agenda of the board of directors public board · provide valuable feedback and ensure the visits...

AGENDA OF THE BOARD OF DIRECTORS

PUBLIC BOARD To be held 10:30 - 13:00 on Wednesday 4 December 2019

Ruffwood Suite, Education Centre, Ormskirk Hospital L39 2AZ

V = Verbal D = Document P = Presentation

Ref No. Agenda Item Lead Duration

PRELIMINARY BUSINESS 10:30

TB197/19

(V)

Chair’s welcome & note of apologies

To note the apologies for absence Chair

10

TB198/19

(D)

Declaration of Directors’ Interests concerning

agenda items

To receive declarations of interest relating to

agenda items and/or any changes to the register

of directors’ declared interests

Chair

TB199/19

(D)

Minutes of the Meeting held on 6 November

2019

To approve the minutes of the Public Board of

Directors

Chair

TB200/19

(D)

Matters arising action Logs - Outstanding &

Completed Actions

To review the Action Logs and receive relevant

updates

Chair

TB201/19

(D/V)

(V/P)

Patients and Engagement Issues including:

• NEDs & Executive Visits/Walkabouts:

o NEDs: (verbal)

o Executives: (document/verbal)

• Patient Story:

Chaplaincy and Spiritual Care - the work and achievements from over the last year and its positive impact on the patient experience To receive the Patient Story and note lessons learnt

NEDs EDs

Michelle Kitson/Martin

Abrams

30

STRATEGIC CONTEXT 11:10

TB202/19

(D)

Chief Executive’s Report

To receive key issues and update from the CEO

CEO 10

Pub

lic B

oard

Age

nda

- 4

Dec

19

of 210

Ref No. Agenda Item Lead Duration

QUALITY & SAFETY 11:20

TB203/19

(P/D/V)

Quality and Safety Reports:

a) Quality Improvement Plan Update

b) Summary of Complaints & Compliments

c) Learning from Deaths Report (formerly

Monthly Mortality Report)

d) Safe Staffing: Monthly

e) Medical Vacancy Rate: Monthly

f) CQC Inspection Update

To receive the presentation and reports

DoN/MD

30

PERFORMANCE & GOVERNANCE 11:50

TB204/19

(P/D)

Integrated Performance Report (IPR)

To receive the report COO 15

TB205/19

(D)

Financial Position at Month 7, 2019/20

To receive the report

DoF

15

TB206/19

(D)

Risk Management

Corporate Risk Register (CRR)

To receive the monthly reports.

DoN

5

TB207/19

(P/D)

Single Improvement Plan Update (SIP)

To receive the report

DCEO/ DoS

10

TB208/19

(P)

Workforce Directorate Presentation

To receive the presentation

DHR 10

TB209/19

(D)

Charity Update

• Name change for the Charity

• Investment Policy for the Charity

To receive the reports

DoF

ITEMS FOR APPROVAL/RATIFICATION 12:45

TB210/19

(V)

a) Learning Lessons to Improve our

People Practices Report

b) Workforce Disability Equality Standard

Information Report April 2019 – March

2020

c) Workforce Race Equality Standard

Information Report April 2018 – March

2019

Chair

10

of 210

To approve the reports

CONCLUDING BUSINESS 12:55

TB211/19

(V)

Questions from Members of the Public

Public 10

TB212/19

(V)

Any Other Business

To receive/discuss any other business not on

the agenda, including items for forward agenda –

8 January 2020

Chair 10

TB213/19 (V)

Message from the Board

• To agree the key messages to be cascaded

throughout the organisation from the Board. Chair

5

TB214/19 (D)

Meeting Evaluation

To give members the opportunity to evaluate the

performance of the Board meeting. Chair 5

TB215/19 (V)

Date and time of next meeting:

10:30, Wednesday 8 January 2020

Seminar Room, Clinical Education Centre,

Southport District General Hospital, PR8 6PN

Chair

13:30

CLOSE

Chair: Neil Masom

ACTIONS REQUIRED:

Approve: To formally agree the receipt of a report and its recommendations OR a particular course of action

Receive: To discuss in depth a report, noting its implications for the Board or Trust without needing to formally approve it

Note: For the intelligence of the Board without the in-depth discussion as above

Assure: To apprise the Board that controls and assurances are in place

For Information: Literally, to inform the Board

Pub

lic B

oard

Age

nda

- 4

Dec

19

of 210

1

Re

gis

ter

of

Inte

rests

De

cla

red

by t

he B

oard

of

Dir

ecto

rs 2

01

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Page 4 of 210

2

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Page 5 of 210

3

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Page 6 of 210

4

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20

19

Page 7 of 210

1

Minutes of the Public Section of the Board of Directors’ Meeting

Wednesday, 6 November 2019

Seminar Room, Clinical Education Centre, Southport Hospital (Subject to the approval of the Board on 4 Dec 2019)

Members Present

Mr J Birrell, Non-Executive Director

Mr D Bricknell, Non-Executive Director

Mrs J Cosgrove, Executive Director of Nursing,

Midwifery & Therapies

Mrs J Gorry, Non-Executive Director

Mrs T Patten, Acting Chief Executive / Executive

Director of Strategy

Mr S Shanahan, Executive Director of Finance

Mr G Singh, Non-Executive Director

In Attendance

Mr S Christian, Chief Operating Officer

Mrs A Davenport, Interim Associate Director for Corporate Governance

Mr T Ellis, PR & Communications Manager

Mrs P Gibson, Non-Executive Director Designate

Mrs C Griffiths, NHSE/I Improvement Director

Mrs A Marshall, PA to the Chief Executive & Chair

Mrs J Royds, Director of Human Resources & Organisational Development

Apologies:

Dr T Hankin, Executive Medical Director

Neil Masom, Chair

AGENDA

ITEM

ACTION LEAD

PRELIMINARY BUSINESS

TB180/19 Chair’s Welcome and Note of Apologies

Mr Birrell opened the meeting by welcoming members of the public who were in attendance. He reminded them that although this is a meeting held in public it is not a public meeting. Therefore he would give those in attendance an opportunity to ask questions at the end of the meeting. Apologies noted from Mr Masom, Dr Hankin and Mrs Roberts.

TB181/19 Declaration of Directors’ Interests Concerning Agenda Items

The Chair asked that members declare any interests in relation to the agenda items and asked that any changes or additions to the Register of Interests declared by the Board of Directors should be submitted to the Company Secretary. Mr Singh confirmed that he had been asked to become a member of

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the Medical Education Charity at Southport & Ormskirk Hospital NHS Trust.

TB182/19 Minutes of the Meeting Held On 6 March 2019

The minutes of the meeting held on 2 October were agreed as a correct record and were approved. . RESOLVED: The Board approved the minutes as an accurate record.

TB183/19 Matters Arising Action Log

The Board considered the following matters arising in turn: January 2019, Min No. TB028/19 Monthly Mortality Report/External Mortality Review Dr Hankin to provide a progress update to provide Board assurance. September 2019, Min No. TB149/19 Quality Improvement Plan Awaiting final CQC report

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TB184/19 Patient and Engagement Issues including:

• NEDs & Executive Visits/Walkabouts

• Patient/Staff Story: Surgical Assessment Unit – How they improved the patient journey

NEDs & Executive Visits/Walkabouts Mrs Gorry & The Director of Finance had visited Spinal Injuries Unit (SIU)on 23 October. The SIU had recently been refurbished following the Klebsiella outbreak. The visit went well with engaging feedback from the staff, who were proud of the patient centred team, the standard of work and care and the comprehensive induction programme in place. It was noted however the staff on SIU felt frustrated with overall communications which came from the management team of the hospital and were unsure how they fitted into the strategic plans for the future. There are elements of the IT systems which do not align. Some of the staff felt the profile of SIU should be raised and run as a separate Clinical Business Unit (CBU). There was a suggestion to link the NEDs with designated wards. The Acting Chief Executive & Director of Strategy will provide a summary of actions from the NED and Executive visits which would provide valuable feedback and ensure the visits are viewed as a meaningful exercise. It was noted that both the Chief Operating Officer and the Director of

Nursing, Midwifery & Therapies were providing support and visibility around the wards during this period of overwhelming demand. The Director of Human Resources & Operational Development confirmed there were dates in the diary for her and Gurpreet Singh to arrange ward visits during the next couple of months. Back to the floor visits for all of the Executive Team were also being arranged. Patient/Staff Story: Surgical Assessment Unit – How they improved the patient journey The Board were apprised of the background of the opening of the

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Surgical Assessment Unit (SAU). The SAU was 18 months in the planning and opened in October 2018. It is a purpose built area for ambulatory patients who require surgical review. The process of embedding the new service into practice has taken 12 months. There were some initial teething issues but these have now been resolved. The aim of the unit is to reduce avoidable admissions. Some of the achievements to date include: ➢ March 2019 - Cohort 4 NHS Elect Programme: Trust

commitment to best practice and developing ambulatory models of care. The team have been asked to coach Cohort 5 and asked to share their data template

➢ May - Acute Abdomen Pathway formalised

➢ June - Pilot of Hot clinic

➢ July - Formalisation of Standard Operating Policy for Hot Clinic and Ward Attender Referral Process

The work continues to provide excellent safe and appropriate care. Improvements to service provision adapt in relation to feedback received. There is further work underway with NHS Elect to ringfence the unit and increase revenue from Best Practice Tariff. There had been some HRG coding issues which had indicated under-costing however this issue has been resolved and should be reflected in the August data. The staff on SAU are very proud of this service and are looking forward to the future development of the unit. The next 12 months will be looking at developing a 7 day service.

