agenda and papers f ormal meeting of the kent community … · 2019-01-25 · steve howe,...

Agenda and Papers

for the

Formal meeting of the

Kent Community Health NHS Foundation Trust Board

In Public

to be held at 10am on

Thursday 31 January 2019

in

Oak Room Oakwood House Oakwood Park

Maidstone ME16 8AE

Meeting of the Kent Community Health NHS Foundation Trust Board

to be held at 10am on Thursday 31 January 2019 in the Oak Room, Oakwood House, Oakwood Park,

Maidstone ME16 8AE

This meeting will be held in Public

AGENDA

1. STANDARD ITEMS

1.1

Introduction by Chair

Trust Chair

1.2 To receive any Apologies for Absence

Trust Chair

1.3 To receive any Declarations of Interest

Trust Chair

1.4 To agree the Minutes of the Kent Community Health NHS Foundation Trust Board meeting held on 29 November 2018

Trust Chair

1.5 To receive Matters Arising from the Kent Community Health NHS Foundation Trust Board meeting held on 29 November 2018

Trust Chair

1.6 To receive the Trust Chair’s Report

Trust Chair

Verbal

1.7 To receive the Chief Executive’s Report

• Care Quality Commission

Chief Executive

2. BOARD ASSURANCE/APPROVAL

2.1

To receive the Patient Story Chief Nurse (Interim)

2.2

To receive the Board Assurance Framework

Corporate Services Director

Age

nda

Page 1 of 144

Board Committee Reports

2.3

To receive the Quality Committee Chair’s Assurance Report

Chair of Quality Committee

2.4

To receive the Strategic Workforce Committee Chair’s Assurance Report

Chair of Strategic Workforce Committee

2.5

To receive the Audit and Risk Committee Chair’s Assurance Report

Chair of Audit and Risk Committee

2.6 To receive the Charitable Funds Committee Chair’s Assurance Report

Deputy Chair of Charitable Funds Committee

2.7 To receive the Integrated Performance Report

• Assurance on Strategic Goals

• Quality

• Workforce

• Finance

• Operational

Director of Finance

Chief Nurse (Interim)

Director of Workforce, Organisational Development and Communications

Director of Finance

Chief Operating Officer/ Deputy Chief Executive

2.8 To receive the Trust Preparedness for Brexit Report


2.9 To receive the Winter Pressures Update Report

Chief Operating Officer/Deputy Chief Executive

3. STRATEGY AND PLANNING

3.1

To receive the NHS Long Term Plan and Impact for Kent Community Health NHS Foundation Trust Report

Director of Strategy

4. REPORTS TO THE BOARD

4.1

To receive the Learning From Deaths Report

Medical Director

Page 2 of 144

4.2 To receive the Freedom To Speak Up Report


4.3 To receive the Community Hospitals Safer Staffing Review


4.4 To receive the Minutes of the Charitable Funds Committee meeting of 25 July 2018

Deputy Chair of Charitable Funds Committee

5. ANY OTHER BUSINESS

To consider any other items of business previously notified to the Trust Chair

Trust Chair

6. QUESTIONS FROM MEMBERS OF THE PUBLIC RELATING TO THE AGENDA

7. DATE AND VENUE OF NEXT MEETING

Thursday 28 March 2019

Rooms 6 and 7, Kent Community Health NHS Foundation Trust Offices, Trinity House, 110 – 120 Upper Pemberton, Kennington, Ashford, Kent TN25 4AZ

Age

nda

Page 3 of 144

Unconfirmed Minutes

of the Kent Community Health NHS Foundation Trust Board meeting held at 10am on Thursday 29 November 2018

in Rooms 6 and 7, Kent Community Health NHS Foundation Trust Offices, Trinity House, 110 – 120 Upper Pemberton, Eureka Park, Kennington, Ashford,

Kent TN25 4AZ

Meeting held in Public

Present: John Goulston, Trust Chair (Chair) Pippa Barber, Non-Executive Director Paul Bentley, Chief Executive Peter Conway, Non-Executive Director Martin Cook, Non-Executive Director Designate Professor Francis Drobniewski, Non-Executive Director Designate Richard Field, Non-Executive Director Gordon Flack, Director of Finance Steve Howe, Non-Executive Director Louise Norris, Director of Workforce, Organisational

Development and Communications Dr Sarah Phillips, Medical Director Dr Mercia Spare, Interim Chief Nurse Bridget Skelton, Non-Executive Director Gerard Sammon, Director of Strategy Lesley Strong, Deputy Chief Executive/Chief Operating Officer Jen Tippin, Non-Executive Director Nigel Turner, Non-Executive Director In Attendance: Gina Baines, Committee Secretary (minute-taker) Natalie Davies, Corporate Services Director

29/11/1 Introduction by Chair

Mr Goulston welcomed everyone present to the Public Board meeting of Kent Community Health NHS Foundation Trust (the Trust). Mr Goulston advised that this was a formal meeting of the Board held in public, rather than a public meeting, and as such there would be an opportunity for public questions relating to the agenda at the end of the meeting.

29/11/2 Apologies for Absence

There were no apologies

Min

utes

Page 4 of 144

of 7

The meeting was quorate.

29/11/3 Declarations of Interest

No conflicts of interest were declared other than those formerly recorded.

29/11/4 Minutes of the Meeting of 27 September 2018

The Board AGREED the minutes.

29/11/5 Matters Arising from the Meeting of 27 September 2018

The actions were confirmed and closed. The Board RECEIVED the Matters Arising.

29/11/6 Chair’s Report Mr Goulston presented the verbal report to the Board for information.

Mr Goulston had met with various stakeholders since becoming Trust Chair on 1 November 2018. These included the members of the Board, the Council of Governors, the chairs of the other NHS providers in Kent and also Glenn Douglas the Chief Executive of the Kent and Medway Sustainability and Transformation Partnership (STP) and Accountable Officer for the Kent and Medway CCGs. Mr Goulston had also visited Birmingham Community Healthcare NHS Foundation Trust as part of his induction to see how the Board and Council of Governors in a similar organisation worked. Mr Goulston and Mr Bentley had attended an NHS Provider community services network meeting where support had been expressed for further investment in the frailty pathway within community services. It had been agreed that NHS Providers would take this forward. The concept of moving from age-related to risk-based services for older people had also been discussed. Mr Goulston was undertaking a number of visits to services within the Trust. He had visited Sevenoaks Hospital the previous week. The following day he would be visiting the One You Shop in Ashford. Earlier in the month, he had visited the Medway Campus of Canterbury Christ Church University where he had been shown the healthcare campus simulation suite by Dr Susan Plummer, Campus Director and Appointed Governor (Universities) of the Trust’s Council of Governors. Mr Goulston had also participated in a meeting with the Chair of NHS Improvement (NHSI). He had been one of eight chairs of community trusts to attend the session which had been organised by NHS Providers. There had been a good discussion where a range of ideas had been well received.

Page 5 of 144

of 7

The Board RECEIVED the Chair’s Report.

29/11/7 Chief Executive’s Report Mr Bentley presented the report to the Board.

Mr Bentley added that a number of Listening Events had taken place in east Kent over the last few weeks regarding the reconfiguration options for urgent care services in the area. The report on the events was yet to be received. Members of the Board had been present at the majority of the meetings. Kent and Medway Medical School had made the required, formal submission to the General Medical Council. The Trust wished to play a central role in the school in the future and the new Dean had indicated that he supported this. With regards to the Trust’s Staff Flu Vaccination Campaign, Prof Drobniewski underlined the importance of maximising the vaccination programme to protect patients, their families and staff. Mr Bentley confirmed that there was a comprehensive vaccination programme in place internally which was easily accessible to staff. In response to a question from Mr Field regarding whether the initiative to partner with UNICEF had been effective in increasing the take-up of the vaccination to date, Ms Strong indicated that it had been. In response to a question from Ms Barber regarding how the Trust might identify and measure the impact of the Time to Change initiative, Mr Bentley suggested metrics relating to the level of staff absence, productivity and how staff saw the organisation would be relevant. It was agreed that the Strategic Workforce Committee would receive this assurance on behalf of the Board. Action – Ms Norris Ms Skelton added that the Time to Change initiative had been discussed at the Strategic Workforce Committee the previous day. It too had considered the identification and measurement of the impact of the initiative. It had also considered what else the Trust might do to address mental health issues such as reducing stress and increasing how staff felt valued. It had been agreed that this was a critical initiative. Ms Norris indicated that the Time to Change champions would be involved in identifying how their contribution was measured and the Strategic Workforce Committee would receive further updates. The Board RECEIVED the Chief Executive’s Report.

29/11/08 Patient Story Dr Spare presented the video to the Board in relation to an error which had occurred in the Home Enteral Nutrition (HEN) Service.

Min

utes

Page 6 of 144

of 7

Dr Spare confirmed that the Trust and HEN Service had worked collaboratively with the patient’s mother at every stage of the investigation and that the findings had been shared across the wider HEN network. There was a desire to reduce the number of non-value adding handoffs to improve safety and this would be addressed through the Trust’s Quality Improvement (QI) programme. In response to a question from Mr Conway as to why the Trust was involved in the pathway, Dr Spare explained that this had been a commissioning decision. In response to his comment regarding whether better use could be made of technology to reduce the chance of error in the future, it was agreed that this and the commissioning decision would be investigated further. Dr Phillips added that issues with the manufacturer’s website had been identified in the investigation and these had been fed back to the manufacturer. Action – Dr Spare In response to Mr Conway’s suggestion that staff should be encouraged and supported to challenge established routines, Dr Phillips commented that the QI programme would address this. It would provide an opportunity for a fresh approach towards learning from mistakes; allowing for a greater focus on human factors as well as exploring new ways of supporting the relevant staff during a Serious Incident (SI) investigation. In response to a question from Ms Tippin regarding whether the incident should have been classified earlier as an SI, Dr Phillips explained that the incident had initially been identified as a potential SI when the complaint was raised by the mother. All potential SIs were reviewed by the Trust and it was at that time that it was classified as a Serious Incident because of the potential national significance of the incident. Mr Howe added that he had participated in the conference call where the incident had been reviewed following its investigation. He confirmed that there had been a similar discussion to that of the Board on the call. Mr Sammon reflected that the video highlighted the importance of having patient groups involved in service redesign. The Board RECEIVED the Patient Story.

29/11/9 Quality Committee Chair’s Assurance Report Mr Howe presented the report to the Board for assurance.

Ms Barber added that she had visited Canterbury Long Term Services earlier in the month. She had met with the clinical leads and other members of staff in the team and seen how they managed their staffing issues. She could confirm that the escalation process was in place. Staff had also spoken to her about their QI projects. These were seeking to reduce the number of incidents that occurred and complaints received by the service.

Page 7 of 144

of 7

Ms Barber also highlighted that the Quality Committee had received the six- monthly review of the Trust’s Quality Goals for 2018/19 at its meeting earlier in the month. The Trust was on target for all, bar two which related to staff turnover and care plans. The Strategic Workforce Committee was monitoring turnover and the Quality Committee would continue to scrutinise care plans. The Board RECEIVED the Quality Committee Chair’s Assurance Report.

29/11/10 Strategic Workforce Committee Chair’s Assurance Report Ms Skelton presented the report to the Board for assurance.

The Strategic Workforce Committee had met the previous day. There had been a wide ranging discussion which included seeking assurance on the Staff Flu Vaccination Programme, the impact of the Time to Change initiative, the use of statistical process control methodology in workforce performance reporting, progress on the Nursing Academy, the devolved authority framework, the introduction of the Advanced Clinical Practitioner (ACP) role, scrutiny of the Integrated Performance Report Operational Report, the work by the Human Resources Team to align workforce initiatives with strategy and workforce priorities, reducing duplication, embedding safe staffing across all services and talent management. In response to a question from Mr Cook regarding what the Trust was doing to improve retention and reduce sickness absence, Ms Skelton reported that there were distinct issues in different parts of the organisation. The data that had been gathered from the Big Listen exercise earlier in the year had provided valuable pointers about what the Trust could do to reduce stress and turnover and improve retention. It had also provided good data regarding how people felt valued which had impacted positively on sickness rates. The Committee had agreed to focus on hotspots and learn from good practice rather than address generalities. In response to a question from Ms Tippin regarding whether the Trust would be implementing the guidelines on workforce engagement which have been published by the Financial Reporting Council (FRC) recently, Ms Norris explained that the NHS was committed to implementing best practice. Ms Skelton suggested that a gap analysis of the published guidelines would be helpful. Action – Ms Norris In response to a question from Ms Tippin regarding whether the Trust would be reporting its performance on Black and Asian Minority and Ethnic (BAME) pay as well as gender pay, Ms Norris indicated that the Trust’s Equality and Diversity Group would welcome the opportunity to carry out this further work on pay. Action – Ms Norris

Min

utes

Page 8 of 144

of 7

In response to a question from Mr Bentley as to whether BAME staff were more likely to be disciplined than white members of staff in the Trust, Ms Norris confirmed that the Trust’s analysis of data from the last two years indicated that this was not the case. With regards to the Dental Service, the recent addition of the London teams had prompted a change in the ethnicity mix of the service. The report that had been received by the Strategic Workforce Committee indicated that there had been no change in the application of the Disciplinary Policy amongst BAME staff in that service. Mr Goulston provided an update on his action to review the role of the non-executive director in the Kent and Medway STP that had been proposed in the Committee Chair’s report in relation to the Well-Led Review. He confirmed that the STP was forming a governance group. Four equivalent non-executive directors from the local authority, the clinical commissioning groups (CCGs), an acute provider and a non-acute provider would be members of the group. With regards to membership by the non-acute provider, it had been agreed that Mr Andrew Ling, Chairman of Kent and Medway NHS and Social Care Partnership Trust (KMPT) would attend for half the year followed by Mr Goulston for the second half of the year. The Board RECEIVED the Strategic Workforce Committee Chair’s Assurance Report.

29/11/11 Audit and Risk Committee Chair’s Assurance Report Mr Conway presented the report to the Board for assurance.

It was confirmed that the November meeting of the Audit and Risk Committee (ARC) had been postponed until mid-December. The Board RECEIVED the Audit and Risk Committee Chair’s Assurance Report.

29/11/12 Integrated Performance Report Mr Flack presented the report to the Board for assurance.

The report would continue to evolve over the coming months as it reflected a move away from a RAG rating of performance to a greater use of statistical process control techniques. This change would provide greater assurance and clarity to the Board around the data presented. Representatives from NHSI had attended the Management Committee meeting earlier that week and presented an informative session on reporting and interpreting performance data to support this change of approach. A number of non-executive directors had attended the session which had been welcomed. Quality Committee Dr Spare and Dr Phillips presented the report to the Board for assurance.

Page 9 of 144

of 7

Dr Spare confirmed that with regards to staffing levels at the community hospitals in Deal, Tonbridge and Edenbridge she was confident that the right measures were in place to maintain them. She would work closely with Ms Strong to ensure that they were achieved. In response to a question from Mr Field regarding the current status of West View Integrated Care Centre, Ms Strong confirmed that this unit, registered with Kent County Council, (KCC) had been inspected by the Care Quality Commission (CQC) who had produced a report with recommendations for KCC. The delineation of health beds and social care beds had required further clarity and this had now been addressed. Discussions were continuing with the relevant CCG regarding contractual arrangements relating to beds and this was expected to be resolved in the next few weeks. Ms Strong confirmed that the Trust had informed the CCG that it would cease the provision of these beds in March 2019 unless a satisfactory resolution was reached. In response to a question from Mr Goulston regarding whether the downward trend in the response rates for patient experience in the minor injuries units and community hospitals was significant, and if so what actions were in place, Mr Flack confirmed that this had been reviewed. While both patient satisfaction and waiting times still benchmarked very favourably, the pressure in the system, and Accident and Emergencies particularly had correlated with a slight increase in waiting times. Mr Goulston suggested that a narrative which explained how the Trust was addressing this would be helpful. It was agreed that this would be addressed. Action - Mr Flack Workforce Report Ms Norris presented the report to the Board for assurance. The report had been scrutinised by the Strategic Workforce Committee the previous day. Ms Norris identified an error in the report with regards to the level of mandatory training compliance in Month Seven. This should read 85% and not 75%. This would be amended and republished. Action – Ms Norris Mr Cook stated that as the Trust pushed on with its changing approach to mental health support, a spike in sickness absence rates might be seen as staff became more open about this illness. In response to a question from Mr Cook regarding how the Trust was addressing the range of sickness absence reasons beyond the top five identified in the report, Ms Norris confirmed that deep dives were carried out locally covering all reasons for absence. The Strategic Workforce Committee would be carrying out its own deep dive at its meeting in January 2019 where it would address the various sickness absence themes

Min

utes

Page 10 of 144

of 7

and scrutinise how the Trust was addressing them. Finance Report Mr Flack presented the report to the Board for assurance. The Finance, Business and Investment (FBI) Committee had received the report the previous day. It had been assured that the Cost Improvement Programme (CIP) scheme deficits were on track to deliver by the end of the financial year. Operational Report Ms Strong presented the report to the Board for assurance. With regards to the Health Visiting Six to Eight Week Checks Key Performance Indicator (KPI), the Quality Committee had received assurance that work was underway to improve performance and meet the target. With regards to Referral To Treatment (RTT) waiting times across all services, there would be a deep dive at the Quality Committee in January 2019 to understand what was happening within those services and the potential risk to patients. The Board would receive assurance through the Quality Committee Chairs Assurance report at its January 2019 Board meeting. In response to a question from Ms Barber as to why no further investment had been forthcoming from the CCGs to support the Trust’s management of the Orthopaedic Services waiting lists in east Kent, Ms Strong indicated that the CCGs were financially. The Trust continued to review its approach to ensure every possible improvement could be made. The Board RECEIVED the Integrated Performance Report.

29/11/13 Winter Plan Ms Strong presented the report to the Board for approval. The Strategic Workforce Committee had reviewed the workforce elements of the winter plan at its meeting the previous day. In response to a question from Ms Skelton regarding how the Trust’s community hospitals would respond to the issues that were highlighted in the daily conference calls that took place at the peak of winter activity, Ms Strong indicated that decisions would centre on the rapid transfer of patients and these would be addressed by the acute hospitals. Mr Sammon highlighted the use of the Single Health Resilience Early Warning Database (SHREWD) tool in providing up-to-date information to support the decision making by the Trust and its partners.

Page 11 of 144

of 7

In response to a question from Mr Cook regarding the contribution that volunteers would make during winter, Ms Strong explained that their contribution was recognised as part of the whole system plan. The Red Cross contributed to supporting patient discharge and would be present at A&E departments within the acute hospitals in east Kent. In response to a comment from Mr Turner regarding the recruitment and retention of staff in the relevant services to provide the capacity that was needed during the winter pressures, Ms Strong confirmed that in east Kent operations, a resourcing team was in place to focus on the recruitment process and provide an administrative lead. This was proving to have some success. In response to a question from Prof Drobniewski regarding how quickly the Trust could set up an additional ward in order to increase capacity, Ms Strong explained that in the previous year an escalation ward had been opened at Sheppey Community Hospital. This had taken two weeks to put in place. The main challenge had been staffing, but lessons had been learnt in preparation for the forthcoming winter. In response to a question from Mr Conway regarding what additional resource had been provided to Kent Social Services, Ms Strong confirmed that it had received additional government money. It would publish its winter plan following approval by the KCC Cabinet in December 2018. It was agreed that a progress report would be presented to the Board at its meeting in January 2019. Action – Ms Strong

The Board APPROVED the Winter Plan.

29/11/14 Standing Financial Instructions Mr Flack presented the report to the Board for approval.

In response to a question from Mr Goulston regarding whether a non-executive director had been nominated to oversee the NHS security management service, it was confirmed that this appointment was still outstanding. The non-executive directors were asked to discuss this further outside of that day’s meeting and suggest a nomination to Mr Goulston and Mr Flack. Action – Non-executive directors The Board APPROVED the Standing Financial Instructions.

29/11/15 Board Membership and Non-Executive Director Responsibilities Report Mr Goulston presented the report to the Board for approval.

Min

utes

Page 12 of 144

of 7

It was agreed that the Council of Governors would receive the report for noting when it met in February 2019. Action – Ms Davies The Board APPROVED the Board Membership and Non-Executive Director Responsibilities Report.

29/11/16 Seasonal Infection Prevention and Control Report

Dr Spare presented the report to the Board for assurance. The Quality Committee had received and scrutinised the report earlier that month. The Board RECEIVED the Infection Prevention and Control Report.

29/11/17 Learning From Deaths Report Dr Phillips presented the report to the Board for assurance.

In response to questions from Ms Skelton regarding how the Trust implemented lessons learnt, how it could satisfy itself that the lessons had been implemented, and how the results were fed back to staff, Dr Phillips confirmed that the membership of the investigation team rotated and monthly Matrons meetings were used to disseminate learning. Where the same issues were repeatedly disseminated, these would be investigated further via an audit. Ms Barber confirmed that she was the Non-Executive Director Trust Lead for Mortality and Learning from Deaths. She had observed an investigation meeting and highlighted that the addition of a pharmacist as a member of the meeting was helpful. She had observed the discussions and the learning that had been identified and indicated that it was a constructive process. She would be attending a further investigation meeting in January 2019 and would be focusing on the process in relation to patients with learning disabilities. In response to a question from Dr Spare regarding the work that was being carried out by the Kent and Medway Learning Disabilities Mortality Review (LeDeR) Strategy Group, Dr Phillips confirmed that its work would be monitored by herself. She was liaising with KCC’s Director of Public Health who was involved. The Trust was supportive of the group’s aims and objectives. As it was an NHS England (NHSE) commissioned service, the Trust would continue to escalate issues it identified which were not being addressed. In response to a question from Ms Tippin regarding identifying the top three learning outcomes which the Board could monitor going forward, it was agreed that this would be included in the next report that the Board received. Action – Dr Phillips

Page 13 of 144

of 7

In response to a question from Ms Strong regarding investigating children’s deaths across both KCC and the Trust, Dr Phillips confirmed that the Trust’s Head of Safeguarding, Ms Julie Beavers was a member of the Trust’s Mortality Surveillance Group and provided a link between the two organisations. Mr Howe added that both the Trust’s End of Life Steering Group and Mortality Surveillance Group had an overlap of membership. The Board RECEIVED the Learning From Deaths Report.

29/11/18 Patient Experience and Complaints Report Dr Spare presented the report to the Board for assurance.

The Quality Committee had received and scrutinised the report earlier that month. Ms Tippin commented that staff should be proud of the results that were contained within the report. In response to her question as to how this data was used internally, Mr Bentley confirmed that it was fed back regularly to staff at the Trust’s Senior Leaders Conference and Team Leaders Conference that took place during the year. In addition, he and the other executive directors also highlighted the positive feedback that was received when they visited services. He was pleased that performance remained consistent even at times of pressure within services. It underlined that the Trust was serving its community well. In response to questions from Mr Cook as to whether it was good to encourage people to complete the survey, and why in the summer months other trusts had an upward trend in the number of survey responses compared to the Trust, it was agreed that this would be investigated. Action – Dr Spare The Board RECEIVED the Patient Experience and Complaints Report

29/11/19 Freedom To Speak Up (FTSU) Report Ms Davies presented the report to the Board for assurance.

The Audit and Risk Committee reviewed the process and controls in place to manage concerns reported by staff and the Strategic Workforce Committee would review the cultural recommendations from the November 2018 report by the National Guardian’s Office that had reviewed the handling of speaking up cases at Nottinghamshire Healthcare NHS Foundation Trust. In response to a comment from Mr Field that greater diversity was needed amongst the Trust’s FTSU ambassadors, it was agreed that this would be addressed with the support of its diversity networks. Action – Ms Davies

Min

utes

Page 14 of 144

of 7

Ms Tippin confirmed that she was the Non-Executive Director with responsibility for Freedom To Speak Up. In response to a question from Ms Tippin as to who carried out the investigation of individual concerns, Ms Davies confirmed that this was carried out by an independent manager. The ambassador’s role was to support the member of staff who had raised the concern. In response to a question from Ms Tippin as to how the Trust protected the anonymity of the staff member who had raised the concern, Mr Conway reported that the ARC had reviewed this. It was confirmed that the report that was presented to the ARC would be shared with Ms Tippin. In response to a question from Mr Flack regarding the support that was provided to the FTSU ambassadors, Ms Davies confirmed that there was a support network but that this could be improved. It was agreed that this would be addressed. Action – Ms Davies It was confirmed that the Board would receive a report twice a year. It was agreed that the report on Nottinghamshire Healthcare NHS Foundation Trust would be circulated to the Board. Action – Ms Davies The Board RECEIVED the Freedom To Speak Up Guardian’s Report

29/11/20 Any Other Business

There was no further business to discuss. Mr Bentley extended his thanks on behalf of the Board to Mr Field for his contribution as Interim Chair.

29/11/21 Questions from members of the public relating to the agenda

In response to a question from Mr John Fletcher, Public Governor Ashford regarding whether there was one body in Kent that had oversight of the continuing problems faced by the county’s GPs, clinical commissioning groups, and the acute trusts, Mr Goulston suggested that this was the responsibility of the Kent and Medway STP. Mr Bentley added that he was optimistic that health service commissioning in Kent and Medway would improve. He supported the STP’s ambitions to improve stroke outcomes for patients. He also added that he welcomed the work being done to support GPs across Kent and Medway coming together to work in a more effective way.

The meeting closed at 12.45pm.

Page 15 of 144

of 7

29/11/22 Date and Venue of the Next Meeting

Thursday 31 January 2019, The Oak Room, Oakwood House, Oakwood Park, Maidstone ME16 8AE

Min

utes

Page 16 of 144

MA

TT

ER

S A

RIS

ING

FR

OM

BO

AR

D M

EE

TIN

G O

F 2

9 N

OV

EM

BE

R 2

018

(P

AR

T O

NE

)

Ag

en

da

n

um

be

r A

ge

nd

a I

tem

A

cti

on

ag

ree

d l

as

t m

ee

tin

g

By W

ho

m

Cu

rre

nt

Sta

tus

/Up

da

te

29

/11

/7

Ch

ief

Exe

cu

tive

’s

Re

po

rt

Fo

r th

e S

tra

tegic

Work

forc

e C

om

mitte

e

to r

ece

ive

assu

ran

ce

on

beh

alf o

f th

e

Bo

ard

re

ga

rdin

g th

e ide

ntifica

tio

n a

nd

m

ea

su

rem

ent

of

the

im

pa

ct of

the

Tim

e

To C

ha

nge

pro

gra

mm

e.

Ms N

orr

is

Th

is ite

m w

ill b

e a

dd

ed t

o th

e S

tra

tegic

W

ork

forc

e C

om

mitte

e fo

rwa

rd p

lan

.

Pro

po

se

d c

losu

re.

29

/11

/8

Pa

tie

nt

Sto

ry

To in

ve

stiga

te f

urt

he

r th

e b

ette

r of

use

of

tech

no

logy in

th

e H

om

e E

nte

ral

Nu

tritio

n (

HE

N)

Se

rvic

e t

o r

ed

uce

the

ch

an

ce

of

err

or

as w

ell

as t

he

co

mm

issio

nin

g d

ecis

ion

re

latin

g t

o t

he

p

atien

t pa

thw

ay.

Dr

Sp

are

An

in

ve

stiga

tio

n is u

nde

rwa

y a

nd

fu

rth

er

info

rma

tio

n is a

wa

ite

d.

29

/11

/10

Str

ate

gic

Wo

rkfo

rce

C

om

mitte

e C

ha

ir’s

A

ssu

ran

ce

Re

po

rt

To u

nd

ert

ake

a g

ap

ana

lysis

of

the

gu

ide

line

s o

n w

ork

forc

e e

nga

gem

ent

pu

blis

hed

by t

he

Fin

ancia

l R

ep

ort

ing

Co

un

cil

(FR

C).

Ms N

orr

is

Th

is ite

m w

ill b

e a

dd

ed t

o th

e S

tra

tegic

W

ork

forc

e C

om

mitte

e fo

rwa

rd p

lan

.

Pro

po

se

d c

losu

re.

Mat

ters

Aris

ing

Page 17 of 144

Ag

en

da

n

um

be

r A

ge

nd

a I

tem

A

cti

on

ag

ree

d l

as

t m

ee

tin

g

By W

ho

m

Cu

rre

nt

Sta

tus

/Up

da

te

29

/11

/10

Str

ate

gic

Wo

rkfo

rce

C

om

mitte

e C

ha

ir’s

A

ssu

ran

ce

Re

po

rt

To lia

ise

with

th

e T

rust’s E

qu

alit

y a

nd

D

ive

rsity G

rou

p o

n th

e T

rust’s

pe

rfo

rma

nce

on

Bla

ck a

nd

Asia

n

Min

ority

an

d E

thn

ic (

BA

ME

) p

ay.

Ms N

orr

is

The

BA

ME

gro

up

ha

s b

een

in

vite

d t

o

co

nsid

er

this

are

a o

f w

ork

. P

ropo

se

d

clo

su

re.

29

/11

/12

Inte

gra

ted

P

erf

orm

an

ce

Re

po

rt (

IPR

)

To in

clu

de

a n

arr

ative

in

fu

ture

IP

Rs o

n

ho

w t

he

Tru

st

wa

s a

ddre

ssin

g a

ny

do

wn

wa

rd t

ren

ds in

the

re

sp

on

se

rate

s

for

pa

tie

nt e

xp

erie

nce

or

up

wa

rd t

rend

s

in w

aitin

g t

ime

s.

Mr

Fla

ck

Th

is h

as b

een

in

co

rpo

rate

d in

to t

he

n

ew

IP

R d

esig

n t

o h

igh

ligh

t sta

tistica

lly

sig

nific

an

t va

ria

tio

n.

Pro

po

se

d c

losu

re.

29

/11

/12

Inte

gra

ted

P

erf

orm

an

ce

Re

po

rt (

IPR

)

To a

me

nd

th

e W

ork

forc

e R

epo

rt t

o

co

rre

ct

the

err

or

rela

ting t

o t

he le

ve

l of

ma

nd

ato

ry t

rain

ing c

om

plia

nce

in

Mon

th

Se

ve

n.

Ms N

orr

is

Actio

n c

om

ple

ted

. P

rop

osed

clo

su

re.

29

/11

/13

Win

ter

Pla

n

To p

resen

t a

pro

gre

ss r

ep

ort

to

the

B

oa

rd a

t its m

ee

tin

g in

Ja

nua

ry 2

01

9.

Ms S

tro

ng

Age

nd

a ite

m.

Pro

po

sed

clo

su

re.

29

/11

/14

Sta

nd

ing F

ina

ncia

l In

str

uction

s

To s

ugge

st

a n

om

ina

tio

n fo

r a

no

n-

exe

cu

tive

dire

cto

r to

ove

rse

e t

he

Tru

st’s

NH

S s

ecu

rity

ma

na

ge

me

nt

se

rvic

e t

o

Mr

Go

uls

ton a

nd

Mr

Fla

ck.

No

n-

Exe

cu

tive

D

ire

cto

rs

Mr

Be

ntle

y h

as c

onfirm

ed

th

at th

is

ma

tte

r w

ill b

e d

iscu

ssed

at th

e C

ha

ir –

N

on

Exe

cu

tive

Dire

cto

r M

ee

tin

g t

akin

g

pla

ce

on

31

Jan

ua

ry 2

01

9.

29

/11

/15

Bo

ard

Mem

be

rsh

ip

an

d N

on

-Exe

cu

tive

D

ire

cto

r R

esp

on

sib

ilitie

s

Re

po

rt

Fo

r th

e C

ou

ncil

of

Go

ve

rno

rs t

o r

ece

ive

th

e r

ep

ort

fo

r n

otin

g a

t its n

ext

mee

tin

g.

Ms D

avie

s

Th

is m

att

er

be

en

in

clu

de

d o

n th

e

age

nd

a o

f th

e F

eb

rua

ry 2

01

9 C

oun

cil

of

Go

ve

rno

rs m

ee

tin

g.

Pro

po

se

d

clo

su

re.

Page 18 of 144

Ag

en

da

n

um

be

r A

ge

nd

a I

tem

A

cti

on

ag

ree

d l

as

t m

ee

tin

g

By W

ho

m

Cu

rre

nt

Sta

tus

/Up

da

te

29

/11

/17

Le

arn

ing F

rom

D

ea

ths R

ep

ort

To in

clu

de

the

to

p th

ree

le

arn

ing

ou

tcom

es in

th

e n

ext

rep

ort

to

th

e

Bo

ard

. D

r P

hill

ips

Th

is w

ill b

e in

clu

de

d in t

he

rep

ort

th

at

the

Bo

ard

re

ce

ive

s a

t its J

an

ua

ry 2

01

9

me

etin

g a

nd

futu

re r

epo

rts.

Pro

po

sed

clo

su

re.

29

/11

/18

Pa

tie

nt

Exp

erie

nce

a

nd

Co

mp

lain

ts

Re

po

rt

To in

ve

stiga

te w

hy in

th

e s

um

me

r m

onth

s o

the

r tr

usts

had

an u

pw

ard

tr

en

d in t

he

nu

mb

er

of su

rve

y

resp

on

se

s c

om

ple

ted c

om

pa

red t

o

KC

HF

T.

Dr

Sp

are

Th

is is u

nde

r co

ntin

uou

s r

evie

w w

ith

th

e c

urr

en

t o

rga

nis

ation

s t

he

Tru

st

be

nch

ma

rks a

ga

inst.

29

/11

/19

Fre

ed

om

To S

pe

ak

Up

(F

TS

U)

Re

po

rt

To a

dd

ress th

e n

eed

fo

r gre

ate

r d

ive

rsity a

mo

ngst

the

Tru

st’s F

TS

U

am

ba

ssad

ors

th

rou

gh

its

div

ers

ity

ne

two

rks.

