trust year on year. The Trust recently appointed a Foundation Trust membership manager, which started in post in August 2011. This role sits within the Trust communication department and is responsible for proactively recruiting new members, organising membership events and supporting our members, and eventually elected governors. Phase 4 – Influencing / Interactivity Aim – To show how FT members can/are influencing the running of the Trust A calendar and series of FT membership events is being developed in partnership with clinicians and other departments across the Trust as part of the strategy. Future member events might range from health fairs, discussion forums, information lectures on key speakers and health-related presentations from our clinical speakers

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(called Medicine for Members) to exclusive invitations to open days and tours of new hospital departments and facilities. All sessions will be free and open to all members. Some members may be interested in taking part in Trust surveys and consultations about the Trust and its hospitals and services. The aim is to involve our staff and public members on a variety of topics through surveys, forums and presentation road shows. The recent Board Seminar on engagement will inform this process. The Trust will soon begin encouraging public members to consider becoming a governor. This will entail holding awareness and training sessions for members who express an interest in becoming a governor. Elections will take place in Winter 2012.

Key messages The Trust is currently in the process of reviewing and developing its Foundation Trust message as part of the recruitment and engagement strategy to:

build on the previous communication activity and message

help target specific groups of people to become FT members

promote the benefits of becoming a FT member

address the questions posed by potential FT public members

attract public interest and involvement among across section of the communities served by the Trust

explain to staff the purpose, plans and timeframe for the Trust becoming a FT.

ensure new/existing staff are aware that they are routinely signed up as staff members.

explain the role of partner agencies and stakeholders in the Trust‟s plans to become a FT.

differentiate between the Trust and other NHS Foundation Trusts locally

Every potential FT public member wants to know what's in it for me? This is the motivating factor of our target market and needs to be made clear and promoted in all future marketing communications and recruitment activity. Marketing material must put the „public‟ at the focus of the message.

It‟s free to become a FT member/ to join, with no obligation.

You can be involved as much or as little as you like.

You will receive a FT membership newsletter twice yearly.

You will receive exclusive invitations to member events at local hospitals.

You will have a greater say in how we run and develop hospital services.

You will have the opportunity to share your personal experiences, views and opinions on hospital services provided by the Trust including patient care, treatment, waiting times, parking & transport, privacy & dignity etc.

You will have the opportunity to vote to elect Trust Governors.

You will be eligible to receive discounts for local and high street retailers through NHS discounts.com

Recruitment - Going forward

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Review and redesign existing marketing communications material and message, incl. leaflet, website and membership magazine.

Build on previous recruitment and marketing communication activity and achievements to date to recruit more FT public members. Create Frequently Asked Questions (FAQs).

Implement existing and new methods of membership recruitment.

Elicit and work in partnership with variety of departments and volunteers within the Trust and partner agencies to recruit and engage with FT members.

Set up a FT membership steering/working group, comprising FT membership manager, head of communication, patient partnership manager, Patient Information Reference Group representative(s), site leads, outpatient staff.

Set up a FT reference group comprising staff side and volunteers – to obtain views/ideas.

Create „FT Ambassadors‟ within key recruitment areas – i.e. volunteers with out-patients and on wards, desk/reception staff.

Measurement of previous and future FT recruitment activity – create system to measure which recruitment activity is effective.

Develop effective and durable two-way/interactive communication channels.

Carry out some evaluation and insight work with existing and non-members members (sample) to help target specific geo-demographic groups.

Plan a targeted recruitment campaign aimed at young people, communities in North Manchester, BME communities, patients with chronic diseases etc.

Greater emphasis for staff to help promote/sign-up members i.e. „refer a friend/spouse/family members‟.

Send thank you letters and FT information/leaflets/forms to people who have made charitable donations to the Trust.

Strong PPI function - build on relations and promote FT membership with community and patient groups.

Consider developing a social media/networking strategy e.g. Twitter

Continue with signing up sub contracted staff who work at the Trust.

“Get the local media on board” – set up meetings with local press editors.

Enlist the support of local football clubs and local authorities.

Further identification of good-news stories and PR angles for local publicity e.g. polls, surveys of FT members…

Cross corporate involvement with partner agencies i.e. encourage staff employed by local authority, PCT, local Police, local teachers to become members.

Link with colleges, local council youth services and youth council.