Patient Story – Sally’s Story

The outcome from Sally’s story was very positive. Sally had given

permission to use both her story and her name. Following a 3 year

history of a cyst to her back Sally’s GP referred her to SAU for

assessment. As a result of the review Sally was listed by the

Surgeon for same day ‘see and treat’. This process allowed Sally to

attend the hospital on the morning of her procedure. Her husband

who required a carer was able to attend with her and was looked

after by the staff on duty. The procedure was completed and Sally

was discharged home. There was no capacity within the

Community to provide a wound check the following day so Sally

returned to the unit for wound care and no follow up appointment

was required.

Mr Birrell thanked Gemma for attending the meeting offered his praise for the development of the service and encouraged Board members to visit the area. The Chief Operating Officer praised Gemma and her team for their hard work and dedication noting that Gemma was an exemplar colleague.

RESOLVED: The Board received the presentation and noted the excellent progress being made

STRATEGIC CONTEXT

TB1850/19 Chief Executive’s Report

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The Chief Executive’s Report was presented to the Board, with key issues being highlighted as follows: ➢ Ormskirk hospital is the key to winter planning.

The Trust plans to make better use of the excellent facilities at Ormskirk hospital following extensive clinical consultations.

➢ Visit by the Secretary of State for Health and Social Care Matt Hancock, the Secretary of State for Health and Social Care, visited Southport hospital visited the Trust on 9 October. He was visiting at the invitation of Southport MP Damien Moore.

➢ Time to Shine Awards Nearly 250 staff and guests gathered at Formby Hall Golf Resort and Spa last month to celebrate our annual staff awards, the Time to Shine Awards. Congratulations to be offered to the Time to Shine winners and moninees.

➢ Bed reopening in Spinal Injuries Centre North West Regional Spinal Injuries Centre at Southport hospital has begun to reopen after closing to admissions in the summer following an increase in the incidence of patients colonised with the Klebsiella bacteria.

➢ Flu Campaign at week 5 – 73% ➢ Winter Plan approved at Private Board subject to a

clinical conversation. ➢ Electronic Medical Prescribing.

£700k funding approved to support implementation of Electronic Medical Prescribing, this is a major investment into IT systems it is hoped this will be mobilised by the beginning of January 2020.

RESOLVED: The Board noted the report.

QUALITY & SAFETY

TB186/19 QUALITY & SAFETY REPORTS

The key issues from the 5 comprehensive reports provided in relation to this agenda item (Summary of Complaints & Compliments, Learning from Deaths Report (formerly Monthly Mortality Report), Quality Improvement Plan, Safe Staffing, CQC update, and Freedom to Speak Up Quarterly Update and Relaunch of Strategy) were highlighted in a presentation to the Board, as follows: Quality Improvement Priorities Complaints & Compliments This month’s report shows a breakdown of the number of compliments, complaints and concerns received for the month of September and the improvements now in place following the closure of complaints in August. It was noted the number of complaints and concerns had appeared to stabilise, however plans to address the backlogs will be managed by the newly appointed Deputy Directors of Nursing.

Action: Director of Nursing, Midwifery & Therapies By: January Board

Learning from Deaths Report (formerly Monthly Mortality

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Report) It was noted the Monthly Mortality Report to the Board is now a

Learning from Deaths Report. In April the HSMR increased to 118

from 82.8 the previous month. There had been no significant spikes

in any disease specific areas and the main primary diagnoses of

these patients were similar to previous months. Fortnightly Mortality

Meetings are now in place to support the delivery of a responsive

and learning approach to the screening of deaths.

Mortality Screening Following a review of the process the screening rate has shown an

improvement. Structured Judgement Reviews and potential

avoidance of death reviews are in place. There are still a

percentage of patients receiving poor care. Director of Nursing,

Midwifery & Therapies noted these cases would be managed

through the Mortality Operational Group and the themes would be

consolidated.

Quality Improvement Plan Training is being delivered on the Older Peoples Care Training

Programme to include Nutrition, Hydration & Mouth Care, Dementia

& Delirium, Continence, End of Life Care, Falls, Care of the

Deteriorating Patient, Infection Prevention and Control (IPC) and

Medicines Management. There are some issues around nutrition

due to the lack of ability to release Dietitians from clinical duties in

the absence of a Dietetic lead. The Falls Strategy is being

developed with a view to launch in November. A new Neck of

Femur (NOF) Pathway has been approved and will be reviewed and

audited.

IPC Update

The Team is working across the Community in conjunction with

AQUA. There is a focus on reducing antimicrobial use. The C.Diff

target is more challenging this year due to a change in how cases

are attributed to the Trust. There had been an MRSA bacteraemia

in August which was the first one in almost 2 years and was a result

of cannulation, relevant learning identified. To date there have been

3 cases of flu but no transmission noted and a table top exercise

has been completed. Klebsiella outbreak on Spinal Injuries Unit had

been handled effectively.

Medicines Management

Following the issues raised by the CQC and the information

provided by the Model Hospital Team which identified the

department was under resourced a Business Case for additional

staffing had been completed and was approved at Private Board on

6 November 2019.

Safe Staffing There has been an overall improvement to the fill rate which is as a result of an increase in the number of allocate on arrival shifts which attract an enhanced rate. There have been a number of recruitment events but the Trust is only just managing to maintain

Comms

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safe staffing levels. The Trust has one of the highest vacancy rates across Cheshire & Merseyside. International recruitment is a consideration. There is no central point for the management of medical vacancies and these are managed within the individual CBUs. The Executive Medical Director will be asked to provide a paper update to the Board which will provide details of the medical vacancy rate across the Trust, it was noted this would be a complex piece of work and would require discussion at Workforce Committee.

Action: Executive Medical Director By: December Board

Improving Criteria Led Discharge Important for the Trust to ensure there are nurses available to support Criteria Led Discharge, work is progressing in this area but not something that will be fully established this year. The Red to Green multi-disciplinary approach will also support patient flow. CQC Update The Trust received the draft report for factual accuracy checking on 8 October 2019 the Quality Team worked with the Core Service leads to identify any inaccuracies and the report was returned by the deadline 29 October 2019. The CQC have been asked to consider amendment to some key ratings. The date for official publication of the report is yet unclear due to the process of Purdah. Freedom to Speak Up Quarterly Update During October the Freedom To Speak Up Champions engaged in different activities, plans for November include drop-in sessions to recruit more Champions. It had been noted within the Freedom To Speak Up Index Report that the Trust had been listed in the bottom 10 but there was no indication as to why this is the case. Martin Abrams is meeting with the Regional Liaison Lead for the North West to discuss the potential to ‘buddy up’ with an organisation which has shown improvement. RESOLVED: The Board received the Complaints & Compliments Report, the Learning from Deaths Report (formerly Monthly Mortality Report) and the Monthly Safe Staffing Report and was assured by the Quality Improvement Report and the CQC Preparation Update

PERFORMANCE & GOVERNANCE

TB187/19 Assurance & Performance

INTEGRATED PERFORMANCE REPORT The Chief Operating Officer provided an overview of this report which identified an improvement of 31 indicators and a deterioration of 24. Key areas: 12 hour DTA breaches 5 declared for the month of September 4 of which were attributed to patient flow and 1 a delay in securing a mental health bed. Assurance given that all patients did receive senior review during this time. Currently showing as an outlier for the region which is also bringing scrutiny from the Regulators.

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RTT Remains above the 92% target however performance is currently being impacted by anaesthetics and various workforce issues. C.Diff Mr Birrell asked for clarification of the Trust target as there appeared to be conflicting information within the description and narrative columns.

Action: Executive Medical Director By: December Board

Friends & Family Test Performance has shown a significant deterioration in comparison to the previous month. LOS Interventions in place are showing an improvement, with continued work around embedding the Home First solution.

Theatre Productivity July – September 2019 showed an improvement of 5%

Agency Staff Costs continue to remain high due to the reliance on agency staff to provide safe patient care in both medical and nursing areas. The Director of Human Resources & Organisational Development noted there are 4 consultant panel interviews taking place over the next 3 weeks and there have recently been 3 appointments within the Anaesthetics Department which is a positive step.

Diagnostic Waits There was a demonstrable improvement for the third month in a row however Radiology and Endoscopy are key services which are impacting on performance. The Trust has improvement plans in place to address the issues. Mr Birrell noted that the sickness rate was currently at the lowest level for some time however the staff turnover rate was the highest. The Director of Human Resources & Organisational Development advised there was a focused piece of work underway looking at staff retention issues. For noting there are currently over 450 recruitment opportunities in various stages of progression. The Executive Assurance Reports were noted. RESOLVED: The Board received the IPR

TB188/19 Financial Position at Month 6, 2019/20

The report for month 6 of 2019/20 was received and noted by the Board. The Director of Finance noted the Trust had delivered the Quarter 2 plan and assured the Board that accounting adjustments had been made in conjunction with the Regulators. However he noted the financial position was set to get more challenging in the forthcoming months. The Trust currently has an unmitigated risk of £5m to the delivery of the control total. Agency spend had increased to above £1m which is a significant risk heading into

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winter. The use of Thornbury Agency has reduced but there was still a reliance on Tier 2 nursing agency and an increase in the use of allocate on arrival which is paid at an enhanced rate. RESOLVED: The Board received the report

TB189/19 Risk Management: Risk Register

The Risk Management Risk Register was received and noted by the Board. A more detailed discussion took place relating the following risks:

• Risk 1688 – Inadequate Staffing Levels in Anaesthetic Department. This is for discussion at Risk & Compliance Group to consider the potential to reduce the risk score.