Ms D

avie

s

Th

is h

as b

een

dis

cu

sse

d w

ith

th

e

Gu

ard

ian

an

d w

ill b

e a

ctio

ned

. P

rop

ose

d c

losu

re.

29

/11

/19

Fre

ed

om

To S

pe

ak

Up

(F

TS

U)

Re

po

rt

To a

dd

ress th

e im

pro

ve

men

t of

the

su

ppo

rt n

etw

ork

pro

vis

ion

fo

r th

e F

TS

U

am

ba

ssad

ors

. M

s D

avie

s

Th

is h

as b

een

dis

cu

sse

d w

ith

th

e

Gu

ard

ian

an

d w

ill b

e a

ctio

ned

. S

up

po

rt

for

the G

ua

rdia

n is a

lso

be

ing

de

ve

lop

ed.

Pro

po

sed

clo

su

re.

29

/11

/19

Fre

ed

om

To S

pe

ak

Up

(F

TS

U)

Re

po

rt

To c

ircu

late

th

e N

ott

ingh

am

sh

ire

H

ea

lth

ca

re N

HS

Fo

und

ation

Tru

st

rep

ort

to

the

Bo

ard

. M

s D

avie

s

Actio

n c

om

ple

te.

Pro

po

se

d c

losu

re.

Mat

ters

Aris

ing

Page 19 of 144

Committee / Meeting Title: Board Meeting - Part 1 (Public)

Date of Meeting: 31 January 2019

Agenda Number: 1.7

Agenda Item Title: Chief Executive’s Report

Presenting Officer: Paul Bentley, Chief Executive

Action - this paper is for: Decision ☐ Information ☒ Assurance ☐

Report Summary

This report highlights key business and service developments in Kent Community Health NHS Foundation Trust in recent weeks.

Proposals and /or Recommendations

Not applicable.

Relevant Legislation and Source Documents

Has an Equality Analysis (EA) been completed?

Not applicable.

Paul Bentley, Chief Executive Tel: 01622 211903

Email: [email protected]

Chi

ef E

xecu

tive'

s R

epor

t

Page 20 of 144

CHIEF EXECUTIVE’S REPORT

January 2019

As previously I wanted to highlight to the Board the following significant developments since my last formal report during the Board meeting in November 2018, my regular practice is to categorise the report into patients, our staff teams and partnerships. Since we last met as a board there have been a number of national developments, some local developments and the expected and planned for increase in demand on services generated by winter. Staff

1. Service Visits

I was fortunate to speak at a celebration of our Wound Centre in Herne Bay, attended by a wide range of patients, carers, team members and others associated with the Centre, the Chief Nurse and I also visited Heron Ward in Herne Bay, both were uplifting and a strong testament to the compassion and skill of our teams in both settings. In mid-January I spent some time with our health-visiting team based in Gravesend, which was another uplifting visit as I was able to see the enthusiasm and professionalism with which the team undertake their often challenging roles.

2. Care Quality Commission

On 2 January 2019 on behalf of the Trust I received the formal notification that our regulators the CQC will undertake a well-led inspection of the Trust within a maximum of six months from the date of the letter, this inspection process will include an inspection of a least one of our seven core services. As part of this process the Trust submitted its completed Provider Information Request on 22January 2019, incorporating the Trust self-assessment ratings and well-led submission which the Board scrutinised in January 2019. The information about the forthcoming inspection has been widely communicated throughout the Trust.

Chi

ef E

xecu

tive'

s R

epor

t

Page 21 of 144

3. Launch of NHS 10 Year Plan

In January the NHS long term plan was launched, a full paper exploring the plan is included later in the agenda, but the publication of the plan is significant for both the NHS and the Trust. The direction of the NHS is consistent with that identified in the Five Year Forward View published in 2014, and presents opportunities for the people we serve to receive better care closer to home. It also crystallises the role of the Kent and Medway STP which is important to note for the Board, and again is explored in the full report.

Partnerships

1. New Contracting Round

Contract discussions have started in all systems and all are taking place collaboratively. Local care investments are jointly agreed as the top priority for the Trust. Consistent with the national timetable draft Trust plans will be submitted on 12th February, with the full plan in early April 2019. The Trust is expected to make a surplus of £2.2m (1%) underpinned by breakeven plus £2.2m of Provider Sustainability Funds from NHSI. 2. New Planning Guidance

The planning guidance for the NHS was published in two parts, one in late December and the second part in January, the guidance is significant as it establishes a new financial architecture to return the NHS provider sector to financial balance, with changes included but not limited to Payment by results tariff, market forces factor, the use of financial control totals and payments made to the Trust under Commissioning for Quality and Innovation national goals. These are significant changes which have been explored in the sub-committee of the Board but are worthy of Board attention.

3. Procurement and Commercial Standards Accreditation

The Trust has been formally awarded Level 1 Procurement & Commercial Standards accreditation the first community or mental health trust to achieve this in any of the southern regions.

Patients

1. Hospital at Home We launched Hospital@home in December 2018, the scheme is designed to reduce the demand on the acute hospital sector and we developed out approach with the support of and in conjunction with acute trust colleagues. Early

Page 22 of 144

indicators are that in the first six weeks since it launched, we have saved around 150 bed days and helped more than 30 patients. The service attracted some positive media coverage, which the board can view using the link: https://www.itv.com/news/meridian/2019-01-17/medical-care-and-support-for-

patients-at-home/

2. Winter Planning Nationally the NHS, although seeing an increase in demand in December and early January, is managing more effectively than last year. The role of KCHFT services is to maintain patient flow throughout the system and facilitate discharges and prevent hospital admissions. Our staff have been working hard to maintain capacity in the services with the emphasis on reducing the number of patients experiencing delays to discharge. The new schemes agreed in both East and West Kent are beginning to have an impact on the system and these are set out in more detail in the winter update report later in the agenda. There is an expectation with colder weather forecast that the demand on services will increase towards the end of the month and the services are to creating additional capacity.

3. Planning for exiting the European Union

Since the last time we met as a Board the Trust and the Kent and Medway STP has spent time contingency planning in the event of leaving the European Union without a transitional agreement in place. Whilst planning is taking place nationwide the particular geographical issues presented by delivering services in Kent are being addressed Kent and Medway wide with the STP co-ordinating a system view and the Trust undertaking Trust wide planning. A separate briefing is included in the Board agenda. I would like to take the opportunity to thank all team members for their hard work since the last time we met as a board at this very busy and demanding time of year.

Paul Bentley Chief Executive January 2019

Chi

ef E

xecu

tive'

s R

epor

t

Page 23 of 144



Agenda Number: 2.2

Agenda Item Title: Board Assurance Framework

Presenting Officer: Natalie Davies, Corporate Services Director

Action - this paper is for: Decision ☐ Information ☐ Assurance ☒

Report Summary

The function of the Board Assurance Framework (BAF) is to inform and elicit discussion about the significant risks which threaten the achievement of the Trust’s strategic objectives.

To provide assurance that these risks are being effectively managed, the BAF details the controls in place to mitigate each risk, any gap in control, assurance of the controls’ effectiveness, the actions planned and being executed together with the date by when the actions are due to be completed.

The full BAF as at 23 January 2019 is shown in Appendix 1.


The Board is asked to note this report.



No ☒

High level position described and no decisions required.

Barry Norton, Head of Risk Management Tel: 01233667744


Boa

rd A

ssur

ance

Fra

mew

ork

Page 24 of 144

1

BOARD ASSURANCE FRAMEWORK

1. Introduction

1.1 The Board Assurance Framework (BAF) is comprised of strategic risks

identified against the strategic goals defined within the Integrated Business Plan (IBP) in addition to risks identified against the achievement of business and operational objectives with a high gross (inherent) risk rating.

1.2 The BAF is therefore comprised of high risks. Refer to section 7 below for a definition of high risk.

1.3 Risks may be identified by Services or Directorates and escalated

upwards to the Executive Team, or may be identified at the Board or any of its sub Committees.

1.4 The Executive Team review newly identified high risks to ensure that those

with significant potential to impact on the achievement of strategic goals are recorded on the BAF and reported to the Board. This allows the Board to monitor mitigating actions. As actions are implemented, controls improve and this can enable the exposure to risk to reduce.

1.5 The full BAF as at 23 January 2019 is shown in Appendix 1. This version

was presented at any other meetings or committees.

2. Amendments to the BAF

2.1 Since the BAF was last seen by the Board the document has undergone a subtle refresh. All risks are now categorised in line with the Trust’s goals: ‘Prevent ill health’, ‘Deliver high-quality care at home and in the community’, ‘Integrate services’ and ‘Develop sustainable services’. The following headings ‘Assurances’ and ‘Gaps in control and assurance’ have been amended to ‘Positive Assurances’ and ‘Gaps in control or Negative Assurance’ respectively.

3. New risks

3.1 Since the BAF was last presented to the Board there have been three new risks added.

Boa

rd A

ssur

ance

Fra

mew

ork

Page 25 of 144

2

3.2 BAF ID101 ‘Develop Sustainable Services (Strategic Objective Enablers)’ Uncertainty around Brexit may affect our ability to deliver core objectives.

3.3 BAF ID102 ‘Deliver High Quality Care at Home and in the Community’

Inability to recruit and retain staff appropriately could have a detrimental impact on maintaining quality of care and morale.

3.4 BAF ID103 ‘Integrate Services’ Changes in the system architecture may

provide uncertainty in the future delivery of integrated services

4. Risks that have been closed since the last report 4.1 BAF ID37 ‘Ensuring that patients and clinicians have access to high quality

specialist community services’ Patient care may suffer if we are unable to recruit and retain a quality workforce with the right clinical leadership. This risk has been superseded by risk BAFID102 which was introduced to the BAF in January 2019.

4.2 BAF ID73 ‘Dedicating time, resources, expertise and leadership to fully implement the 'Home First' service model across Kent’ That the organisation may not be able to adapt and implement the change and transformation of service due to poor morale and the changes needed in the organisational culture. This risk has also been superseded by risk BAFID102.

5. Risks that have been de-escalated since the last report

5.1 BAF ID98 ‘Strategic Objective Enablers’ Deteriorating financial position in Kent and Medway, particularly in east Kent jeopardises the stability of the system to maintain commitment to local care and/or places additional pressures on the Trust as seen as organisation with financial flexibility as over delivered financial surplus.

6. Risks previously de-escalated to Directorate risk registers that have

closed 6.1 There are no risks that have been de-escalated to Directorate risk

registers that have now closed.

6.2 The total number of risks documented on the BAF is five. Figure 1 (below) provides a visual representation of the organisational risk profile based on the current risk rating within section 1 of the BAF.

6.3 Figure 1: Organisational High Risk Profile

Page 26 of 144

3

7. High risk definition 7.1 A high risk is defined as any risk with an overall risk rating of 15 or above,

as well as those risks rated as 12 with a consequence score of 4. The risk matrix below provides a visual representation of this.

7.2 Figure 2: Trust risk matrix

← Consequence / Severity →

Insignificant Minor Moderate Major Catastrophic

↓Likelihood ↓ 1 2 3 4 5

Rare 1 1 2 3 4 5

Unlikely 2 2 4 6 8 10

Possible 3 3 6 9 12 15

Likely 4 4 8 12 16 20

Almost Certain 5 5 10 15 20 25

The scores obtained from the risk matrix are assigned grades as follows:

1 – 6 Low risk

8 – 12 Medium Risk

12 – 25 High Risk

Boa

rd A

ssur

ance

Fra

mew

ork

Page 27 of 144

4

8. Risk Overview 8.1 The total number of open risks within the Trust stands at 275 this is

comprised of 120 low risks, 145 medium risks and 10 high risks. Figure 3 (below) provides a visual representation. Low risks are initially reviewed by Heads of Service with further reviews by the responsible officer at least bi monthly. Medium risks would initially be reviewed by Heads of Service and then onward to the Community Service Director/Assistant Director for approval, these would normally be reviewed on a monthly basis. All risks are extracted by the Risk Team on a weekly basis and the officer responsible for those risks that have passed their review date or target completion date are contacted by the team to prompt a review.

8.2 Figure 3: Organisational Risk Overview.

9. Recommendation

9.1 The Board is asked to consider the Board Assurance Framework in Appendix 1 and determine whether sufficient mitigating actions are in place to address these.

Barry Norton Head of Risk 23 January 2019

Page 28 of 144

G A R

ID

Opened

Board Level Risk Owner

CL

Rating

Con

trol

s D

escr

iptio

nPo

sitiv

e A

ssur

ance

sG

aps

in c

ontr

ol o

r Neg

ativ

e A

ssur

ance

CL

Rating

Action owner

Confidence Assessment

Target Date (end)

Indi

vidu

al A

ctio

nsO

wne

rTa

rget

Com

plet

ion

(end

)St

atus

Prog

ram

me

Man

ager

bei

ng a

ppoi

nted

to C

IS c

hang

e pr

ojec

tG

ordo

n Fl

ack

Sep

2018

G

Set u

p go

vern

ance

stru

ctur

eG

ordo

n Fl

ack

Nov

201

8G

Stru

ctur

ed p

rogr

amm

e of

clin

ical

eng

agem

ent i

nclu

ded

in th

e pr

ogra

mm

e.

Sara

h Ph

illips

Nov

201

9G

Def

initi

on o

f pro

gram

me

stru

ctur

e an

d pr

ogra

mm

e te

amG

ordo

n Fl

ack

Sep

2018

G

Proj

ect l

eade

rshi

p ap

poin

ted.

Gor

don

Flac

kD

ec 2

018

G

Indi

vidu

al A

ctio

nsO

wne

rTa

rget

Com

plet

ion

(end

)St

atus

Loc

al C

are

Gro

up im

plem

enta

tion

Paul

Ben

tley

Jul 2

018

GKC

HFT

invo

lvem

ent i

n C

CG

wor

kfor

ce g

roup

Loui

se N

orris

GR

evie

w m

itiga

tion

plan

sG

ordo

n Fl

ack

Oct

201

8G

Rec

over

y pl

an fo

r eas

t Ken

tG

ordo

n Fl

ack

Oct

201

8G

Proa

ctiv

ely

seek

opp

ortu

nitie

s to

sta

bilis

e th

e sy

stem

and

su

ppor

t inv

estm

ent i

n lo

cal c

are

Gor

don

Flac

kM

ar 2

019

G

Hos

pita

l at H

ome

laun

chG

ordo

n Fl

ack

Nov

201

8G

Indi

vidu

al A

ctio

nsO

wne

rTa

rget

Com

plet

ion

(end

)St

atus

Mon

itor W

inte

r Pre

ssur

e Pl

ans

thro

ugh

Gov

erna

nce

stru

ctur

es -

KPI's

for E

ast &

Wes

t Ken

t hav

e be

en a

gree

d Le

sley

Stro

ngM

ar 2

019

A

Flu

Vacc

inat

ion

Prog

ram

me

Del

iver

yM

erci

a Sp

are

Feb

2019

AO

vers

ee th

e ne

wly

impl

emen

ted

'Rap

id T

rans

fer s

ervi

ce i

n th

e Ea

st in

add

ition

to th

e cr

eatio

n of

loca

l car

e sc

hem

es.

Lesl

ey S

trong

Mar

201

9A

12H

43

Indi

vidu

al A

ctio

nsO

wne

rTa

rget

Com

plet

ion

(end

)St

atus

Coo

rdin

atio

n w

ith th

e ST

P on

goin

gPa

ul B

entle

yFe

b 20

19A

Staf

f tra

inin

g on

stra

tegy

and

com

man

d gr

oups

whi

ch w

ill be

co

mpl

eted

by

the

end

of F

ebru

ary

Nat

alie

Dav

ies

Feb

2019

A

Inte

rnal

Bre

xit w

orks

hop

and

tabl

e to

p ex

erci

se to

be

held

Nat

alie

Dav

ies

Dec

201

8G

Fortn

ight

ly re

view

s - t

o ke

ep p

lans

und

er re

view

Nat

alie

Dav

ies

Feb

2019

G

Medium

Lesley Strong

100

Nov 2018

Inte

grat

e Se

rvic

es

Ris

k th

at th

e or

gani

satio

n’s

serv

ices

may

suf

fer s

igni

fican

t ch

alle

nges

as

resu

lt of

the

impa

ct o

f win

ter p

ress

ures

.4

416

Emer

genc

y Pl

anni

ng e

xerc

ises

Flu

vacc

inat

ion

Prog

ram

me

An e

stab

lishe

d N

atio

nal E

mer

genc

y Pr

essu

res

Pane

l has

bee

n es

tabl

ishe

d to

iden

tify

leve

ls o

f sys

tem

risk

and

reco

mm

end

resp

onse

s

R

epor

ting

perfo

rman

ce fo

r Min

or In

jury

Uni

ts

Who

le s

yste

m w

inte

r pla

ns h

ave

been

agr

eed

by th

e Lo

cal A

&E

Del

iver

y Bo

ards

. Th

ese

incl

ude

esca

latio

n pl

ans

with

key

ac

tions

to b

e ta

ken

if ce

rtain

trig

gers

are

reac

hed.

Extra

bed

cap

acity

by

redu

cing

del

ayed

tran

sfer

s of

car

e

Emer

genc

y Pl

ans

succ

essf

ul d

urin

g te

stin

g

St

aff f

lu v

acci

natio

n pr

ogra

mm

e –

this

is

unde

rway

for K

CH

FT s

taff.

Loc

al

targ

ets

have

bee

n se

t whi

ch in

clud

e m

axim

um o

f 14

patie

nts

at a

ny o

ne ti

me

in

KCH

FT c

omm

unity

hos

pita

ls

W

inte

r Pre

ssur

e Pl

ans.

A

ctio

ns

have

bee

n id

entif

ied

in o

rder

to re

duce

the

gap

in c

ontro

ls re

latin

g to

this

risk

.

Upd

ated

23

Janu

ary

2019

Def

initi

ons:

Initi

al R

atin

g =

The

risk

ratin

g at

the

time

of id

entif

icat

ion

Cur

rent

Rat

ing

= R

isk

rem

aini

ng w

ith c

urre

nt c

ontro

ls in

pla

ce. T

his

is

revi

ewed

mon

thly

and

sho

uld

decr

ease

as

actio

ns t

ake

effe

ct.

Targ

et D

ate

= M

onth

end

by

whi

ch a

ll ac

tions

sho

uld

be c

ompl

eted

Initi

al ra

ting

Cur

rent

ratin

g

Appe

ndix

1

Ris

ks w

ith a

hig

h ne

t ris

k ra

ting

whi

ch h

ave

not b

een

tole

rate

d.

Act

ion

stat

us k

ey:

Act

ions

com

plet

edO

n tra

ck b

ut n

ot y

et d

eliv

ered

Orig

inal

targ

et d

ate

is u

nach

ieva

ble

Plan

ned

Act

ions

and

Mile

ston

es

Boa

rd A

ssur

ance

Fra

mew

ork

Sect

ion

1

Ris

k D

escr

iptio

n(S

impl

e Ex

plan

atio

n of

the

Ris

k)

43

Dev

elop

Sus

tain

able

Ser

vice

s (S

trat

egic

Obj

ectiv

e En

able

rs)

101

Dec 2018

Natalie Davies

Unc

erta

inty

aro

und

Brex

it m

ay a

ffect

our

abi

lity

to d

eliv

er c

ore

obje

ctiv

es4

3Lo

cal H

ealth

Res

ilienc

e Pa

rtner

ship

(LH

RP)

term

s of

refe

renc

eEx

ecut

ive

lead

app

oint

edH

ead

of R

esilie

nce

JDAc

tion

plan

dev

elop

edBr

exit

risk

regi

ster

est

ablis

hed

Reg

ular

dis

cuss

ion

and

revi

ew a

t Ex

ec/M

anag

emen

t Com

mitt

ee a

nd B

oard

.N

HS

Engl

and

(NH

S E)

repo

rting

re

quire

men

ts m

et.

LHR

P m

eetin

gs a

ttend

ance

. Fu

rther

dev

elop

pla

n in

resp

onse

to n

ew

info

rmat

ion.

Mon

thly

Tru

st B

rexi

t mee

tings

hel

d.

Wor

king

in c

olla

bora

tion

with

Clin

ical

C

omm

issi

onin

g G

roup

s (C

CG

s)

Natalie Davies

Medium

Jan 2019

12H

Lesley Strong

April 2019

312

HG

over

nanc

e st

ruct

ure

& pr

ojec

t pla

n in

pla

ceEn

gage

men

t with

the

proj

ect t

eam

del

iver

ing

the

Kent

Car

e R

ecor

d Pr

ojec

t Lea

ders

hip

team

job

desc

riptio

nsPh

ase

impl

emen

tatio

n pl

an a

nd re

sour

cing

app

ropr

iate

lyC

omm

unic

atio

n pl

ans

deve

lope

d w

ith s

take

hold

ers

inc.

co

mm

issi

oner

s.

Reg

ular

Boa

rd re

ports

link

ed to

oth

er

proj

ects

Proj

ect G

roup

repo

rt to

Exe

c T

eam

and

Bo

ard

Tim

esca

les

to im

plem

ent n

ew s

yste

mC

ompr

ehen

sive

pro

gram

me

plan

for

repl

acem

ent s

yste

m to

be

deve

lope

d in

re

spon

se to

em

ergi

ng ti

mes

cale

s

Prev

ent I

llnes

s

Nov 2019

43

12H

Gordon Flack

Medium

Ove

rsee

the

new

ly im

plem

ente

d H

ospi

tal a

t Hom

e' s

chem

e in

th

e W

est '

in a

dditi

on to

the

crea

tion

of lo

cal c

are

sche

mes

.

99

Lesl

ey S

trong

Mar

201

9A

February 2019

12H

Gordon Flack

Impl

emen

ting

a cl

inic

al s

yste

m in

clud

ing

doub

le ru

nnin

g w

ith

the

exis

ting

syst

em a

nd a

t the

sam

e tim

e as

the

Ken

t Car

e R

ecor

d is

bei

ng im

plem

ente

d m

ay n

egat

ivel

y im

pact

on

prod

uctio

n of

tim

ely

info

rmat

ion.

4

43

12H

High

Mar 2019

Paul Bentley

103

Jan 2019

Gordon Flack

Cha

nges

in th

e sy

stem

arc

hite

ctur

e m

ay p

rovi

de u

ncer

tain

ty

in th

e fu

ture

del

iver

y of

inte

grat

ed s

ervi

ces

43

12H

Sust

aina

bilit

y an

d Tr

ansf

orm

atio

n Pl

an (S

TP) P

rogr

amm

e Bo

ard

TOR

s an

d m

embe

rshi

pTO

Rs

for:

Loca

l Car

e Bo

ards

; Fra

ilty

Gro

up; C

hief

Exe

cutiv

es

Foru

mST

P G

over

nanc

e St

ruct

ures

Dire

ctor

of S

trate

gy jo

b de

scrip

tion

Wes

t Ken

t Im

prov

emen

t Boa

rd te

rms

of re

fere

nce

East

Ken

t Tra

nsfo

rmat

ion

Boar

d te

rms

of re

fere

nce

NH

S I/E

sys

tem

mee

ting

term

s of

refe

renc

e

Loca

l Car

e In

vest

men

t rec

eive

d fo

r bot

h ea

st a

nd w

est K

ent -

Hos

pita

l at H

ome

and

Rap

id T

rans

fer o

f Car

e sc

hem

e.C

omm

unity

Car

e Fu

ndin

g in

crea

se in

fin

anci

al s

ettle

men

tC

hief

Exe

c re

port

to th

e bo

ard

Reg

ular

Stra

tegi

c de

velo

pmen

t upd

ate

to

the

boar

dN

on e

xecu

tive

mem

bers

hip

of th

e ST

P bo

ard.

Boa

rd A

ssur

ance

Fra

mew

ork

Page 29 of 144

ID

Opened

Board Level Risk Owner

CL

Rating

Con

trol

s D

escr

iptio

nPo

sitiv

e A

ssur

ance

sG

aps

in c

ontr

ol o

r Neg

ativ

e A

ssur

ance

CL

Rating

Action owner

Confidence Assessment

Target Date (end)

Initi

al ra

ting

Cur

rent

ratin

g

Plan

ned

Act

ions

and

Mile

ston

esR

isk

Des

crip

tion

(Sim

ple

Expl

anat

ion

of th

e R

isk)

Indi

vidu

al A

ctio

nsO

wne

rTa

rget

Com

plet

ion

(end

)St

atus

Ope

n C

linic

al A

cade

my

with

50

stud

ents

Loui

se N

orris

Feb

2019

A

Scop

ing

exte

nsio

n to

clin

ical

aca

dem

yLo

uise

Nor

risSe

p 20

19A

Inte

rnat

iona

l rec

ruits

arr

ive

Loui

se N

orris

Jun

2019

A

Impl

emen

t Big

Lis

ten

actio

n pl

anPa

ul B

entle

yAp

r 202

0A

Impl

emen

t QI s

trate

gy a

ctio

n pl

anSa

rah

Philli

psM

ar 2

020

A

Impl

emen

t wel

l bei

ng a

ctio

n pl

anLo

uise

Nor

risM

ay 2

019

A

Impl

emen

t WR

ES a

ctio

n pl

anLo

uise

Nor

risM

ar 2

019

A

Del

iver

Hig

h Q

ualit

y C

are

at H

ome

and

in th

e C

omm

unity

Louise Norris

43

12H

vaca

ncie

s 9.

69%

, tur

nove

r 18.

14%

Medium

Dec 2020

Stra

tegi

c W

orkf

orce

Com

mitt

ee T

oRs,

Serv

ice

qual

ity v

isits

Dire

ctor

of W

orkf

orce

JD

;W

orkf

orce

Stra

tegy

Agr

eed

Ope

ratio

nal w

orkf

orce

repo

rtsC

ompl

aint

s sy

stem

est

ablis

hed

agai

nst a

gree

d po

licy

Frie

nds

and

Fam

ily T

est

Tale

nt M

anag

emen

t Stra

tegy

Tim

e to

Cha

nge

Cha

mpi

ons

syst

em e

stab

lishe

d

Serv

ice

visi

t rep

orte

d to

qua

lity

com

mitt

ee,

Wor

kfor

ce re

port

to b

oard

, IPR

KPI

s re

porte

d an

d re

view

ed b

y Bo

ard,

Saf

er

Staf

fing

repo

rts, w

orkf

orce

pla

ns, T

ime

to

hire

ben

chm

arks

pos

itive

ly, b

ank

fill r

ates

im

prov

ing,

age

ncy

usag

e re

port.

Wor

kfor

ce re

port

to S

WC

102

Jan 2019

Louise Norris

Inab

ility

to re

crui

t and

reta

in s

taff

appr

opria

tely

cou

ld h

ave

a de

trim

enta

l im

pact

on

mai

ntai

ning

qua

lity

of c

are

and

mor

ale

43

12H

Page 30 of 144



Agenda Number: 2.3

Agenda Item Title: Quality Committee Chair’s Assurance Report

Presenting Officer: Steve Howe, Chair of Quality Committee


Report Summary

The paper summarises the Quality Committee meetings held on 22 January 2019.


The Board is asked to receive the Quality Committee Chair’s Assurance Report.



No ☒

High level position described and no decisions required. The paper will have no

impact on people with any of the nine protected characteristics

Steve Howe, Non-Executive Director Tel: 01622 211906

Email:

Qua

lity

Com

mitt

ee C

hair'

sR

epor

t

Page 31 of 144

QU

AL

ITY

CO

MM

ITT

EE

CH

AIR

’S A

SS

UR

AN

CE

RE

PO

RT

JA

NU

AR

Y 2

01

9

Th

is r

ep

ort

co

ve

rs t

he

Qu

alit

y C

om

mitte

e m

ee

tin

g h

eld

on

22

Ja

nu

ary

20

19

A

ge

nd

a i

tem

A

ss

ura

nc

e a

nd

Ke

y p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

Assu

ran

ce

re

po

rts w

ere

rece

ive

d f

rom

:

Pa

tie

nt

Safe

ty a

nd

Clin

ica

l R

isk G

rou

p;

Pa

tie

nt

Exp

erie

nce

Gro

up

;

Clin

ica

l E

ffe

ctive

ne

ss

Gro

up

.

Qu

ali

ty M

etr

ics

: It

wa

s n

ote

d th

at th

ere

wa

s a

re

du

ctio

n

in t

he n

um

be

r of

sh

ifts

acro

ss t

he

Tru

st

wh

ere

on

ly o

ne

Re

gis

tere

d N

urs

e (

RN

) w

as o

n d

uty

– 9

3 in D

ece

mb

er

from

10

3 in

No

ve

mb

er.

Ed

en

brid

ge

Com

mu

nity H

osp

ita

l is

the

ou

tlie

r w

ith

31

sh

ifts

in

De

cem

be

r, b

ut

this

ha

s b

een

mitig

ate

d w

ith

a H

ea

lth C

are

Assis

tan

t (H

CA

) sh

ift fill

rate

of

be

twe

en

12

3.4

% o

n d

ays a

nd

10

4%

on

nig

hts

.

The

Com

mitte

e w

as p

lea

sed

to n

ote

th

ere

were

no

avo

ida

ble

cate

go

ry t

hre

e o

r fo

ur

pre

ssu

re u

lce

rs in

the

Tru

st’s c

are

du

rin

g t

he

mo

nth

s o

f N

ove

mb

er

an

d

De

ce

mb

er

20

18.

The

re w

as a

slig

ht

rise in

the

nu

mb

er

of

avo

ida

ble

fa

lls

(tw

o in

No

ve

mb

er

and

fo

ur

in D

ece

mb

er)

bu

t a

vo

ida

ble

me

dic

atio

ns in

cid

en

ts c

on

tinu

e to

fa

ll w

ith

18

avo

ida

ble

incid

en

ts r

eco

rded

in

De

ce

mb

er.

The

Tru

st

rem

ain

s o

n tra

jecto

ry f

or

ach

ievin

g a

10

%

The

Com

mitte

e d

iscu

sse

d th

e t

rian

gu

latio

n

of

all

the

ava

ilab

le q

ua

lity m

etr

ics f

or

Ed

enb

rid

ge

Com

mu

nity H

osp

ita

l w

hic

h w

ere

in n

orm

al bo

und

s, b

ut w

ou

ld r

em

ain

a fo

cu

s

for

the g

rou

p.

Qua

lity

Com

mitt

ee C

hair'

sR

epor

t

Page 32 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

red

uction

of

avo

ida

ble

ha

rms a

t th

e e

nd

of

this

fin

an

cia

l

ye

ar.

Pa

tie

nt

Ex

pe

rie

nc

e C

om

bin

ed

Sa

tis

fac

tio

n S

co

re: In

Qu

art

er

3,

15

,66

2 s

urv

eys w

ere

co

mp

lete

d w

ith

a

sa

tisfa

ction

sco

re o

f 9

7%

. T

he

Frien

ds a

nd

Fam

ily T

est

(FF

T)

sco

re a

t 96

.5%

wa

s s

ligh

tly lo

we

r th

an

th

e p

revio

us

qu

art

er’s r

esu

lt o

f 9

7.4

%.

Co

mp

lain

ts r

em

ain

at a

his

torica

l lo

w,

wh

en

co

mpa

red t

o

the

la

st

thre

e y

ea

rs’ d

ata

, w

ith

51

co

mp

lain

ts lo

gge

d in

Qu

art

er

Th

ree

.

It w

as n

ote

d th

at a

gre

at

de

al of

wo

rk h

as b

ee

n

un

de

rta

ken

on

NIC

E a

ssu

ran

ce

. F

rom

630

po

licy

gu

ida

nce

cla

ssifie

d a

s ‘n

ot

asse

sse

d’ in

Ma

y 2

018

, th

ere

we

re o

nly

12

NIC

E g

uid

an

ce

po

licie

s r

equ

irin

g a

ssu

ran

ce

in D

ecem

be

r 2

018

.

Me

dic

al D

evic

es

The

Bo

ard

will

re

ca

ll th

at

the

Au

dit a

nd R

isk C

om

mitte

e

requ

este

d th

at

the

Qu

alit

y C

om

mitte

e r

evie

w t

he

assu

ran

ce

of

eff

ective

ne

ss o

f E

ME

ma

inte

nan

ce

of

me

dic

al d

evic

es.

On

exa

min

atio

n a

hig

h n

um

be

r of

me

dic

al d

evic

es w

ere

sh

ow

n a

s ‘o

ut of

da

te’ th

rou

gh

issu

es w

ith

th

e d

ata

base

(I-

Le

ad

er)

. A

tem

pora

ry

ad

min

istr

ato

r w

as r

ecru

ite

d to

ove

rse

e t

he

actio

n p

lan

an

d

It is r

equ

este

d th

at th

is r

ep

ort

is fo

rwa

rde

d

to t

he

Au

dit a

nd R

isk C

om

mitte

e a

s

evid

en

cin

g S

ign

ific

ant A

ssu

ran

ce

in

th

is

are

a.

Page 33 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

assis

t in

cle

an

sin

g t

he

da

ta h

eld

. T

he

Com

mitte

e w

as

ple

ased

to r

ece

ive

a p

ap

er

pro

vid

ing s

ign

ific

an

t a

ssu

ran

ce

tha

t a

ction

s t

ake

n h

ave

mitig

ate

d th

e r

isk a

nd

the

Tru

st

is

me

etin

g in

tern

al K

ey P

erf

orm

an

ce

In

dic

ato

rs (

KP

I) a

nd

is

exp

ecte

d to

mee

t a s

tre

tch

ta

rge

t of

98

% c

om

plia

nce

by

Ma

rch

201

9.