Engage/contact local councillors to encourage membership sign-up.

Membership Engagement

Develop a calendar of regular member engagement events.

Review and produce future editions of the FT newsletter.

Improve greater engagement and involvement with existing and new FT public members and staff through events, polls and surveys, consultation and proactive two-way communication such as email and twitter.

Engage with staff directly and via staff side representatives (e.g. CJNCC) and raise awareness among staff that they are members and have a voice.

Staff engagement should be routinely part of the operational running of the Trust and in developing and reviewing policies and services.

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Explain and encourage staff members to offer ideas to help the Trust recruit more members and for future member events.

Enter into detailed discussions with stakeholders about their involvement and governor nomination.

Identify, research and plan calendar of FT Membership Engagement events, commencing APM 13 September (e.g. „Medicine for Members‟, exclusive tours of specific wards and developments, presentations).

Faster reply/response to application. Ensure FT members are sent standard letter and FT newsletter once on database.

Promote and support Governor Elections.

Design and create E-zine, using dot.mailer - called „Member Memo‟ – link to Trust‟s new Foundation Trust web pages.

Identify list of possible topics for a regular or ad hoc survey/questionnaires for FT members to complete (link with PPI).

Create dedicated membership area on new Trust website – events calendar, news/updates, reports, Member Memos and the FT membership magazines, link to NHS discounts.com.

Governors Communications

Support the governor election process.

Promote and encourage staff and public members to consider becoming a governor.

Arrange pre-election workshops and sessions for prospective governors.

Engage with staff (and via staff side representatives CJNCC) and raise awareness among staff that they are members and have a voice, which can be used to elect governors and influence the running of the Trust.

Develop bespoke Governor newsletter/e-zine and communication mechanisms.

Andrew Lynn Head of Communication

19 August 2011

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Agenda Item 11

Title of Report Clinical Governance & Quality Committee Minutes – July 2011

Executive Summary

The minutes from the Clinical Governance and Quality Committee in July 2011 reflect discussions on the following agenda items:

Serious Untoward Incident

Intestinal Obstruction Without Hernia.

Job Description for Clinical Representation

Claims Annual Report 2010/11

Actions Requested:

The Board is asked to note the content of the minutes

Corporate objectives supported by this paper: All Corporate Objectives are supported by a risk assessment which is included in the Corporate Risk Register.

Risks: Risks identified at the meeting are all on the corporate risk register and linked to the assurance framework both of which are monitored at this meeting

Public and/or Patient Involvement: Not relevant for this paper

Resource Implications: Not relevant for this paper

Communication: The Clinical Governance and Quality Committee communicates its work through the Trust Board, Divisional Governance Committees and the Health and Safety structure. Any incidents likely to attract media coverage are handled with the communication department.


Assurance √

Contract √



HR √

IM&T √



Sustainability √

Name Mr J Saxby




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CG&QC/HCJuly11 1

THE PENNINE ACUTE HOSPITALS NHS TRUST Clinical Governance & Quality Committee

15 July 2011 PRESENT: Ms P Anderson Divisional Head of Nursing representing Mr S Taylor Dr S Bradley Deputy Medical Director Dr I Cartmill Consultant Microbiologist Mr J Coleman Associate Director, Diagnostics & Cl Support Mr V Crumbleholme Associate Director of Nursing Ms C Cullen Consultant, Orthopaedic Surgeon Mr M Holly Non Executive Director Dr C Kenny Assoc Medical Director/Director of Medical Education Dr I Lawrie Consultant, Palliative Care Dr A Mukherjee Consultant, Paediatrician Mr R Pickering Director of HR and OD Miss C Rice Consultant, Obstetrician & Gynaecologist Mr J Saxby Chief Executive (Chair) Dr S Smith Head of Safeguarding APOLOGIES: Mrs M Carroll Director of Nursing Dr P Cook Consultant, Palliative Care Mrs H Curtis Governance Director Dr R Jameson Medical Director Ms P Jones Chief Pharmacist Mr J Lindars Acting Divisional Director, Surgery Dr R Parikh Consultant Geriatrician Mr C Sleight Divisional Director, Diagnostics & Cl Support Ms E Stringer Interim Head of Midwifery Mr S Taylor Divisional Director, Medicine Ms C Trinick Acting Divisional Director, Wm & Children ALSO IN ATTENDANCE FOR PART OF THE MEETING Mrs D Pullen Head of Claims 135/11 MINUTE OF CLINICAL GOVERNANCE COMMITTEE HELD ON 17 JUNE 2011

The minute of the Clinical Governance Committee Meeting dated 17 June 2011 was received and noted after the following amendment had been made:

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CG&QC/HCJuly11 2

Second paragraph of 119/11 should read „Mrs Curtis enquired if there was a hotline for people to contact. Mrs Carroll will report back at the next meeting‟.