• Risk 2056 – Lost to Follow Up. Work continues following the identification of a number of individual incidents where patients were not on the RTT pathway. 98% of pathways closed down the remaining 2% required clinical review following which they were also closed down. Comprehensive overview will take place at the next Quality & Safety Committee.

RESOLVED: The Board received the Risk Register report.

OTHER REPORTS FOR RECEIVING

TB190/19 SINGLE IMPROVEMENT PLAN UPDATE (SIP)

The Board received the Single Improvement Plan Board update. The Acting Chief Executive & Director of Strategy advised that following a recent Southport & Ormskirk Improvement Board the Trust had been asked to review the detail contained within the narrative of the assurance reports to ensure a clear and comprehensive progress update was provided. Business Planning Session arranged for 7 November to agree quality and operational priorities for next year. The outline Pre Consultation Business Case has been completed and unlikely to be circulated until after the General Election on 13 December. RESOLVED: The Board received the paper.

TB191/19 ITEMS FOR APPROVAL/RATIFICATION

a) To ratify the decision taken under Emergency Powers Section 4.3 of the Standing Orders on 25 October 2019 to approve application for an uncommitted Revenue Support Loan for November 2019

RESOLVED: The Board noted and approved the request.

CONCLUDING BUSINESS

TB192/19 Questions from Members of the Public

Ms Wright - Could the Trust confirm where the company was based that covered the out-sourcing of Radiology.

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There being no other business, the meeting was adjourned

In view of the high numbers of vacancy rates especially within Radiology the Trust had developed a solution to ensure the timely review of patient assessments was provided. The service has been outsourced via the national framework to Telemedicine who are an internationally based company with their head office in Australia. Ms Wright - Clarity around Criteria Led Discharge Juliette Cosgrove, Director of Nursing advised that the Multi-Disciplinary Team decides a criteria for discharge for individual patients and when this is met then the patient can go home. This is normally led by a nurse. This process is designed to prevent discharge delays when Therapies are required. It is not an alternative to using doctors.

TB193/19 ANY OTHER BUSINESS

To receive/discuss any other business not on the agenda.

TB194/19 Message from the Board

Messages which the Board wished to communicate to the wider Trust were:

• SAU – Spotlight on positive achievements

• Thank you - Time to Shine award winners and nominees

• More patients treated – less Theatres used

• Achievement of Quarter 2 Finance Plan

• EPMA Funding

• Approval of Winter Plan Business Case

• Sickness at lowest level since September 2014

Communications

TB195/19 Meeting Evaluation

To give members the opportunity to evaluate the performance of the Board meeting

• Clear presentations to support discussions

• Willingness to respond to questions

• Would be helpful if Board members introduced themselves

• Page direction would be helpful

• Time Management of meeting – some items rushed, insufficient time to cover items

TB196/19 DATE, TIME AND VENUE OF THE NEXT MEETING

Wednesday 4 December 2019, 10:30am Ruffwood Suite, Education Centre, Ormskirk District General Hospital

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Board Attendance 2019/20

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

Neil Masom (Chair) ✓

Jim Birrell ✓

David Bricknell ✓

Ged Clarke ✓

Juliette Cosgrove ✓

Julie Gorry ✓

Terry Hankin ✓

Silas Nicholls ✓

Therese Patten ✓

Steve Shanahan ✓

Gurpreet Singh A

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

Pauline Gibson ✓

Audley Charles ✓

Steve Christian ✓

Jane Royds ✓

A = Apologies ✓ = In attendance

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PUBLIC TRUST BOARD 4 DECEMBER 2019

Agenda Item TB202/19 Report Title Acting Chief Executive report

to Board

Executive Lead Acting Chief Executive

Lead Officer

Action Required

(Definitions below)

To Approve ✓ To Note

To Assure To Receive

For Information

Executive Summary

• Care Quality Commission report published

• £1.4m investment in electronic prescribing

• Further improvement is mortality performance

• CQC Children’s and young people’s survey

• Honorary professorship for Dr May Ng

Strategic Objective(s) and Principal Risks(s)

(The content provides evidence for the following Trust’s strategic objectives for 2019/20)

Strategic Objective Principal Risk

✓ SO1 Improve clinical outcomes and patient safety to ensure we deliver high quality services

If quality is not maintained in line with regulatory standards this will impede clinical outcomes and patient safety.

✓ SO2 Deliver services that meet NHS constitutional and regulatory standards

If the Trust cannot achieve its key performance targets it may lead to loss of services.

✓ SO3 Efficiently and productively provide care within agreed financial limits

If the Trust cannot meet its financial regulatory standards and operate within agreed financial resources the sustainability of services will be in question.

✓ SO4 Develop a flexible, responsive workforce of the right size and with the right skills who feel valued and motivated

If the Trust does not attract, develop, and retain a resilient and adaptable workforce with the right capabilities and capacity there will be an impact on clinical outcomes and patient experience.

✓ SO5 Enable all staff to be patient-centred leaders building on an open and honest culture and the delivery of the Trust values

If the Trust does not have leadership at all levels patient and staff satisfaction will be impacted

✓ SO6 Engage strategic partners to maximise the opportunities to design and deliver sustainable services for the population of Southport, Formby and West Lancashire

If the system does not have an agreed acute services strategy it may lead to non-alignment of partner organisations plans resulting in the inability to develop and deliver sustainable services

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Linked to Regulation & Governance (the report supports …..)

CQC KLOEs

GOVERNANCE

✓ Caring Statutory Requirement

✓ Effective Annual Business Plan Priority

✓ Responsive Best Practice

✓ Safe Service Change

✓ Well Led

Impact (is there an impact arising from the report on any of the following?)

Compliance Legal

✓ Engagement and Communication Quality & Safety

Equality Risk

Finance Workforce

Equality Impact Assessment

If there is an impact on E&D, an Equality Impact Assessment must accompany the report)

Policy

Service Change

Strategy

Next Steps (List the required Actions and Leads following agreement by Board/Committee/Group)

N/A

Previously Presented at:

Audit Committee Quality & Safety Committee

Charitable Funds Committee Remuneration & Nominations Committee

Finance, Performance & Investment

Committee Workforce Committee

GUIDE TO ACTIONS REQUIRED (TO BE REMOVED BEFORE ISSUE):


Receive: To discuss in depth a report, noting its implications for the Board or Trust without needing to formally approve




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ACTING CHIEF EXECUTIVE’S REPORT TO BOARD – December 2019 Care Quality Commission report published Improvements to care and leadership were recognised in the Trust’s latest Care Quality Commission report published on 29 November. It was our first full inspection since November 2017.

Across many of the Trust’s services, the inspectors found staff to be kind, treated people with compassion and respected their privacy and dignity.

They said leaders were approachable, experienced and capable, and were helping staff to develop their skills. There was active engagement between patients, staff and leaders alongside external stakeholders and equality groups to further develop collaboration and improve services.

Eight areas of inspection were rated as improving: six at Southport hospital in urgent and emergency care, surgery and end of life care, and two in the children’s and young people’s services at Ormskirk.

End of life care and Sefton Sexual Health were both rated “good”. This is the first time they have been inspected as individual services. Overall the Trust remains rated “requires improvement”.

The report reflects the significant progress the Trust is making. While we recognise there is still much work to do, it also shows us on track to meet our ambition of being rated “good” by 2020.

“I want to thank all our staff for their dedication and hard work that made these improvements to patient care possible.”

£1.4m investment in electronic prescribing Our staff will move away from handwritten prescriptions next year thanks to a £1.4m investment in electronic prescribing. The Department of Health will give £700,000 to make the scheme possible. The new system will be provided by our existing electronic patient record provider and interface with the pharmacy system. Electronic prescribing will be phased in over 18 months with the first areas going live by the early summer. Working this way saves time and benefits patients by:

• Reducing medication errors by up to 30% compared with paper systems • Ensuring fast access to potentially lifesaving information on prescribed

medicines • Building up a complete, single electronic record to reduce duplication of

information-gathering

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Electronic prescribing will also mean information about patients’ medicines can be more easily and reliably shared between all the clinical professionals a patient comes into contact with, including general practitioners. Further improvement is mortality performance I am pleased to report the latest national figure for SHMI, the Standardised Hospital Mortality Indicator, showed the Trust performing better than expected at 99.62.

SHMI is the ratio between the actual number of patients who die following hospitalisation and number who would be expected to die on the basis of average England figures. It also includes deaths in hospital and deaths 30 days after discharge.

The result is particularly pleasing given the Trust was a national outlier for SHMI less than a year ago. It is also a tribute to the dedication, commitment and hard work of staff across organisation that we have made such a dramatic improvement to patient care.

The fall reflects a rapid decline in the other national mortality indicator, HSMR (Hospital Standardised Mortality Ratio), which tracks the ratio of observed to expected deaths.