Le

arn

ing f

rom

Dea

ths

The

Com

mitte

e r

ece

ive

d th

e L

ea

rnin

g f

rom

De

ath

s R

ep

ort

pro

du

ce

d in a

cco

rda

nce

with

na

tio

na

l gu

idan

ce

. T

he

rep

ort

ide

ntifie

s a

rea

s o

f go

od p

ractice id

en

tifie

d f

rom

th

e

revie

ws,

an

d t

he

me

s fo

r le

arn

ing w

he

re im

pro

ve

me

nts

ca

n b

e m

ade

. A

lth

ou

gh

the

Tru

st

is o

nly

re

qu

ire

d t

o r

evie

w

inp

atien

t de

ath

s in

com

mu

nity h

osp

ita

ls,

a p

roce

ss h

as

be

gu

n fo

r sam

plin

g o

ne

or

two

dea

ths p

er

mon

th in t

he

co

mm

un

ity.

Qu

alit

y I

mpa

ct

Asse

ssm

en

t P

roce

ss

The

Tru

st

co

ndu

cte

d a

ga

p a

na

lysis

fo

llow

ing

th

e r

ep

ort

into

th

e fa

ilin

gs w

ith

in L

ive

rpo

ol C

om

mun

ity N

HS

Tru

st

an

d th

e K

irku

p 2

019

Re

po

rt. It

wa

s r

eco

gn

ised

tha

t w

hile

the

re w

as a

rob

ust

inde

pen

den

t re

vie

w b

y n

on

-exe

cu

tive

dire

cto

rs (

NE

Ds)

of

the Q

ua

lity I

mpa

ct A

sse

ssm

ent

(QIA

)

pro

ce

ss,

the

wid

er

impa

ct

of

co

st

imp

rove

men

t

pro

gra

mm

e

(CIP

s)

there

we

re t

wo

are

as f

or

imp

rove

men

t:

Qua

lity

Com

mitt

ee C

hair'

sR

epor

t

Page 34 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

Go

ve

rna

nce

arr

an

ge

me

nts

fo

r Q

IA’s

fo

r p

rogra

mm

es a

nd

pro

jects

no

t co

nsid

ere

d a

CIP

.

Fu

rth

er

de

ve

lop

me

nt of

the N

ED

dee

p d

ive

pro

ce

ss.

The

Com

mitte

e w

as b

rie

fed

on

th

e f

ind

ings o

f th

e N

ED

de

ep

div

e in

to th

e S

pee

ch

an

d L

an

gua

ge

The

rap

y (

SA

LT

)

Se

rvic

e C

IP Q

IA fo

r fina

ncia

l ye

ar

201

8/1

9 tha

t w

as

co

ndu

cte

d in

De

ce

mb

er

20

18

.

Re

ferr

al to

Tre

atm

ent

Pe

rfo

rma

nce D

eep

Div

e

The

Ch

ief

Ope

ratin

g O

ffic

er

had

pre

vio

usly

id

en

tified

a

co

nce

rn th

at

the

Tru

st w

as m

issin

g its

18

-we

ek R

efe

rra

l to

Tre

atm

en

t ta

rge

t in

a n

um

be

r of

co

nsu

lta

nt-

led

are

as a

nd

the

Com

mitte

e w

as b

riefe

d b

y s

erv

ice

le

ad

s o

n t

he

ba

ckgro

un

d a

nd

pro

pose

d m

itig

atio

ns to

th

e issu

e.

Data

reve

als

th

at

the

re w

as a

de

clin

e in

bo

th c

om

ple

te a

nd

inco

mp

lete

path

wa

ys s

ince

Fe

bru

ary

/Ma

rch

20

18

an

d t

he

ch

ron

ic p

ain

an

d o

rth

op

aed

ic s

erv

ice

s w

ere

of

pa

rtic

ula

r

co

nce

rn w

ith

a s

ign

ific

an

t n

um

be

r (3

13

fo

r O

cto

be

r)

wa

itin

g lo

nge

r th

an

18 w

ee

ks.

Th

rou

gh

mitig

atio

n a

ctio

n

this

num

be

r w

as r

ed

uce

d to

18

2 in N

ove

mbe

r, w

ith

pa

rtic

ula

r im

pro

ve

men

t n

ote

d in t

he

Ch

ron

ic P

ain

Se

rvic

e

wh

ich

is n

ow

on

ta

rge

t. A

ll re

ferr

als

are

tria

ge

d b

y a

sen

ior

clin

icia

n a

nd

pa

tie

nts

are

ad

vis

ed

to c

onta

ct th

e s

erv

ice

or

the

ir G

P s

hou

ld t

he

ir c

on

ditio

n d

ete

rio

rate

.

While

it

is n

ote

d th

at th

ere

is a

n im

pro

vin

g

sta

tistica

l p

ictu

re,

the

Co

mm

itte

e h

as

requ

este

d r

egu

lar

assura

nce

up

da

tes.

Page 35 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

He

alth

Vis

itin

g S

erv

ice

T

he

Bo

ard

will

re

ca

ll th

e C

om

mitte

e, a

lert

ed

by t

he

Ch

ief

Op

era

tin

g O

ffic

er,

he

ld c

on

ce

rns o

ve

r th

e w

ork

forc

e

me

tric

s a

nd

mo

rale

of

the

Hea

lth

Vis

itin

g S

erv

ice

;

alth

ou

gh

qu

alit

y m

etr

ics a

t th

at tim

e w

ere

giv

ing n

o c

au

se

for

co

nce

rn.

Fo

llow

ing a

n in

itia

l d

eep

div

e,

the C

om

mitte

e

requ

este

d a

six

-mo

nth

re

po

rt o

n tu

rna

roun

d. V

aca

ncie

s in

Mo

nth

Nin

e w

ere

13

.06

%,

bu

t th

ere

ha

d b

een

a

de

ve

lop

me

nt of

a B

and

5 r

ole

and

17

RN

s w

ere

no

w in

pla

ce

. M

ost

no

tice

ab

le w

as a

re

du

ction

in

str

ess r

ela

ted

ab

sen

ce

fro

m 4

% in

July

to

1.5

% in

No

ve

mb

er.

In

tern

al

sta

ff s

urv

ey r

esu

lts s

ho

w a

n im

pro

ve

men

t in

all

ke

y a

rea

s,

he

lped

by a

com

bin

atio

n o

f str

on

g lea

de

rsh

ip a

nd p

ractica

l

me

asu

res s

uch

as t

he

mo

ve

fro

m t

ab

lets

to

lap

top

s.

The

Com

mitte

e h

as r

equ

este

d a

fu

rth

er

up

da

te in f

ou

r m

on

ths.

Ra

tifica

tio

n o

f P

olic

y

The

Com

mitte

e r

atifie

d t

he

po

licy f

or

Clin

ica

l R

eco

rd

Ke

ep

ing (

QC

04

3).

SC

Ho

we

CB

E

Ch

air

of

Qu

ali

ty C

om

mit

tee

23

Ja

nu

ary

20

19

Qua

lity

Com

mitt

ee C

hair'

sR

epor

t

Page 36 of 144



Agenda Number: 2.4

Agenda Item Title: Strategic Workforce Committee Chair’s Assurance Report

Presenting Officer: Bridget Skelton, Chair of Strategic Workforce Committee


Report Summary

The paper summarises the Strategic Workforce Committee meeting held on 28 November 2018. A verbal update on the meeting held on 30 January 2019 will also be provided.


The Board is asked to receive the Strategic Workforce Committee Chair’s Assurance Report.



No ☒



Bridget Skelton, Non-Executive Director Tel: 01622 211906

Email:

Str

ateg

ic W

orkf

orce

Com

mitt

ee C

hair'

s R

epor

t

Page 37 of 144

ST

RA

TE

GIC

WO

RK

FO

RC

E C

OM

MIT

TE

E (

SW

C)

CH

AIR

’S A

SS

UR

AN

CE

RE

PO

RT

Th

is r

ep

ort

is fo

un

ded

on

th

e S

tra

tegic

Wo

rkfo

rce

Com

mitte

e m

ee

tin

g h

eld

on

Wedn

esd

ay 2

8 N

ove

mb

er

20

18

. A

ge

nd

a i

tem

A

ss

ura

nc

e a

nd

Ke

y p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

Work

forc

e R

ep

ort

R

ece

ive

d r

ep

ort

with

an

upd

ate

on

the

cu

rrent

wo

rkfo

rce

po

sitio

n a

s a

t O

cto

be

r 2

018

, de

taili

ng

a v

arie

ty o

f m

etr

ics

inclu

din

g a

bse

nce,

turn

ove

r, a

ge

ncy u

sa

ge

, va

ca

ncie

s

an

d tra

inin

g c

om

plia

nce

.

Assu

ran

ce

wa

s g

ive

n o

n p

rovid

ing

ma

xim

um

op

po

rtu

nity

for

sta

ff t

o h

ave

flu

ja

bs t

o e

nsu

re t

he T

rust m

inim

ised

sic

kn

ess t

hro

ugh

the

win

ter

pe

riod

.

The

se

co

nd w

ave

of

Tim

e to

Cha

nge

Cha

mp

ion

s w

ere

ab

ou

t to

be

tra

ine

d. Im

pa

ct m

ea

su

rem

en

t qu

erie

d -

ju

st

on

e o

f se

ve

ral in

dic

ato

rs t

o e

vid

en

ce a

ta

rge

t re

du

ction

in

str

ess le

ve

ls.

Da

ta to

cap

ture

accu

racy o

f a

pp

rais

al co

mp

letio

ns

hin

de

red

by c

om

ple

x u

se

r e

xp

erie

nce

. S

up

plie

r of

syste

m

to b

e c

on

tacte

d to

ma

ke

it

mo

re u

se

r-fr

ien

dly

.

Be

nchm

ark

da

ta to

be

co

llecte

d o

n s

tre

ss

leve

ls t

o m

ake

com

pa

riso

ns o

n T

rust

va

ria

nce

.

Sta

tistica

l P

roce

ss C

on

tro

l m

eth

od

olo

gy t

o

be

ad

opte

d t

o e

nsu

re r

ep

resen

tatio

n o

f da

ta.

Nu

rsin

g A

ca

dem

y

Re

po

rt h

ea

rd a

bo

ut th

e p

rogre

ss w

ith

se

ttin

g u

p th

e

KC

HF

T N

urs

ing A

cad

em

y (

Th

e in

tro

du

ctio

n o

f n

urs

e

ap

pre

ntice

s a

nd a

sso

cia

te n

urs

e a

pp

ren

tice

s a

s p

art

of

Str

ateg

ic W

orkf

orce

Com

mitt

ee C

hair'

s R

epor

t

Page 38 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

the

Tru

st’s r

ecru

itm

en

t a

nd

rete

ntio

n s

tra

tegy).

Fu

rth

er

recru

itm

ent

has h

ad t

o ta

ke p

lace t

o fill

pla

ce

s.

No

w f

ille

d a

ll nu

rse

posts

, tw

o d

ow

n o

n a

ssocia

tes.

Ba

se

s

ha

ve

be

en

fo

und

an

d p

lace

me

nts

map

pe

d o

ut. S

om

e

fun

din

g h

as b

een

se

cure

d f

rom

He

alth

Ed

ucatio

n

En

gla

nd

. F

ull

imp

lem

en

tation

pro

gra

mm

e w

ith

asso

cia

ted

risk r

egis

ter

un

de

rpin

s th

is in

itia

tive

.

De

vo

lvin

g A

uth

ority

Fra

me

wo

rk

A p

iece o

f w

ork

de

sig

ne

d to

en

ga

ge

an

d e

mpo

we

r p

eo

ple

at

the

fro

nt

line.

De

vo

lve

d f

ram

ew

ork

cro

sse

s o

ve

r w

ith

th

e e

xis

tin

g T

rust’s

va

lue

s a

nd

beh

avio

urs

; n

ee

ds to

be

alig

ne

d o

r in

tegra

ted

toge

the

r.

Work

in

pro

gre

ss a

s to w

ha

t is

de

vo

lve

d in

both

fin

an

ce

an

d H

R. It

no

w n

ee

ds to

fu

lly in

clu

de

op

era

tion

s a

nd

le

arn

from

Tra

nsfe

rrin

g I

nte

gra

ted

Ca

re in

th

e C

om

mu

nity

(TIC

C).

Pa

pe

r to

th

e J

an

ua

ry 2

01

9 S

WC

se

ttin

g o

ut

wh

at

is t

o b

e d

evo

lve

d a

nd

ho

w t

he

imp

lem

enta

tion

of

this

ne

w w

ay o

f w

ork

ing

will

be

ach

ieve

d.

Pe

op

le S

trate

gy A

ctio

n

Pla

n

Up

da

te o

n t

he

pro

gre

ss o

f th

e 2

018

/19

im

ple

me

nta

tion

pla

n to

sup

po

rt t

he

Peo

ple

Str

ate

gy.

Th

is h

as m

ostly

be

en

com

ple

ted.

The

pla

n fo

r 2

01

9/2

0 to

com

e to

th

e S

WC

in

Ma

rch

201

9.

Ad

va

nce

d C

linic

al

Pra

ctitio

ne

rs (

AC

P)

Re

po

rt

Assu

ran

ce

wa

s p

rovid

ed

on

th

e s

ucce

ssfu

l in

tro

du

ction

of

the

AC

P r

ole

, su

pe

rvis

ed

by c

on

su

lta

nt

ge

ria

tric

ian

s,

Fra

ilty G

Ps a

nd

Le

ad

AC

P.

Ro

bu

st

str

uctu

res a

re in

pla

ce

an

d a

n a

pp

rais

al p

rocess.

Dis

cu

sse

d p

ote

ntia

l e

xp

an

sio

n o

f th

e A

CP

ro

le,

The

ca

se

fo

r a

fu

rth

er

co

ho

rt to

be

te

ste

d in

on

-go

ing d

iscu

ssio

n w

ith

str

ate

gic

pla

nn

ing

mo

de

ls.

Con

clu

sio

ns to

be p

art

of

a s

tra

tegic

wo

rkfo

rce

pla

nn

ing p

ap

er

com

ing b

ack to

the

SW

F in M

arc

h 2

019

.

Page 39 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

reco

gn

isin

g t

he

su

cce

ss o

f th

e p

rogra

mm

e b

ut

ca

utio

us

ab

ou

t cap

acity,

rete

ntio

n a

nd

fit w

ith

wid

er

str

ate

gic

wo

rkfo

rce

pla

nn

ing.

Op

era

tion

al W

ork

forc

e

Re

po

rt

Assu

ran

ce

wa

s p

rovid

ed

th

at o

pe

ratio

na

lly t

he

Tru

st

un

de

rsto

od

wh

ere

the

ch

alle

ngin

g w

ork

forc

e h

ots

po

ts

we

re a

nd

actio

ns w

ere

in

pla

ce

to a

dd

ress the

m.

Re

cru

itm

en

t U

pd

ate

R

ece

ive

d a

pa

pe

r se

ttin

g o

ut

the

ch

alle

nge

s fa

ce

d in

recru

itm

en

t an

d th

e a

ctio

ns b

ein

g t

aken

to r

em

ed

y t

he

m.

Ove

r th

e s

um

me

r th

e te

am

wa

s w

ork

ing a

t h

alf c

ap

acity

with

bo

th v

aca

ncie

s a

nd

sic

kn

ess,

wo

rkin

g a

ga

inst

an

incre

asin

g v

olu

me

of

va

ca

ncie

s. T

he t

ea

m is n

ow

at fu

ll

ca

pa

city w

ith

tra

inin

g a

nd

re

ten

tion

activitie

s t

o e

nsu

re

qu

alit

y a

nd

co

nsis

ten

cy o

f se

rvic

e.

Issue

s w

ith

Occu

patio

na

l H

ea

lth a

re b

ein

g a

dd

resse

d b

y c

lose

pe

rfo

rma

nce

ma

na

ge

me

nt,

as w

ell

as a

n a

lte

rna

tive

pro

vid

er

be

ing s

ou

gh

t. M

an

age

me

nt m

ee

tin

gs a

re b

ein

g

att

en

ded

to

en

su

re ind

ivid

ua

l is

su

es a

re u

nders

too

d a

nd

ad

dre

sse

d.

NH

S E

mp

loye

es P

olic

y

Up

da

te

The

up

date

on

th

e N

HS

Em

plo

ye

rs P

olic

y B

oa

rd a

ssu

res

tha

t th

e T

rust

is s

igh

ted

on n

atio

na

l p

rio

ritie

s a

nd

issu

es.

Alig

nin

g I

nitia

tive

s

Tru

st-

wid

e w

ork

forc

e in

itia

tive

s h

ave

bee

n s

et

ou

t a

ga

inst

the

Pe

op

le S

tra

tegy a

nd

lo

ca

l in

itia

tive

s id

en

tifie

d a

ga

inst

wo

rkfo

rce

prio

ritie

s.

Furt

he

r w

ork

is r

equ

ire

d o

n

me

asu

rem

ent

an

d w

he

the

r in

itia

tive

s a

re lo

ng t

erm

or

Str

ateg

ic W

orkf

orce

Com

mitt

ee C

hair'

s R

epor

t

Page 40 of 144

Ag

en

da

ite

m

As

su

ran

ce

an

d K

ey p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

qu

ick w

ins a

nd

sh

ort

term

. T

he v

alu

e o

f h

avin

g a

n

ove

rvie

w is t

o b

e e

xp

lore

d t

o r

ed

uce

du

plic

atio

n, e

nsu

re

lesso

ns a

re le

arn

t an

d c

ap

acity is t

arg

ete

d o

n t

he

mo

st

imp

actfu

l p

iece

s o

f w

ork

.

De

ve

lop

ing W

ork

forc

e

Safe

gu

ard

s

NH

S I

mp

rove

me

nt (N

HS

I) h

as issue

d g

uid

an

ce

to

tru

sts

on

em

be

dd

ing s

afe

sta

ffin

g g

ove

rna

nce

on

all

se

rvic

es,

usin

g e

vid

en

ce

, p

rofe

ssio

na

l ju

dgem

en

t an

d o

utc

om

es.

An

asse

ssm

en

t of

the n

urs

ing e

sta

blis

hm

en

t a

nd

skill

mix

mu

st b

e r

ep

ort

ed

tw

ice

a y

ea

r a

nd

a s

tate

me

nt

ma

de

to

NH

SI

to c

onfirm

th

e T

rust’s s

taff

ing g

ove

rna

nce

pro

ce

sse

s

are

safe

an

d s

usta

ina

ble

on

ce

a y

ea

r.

A g

ap

an

aly

sis

to

dete

rmin

e w

ha

t fu

rthe

r

wo

rk is r

equ

ire

d t

o e

nsu

re c

om

plia

nce

is

un

de

rwa

y a

nd

will

co

me

to

th

e S

WC

in

Ma

rch

201

9.

Ta

len

t M

an

agem

ent

Assu

ran

ce

wa

s p

rovid

ed

th

at

the T

rust

is b

ein

g p

roa

ctive

to d

eve

lop

and

re

tain

its

ta

lent

po

ol, w

ith

fu

rthe

r le

sso

ns

lea

rnt fo

r th

e 2

01

9 ta

len

t m

ana

ge

men

t ro

und

, to

en

su

re

the

info

rma

tio

n c

olle

cte

d is o

bje

ctive

and

consis

ten

t.

Bri

dg

et

Sk

elt

on

Ch

air

, S

tra

teg

ic W

ork

forc

e C

om

mit

tee

We

dn

es

da

y 2

8 N

ove

mb

er

201

8

Page 41 of 144



Agenda Number: 2.5

Agenda Item Title: Audit and Risk Committee Chair’s Assurance Report

Presenting Officer: Peter Conway, Chair of Audit and Risk Committee


Report Summary

The paper summarises the Audit and Risk Committee meeting held on 12 December 2018.


The Board is asked to receive the Audit and Risk Committee Chair’s Assurance Report.



No ☒



Peter Conway, Non-Executive Director Tel: 01622 211906

Email:

Aud

it an

d R

isk

Com

mitt

eeC

hair'

s R

epor

t

Page 42 of 144

AU

DIT

AN

D R

ISK

CO

MM

ITT

EE

(A

RA

C)

CH

AIR

’S A

SS

UR

AN

CE

RE

PO

RT

Th

is r

ep

ort

is fo

un

ded

on

th

e A

ud

it a

nd

Ris

k C

om

mitte

e m

ee

tin

g h

eld

on

Wedn

esd

ay 1

2 D

ece

mb

er

20

18

. A

rea

A

ss

ura

nce

Is

su

es

an

d/o

r N

ext

Ste

ps

Ris

k M

ana

gem

ent

Ris

k m

anag

em

ent a

nd

re

po

rtin

g c

ontin

ue

s to

be

eff

ective

alth

ou

gh A

RA

C r

ecom

me

nd

s th

at

the

Exe

cu

tive

Ma

na

ge

me

nt u

nd

ert

ake

s a

refr

esh o

f th

e B

oard

Assura

nce

Fra

me

wo

rk (

BA

F).

Th

e E

xe

cu

tive t

o r

efr

esh th

e B

AF

, p

ayin

g p

art

icu

lar

att

entio

n t

o:

-defin

ing t

he r

isk m

ore

pre

cis

ely

-c

reatin

g a

bette

r lin

k b

etw

een

ga

ps in

co

ntr

ol a

nd

action

s

-in

div

idua

l a

ction

s b

ein

g r

ele

va

nt,

tim

ely

and

inclu

din

g

outc

om

es

-ris

k a

pp

etite

and

confide

nce

-r

esid

ua

l risk r

ating

s b

ase

d o

n e

vid

en

ce

.

Inte

rnal A

udit a

nd C

oun

ter

Fra

ud

Po

sitiv

e a

ssu

rance

on p

erf

orm

ance m

onito

ring

, a

ction

pla

n p

rog

ress a

nd t

he im

ple

me

nta

tion

of

prior

recom

me

nd

atio

ns.

Th

e S

trate

gic

Work

forc

e C

om

mitte

e (

SW

C)

to c

onsid

er

and

ga

in a

ssura

nce

on:

-co

ntr

ols

on o

ve

rtim

e

-peo

ple

ris

ks p

ost th

e B

AF

refr

esh

-me

ssag

ing

to E

U n

ationa

ls

-issu

es a

risin

g fro

m t

he n

ew

pa

yro

ll a

rra

ng

em

ents

.

Clin

ica

l A

udit

Pa

pe

r re

ce

ive

d a

nd

accep

ted

. F

utu

re r

eport

ing

to

be r

evis

ed t

o r

em

ove

du

plic

ation

with

B

oard

/Qu

alit

y C

om

mitte

e a

nd

mo

re c

losely

alig

ned

with

A

RA

C’s

Term

s o

f R

efe

ren

ce

(b

y F

eb

ruary

2019).

Leg

al S

erv

ice

s

Ne

glig

en

ce c

laim

s,

coro

ner

activity,

He

alth

&

Sa

fety

and

oth

er

leg

al a

ctivity a

re a

ll b

ein

g w

ell

ma

nag

ed

.

(1)

Fu

ture

Leg

al S

erv

ice

s r

eport

ing

to

AR

AC

to

be

re

fin

ed

to

avo

id d

up

lica

tio

n w

ith

th

e Q

ualit

y C

om

mitte

e

(QC

) scru

tinis

ed a

ctivity a

nd

AR

AC

’s T

erm

s o

f

Aud

it an

d R

isk

Com

mitt

eeC

hair'

s R

epor

t

Page 43 of 144

A

rea

A

ss

ura

nce

Is

su

es

an

d/o

r N

ext

Ste

ps

Re

fere

nce (

by F

eb

ruary

2019).

(2

) T

he S

WC

to c

onsid

er

co

nsu

lta

nt

wo

rk p

lans,

su

pe

rvis

ion a

nd

ap

pra

isals

(if n

ot a

lre

ad

y c

ove

red

by t

he

Me

dic

al D

ire

cto

r’s r

epo

rts t

o t

he A

RA

C)

(3)

The Q

C to

ga

in a

ssu

rance

on

clin

ica

l re

cord

ke

ep

ing

(4

) M

r F

lack,

Dire

cto

r of F

inan

ce

to

ensu

re M

oJ e

sta

tes

risk (

£32

0,0

00)

addre

ssed

by y

ear

end

(5

) M

s D

avie

s,

Co

rpo

rate

Se

rvic

es D

ire

cto

r to

rep

ort

b

ack o

n c

om

plia

nce

with

su

bje

ct a

ccess r

eq

uests

tim

e

limits.

Ris

ks in P

art

ners

hip

Work

ing

O

utlin

e p

ap

er

on K

ent a

nd

Me

dw

ay (

K&

M)

Ca

re

Re

cord

rece

ive

d.

Th

e A

RA

C is s

upp

ort

ive

of

obje

ctive

s a

nd t

he p

rop

ose

d

risk m

itig

atio

ns. T

he b

usin

ess c

ase is to

be s

ubm

itte

d t

o

the B

oard

. A

reas t

o c

onsid

er

– s

kin

in

th

e g

am

e fo

r a

cute

s a

nd p

rim

ary

care

plu

s invo

lve

me

nt

of

KC

C.

Esta

tes

Po

sitiv

e a

ssu

rance

. T

he r

ela

tion

ship

with

NH

S P

rope

rty S

erv

ice

s (

NH

SP

S)

rem

ain

s c

halle

ng

ing

. N

o im

me

dia

te n

ee

d fo

r e

scala

tion

to

CE

O le

ve

l d

iscu

ssio

ns.

De

pe

nd

ing

on p

rog

ress in

th

e

next

ye

ar,

co

nsid

era

tio

n to

be g

ive

n t

o a

ppro

ach

ing

NH

SE

with

oth

er

com

mun

ity t

rusts

sug

gesting

a

lte

rna

tive

op

era

tin

g m

od

els

.

Da

ta I

nte

grity

P

ositiv

e a

ssu

rance

re

ceiv

ed a

cro

ss th

e r

ang

e o

f d

ata

an

d info

rmatio

n s

yste

ms f

rom

th

is a

nnu

al

Da

ta I

nte

grity

Re

vie

w.

Ele

ctr

onic

re

cord

s a

nd

co

mp

lete

ne

ss o

f d

ata

lo

ad

ing

to

re

ceiv

e f

ocus u

nd

er

futu

re C

linic

al A

udit a

ctivity.

Bre

xit

Lim

ite

d a

ssura

nce a

s t

he p

rob

abili

ty a

nd

se

ve

rity

of

risks r

em

ain

flu

id w

ith

su

bsta

ntia

l dependencie

s o

n t

hird p

art

ies s

uch a

s D

oH

(d

rug

s),

KC

C (

sta

ff m

obili

ty,

part

icu

larly M

20

co

rrid

or)

and S

TP

(b

uild

ing o

n e

xis

tin

g r

esili

ence

arr

ang

em

ents

, p

lann

ing

sce

na

rios, e

tc).

Bre

xit t

o b

e u

nd

er

mo

nth

ly r

epo

rtin

g to

th

e B

oard

until

the o

utc

om

e is c

leare

r an

d r

isks q

uan

tifie

d a

nd

m

itig

ate

d. T

he A

RA

C r

eco

mm

end

ed t

he a

pp

oin

tme

nt

of

a B

oard

Le

ve

l S

RO

for

Bre

xit.

Sin

gle

Te

nd

er

Waiv

ers

, L

osse

s

and

Sp

ecia

l P

aym

ents

Pro

cesse

s b

ein

g w

ell

ma

na

ge

d a

nd

po

sitiv

e

assura

nce r

eceiv

ed

. T

he tre

nd

lin

e o

f D

entistr

y p

atie

nt

write

-off

s t

o b

e

revie

we

d.

Page 44 of 144

A

rea

A

ss

ura

nce

Is

su

es

an

d/o

r N

ext

Ste

ps

AR

AC

Eff

ective

ne

ss a

nd

Eva

luatio

n o

f th

e M

eetin

g

Pro

po

sals

for

de-d

up

lica

tio

n (

with

Bo

ard

an

d

oth

er

co

mm

itte

es)

plu

s tig

hte

r fo

cus o

n A

RA

C’s

T

erm

s o

f R

efe

rence

acce

pte

d.

Pe

ter

Co

nw

ay

Ch

air

, A

ud

it a

nd

Ris

k C

om

mit

tee

17 D

ece

mb

er

201

8

Aud

it an

d R

isk

Com

mitt

eeC

hair'

s R

epor

t

Page 45 of 144



Agenda Number: 2.6

Agenda Item Title: Charitable Funds Committee Chair’s Assurance Report

Presenting Officer: Richard Field, Deputy Chair of Charitable Funds Committee


Report Summary

The paper summarises the Charitable Funds Committee meeting held on 29 November 2018. A verbal report will be given of the meeting held on 30 January 2019.


The Board is asked to receive the Charitable Funds Committee Chair’s Assurance Report.



No ☒



Jen Tippin, Non-Executive Director Tel: 01622 211906

Email:

Cha

ritab

le F

unds

Com

mitt

eeC

hair'

s R

epor

t

Page 46 of 144

CH

AR

ITA

BL

E F

UN

DS

CO

MM

ITT

EE

CH

AIR

’S A

SS

UR

AN

CE

RE

PO

RT

Th

is r

ep

ort

is fo

un

ded

on

th

e C

ha

rita

ble

Fu

nds C

om

mitte

e m

eetin

g h

eld

on

Thu

rsd

ay 2

9 N

ove

mb

er

20

18

. A

ge

nd

a i

tem

A

ss

ura

nc

e a

nd

Ke

y p

oin

ts t

o n

ote

F

urt

he

r a

cti

on

s a

nd

fo

llo

w u

p

Dra

ft 2

01

7/8

Accou

nts

T

he

dra

ft a

cco

un

ts fo

r 2

017

/18 w

ere

re

vie

we

d a

nd

will

be

pre

se

nte

d fo

r fina

l a

ppro

va

l in

Ja

nu

ary

20

19

. T

he

acco

un

ts h

ad

als

o b

een

in

de

pen

den

tly r

evie

we

d b

y t

he

Tru

st’s a

ud

ito

rs,

Gra

nt T

ho

rnto

n.

The

acco

unts

will

be

pre

se

nte

d fo

r fina

l

ap

pro

va

l a

t th

e J

anu

ary

20

19

me

etin

g o

f th

e

Ch

arita

ble

Fu

nd

s C

om

mitte

e a

he

ad

of

the

de

ad

line

fo

r th

e C

ha

ritie

s C

om

mis

sio

n.

Ma

rke

tin

g t

he

Ch

arita

ble

Fu

nd

s

A r

ep

ort

wa

s r

ece

ive

d fro

m th

e M

ark

etin

g T

eam

on

pro

gre

ss.

A q

ue

stion

wa

s r

ais

ed

on

ho

w c

om

fort

ab

le th

e

Tru

st

wa

s o

n c

on

tin

uin

g t

o u

se

th

e b

rand

‘i-

care

’, g

ive

n

the

sim

ilarity

in

na

me

to

oth

er

org

an

isa

tio

ns a

nd

th

e

inte

ntio

n to

pro

mote

the

ch

arity

on

so

cia

l m

edia

.

The

Exe

cu

tive

Te

am

wa

s a

sked

to

re

-

co

nsid

er

the

use

of

the n

am

e ‘i-

ca

re’ ah

ead

of

the

ne

xt

Ch

arita

ble

Fu

nd

s C

om

mitte

e in

Ja

nua

ry 2

01

9.

Re

se

rve

s P

olic

y

Fo

llow

ing its

an

nu

al re

vie

w,

the

Re

se

rve

s P

olic

y w

as

pre

se

nte

d fo

r ap

pro

va

l. N

o c

ha

nge

s w

ere

pro

po

sed

.

No

ne

re

qu

ire

d.

Fu

nd

Man

age

r

Pre

se

nta

tio

n

A p

resen

tatio

n w

as r

ece

ive

d f

or

assu

ran

ce

on t

he

pla

ns

for

He

ron

Ward

, Q

ue

en

Vic

toria

Mem

oria

l H

osp

ita

l, H

ern

e

Ba

y w

hic

h w

ill b

en

efit fr

om

th

e u

se

of

the

Me

rmik

ide

s

Re

str

icte

d F

un

d.

The

Com

mitte

e w

ill r

ece

ive

an

assu

ran

ce

rep

ort

fro

m th

e B

ow

Ro

ad

Fu

nd M

an

age

r in

Ja

nua

ry 2

01

9.

Je

n T

ipp

in,

Ch

air

of

the

Ch

ari

tab

le F

un

ds

Co

mm

itte

e,

10 D

ecem

be

r 2

01

8

Cha

ritab

le F

unds

Com

mitt

eeC

hair'

s R

epor

t

Page 47 of 144



Agenda Number: 2.7

Agenda Item Title: Integrated Performance Report

Presenting Officer: Gordon Flack, Director of Finance


Report Summary

The Integrated Performance Report has been revised for this month, taking on board recommendations from NHS improvement in the way that the report is presented with the use of Statistical Process Control (SPC) chart. The use of these charts has been presented and agreed through the Executive Team, as well as the revised summary scorecard. It should be noted that the full Finance, Workforce and Quality reports will still be presented at their respective committees. The report has been produced in collaboration with the Executive Team and their support teams. This report contains the following sections:

• Corporate Scorecard and Summary

• Quality Report

• Workforce Report

• Finance Report

• Operational Report

Historic data has been provided to show trends, with the SPC charts being used to show a rolling 25 month view of performance for each indicator. Upper and Lower control limits are used to indicate a shift in performance over a sustained period and to highlight where performance deviates from these expected ranges. Key Highlights from report Quality

• One new grade 2 pressure ulcers categorised this month (twelve

for the year and on target to meet annual target)

• Grade 3/4 pressure ulcers (5) well below target for the year to

date. None for November and December.

• Community Hospital fill rates positive at 95% (day) and 95%

(night)

• Reducing overall trend for medication incidents, however

increased low harm incidents.

Workforce

• Turnover remains above the 16.47% target and although

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 48 of 144

reducing is still unlikely to meet target with process change.

• Sickness absence remains above the Trust target at 4.55% for

the month and consistently above the mean.

• Vacancy rates remain consistently high at 9.7%, with a high

level or recruitment activity ongoing.

• An increase in temporary staff shift requests, although fill rates

are showing normal variation.