136/11 MATTERS ARISING FROM THE MINUTE

49/11 – Unexpected Deaths – A Way Forward – Dr Bradley explained that the Divisions are progressing with arranging Mortality/Morbidity meetings. Ms Anderson stated that meetings are currently being established within the Division of Medicine.

49/11 – Unexpected deaths – A Way Forward – The pro forma has been requested from Tameside. When it is received it will be circulated.

Action: HC

49/11 – Unexpected Deaths – A Way Forward - Dr Bradley stated the CHKS data had been analysed and will be circulated to the Divisions.

Action: SB

67/11 – Clinical Incident Dashboard 3rd and 4th degree obstetric tears – Miss Rice advised that the 3 and 4th degree data has been agreed and closed. There is still an issue with Dr Foster data on obstetric trauma and this is being reviewed at national level. Mrs Curtis is aware of this and Dr Bradley stated it is being reviewed through AQUA.

Action: HC 85/11 – Surgery Minutes – Transfer of patients out of hours – Ms Anderson reported that following discussions at previous meetings of this Committee on the appropriateness of patients being transferred a piece of work has been completed at Oldham. Mr Taylor is liaising with Mr Lindars and an update will be given to the September meeting. 95/11 – CQC Mortality outlier alert for intestinal obstruction – This is an agenda item.

204/10 – NPSA/2010/RRR018 – Preventing fatalities from medication loading doses – Dr Lawrie stated that work is ongoing. An update will be given to the October meeting. 208/10 – PALS/Complaints Report July – September 2010 – Mr Saxby advised that a meeting had been held with the Divisional Directors and the key issues have been addressed.

Close

72/10 – Head Injury Audit – Mr Taylor will update at the September meeting. Action: ST

71/11 – NPSA/2011/PSA002 – Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants - This is an agenda item.

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113/11 – Exception Reports – Mrs Curtis had circulated the membership of the VTE Committee.

Close

114/11 – Clinical Incidents Dashboard – Mrs Curtis was doing further work around “ambulance issues” which are increasing. Mrs Curtis will bring details to the September meeting.

Action: HC

119/11 – Managing Allegations Policy – Mr Crumbleholme advised that a „Concern hotline‟ had been organised. To date two calls had been received.

Close

122/11 – Elective & Emergency Surgery in the Elderly: An Age Old Problem – CEPOD Report – An update will be given to the September meeting

Action: JL

In the matters arising sheet which had been circulated with the papers for the meeting the action should have said Mr Lindars not Mrs Curtis.

126/11 – Patient Safety Committee – Dr Bradley advised that a representative has now been identified for the Division of Surgery.

Close

PERFORMANCE. 137/11 EXCEPTION REPORTS Dr Bradley spoke to the mortality report. The Trust continues to improve but there is variance between and on the sites. Dr Bradley stated this is being reviewed. Mr Saxby requested a specific piece of work be undertaken to identify the variances.

Action: SB Dr Bradley spoke to the VTE report and said the Trust is achieving over 90% but we still need to improve, areas are being targeted that are low in undertaking VTE assessments. 138/11 CLINICAL INCIDENT DASHBOARD Mr Saxby presented the Clinical Incident Dashboard. There were no major changes from previous months. Dr Lawrie reported that the Medicine Governance Committee is targeting pressure ulcers and looking for zero tolerance.

Mr Saxby spoke to the STEIS report and gave an update on the STEIS incidents which are currently open.

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CG&QC/HCJuly11 4

Mr Saxby enquired about patients who are repatriated from abroad and whose infection status is unknown. Mr Crumbleholme advised this is to be discussed at the Directorate meeting.