CQC Children’s and young people’s survey The latest Care Quality Commission (CQC) children and young people’s survey shows what our patients already know – we have a great team caring for children at Ormskirk hospital. One hundred and fifty-three patients responded to the annual national survey. It found the children’s team provided care that was as good or better than the other trusts surveyed. Staff introducing themselves to patients, giving them sufficient privacy and explaining procedures were particularly noted in the survey. Honorary professorship for Dr May Ng Congratulations to Dr May Ng who has been awarded the title of Honorary Associate Professor from the University of Liverpool. This is in recognition of her commitment to reduce variation in care for diabetes and her outstanding delivery of education and training in paediatric endocrinology and diabetes. Dr Ng, a Consultant Paediatrician who is Associate Medical Director for Specialist Services, has received numerous national awards for her leadership roles and has a wide research portfolio of more than 120 publications as well a best-selling book, A Journey With Brendan, documenting an autism journey with her son. Page 25 of 210

In brief … Chief Executive. Trish Armstrong-Child joined the Trust as Chief Executive on Monday 2 December. Flu vaccinations. As we approached the end of November, 83% of frontline staff had been vaccinated – this includes 98% of all allied health professionals such as therapists. Many non-clinical colleagues have also received their jab. Thanks a Bunch. Each month staff nominate colleagues for our Thanks a Bunch Award for someone who’s gone the extra mile and deserves recognition. The most recent awards were made to:

• The Anaesthetic team

• Lynne Finnigan, diabetic nurse

• Matt Parry, casting manager Therese Patten Acting Chief Executive December 2019

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PUBLIC TRUST BOARD 4 December 2019

Agenda Item TB203/19a Report Title Quality Improvement Report

Executive Lead Juliette Cosgrove, Director of Nursing, Midwifery, Therapy & Governance

Lead Officer Jo Simpson, Assistant Director of Quality

Bridget Lees, Deputy Director of Nursing

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

This paper provides the Board with an update on the progress of the Quality Improvement Plan and progress made in relation to actions and recommendations relating to the Quality Priorities The Board is asked to note progress identified in this report in relation to the Quality Improvements and the proposed single reporting template which will be used for assurance for both internal and external requirements.




SO1 Improve clinical outcomes and patient safety to ensure we deliver high quality services


SO2 Deliver services that meet NHS constitutional and regulatory standards


SO3 Efficiently and productively provide care within agreed financial limits


SO4 Develop a flexible, responsive workforce of the right size and with the right skills who feel valued and motivated


SO5 Enable all staff to be patient-centred leaders building on an open and honest culture and the delivery of the Trust values


SO6 Engage strategic partners to maximise the opportunities to design and deliver sustainable services for the population of Southport, Formby and West Lancashire

Absence of clear direction, engagement and leadership across the system is a risk to the sustainability of the Trust and will lead to declining clinical standards.

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Linked to Regulation & Governance

CQC KLOEs

GOVERNANCE

Caring Statutory Requirement

Effective Annual Business Plan Priority

Responsive Best Practice

Safe Service Change

Well Led


Compliance Legal

Engagement and Communication Quality & Safety

Equality Risk

Finance Workforce



Policy

Service Change

Strategy


Board of Directors






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QUALITY IMPROVEMENT PLAN UPDATE DECEMBER 2019

1. PURPOSE OF REPORT

This paper provides the Board of Directors with an update on the progress of the Quality Improvement Plan and progress made in relation to actions and recommendations relating to the Quality Priorities

2. QUALITY IMPROVEMENT

The Quality Improvement Plan (QIP) is an integral component of the Trust’s Vision 2020 Programme. This means that in terms of the governance arrangements, the delivery of the QIP is monitored through Trust Board in the following way:

• The delivery of the programme is managed and monitored through the Hospital Management Board via the Hospital Improvement Board. Programme governance of the plan is managed through the Quality and Safety Group (QSG). Day to day management is delivered through the work streams.

• Reports feed into the Quality and Safety Committee to ensure appropriate assurance as part of the Trust’s Quality and Safety Integrated Performance Report and Quality Improvement Plan Update.

• External governance is provided through the Southport and Ormskirk Improvement Board

• Quality Priorities will also be reported through the annual Quality Account.

The Quality and Safety group operationally monitor delivery of the Quality Priorities:

• Care of the Older Patient

• Care of the Deteriorating Patient

• Infection Prevention and Control

• Medicines Management

In addition to the four identified Trust Quality Priorities, another four quality areas have been

identified and are reported to Hospital Improvement Board (HIB) based on the Vision 20/20

Single Improvement Plan, the work streams include:

• Clinical Workforce Development (incorporating clinical education, medical staffing numbers and professional standards)

• Quality Standards Compliance (Quality Improvement and CQC preparation and delivery of Quality Improvement Plan)

• Patient Experience and Engagement

• Patient Safety (complaints and Risk Management)

• Safeguarding (Improve training compliance and documentation regarding Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS)

• Safe and Effective Discharge

• Documentation

The work streams will be reviewed again following publication of the 2019 CQC Report.

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3. FUTURE REPORTING POSITION

The Quality Priority Programme Leads have been allocated a dedicated programme resource, the PMO support are developing full standardised suite of programme documentation including Driver Diagrams, Programme Initiation Documentation (PID), Highlight Report and Gantt Charts, these will be completed and signed off ready for committees in January 2020. For each of the four quality priorities, the Programme Leads are developing improvement measures to monitor improvement and provide assurance, these will include structure, process and outcomes. Any areas for improvement identified during the recent CQC inspections associated to the four quality priorities will be incorporated into the reporting framework.

The Deteriorating Patient summary below provides as example of how the new Quality

Priority reporting dashboard will As advised at the meeting this report template for quality

improvement is being modified to provide assurance and demonstrate a continuous cycle of

improvement.

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4. CURRENT POSITION

Whilst improvement measures are being developed, the table below provides a summary update in relation to the four quality priorities

Care of the Older Patient:

Mouth Care Matters launched on Ward 14B 04/11/19 Falls bundle now on all wards at both Southport and Ormskirk sites. Cognitive impairment risk assessment and care plan now on all wards at Southport and Ormskirk sites. Revised nutritional screening policy has been rolled out on Ward 10B with demonstrable improvement. Dietetic lead now in post and will continue this piece of work. The training programme for Care of Older People has continued to be delivered with excellent feedback. 170 people are booked to undertake the programme by the end of 2019. The first member of the Dementia and Delirium Team in post 04.11.19 and the Admiral Nurse due in post 16.12.19 Continence project is being revised with a focus on 1 specific ward (7b) to enable greater focus and pace.

Infection Prevention and Control (IPC): Priorities in relation to policy updates is ongoing E Coli Bacteraemia: YTD reduction by 2 cases in September when compared with last year’s data. The trust has enrolled with AQuA: Action on Anti-Microbial reduction programme starting in November which will further support E coli reduction Spinal Centre refurbishments and deep cleaning: - Patient room and bathroom refurbishment nearing completion - Domestic hours increased to correspond with national guidelines - A Public Health England (PHE) Assurance visit of national experts took place on 12 November to provide advice and verify adequacy of processes undertaken, the Trust are awaiting the final report Influenza: 14B Influenza cases x 3 - all contacts reviewed and no transmission and minimal impact on operational capacity Management of Seasonal Influenza policy passed by policy group Table top exercise completed in Oct 19 using the influenza policy conducted by Emergency Planning Point of care Influenza testing analyser now installed in Southport lab; staff currently being trained, but should come on-line mid-November

Medicines Management: Medicines Management Business Case approved at Board 6 November 2019 Serious Incident RCA in relation to the CQC concern has been completed and

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recommendations have been incorporated into Medicine management development plan, after been through SIRG Focus remains on improving 7 day working, staffing and Electronic prescribing Two new additions to the improvement plan include a 6 month plan and assurance tracker. Ward checklists now in place, however anecdotal feedback is that compliance is poor. Weekly audits commenced 21 October and outcomes are to be fed into the tracker to provide assurance against compliance and identify any gaps. The funding application of £700,000 for EPMA (Electronic Prescribing and Medicines Administration) has been approved by NHSE/I

5. RECOMMENDATION

The Board are asked discuss progress identified in this report in relation to the Quality Improvement and to approve a single reporting template which will be used for assurance for both internal and external requirements.

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Agenda Item TB203/19b Report Title Complaints & Compliments

Executive Lead Juliette Cosgrove, Director of Nursing, Midwifery & Therapies

Lead Officer Mandy Power, Associate Director of Integrated Governance

Action Required

(Definitions below)

To Approve To Note

To Assure ✓ To Receive

For Information

Executive Summary

This report provides a breakdown on the number of compliments, complaints, concerns received in

the month of September and the improvements put in place following closure of complaints in

September 2019.

The numbers of complaints and concerns are decreasing; some of the same themes are coming

through but discharge has featured this month within the themes.

• Clinical Treatment – in particularly co-ordination of medical treatment

• Staff attitude/behaviour

• End of life

• Admission/transfers/discharge procedure

• Communication

• Date for appointment

The themes are subject to going improvement work within the Trust.

Recommendation

The Board is asked to receive the report











If the Trust does not attract, develop, and retain a resilient and adaptable workforce with the right capabilities and capacity there will be an impact

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on clinical outcomes and patient experience.