Finance

• CIP savings currently 9.6% behind target, although forecast year

end position is for full achievement

• Capital Expenditure year to date is £2,062k, representing 67%

of the YTD plan

• YTD surplus ahead of plan (2.2%)

Operations

• NHS Health Checks (76.4%) and Stop smoking Quits (55.9%)

remain behind plan but are improving through a period of normal

variation.

• Health Visiting mandatory check performance against the New

Birth and 6-8 week visit are both on target and showing normal

variation.

• Referral to treatment incomplete wait times for consultant-led

services has improved above the 92% target, following a period

of adverse variation. No patients are now waiting above 52

weeks.

• Some waiting times for other AHP services on an non

consultant-led pathway are high, with particular reference to

MSK Physio in west Kent (Block)

• Audiology 6 week diagnostics are marginally below the 99%

target, although showing normal variation

• The newly introduced End of Life indicator, measuring the level

of electronic care planning for End of Life patients continues to

fall below the 60% target.

• Delayed Transfers of Care (DTOCs) consistent and below target

year to date, although showing a slight increasing trend on the

last 2 months.

• For Specialist and Children’s service, reported outcomes are

being either partially or fully achieved in 90% of cases.

• Late requests from KCC are impacting the performance against

the Looked After Children 28 day initial assessment national

target, although still being achieved most months. Internal

timescales are meeting the standard but are reliant on receiving

the requests within 5 working days

Page 49 of 144

• Activity for Intermediate Care services in east Kent, as well as

some Specialist and Elective Services (in particular Podiatry,

Epilepsy, Diabetes and Continence) continue to fall significantly

below the annual plan.


The Board is asked to note this report.


Not Applicable


No ☒


Nick Plummer, Assistant Director of Performance and Business Intelligence

Tel: 01233 667722


Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 50 of 144

Integrated

Perform

ance Rep

ort 2

018/19

Janu

ary 2019

repo

rt

Part One

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 51 of 144

Con

tent

s

P

age

3

P

age

4

Glo

ssar

y of

Ter

ms

Ass

uran

ce o

n St

rate

gic

Goa

ls

Pag

e 5-

8

Cor

pora

te S

core

card

Pag

e 9-

16

Q

ualit

y R

epor

t

Pa

ge 1

7-22

Wor

kfor

ce R

epor

t P

age

23

F

inan

ce R

epor

t

Pa

ge 2

4-37

Ope

ratio

nal R

epor

t P

age

38

A

ppen

dix

1 –

SPC

Cha

rts

Page 52 of 144

Glo

ssar

y of

Ter

ms

SPC

– S

tatis

tical

Pro

cess

Con

trol

LTC

– L

ong

Term

Con

ditio

ns N

ursi

ng S

ervi

ce

ICT

– In

term

edia

te C

are

Ser

vice

Qua

lity

Scor

ecar

d –

Wei

ghte

d m

onth

ly ri

sk ra

ted

qual

ity s

core

card

s

C.D

iff –

Clo

strid

ium

Diff

icile

MR

SA –

Met

hici

llin

Res

ista

nt S

taph

yloc

occu

s A

ureu

s

MIU

– M

inor

Inju

ry U

nit

RTT

– R

efer

ral t

o Tr

eatm

ent

GU

M –

Gen

itour

inar

y M

edic

ine

CQ

UIN

– C

omm

issi

onin

g fo

r Qua

lity

and

Inno

vatio

n

MTW

– M

aids

tone

and

Ton

brid

ge W

ells

NH

S T

rust

WTE

– W

hole

Tim

e E

quiv

alen

t

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 53 of 144

Non

-SPC

KPI

on

targ

etN

on-S

PC K

PI p

erfo

rman

ce u

nder

revi

ewN

on-S

PC K

PI o

ff ta

rget

Spec

ial C

ause

Not

e - t

his

indi

cate

s th

at s

peci

al c

ause

var

iatio

n is

occ

urrin

g in

a K

PI,

with

the

varia

tion

bein

g in

a fa

vour

able

dire

ctio

n.

Hig

h ( H

)spe

cial

cau

se n

ote

indi

cate

s th

at v

aria

tion

is u

pwar

ds in

a K

PI w

here

per

form

ance

is id

eally

abo

ve a

targ

et li

ne e

.g. N

ew B

irth

Vis

its. L

ow (L

) spe

cial

cau

se c

once

rn is

whe

re th

e va

rianc

e is

dow

nwar

ds fo

r a b

elow

targ

et K

PI e

.g. D

NA

Rat

e

1.0

Ass

uran

ce o

n St

rate

gic

Goa

ls

Spec

ial C

ause

Con

cern

- th

is in

dica

tes

that

spe

cial

cau

se v

aria

tion

is o

ccur

ring

in a

KP

I, w

ith th

e va

riatio

n be

ing

in a

n ad

vers

e di

rect

ion.

Lo

w ( L

) spe

cial

cau

se c

once

rn in

dica

tes

that

var

iatio

n is

dow

nwar

ds in

a K

PI w

here

per

form

ance

is id

eally

abo

ve a

targ

et li

ne e

.g. N

ew

Birt

h V

isits

. Hig

h sp

ecia

l cau

se c

once

rn (H

) is

whe

re th

e va

rianc

e is

upw

ards

for a

bel

ow ta

rget

line

KP

I e.g

. DN

A R

ate

Ove

rall,

of t

he 3

6 in

dica

tors

that

we

are

able

to p

lot o

n a

stat

istic

al p

roce

ss c

ontro

l (SP

C) c

hart,

2.8

% a

re e

xper

ienc

ing

favo

urab

le in

-mon

th v

aria

tion

(1, K

PI 4

.3),

11.1

% a

re s

how

ing

in- m

onth

adv

erse

var

ianc

e (4

, K

PIs

2.14

, 2.2

0, 5

.3 a

nd 5

.5 )

and

the

rem

aini

ng 8

6.1%

(30)

are

sho

win

g no

rmal

var

iatio

n.

25%

of t

he K

PIs

are

cons

iste

ntly

ach

ievi

ng ta

rget

(KPI

s 1.

4, 2

.12,

2.1

3, 2

.18,

2.1

9, 4

.3, 4

.5 a

nd 5

.4),

16.7

% (K

PIs

1.1,

1.2

, 2.8

, 3.5

, 4.1

and

5.3

) are

con

sist

ently

faili

ng,

with

the

rem

aini

ng 5

8.3%

var

iabl

y ac

hiev

ing

targ

et w

ith n

o tre

nd o

f con

sist

ent a

chie

vem

ent/f

ailu

re.

Of t

he 9

indi

cato

rs w

here

an

SPC

cha

rt is

not

app

ropr

iate

, 77.

8% (7

) hav

e ac

hiev

ed th

e in

-mon

th ta

rget

, with

11.

1% (1

, KPI

3.3

) rat

ed a

s am

ber a

nd 1

1.1%

(1, K

PI 2

.7) f

ailin

g th

e ta

rget

.

0%20%

40%

60%

80%

100%

Preven

t Ill He

alth

Deliver high‐qu

ality

care at

home an

d in th

e commun

ity

Integrate Services

Develop

Sustainab

le Services

Be The

Best E

mployer

Favourable Variance KP

Is (%

)

0%20%

40%

60%

80%

100%

Preven

t Ill He

alth

Deliver high‐qu

ality

care at

home an

d in th

e commun

ity

Integrate Services

Develop

Sustainab

le Services

Be The

Best E

mployer

Common

Variance KP

Is (%

)

0%20%

40%

60%

80%

100%

Preven

t Ill Health

Deliver high‐qu

ality

care

at hom

e an

d in th

ecommun

ity

Integrate Services

Develop

Sustainab

leServices

Be The

Best E

mployer

Adverse Va

riance KP

Is (%

)

Page 54 of 144

Met

ricLo

wer

Mea

nU

pper

KPI

1.1

Sto

p Sm

okin

g - 4

wee

k Q

uitte

rsN

ovem

ber 2

018

62.9

%Fa

il10

0%35

%60

%85

%KP

I is

expe

rienc

ing

natu

ral v

aria

tion,

follo

win

g a

reca

lcul

atio

n of

the

cont

rol l

imits

from

Apr

il 20

18.

KPI i

s cu

rren

tly u

nlik

ely

to m

eet t

arge

t with

out

a pr

oces

s ch

ange

with

the

uppe

r con

trol l

imit

at th

en ta

rget

leve

l

KPI

1.2

Hea

lth C

heck

s C

arrie

d O

ut

Nov

embe

r 201

876

.4%

Fail

100%

52%

69%

86%

KPI i

s ex

perie

ncin

g na

tura

l var

iatio

n, fo

llow

ing

a re

calc

ulat

ion

of th

e co

ntro

l lim

its fr

om A

pril

2018

.

KPI i

s cu

rren

tly u

nlik

ely

to m

eet t

arge

t with

out

a pr

oces

s ch

ange

with

the

uppe

r con

trol l

imit

at th

en ta

rget

leve

l

KPI

1.3

Hea

lth V

isiti

ng -

New

Birt

h Vi

sits

Und

erta

ken

by 1

4 da

ysN

ovem

ber 2

018

91.3

%90

%88

%92

%95

%KP

I will

mos

tly a

chie

ve ta

rget

but

the

cont

rol

limits

indi

cate

that

faili

ng th

e ta

rget

is a

po

ssib

ilty

with

in th

e cu

rren

t pro

cess

KPI

1.4

Hea

lth V

isiti

ng -

6-8

wee

k ch

eck

unde

rtak

en b

y 8

wee

ksN

ovem

ber 2

018

87.6

%80

%86

%89

%93

%KP

I is

cons

iste

ntly

ach

ievi

ng th

e ta

rget

with

th

e lo

wer

lim

it ab

ove

the

targ

et. T

his

sugg

ests

fa

iling

to m

eet t

he ta

rget

is u

nlik

ely

to o

ccur

.

KPI

1.5

Sch

ool H

ealth

- R

ecep

tion

Chi

ldre

n Sc

reen

ed fo

r Hei

ght a

nd

Wei

ght

Dec

embe

r 201

880

.1%

90%

(yea

r en

d)KP

I is

cum

ulat

ive

thro

ugh

the

scho

ol y

ear

KPI i

s on

traj

ecto

ry to

ach

ieve

targ

et b

y th

e en

d of

the

18/1

9 sc

hool

yea

r

KPI

1.6

Sch

ool H

ealth

- Ye

ar 6

C

hild

ren

Scre

ened

for H

eigh

t and

W

eigh

tD

ecem

ber 2

018

78.2

%90

% (y

ear

end)

KPI i

s cu

mul

ativ

e th

roug

h th

e sc

hool

yea

rKP

I is

on tr

ajec

tory

to a

chie

ve ta

rget

by

the

end

of th

e 18

/19

scho

ol y

ear

KPI

1.7

LTC

/ICT

- Adm

issi

ons

Avoi

danc

e (u

sing

agr

eed

crite

ria)

Nov

embe

r 201

864

2352

5742

8056

7670

73KP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

KPI

1.8

% L

TC/IC

T pa

tient

s th

at

had

at le

ast o

ne v

isit

whi

ch

Avoi

ded

a H

ospi

tal A

dmis

sion

Nov

embe

r 201

816

.4%

15.0

%11

.9%

16.2

%20

.5%

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

Met

ric

18/1

9 YT

D

Actu

al

18/1

9 YT

D

Targ

etK

PI 2

.1 N

umbe

r of T

eam

s w

ith a

n Am

ber o

r Red

Qua

lity

Scor

ecar

d R

atin

g N

ovem

ber 2

018

01

58

Ther

e ha

ve b

een

5 Am

ber/R

ed ra

tings

for t

he

finan

cial

yea

r to

date

with

Apr

il (2

) bei

ng th

e hi

ghes

t mon

th

KPI

2.2

Nev

er E

vent

sD

ecem

ber 2

018

00

00

No

neve

r eve

nts

expe

rienc

ed th

is y

ear.

Last

ev

ent i

n D

ecem

ber 2

016

KPI

2.3

Infe

ctio

n C

ontr

ol: C

.Diff

Dec

embe

r 201

80

00

0N

o C

-Diff

cas

es th

is y

ear.

Last

cas

e w

as in

Fe

brua

ry 2

018

KPI

2.4

Infe

ctio

n C

ontr

ol: M

RSA

ca

ses

whe

re K

CH

FT p

rovi

ded

care

Dec

embe

r 201

80

04

04

case

s th

is y

ear (

One

in e

ach

of A

pril,

Au

gust

, Sep

tem

ber a

nd O

ctob

er)

Met

ricLo

wer

Mea

nU

pper

KPI

2.5

Inpa

tient

Fal

ls (M

oder

ate

and

Seve

re H

arm

) per

100

0 O

ccup

ied

Bed

Day

sD

ecem

ber 2

018

CC

V0.

000.

19-0

.28

0.18

0.63

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

Actu

alTa

rget

Com

men

tary

Actu

alTa

rget

Com

men

tary

1. Prevent Ill Health 2. Deliver high-quality care at home and in the community

Actu

alTa

rget

Com

men

tary

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 55 of 144

Met

ricLo

wer

Mea

nU

pper

KPI

2.6

Avo

idab

le P

ress

ure

Ulc

ers

- G

rade

3 &

4D

ecem

ber 2

018

01

-2.4

0.9

4.2

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs. T

here

hav

e be

en 5

inci

dent

s th

is y

ear c

ompa

red

to 1

0 by

the

sam

e st

age

of

2017

/18

KPI

2.7

Per

cent

age

of E

nd o

f Life

pa

tient

s w

ith a

n up

date

d Pe

rson

alis

ed C

are

Plan

(PC

P)N

ovem

ber 2

018

18.9

%60

.0%

Cur

rent

ly to

o fe

w d

ata

poin

ts to

plo

t an

SPC

ch

art

KPI i

s co

nsis

tent

ly fa

iling

the

targ

et, a

lthou

gh

is a

new

targ

et a

nd d

ata

colle

ctio

n. S

ee

Ope

ratio

nal R

epor

t for

mor

e de

tail

KPI

2.8

Con

trac

tual

Act

ivity

: YTD

as

% o

f YTD

Tar

get

Nov

embe

r 201

898

.2%

100.

0%95

.0%

97.3

%99

.5%

KPI w

ill c

onsi

sten

tly fa

il th

e ta

rget

, with

the

uppe

r lim

it be

low

the

targ

et. T

his

sugg

ests

ac

hiev

emen

t is

likel

y to

be

dow

n to

cha

nce

with

out a

pro

cess

or t

arge

t cha

nge

KPI

2.9

Tru

stw

ide

Did

Not

Atte

nd

Rat

e: D

NAs

as

a %

of t

otal

act

ivity

Nov

embe

r 201

83.

3%4.

0%3.

1%3.

6%4.

2%

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs.H

owev

er, t

he ta

rget

is n

ear t

he

uppe

r lim

it su

gges

ting

failu

re to

mee

t tar

get i

s un

likel

y.

KPI

2.1

0 LT

C/IC

T R

espo

nse

Tim

es

Met

(%) (

requ

ired

time

varie

s by

pa

tient

)N

ovem

ber 2

018

97.5

%95

.0%

94.8

%96

.5%

98.2

%KP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

, alth

ough

failu

re is

unl

ikel

y w

ith

the

targ

et m

argi

nally

abo

ve th

e lo

wer

lim

it

KPI

2.1

1 Pe

rcen

tage

of R

apid

R

espo

nse

Con

sulta

tions

sta

rted

w

ithin

2hr

s of

refe

rral

acc

epta

nce

Nov

embe

r 201

895

.5%

95.0

%88

.0%

94.3

%10

0.7%

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

KPI

2.1

2 To

tal T

ime

in M

IUs:

Les

s th

an 4

hou

rsN

ovem

ber 2

018

99.8

%95

.0%

99.5

%99

.8%

100.

1%KP

I is

cons

iste

ntly

ach

ievi

ng th

e ta

rget

with

th

e ta

rget

sig

nific

antly

bel

ow th

e lo

wer

lim

it

KPI

2.1

3 C

onsu

ltant

Led

18

Wee

k R

efer

ral t

o Tr

eatm

ent (

RTT

) -

Inco

mpl

ete

Path

way

sN

ovem

ber 2

018

96.4

%92

.0%

92.9

%95

.6%

98.2

%KP

I is

now

sho

win

g co

mm

on c

ause

var

iatio

n fo

llow

ing

a pe

riod

of n

egat

ive

vario

atio

n eb

low

th

e m

ean

KPI i

s co

nsis

tent

ly a

chie

ving

the

targ

et w

ith

the

low

er li

mit

abov

e th

e ta

rget

, sug

gest

ing

failu

re to

mee

t tar

get i

s an

unl

ikel

y ev

ent.

KPI

2.1

4 AH

P (N

on-C

onsu

ltant

Led

) R

efer

ral t

o Tr

eatm

ent T

imes

(RTT

) N

ovem

ber 2

018

89.9

%92

.0%

91.1

%94

.1%

97.0

%KP

I is

expe

rienc

ing

low

adv

erse

var

iatio

n w

ith

the

last

thre

e m

onth

s be

low

the

low

er c

ontro

l lim

it

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

KPI

2.1

5 Ac

cess

to G

UM

: with

in 4

8 ho

urs

Nov

embe

r 201

810

0.0%

100.

0%10

0.0%

100.

0%10

0.0%

Con

sist

ently

mee

ting

targ

et. F

ailu

re to

mee

t ta

rget

wou

ld b

e co

nsid

ered

a c

hanc

e ev

ent

with

out a

pro

cess

cha

nge.

Has

met

targ

et fo

r th

e la

st 5

yea

rs

KPI

2.1

6 Le

ngth

of C

omm

unity

H

ospi

tal I

npat

ient

Sta

y (M

edia

n Av

erag

e)

Nov

embe

r 201

820

.121

.014

.820

.225

.6KP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

KPI

2.1

7 R

esea

rch:

Par

ticip

ants

re

crui

ted

to n

atio

nal p

ortfo

lio

stud

ies

(Yea

r to

Dat

e)D

ecem

ber 2

018

252

160

KPI i

s cu

mul

ativ

eKP

I is

cons

iste

ntly

ach

ievi

ng th

e ta

rget

of 6

0 pe

r qua

rter

KPI

2.1

8 Pe

rcen

tage

of p

atie

nt

goal

s ac

hiev

ed u

pon

disc

harg

e fo

r pl

anne

d an

d th

erap

y se

rvic

esN

ovem

ber 2

018

90.8

%80

.0%

84.5

%89

.6%

94.6

%

KPI i

s co

nsis

tent

ly a

chie

ving

the

targ

et a

s th

e lo

wer

lim

it is

sig

nifc

antly

abo

ve th

e ta

rget

. Th

is w

ould

mea

n fa

ilure

to m

eet t

arge

t wou

ld

likel

y be

due

to c

hanc

e

KPI

2.1

9 Fr

iend

s an

d Fa

mily

- Pe

rcen

tage

of P

atie

nts

who

wou

ld

Rec

omm

end

KC

HFT

Dec

embe

r 201

896

.3%

95.0

%95

.9%

97.2

%98

.5%

KPI i

s co

nsis

tent

ly a

chie

ving

the

targ

et a

s th

e lo

wer

lim

it is

abo

ve th

e ta

rget

. Thi

s su

gges

ts

faili

ng to

mee

t tar

get i

s an

unl

ikel

y ev

ent.

KPI

2.2

0 Fr

iend

s an

d Fa

mily

Tes

t (P

atie

nts

surv

eyed

for M

IUs

&

Com

m. H

osp)

- R

espo

nse

Rat

eD

ecem

ber 2

018

12.7

%20

.0%

12.9

%18

.2%

23.5

%KP

I is

expe

rienc

ing

low

adv

erse

var

iatio

n w

ith

the

last

11

mon

ths

belo

w th

e m

ean

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

KPI

2.2

1 C

linic

al A

udit:

% o

f aud

it re

com

men

datio

ns im

plem

ente

d by

de

adlin

eD

ecem

ber 2

018

86.0

%85

.0%

45.8

%75

.9%

105.

9%KP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

KPI

2.2

2 N

ICE

Tech

nica

l Ap

prai

sals

revi

ewed

by

requ

ired

time

scal

es fo

llow

ing

revi

ewD

ecem

ber 2

018

100.

0%10

0.0%

100.

0%10

0.0%

100.

0%

Con

sist

ently

mee

ting

targ

et. F

ailu

re to

mee

t ta

rget

wou

ld b

e co

nsid

ered

a c

hanc

e ev

ent

with

out a

pro

cess

cha

nge.

Has

met

targ

et fo

r th

e la

st 5

yea

rs

Actu

alTa

rget

Com

men

tary

2. Deliver high-quality care at home and in the community

Page 56 of 144

Met

ricLo

wer

Mea

nU

pper

KPI

3.1

Del

ayed

Tra

nsfe

rs o

f Car

e fr

om a

Com

mun

ity H

ospi

tal b

ed a

s a

% o

f Occ

upie

d B

ed D

ays

Nov

embe

r 201

813

.2%

9.5%

4.3%

10.3

%16

.3%

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

KPI

3.2

Per

cent

age

of L

TC/IC

T R

efer

rals

com

ing

from

with

in

KC

HFT

Nov

embe

r 201

818

.6%

10.0

%14

.9%

18.8

%22

.7%

KPI i

s co

nsis

tent

ly a

chie

ving

the

targ

et w

ith

the

targ

et c

onsi

dera

bly

belo

w th

e lo

wer

lim

it

KPI

3.3

CQ

UIN

s (%

of C

QU

IN

mon

ey a

chie

ved

to 1

8/19

Q2)

Sept

embe

r 201

894

.5%

100%

SPC

not

app

ropr

iate

for t

his

met

ricKP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

, with

2 o

f the

last

8 q

uarte

rs

achi

evin

g 10

0%

KPI

3.4

Hom

e Fi

rst c

ost s

avin

g -

redu

ctio

n of

exc

ess

bed

days

- M

onth

ly A

vera

ge £

s (W

est K

ent)

Nov

embe

r 201

8£1

8,11

2£4

0,00

0-£

69,6

10£2

3,85

5£1

17,3

19KP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

KPI

3.5

Ave

rage

wai

t tim

e (m

inut

es) f

or M

TW A

ccid

ent a

nd

Emer

genc

y Se

rvic

esD

ecem

ber 2

018

297

240

247

313

380

KPI i

s co

nsis

tent

ly fa

iling

the

targ

et a

s th

e lo

wer

lim

it is

abo

ve th

e ta

rget

. Thi

s su

gges

ts

perfo

rman

ce is

unl

ikel

y to

dec

reas

e to

mee

t ta

rget

with

out a

pro

cess

cha

nge

Met

ricLo

wer

Mea

nU

pper

KPI

4.1

Per

cent

age

of L

TC/IC

T Fa

ce to

Fac

e C

onta

cts

carr

ied

out

in a

clin

ic (t

arge

t to

incr

ease

)N

ovem

ber 2

018

3.4%

5.0%

2.9%

3.8%

4.6%

KPI i

s co

nsis

tent

ly fa

iling

the

targ

et w

ith th

e ta

rget

abo

ve th

e up

per l

imit.

Thi

s su

gges

t ac

hiev

ing

targ

et w

ithou

t a p

roce

ss c

hang

e w

ill

be d

own

to c

hanc

e an

d ne

eds

revi

ew

KPI

4.2

Bed

Occ

upan

cy: O

ccup

ied

Bed

Day

s as

a %

of a

vaila

ble

bed

days

Nov

embe

r 201

890

.2%

87.0

%83

.2%

89.2

%95

.3%

Tren

d ha

s im

prov

ed fo

llwin

g 6

mon

ths

of

adve

rse

perfo

rman

ce b

elow

the

mea

nKP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

KPI

4.3

Inco

me

& E

xpen

ditu

re -

Surp

lus

(%)

Dec

embe

r 201

82.

2%1.

0%1.

1%1.

4%1.

8%KP

I is

expe

rienc

ing

high

favo

urab

le v

aria

tion

with

the

this

mon

th's

sur

plus

per

form

ing

abov

e th

e up

per c

ontro

l lim

it

KPI i

s co

nsis

tent

ly a

chie

ving

the

targ

et a

s th

e lo

wer

lim

it is

abo

ve th

e ta

rget

. Thi

s su

gges

ts

perfo

rman

ce is

unl

ikel

y to

dec

reas

e to

bel

ow

targ

et

KPI

4.4

Cos

t Im

prov

emen

t Pla

ns

(CIP

) Ach

ieve

d ag

ains

t Pla

n (%

)D

ecem

ber 2

018

90.4

%10

0.0%

67.5

%84

.5%

101.

5%KP

I will

var

iabl

y m

eet t

he ta

rget

som

e m

onth

s an

d fa

il ot

hers

, exp

ecia

lly e

arly

in e

ach

finan

cial

yea

r

KPI

4.5

Ext

erna

l Age

ncy

spen

d ag

ains

t Tra

ject

ory

(£00

0s)

Dec

embe

r 201

8£4

65,6

26£6

28,0

00£2

03,9

93£3

84,3

36£5

64,6

79

KPI i

s co

nsis

tent

ly a

chie

ving

the

targ

et a

s th

e up

per l

imit

is b

elow

the

targ

et. T

his

sugg

ests

pe

rform

ance

is u

nlik

ely

to in

crea

se to

abo

ve

targ

et

Met

ric

18/1

9 YT

D

Actu

al

18/1

9 YT

D

Targ

etK

PI 4

.6 A

nnua

l Val

ue o

f Ten

ders

W

on b

y K

CH

FT (o

f tho

se th

at

reac

h aw

ard

stag

e - £

000s

)D

ecem

ber 2

018

£0N

o Ta

rget

No

tend

ers

that

hav

e be

en s

ubm

itted

by

KCH

FT h

ave

been

aw

arde

d th

is y

ear

KPI

4.7

Ann

ual V

alue

of T

ende

rs

Lost

by

KC

HFT

(of t

hose

that

reac

h aw

ard

stag

e - £

000s

)D

ecem

ber 2

018

£0N

o Ta

rget

No

tend

ers

that

hav

e be

en s

ubm

itted

by

KCH

FT h

ave

been

aw

arde

d th

is y

ear

4. Develop sustainable services

Actu

alTa

rget

Com

men

tary

Actu

alTa

rget

Com

men

tary

Actu

alTa

rget

Com

men

tary

No

Targ

et

No

Targ

et

£0£0

3. Integrate Services

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 57 of 144

Met

ricLo

wer

Mea

nU

pper

KPI

5.1

Sic

knes

s R

ate

Dec

embe

r 201

84.

55%

3.90

%3.

83%

4.50

%5.

17%

KPI w

ill s

omet

imes

ach

ieve

the

targ

et,

alth

ough

will

fail

mor

e of

ten

due

to th

e lo

wer

lim

it be

ing

mar

gina

lly b

elow

the

targ

et

KPI

5.2

Sic

knes

s R

ate

(Str

ess

and

Anxi

ety)

Dec

embe

r 201

81.

13%

1.15

%1.

04%

1.24

%1.

43%

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

KPI

5.3

Unp

lann

ed T

urno

ver

Dec

embe

r 201

815

.9%

14.1

%14

.5%

15.5

%16

.5%

KPI i

s ex

perie

ncin

g hi

gh a

dver

se v

aria

tion

with

the

last

12

mon

ths

perfo

rmin

g ab

ove

the

mea

n

KPI i

s co

nsis

tent

ly fa

iling

the

targ

et w

ith th

e ta

rget

bel

ow th

e lo

wer

lim

it. T

his

sugg

est

achi

evin

g ta

rget

with

out a

pro

cess

cha

nge

will

be

dow

n to

cha

nce

and

need

s re

view

KPI

5.4

Man

dato

ry T

rain

ing:

C

ombi

ned

Com

plia

nce

Rat

eD

ecem

ber 2

018

95.9

%85

.0%

88.1

%95

.7%

103.

4%KP

I is

cons

iste

ntly

ach

ievi

ng th

e ta

rget

as

the

low

er li

mit

is a

bove

the

targ

et

KPI

5.5

Gro

ss V

acan

cy F

acto

r (%

of

the

budg

eted

WTE

unf

illed

by

perm

anen

t wor

kfor

ce)

Dec

embe

r 201

89.

7%9.

7%6.

7%8.

8%10

.9%

KPI i

s ex

perie

ncin

g hi

gh a

dver

se v

aria

tion

with

the

last

12

mon

ths

perfo

rmin

g ab

ove

the

mea

n

KPI w

ill v

aria

bly

mee

t the

targ

et s

ome

mon

ths

and

fail

othe

rs

Actu

alTa

rget

Com

men

tary

5. Be The Best Employer

Page 58 of 144

2.0

2.1

As

Qua

lity

Re

ssur

ance

on

Sa

The

shift

fiin

crea

sing

Onl

y E

den

Thre

e ho

spR

N s

hifts

wre

sulte

d in

be

en t

o c o

addi

tiona

l s

Whi

le P

riman

d so

had

Wes

tvie

w w

nigh

t shi

fts

Sta

ffing

is

unde

rtaki

n g

epor

t af

er S

taffi

ng

ill r

ates

for

com

1% fr

om N

ove m

brid

ge H

ospi

tal

pita

ls h

ad a

nig

hw

ere

unab

le to

an

ove

rfill

rate

fov

er w

hen

the

staf

f to

prov

ide

s

mro

se w

ard

has

d 43

RN

day

shi

fw

hich

cur

rent

ly

s. re

view

ed d

aily

ag

the

audi

t for

th

mun

ity h

ospi

tal

mbe

r. T

he n

ight

had

a da

y fil

l rat

ht fi

ll ra

te u

nder

9be

fille

d by

ban

for H

CA

s. T

here

RN

shi

fts c

ould

safe

car

e fo

r pat

no p

lann

ed R

N

fts a

nd 3

0 R

N n

iha

s on

ly o

ne u

n

and

shor

tage

s a

he 6

mon

thly

saf

war

ds a

re s

et o

shift

fill

rate

for

te b

elow

95%

, in

95%

. Ede

nbrid

gnk

or

agen

cy th

ee

have

bee

n ad

dd

not

be f

illed

, tie

nts

with

cog

ni

shift

s be

caus

e ig

ht s

hifts

on

e-r

nit o

f 15

beds

an

are

subj

ect t

o th

fer s

taffi

ng re

viewou

t bel

ow.

The

RN

’s w

as 9

5%,

ncre

asin

g by

0.7

ge h

ad d

ropp

ed t

e w

ards

incr

eas

ditio

nal H

CA

s on

and

addi

tiona

lltiv

e im

pairm

ent .

it is

a th

erap

y w

rost

er.

nd th

e re

gist

ered

he s

ame

esca

law

s.

day

fill

rate

for

drop

ping

from

9

7% fr

om th

e pr

ev

to 8

7.1%

, whi

le

sed

the

use

of H

n a

num

ber o

f sh

y W

hits

tabl

e an

. war

d, th

ey e

mpl

o

d nu

rse

fill r

ate

i

tion

proc

esse

s arre

gist

ered

nur

s99

% in

Nov

embe

viou

s m

onth

to 8

Dea

l and

QV

MH

HC

A s

taff

to e

xphi

fts in

mos

t hos

nd T

anke

rton,

Q

oyed

tem

pora

ry

s am

ber a

t 90%

as o

ther

KC

HFTse

s (R

N)

in D

ecer

.

81.5

% in

Dec

em

H b

oth

drop

ped

pand

gen

eral

ca

spita

ls, t

he m

ajo

QV

MH

and

Fav

staf

fing

to p

rov

% fo

r day

s an

d g

T w

ards

. A

ll w

a

cem

ber

was

95%

ber.

to 9

1.9%

. W

her

apac

ity w

hich

ha

ority

of t

hese

hav

vers

ham

req

uire

ide

nurs

ing

cove

reen

at 9

1.7%

fo

ards

are

cur

rent

%, re

as

ve

ed

er

or

tly

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 59 of 144

2.2

A 2.2

2.2ss

uran

ce o

n Pr

2.1

Cat

egor

y 2

The

num

b eag

reed

traj

finan

cial

ye

Ther

e ha

s as

avo

idab

The

belo

w

2.2

Cat

egor

y 3,

The

num

b etra

ject

ory

o

ress

ure

Ulc

ers

Pres

sure

Ulc

er

er o

f avo

idab

le

ecto

ry o

f a 1

0 %ea

r to

date

.

been

1 c

ateg

ory

le. T

his

occu

rred

char

t sho

ws

tha

4 or

Ung

rada

b

er o

f avo

idab

le s

of 1

0% re

duct

ionrs

cate

gory

2 h

arm

% re

duct

ion

in a

v

y 2

pres

sure

ulc

ed

in L

ong

Term

at th

e le

vel o

f ca

ble

Pres

sure

Ulc

serio

us h

arm

s a

n in

avo

idab

le h

ams

acqu

ired

in o

void

able

har

ms

er a

cqui

red

in o

uS

ervi

ces,

Tha

ne

tego

ry 2

pre

ssu

cers

acqu

ired

in o

ur

arm

s, re

achi

ng aou

r ca

re to

the

on th

e pr

evio

us

ur c

are

durin

g D

et. re u

lcer

s is

acq

u

care

to th

e en

d a

72%

redu

ctio

n

end

of D

ecem

bye

ar o

f 18,

rea

Dec

embe

r tha

t, fo

uire

d w

ithin

our

c

of N

ovem

ber

isfo

r the

fina

ncia

lber

is 1

2. T

he tr

chin

g a

33%

red

ollo

win

g in

vest

ig

care

is n

ot o

f co

s 5.