139/11 NATIONAL PATIENT SAFETY AGENCY ALERTS COMPLIANCE NPSA/2009/PSA004A/PSA004B – Safer spinal (intrathecal) NPSA/2011/PSA001 – Update will be given in October. NPSA/2010/RRR018 – Preventing fatalities from medication loading doses – Dr Lawrie advised that a task and finish group has been established and work is on track. An update will be given in October. NPSA/2010/RRR019 – Safer ambulatory syringe drivers – an update will be given in October. NPSA/2011/PSA003 – The adult patient‟s passport to safer use of insulin – An update will be given to the January meeting. 140/11 PATIENT EXPERIENCE INCLUDING CQUINS – EXCEPTION REPORT There were no patient experience exception reports. 141/11 CLINICAL EFFECTIVENESS INCLUDING CQUINS – EXCEPTION REPORT Dr Bradley advised that the action plan template had been circulated for information. Dr Lawrie raised concerns where “incomplete action” was being reported. Dr Bradley responded that a number of action plans have not been received. Mrs Carroll and Dr Bradley have contacted those who have not returned the action plans to emphasise the urgency and importance of completing them in a timely manner. 142/11 SERIOUS UNTOWARD INCIDENT 136350 Mr Saxby said that the action plan which had been circulated followed a root cause analysis which had been undertaken. Mr Saxby thought it would be useful for a five case audit from each site to be undertaken in August/September. Miss Rice suggested this should also include gynaecology. Dr Kenny will coordinate for all surgical patients and report back on the findings.

Action: CK

143/11 NPSA/2011/PSA002 – REDUCING THE HARM CAUSED BY MISPLACED NASOGASTRIC FEEDING TUBES IN ADULTS, CHILDREN AND INFANTS – ACTION PLAN

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CG&QC/HCJuly11 5

Mr Crumbleholme gave an update to the Committee and explained that a working group had been established and work is on track for completion of the alert by 12 September 2011. 144/11 INTESTINAL OBSTRUCTION WITHOUT HERNIA Mr Saxby reported that Dr Jameson had requested an extension due to the review of case notes. Dr Kenny will check with Dr Jameson on progress and report back to the September meeting.

Action: CK

Dr Lawrie stated that the morbidity and mortality meetings are improving and that an after death task and finish group has been established to analyse procedures that should be undertaken after death, eg completion of death certificate, reporting to the coroner where necessary, etc. 145/11 JOB DESCRIPTION FOR CLINICAL REPRESENTATION The job description had been circulated for approval by the Committee. Miss Rice raised concerns about the time allocation if people have to travel from different sites. Miss Rice will raise concerns with Dr Jameson.

Action: CR

146/11 CLAIMS ANNUAL REPORT 2010/11 Mrs Pullen spoke to the Claims Annual Report and reported that there had been an increase in new and settled claims. Mrs Pullen stated that the Trust has received more requests for statements regarding inquests in this financial year than any of the previous years. Mrs Pullen stated that the Divisional Directors have agreed that it would be useful for a mock inquest to be arranged to help staff prepare for what can sometimes be a pressured experience. Mrs Pullen will co-ordinate this. FOR SCRUTINY AND FOLLOW UP 147/11 PATIENT EXPERIENCE & EQUALITY AND DIVERSITY COMMITTEE The minute of the Patient Experience & Equality and Diversity Committee dated 7 April 2011 was received and noted. Dr Lawrie stated that on the patient satisfaction survey one of the major issues was car parking. Mr Saxby explained that a draft Operational Policy and Strategy on car parking is to be issued in August. 148/11 PENNINE ACUTE DRUGS & THERAPEUTICS COMMITTEE The minute of the Pennine Acute Drugs & Therapeutic Committee dated 1 April 2011/6 May 2011 was received and noted.

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149/11 ORGAN DONATION COMMITTEE The minute of the Organ Donation Committee dated 16 June 2011 was received and noted. Mr Holly enquired if the audit had been undertaken. Dr Bradley will give an update at the September meeting.

Action: SB 150/11 PENNINE ACUTE CANCER COMMITTEE The minute of the Pennine Acute Cancer Committee dated 26 May 2011 was received and noted. 151/11 CLINICAL AUDIT & EFFECTIVENESS COMMITTEE The minute of the Clinical Audit & Effectiveness Committee dated 15 June 2011 was received and noted. Mr Holly enquired when the annual report will be submitted to the Committee. Dr Bradley will find out and report back to the September meeting.