CQC KLOEs

GOVERNANCE

✓ Caring ✓ Statutory Requirement




✓ Well Led


✓ Compliance Legal

Engagement and Communication ✓ Quality & Safety

Equality Risk

Finance Workforce



Policy

Service Change

Strategy


Continue to monitor complaints and compliments. Weekly complaints review meeting to review all complaints over 40 day response target.






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Complaints & Compliments

October 2019

1.0 Introduction

This report provides a breakdown on the number of compliments, complaints, concerns received in the month of October, it does not relate to care or experience received in Month.

2.0 Compliments

The compliments received across the trust related to the quality of care received by Patients, Communications with relatives & patients, staff behaviour, attitude, staff availability & competence, cleanliness & hospital facilities, transport and also related to Privacy & dignity.

Planned care received the most compliments with 43 in total and General Surgery – Colorectal (11A) receiving 15 compliments in the month.

The Urgent Care Business Unit received 19 Compliments, with the Short Stay Unit reporting 6 compliments.

The Women & Children’s Business Unit received 6 compliments, of which all 6 related to Paediatric ward.

2.1 Complaints

The complaints data has been split in to low level concerns and formal complaints graded 3 or above using the trust grading tool. The formal complaints often include more than one area of complaint.

A total of 30 formal complaints were received in October.

Urgent Care received 16 complaints, with Ward 10A (EAU) accounting for 4 and A&E 2. Planned Care received 6 complaints, in 3 different areas. Specialist Services received 7 complaints, of which 2 related to Maternity. 1 complaint was received by Estates and Facilities and related to Security.

The following themes were identified:

• Clinical Treatment – in particularly co-ordination of medical treatment

• Staff attitude/behaviour

• End of life

• Admission/transfers/discharge procedure

• Communication

• Date for appointment

All complaints are currently being reviewed within the Business Units and response and relevant actions are being put in place.

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Improvements identified

There have been 18 complaints closed during the month of September, there has been some key areas of improvement work been identified through the complaints process. The following are areas were improvement has been highlighted Urgent Care

Following the closure of complaints the Urgent Care Business Unit have met with a number of complainants and offered apologies for nursing care and attitude of staff. The changes in practice are limited this month but are as follows:-

• Following a complaint about feeling rushed and wasting the physiotherapist time, the physiotherapy department are reviewing their communication processes.

• A complaint has been received from a patient’s son who is complaining about the care given to his father and disagrees with the clinician’s assessment that he patient requires a PEG feeding tube. After several meeting with the family the Trust is pursuing a Court of Protection order in the patient’s best interest for a PEG tube to be placed.

Planned care Prior to the closure of complaints the Business Unit have met with complainants and apologised for the poor care and pressure ulcers a patient experienced. A review of discharge processes is underway across the Trust. Specialist Services

Following the closure of a complaint the Specialist Service Business Unit has implemented the following changes in practice:-

• Review of environment and processes with parents when seeing children in

the community paediatrics.

• Matron and Lead midwife is liaising and supporting a patient who complained

about the attitude of a midwife. The concerns have eben shared with the

midwife.

Concerns

There have been a total number of 57 concerns raised this month. 11 were requests for information, 8 related to oral communication and 13 related to appointment dates.

3.0 Conclusion

There has been an increase in the number of complaints received this month but they are comparable with the numbers received last year in October, overall the complaints and concerns are decreasing. The same themes are coming through. The themes are subject to going key areas of improvement work within the Trust.

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Agenda Item

TB203/19c Report Title Learning from Deaths Monthly Report

(Formerly The Mortality Report)

Executive Lead Dr Terry Hankin, Medical Director

Lead Officer

Dr. Chris Goddard, Associate Medical Director of Patient Safety

Authors Rachel Flood-Jones, Project Delivery Manager

Mike Lightfoot, Head of Information

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

The Committee is asked to receive the report for assurance the measures for mortality

alongside detail of the activity supporting the improvement of quality of care and performance.

1.0 Executive Summary

2.0 Mortality Indicators

• Summary Hospital-level Mortality Indicator (SHMI) – 12 month rolling published up to

May 2019

• Hospital Standardised Mortality Ratio (HSMR) – Rolling 12 month and in month for

June 2019

• Disease-Specific Mortality Ratios – April 2019

3.0 Mortality Improvement Activity

4.0 Learning from Deaths: Structured Judgement Reviews (SJRs)

5.0 National Learning

6.0 Conclusions & Recommendations 7. 0 Appendices:

Appendix 1: The External Mortality Review Board Assurance Action Plan: November 2019 Appendix 2: Recognition and Care of the Deteriorating Patient Project Highlight Report

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Appendix 3: Mortality Dashboard.(Dr Foster Mortality Data) November 2019

Appendix 4: Distribution Performance Graph, May 2019

Appendix 5: Mortality Indicators

















CQC KLOEs

GOVERNANCE


✓ Effective ✓ Annual Business Plan Priority

✓ Responsive ✓ Best Practice

✓ Safe ✓ Service Change

✓ Well Led




Equality Risk

Finance Workforce

Equality Impact Assessment Policy

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Service Change

Strategy



Audit Committee ✓ ✓ Quality & Safety Committee




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1. Executive Summary

• The Month by Month HSMR is inherently unstable. It is affected by the number of

deaths in that month and the case mix, which changes. It does however allow

analysis of what the underlying contributors are. These are the causes of demand

capacity mismatch. This month (HSMR 61.5) discharge and AED flow improved

dramatically – thus the system could cope better with demand.

• The Rolling HSMR and SHMI give a better indication of direction of travel. The trend

of both is towards improvement, again reflecting the investment made in quality.

• Capacity and Demand must be actively managed, should demand increase,

commensurate increases in capacity are required to maintain safety. This is not just

attendance at AED, but can be across different parts of the system including

inpatient wards – what is our surge plan and how is it governed / activated?

• Mortality screening rates remain around 90%, 117 SJRs were performed in 2018-

2019, which is the target and has been met. The challenge now is using this

information to identify and propose improvement work. The first areas will be end of

life care, AKI and fractured Neck of Femur.

• The Board is asked to receive the report for assurance, the measures for mortality

alongside detail of the activity supporting the improvement of quality of care and

performance.

2. Mortality indicators

2.1 Performance Indicator Chart: Key National and Local Mortality Indicators

2018/19 2019/20

Target

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

Rolling 12 Month

HSMR 112.8 112.3 112.0 102.9 98.7 94.8 96.3 97.4 94.4 100.0

Monthly HSMR 75.7 91.3 105.3 84.7 81.5 82.8 121.0 96.8 61.5 100.0

SHMI 111.1 101.9 101.3 101.1 100.0

Local HSMR

Bronchitis 136.6 136.6 138.1 133.0 118.4 105.9 116.2 111.4 108.7 100.0

Local HSMR

LRTI 137.6 137.4 138.9 134.1 119.5 106.8 120.8 112.3 109.6 100.0

Local HSMR

Pneumonia 121.7 122.1 120.1 112.6 104.8 103.7 110.2 107.1 102.6 100.0

Local HSMR

Septicemia 89.9 89.7 90.2 81.1 79.1 80.0 79.5 75.0 74.6 100.0

Local HSMR

Stroke 107.9 110.1 112.0 100.3 100.2 103.5 105.5 96.8 94.9 100.0

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Local HSMR UTI 114.9 123.5 120.0 106.2 109.0 80.0 84.2 91.2 85.2 100.0

Local HSMR

Acute Renal

Failure 96.1 107.4 128.8 126.8 115.0 101.3 112.8 112.4 116.2 100.0

Mortality

Screens - % 300.00% 150.00% 151.85% 249.46% 113.33% 425.00% 105.49% 121.95% 312.50% 528.81% 253.85% 88.89% 90.00%

SJRs 21.0 13.0 7.0 13.0 4.0 9.0 6.0 4.0 10.0 11.0 13.0 12.0 0.0

2nd Review 2.0 2.0 0.0 2.0 1.0 0.0 0.0 0.0 1.0 1.0 1.0 0.0 0.0

In Hospital

Deaths 59.0 69.0 81.0 94.0 60.0 72.0 91.0 82.0 48.0 60.0 52.0 63.0 77.0

In Hospital

Deaths Crude

Rate 17.5 20.6 24.5 27.5 19.2 21.6 30.2 25.6 16.0 17.8 15.4 19.4 31.0

LD Deaths 0.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 1.0 0.0 0.0 1.0

Steis Incidents 10.0 2.0 3.0 4.0 6.0 3.0 4.0 5.0 5.0 6.0 8.0 4.0 5.0

Explicit values for a rolling 12 month period, when no national target is available a baseline from last year has been used

2.2 SHMI (to May 19)

The SHMI is now being reported monthly by NHS digital and is therefore now presented as

such. SHMI is calculated as observed deaths over expected deaths as predicted by a risk

adjustment model. This figure includes deaths within 30 days of discharge and deaths of

patients receiving palliative care. Compared to the same time period in previous years, we

have less deaths in total and more deaths are ‘expected’ on the SHMI risk adjustment.

The trusts SHMI is within the expected range, meaning that our mortality rate as measured

in this model is ‘as expected’.

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2.3 HSMR - Hospital Standardised Mortality Ratio (Monthly June 19)

The in-month HSMR for June (most recent month with data available) is 61.5 (previous two

months 96.8 and 121) This reflects the inherent volatility in mortality rates when viewed

monthly in isolation. Comparing May to June, the data suggests that the improved figure is

driven by improved harm free care (i.e. increased clinical quality) reduced time spent in the

A&E department - which implies more efficient diagnosis and treatment, and a reduction in

deaths after discharge and days spent waiting for discharge once clinically stable. HSMR

is also produced as an observed mortality over expected. This model excludes patient

deaths of those receiving palliative care. Palliative care rates are currently around 40% of

all deaths. This will influence the HSMR figure, but not the SHMI.