The

trus

t is

l yea

r to

date

.

rust

is o

n ta

rget

duct

ion

in a

void

gatio

n, h

as n

ow

once

rn.

on

targ

et to

act o

f ach

ievi

ng th

able

har

m fo

r th

been

cat

egor

ise

chie

ve th

e ag

ree

he

he

ed

ed

Page 60 of 144

2.3

A

Ther

e w

ere

serio

us in

c

The

char

t bso

me

mon

t

The

Tiss

ueoc

cur t

o id

e

ssur

ance

on

Fa

Ther

e w

ere

com

mun

ity Th

e fo

urth

su

ppor

ted

prop

erty

. T

e no

avo

idab

le c

iden

ts.

belo

w s

how

s th

ath

s an

d fa

il ot

he

e V

iabi

lity

Team

entif

y ke

y th

eme

alls

e 56

fal

ls r

epor

y ho

spita

l and

on

fall

occu

rred

in t

livin

g ac

com

mod

The

num

ber o

f avca

tego

ry 3

or a

b

at c

ateg

ory

3 or

rs.

lead

s a

pres

sues

less

ons

to a

llo

rted

acro

ss K

Cne

in a

clin

ic a

rea

the

Com

mun

ity

datio

n an

d su

sta

void

able

falls

habo

ve p

ress

ure

ul

r ab

ove

pres

sur

ure

harm

red

ucti

ow le

arni

ng to

b

HFT

in

Dec

ema

whi

ch re

sulte

d

unde

r the

car

e o

aine

d a

fract

ure

as re

duce

d si

ncece

rs a

cqui

red

in

re u

lcer

s ar

e al

s

ion

grou

p, a

nd t

e sh

ared

.

ber

2018

, 4

of

d in

no

harm

to t

of th

e In

tegr

ated

d ne

ck o

f fem

ure

Q1

May

201

7 a

n ou

r car

e du

ring

so e

xper

ienc

ing

the

team

are

wo

thes

e w

ere

fou

he p

atie

nt.

d C

are

Team

, To

r whi

lst a

ttem

ptin

and

rem

ain

consg

Nov

embe

r or D

com

mon

cau

se

orki

ng c

lose

ly w

und

to b

e av

oid

onbr

idge

. Th

e p

ng to

hel

p th

e P

sist

ently

low

withD

ecem

ber t

hat w

e va

riatio

n an

d w

with

team

s w

here

dabl

e.

Two

of

patie

nt fe

ll in

the

hysi

othe

rapi

st g

h a

slig

ht ri

se in

wer

e id

entif

ied

a

will

ach

ieve

targ

e pr

essu

re h

arm

thes

e w

ere

in

mai

n en

tranc

e ga

in a

cces

s to

thD

ecem

ber.

as

et

ms a of

he

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 61 of 144

2

.4 A

ssur

ance

on

A to

tal o

f 1A

void

able

m

Med

icat

ion

inc

18 a

void

able

me

med

icat

ion

inci

dcide

nts

edic

atio

n in

cide

nde

nts

cont

inue

tonts,

acq

uire

d in

o

redu

ce.

our

care

, hav

e

been

rep

orte

d aan

d in

vest

igat

ed

d to

dat

e du

ring

Dec

embe

r 20

1

8.

Page 62 of 144

The

high

e snu

mbe

r du

prep

arat

ion

Of t

he 1

8 a

15

3 ( 1

Thes

e re

laan

d a

dou b

All

inci

dent

Ther

e w

ere

The

re w

ere

failu

re in

C

st r

epor

ted

cate

ring

Dec

embe

r n/

supp

ly in

cide

nt

avoi

dabl

e in

cide

n(8

3%) r

esul

ted

i17

%) r

esul

ted

inte

d to

a c

ontra

cbl

e do

se o

f a d

ruts

wer

e in

vest

iga

e no

inci

dent

s th

e a

larg

e nu

mbe

IS to

dow

nloa

d egor

y of

avo

idab

2018

. Th

e se

cots

mak

ing

up 1

7

nts

that

occ

urre

dn

no h

arm

to th

e lo

w h

arm

to th

ece

ptio

n in

ject

ion

ug b

eing

adm

inis

ated

and

the

less

at re

sulte

d in

se

er o

f low

har

m

patie

nts’

vis

its t obl

e in

cide

nts

we

ond

high

est r

ep7%

eac

h of

the

to

d du

ring

Dec

eme

patie

nt w

ith th

ee

patie

nt w

ith th

en

bein

g ad

min

ist

ster

ed. T

he p

atie

sons

lear

nt h

ave

ever

e ha

rm o

r de

inci

dent

s in

Sep

o ta

blet

s. T

his

uere

omitt

ed m

eor

ted

cate

gory

oot

al n

umbe

r dur

ber 2

018:

e

maj

ority

of t

hees

e in

cide

nts

bete

red

afte

r on

e en

ts w

ere

mon

itoe

been

sha

red.

eath

of a

pat

ient

ptem

ber,

abov

e un

derly

ing

issu

edica

tion

and

wr

of a

void

able

inc

ing

Oct

ober

201

ese

bein

g om

itte

eing

wro

ng fr

equ

wee

k in

stea

d of

ored

in a

ll ca

ses

t. the

uppe

r co

ntr

has

now

bee

n rro

ng q

uant

ity m

iden

ts is

wro

ng

8.

d m

edic

atio

n.

ency

, wro

ng q

u af t

wo

wee

ks, t

hes.

rol l

imit,

indi

cati

reso

lved

.

mak

ing

up 2

2%

frequ

ency

, and

antit

y an

d w

rong

e ad

min

istra

tion

ng w

hich

wer

e

each

of

the

tot

wro

ng m

etho

d

g dr

ug /

med

icin

n of

a w

rong

dru

as a

res

ult o

f th

ta

l of

e.

ug

he

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 63 of 144

2.5

A

2.

5

2.5ss

uran

ce o

n Pa

5.1

Mer

idia

n Pa

4,32

9 su

rvD

ecem

ber.

rece

nt y

ear

trend

and

in

5.2

The

NH

S Fr

i

The

NH

S F

2018

, 0.7

%‘d

on’t

know

the

dent

al s

To a

ssis

t win

clud

ed in

by K

CH

FT at

ient

Exp

erie

n

atie

nt E

xper

ienc

veys

wer

e co

m S

urve

y vo

lum

ers

due

to th

e C

hnc

reas

e in

Jan

u

iend

s an

d Fa

m

Frie

nds

and

Fam

% o

f our

pat

ient

s w

’ res

pons

e in

Dse

rvic

e, 2

for M

S

with

ben

chm

arki

repo

rting

. Nor

foas

a ra

tio o

f thenc

e

ce s

urve

y re

sul

plet

ed b

y K

CH

es h

ave

decr

eahr

istm

as p

erio

d ar

y 20

19.

ily T

est (

FFT)

mily

Tes

t sco

re f

chos

e no

t to

rec

Dec

embe

r co

mp

SK

phy

siot

hera

p

ing,

Nor

folk

Com

olk

aver

age

arou

eir s

ervi

ce p

rovi

slts

FT p

atie

nts,

re

sed

in D

ecem

ban

d is

not

rel

at

for D

ecem

ber o

fco

mm

end

the

sear

ed to

37

in N

py, 1

for p

ulm

ona

mm

unity

Hea

lth

und

98%

for t

hesi

on.

elat

ives

and

car

ber

com

pare

d w

ted

to a

ny s

peci

f 96.

3% re

com

mer

vice

they

rece

ovem

ber.

30

o far

y re

hab,

1 fo

r

and

Car

e N

HS

eir N

HS

FFT

sco

rers

with

a s

trow

ith N

ovem

ber.

Tifi

c se

rvic

es. S

u

men

d is

con

sist

eiv

ed, a

repe

titio

nf t

he ‘d

on’t

know

inte

rmed

iate

ca

S T

rust

, who

hav

ore,

how

ever

theon

g co

mbi

ned

This

is in

line

wrv

ey v

olum

es a

nt w

ith N

ovem

bn

of th

e 0.

7% in

w

’ res

pons

es w

ere

and

1 fo

r hea

ve b

een

give

n a

ey c

olle

ct le

ss th

satis

fact

ion

sco

with

the

gen

eral

re a

ntic

ipat

ed to

ber’s

sco

re (9

6.6

Nov

embe

r. 3

8 er

e ch

ildre

n an

dal

th w

alks

.

a C

QC

rat

ing

ofan

a ¼

of t

he s

u

ore

of 9

6.99

%

tre

nd s

een

ove

o fo

llow

the

usu

6%).

In D

ecem

bepe

ople

cho

se th

d th

ere

wer

e 3

fo

f out

stan

ding

, ar

urve

ys c

ondu

cte

in

er

al

er

he

or

re

ed

Page 64 of 144

2.6

Ass

uran

ce o

n C

linic

al A

udit

and

Res

earc

h

2.6.

1 A

udit

The

annu

al K

PI t

arge

t is

for 9

5% o

f clin

ical

aud

it re

com

men

datio

ns to

be

impl

emen

ted.

Thi

s is

ach

ieve

d vi

a a

step

ped

targ

et d

urin

g th

e ye

ar.

Targ

et fo

r Dec

embe

r has

bee

n ac

hiev

ed.

2.6.

2 C

linic

al A

udit

Rep

ortin

g

This

rel

ates

to

rece

ivin

g th

e fu

ll re

port

with

in a

spe

cifie

d tim

efra

me

afte

r re

ceip

t of

das

hboa

rd r

epor

ting.

Ste

pped

tar

get

intro

duce

d fo

r re

porti

ng a

nd ta

rget

for e

nd o

f yea

r inc

reas

ed fr

om 5

0% to

80%

follo

win

g on

goin

g im

prov

emen

t in

perfo

rman

ce. T

arge

t for

Dec

embe

r not

ac

hiev

ed w

ith 9

repo

rts o

verd

ue.

Rep

orts

ove

rdue

for A

dults

, Adu

lts S

ES

, Chi

ldre

n’s

Spe

cial

ist,

Pub

lic H

ealth

and

Den

tal.

2.6.

3 R

esea

rch

KC

HFT

wor

ks to

del

iver

an

annu

al r

ecru

itmen

t ple

dge

to th

e K

ent S

urre

y an

d S

usse

x C

linic

al R

esea

rch

Net

wor

k to

del

iver

hig

h qu

ality

na

tiona

l stu

dies

(kno

wn

as p

ortfo

lio s

tudi

es) t

o lo

cal p

atie

nts.

Thi

s is

a K

ey P

erfo

rman

ce In

dica

tor f

or re

sear

ch.

2.6.

4 N

atio

nal I

nstit

ute

for C

linic

al E

xcel

lenc

e (N

ICE)

The

num

ber o

f NIC

E g

uida

nce/

sta

ndar

ds th

at w

ere

issu

ed in

Dec

embe

r 201

8 w

as s

even

teen

.

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 65 of 144

Th

e nu

mbe

r of

gui

danc

e/st

anda

rds

issu

ed in

Aug

ust 2

018

that

wer

e du

e fo

r as

sess

men

t in

Nov

embe

r 20

18 w

as fo

urte

en. T

hree

of t

he

guid

ance

/ sta

ndar

ds is

sued

wer

e de

emed

app

licab

le to

at l

east

one

ser

vice

thro

ugho

ut th

e Tr

ust.

Page 66 of 144

3.0

3.1

A 3.1

3.1W

orkf

orce

ssur

ance

on

Re

1.1

Turn

over

The

cont

r oB

ank

wer

e

Follo

win

g t

dow

nwar

d

At

the

pea

resu

lting

in

1.2

Stab

ility

This

dat

a h

seen

that

tco

ntra

ct. T

now

a s

hifte

Rep

ort:

eten

tion

ol li

mits

wer

e re

s tr

eate

d. It

was

a

this

reb

asin

g, t

utre

nd in

turn

ove

ak i

n A

ugus

t 20

n st

aff l

eavi

ng.

has

only

bee

n co

ther

e w

as a

sig

This

was

then

fot t

o a

posi

tive

vaset i

n D

ecem

ber

antic

ipat

ed th

at

urno

ver

is e

xpe

er in

rece

nt m

ont

018

ther

e w

ere

onsi

dere

d as

pa

nific

ant s

hift

cha

ollo

wed

by

a ru

nar

iatio

n bu

t out

sir 201

7 to

refle

ct

this

cha

nge

wou

erie

ncin

g co

mm

oth

s as

the

outp

u

sign

ifica

nt s

truc

art o

f thi

s re

port

ange

the

autu

mn

of d

eter

iora

tinde

the

cont

rol l

i mthe

Boa

rd a

gre

uld

have

a 2

% im

on c

ause

var

iat

uts

of th

e B

IG L

is

ctur

al c

hang

es i

for t

he la

st 2

mo

mn

of 2

017

whi

cg

perfo

rman

ce

mits

aga

in. T

his em

ent t

o ch

ang

mpa

ct o

n th

e tu

r

ion

but

is f

ailin

gst

en a

re im

plem

in H

ealth

Vis

itin

onth

s. W

hen

loch

we

belie

ve w

whi

ch w

ould

ha

is b

eing

inve

stige

the

way

in w

hrn

over

rate

whi

ch

g to

mee

t th

e ta

ente

d.

ng,

Chi

ldre

n an

d

okin

g at

the

dat

as a

con

sequ

enav

e w

arra

nted

inga

ted

furth

er.

hich

leav

ers

who

h is

refle

cted

in

arge

t. H

owev

er

d S

peci

alis

t an

d

a in

the

form

of

nce

of th

e lo

ss

nves

tigat

ion

at to

rem

aine

d on

thth

e da

ta.

we

have

see

n

d D

enta

l se

rvic

e

an S

PC

it c

an b

of th

e no

rth K

ehe

tim

e. T

here

he a es

be

nt

is

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 67 of 144

3.2

A 3.2ss

uran

ce o

n Si

2.1

Sick

ness

Ab

The

sick

neth

e lik

elih

osy

stem

nee

A s

epar

ate

man

age

sipr

ovid

ers

thickn

ess

bsen

ce

ess

abse

nce

per

od o

f the

targ

eted

s to

be

rede

sig

e pa

per h

as b

eeck

ness

abs

enc e

he T

rust

has

perrfo

rman

ce is

cur

t bei

ng m

et is

sgn

ed.

n pr

esen

ted

to t

e.

In r

each

ing

rform

ed b

ette

r thre

ntly

ope

ratin

g su

bjec

t to

rand

o

the

Stra

tegi

c W

oth

is d

ecis

ion

it ha

n ot

her T

rust

swith

in th

e co

ntr

m v

aria

tions

. T

orkf

orce

Com

mi

may

be

wor

th

s un

til th

e la

st 2

rol l

imits

but

as

tTh

is m

eans

that

ttee

prov

idin

g a

cons

ider

ing

tha

mon

ths

of th

e dath

e Tr

ust t

arge

t ei

ther

the

targ

e

assu

ranc

e on

the

at w

hen

benc

hmat

a se

t

is s

et n

ear t

he

et s

houl

d be

rec

e co

ntro

ls a

nd a

mar

ked

agai

nst lo

wer

con

trol l

imco

nsid

ered

or

th

actio

ns in

pla

ce t

othe

r co

mm

uni

mit he

to

ty

Page 68 of 144

3.22.

2 St

ress

Abs

e

Stre

ss a

bsin

crea

se c

ath

e au

tum

nto

det

erm

in

Initi

ativ

es i

taki

ng p

lac

with

eve

ntsen

ce

ence

is re

porti

n gan

not b

e at

tribu

tn

and

win

ter o

f 2ne

whe

ther

per

fo

n pl

ace

incl

ude

ce in

Nov

embe

r as

happ

enin

g ac

rog ab

ove

the

upp

ted

to a

ny o

ne s

2018

as

initi

ativ

eor

man

ce w

ill re

tu

the

Tim

e to

Cha

and

loca

l act

ion

oss

the

Trus

t.

per c

ontro

l lim

it a

serv

ice

but i

ncre

aes

aim

ed a

t red

uur

n to

with

in th

e

ange

pro

ject

, wh

plan

s be

ing

devan

d w

ell a

bove

tas

ed a

cros

s a

rauc

ing

this

met

ric

cont

rol l

imits

or

hich

con

tinue

s at

velo

ped

with

in sta

rget

s, fo

llow

ing

ange

. The

re h

asha

ve b

egun

to t

r whe

ther

furth

er

t pac

e, w

ith th

e s

ervi

ces

in J

anuag

an in

crea

se d

us

how

ever

bee

n ta

ke e

ffect

. Thi

s r r

edes

ign

need

s

seco

nd in

duct

ion

ary.

Our

ant

i-bu

urin

g th

e su

mm

ea

slow

dow

nwa

data

sho

uld

be

s to

take

pla

ce

n of

Tim

e to

Cha

llyin

g ca

mpa

igner

of 2

018.

Thi

s rd

tren

d ac

ross

w

atch

ed c

lose

l y

ange

cha

mpi

ons

has

also

beg

un

y s n

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 69 of 144

3.3

A 3.3ss

uran

ce o

n Fi

3.1

Esta

blis

hme

Vac

anci

es

the

incr

eas

effe

ct.

Janill

ing

Vaca

ncie

s

ent a

nd V

acan

c

are

curr

ently

rese

in v

acan

cies

nu

ary

will

hav

e vs ci

es

porti

ng a

bove

thin

Dec

embe

r, r

very

hig

h le

vels

ohe m

ean,

with

ac

rece

nt tr

ends

ha

of n

ew s

tarte

rs tch

ieve

men

t of t

hav

e be

en d

ownw

to c

ount

erac

t thehe

targ

et b

eing

vw

ards

as

cont

inu

e in

crea

se in

vac

varia

ble

depe

ndue

d hi

gh le

vels

ca

ncie

s se

en in

dant

on

natu

ral v

of r

ecru

itmen

t aD

ecem

ber.

varia

tion.

Des

pit

activ

ity h

as ta

ke

te

en

Page 70 of 144

3.3

3.33.

2 Te

mpo

rary

S

Ther

e is

no

top

of th

e c

qual

ity im

p

3.3

Age

ncy

Spe

The

shar

p w

ith b

udg e

curr

ent

fina

win

ter p

resSt

aff U

sage

o ta

rget

set

for t

hco

ntro

l lim

its, t

hero

vem

ent p

roje

c

end

drop

in s

pend

inet

ed y

ear

to d

ate

anci

al p

ositi

on s

ssur

es a

nd th

is ishe

Ban

k fil

l rat

e e

proc

ess

wou

ldct

and

mon

itor t

h

n A

pril

2017

is a

e tra

ject

orie

s ha

serv

ices

hav

e be

s th

e ca

use

of th

alth

ough

loca

llyd

need

to b

e re

dhe

impa

ct g

oing

attri

buta

ble

to th

eas

just

mov

ed o

een

enco

urag

edhe

incr

ease

in s

py th

e te

am a

re s

esig

n to

mak

e t

forw

ard

of c

han

e in

trodu

ctio

n of

outs

ide

the

uppe

d to

use

tem

por

pend

aga

inst

thise

t a 7

0% b

ank

his

chan

ge b

ut t

nges

.

f the

nat

iona

l cap

er c

ontro

l lim

it a

rary

sta

ff, in

clud

s ta

rget

.

fill r

ate

of th

e to

this

is a

n id

eal o

ps in

age

ncy

rat

and

is a

ppro

ach

ding

age

ncy,

to

tal f

ill ra

te. A

s th

oppo

rtuni

ty to

co

tes.

Age

ncy

spe

hing

the

100

% t

redu

ce b

ackl

og

his

rate

is a

t the

onsi

der t

his

as a

end

in c

ompa

riso

arge

t. G

iven

th

s or

to

cope

wit

e a on

he

th

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 71 of 144

3.4

A 3.4ss

uran

ce o

n Tr

4.1

Man

dato

ry T

Man

dato

ry

App

rais

al o

was

99.

3 %ra

inin

g C

ompl

ia

Trai

ning

Com

p

Trai

ning

figu

res

obje

ctiv

e se

tting

%

ance

lianc

e

s ar

e cu

rrent

ly in

for

the

curr

ent n

a st

ate

of n

atur

appr

aisa

l yea

r ral v

aria

tion

arou

(FY

18/1

9) is

cuun

d th

e m

ean,

a

rren

tly r

epor

tingan

d ar

e co

nsis

te

g at

80%

com

ple

ntly

on

targ

et.

ete.

App

rais

al s

i

gn o

ff fo

r 17

/18

Page 72 of 144

4.0

Fina

nce

Rep

ort:

4.1

Ass

uran

ce o

n Fi

nanc

ial S

usta

inab

ility

4.

2 K

ey M

essa

ges

Surplus: T

he Trust achieved a surplus of £3,72

1k to the en

d of Decem

ber. Pay has und

erspen

t by

£8,33

7k, a

nd non

‐pay and

dep

reciation/interest

have overspe

nt by £3

,471

k and £5

4k re

spectiv

ely. Incom

e has u

nder‐recovered

by £3

,208

k.

Continuity of S

ervices Risk Rating: EBITD

A Margin achieved

is 3.7%. The

Trust sc

ored

1 against th

e Use of R

esou

rces Rating, th

e be

s t possib

le sc

ore.

CIP: The

Trust achieved CIPs of £

2,81

3k to

the en

d of Decem

ber a

gainst a plan of £3,11

1k, w

hich is £29

8k beh

ind target.

Cash and

Cash Eq

uivalents: The cash and

cash eq

uivalents balance was £32

,531

k, equ

ivalen

t to 56 days expen

diture. The Trust recorded

the

following YTD pu

blic se

ctor paymen

t statistics 9

9% fo

r volum

e and 98

% fo

r value

.

Capital: Capita

l Expen

diture year to date is £2,06

2k, rep

resenting 67

% of the

YTD

plan. The

Trust's forecast capita

l expen

diture fo

r 201

8‐19

is £3.7m

, represen

ting a £2

64k varia

nce to plan. The

forecast overspe

nd of £

262k re

lates to investmen

t in WiFi infrastructure for w

hich add

ition

al cen

tral

fund

ing (PDC

) has been agreed

.

Agen

cy: Tempo

rary staff costs for De

cembe

r were £9

66k, rep

resenting 7.6%

of the

pay bill. Of the

tem

porary staffing

usage in

Decem

ber, £3

61k

related to external agency and £1

04k to locums, 3.7% of the

pay bill.

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 73 of 144

5.0

5.1

A 5.1O

pera

tion

ssur

ance

on

Na

1.1

Hea

lth C

hec

Hea

lth C

he

Hea

lth C

hedu

e to

the

pr

ocur

ed b

on th

e ne

wpe

rform

anc

will

be

initi

ada

ta e

rror

s18

/19

targ

eon

ce th

ere

prac

tices

aqu

ality

of d

‘am

ber’

figim

prov

e p e

al re

port

: at

iona

l Per

form

cks

and

SS Q

ui

ecks

ecks

is n

ow e

xpe

sign

ifica

nt c

han

y K

CC

. How

eve

w s

yste

m a

nd c

once

man

agin

g th

eat

ed o

n a

mon

ths

and

impr

ove

aet

as

this

is th

e f

is a

poo

r st

art

and

a fe

w a

re s

tat

a im

porte

d an

ures

, al

thou

gh

erfo

rman

ce a

s mm

ance

Sta

ndar

d

ts

erie

ncin

g a

perio

nge

whe

n th

e N

er, t

he tr

end

look

nseq

uent

ly th

e p

e co

ntra

ct to

try

hly

basi

s fro

m O

ssur

ance

for

the

first

yea

r of a

fiv

to th

e ye

ar.

Pe

till n

ot b

eing

abl

nd re

solv

ed m

osK

CH

FT a

re c

o nm

uch

as p

ossi

bleds

and

Con

trac

od o

f com

mon

cN

HS

Hea

lth C

heks

to b

e a

posi

tivpr

actic

es h

ave

ban

d re

solv

e th

eO

ctob

er 2

018

(the

GP

pra

ctic

es.

ve y

ear c

ohor

t to

erfo

rman

ce c

ont

e to

impo

rt fo

ll ot o

f the

invi

tatio

nnt

inui

ng t

o ex

plo

e.

ctua

l Tar

gets

ause

var

iatio

n fo

ecks

IT

infra

stru

ve s

hift

abov

e th

been

una

ble

to in

e is

sues

out

lined

is w

as o

rigin

ally

Thi

s on

the

He

o se

e if

the

targ

ein

ues

to b

e si

gnow

ing

the

Apo

llon

erro

rs th

at w

eror

e ot

her

oppo

ror th

e la

st 4

mon

ctur

e ch

ange

d o

he m

ean.

The

re

nvite

thei

r pop

ula

d. In

this

res

pec

y ag

reed

as

qua

ealth

Impr

ovem

eet

cou

ld b

e sp

rea

nific

antly

impa

cto

quer

y ru

ns.

Tre

repo

rted.

The

rtuni

ties

for

Hea

nths

, fol

low

ing

aon

the

1st

Apr

ilha

ve b

een

som

atio

n fo

r 18/

19.

ct, i

t has

bee

n a

arte

rly),

whi

ch s

hen

t ris

k re

gist

er

ad a

s th

is p

rogr

ed d

ue to

the

dhe

cha

nge

to m

e ta

rget

traj

ecto

alth

Che

ck d

eliv

a re

calc

ulat

ion

of 2

018

whi

ch is

e

prob

lem

s w

it hK

CC

is a

war

e o

agre

ed th

at th

e A

houl

d he

lp m

inim

also

. K

CH

FT tr

ram

me

is v

ery

diel

ay in

ava

ilabl

em

onth

ly q

uerie

s h

ry h

as b

een

ame

very

in a

n ef

fortf t

he c

ontro

l lim

ia

new

IT

syst

eh

load

ing

softw

arof

this

issu

e an

d A

pollo

que

ry r

unm

ise

any

pote

nti

ryin

g to

neg

otia

tiff

icul

t to

catc

h u

e da

ta fo

r th

e G

has

impr

oved

then

ded

in li

ne w

itt

to m

aint

ain

an

ts

m

re

is

ns

al

te

up

GP

he

th

nd

Page 74 of 144

5.1

Stop

Sm

ok

Sto

p S

mok

path

way

s i

inte

rven

tion

supp

ort

to

enco

urag

i npr

egna

nt m

smok

ers

1.2

Hea

lth V

isiti

New

Birt

h

A s

light

do

arou

nd th

ere

ports

.

king

Qui

ts

king

qui

ts a

lso

hin

to o

ne a

s pe

n ou

tcom

es o

nto

upda

te o

utco

me

ng.

Sm

okin

g pr

em

ums,

KC

C a

nd

ing Visi

ts

ownw

ard

trend

w m

ean

leve

l. Th

had

a si

gnifi

cant

r th

e ne

w c

ont

o th

e ne

w d

ata

ses

pul

ling

us in

ev

alen

ce c

ontin

d K

CH

FT w

ill b

e

was

evi

dent

for m

e ta

rget

of 9

0%

t eve

nt a

fter

the

tract

ual

agre

emsy

stem

. Q

3 sh

olin

e w

ith 2

017

ues

to m

ove

in

e m

eetin

g to

dis

mon

ths

5 an

d 6,

has

bee

n co

ns

ON

E Y

OU

Ser

ent

with

KC

C,

ows

an u

plift

from

perfo

rman

ce (

Na

dow

nwar

ds t

scus

s ne

w a

ppro

, alth

ough

this

his

tent

ly a

chie

vedrv

ices

had

impl

em

ainl

y im

pact

inm

Q1

and

Q2

asN

ov 1

8 -

43.5

8%tre

nd,

and

with

oa

ches

to e

ngag

as s

tabi

lised

in

d an

d w

ill b

e cl

oemen

ted

a ne

w

ng t

he a

bilit

y o

3rd

par

ties

have

% o

f ta

rget

, N

ovth

e su

cces

sful

ogi

ng th

e co

unty

’

the

last

cou

ple

osel

y m

onito

red

IT s

yste

m c

omb

f ou

r 3rd

par

ties

e re

ceiv

ed fo

cus

v 17

- 4

5.68

% o

outc

omes

of

the

’s to

ughe

st a

nd

of m

onth

s w

ith

thro

ugh

the

mobi

ning

thre

e cl

ies

to u

ploa

d th

ese

d an

d su

stai

neof

targ

et)

whi

ch

e H

ome

Vis

its f

oha

rdes

t to

reac

perfo

rman

ce n

oon

thly

dis

trict

lev

nt

eir

ed

is

or

ch

ow

vel

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 75 of 144

6-8

Wee

k C

As

with

new

and

8 an

d do

wn

into

aChe

cks

w b

irth

visi

ts, t

heha

ve im

prov

ed

any

adve

rse

trener

e w

as a

dip

inan

d ho

pefu

lly t

nds.

n m

onth

s 5

and

the

posi

tive

tren6,

with

bot

h m

ond

will

con

tinue

.nths

per

form

ing

Mon

thly

pro

cesou

tsid

e of

the

css

es c

ontin

ue to

cont

rol l

imits

. Ho

o be

in p

lace

fo

owev

er, m

onth

s or

loca

litie

s to

dr

7 rill

Page 76 of 144

5.1

5.11.

3 N

atio

nal C

h

The

mea

supr

ogra

mm

e

1.4

Min

or In

jury

KC

HFT

’s a

Alth

ough

tsi

gnifi

cant

lyild M

easu

rem

e

urem

ent p

rogr

ames

cur

rent

ly a

bo

y U

nits

(MIU

) 4

achi

evem

ent o

f the

re w

as a

sm

y ab

ove

targ

et fo

Curren

t Mo

18/19 Scho

Year to

Nov

17/18 Scho

Year

Annu

al Ta ren

t Pro

gram

me

mm

e fo

r Yea

r R

ove

75%

and

imp

Hou

r Wai

t Tar

g

he 4

hou

r wai

t ta

mal

l de

crea

se i

nor

the

mon

th. I

nd

Year

R

onth

80.1%

ool

v‐18

80.1%

ool

97.3%

rget

90%

(NC

MP)

and

6 pu

pils

is p

prov

ed o

n th

e sa

get

arge

t for

Min

or I

n M

arch

201

8 de

ed, t

he c

ontro

Year

6

78.2%

78.2%

95.7%

90%

0.0%

50.0%

100.0%

prog

ress

ing

wel

lam

e po

sitio

n in

t

Inju

ries

Uni

ts h

aw

hich

res

ulte

d ol

rang

e su

gges

t

%%%

Sep

Oct l a

gain

st tr

ajec

toth

e pr

evio

us s

ch

as c

onsi

sten

tly b

in m

argi

nally

bts

that

failin

g ta

r

tNov

De

18/19 Scho

o

Year R

Ye ory

for t

he 1

8/19

hool

yea

r

een

high

, with

vbr

each

ing

the

lrg

et is

hig

hly

unl

ecJan

F

ol Year

ear 6

9 sc

hool

yea

r, w

i

very

littl

e va

riatio

ower

con

trol

limik

ely

to h

appe

n.

Feb

Mar

th b

oth

on fr

om th

e m

eam

it, t

his

was

st

n.

till

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 77 of 144

5.1

5.11.

5 G

UM

48h

r

Acc

ess

to G

1.6

Con

sulta

nt-

The

prop

o rw

orse

ned

bbe

en w

ithin

bein

g th

at t

The

abov

ebe

low

18

w

GU

M c

linic

s w

ith

-Led

RTT

Inco

m

rtion

of p

atie

nts

betw

een

Aug

ust

n ou

r A

dult

Chr

oth

e ta

rget

has

be

tab

le s

how

s th

wee

ks, w

ith o

nly KC O C Chi

n 48

hrs

has

be

mpl

ete

Wai

ts O

v

on a

con

sulta

nt 2

017

and

Mar

con

ic P

ain

and

Oee

n ac

hiev

ed a

n

he c

urre

nt b

reak

2 w

aits

abo

ve 3

KCHF

T To

tal

Chronic Pain

Ortho

paedics

Children's A

udiolo

Community

Paediaee

n co

nsis

tent

ly

ver 1

8 w

eeks

nt-le

d R

efer

ral t

och

201

8 an

d th

eO

rthop

aedi

cs s

ernd

per

form

ance

kdow

n of

the

wa

36 w

eeks

. The

a

0‐12

W80

926

036

154

043

1

gy atrics

y 10

0%, w

ith n

o r

o Tr

eatm

ent (

RT

en s

tabi

lised

. Th

rvic

es in

eas

t Ke

has

impr

oved

a

aitin

g lis

t fo

r al

l ve

rage

wai

t for

Wks

12‐18 Wks

189

143

525

51

00

127

552

5

repo

rted

brea

ch

TT)

path

way

at

e va

st m

ajor

ity o

ent a

nd th

ese

hbo

ve th

e m

ean.

serv

ices

on

a c

patie

nts

wai

ting

8‐36

Wks

36‐52 W

660

106

10

08

018

01

es

mon

th e

nd w

hoof

our

inco

mpl

etha

ve g

reat

ly im

p co

nsul

tant

-led

pov

er 1

8 w

eeks

ks52

+ Wks

< 18

19

09

010

09

19

o ar

e w

aitin

g le

ste

pat

hway

s ov

epr

oved

in m

onth

athw

ay.

96.4

%

is 2

1.4

wee

ks.

8 Weeks

93.4%

96.4%

00.0%

98.8%

96.4%

ss th

an 1

8 w

eek

er 1

8 w

eeks

hav

8, w

ith th

e re

su

of w

aits

are

no

ks

ve

ult

ow

Page 78 of 144

5.1

5.11.

7 6

Wee

k D

iag

Whi

le 6

we

perfo

rman

cth

e ch

alle

n

1.8

End

of L

ife C

gnos

tics

(Aud

io

eek

diag

nost

ics

ce h

as im

prov

edgi

ng 9

9% ta

rget

Car

e

Curren

18/19

17/18

Annu

aolog

y)

wai

ts f

or p

aed

d in

rece

nt m

onth

t nt M

onth

18.9

YTD

30.9 N/

al Target

60.0ia

tric

audi

olog

y hs

and

is e

xper

i

9% 9% /A 0%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

expe

rienc

ed a

ie

nce

com

mon

c

May

Jun

La

perio

d of

neg

aca

use

varia

tion.