Action: SB 152/11 CRITICAL CARE STEERING GROUP The minute of the Critical Care Steering Group dated 27 May 2011 was received and noted. Mr Holly asked for the Department of Health Guidelines on Safe Care to be forwarded to him. Mr Crumbleholme will arrange this.

Action: VC 153/11 DIAGNOSTICS AND CLINICAL SUPPORT The minute of the Division of Diagnostics and Clinical Support meeting dated 6 June 2011 was received and noted. 154/11 MEDICINE The minute of the Division of Medicine Governance meeting dated 3 June 2011 was received and noted. Ms Cullen enquired about the number of red incidents being reported and if action plans were implemented. Dr Lawrie stated all red incidents within Medicine are currently being reviewed and a large number have been closed. Ms Cullen felt it would be useful to know how many red incidents are open for each Division. Mrs Curtis will be asked to obtain this information and also how long the

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incidents have been open and how many are over six months old. This information should be routinely reported to the Clinical Governance Committee

Action: HC

Ms Anderson had undertaken an audit of ten red incidents, that they were completed correctly and if an action plan had been devised. The outcome was very positive and there was only one incident which was not completed appropriately and did not have an action plan. 155/11 SURGERY The minute of the Division of surgery meeting held in June was submitted to the June meeting of the Committee.

156/11 WOMEN & CHILDREN The minute of the Division of Women & Children meeting dated 15 June 2011 was received and noted. Mr Saxby stated that the issue regarding midwives not being allowed to go on divert has now been resolved. FOR INFORMATION There was nothing for information ANY OTHER BUSINESS There was no further business. 134/11 DATE, TIME AND PLACE OF NEXT MEETING

The next meeting of the Clinical Governance & Quality Committee will be held on Friday, 16 September 2011 in the Monsall Room, North Manchester General Hospital at 12.30 pm

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Agenda item 12

Title of Report Risk Management Committee Minutes – July 2011

Executive Summary

The minutes from the Risk Management Committee in July 2011 reflect discussions on the following agenda items:

Closure of lower hospital at Fairfield General Hospital where documents are stored

Annual Fire Report 2010-11

Emergency Planning and Service Continuity Report

Criminal Records Bureau Checks (CRB)

Actions Requested:

The Board is asked to note the content of the minutes

Corporate objectives supported by this paper: All Corporate Objectives are supported by a risk assessment which is included in the Corporate Risk Register.

Risks: Risks identified at the meeting are all on the corporate risk register and linked to the assurance framework both of which are monitored at this meeting

Public and/or Patient Involvement: Not relevant for this paper

Resource Implications: Not relevant for this paper

Communication: The Risk Management Committee communicates its work through Trust Board, Clinical Governance and Quality Committee, Divisional Governance Committees and the Health and Safety structure. Any incidents likely to attract media coverage are handled with the communication department.


Assurance √

Contract √



HR √

IM&T √



Sustainability √

Name Mr J Saxby




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RiskMgmt/July2011 Page 1 of 6

MINUTES OF THE RISK MANAGEMENT COMMITTEE HELD ON 12 JULY 2011 AT 10.30 AM IN THE MONSALL ROOM, NMGH PRESENT Mr G Barclay Head of Corporate Development Mr R Chadwick Director of Finance Mrs H Curtis Governance Director Mr J Lindars Divisional Director, Surgery Mr H Mullen Director of Operations Mr T Pickstone Non Executive Director Mr J Saxby Chief Executive (Chair) Mr C Sleight Divisional Director, Diag & Cl Support Ms E Stringer Acting Head of Midwifery Services Mr S Taylor Divisional Director, Medicine Mrs C Walters Associate Director of IM&T Mr J Wilkes Director of Facilities APOLOGIES Mrs C Guereca Non Executive Director Mrs C Trinick Divisional Director, Wm & Children ALSO IN ATTENDANCE FOR PART OF THE MEETING Mr N Hayes Deputy Director of Human Resources RM/068/11 MINUTES OF RISK MANAGEMENT COMMITTEE MEETING

The minute of the Risk Management Committee meeting held on 10 May 2011 was submitted and noted.

MATTERS ARISING RM/069/11 RM/046/11 – CCTV Update

Mr Wilkes will bring information on the radius of coverage of the recently installed CCTV cameras to the September meeting.