2.4 HSMR - Hospital Standardised Mortality Ratio (Rolling to June 19)

Rolling HSMR to June 2019 is 94.4. This is again within the expected range. Rolling HSMR

is averaged over 12 months and is therefore less prone to in-month variation. Consistent

factors affecting HSMR over the past 12 months are metrics of AED flow – particularly

arrival to departure times. This probably reflects clinical teams being able to assess,

diagnose and treat better and more effectively when clinical capacity and demand is

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deterioration in AED flow my represent issues that have not been dealt with further down

the inpatient or community pathways.

2.5 Diagnosis Groups

Respiratory: LRTI and Acute bronchitis have a low risk of death. Analysis of these cases

shows that these patients frequently have high co-morbidity burdens and this is not being

captured as the primary diagnosis. These are now subject to clinical review to ascertain the

appropriate diagnosis. Pneumonia continues to be the subject of improvement work,

establishing and embedding the pneumonia clinical pathway and performing appropriate

diagnostics are the foci.

Renal Failure: A task and finish group is operational to lead AKI work. This is following the

AQ indicators of clinical quality, supported by the AKI pathway and 12 hourly AKI alerts.

3. Mortality Improvement Activity

The Deteriorating Patient Project is the second phase of the Reducing Avoidable Mortality

Project and is one of the Trust’s four key Quality Priorities in line with Vision 2020.

A more detailed update on the project can be found under Appendix 1 in the form of the

monthly project highlight report.

3.1 Update on Recognition and Care of the Deteriorating Patient Programme

Primary Driver Progress and achievements this month

Appropriate Assessment & Admission

The Surgical Ambulatory Emergency Care Project Group are working on a pathway for improved, appropriate GP referrals to the Surgical Assessment Unit. Members of the Emergency Department are working with Strata Networking Solutions to design an electronic GP referral system directly into the Ambulatory Care Unit.

Senior Ownership The Electronic Board Round is in the final iteration of the PDSA cycle. The pilot has been well received by the Consultants and Drs on Ward 10A (Gastro). The tool captures the level of escalation (ward care, critical care or end of life care) for each patient and records the direct or remote senior review of all Daily Board Rounds. There is a currently delay in securing resource from the IT Team to complete the fixes required to finalise the electronic functionality for roll out.

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Primary Driver Progress and achievements this month

Correct Pathways of Care The AKI Steering Group is now driving the required activity to improve compliance to best practice. Linking into the Deteriorating Patient Group ensures the triangulation with business intelligence and the Critical Care Outreach Team. The scoping session of the 1st November was supported by attendance and input from the Advanced Quality Alliance (AQUA). New areas of focus have been incorporated into the work stream include: IV and Fluid Balance, Insulin, Abdominal Pain Pathway, Fractured Neck of Femur and Gastro-Intestinal Bleed.

Observations & Escalations The Observations QI Project continues on Ward 9A (Short Stay Unit). Iterations of the PDSA cycle are continuing with the use of business intelligence to identify when and why patients are being taken off protocol for observations and how compliance with the Trust Track and Trigger Policy can be improved. Changes to reporting are with System C to realign ‘breach’ and ‘overdue’ parameters with Trust protocol to produce accurate reporting in line with revised timeframes. Training requirements are being scoped in order to ensure that all relevant employees have the most up to date training in management of the deteriorating patient. (Acute Illness Management Training (AIMS) and Red Day Training in particular for which funding will be required to deliver.

Future Care Planning Strata Networking Solutions have undertaken process mapping with key stakeholders from the Trust, Queenscourt Hospice and community service providers to design a tool with which Anticipatory Clinical Management Plans can be shared. This will ensure that there is one version of the truth and a single plan that can be accessed for each relevant patient at any access point. The project team is yet to understand from Strata to what level the model will be delivered under the existing contract.

Learning from Deaths The Trust has a total of 40 SJR level one reviewers across all specialities that are key to the success of the process. An increased focus of thematic reviewing of deaths from the SJR process will support the dissemination of learnings. The first thematic presentation to the Grand Round will be given on 29th November by Dr MacDonald on End of Life deaths. The revised Learning from Deaths Board Report along with high level fortnightly Mortality Meetings will support the delivery of a responsive and learning focused approach to the screening of deaths and the findings of the Structured Judgement Review.

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4. Learning from Deaths: Structured Judgement Reviews (SJR)

4.1 Screening

The above table details the screening process and rates. This demonstrates improved

screening with September and October 2019 meeting the 90% target.

Within 3 months, on average 80% of reviews have been completed. There are delays in

terms of the availability of case notes for review, and the timeliness of allocation of a

reviewer. These process issues are under investigation to try and make reviewing more

timely.

4.2 First Structured Judgement Review

The number of reviews completed is gradually increasing. 117 reviews have been

completed for 2018/19, meeting our target of 10% of all inpatient deaths.

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Graphical presentation of all reviews performed demonstrates that ongoing (or ward

based) care, in the opinion of our reviewers, is where a patient is most likely to

experience ‘poor’ or at best ‘adequate’ care. Improvement focus should be targetted at

this area of the patients journey, which is reflected in the senior ownership and correct

pathways of care aspects of the Deteriorating Patient Project.

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11

When broken down further by clinical areas with 18 or more reviews it can be seen that

the situation with ongoing care is most acute in the general medical population. Also of

note is a higher proportion than overall of adequate, poor or very poor end of life care.

Critical Care reviews have a higher proportion of excellence overall, but have 3 cases of

poor care around a procedure, which is a higher proportion than other clinical areas.

Analysis of individual cases in individual clinical areas is required for further insights.

4.3 Second Structured Judgement Review

This table shows the conversion rate by specialty from 1st to 2nd SJR. The criteria for

this is ‘poor’ or ‘very poor’ care in the overall category. To date 8 second reviews have

been completed. All second reviews are presented to the Mortality Operational

Committee.

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The data above demonstrates the change in the assessment of overall care and the

change in avoidability judgement between first and second SJR. In 5/9 cases the care

judgement remains the same, in 3 further cases the judgement has changed by one

category, and in a further case the judgement has changed dramatically from, ‘very

poor’ to ‘good’. These cases are all discussed at MOG to allow the rationale to be

presented by the reviewers.

An avoidability assessment is made by the first reviewer using the Hogan scale. This

assessment is then made again by the second reviewer. The case is presented at the

MOG and a committee decision is made on avoidability. Should the committee agree

that the death is more likely than not to be avoidable (definite or probable) then this

case is referred to SIRG for appropriate action. To date 2 cases have been identified

as avoidable by first reviewers, this judgement has been upheld in one case, which

was referred to SIRG, underwent a full RCA, and the findings have been shared with

the Sefton Coroner’s office.

4.6 Lessons Learned: Process & Activity

The trust will hold 3 Grand Rounds a year based on the finding from SJRs. The first of these will

be held on the 29th of November and facilitated by Dr McDonald. The discussion will focus

around decision making at the end of life using case examples from the past 12 months.

A Lessons Learned Bulletin is produced in order to communicate out important points from the

MOG, including relevant findings from SJRs. This is produced on a monthly basis by Janette

Mills, Head of Audit and Effectiveness.

We have cross referenced data from coding and SJR to identify ten cases of death from AKI.

These cases will be reviewed for learning to add extra information to the AKI improvement

work.

Further work is planned to use our SJR database to provide an information source to design

improvements going forward such as in the case of femoral neck fractures.

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5. Conclusions & Recommendations

Successive mortality reports have stressed the link between AED flow and mortality

rates. This report also makes this point. However, the association is with the whole

system and not just AED. AED flow deteriorates when whole system capacity is

outstripped by demand. When this occurs the system becomes less safe and mortality

rates rise.

Our hospital population is a population which does not have a large degree of

physiological resilience, either due to frailty or multi-morbidity, thus, variations in the

capacity / demand equation are particularly dangerous.

The equation is affected by the number of patients arriving, the number departing and

the capacity of the staff within the system (vacancies, stress, sickness, training and

experience in the organisation).

Better balancing these demands by increasing staffing and their skill set, standardising

processes of care and working to provide alternatives to hospital admission - were

appropriate, has reduced our headline mortality figures and improved the safety of our

care.

Recent events demonstrate that sudden increases in demand, without commensurate

increases in capacity threaten safe patient care. This can either be predictable (winter)

or unpredictable.

Recommendations

Proactive monitoring of capacity and demand within the system occurs; those

performing this monitoring must be clear that decisions taken to manage surges in

demand have real consequence on patient mortality.

Continue to evaluate and invest in activity which provides capacity to manage serious

illness quickly and aggressively to reduce complications and length of stay.

Encourage and support interventions which support staff to work reliably and

consistently, with minimal variation, such as through the adoption of appropriate IT or

best practice pathways which are clear and available.

Support ward processes and ward care with the same intention as supporting AED in

order to improve the quality of patient care and thereby improve flow and improve

safety. Start by engaging with ward teams such as junior medical staff and junior nurses

to understand the issues they face.

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14

6.