Jul

Aug

ast 1

2 mon

ths treat

ive

varia

tion

frH

owev

er, r

ece n

Sep

Oct

end

om J

anua

ry 2

0nt

per

form

ance

i

Nov

18 t

o A

pril

201

s ge

nera

lly b

elo

8,

ow

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 79 of 144

5.1

The

end

ofth

eir

time

o31

%, t

he p

year

has

be

1.9

Del

ayed

Tra

KC

HFT

’s ta

9.5%

as

a al

thou

gh t h

in E

ast K

en

f life

indi

cato

r is

of d

eath

; the

refo

pers

onal

ised

car

een

set a

t 60%

ansf

ers

of C

are

arge

t for

del

aye

rate

of o

ccup

iehi

s pe

riod

has

ennt

. Thi

s le

vel w

ill

new

for 1

8/19

, or

e no

tren

d da

re p

lann

ing

win

d

(DTO

Cs)

d tra

nsfe

rs is

t oed

bed

day

s. T

hnd

ed w

ith th

e la

l be

mon

itore

d tore

porti

ng th

e pe

ata

is a

vaila

ble

pdo

w o

n C

IS is

st

o re

duce

to a

n a

ere

was

a s

usta

ast 2

mon

ths

abo

o se

e if

the

trender

cent

age

of E

ndpr

ior

to A

pril

20til

l bei

ng e

mbe

dd

aver

age

of 7

per

aine

d pe

riod

of

ove

the

mea

n. T

d co

ntin

ues.

d of

Life

pat

ient

s18

. Whi

le th

e p

ded

and

perfo

rm

r da

y in

bot

h ea

sim

prov

ed p

erfo

This

has

bee

n cas

who

had

an

uer

form

ance

for

man

ce s

houl

d st

a

st K

ent a

nd w

esrm

ance

from

Oc

ause

d by

an

incpd

ated

per

sona

the

year

to d

ate

art t

o im

prov

e. T

st K

ent,

whi

ch e

ctob

er 2

017

to

crea

sed

leve

l of al

ised

car

e pl

an

e eq

uate

s to

on

The

targ

et fo

r th

equa

tes

to a

roun

Sep

tem

ber

201

dela

yed

trans

fe

at

nl

y hi

s nd

8,

rs

Page 80 of 144

5.1

5.1

5.1

1.10

Loo

ked

Aft

Initi

al H

ealt

perfo

rman

cK

CH

FT is

sw

hich

was

Com

plia

nce

mon

th 8

Pe

1.11

NH

S N

umb

NH

S N

umb

have

a N

HS

1.12

Bed

Occ

up

Bed

Occ

uppa

rticu

lar

cm

onth

8 im

ter C

hild

ren

Ini

th A

sses

smen

t (ce

is s

till v

aria

ble

stru

gglin

g to

influ

100%

for t

his

re

e w

ith th

e R

evie

erfo

rman

ce a

t 93

ber C

ompl

eten

e

ber

com

plet

ene

S n

umbe

r ass

ig

panc

y

panc

y is

sho

win

conc

ern.

Alth

oug

mpr

ovin

g. T

his

ha

tial H

ealth

Ass

(IHA

) per

form

ane

and

liabl

e to

faue

nce.

We

have

epor

ting

perio

d.

ew H

ealth

Ass

es3.

8%

ess

ss a

cros

s K

CH

ned

(alth

ough

l a

ng a

var

ying

tre

gh m

onth

s 5-

7 as

hig

hlig

hted

th

essm

ents

(IH

A

ce is

sho

win

g co

ailin

g ta

rget

som

e an

add

ition

al K

ssm

ent t

arge

t is

FT’s

mai

n sy

ste

ater

upd

ated

) an

end

with

no

pew

ere

belo

w t

arha

t the

dip

in p

erAs)

and

Rev

iew

omm

on c

ause

vm

e m

onth

s. T

his

KPI

to e

nsur

e th

a

cont

inui

ng to

ex

ems

are

cons

ist

nd O

vers

eas

MIU

erio

ds o

f sp

ecia

rget

and

low

er t

rform

ance

sho

ul

Hea

lth A

sses

s

varia

tion

and

is a

is d

ue to

late

req

at w

e co

mpl

ete

t

xper

ienc

e a

perio

tent

ly c

.100

%,

wU

atte

ndan

ces.

l ca

use

varia

ti oth

an t

he m

ean

d no

t be

of c

oncm

ents

(RH

As)

achi

evin

g ta

rget

qu

ests

bei

ng re

cth

e IH

A w

ithin

23

od o

f pos

itive

va

with

the

mai

n ex

on o

r ch

ange

s i

leve

l of

occu

pace

rn a

t thi

s st

agem

ost m

onth

s. H

ceiv

ed fr

om K

CC

3 da

ys o

f rec

eip

aria

tion

abov

e th

xcep

tion

bein

g

in p

erfo

rman

ce

ncy,

thi

s ha

s n o

e.

How

ever

, C

and

whi

ch

pt o

f the

refe

rral

e m

ean,

with

new

birt

hs y

et t

that

wou

ld b

e ot

con

tinue

d w

it

to a th

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 81 of 144

5.1

5.2

A 5.21.

13 C

QU

IN

The

Q2

CQ

prop

ortio

na

ssur

ance

on

ac

2.1

Act

ivity

Dur

ing

No v

2018

KC

HF

The

larg

es5.

5%) a

nd Q

UIN

ach

ieve

mal

ly h

ighe

r val

ue

ctiv

ity a

nd p

rod

vem

ber

2018

KC

FT a

re 1

.8%

be

st v

aria

nces

are

D

enta

l Ser

vice

sent

(% o

f po

ten

is p

lace

d on

Q4

duct

ivity

CH

FT c

arrie

d ou

low

targ

et fo

r se

with

in L

ong

Tes

(-3.

6%).

ntia

l inc

ome)

is

4.

ut 1

96,0

77 c

linic

ervi

ces

that

hav

erm

Con

ditio

ns at

94.

5% (

100%

cal c

onta

cts,

of w

ve c

ontra

ctua

l ac

(-1.

8%),

Inte

rme%

in Q

1),

alth

ou

whi

ch 1

0,10

0 w

ect

ivity

targ

ets

in

edia

te C

are

Serug

h th

e w

eigh

tin

ere

MIU

atte

nda

plac

e, a

slig

ht i

rvic

es (

-9%

), S

p

ng o

f th

e C

QU

IN

ance

s. F

or th

e y

impr

ovem

ent o

npe

cial

ist

and

EleN

S m

eans

tha

t

year

to N

ovem

ben

the

M7

posi

tioec

tive

Ser

vice

s

a er

n. (-

Page 82 of 144

The

follo

wi

Ele

ctiv

e S

epe

riods

of

leve

ls in

8 o

Interm

ediate Care

Community

Hospita

Long Term Con

ditio

Service Type

Children's S

pecialist

Learning Disa

bilities

Dental Service ‐ All

All Services (contra

*Children's U

nivers

All Services (includ

MIU Attendances

Community

Hospita

Specialist a

nd Elect

Community

Hospita in

g ch

arts

sho

wer

vice

s, w

hich

aco

mm

on c

ause

of th

e la

st 9

mon

al Occupied Be

d Da

ys (EK)

ons

t Services

s ‐ Face to Face

currencies

actual)

sal Services

ding

those with

out targets)

al Adm

issions

tive Services

al Occupied Be

d Da

ys (W

K) w th

e m

onth

ly a

cal

l sho

wed

an

ime

varia

tion,

alth

ont

hs.

58 18 10 1 2, 2, 28 3, 41 17 12 147

196

M8 A ct

ivity

aga

inst

tam

prov

emen

t in

mou

gh t

he b

igge

s

,437

433,558

,401

158,414

,100

92,009

198

1,514

210

16,913

297

18,382

,025

217,223

835

65,546

,988

650,913

,714

124,112

,872

79,132

7,957

1,122,875

6,077

1,443,060

Actual

YTD Ac

tual

arge

t for

Lon

g T

mon

th 8

, par

ticu

st c

once

rn is

IC

441,586

‐1

174,164

‐9

75,139

22

1,213

24

17,346

‐2

229,746

‐5

121,919

1.

82,100

‐3

1,143,213

‐1

N/A

N

YTD Target

YTD V er

m C

ondi

tions

,la

rly in

Lon

g Te

T/R

apid

Res

pon

1.8%

Positive

9.0%

Negative

2.5%

Negative

4.8%

Negative

2.5%

Positive

Positive

5.5%

Negative

Negative

Positive

.8%

Positive

.6%

Negative

1.8%

Positive

N/A

Positive

Mov

emen

tVa

riance

, Int

erm

edia

te C

erm

Con

ditio

ns.

nse

whi

ch h

as

Contrac

Internal BRA

G

Car

e S

ervi

ces

aA

ll th

ree

area

s ex

perie

nced

low

*these figures a

rtotals as th

ey do

target

ct BRG

nd S

peci

alis

t an

are

expe

rienc

inw

er t

han

aver

ag

Internal

Contract

>+5%

>+10%

>‐5%

>‐10%

+/‐ 2

.5‐5%

n/a

<+/‐ 2.5%

<+/‐ 10%

No Target

e no

t included in th

e table

n’t h

ave a contractual

nd

ng

ge

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 83 of 144

5.2

5.22.

2 D

NA

rate

s

DN

A ra

tes

The

gene

r ata

rget

clo

se

2.3

Clin

ic b

ased

cont

inue

to fa

ll al

var

iatio

n is

co

e to

the

uppe

r co

d ac

tivity

belo

w th

e ta

rge

omm

on c

ause

, von

trol l

imit

then

et o

f 5%

, alth

oug

varia

bly

perfo

rmth

is w

ould

indi

cagh a

re s

igni

fican

min

g ab

ove

and

ate

that

it is

unl

ikntly

hig

her w

ithin

belo

w th

e m

eake

ly th

at le

vels

wn so

me

serv

ices

n w

ith n

o di

sce

wou

ld in

crea

se a

, par

ticul

arly

ch i

rnib

le p

atte

rn. H

abov

e ta

rget

.

ildre

n’s

ther

apie

How

ever

, with

th

s.

he

Page 84 of 144

5.2

5.3

The

targ

et

incr

ease

d t

achi

eve

thi

wou

ld s

ugg

2.4

Adm

issi

ons

Whi

le th

ere

mea

n to

inpe

rform

anc

3 A

ssur

ance

on

Wai

ting

timpe

rform

anc

dow

n to

the

Blo

ck A

QP

serv

ice

is im

for L

ong

Term

ath

roug

h in

itiat

ive

s ta

rget

with

out

gest

reac

hing

5%

s A

void

ed

e ap

pear

s to

hav

dica

te th

at p

erfo

ce b

eing

var

iabl

e

n Lo

cal W

ait T

im

mes

for a

ll no

n co

ce b

eing

bel

ow

e cl

earin

g of

the

P P

hysi

othe

rapy

.m

pact

ing

the

ov

and

ICT

serv

ices

es s

uch

as th

e w

som

e fo

rm o

f pr

% w

ithou

t som

e

ve b

een

a hi

ghe

orm

ance

is s

till

e, a

chie

ving

the

mes

onsu

ltant

-led

AH

the

mea

n, w

ith

e ba

cklo

g in

som

Thi

s is

like

ly to

eral

l per

form

ancs

is to

incr

ease

cw

ound

clin

ics,

wit

roce

ss c

hang

e.

form

of c

hang

e

er le

vel o

f adm

isva

riabl

e m

onth

ta

rget

mon

thly

i

HP

ser

vice

s ar

e th

e la

st 3

mon

t hm

e se

rvic

es, w

ito

cont

inue

in th

ece

.

clin

ic b

ased

act

ivth

the

proc

ess

liTh

e ab

ove

cha r

wou

ld b

e un

like

ssio

ns a

void

ed in

to m

onth

. Yea

r is

not

alw

ays

gu

curr

ently

exp

eri

hs a

lso

falli

ng b

th a

vie

w to

red

ue

com

ing

mon

thsvi

ty to

at l

east

5m

its re

calc

ulat

ert

show

s th

at th

ely

to o

ccur

.

n th

e la

st 8

mon

to d

ate

perfo

rmua

rant

eed.

enci

ng a

per

iod

belo

w th

e ta

rget

uc

ed lo

ng w

aits

s w

ithin

Wes

t Ke%

of a

ll ac

tivity

ced

form

Aug

ust 2

e cu

rren

t upp

er c

nths

, thi

s ha

d re

dm

ance

aga

inst

ta

of s

peci

al c

aus

leve

l of 9

2%. T

on th

e w

aitin

g en

t Blo

ck M

SK

Pcarr

ied

out.

Whi

2017

, we

are

cur

cont

rol l

imit

is a

r

duce

d in

Sep

tem

arge

t is

favo

urab

e va

riatio

n w

ith

The

dip

in r

ecen

tlis

t, pa

rticu

larly

P

hysi

o, w

hich

d

le th

is h

as

rren

tly u

nlik

ely

toro

und

4.6%

whi

c

mbe

r to

belo

w th

ble,

alth

ough

wit

the

last

7 m

onth

t mon

ths

is p

art

with

in W

est K

eue

the

size

of t

h

o ch

he

th

hs

tly

nt

he

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 85 of 144

5.

44 O

utco

mes

Agg

rega

te

outc

ome

i nab

ove

char

the

rang

e oou

tcom

es a

re

n th

e va

st m

ajor

rt al

so s

how

s th

aof

per

form

ance

vcurr

ently

rep

ort

rity

of c

ases

on

at a

chie

vem

ent

vary

ing

mon

th to

ed f

or A

dult

Sp

a co

nsis

tent

ba

of ta

rget

is a

lwa

o m

onth

sho

uld

npeci

alis

t an

d C

has

is, w

ith th

e ab

ays

likel

y to

occ

not f

all l

ow e

nouhi

ldre

n’s

Ther

apy

bove

sho

win

g n

ur u

nles

s a

proc

ugh

to b

reac

h ta

y se

rvic

es,

with

o sp

ecia

l cau

sece

ss c

hang

e oc

crg

et.

h pa

tient

s re

ceiv

e va

riatio

n in

rec

curs

, as

the

con

ving

a f

avou

rab

cent

mon

ths.

Th

trol l

imits

indi

ca

le

he

te

Page 86 of 144

The

follo

wi

deta

il on

osu

mm

aris

e

Worsene

Not Ach

Partially

Mostly

AFully Achng

tabl

e an

d ch

outc

omes

. E

ach

ed.

S Ele

ed ieved

y Ac

hieved

Achieved

hieved

hart

show

s th

e p

out

com

e w

ill b

pecialist and

ectiv

e Services

C

2.4%

7.5%

33.1%

11.7%

45.2%

prop

ortio

n of

the

be s

peci

fic t

o th

Children's S

peciali

Services

0.0%

2.3%

13.4%

14.5%

69.8%

e gr

adin

g of

eac

he p

atie

nt a

nd w

st

ch o

utco

me

for

tw

ill b

e pe

rson

althe

year

to d

ate

lised

, th

eref

ore e,

spl

it by

ser

vic

not

allo

win

g fuce

type

for

furth

erth

er d

etai

l to

b

er

be

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 87 of 144

App

endi

x - S

core

card

SPC

Cha

rts

1. P

reve

nt Il

l Hea

lth

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

140.0%

Stop

Smok

ing Quits

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

120.0%

Health Che

cks

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

6‐8 Wee

k Ch

ecks

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

3750

4250

4750

5250

5750

6250

6750

7250

Admission

s Av

oide

d

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

% LT

C/ITC Patie

nts with

an avoide

d ad

mission

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

New

Birth Visits

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Data Outsid

e Limits

Common

Variance

Page 88 of 144

2. D

eliv

er h

igh-

qual

ity c

are

at h

ome

and

in th

e co

mm

unity

‐0.40

‐0.20

0.00

0.20

0.40

0.60

0.80

Mod

erate an

d Severe fa

lls per 1,000

bed

days

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

‐3.0

‐2.0

‐1.00.0

1.0

2.0

3.0

4.0

5.0

Category 3/4 Pressure Ulcers

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

Contractua

l activity

against ta

rget

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

DNA Ra

te

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

LTC/ICT Re

spon

se Tim

es Being

Met

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

% 2Hr

Rap

id Respo

nses m

et

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

MIU 4Hr

Target

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

Consultant‐Led

RTT

Incomplete Waits

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

99.0%

99.2%

99.4%

99.6%

99.8%

100.0%

100.2%

GUM Access with

in 48H

rs

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 89 of 144

2. D

eliv

er h

igh-

qual

ity c

are

at h

ome

and

in th

e co

mm

unity

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Med

ian length of stay (days)

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Positiv

e ou

tcom

es achieved for p

lann

ed care an

d therap

y services

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

93.00%

94.00%

95.00%

96.00%

97.00%

98.00%

99.00%

Percen

tage of p

atients who

wou

ld re

commen

d ou

r services

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Friend

s an

d Family Respo

nse Ra

te (M

IU and

Inpa

tients)

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Clinical Aud

it Im

plem

entatio

ns by de

adlin

e

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

98.0%

98.5%

99.0%

99.5%

100.0%

100.5%

NICE gu

idan

ce re

view

ed with

in timescales

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

AHP Non

Con

sulta

nt‐le

d 18

Wee

k complete waits with

in 18

wee

ks

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

Page 90 of 144

3. In

tegr

ate

Serv

ices

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

Delayed Tran

sfers of Care

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Percen

tage of ICT/LTC

Referrals from with

in KCH

FT

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

‐£100,00

0

‐£50,000£0

£50,00

0

£100,000

£150,000

Home First saving ‐W

est K

ent

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

050100

150

200

250

300

350

400

450

500

Average wait tim

e (m

inutes) for Acciden

t and

Emergency

Services (W

est K

ent)

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 91 of 144

4. D

evel

op s

usta

inab

le s

ervi

ces

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

LTC/ICT % Con

tacts in clin

ic

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

Bed Occup

ancy

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

0.00

%

0.50

%

1.00

%

1.50

%

2.00

%

2.50

%

Income an

d Expe

nditu

re Surplus vs plan

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

CIP Ac

hieved

Against Plan

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

0

100000

200000

300000

400000

500000

600000

700000

External Agency Sp

end

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

Page 92 of 144

5. B

e Th

e B

est E

mpl

oyer

3.0%

3.5%

4.0%

4.5%

5.0%

5.5%

Sickne

ss Rate

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

Sickne

ss Rate (Stress)

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

10.0%

11.0%

12.0%

13.0%

14.0%

15.0%

16.0%

17.0%

Unp

lann

ed Turno

ver

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

82.0%

87.0%

92.0%

97.0%

102.0%

107.0%

Man

datory Training Ra

te

values

Target

Mean

UCL

LCL

Positive Va

riance

Negative Va

riance

Breach

Common

Variance

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

13.0%

Vacancy Ra

te

values

Target

Mean

UCL

LCL

Positive Va

riatio

nNegative Va

riatio

nBreach

Common

Variatio

n

Inte

grat

ed P

erfo

rman

ceR

epor

t

Page 93 of 144



Agenda Number: 2.8

Agenda Item Title: Preparedness for Brexit Report

Presenting Officer: Natalie Davies, Corporate Services Director


Report Summary

This report provides information and assurance to the Board of the Trust’s position

in relation to its preparedness for Brexit.


For the Board to note the report.



No ☒


Natalie Davies, Corporate Services Director Tel: 01622 211904


Tru

st P

repa

redn

ess

for

Bre

xit

Rep

ort

Page 94 of 144

PREPAREDNESS FOR BREXIT

1. Introduction

The United Kingdom (UK) is scheduled to exit the European Union (EU) at 2300

(GMT) on 29 March 2019.

The Secretary of State for Health and Social Care has issued a number of letters

and information on the Government’s revised Border Planning Assumptions to

industry and the health and care system.

These letters focus on supply chain implications in the event that the UK leaves the

EU without a ratified agreement – a ‘no deal’ exit.

The potential implications of a ‘no deal’ exit or indeed one with a deal are difficult to

fully quantify but it is our duty to prepare for all scenarios. The impact in Kent could

be felt particularly acutely with the entry and exit points to mainland Europe and in

response a coordinated plan across the county is required. This preparation is being

undertaken in partnership with health, social care, police and other organisations in

Kent.

2. Background

With the publication of the Department of Health and Social Care’s 'EU Exit

Operational Readiness Guidance' in December 2018, the Government set out its

expectation for all health and care commissioners and providers (including adult

social care providers) to undertake local EU Exit readiness planning, local risk

assessments and test and plan appropriately for the UK’s withdrawal from the EU on

the 29 March 2019.

The guidance covered seven key areas of risk:

1. supply of medicines and vaccines,

2. supply of medical devices and clinical consumables,

3. supply of non-clinical consumables, goods and services,

4. workforce,

5. reciprocal healthcare,

6. research and clinical trials,

7. data sharing, processing and access.

In addition, Kent and Medway health and care organisations are part of the Kent

Resilience Forum (KRF) multi-agency EU Exit planning.

Page 95 of 144

Owing to its unique geography and large number of UK border ports, (Dover

Harbour, Euro Tunnel and Ramsgate Harbour) these plans focus primarily on the

potential increased traffic volume caused by border checking delays.

To ensure a consistent and joined up approach to planning and assurance, the Kent

and Medway Sustainability and Transformation Partnership (STP) is coordinating the

business continuity (BC) review and planning for health and care commissioners and

providers.

In November 2018, NHS provider organisations were also directed by NHS

Improvement to review their supply chains. The outputs from these reviews were fed

into the Governments EU Exit Operational Readiness Guidance.

3. Assessment

3.1 Governance structure

The Chief Executive has appointed the Corporate Services Director as the lead

Director for the EU exit. The Trust has set up a small team lead by the emergency

planning function to coordinate the Trust response. A Trust wide committee has

been formed reporting to the Executive Team to develop and test the readiness

plans.

A number of working groups report to the Committee. These are:

• Adults East including CYP and SES

• Adults West

• Pharmacy

• Contracts, Procurement and Estates

• Service Prioritisation

• IT

• Dental

• Facilities

The issue of transportation and movement across the county is considered by each

group and coordinated through the committee.

The Trust work programme echoes the Sustainability and Transformation

Partnership in dividing it into three phases:

• Planning phase (Current – March 2019)

o Identification of impacts

o Assurance of Business Continuity plan and service plans

o Coordination of plans with key partners

o Command and Control structure review

Tru

st P

repa

redn

ess

for

Bre

xit

Rep

ort

Page 96 of 144

o Training, testing and exercise

o Communications

• Response phase (March 2019 - )

o Operational response active

o STP Strategic and tactical response teams operational

o Communications

• Recovery phase

o Asses and support recovery as required

o Communications

The STP has appointed a Director with responsibility for EU Exit and is coordinating with the Local Health Resilience Partnership (LHRP) and the other statutory organisations. Monthly meetings of the LHRP are being held at which the Trust is represented.

3.2 Committee Sub-Groups

3.2.1 Workforce

The impact on the workforce of Britain leaving the EU has been considered. The Trust is aware of 101 members of staff with nationality aligned with the EU. Each of these members of staff has been written to and the Trust has offered to fund their application fee to remain. There will be no change to staff’s current rights under EU law until the end of the planned implementation period on 31 December 2020.

3.2.2 Medicines

The Chief Pharmacist is part of a communication group with NHS England (NHSE) reviewing the implications of Brexit. This group communicates weekly to assess the on-going implications. At this stage, NHSE advises that no drugs should be stockpiled but to ensure that stores are kept up to date. This is in place.

3.2.3 Procurement contract

Procurement has completed a review of all expenditure contracts with suppliers

which has been, or is set to be, over £100k. Suppliers have been reviewed for

any implications for the supply chain. NHSE has requested a return on this

matter in which the trust identified priority areas for review. 17 contracts have

been identified under these categories with an assessment and mitigations

completed.

Services are in the process of identifying any contract that they hold directly

with suppliers or are held through a third party. Clinical commissioning groups

Page 97 of 144

who hold some contracts e.g. the supply of continence products, have been

contacted for assurance. This is being coordinated through the STP.

3.2.4 Medical devices

Medical devices have been considered as part of the supply of contracts and

suppliers. In addition, assurance has been provided that the list of devices is up

to date and maintained appropriately.

4. Travel

The STP, on behalf of the Kent and Medway CCGs and providers, has been

contributing to the KRF road traffic planning to ensure the health and care needs are

recognised in these national plans.

Several tests of the Kent Resilience Forum plan have been held; including the recent

lorry test between Manston and Dover, and the learning from these is being collated

and will be fed into a series of health specific exercises. The potential impact of

Brexit on Kent’s roads could be significant. The Police are planning for between

three and six months of disruption to Kent roads. This has been the discussion of the

Local Health Resilience Partnership over the last few months. However, preparations

in the last two months have increased.

A Brexit workshop was held on 22 November 2018 where the plans for Operation

Brock including plans for haulage storage at Manston and the potential closure of the

M26 will all be reviewed together with corresponding management plans and tactical

response. The introduction of Operation Brock and related plans is solely the

decision of the Kent Police Service. The decision to implement one of these

operations will also trigger command groups to be established to coordinate the

implementation and take an over view. The NHS will be required to attend these

command groups and NHSE has asked both commissioners and providers to ensure

they are ready to attend as needed. In readiness for this, the Police are holding

training days for both Strategic and Tactical Command. A multi-agency table top

exercise is scheduled for 12 February 2019 at which the Trust will be represented.

In the Trust, services have been looking at the potential impact of Brexit on travel for

a number of months. The issue of travel across the county is incorporated in service

Business Continuity Plans and these measures are being coordinated across the

trust. A specific transport plan, akin to the previous Fuel Strike plan is being

refreshed. This will include different levels of response and work is on-going to

identify:

• Staff’s closest base

• Alternative methods of travel and their feasibility for specific services

Tru

st P

repa

redn

ess

for

Bre

xit

Rep

ort

Page 98 of 144

• Alternative methods of communication

• Staff accommodation at bases

• Use of the voluntary sector

• Core service response

5. Plans

The Trust has a draft operational Brexit plan which will be tested through a number

of table top exercises, the STP exercise held on 12 February 2019 and an internal

exercise facilitated by the Head of Emergency Preparedness, Resilience and

Response on 13 February 2019.

Following this exercise and the identified learning, the plan will be updated and

brought for approval to the executive early March 2019.

6. Multi Agency Assurance and Risk

An assurance template has been created by the STP and circulated to all

commissioners and providers (including general practice) of health and social care. It

has been designed to identify assurance gaps and risks as well as prompt

organisations to test their contingency plans against the seven key areas of activity

and the scenario of major traffic disruption caused by delays at the borders. This will

be completed by the Trust by the deadline of the end of January. The STP will then

collate responses into an action plan to address any identified gaps. The current

Trust risk register is shown at Appendix A and the STP EU Exit Risk Register is

shown at Appendix B.

7. Conclusion

Planning is well underway for the UK’s exit from the European union, however, it is an area of uncertainty and plans must remain flexible to respond. Kent Community Trust is integrated into the whole system planning and work to coordinate across organisations has stepped up in the last few weeks. Natalie Davies Corporate Services Director 24 January 2019

Page 99 of 144

Ap

pe

nd

ix A

K

CH

FT

Ris

k R

eg

iste

r K

en

t C

om

mu

nit

y H

eal

th N

HS

Fou

nd

atio

n T

rust

No

De

al E

xit

fro

m t

he

Eu

rop

ean

Un

ion

Ris

k A

sse

ssm

en

tG

ree

n =

Ris

k <

5A

mb

er =

Ris

k >

10R

ed =

Ris

k b

etw

een

10

- 1

5

Ris

k n

o.

Haz

ard

/ T

hre

atIm

pac

tsR

isk

Typ

eLi

kelih

oo

dIm

pac

tR

isk

Sco

reM

itig

atio

nR

isk

Ow

ne

r

Tru

stW

ork

forc

e in

clu

din

g r

eci

pro

cal h

eal

thca

re0

1

10

1 k

no

wn

sta

ff w

ith

EU

nat

ion

alit

y

If s

taff

are

no

t aw

ard

ed E

U c

itiz

ensh

ip (

202

1)

the

Tru

st w

ill

enco

un

ter

a st

aff

sho

rtag

e.

Clin

ical

Rep

uta

tio

nal

Reg

ula

tory

23

6

Tru

st h

as w

ritt

en t

o a

ll kn

ow

n e

ffec

ted

sta

ff a

nd

re

qu

est

that

th

ey

app

ly f

or

citi

zen

ship

. Th

e Tr

ust

will

re

fun

d t

he

app

licat

ion

fee

of

£6

5.U

pd

ate

10

.01

.19

Pu

blic

ity

on

-go

ing

for

all s

taff

. U

pd

ate

: N

o lo

nge

r

a fe

e f

or

Cit

ize

nsh

ip

Louis

e N

orr

is –

Dire

cto

r o

f

Wo

rkfo

rce

,

Com

munic

ations

and O

D

Tru

st S

up

ply

of

Me

dic

ine

s an

d V

acci

ne

s 0

2

Pre

dic

ted

to

be

an

imp

act

on

imp

ort

ed

ph

arm

ace

uti

cal p

rod

uct

sP

atients

may n

ot re

ceiv

e a

ppro

pri

ate

medic

ines

Clin

ical

Rep

uta

tio

nal

Reg

ula

tory

23

6

Ch

ief

Ph

arm

aci

st is

in c

om

mu

nic

atio

n w

ith

NH

S E

ph

arm

aci

sts

and

rece

ivin

g w

eekl

y ad

vice

fro

m D

epu

ty C

hie

f P

har

ma

cist

En

glan

d.

Ad

vise

d t

o k

eep

un

der

re

view

at

this

sta

ge b

ut

no

t to

tak

e an

y fu

rth

er

acti

on

. U

pd

ate

: N

ew

agr

ee

me

nt

wit

h B

oo

ts f

or

acce

ss t

o 2

4 h

ou

r

me

dic

ine

s th

rou

gh P

har

mac

ist

on

cal

l.

Sara

h L

eave

r -

Tru

st C

hie

f

Ph

arm

aci

st

Tru

st Su

pp

ly o

f C

linic

al C

on

sum

able

s (P

rocu

rem

en

t /

con

trac

ts)

Sup

ply

of

no

n c

linic

al g

oo

ds

and

se

rvic

es

(Fac

iliti

es/

Ho

tel S

erv

ice

s)0

3

Pro

cure

me

nt

are

co

mp

leti

ng

revi

ew

s o

f al

l exp

en

dit

ure

wit

h s

up

plie

rs o

ver

£1

00

k to

de

term

ine

an

y ri

sks.

Po

ssib

le d

ela

y o

f N

HSP

S to

re

pai

r b

roke

n s

yste

ms

and

eq

uip

me

nt.

Co

nce

rn r

e:

the

dis

po

sal o

f cl

inic

al w

aste

The

Tru

st w

ou

ld n

ot

be

able

to

acc

ess

goo

ds

and

ser

vice

s af

ter

a

no

dea

l Bre

xit

.

A r

isk

/ h

arm

to

pat

ien

ts

An

infe

ctio

n r

isk

Fin

anci

al

Rep

uta

tio

nal

Reg

ula

tory

23

6

NH

S Se

lf a

sses

smen

t m

eth

od

olo

gy c

om

ple

ted

Esta

tes

KC

HFT

wo

rk s

tre

am a

re r

evi

ewin

g th

ese

issu

es

Co

ntr

act

is b

ein

g re

view

ed

An

nab

elle

Wh

ible

y-

Smit

h

Mar

gare

t La

ng

Rac

hel

GIL

HO

OLY

Tru

stSu

pp

ly o

f M

ed

ical

De

vice

s0

4

Ava

ilab

ility

of

me

dic

al d

evi

ces

cou

ld b

e im

pac

ted

by

tran

spo

rt c

on

cern

s.

Pat

ien

ts a

nd

sta

ff m

ay

no

t re

ceiv

e th

e d

evic

es r

eq

uir

ed

.

Clin

ical

Rep

uta

tio

nal

Reg

ula

tory

Fin

anci

al

13

3

Ass

essm

ent

of

ma

in c

on

tra

cts

for

med

ical

dev

ices

del

iver

y an

d

pro

cure

men

t co

mp

lete

d.

The

Tru

st t

o a

gre

e an

d id

enti

fy a

lea

d f

or

new

sys

tem

an

d a

sset

ma

nag

eme

nt.

Exec

Tea

m

Tru

stTr

ave

l0

5Tr

ansp

ort

in

th

e a

rea

incl

ud

ing

mo

torw

ays,

th

e p

ort

an

d t

he

ch

ann

el t

un

ne

l

cou

ld b

e s

eve

rely

co

mp

rom

ise

d w

ith

th

e in

tro

du

ctio

n o

f e

xte

nsi

ve b

ord

er

con

tro

ls

Ris

k o

f st

aff

no

t b

ein

g ab

le t

o g

ain

acc

ess

to w

ork

pla

ce.

If

Op

Bro

ck is

in p

lace

th

e h

ealt

h r

isk

to t

he

pu

blic

wh

ich

co

uld

imp

act

on

th

e Tr

ust

. D

elay

ed d

eliv

er o

f eq

uip

men

t an

d m

edic

ines

Clin

ical

Rep

uta

tio

nal

Fin

anci

al

34

12

Ensu

re c

urr

en

t in

form

ati

on

is c

om

mu

nic

ated

to

ap

pro

pri

ate

staf

f as

it

is a

vaila

ble

. B

usi

nes

s C

on

tin

uit

y P

lan

s re

fre

shed

an

d u

pd

ated

. Tr

igge

r

do

cum

ents

cu

rre

ntl

y b

ein

g w

ritt

en w

hic

h w

ill f

orm

par

t o

f th

e Tr

ust

op

erat

ion

al p

lan

. Map

pin

g o

f st

aff

is in

pro

gre

ss. N

HS

E an

d t

he

KR

T

are

fac

ilita

tin

g w

ork

sho

ps.