Action: JW RM/070/11 RM/047/11 – Needlestick Injuries/Needlesafe devices

Mrs Trinick will give an update at the September meeting. Action: CT

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RM/071/11 RM/048/11 - Managing the risk of Self Harm

As reported previously Mr Taylor had met with the Acute Manager for Mental Health Services at another Trust to discuss the possibility of adapting their clinical management plan for use by the Trust following their receipt of a Coroners Rule 43 letter. Mr Taylor reported that a draft response has been completed in response to the Rule 43 letter. Mr Taylor informed the Committee that all the Medical Assessment Units now have electronic control exits. The Division is working with Dr Smith, Head of Safeguarding to review arrangements for the management of patients who are at risk. Mr Taylor will give an update to the September meeting.

Action: ST

RM/072/11 RM/049/11 – Data storage This is an agenda item. RM/073/11 RM/050/11 – Minutes of Trust Health & Safety Committee – NMGH

basement access Mr Wilkes reported that access to the NMGH basement has now been greatly

reduced and everyone who has been granted access will receive a letter reminding them of rules that are to be followed. The basement area will be monitored and Mr Wilkes will give an update to the September meeting on findings.

Action: JW RM/074/11 RM/053/11 – Information Governance

Ms Walters had informed a previous meeting that some patients had reported

issues to the Information Commissioners office. Mr Mullen explained that this had been discussed at the Operational Management Group meeting. Mrs Walters said that the Information Commissioner had been satisfied with responses provided by the Trust. Nevertheless following a review, internal protocols have been changed.

Close RM/075/11 RM/054/11 – Clinical Governance & Quality Committee - Dashboard An observation had been made to the Trust Board by the SHA about

highlighting the most important items in the minute of the Clinical Governance & Quality Committee. Mrs Curtis explained that the cover sheets provided for each document will contain the most important items.

Action: HC

RM/076/11 RM/055/11 – Governance Dashboard Mrs Curtis informed the Committee that the incident cause of „electrocution‟ has

now been changed to „electronic shock‟.

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Close RM/077/11 GOVERNANCE DASHBOARD

Mrs Curtis said that the number of needlestick injuries is being reviewed to establish whether the use of needlesafe devices has reduced the number of incidents. This will be trended over time. Mrs Curtis stated that verbal abuse is still one of the most frequently recorded incidents. Manual handling incidents appear low in numbers but this is being monitored.

Mr Saxby enquired if the number of incidents of „security staff detained on ward‟ was correct and if so precisely what it was that was being recorded. Mr Taylor will raise this at the next site NMGH Health & Safety Committee meeting and will report back to the September Risk meeting.

Action: ST RM/078/11 DOCUMENT MANAGEMENT REPORT

Mr Saxby noted that there are still a number of “red” documents. Mr Taylor explained that all the documents for the Division of Medicine have been updated and will be removed from the report. Mr Saxby was concerned about two outstanding documents relating to MRSA. Mrs Curtis will write to Mrs Chadwick, Infection Control and report back to the September meeting.

Action: HC

RM/079/11 CLOSURE OF LOWER HOSPITAL AT FAIRFIELD HOSPITAL WHERE DOCUMENTS ARE STORED

Mr Mullen gave an update on work currently being undertaken to vacate the lower hospital at Fairfield where a wide range of documents had traditionally been stored for a number of years. Mrs. Parr had contacted all departmental heads who had records stored within the building and asked for the documents to be removed. Mrs. Curtis explained this had been discussed at the Trust Health & Safety Committee. Some of the records are animal contaminated and Mrs. Chadwick, Infection Control had been asked to undertake a risk assessment of the building to ensure that it was safe even to work to clear records stored. This risk assessment had been circulated to the Committee. Mr Mullen said that Ms White, Medical Records will liaise with Mr Barclay on the removal of documents. The Committee approved the complete vacation of the buildings and agreed that once empty they should be demolished. The vacated land would be converted into additional car parking space. An update will be given to the September meeting.

Action: HM/GB

Mr Saxby enquired if there were any other buildings within the Trust with problems regarding contamination and Mr Wilkes explained that any that have been identified are not in use.