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pla

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tie

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lans –

cle

arly c

om

munic

ate

d a

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ocum

ente

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ith the

wa

rd M

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on the

re

quir

ed

cri

teri

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or

dis

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se

the

dis

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to

cre

ate

flo

w a

nd w

ork

ha

rd to

ge

t th

ose

pa

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t ca

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ple

tio

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kin

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anspo

rt f

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ptly

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multi

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ulti

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ppro

ach to

re

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atie

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da

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r

to f

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de

lays a

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xpe

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ongo

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e

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r

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tie

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Adm

issio

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Exe

cutive

Le

ad:

Chie

f

Ope

rating

Off

ice

r

Patient Flow

EM

R

Actio

n 1

No

v-1

8

Page 54 of 210

15

Exte

rnal M

ort

ality

Acti

on

Pla

n, B

oard

Assu

ran

ce R

ep

ort

– P

ag

e 2

EM

BA

R

Th

e E

xte

rna

l M

ort

ali

ty A

cti

on

Pla

n (

Inc

lud

ing

7 R

CA

Ca

se

s)

Bo

ard

Pro

gre

ss

As

su

ran

ce

Re

po

rt 2

01

9-2

1

Ori

gin

Re

co

mm

en

da

tio

n D

eta

il

Pro

gra

mm

e /

Pro

jec

t

Le

ad

(s)

Sta

rt

Da

te

Pro

jec

ted

Co

mp

leti

o

n D

ate

Co

mp

leti

o

n %

BR

AG

U

pd

ate

21

st

Oc

tob

er

20

19

d.

Mu

lti-

Sp

ec

ialt

y

Te

am

Wo

rkin

g

Te

am

wo

rkin

g to

im

pro

ve

pa

tie

nt

ma

na

ge

me

nt th

rough the

pa

thw

ay

inclu

din

g in-r

ea

ch to

em

erg

ency

de

pa

rtm

ent a

nd c

ritica

l ca

re

outr

ea

ch to

all

are

as.

90

%G

A m

ulti

-dis

cip

lina

ry te

am

(M

DT

) a

ppro

ach is the

co

rne

rsto

ne

of

the

da

ily R

ed to

Gre

en B

oa

rd R

ounds. M

ini a

udits a

re

curr

ently

be

ing u

nde

rta

ke

n f

or

two

we

eks to

ensure

the

co

rre

ct a

nd c

om

ple

te M

DT

atte

nda

nce

in li

ne

with n

ew

'Re

d to

Gre

en

Bo

ard

Ro

und' S

tanda

rd O

pe

rating P

roce

dure

. W

ard

s a

re b

ein

g a

ske

d to

fo

cus o

n k

ey a

ctivity:

• E

nsuri

ng bo

ard

ro

unds h

appe

n -

with a

fir

m f

ocus o

n a

gre

ein

g the

ne

ce

ssa

ry a

ctio

ns to

ensure

eve

ry p

atie

nt ha

s a

pla

n to

pro

gre

ss the

ir c

are

to

wa

rds d

ischa

rge

• E

arly s

enio

r re

vie

w o

f a

ll in

pa

tie

nt ca

re p

lans –

cle

arly c

om

munic

ate

d a

nd d

ocum

ente

d w

ith the

wa

rd M

DT

on the

re

quir

ed

cri

teri

a f

or

dis

cha

rge

• U

se

the

dis

cha

rge

lounge

to

cre

ate

flo

w a

nd w

ork

ha

rd to

ge

t th

ose

pa

tie

nts

tha

t ca

n g

o h

om

e to

da

y a

wa

y a

s s

oo

n a

s

po

ssib

le

• E

arly c

om

ple

tio

n o

f T

TO

s a

nd b

oo

kin

g o

f tr

anspo

rt f

or

dis

cha

rge

• R

efe

rra

ls m

ade

by w

ard

MD

T te

am

s a

re a

ctio

ne

d p

rom

ptly

(e

.g. th

era

py, ra

dio

logy, pha

rma

cy)

• D

ela

ys to

dis

cha

rge

to

be

esca

late

d to

the

Be

d M

ana

ge

me

nt T

ea

m

Lo

ng S

tay T

ue

sda

ys: a

multi

-dis

cip

lina

ry a

nd m

ulti

-age

ncy a

ppro

ach to

re

vie

w p

atie

nts

with a

length

of

sta

y o

f 7

da

ys o

r o

ve

r

to f

ind s

olu

tio

ns to

de

lays a

nd e

xpe

dite

dis

cha

rage

are

ongo

ing.

RC

A

Actio

n 1

Ensure

tha

t pa

thw

ays o

f ca

re f

or

ke

y c

ause

s o

f clin

ica

l de

teri

ora

tio

n

are

; up to

da

te, a

va

ilable

, cle

ar

and

use

d a

cro

ss the

org

anis

atio

n.

The

se

must in

clu

de

Se

psis

,

Pne

um

onia

and A

KI. T

rain

ing g

aps

on the

se

pro

ce

sse

s f

or

do

cto

rs

and n

urs

es m

ust be

ide

ntifie

d a

nd

clo

se

d o

rga

nis

atio

n-w

ide

, to

inclu

de

the

ba

sic

inve

stiga

tive

and

the

rape

utic s

tra

tegie

s f

or

the

fir

st

ho

urs

of

ca

re a

nd c

rite

ria

fo

r

refe

rra

l.

Ma

r-1

8O

ngo

ing

until e

nd o

f

pro

ject

Ma

rch

20

20

40

%A

The

Tru

st's

Clin

ica

l Educa

tio

n L

ea

d ha

s inclu

de

d the

re

vis

ed A

KI P

ath

wa

y (

Apri

l 20

19

) in

to the

Tru

st's

'Do

cto

rs in T

rain

ing:

Wo

rkin

g H

andbo

ok'

AK

I is

big

ge

st is

sue

fro

m a

n A

Q p

ers

pe

ctive

. T

he

Tru

st no

w h

as a

de

dlc

ate

d A

KI S

tee

ring G

roup w

hic

h m

ee

ts o

nce

a m

onth

to d

rive

ta

rge

ted a

ctivity.

Sin

ce

Ja

nua

ry, da

ily a

uto

ma

ted a

lert

s o

f ne

w c

ase

s o

f A

KI a

re s

ent by the

Me

dw

ay T

ea

m to

bo

th the

Cri

tica

l Ca

re O

utr

ea

ch

Te

am

and the

Pha

rma

cy T

ea

m.

The

ne

w 2

4/7

Cri

tica

l Ca

re O

utr

ea

ch T

ea

m is n

ow

re

vie

win

g p

atie

nts

with A

KI le

ve

l 3. T

he

se

im

pro

ve

me

nts

sho

uld

be

refle

cte

d in the

ne

xt bia

nnua

l re

po

rt f

rom

the

Adva

ncin

g Q

ua

lity A

llia

nce

(A

QU

A)

in O

cto

be

r 2

01

9. It is e

xpe

cte

d tha

t

impro

ve

me

nts

will

be

vis

ible

in N

ove

mbe

r 2

01

9 r

epo

rtin

g o

n O

cto

be

r da

ta.

Jul-1

81

00

%B

Ma

r-2

06

0%

A

EM

R

Actio

n 3

Re

vie

w a

nd/o

r e

sta

blis

h a

pne

um

onia

pa

thw

ay to

ensure

tha

t

it m

ee

ts n

atio

na

l guid

elin

es.

De

teri

ora

ting

Pa

tie

nt P

roje

ct

No

v-1

8M

ay-1

99

0%

GT

he

Pne

um

onia

Ca

re P

ath

wa

y is r

ea

dily

ava

ilable

acro

ss the

Tru

st a

nd h

as b

ee

n g

ive

n a

dditio

na

l fo

cus b

y the

Co

nsulta

nt in

Acute

Me

dic

ine

in the

Em

erg

ency A

mbula

tory

Unit.

The

Asso

cia

te D

ire

cto

r fo

r P

atie

nt S

afe

ty a

nd the

Tru

st's

Clin

ica

l Educa

tio

n L

ea

d a

re inco

rpo

rating the

Pne

um

onia

Ca

re

Pa

thw

ay into

the

junio

r do

cto

rs' t

rain

ing p

rogra

mm

e.

Blu

e

Re

d

Am

be

r

Gre

en

Activity c

om

ple

ted

Sig

nific

antly d

ela

yed a

nd/o

r of hig

h r

isk -

not exp

ecte

d to r

ecover

Slig

htly d

ela

yed a

nd / o

r of lo

w r

isk -

can b

e r

ecovere

d

Pro

gre

ssin

g o

n s

chedule

Ma

r-2

0

Are

a R

eq

uir

ing

Imp

rov

em

en

t

Pa

tie

nt F

low

Impro

ve

me

nt

Pro

gra

mm

e

(De

teri

ora

ting

Pa

tie

nt P

roje

ct:

'Appro

pri

ate

Asse

ssm

ent &

Adm

issio

n')

Exe

cutive

Le

ad:

Chie

f

Ope

rating

Off

ice

r

Impro

ve

aw

are

ne

ss o

f S

epsis

6

guid

elin

es a

nd m

onito

r a

dhe

rence

.