Jan

Alle

n

Tru

stP

erf

orm

an

ce

an

d M

ap

pin

g o

f S

erv

ice

s, M

ap

pin

g o

f sta

ff0

6C

QC

Re

qu

ire

me

nts

KC

HF

T R

eq

uir

em

en

t

KC

HFT

ma

y n

ot

be

fully

co

mp

lian

t

KC

HFT

do

no

t h

ave

an in

tera

ctiv

e m

ap

of

staf

f lo

cati

on

s

Clin

ical

Rep

uta

tio

nal

Reg

ula

tory

Fin

anci

al

23

6C

on

sid

er w

ith

th

e C

QC

th

eir

req

uir

em

ents

Rev

iew

th

e lo

cati

on

s o

f st

aff

Nic

k P

lum

me

r

Shar

on

Bar

ker

Tru

st I

T/T

ele

co

ms

0

7

IT a

nd

te

leco

ms

syst

em

s m

ay b

e o

verw

he

lme

d.

Re

vie

w t

he

fo

llow

ing

syst

em

s;

Skyp

e f

or

Bu

sin

ess

VP

N

Tele

con

fere

nce

Lap

top

pro

visi

on

Staf

f m

ay

no

t b

e p

rep

are

d f

or

vid

eo c

on

fere

nci

ng

.

Tele

con

fere

nce

eq

uip

men

t m

ay

nee

d r

ep

laci

ng

.

Lack

of

rep

lace

me

nt

lap

top

s

Imp

act

on

th

e sy

stem

if

ther

e is

a in

cre

ased

nu

mb

er o

f st

aff

wo

rkin

g fr

om

ho

me

Clin

ical

Rep

uta

tio

nal

Reg

ula

tory

Fin

anci

al

13

3C

om

ms/

tra

inin

g to

en

cou

rage

sta

ff t

o d

ow

nlo

ad S

KYP

E fo

r b

usi

nes

s

Rep

lace

tel

eph

on

es in

key

are

as a

nd

re

pla

ce w

ith

a r

ob

ust

sys

tem

Inve

stig

ate

the

pu

rch

ase

of

lap

top

s

Rev

iew

imp

act

of

staf

f w

ork

ing

fro

m h

om

e o

n d

eliv

ery

of

care

Mar

k A

shb

y

Tru

st D

ata

sh

ari

ng

an

d a

cc

es

s

8N

on

e id

en

tifi

ed

Tru

st R

ese

arc

h a

nd

Clin

ical A

ud

it

9

For

rese

arch

- t

hre

at t

o r

ecr

uit

me

nt

nu

mb

er.

For

clin

ical

au

dit

- t

hre

at t

o c

om

ple

tin

g lo

cal c

linic

al a

ud

its

and

fai

lure

to

fulf

il re

qu

ire

me

nts

of

nat

ion

al a

ud

its

wh

ich

fo

rm p

art

of

the

Qu

alit

y

Acc

ou

nts

.

Res

earc

h -

re

sea

rch

del

iver

y st

aff

ma

y n

ot

be

able

fu

lfil

stu

dy

req

uir

em

ents

fo

r ti

me

and

tar

get

in t

he

recr

uit

men

t o

f p

atie

nts

to

stu

die

s an

d c

linic

al t

rial

s. T

his

will

mea

n t

hat

we

fail

to m

eet

rese

arc

h o

bje

ctiv

es a

nd

fai

l to

fu

lfil

ou

r p

led

ged

re

cru

itm

ent

figu

res

- th

is h

as t

he

po

ten

tial

to

imp

act

on

ou

r fu

nd

ing

fro

m K

SS

Clin

ical

Res

earc

h N

etw

ork

.

Clin

ical

au

dit

- p

ote

nti

al im

pac

t o

n o

ur

abili

ty t

o m

eet

the

sub

mis

sio

n r

eq

uir

em

ents

of

aud

its

on

th

e N

atio

nal

Clin

ical

Au

dit

of

Pat

ien

t O

utc

om

es P

rogr

am

me

(N

CA

PO

P)

wh

ich

are

ma

nd

ated

nat

ion

ally

an

d f

orm

par

t o

f th

e Q

ual

ity

Acc

ou

nts

.

Clin

ical

Rep

uta

tio

nal

Reg

ula

tory

Fin

anci

al

13

3

Rai

se i

ssu

e w

ith

Ch

ief

Op

erat

ing

Off

icer

at

KSS

Clin

ical

Res

earc

h

Net

wo

rk.

Ind

ivid

ual

str

ate

gies

re

qu

ire

d f

or

each

stu

dy.

Mo

nit

or

pro

gre

ss a

gain

st n

atio

nal

au

dit

s an

d d

iscu

ss a

lter

nat

e st

rate

gies

fo

r

sub

mis

sio

n w

ith

au

dit

lea

ds.

Daw

n N

ort

ma

n

Tru

st P

repa

redn

ess

for

Bre

xit

Rep

ort

Page 100 of 144

Appendix B STP Risk Register

Area Concern Possible mitigation

Business Continuity (BC) Existing BC plans have not been tested against EU Exit risk assessment scenarios.

- Kent and Medway NHS organisations involved in the EU Exit planning programme.

- CCG table top exercises to be held in February against key risks.

- Assurance around provider BC plans and risk assessment being collated and reviewed.

-

Medication Management of drug stocks in England is being centrally managed by the DoH and NHSE. This sits outside the control of the STP.

- Ensuring a consistent message goes out to patients and clinicians about not stockpiling medication.

- Encouraging 28 day prescribing in the majority of patients to reduce medication 'held' by patients

- Encouraging patients to only order what they need.

- Working with local community pharmacies and GP practices to manage specific stock issues

-

Command and Control The potential longevity and input requirement to Tactical Command Group (TCG) during the response phase presents capacity issues for Category two responders.

- CCGs to review its on-call provision (including equipment and training) and availability for an extended period of time.

- Providers to review their incident response provision and availability for an extended period of time.

- CCGs consider creating a dedicated resource to respond to the demands of the TCG.

Page 101 of 144

Area Concern Possible mitigation

Traffic disruption Traffic management actions may increase local traffic levels and impact on staff movement and service delivery. Impact for all agencies.

- Assurance around provider BC plans and risk assessment being collated and reviewed.

- Input into traffic management plans to ensure mitigations are identified.

- Map potential “hot spots” and design specific solutions.

Communications National communications have centred on supply chain maintenance. In addition local plans will address any issue that could impact patients and service delivery, including, traffic disruption.

- Kent and Medway comms plan.

Tru

st P

repa

redn

ess

for

Bre

xit

Rep

ort

Page 102 of 144



Agenda Item: 2.9

Subject: Winter Pressures Update Report

Presenting Officer: Lesley Strong, Chief Operating Officer/Deputy Chief Executive

Action - this paper is for: Decision ☐ Assurance X

Report Summary (including purpose and context)

The Board received a paper at the December 2018 meeting outlining the Trust’s plans to

manage the additional pressures over winter. This paper is to update the Board on the

actions taken by Kent Community Health NHS Foundation Trust (KCHFT) to manage patient

care during this time.

Overall, the wider systems have been able to cope with the increase in pressure during

December and early January and have remained at OPEL 2 escalation levels. There is an

expectation with the forecast of colder weather that these pressures will increase.

The paper sets out the position within KCHFT services and includes the impact of the new

schemes.


The Board is asked to note the update.



No


Lesley Strong, Chief Operating Officer, Deputy Chief Executive

Tel: 01622 211937


Win

ter

Pre

ssur

es U

pdat

eR

epor

t

Page 103 of 144

WINTER PRESSURES UPDATE REPORT

Updates on actions taken by Kent Community Health NHS Foundation Trust

(KCHFT)

1. Introduction

The Board received a paper at the December meeting outlining the Trust plans to

manage the additional pressures over winter. This paper is to update the Board on

the actions taken by KCHFT to manage patient care during this time.

2. Background

The winter of 2017/18 presented significant challenges to the health and social care

system. At this point last year the level of demand for services was high with severe

pressures across the health and social care system. The increased demand was

due to sicker and frailer patients with increasing numbers of respiratory conditions,

flu and norovirus.

For this reason planning for winter 2018/19 started much earlier both internally and

within the local systems. The KCHFT plan was approved by the Board at its meeting

in December 2018. The aim of the plan is to ensure that services are in place to

face the expected increase in demand and to ensure the continued safe and

responsive delivery of high quality of care.

Community services have a key role to play in managing winter pressures

particularly in supporting patient flow. The plan focused on the following key areas:

• Supporting system flow through improving patient discharge and preventing

admission

• Workforce

• Increasing capacity of existing services

• Escalation plans

3. Assessment

3.1 Whole System Performance

National analysis by NHS Providers showed that on the whole trusts have coped

better than expected with demand pressures in December. The pressures have

increased in the systems in January but to date performance is stable with both East

Win

ter

Pre

ssur

es U

pdat

eR

epor

t

Page 104 of 144

and West Kent systems mostly staying at escalation level OPEL 2. However the

pressure is expected to increase imminently with the forecast of colder weather.

System Performance Indicators taken from NHS Improvement scorecard, 1 week

average for w/e 14/1/19

Indicator MTW EKHUFT

A&E performance 91.5% 78.9%

Bed occupancy 94.1% 90.8%

Delayed transfers of care 4.25% 6.3%

• A&E performance has been maintained around normal levels in both acute

trusts although this has been under the 95% target for some time

• Bed occupancy within the acute trusts continues to fluctuate.

• Delayed transfers of care in the acute trusts are rising in West Kent and

decreasing in East Kent

The whole system escalation status is constantly under review with regular

conference calls when the system pressures escalate.

The key role of community services at this time is to ensure good patient flow

through our services to support the timely discharge of patients from acute hospitals

to community services and community services to other settings. The emphasis is

on reducing the number of patients experiencing delays to discharge to improve their

care and free up capacity.

3.2 Key Areas of Focus

Supporting patients to return home or preventing an admission

Core services have continued to respond to referrals to maintain patient care. The

focus since Christmas is on maintaining flow and this means that the community

hospitals, rapid response teams, Home Treatment Service and community nursing

and therapy teams are working to capacity at this time e.g. rapid response service in

West Kent is reporting activity of 48% above target.

There have been a higher number of patients whose transfer has been delayed from

community services particularly in East Kent and we are working with other partners

to move patients to where they should be cared for.

Supporting patients with rehabilitation needs in Community Hospitals

Currently the hospitals have been able to maintain patient flow through daily board

rounds to review patients’ needs and agree discharge plans. There have been a

higher number of patients whose discharge has been delayed in East Kent since

Christmas. There are ongoing discussions with partners to resolve this and KCHFT

Page 105 of 144

is currently working with a company, CHS, to support those patients who are self-

funding a placement or package of care.

Last week there was been greater pressure on the beds and higher bed occupancy.

Both East and West Kent have access to independent sector spot purchased beds

and our teams are working to place patients in the most effective environment to

meet their needs.

Up until 20 January there has been no requirement for additional escalation beds but

with the expectation of a rise in demand towards the end of the month, 6 escalation

beds in East Kent will be opened in the week commencing 21 January.

Infection control outbreaks:

There have been three outbreaks since the beginning of December. Outbreak

precautions were agreed with the Infection Control Team and no unit closed to

admissions

• Elizabeth Ward Deal Norovirus

• Goldsmid Ward, Tonbridge respiratory outbreak.

• Hawkhurst Hospital, respiratory outbreak

New models of service to support acute trusts to assess and discharge patients

As part of winter planning and the development of local care initiatives, new

schemes in both East and West Kent were agreed at the end of last year. This

section outlines the impact these schemes are having during a period of increased

demand.

West Kent

Hospital at Home (Virtual Ward)

The new model of care enables patients to leave the acute hospital as soon as they

are clinically stable and complete the remainder of their acute pathway at home

remaining under the care of the Consultant.

The new service started in November 2018 with the clinical coordinators working

within the acute trust to develop the initial pathway of care for patients with cellulitis.

The first patients were accepted on to the service at the end of November.

Win

ter

Pre

ssur

es U

pdat

eR

epor

t

Page 106 of 144

Performance as of 21 January:

Number of patients through the scheme 38

Bed days saved 205

Average length of stay of patients on service 7 days

Treatment / Intervention 67% IV antibiotics

The service is not yet achieving the target of 30 patients at any one time but is

continuing to increase number of referrals

East Kent

Rapid transfer service:

There is an ongoing focus on improving discharges from EKUHFT. This service is

formed of the following parts:

• Rapid Transfer of Care team based in the acute hospital sites. The teams are

now in place to identify complex patients and facilitate their discharge. There

is a target of 245 complex discharges per week. Performance is improving as

the service becomes more established as follows:

Week Beginning: Total

26/11 144 (58%)

3/12 171 (69%)

10/12 136 (55%)

17/12 189 (77%)

24/12 153 (62%)

31/12 170 (69%)

7/1 199 (81%)

14/1 221 (90%)

The team are working closely with EKHUFT and KCC staff to increase the number of

patients who are supported to leave the acute trust under the following pathways.

• Rapid transfer service home

The current model is changing at the end of January with the remodelled

service to be provided by the rapid response service with additional health

care assistants in the teams. There has been a successful recruitment

campaign with the new staff coming into post during January. Part of the

service will be provided by domiciliary care agencies providing a domiciliary

care plus model under contract with KCHFT. This will be in place by the end

of the month.

• Rapid transfer of care bed based model

Page 107 of 144

The bed based model within the independent sector has been remodelled to

provide a block contract for 40 beds and the ability to spot purchase beds

against individual patient needs. The service is for patients with complex

needs who need a longer period of assessment outside of the acute trust.

Between 18 December 2018 to 18 January 2019, 35 beds have been spot

purchased with a further 21 patients currently under assessment.

The rapid transfer service has taken on management of both the contracted

beds and the spot purchasing arrangements with the contract moving to

KCHFT in April.

The service will deliver an increase in the number of patients discharged

through a reduction in length of stay in the block contract beds and improved

bed occupancy.

Alternatives to A&E

The winter edition of our Community Health Magazine promoted how to keep well in

winter and alternatives to A&E including the KCHFT minor injury units. Activity is

6.3% higher in the units in December 2018 compared to December 2017.

Staff Health and Wellbeing

There is increased demand on all community services and the need for additional

staff to support our substantive staff. All bank staff were directly contacted to ask if

they were available for additional shifts in January and February and an incentive

scheme agreed. It is too early at this point to measure its impact.

Staff flu campaign.

Staff flu vaccination uptake as of 21 January

Patient Facing 48%

Non Patient Facing 54%

Grand Total 50%

The Chief Nurse has revised the plan and the team are now specifically targeting the

groups who have the highest non-compliance rates.

4. Conclusion

The systems are expected to come under increased pressure over the coming

weeks with colder weather forecast. The plans are under constant review both

internally and within the whole system.

The Board is asked to note the actions taken by KCHFT in response to the

pressures and the work across the whole systems.

Win

ter

Pre

ssur

es U

pdat

eR

epor

t

Page 108 of 144

Lesley Strong Chief Operating Officer/Deputy Chief Executive January 2019

Page 109 of 144



Agenda Number: 3.1

Agenda Item Title: NHS Long Term Plan and Impact for Kent Community Health NHS Foundation Trust Report

Presenting Officer: Gerard Sammon, Director of Strategy

Action - this paper is for: Decision ☐ Information ☒ Assurance ☒

Report Summary

This paper sets out a brief summary of The NHS Long Term Plan which was published earlier in the month. It goes onto provide an initial high level assessment of its impact on the Trust and our planned next steps.


To note the report.



No ☒


Gerard Sammon, Director of Strategy Tel: 01622211938


NH

S L

ong

Ter

m P

lan

Rep

ort

Page 110 of 144

NHS LONG TERM PLAN

1. Introduction

1.1 This paper sets out a brief summary of The NHS Long Term Plan (the Plan) which was published earlier in the month. It goes onto provide an initial high level assessment of its impact on the Trust and our planned next steps.

1.2 A full copy of the Plan alongside a number of case studies can be found at: https://www.longtermplan.nhs.uk .

2. Background

2.1 The Plan sets out a strategy for the NHS for the next ten years. This follows on from last June’s announcement by the Prime Minister of a £20.5bn annual real terms uplift for the NHS by 2023/24.

2.2 It is therefore a broad reaching and aspirational document which describes a new service model for the 21st Century and the continuation of a policy direction towards an Integrated Care System (ICS) architecture. There is greater emphasis on primary and community care, mental healthcare, prevention and tackling health inequalities.

2.3 Prominence is also placed on giving a strong start in life for children and

young people and better care for major health conditions tackling causes of early death in areas such as heart disease and stroke, cancer, respiratory conditions, dementias, and self-harm.

2.4 The principles behind workforce reforms are also set out and so too are far reaching ambitions for the NHS in digital services and changes to the financial regime.

2.5 The Plan emphasises the importance of the NHS returning to sustainable financial balance and confirms a funding path containing an average increase of 3.4% a year over the next five years. It gives a new guarantee that during this same time period the investment in primary medical and community services will grow faster than the overall NHS budget to create a ring-fenced local fund worth at least an extra £4.5 billion a year in real terms by 2023/24.

3. Assessment

3.1 Much of what the Plan describes is not new, but a continuation of the direction set out in the 2014 Five Year Forward View with collaboration and integration as its touchstones. The organisation has already aligned to

NH

S L

ong

Ter

m P

lan

Rep

ort

Page 111 of 144

the Plan’s direction and continuity is welcomed as it is consistent with our current strategies and priorities and means the organisation is already well calibrated to make the best of the opportunities that it presents.

3.2 The Trust is uniquely placed in Kent to enable more joined-up care in the community and will have a key leadership role to play in ensuring that the greater investment and focus on community, primary care and mental health services is optimised.

3.3 We have already been co-creating better integrated and more

collaborative care models for people and are actively involved in both partnering and providing leadership to local care and frailty services. As the Plan signals the further development of primary care networks and new funding models to back them can be supported by the Trust’s scale and range of offerings, This will mean is has a key role to play in supporting their development and exploring innovations. It also endorses the current organisational priority of workforce which will be required to meet the ambitions of these new care models, and has already led to initiatives such as the establishment of our Nursing Academy.

3.4 The roll out of ICS’s across the country by 2021, and the enhancements of

the role of system working through the revised financial framework and in relation to commissioning structures, regulation and performance management is significant. As noted earlier, much of this direction is not new and so work is already underway in the Kent and Medway Sustainability and Transformation Partnership (STP) in making changes. The STP footprint is already aligned to how the Plan describes an ICS and CCG’s are collaborating in strategic commissioning. The Trust will therefore continue to be fully engaged in shaping what they will look like.

3.5 Having previously embedded the prevention of ill health as part of its strategy and one of its four key goals the Trust is again well positioned to continue to take a key role with implementing this particular part of the Plan. The Trust’s existing partnership with Kent County Council will continue to assist in making the move away from reactive to anticipatory care and active population health management.

3.6 The Trust had hitherto recognised that digital technology can transform how staff and people engage with services and make improvements in care co-ordination. Investment in technology to enable new ways of working has been one of the four key priorities for the Trust in 2018/19 and the Plan will assist in securing further investments against it at a system level.

3.7 The Clinical Commissioning Group (CCG) allocation formulae have been

updated, making them more responsive to extremes of health inequalities and un-met need. Kent and Medway CCG cash uplifts for 2019/20 are 5.9% for core services and 6.8% for primary care The control total in 2019/20 for the Trust has been set at a £2.2m surplus (£3.1m in 2018-19)

Page 112 of 144

supported by a £2.2m (£2.5m in 2018-19) Provider Sustainability Fund.

3.8 A number of key interdependencies for the success of the Plan remain to be addressed and are awaited in future publications. Notably, they include the national workforce implementation plan, along with training and education funding, capital investment, and a sustainable solution for social care funding.

4. Next steps

4.1 The Trust will continue to engage the organisation in sharing what the Plan means and the challenge will then turn to how the plan is implemented. The timing of its publication does give an opportunity for involvement to be had with the development of our 2019/20 priorities and operational plans. This is the start of engagement with local populations and Health Watch has been given a funding source to take that forward.

4.2 The Trust will be working closely with Kent and Medway STP about the future of its integrated care system and the changes it requires given its alignment to the development of an integrated care system.

4.3 We will also be working with the STP to engage in the development of the

detailed national implementation programme which is required by the autumn. To support this planning, local health systems will receive five-year indicative financial allocations for 2012/20 to 2023/24, but will still be asked to produce local plans by Spring for implementing commitments in 2019/20 as it is being viewed as a transitional year.

Gerard Sammon Director of Strategy January 2019

NH

S L

ong

Ter

m P

lan

Rep

ort

Page 113 of 144



Agenda Number: 4.1

Agenda Item Title: Learning from Deaths Report

Presenting Officer: Dr Sarah Phillips, Medical Director


Report Summary

National guidance on learning from deaths requires Kent Community Health NHS Foundation Trust (KCHFT) to collect and publish mortality data and learning points quarterly via a paper to Quality Committee and Public Board. Guidance states this data should include the total number of the Trust’s inpatient deaths and those deaths that the Trust has subjected to case record review. Of these deaths subjected to review, Trusts need to provide estimates of how many deaths were judged more likely than not to have been due to problems in care. The dashboard included has been based on national suggested format. As the Board is aware, the KCHFT Mortality Review Policy was developed following the recommendations made by the National Guidance on Learning from Deaths (2017). Other national publications were also used to guide the content of the policy. The scope of reviews includes all community hospital inpatient deaths, any patients who die under our care with serious mental health needs and all patients with learning disability. Since May 2018, mortality reviews of community hospital inpatient deaths have been conducted through a centralised process where the review team is made up of a doctor, a ward matron or other senior clinical staff member, a pharmacist, a quality lead and centralised administrative support. Members rotate on a monthly basis to maintain a degree of independence and this replaces the previous process of hospital multi-disciplinary team (MDT) teams being allocated deaths from another hospital for review. The new process allows for a more efficient way of reviewing deaths, feeding back learning to teams responsible for patient care and monitoring actions. An internal process for reviewing deaths of patients with Learning Disabilities has been put in place alongside the LeDeR process for additional assurance, for best practice and to meet the Trust’s ethical obligations. Learning from these reviews is taken to the Mortality Surveillance Group and will be included in this report. As defined in the Policy, the Trust Board has overall responsibility for ensuring compliance with all legal and statutory duties, along with best practice including having an overview of the mortality review process and knowledge of the learning that emerges from the reviews that drive improvements in care. The focus of Trust mortality review is on meaningful learning and sharing ways to improve care.

Lear

ning

Fro

m D

eath

s R

epor

t

Page 114 of 144


For assurance.



No ☒


Dr Sarah Phillips, Medical Director Tel: 01622 211922


Page 115 of 144

LEARNING FROM DEATHS REPORT Themes from Mortality Reviews (October to December 2018)

1. Introduction 1.1 National guidance on learning from deaths requires KCHFT to collect and

publish mortality data quarterly via a paper to the Quality Committee and Public Board. The quarterly report must include mortality data and learning points. Guidance states this data should include the total number of the Trust’s inpatient deaths and those deaths that the Trust has subjected to case record review. Of these deaths subjected to review, Trusts need to provide estimates of how many deaths were judged more likely than not to have been due to problems in care.

2. December Dashboard 2.1 The dashboard below has been based on national suggested format and refers

to deaths in community hospitals.

Total Number of Deaths in Scope

Total Deaths Reviewed

Number of deaths judged to be more likely than not due to problems in healthcare

This Month Last Month This Month Last Month This Month Last Month

1 4 2* 8 0 0

This Quarter (QTD) Last Quarter



12 14 12 15 0 0

This Year (YTD) Last Year This Year (YTD) Last Year

This Year (YTD) Last Year

65 22 58 22 0 0

*Deaths reviewed in a given calendar month can exceed the number of deaths reported that month because the figure includes deaths which took place in the previous month, but have fallen into the next month for review. 2.2 The graph below shows the number of deaths per month this quarter along with

the average.

Lear

ning

Fro

m D

eath

s R

epor

t

Page 116 of 144

3. Themes from Mortality Reviews 3.1 The table below outlines the three most common key themes around good

practice and areas for improvement which have emerged from Mortality Reviews this quarter.

3.2 All areas of good practice and areas for learning are reported at the monthly matrons’ meetings in the East and West and wider dissemination to all ward staff is encouraged. These are also reviewed in the monthly Mortality Surveillance Group (MSG).

3.3 The three most common themes in good practice emerging this quarter, aligned to the Five Priorities for Care of the Dying Person:

• Good evidence of communication with family and documentation of patient’s religious wishes, demonstrating person-centred, holistic care (Communicate, Support and Involve)

• Thorough documentation of consent (Communicate, Involve)

• Anticipatory medicines in place early (Recognise, Plan & Do) 3.4 The three most common themes in areas for improvement emerging this quarter,

and actions to take forward.

Themes Comments/Actions

Transfers of Care

1. There is often a lack of handover or SBAR from the acute trust.

Transfer of Care issues are being reported on Datix and will be taken forward with the acute. A Task and Finish Group is planned for 1st February to discuss next steps.

Documentation a) Personalised Care Plans Personalised Care Plans could be more detailed and written plans do not appear to consistently translate into day-to-day action.

Feedback sent to Ward Matrons for dissemination to teams.

Page 117 of 144

Themes Comments/Actions

b) Drug Charts In some cases, two separate drug charts

are used which could cause confusion, as the palliative care chart alone could be used. Some inconsistencies have also been identified, such as morphine sensitivity mentioned on a chart where morphine is prescribed and administered, but the routine medication chart annotates the morphine allergy as having no documented evidence.

This will be incorporated into training. Following the emergence in the previous quarter of themes around medications, the End of Life Nurse Consultant and Pharmacy had programmed updates at the December EOL Champions meetings and arranged two training sessions for community teams, with one to follow in January/February 2019. Further work is ongoing with pharmacists to highlight issues and training for next year.

Recognition of End of Life In some cases, the dying patient could have been recognised earlier and Advance Care Plans completed sooner. While doctors may have identified patients at end of life early, documentation does not always evidence that the whole team is aware.

End of Life Nurse Consultants will be working to encourage earlier recognition of end of life.

Sarah Phillips Medical Director January 2019

Lear

ning

Fro

m D

eath

s R

epor

t

Page 118 of 144



Agenda Number: 4.3

Agenda Item Title: Community Hospitals Safer Staffing Review

Presenting Officer: Mercia Spare, Chief Nurse (Interim)


Report Summary

The National Quality Board (2016) expects the Trust to ensure safe, effective,

caring, responsive and well-led care on a sustainable basis, and that the Trust will

employ the right staff with the right skills in the right place and at the right time. To

demonstrate the Trusts commitment to the above requirement, a twice yearly

assessment and evaluation is undertaken in all community hospital wards. This

report details the findings of the safe staffing review completed during November

2018 for community hospitals.


For the Board to note the report.



No ☒



Sue Mitchell, Assistant Director Patient Safety and Experience

Tel: 073930240018


Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 119 of 144

1

1.0. Introduction

1.1. Patients have the right to be cared for by appropriately qualified and experienced clinical

staff. The National Quality Board (2016) expects the Trust to ensure safe, effective,

caring, responsive and well-led care on a sustainable basis, and that the Trust will

employ the right staff with the right skills in the right place and at the right time. It is

expected that safe staffing reviews will be reported to a Public Board twice a year, and

the Board last received a review in July 2018 with data relating to January to May 2018.

1.2. To demonstrate the Trusts commitment to the above requirement, a twice yearly

assessment and evaluation is undertaken in all community hospital wards. In addition to

this, staffing levels are monitored daily with the option to request additional short term

resource, should the acuity and dependency of patients on the ward increase. Fill rates

are reported to Board monthly.

1.3. KCHFT Board is committed to ensuring safe staffing in all services. As the Community

Hospitals are essentially nurse led, and are isolated units, the Board has committed to

ensuring the safety of patients by having no less than 2 Registered Nurses (RN) on any

given shift. In recognition that rehabilitation patients require a higher level of the key

fundamentals of care, it is considered appropriate to have a higher skill mix of Health

Care Assistants (HCA) to registered nurses than would be the case in an acute ward.

This is monitored and reported to Board monthly by the Chief Nurse. It is recognised that

in addition to nursing care the wards provide rehabilitation which is delivered by

Physiotherapists, Occupational Therapists and Therapy Assistants and therefore it has

been recognised nationally that staffing levels for Therapy staff should be included in the

Safer Staffing Review (Care Hours per Patient Day (CHPPD):Guidance for Mental Health

and Community Trusts, NHS Improvement, October 2018).

1.4. The Ward Matron is not included in the staffing numbers and is supervisory, allowing time

for management and leadership duties to be undertaken, as well as mentoring and

supporting of staff.

2.0. Background

2.1. An accurate calculation of staffing levels to provide safe care is a crucial part of the

planning of clinical care. Therefore the Trust has developed a methodology for

undertaking the assessment that reflects the principles of work undertaken nationally

COMMUNITY HOSPITALS SAFER STAFFING REVIEW

December 2018

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 120 of 144

2

related to calculating safer staffing levels (Safer Nursing Care Tool 2013, NICE SG1, July

2014, Nurse Staffing Levels, Wales 2016). The principles remain the same in that the

three elements of patient acuity, quality indicators, and professional judgement, as

pictured in the below diagram, are considered independently and form the basis on which

to make an informed judgement regarding safe staffing levels.

2.2. KCHFT is commissioned to provide rehabilitation inpatient care and the wards

predominantly care for older patients. It is well recognised that older patients often have

complex care needs and may have significant levels of dependency, and wards therefore

require a workforce with time to deliver appropriate care in a dignified manner.

2.3. This review process has previously only taken account of nursing staff, registered nurses,

assistant practitioners and health care assistants. This audit has included the ward based

physiotherapists and occupational therapists, including therapy assistants.

2.4. The last review in May 2018 determined that, overall the acuity of the patients has

reduced slightly in the east and has increased in the west. This was mainly due to the

number of patients being admitted with cognitive impairment. It found that the therapeutic

workers, where in place were working very well. Some wards were maximising the

support of volunteers with good effect. Quality and safety metrics remained very positive

with an improving picture in reduction of harms for patients and a very positive patient

experience.

3.0. Methodology of review

3.1. All wards returned 21 days of data as required for accurate completion of the audit during

November 2018. The audit focused on the acuity/dependency of the patients with an

allocation of a Red/Amber/Green rating to each bed, as described in appendix 2. A

review meeting was held with the ward matrons and therapy leads and the findings were

analysed and triangulated with six months of quality data for the period of June to

November 2018.

The data focused on:

Page 121 of 144

3

• The quality indicators of avoidable falls, medication incidents, avoidable

pressure harms and serious incidents.

• Patient experience feedback and complaints.

• Professional opinion of the Matron, including any relevant information.

4.0. Summary of findings – Acuity and Dependency

4.1. The data demonstrates that over the period June to November 2018, 50% of the patients

cared for in KCHFT wards had moderate care needs (denoted below in amber), which is

to be expected in patients who are rehabilitating and just over 30% were fairly self-caring

as they prepare for discharge (denoted in green). It is of note that almost 20% of patients

were significantly dependant requiring high levels of support and nursing care (denoted

below in red).

4.2. In the tables below the data has been split by East and West. In the West the green

category has reduced and both the amber and red category has increased indicating an

increase in acuity and dependency since the previous audit which also saw an increase.

In the East the green category has increased, amber category has reduced but there has

been a significant increase in red category which is mostly at Deal.

05

101520253035404550

Dec-17 May-18 Nov-18

Total

Nu

mb

er

of

Be

ds

West Kent Community Hospitals Average patient Acuity December 2017, May 2018 and November 18

Green

Amber

Red

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 122 of 144

4

4.3. The below tables demonstrates the number of beds for each ward and also the average

length of stay for a patient during November. At the time of the audit Faversham had 4 of

its 25 beds closed. Each admission and discharge creates demand on registered nursing

and therapy resource which has a greater impact on those hospitals with shorter stays

4.4. The below chart demonstrates acuity and dependency weighted by beds. The wards with

the highest dependency weighted by beds are Deal and Whit & Tank. Notably Whit &

Tank also having the shortest stay patients and a relatively high number of beds. Most

wards have at least one third of patients who are in the green category and would be

fairly self-caring, the exceptions to this are Deal and Whit & Tank. A data comparison

chart of audit data from November and May is detailed at Appendix 1.

05

101520253035404550

Dec-17 May-18 Nov-18

Total

Nu

mb

er

of

Be

ds

East Kent Community Hospitals Average patient Acuity December 2017, May 2018 & November 2018

Green

Amber

Red

22 21 2318

2218

14 14 12 15

0

5

10

15

20

25

Number of Beds

30

15 14 12

2515

23 22 25

05

101520253035

Average length of stay in November

Page 123 of 144

5

5.0 Summary of Findings – Staffing

5.1 The tables below outlines the planned nursing staffing hours and the actual nursing

staffing hours, this has been broken down further into day and night. Tonbridge –

Primrose ward has not been included in this analysis as it is a Therapy Lead unit.

Monthly planned and actual staffing is relatively consistent with the exception of

Hawkhurst night having more actual staff than planned. Deal, QVMH, Sevenoaks,

Edenbridge and Tonbridge Goldsmid all have lower actual staffing than planned due to

sickness and vacancies. Staffing data for Westview was not being collected at the time of

the audit.

5.2 In several wards there is more actual care staff than planned to assist with personal care, as detailed below.

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

100.0%P

erc

en

tage

of

be

ds

by

Acu

ity

Percentages of Average Patient Acuity November 2018 (excluding empty beds)

Red

Amber

Green

Data source: Patient

0

200

400

600

800

1000

1200

Hours

Monthly Planned and Actual staff hours for Registered Nurses

DayTotal monthly Planned Staffing HoursRN

DayTotal Monthly Actual staff hours RN

NightTotal monthly Planned Staffing HoursRN

NightTotal Monthly Actual staff hours RN

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 124 of 144

6

6.0. Summary of findings - Care Hours Per Patient Per Day

6.1. The charts below highlight the number of care hours provided for patients per day by both care staff and registered nurses. Of note, Deal has low care hours per day when considered alongside the acuity and dependency weighted by bed which is noted as being high. Additionally, Edenbridge have low care hours per patient per day. Low care hours per patient per day may pose a risk to patient safety.