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RM/080/11 TERMS OF REFERENCE FOR THE RISK MANAGEMENT COMMITTEE Mrs Curtis informed the Committee that the amendments had been made.

Terms of Reference Noted

RM/081/11 ANNUAL FIRE REPORT 2010-11

Mr Wilkes spoke to the Annual Fire Report. The number of actual fires and of fire incidents has reduced.

Report was noted

RM/082/11 EMERGENCY PLANNING AND SERVICE CONTINUITY REPORT

Mr Wilkes spoke to the Emergency Planning and Service Continuity Report and reported that the vaccination programme for Winter flu is to be launched in September. It was stressed that additional efforts were needed to ensure a greater percentage of front line staff were vaccinated.

Report was noted Mr Pickstone enquired how the Trust would cope in the event of industrial action later in the year. Many external commentators were anticipating industrial action across the public sector. Mr Hayes advised that contingency plans were in place to ensure that the safety of patients took priority even during a period of industrial action.

RM/083/11 CRIMINAL RECORDS BUREAU CHECKS (CRB)

Mr Hayes reported that with effect from April 2011 changes had been made to payment arrangements for enhanced CRB checks. All new starters now pay for their own CRB checks. This is becoming the norm throughout the NHS. To date 66 appointees have paid for their CRB check. No one has either refused to pay or declined an offer of appointment.

Staff who are currently employed, and move roles where confirmation of a previous check can be confirmed via the Trusts database or though reference to appointees‟ own CRB document, will need no further check. Staff will sign a self declaration which asks direct questions relating to any previous/current police convictions/cautions. This is signed, dated and incorporated within their personal file. It is made clear that any false declaration could result in disciplinary action which may lead to dismissal. A CRB check is processed at a cost to the Trust for internal appointments, where verification of a CRB cannot be confirmed or where the internal appointee has not had a CRB check undertaken,.

Report was noted FOR REVIEW

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RM/084/11 MINUTE OF IM&T PROGRAMME COMMITTEE

The minute of the meeting of the IM&T Programme Committee held on 13 May 2011 was submitted and noted. Mrs Walters stated that Pennine Care have withdrawn from the Electronic Patient Record Lorenzo Project for the NHS. In addition, Morecambe Bay FT have not signed off. Mrs Walters reported that Pennine Acute will continue with the current strategy. Mrs Walters explained that an amendment should be made to the minutes under Number 4 stating the Trust are planning to participate in the project regarding GM electronic communications.

RM/085/11 MINUTE OF RESILIENCE FORUM

The minute of the meeting of the Resilience Forum held on 11 May 2011 was received and noted.

RM/086/11 TRUST HEALTH & SAFETY COMMITTEE

The minute of the meeting of the Trust Health & Safety Committee held on 16 2011 was received and noted. Mrs Curtis reported that the March and June meetings of the Trust Health & Safety Committee had not been quorate; on one occasion due to insufficient managers attending and on the second occasion due to non attendance of Trades Union members. Mrs Curtis reported that under Standing Financial Instructions, an incidence of a non quorate committee should be reported to the senior Committee. In the case of the Health & Safety Committee this was the Risk Management Committee. Mrs Curtis had asked Trades Unions representatives to be identified and Mr Saxby will this when he meets local Trades Union representatives and Full time Officers at a scheduled meeting in early August. Mrs Curtis would also write to all management representatives to remind them of their organizational obligations. After each meeting Mrs Curtis has circulated documents asking for comments.

RM/087/11 MEDICAL & SCIENTIFIC COMMITTEE

The minute of the meeting of the Medical & Scientific Committee held on 29 March 2011 was received and noted.

RM/088/11 NON CLINICAL RECORDS MANAGEMENT COMMITTEE

The minute of the meeting of the Non Clinical Records Management held on 18 May 2011 was received and noted.

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RM/089/11 MINUTE OF CLINICAL GOVERNANCE & QUALITY COMMITTEE

The minute of the meeting of the Clinical Governance & Quality Committee held on 15 April 2011/20 May 2011/17 June 2011 was submitted and noted.

RM/090/11 DATE OF NEXT MEETING – RISK MANAGEMENT COMMITTEE

The next meeting will be held on 13 September 2011 at 10.30 am in the Monsall Room, North Manchester General Hospital

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a g e n d a · jameson added that this was also an area where staff demonstrated commitment and...

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