7.0 Summary of findings – Therapy Staff

7.1 Therapy staffing hours have been collected over the three week period for qualified therapy staff and for assistants as detailed in the first chart below. During the audit there were some staff vacancies which are detailed in the Professional Opinion section below and have affected the therapy staffing hours particularly for Edenbridge, Tonbridge, and Whit &Tank and QVMH. Daily average therapy cumulative staffing hours are also detailed in the second chart. This is the first time the Trust has collected data in this way and therefore it is difficult to conclusions at this point. Therapists do not work to the same

0200400600800

100012001400

Hours

Monthly Planned and Actual hours for Care Staff

DayCare staff monthly planned staff hours

DayCare staff

NightCare staff monthly planned staff hours

NightCare staff

4.8 6.8 7.6 7.53.2

7.6 7.8 6.3

22 23

18

21

14

18

14

22

0

5

10

15

20

25

DEAL HOSPITAL QUEEN VICTORIAMEMORIALHOSPITAL

WHIT & TANKHOSPITAL

FAVERSHAMHOSPITAL

EDENBRIDGEHOSPITAL

SEVENOAKSHOSPITAL

TONBRIDGEGOLDSMID

HAWKHURSTHOSPITAL

Cumulative care hours per patient per day Cumulative CareHours from RNand care staffper patient perday

Number of Beds

Page 125 of 144

7

establishment template as registered and non-registered nurses at this current time, therefore data such as care hours per patient per day could not be determined.

8.0 Summary of Findings - Patient Safety Metrics

8.1 The chart on page 10 triangulates staffing with quality indicators which include incidents,

complaints and patient feedback during two data periods; Column 1: December 2017 to

May 2018 and Column 2: June to November 2018. The narrative below is a summary of

the data.

8.2 Faversham

8.2.1 Faversham currently has 21 beds open. The average length of stay is 15 days. 78% of

the patients are reported as having dementia or cognitive impairment, however, acuity

and dependency of patients is consistent with the same period last year. Registered

nurse fill rate is 98% during the day and 100% at night with unregistered staff being over

planned for both day and night. The daily average of therapy input is 23 hours. The

vacancy rate is high at 23.64 vacancies and agency use is 21% of the pay bill.

Cumulative care hours per patient per day are 7.5. There has been a reduction over the

period in avoidable medication incidents; however, one of those was raised as a Serious

Incident when a patient was not administered anti-epileptic medication. There have been

6 complaints over the previous 12 months which is higher than the other community

0

50

100

150

200

Deal QVMH Whit&Tank Faversham Edenbridge Sevenoaks Tonbridge -Goldsmid

Tonbridge -Primrose

Hawkhurst

Total Hours

Therapy Staffing Hours

OT &Physiotherapists

Therapy Assistants

21.4 20.3 17.5 23.1 13.7 25.5 16.7 17 22.15

22 23

1821

1418

1412

22

0

5

10

15

20

25

30

Deal QVMH Whit&Tank Faversham Edenbridge Sevenoaks Tonbridge -Goldsmid

Tonbridge -Primrose

Hawkhurst

Daily average Therapy cumulative staffing hours

Average dailyTherapy hours

Number of beds

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 126 of 144

8

hospitals. Friends and Family Test scores and overall patient satisfaction scores remain

high with a minimal drop since the previous reporting period.

8.3 Deal

8.3.1 Deal currently has 22 beds open. The average length of stay is 30 days. High levels

(88%) of the patients are reported as having dementia or cognitive impairment; however,

whilst the number of patients who are fairly self-caring remains consistent and those with

moderate care needs have reduced, the highly dependent patients have significantly

increased. When weighted by beds, Deal has the highest levels of acuity and

dependency across all the Community Hospitals. Registered nurse fill rate is 92.9%

during the day and 97.6% at night with unregistered staff being over planned for day

(103.8%) and under at night 95.2%. The daily average of therapy input is 21.4 hours. The

vacancy rate is 14.94 and agency use is 21% of the pay bill. Cumulative care hours per

patient per day are low at 4.8. There has been an increase in avoidable medication

incidents since the same period last year, however there have been no serious incidents.

Patient complaints have reduced. Friends and Family Test remain high with a slight

reduction on the previous period. Overall satisfaction scores have improved.

8.4 QVMH

8.4.1 QVMH currently has 23 beds open. The average length of stay is 14 days. 74% of the

patients are reported as having dementia or cognitive impairment. Acuity and

dependency remains consistent. Registered nurse fill rate is 90.5% during the day and

100% at night with unregistered staff being over planned for both day and night. The

daily average of therapy input is 20.3 hours. The vacancy rate is 14.39 and agency use is

20% of the pay bill. Cumulative care hours per patient per day are 6.8. All quality metrics

remain consistently good with a slight reduction in the Friends and Family Test score.

8.5 Whit & Tank

8.5.1 Whit & Tank currently has 18 beds open. The average length of stay is 12 days so has a

higher turnover of patients than the other community hospitals. A lower number (35%) of

the patients are reported as having dementia or cognitive impairment. Acuity and

dependency remains consistent, but when weighted by beds are also high in comparison

with all other hospitals other than Deal. Registered nurse fill rate is 100% during both day

and night with unregistered staff being over planned for both day and night. The daily

average of therapy input is 17.5 hours. The vacancy rate is low at 4.25 and and agency

use is also low at 12% of the pay bill. Cumulative care hours per patient per day are high

at 7.6. All quality metrics remain consistently good with a reduction in avoidable

medication incidents and high patient experience scores.

8.6 Sevenoaks

8.6.1 Sevenoaks currently has 18 beds open. The average length of stay is 15 days. 79% of

the patients are reported as having dementia or cognitive impairment. Patients with

moderate care needs have increased and those with high dependency have significantly

Page 127 of 144

9

decreased. When weighted by beds acuity and dependency is low in comparison with the

other hospitals. Registered nurse fill rate is 96.4%% during the day and 100% at night

with unregistered staff being over planned for both day and night. The daily average of

therapy input is high at 25.5 hours. The vacancy rate is high at 19.37 and agency use is

17% of the pay bill. Cumulative care hours per patient per day are high at 7.6. All quality

metrics remain consistently good.

8.7 Tonbridge – Goldsmid

8.7.1 Tonbridge currently has 14 beds open. The average length of stay is 22 days. 48% of the

patients are reported as having dementia or cognitive impairment. Acuity and

dependency remains consistent and when weighted by beds acuity and dependency is

low in comparison with the other hospitals. Registered nurse fill rate is 92.9%% during

the day and 103.8% at night with unregistered staff being 97.6% during the day and

95.2% at night. The daily average of therapy input is 16.7 hours. The vacancy rate is high

at 18.34 and agency use is high at 35% of the pay bill. Cumulative care hours per patient

per day are high at 7.8. All quality metrics remain consistently good with a reduction in

avoidable medication incidents.

8.8 Tonbridge – Primrose

8.8.1 While Primrose ward has no planned RN shifts because it is a therapy ward, they

employed temporary staffing to provide nursing cover and so had 43 RN day shifts and

30 RN night shifts during November on e-roster. The unit and model of care is currently

under review. Quality metrics remain good.

8.9 Hawkhurst

8.9.1 Hawkhurst currently has 22 beds open. The average length of stay is 25 days. High

levels (86%) of the patients are reported as having dementia or cognitive impairment.

Acuity and dependency remains consistent and when weighted by beds acuity and

dependency is relatively low in comparison with the other hospitals. Actual staffing for

Registered nurses is over planned with fill rate at 106%% during the day and 121% at

night with unregistered staff being 100% during both day and night. The daily average of

therapy input is 22.2 hours. The vacancy rate is high at 34.9 and agency use is also high

at 29% of the pay bill. Cumulative care hours per patient per day are at 6.3. All quality

metrics remain consistently good with a reduction in avoidable medication incidents.

8.10 Edenbridge

8.10.1 Edenbridge currently has 14 beds open. The average length of stay is 23 days. 71% of

the patients are reported as having dementia or cognitive impairment. Acuity and

dependency remains consistent and when weighted by beds acuity and dependency is

low in comparison with the other hospitals. Registered nurse fill rate is very low at 81%

during the day and 97.6% at night with unregistered staff being 97.6% during the day and

95.2% at night. The daily average of therapy input is also lower than the other hospitals

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 128 of 144

10

at 13.7 hours. The vacancy rate is high at 44.87 and agency use is high at 38% of the

pay bill. Cumulative care hours per patient per day are the lowest across the community

hospitals at 3.2. There were two serious incidents over the 12 months – both avoidable

falls with fracture. However, other quality metrics remain good.

8.11 Westview

8.11.1 Westview currently has 15 beds open. Neither the average length of stay nor the

percentage of patients reported as having dementia or cognitive impairment is recorded.

Acuity and dependency remains consistent and when weighted by beds acuity and

dependency is low in comparison with the other hospitals. Registered nurse fill rate is

90% during the day and 91.7% at night with unregistered staff being 63.6% during the

day and 74.4% at night. There is no therapy data, cumulative care hours per patient per

day or vacancy rate or agency use available. There were two serious incidents over the

12 months – both avoidable falls with fracture. Westview has not returned any patient

feedback or received any complaints.

Page 129 of 144

11

Ho

spit

al

Avo

idab

le

Falls

wit

h

Frac

ture

Avo

idab

le

Med

icat

ion

In

cid

ents

Avo

idab

le

Pre

ssu

re

Ulc

ers

Seri

ou

s in

cid

ents

P

atie

nt

Co

mp

lain

ts

Frie

nd

s &

Fam

ily T

est

Ove

rall

Sati

sfac

tio

n

Sco

re

Fave

rsh

am

0

0

4

2

0

0

0

1

3

3

98

%

97

.90

%

97

.88

%

98

.00

%

Dea

l 1

0

5

8

0

0

1

0

2

1

1

00

%

97

.90

%

93

.44

%

99

.40

%

QV

MH

0

0

6

7

0

0

0

0

1

1

1

00

%

95

.50

%

87

.58

%

88

.80

%

Wh

it &

Tan

k 0

0

1

1

4

0

1

0

0

0

2

97

.0%

1

00

.0%

9

4.7

%

93

.5%

Seve

no

aks

0

0

14

9

0

0

0

0

1

0

9

3.7

%

90

.5%

9

0.5

%

89

.5%

Ton

bri

dge

-

Go

ldsm

id

0

0

14

7

0

0

0

0

2

1

1

00

.0%

1

00

.0%

9

5.6

%

91

.9%

Ton

bri

dge

P

rim

rose

0

0

1

1

7

0

0

0

0

0

0

96

.1%

1

00

.0%

8

9.4

%

92

.3%

Haw

khu

rst

0

0

9

3

0

0

0

0

1

1

98

.3%

9

4.2

%

91

.1%

8

9.4

%

Eden

bri

dge

1

1

5

2

0

0

1

1

1

0

9

8.1

%

94

.2%

9

7.6

%

97

.7%

Wes

tvie

w

2

0

0

0

0

0

2

0

0

0

N/A

N

/A

N/A

N

/A

Day

N

igh

t

Reg

iste

red

Nu

rses

C

are

Staf

f R

egis

tere

d N

urs

es

Car

e St

aff

Ho

spit

al

Bed

s A

vera

ge

Len

gth

o

f St

ay

% P

atie

nts

w

ith

D

emen

tia

or

Co

gnit

ive

Imp

airm

ent

Cu

mu

lati

ve

care

ho

urs

p

er p

atie

nt

per

day

Tota

l M

on

thly

P

lan

ned

St

aff

Ho

urs

Tota

l M

on

thly

A

ctu

al

Staf

f H

ou

rs

% F

ill

Rat

e

Tota

l M

on

thly

P

lan

ned

St

aff

Ho

urs

Tota

l M

on

thly

A

ctu

al

Staf

f H

ou

rs

% F

ill

Rat

e

Tota

l M

on

thly

P

lan

ned

St

aff

Ho

urs

Tota

l M

on

thly

A

ctu

al

Staf

f H

ou

rs

% F

ill

Rat

e

Tota

l M

on

thly

P

lan

ned

St

aff

Ho

urs

Tota

l M

on

thly

A

ctu

al

Staf

f H

ou

rs

% F

ill

Rat

e

Vac

ancy

R

ate

Use

of

agen

cy -

%

of

pay

b

ill

Dai

ly

aver

age

Ther

apy

and

Th

erap

y A

ssis

tan

t h

ou

rs

Fave

rsh

am

21

1

5

78

%

7.5

6

30

62

2.5

9

8.8

%

94

5 1

44

0 1

52

.4%

4

62

46

2 1

00

.0%

4

62

62

7 1

35

.70%

-2

3.6

4 2

1%

2

3.1

Dea

l 2

2

30

8

8%

4

.8

63

0 5

85

92

.9%

7

87

.5

81

7.5

1

03

.8%

4

62

45

1 9

7.6

%

23

1 2

20

95

.2%

-1

4.9

4 2

1%

2

1.4

QV

MH

2

3

14

7

4%

6

.8

63

0 5

70

90

.5%

9

45

12

07

.5

12

7.8

%

46

2 4

62

10

0.0

%

46

2 5

94

12

8.6

%

-14

.39

20

%

20

.3

Wh

it &

Ta

nk

18

1

2

35

%

7.6

6

30

63

0 1

00

.0%

7

87

.5

11

17

.5

14

1.9

%

46

2 4

62

10

0.0

%

46

2 5

17

11

1.9

%

-4.2

5 1

2%

1

7.5

Seve

no

aks

18

1

5

79

%

7.6

6

30

60

7.5

9

6.4

%

94

5 1

09

5 1

15

.9%

4

62

46

2 1

00

.0%

6

93

71

5 1

03

.2%

-1

9.3

7 1

7%

2

5.5

Ton

bri

dge

-

Go

ldsm

id

14

2

2

48

%

7.8

6

30

58

5 9

2.9

%

78

7.5

8

17

.5

10

3.8

%

46

2 4

51

97

.6%

2

31

22

0 9

5.2

%

-18

.34

35

%

16

.7

Ton

bri

dge

P

rim

rose

1

4

25

7.8

1

7.0

Haw

khu

rst

22

2

5

86

%

6.3

6

30

66

7.5

1

06

.0%

4

62

46

2 1

00

.0%

9

45

11

47

.5

12

1.4

%

46

2 4

62

10

0%

-3

4.9

2

9%

2

2.2

Eden

bri

dge

1

4

23

7

1%

3

.2

63

0 5

10

81

.0%

6

30

88

5 1

40

.5%

4

62

45

1 9

7.6

%

46

2 4

62

10

0.0

%

-44

.87

38

%

13

.7

Wes

tvie

w

15

90

0.0

8

10

90

.0%

8

10

11

40

63

.6%

6

60

.0

60

5 9

1.7

%

99

0 7

37

74

.4%

No

vem

ber

2

018

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 130 of 144

12

9.0 The professional opinion of the Ward Matrons and Therapy Staff

9.1. A number of common themes were expressed by the matrons and therapy staff during the

review meetings.

9.2. Evaluation of the tool suggested that further improvements could be made for ease of use

and staff would benefit by receiving training on the tool.

9.3. Registered nurses felt they had little time to spend with patients due to high volume of

paperwork and discharge planning.

9.4. Short average length of stays impact on resources due to the amount of admission and

discharge processes.

9.5. Where workforce is an issue, morning shifts are particularly challenging.

9.6. High reliance on agency staff has the potential to impact the capacity of substantive staff

as agency staff are sometimes unfamiliar with the ward and processes and do not have

access to systems.

9.7. The model for some therapy teams where they share resources across the three hospitals

provides challenges to maintain flexibility especially taken into account sickness, annual

leave and vacancies.

10.0. Conclusion

10.1. The safer staffing review has applied a methodology to identify the right numbers of staff

required for the delivery of safe, quality care in the community hospital inpatient wards. The

review takes into account levels of staffing and a wide range of factors including the type of

ward, professional judgement from ward matrons and therapy leads, and quality and safety

metrics.

10.2. The majority of wards actual registered nurse rota fill is less than planned during the day

with the exception of Whit & Tank at 100% and Hawkhurst being overfilled at 106%.

10.3. Three of the wards night fill rate for registered nurses is at 100%. A further 3 are over 90%

and only Hawkhurst is over planned registered nurse fill at 121.4%.

10.4. Additionally the majority of wards are also using more care staff than planned the day with

the exception of Hawkhurst at 100% and Westview being 63.6%.

10.5. Care staff is over planned for most hospitals at night with the exception of Hawkhurst and

Edenbridge at 100% and Westview being 74.4%.

10.6. Those hospitals with low cumulative care hours per patient per day require further

investigation and benchmarking with peer organisations.

Page 131 of 144

13

10.7. With regard to the therapy input to the ward, it is difficult to draw any conclusions as

provision appears variable and individual patient input was not recorded as part of the audit.

10.8. Key safety and quality metrics for each hospital have remained stable between June and

November 2018 indicating that the wards have provided safe care for patients.

11.0. Recommendations

11.1. The planned rotas for Registered Nurses and Care Staff should be reviewed for individual

hospitals as there may be some opportunity for sharing staff across the wards.

11.2. Further investigation and benchmarking is required to understand the cumulative care

hours per patient per day.

11.3. The therapy data recorded within this audit can be used to benchmark for the next audit;

however, the methodology should be reviewed to ensure that individual patient

rehabilitation is captured.

11.4. Admission criteria must be defined for each ward which is essential to ensure that the right

patients are admitted in order to receiving the right care by the right staff.

Mercia Spare


January 2018

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 132 of 144

14

Appendix 1 Audit Results December 2018

Page 133 of 144

15

Appendix 2

Green

This type of patient may need help with a limited number of areas of daily living and will be progressing

well along the rehabilitation pathway. They will be stable in terms of their health, and able to manage a

degree of self-care. They may need minimal or no help with walking, washing and dressing, eating and

drinking and repositioning. They are likely to be able to communicate well, or with minimal help and have

an awareness of safety. If they have pain this is likely to be controllable and they are likely to be able to

take medication independently. They will be able to self-manage any personal condition or be in the

process of learning to do this.

Amber

This patient is likely to need support with several areas of daily living including washing, dressing, eating

and drinking. They will probably need help when walking, and support to reposition to prevent pressure

damage. They may have fluctuating pain and need help to manage this. These patients may need

assistance with bed/chair transfers. Safety awareness may be limited and they may be confused and/or

have a degree of socially inappropriate behaviour and/or aggression. These patients need a degree of

nursing care and may have one or more long term condition that is unstable, needs treatment and

requires monitoring.

Red

This patient requires a high degree of nursing care. They will include heavily dependent patients, and

medically unstable patients who require frequent monitoring. Patients may be receiving care at the end

of their life. Alternatively patients may be aggressive and disruptive. Patients are likely to require 1-1

care.

Com

mun

ity H

ospi

tals

Saf

erS

taffi

ng R

evie

w

Page 134 of 144

16

Appendix 4 - References

Nurse Staffing Levels (Wales) Act 2016 (2016) Statutory Guidance Welsh Government

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time:

Safe sustainable and productive staffing (July 2016) National Quality Board

Five Year Forward View (2014) NHSE

Health and Social Care Act (2012) UK Parliament

Making the Case for ward sisters/team managers to be supervisory (2011) Royal College of Nursing

NHS Constitution for England (2013) Department of Health

Safer Nursing Care Tool (2013) Shelford Group. The Association of UK University Hospitals

Safe staffing for nursing in adult inpatient wards in acute hospitals (2014) NICE

Safer staffing for older peoples wards, an RCN toolkit (2012) Royal College of Nursing

Care Hours per Patient Day (CHPPD):Guidance for Mental Health and Community Trusts, NHS

Improvement, October 2018

Page 135 of 144



Agenda Number: 4.4

Agenda Item Title: Minutes of the Charitable Funds Committee Meeting of 25 July 2018

Presenting Officer: Richard Field, Deputy Chair of Charitable Funds Committee


Report Summary

The paper presents the confirmed Minutes of the Charitable Funds Committee meeting of 25 July 2018.


The Board is asked receive the confirmed minutes.



No ☒



Jen Tippin, Non-Executive Director Tel: 01622 211906

Email:

Cha

ritab

le F

unds

Com

mitt

eeM

inut

es

Page 136 of 144

CONFIRMED Minutes of the Charitable Funds Committee

held on Wednesday 25 July 2018 in The Boardroom, The Oast, Hermitage Court, Hermitage Lane, Maidstone Kent

ME16 9NT

Present: Jennifer Tippin, Non-Executive Director (Chair) Carol Coleman, Public Governor, Dover and Deal Peter Conway, Non-Executive Director Richard Field, Interim Trust Chair Steve Howe, Non-Executive Director Jane Kendal, Community Services Director, East Kent Fay Sinclair, Head of Communications Bridget Skelton, Non-Executive Director Carl Williams, Head of Financial Accounting In Attendance: Gina Baines, Committee Secretary/Assistant Trust Secretary

(note-taker) 022/18 Introduction by Chair

Jennifer Tippin welcomed everyone present to the meeting of the Charitable

Funds Committee meeting.

023/18 Apologies for Absence

Apologies were received from Jo Bing, Assistant Financial Accountant; Victoria Cover, Head of Clinical Services Urgent Care And Hospitals; Gordon Flack, Director of Finance; Neil Sherwood, Convenor Staffside; Lesley Strong, Chief Operating Officer/ Deputy Chief Executive; Jane Thackwray, Strategic Delivery Manager and Jo Treharne, Head of Marketing. The meeting was quorate.

024/18 Declarations of Interest There were no Declarations of Interest given apart from those formally noted on the record.

Cha

ritab

le F

unds

Com

mitt

eeM

inut

es

Page 137 of 144

of 5

025/18 Minutes and Matters Arising from the Meeting of 27 April 2018

The Minutes were AGREED by the Committee. Matters Arising The Matters Arising from the previous meeting were reviewed and updated as follows: 030/17 Annual Marketing Plan – An article would appear in the autumn edition of Community Health. Action open. All other open actions were closed. The Matters Arising Table was AGREED.

026/18 Relevant Feedback from Other Committees

Finance, Business and Investment Committee Bridget Skelton highlighted that there were budgets available to enhance the environment of the community hospitals and suggested that the Committee should consider how it could support this.

027/18 Marketing the Charitable Funds Report Fay Sinclair presented the report to the Committee for assurance.

In response to a question from Richard Field regarding how the fund could raise awareness of its activities amongst the membership of the Trust and appeal to them to support fund-raising activities, Fay Sinclair confirmed that the database would be used to support this and in line with the new General Data Protection Regulation (GDPR). With regards to raising awareness of legacy-giving at the Trust’s Annual General Meeting, Carol Coleman suggested that it would be more appropriate to change this to general awareness-raising of the charity instead. In response to a question from Jen Tippin regarding whether the target for donations to the general fund was too ambitious, it was agreed that the process for collecting donations when they came into the community hospitals would be reviewed with the aim of improving it. Action – Fay Sinclair on behalf of Jo Treharne In response to a question from Jen Tippin regarding the cost of the 2018 Staff Awards, Fay Sinclair confirmed that it was similar to previous years, with the Charitable Funds and the Trust funding a proportion.

Page 138 of 144

of 5

The Committee APPROVED the marketing objectives for 2018/19 as set out in the report. The Committee NOTED the Marketing the Charitable Funds Report.

028/18 Restricted/Unrestricted Funds Financial Update Quarter One Carl Williams presented the report to the Committee for assurance.

With regards to the £20k of requested spend which had not yet been processed, this had been reviewed the previous week and £8k had been redirected to Trust budgets. There was no further news on the Mermikides Heron Ward Restricted Fund and it was suggested that a presentation be given at the November 2018 Committee meeting. Action – Jane Kendal on behalf of Lesley Strong The draft 2017/18 Accounts and Report would be presented at the November 2018 meeting for comment and the final version would be presented at the January 2019 meeting for approval. In response to a question from Jen Tippin regarding the plans to spend the Mermikides Heron Ward Restricted Fund, Jane Kendal explained why there had been a delay in spending the fund. She confirmed that plans were in place and Phase Two of the project which would utilise the Charitable funds was scheduled to begin in Spring 2019. With regards to the Sensory Room Appeal, Jen Tippin suggested that the remaining money should be used to buy toys to close down the fund. It was agreed that a presentation on the Bow Road Restricted Fund would be made at the November 2018 Committee meeting. Action – Victoria Cover The Committee NOTED the Restricted/Unrestricted Funds Financial Update Quarter One

029/18 Committee Effectiveness Review Jen Tippin presented the report to the Committee for approval.

It was agreed that a presentation from the fund managers would be a standing item on the agenda. In response to a comment from Jen Tippin that ‘i care’ might not have been as successful in fundraising as had been expected, Fay Sinclair commented that charities did take time to embed and required continuous actions if they were to succeed. She recognised that more could be done and suggested that it was too early to say whether the charity had been successful or not. The Committee agreed that the charity had been more proactive than

Cha

ritab

le F

unds

Com

mitt

eeM

inut

es

Page 139 of 144

of 5

previously and had been taking a different approach towards fund-raising. It was agreed that a further review would be undertaken in July 2019 to assess how well it had worked. Action – Fay Sinclair on behalf of Jo Treharne In response to a comment from Jane Kendal that the digital presence of the charity could be strengthened, it was agreed this would be addressed. Action – Fay Sinclair on behalf of Jo Treharne The Committee NOTED the Committee Effectiveness Review.

030/18 Forward Plan Jen Tippin presented the report to the Committee for approval.

The agenda items for November and January were agreed. In response to a question from Carol Coleman regarding whether there was a target set for spending from the unrestricted funds at each of the hospitals, Jen Tippin suggested that a spending plan to address their environments would be helpful. Carol Coleman indicated that the external environment of those hospitals managed by NHS Property Services (NHSPS) needed to be addressed and it was suggested that this should be raised with Natalie Davies, Corporate Services Director. She in turn would be able to raise this with NHSPS. One off items could be considered by the Committee. In response to a question from Peter Conway regarding whether the Audit and Risk Committee could receive the Charitable Funds Annual Report and Accounts, Carl Williams confirmed that the rules required for this to remain with the Charitable Funds Committee. In response to a question from Richard Field regarding how the Committee could keep abreast with developments in charitable funding, Carl Williams confirmed that he and Jo Bing monitored the briefings that were received by the Trust. It was agreed to bring an annual assurance report in January 2018 that set out any changes which had been advised by relevant bodies and to confirm that they had been noted by the Trust. This would then be included in the Committee’s Annual Report to the Board in May 2019. Action – Jo Bing It was agreed to update the Forward Plan. Action – Gina Baines The Committee APPROVED the Forward Plan.

031/18 Any Other Business

There was no other business.

Page 140 of 144

of 5

The meeting ended at 1.07pm.

032/18 Date and time of next meeting Thursday 29 November 2018, 4pm, Room 6 and 7, Kent Community Heath NHS Foundation Trust Offices, Trinity House,110 – 120 Upper Pemberton, Eureka Business Park, Kennington, Ashford, Kent TN25 4AZ

Cha

ritab

le F

unds

Com

mitt

eeM

inut

es

Page 141 of 144

M

ee

ting

of th

e K

en

t Co

mm

un

ity H

ea

lth N

HS

Fo

un

da

tion

Tru

st B

oa

rd

to b

e h

eld

at 1

0a

m o

n T

hu

rsd

ay 3

1 J

an

uary

20

19

in th

e

Oa

k R

oo

m, O

akw

oo

d H

ou

se

, Oa

kw

oo

d P

ark

, M

aid

sto

ne

ME

16 8

AE

Th

is m

ee

ting

will b

e h

eld

in P

ub

lic

A

GE

ND

A

1. S

TA

ND

AR

D IT

EM

S

1.1

In

trodu

ctio

n b

y C

ha

ir

Tru

st C

ha

ir

1.2

T

o re

ce

ive

an

y A

po

logie

s fo

r A

bse

nce

T

rust C

ha

ir

1.3

T

o re

ce

ive

an

y D

ecla

ratio

ns o

f In

tere

st

T

rust C

ha

ir

1.4

T

o a

gre

e th

e M

inute

s o

f the

Ke

nt

Com

mu

nity

He

alth

NH

S F

oun

datio

n

Tru

st B

oa

rd m

ee

ting h

eld

on

29

Nove

mb

er 2

018

T

rust C

ha

ir

1.5

T

o re

ce

ive

Ma

tters

Aris

ing fro

m th

e

Ke

nt C

om

mun

ity H

ea

lth N

HS

F

ou

nda

tion

Tru

st B

oa

rd m

ee

ting h

eld

o

n 2

9 N

ove

mb

er 2

018

T

rust C

ha

ir

1.6

T

o re

ce

ive

the T

rust C

ha

ir’s

Rep

ort

T

rust C

ha

ir

Ve

rba

l

1.7

T

o re

ce

ive

the C

hie

f Exe

cu

tive

’s

Rep

ort

• C

are

Qu

ality

Co

mm

issio

n

C

hie

f Exe

cu

tive

2. B

OA

RD

AS

SU

RA

NC

E/A

PP

RO

VA

L

2.1

To re

ce

ive

the P

atie

nt S

tory

Chie

f Nu

rse

(Inte

rim)

2.2

To re

ce

ive

the B

oa

rd A

ssu

ran

ce

F

ram

ew

ork

Corp

ora

te S

erv

ice

s

Dire

cto

r

Agenda

Page 142 of 144

B

oa

rd C

om

mitte

e R

ep

orts

2.3

To re

ce

ive

the Q

ua

lity C

om

mitte

e

Cha

ir’s A

ssu

ran

ce

Re

po

rt

Cha

ir of Q

ua

lity

Com

mitte

e

2.4

To re

ce

ive

the S

trate

gic

Work

forc

e

Com

mitte

e C

ha

ir’s A

ssu

ran

ce

Re

po

rt

Cha

ir of S

trate

gic

W

ork

forc

e C

om

mitte

e

2.5

To re

ce

ive

the A

ud

it an

d R

isk

Com

mitte

e C

ha

ir’s A

ssu

ran

ce

Re

po

rt

C

ha

ir of A

ud

it an

d R

isk

Com

mitte

e

2.6

T

o re

ce

ive

the C

ha

ritab

le F

und

s

Com

mitte

e C

ha

ir’s A

ssu

ran

ce

Re

po

rt

Dep

uty

Cha

ir of

Cha

ritab

le F

un

ds

Com

mitte

e

2.7

T

o re

ce

ive

the In

tegra

ted

P

erfo

rma

nce R

epo

rt

• A

ssu

ran

ce

on S

trate

gic

Go

als

• Q

ua

lity

• W

ork

forc

e

• F

ina

nce

• O

pe

ratio

na

l

D

irecto

r of F

inan

ce

Chie

f Nu

rse

(Inte

rim)

Dire

cto

r of W

ork

forc

e,

Org

an

isatio

na

l D

eve

lop

men

t an

d

Com

mu

nic

atio

ns

Dire

cto

r of F

inan

ce

Chie

f Ope

ratin

g O

ffice

r/ D

ep

uty

Ch

ief E

xe

cu

tive

2.8

T

o re

ce

ive

the T

rust P

rep

are

dn

ess

for B

rexit R

ep

ort

C

orp

ora

te S

erv

ices

Dire

cto

r

2.9

T

o re

ce

ive

the W

inte

r Pre

ssu

res

Upd

ate

Re

po

rt

C

hie

f Ope

ratin

g

Offic

er/D

epu

ty C

hie

f E

xe

cu

tive

3. S

TR

AT

EG

Y A

ND

PL

AN

NIN

G

3.1

To re

ce

ive

the N

HS

Lon

g T

erm

Pla

n

an

d Im

pa

ct fo

r Ke

nt C

om

mun

ity

Hea

lth N

HS

Fou

nd

atio

n T

rust R

ep

ort

D

irecto

r of S

trate

gy

4. R

EP

OR

TS

TO

TH

E B

OA

RD

4.1

To re

ce

ive

the L

ea

rnin

g F

rom

De

ath

s

Rep

ort

M

ed

ical D

irecto

r

Page 143 of 144

4.2

T

o re

ce

ive

the F

ree

dom

To

Sp

ea

k

Up R

ep

ort

C

orp

ora

te S

erv

ices

Dire

cto

r

4.3

T

o re

ce

ive

the C

om

mun

ity H

osp

itals

S

afe

r Sta

ffing R

evie

w

C

hie

f Nu

rse (In

terim

)

4.4

T

o re

ce

ive

the M

inu

tes o

f the

C

ha

ritab

le F

un

ds C

om

mitte

e m

eetin

g

of 2

5 J

uly

20

18

D

ep

uty

Cha

ir of

Cha

ritab

le F

un

ds

Com

mitte

e

5. A

NY

OT

HE

R B

US

INE

SS

T

o c

on

sid

er a

ny o

the

r item

s o

f b

usin

ess p

revio

usly

no

tified

to th

e

Tru

st C

ha

ir

T

rust C

ha

ir

6. Q

UE

ST

ION

S F

RO

M M

EM

BE

RS

OF

TH

E P

UB

LIC

RE

LA

TIN

G T

O T

HE

AG

EN

DA

7. D

AT

E A

ND

VE

NU

E O

F N

EX

T M

EE

TIN

G

Th

urs

da

y 2

8 M

arc

h 2

01

9

Ro

om

s 6

an

d 7

, Ken

t Co

mm

un

ity H

ea

lth N

HS

Fo

un

datio

n T

rus

t Offic

es

, Trin

ity H

ou

se

, 11

0 –

12

0

Up

pe

r Pe

mb

erto

n, K

en

nin

gto

n, A

sh

ford

, Ken

t TN

25

4A

Z

Agenda

Page 144 of 144