Es

tab

lis

h

Pn

eu

mo

nia

Pa

thw

ay

Imp

rov

e D

eli

ve

ry

of

Pa

thw

ays

of

Ca

re

Patient Flow

Imp

rov

e

co

mp

lia

nc

e w

ith

Se

ps

is 6

Gu

ide

lin

es

/

Mo

nit

or

Co

mp

lain

ce

Wit

h

Se

ps

is P

ath

wa

y

Imp

rov

e

aw

are

ne

ss

of

Se

ps

is

Correct Pathways of Care

EM

R

Actio

n 2

EM

R

Actio

n 1

Apr-

18

Asso

cia

te

Me

dic

al

Dir

ecto

r o

f

Pa

tie

nt

Sa

fety

Co

mplia

nce

with o

f th

e S

epsis

Six

(th

ree

dia

gno

stic a

nd thre

e the

rape

utic s

teps to

be

de

live

red w

ithin

one

ho

ur

of

the

initia

l

dia

gno

sis

of

se

psis

) is

ingra

ine

d a

cro

ss the

Tru

st.

In li

ne

with the

AQ

UA

AQ

da

ta s

et; w

e a

re p

erf

orm

ing w

ell

in r

ela

tio

n to

our

pe

ers

ho

we

ve

r o

ngo

ing a

rea

s o

f cha

llenge

inclu

de

:

pe

rfo

rma

nce

of

blo

od c

ultu

res w

ithin

an h

our

of

dia

gno

sis

and s

enio

r re

vie

w w

ithin

tw

o h

ours

. T

he

mo

st up to

da

te A

Q d

ata

repo

rts o

n a

citvity u

p to

Fe

bru

ary

20

19

; w

e e

xpe

ct to

se

e im

pro

ve

me

nt go

ing f

orw

ard

re

fle

cting the

im

pa

ct o

f th

e incre

ase

d

co

ve

r o

f th

e 2

4/7

Cri

tica

l Ca

re O

utr

ea

ch T

ea

m.

The

Tru

st's

Co

nsulta

nt M

icro

bio

logis

t ha

s p

roduce

d g

uid

ance

on b

est pra

ctice

fo

r ta

kin

g b

loo

d c

ultu

res to

re

duce

co

nta

min

atio

n r

ate

s. T

his

ha

s r

ece

ntly

be

en s

igne

d o

ff a

nd is n

ow

be

ing e

mbe

dde

d thro

ugh tra

inin

g.

No

v-1

8

De

teri

ora

ting

Pa

tie

nt P

roje

ct:

'Co

rre

ct

Pa

thw

ays o

f

Ca

re'

TB

203_

19c

LfD

Rep

ort D

ec 1

9

Page 55 of 210

16

Exte

rnal M

ort

ality

Acti

on

Pla

n, B

oard

Assu

ran

ce R

ep

ort

– P

ag

e 3

EM

BA

R

Th

e E

xte

rnal

Mo

rtali

ty A

cti

on

Pla

n (

Inclu

din

g 7

RC

A C

ases)

Bo

ard

Pro

gre

ss A

ssu

ran

ce R

ep

ort

2019-2

1

Ori

gin

Re

co

mm

en

da

tio

n D

eta

il

Pro

gra

mm

e /

Pro

jec

t

Le

ad

(s)

Sta

rt

Da

te

Pro

jec

ted

Co

mp

leti

o

n D

ate

Co

mp

leti

o

n %

BR

AG

U

pd

ate

21

st

Oc

tob

er

20

19

EM

R

Actio

n 4

Re

vie

w d

octo

rs’ ro

tas to

ensure

suff

icie

nt

da

ily s

enio

r co

ve

r a

nd tha

t ju

nio

r do

cto

rs a

re

no

t unsuppo

rte

d o

r w

ork

ing b

eyo

nd the

ir

ca

pa

bili

tie

s.

AM

Ds o

f

Clin

ica

l

Busin

ess

Units

Ma

r-1

9M

ar-

20

20

%A

The

re

quir

em

ent to

re

vie

w d

octo

rs r

ota

s to

ensure

da

ily s

enio

r co

ve

r o

rigin

ate

d f

rom

re

po

rts tha

t ju

nio

r do

cto

rs w

ere

wo

rkin

g

unsupe

rvis

ed o

n w

ard

s. A

udits to

asse

ss s

taff

ing le

ve

ls h

ave

sho

we

d tha

t th

e issue

is n

ot a

sho

rta

ge

of

do

cto

rs b

ut th

e p

oo

r

ma

na

ge

me

nt o

f ro

tas a

nd the

mis

allo

ca

tio

n o

f sta

ff (

for

exa

mple

co

ho

rts o

f sta

ff a

ll a

tte

ndin

g tra

inin

g a

t th

e s

am

e tim

e).

The

audit is to

be

re

run in N

ove

mbe

r to

asce

rta

in w

he

the

r cha

nge

s in jo

b p

lannin

g a

nd the

mo

dific

atio

n o

f ju

nio

r do

cto

r ro

tas in

August ha

s im

pro

ve

d c

ove

r a

nd s

uppo

rt f

or

junio

r do

cto

rs.

RC

A

Actio

n 2

Ensure

tha

t it is c

lea

r to

eve

ry p

atie

nt, f

am

ily

and s

taff

me

mbe

r w

hic

h c

onsulta

nt te

am

is

the

lea

d p

rovid

er

of

ca

re f

or

eve

ry p

atie

nt,

inclu

din

g w

he

n c

are

is s

ha

red b

etw

ee

n te

am

s

and s

pe

cia

lism

s. D

epa

rtm

enta

l po

licie

s a

nd

wo

rkin

g p

ractice

s m

ust pro

mo

te a

nd s

uppo

rt

co

nsulta

nt le

ade

rship

of

pa

tie

nt ca

re a

nd

co

nsis

tent ha

ndo

ve

r o

f ca

re o

f pa

tie

nts

be

twe

en s

hifts

AM

D o

f

Pa

tie

nt

Sa

fety

with A

MD

s

of

Clin

ica

l

Busin

ess

Units

Apr-

19

Ma

r-2

02

5%

GT

he

Ele

ctr

onic

Wa

rd B

oa

rd P

ilot ha

s e

nte

red into

its

fin

al P

DS

A ite

ratio

n. T

he

to

ol h

as b

ee

n w

ell

rece

ive

d b

y C

onsulta

nts

and

Drs

on W

ard

10

A (

Ga

str

o)

and is s

ucce

ssfu

lly r

eco

rdin

g s

enio

r o

wne

rship

/ invo

lve

me

nt (i

n r

espo

nse

to

Exte

rna

l Mo

rta

lity

Re

vie

w 2

01

8 a

nd the

He

alth

Educa

tio

n E

ngla

nd r

epo

rt w

hic

h s

tate

d tha

t Junio

r D

rs w

ere

n't

be

ing s

uppo

rte

d. A

ltho

ugh w

e w

ere

unde

rta

kin

g D

aily

Bo

ard

Ro

unds o

r re

vie

ws a

fte

r Jnr

Dr

Bo

ard

Ro

unds, e

vid

ence

wa

s r

equir

ed to

pro

ve

this

).

The

Ele

ctr

onic

Bo

ard

Ro

und r

equir

es a

n e

sca

latio

n le

ve

l to

be

ide

ntifie

d f

or

ea

ch p

atie

nt (a

s s

tipula

ted in the

NE

WS

2 P

olic

y):

wa

rd c

are

, cri

tica

l ca

re o

r e

nd o

f lif

e c

are

. T

he

be

ne

fits

of

the

syste

m a

re tha

t: w

e c

an c

orr

ela

te N

EW

S2

Sco

res a

ga

inst th

e

Esca

latio

n s

tatu

s / p

lan, w

e w

ill b

e a

ble

to

pro

duce

a li

st o

f pa

tie

nts

who

ne

ed to

be

se

en b

y the

Tra

nsfo

rm T

ea

m a

nd w

e w

ill

ha

ve

a li

st o

f pa

tie

nts

who

are

at ri

sk.

The

pilo

t ha

s h

ow

eve

r sho

wn tha

t th

e a

lloca

ted c

onsulta

nt fo

r e

ach p

atie

nt is

oft

en u

ncle

ar,

(T

he

re

spo

nsib

le c

onsulta

nt sho

uld

be

do

cum

ente

d a

bo

ve

the

pa

tie

nt's

be

d, in

the

nurs

ing h

ando

ve

r no

tes a

nd o

n M

edw

ay. T

he

sta

nda

rdis

ed n

urs

ing

do

cum

enta

tio

n tha

t w

as u

se

d to

ca

ptu

re this

info

rma

tio

n is n

o lo

nge

r in

co

nsis

tent use

and n

ee

ds to

be

fa

cto

red into

the

Do

cum

enta

tio

n P

roje

ct.)

EM

R

Actio

n 5

Re

vie

w s

tanda

rds o

f do

cum

enta

tio

n to

ensure

tha

t sta

ff a

lwa

ys s

ign a

nd d

ate

the

ir

entr

ies a

nd tha

t ha

ndo

ve

r o

f ca

re is c

lea

rly

do

cum

ente

d inclu

din

g the

re

spo

nsib

le

Co

nsulta

nt.

Ma

r-2

17

%R

De

dic

ate

d P

rogra

mm

e M

ana

ge

me

nt suppo

rt is n

ow

allo

ca

ted to

the

Tru

st's

Do

cum

enta

tio

n P

roje

ct in

ord

er

to e

nsure

tha

t th

e

sco

pe

of

wo

rk c

onsid

ers

all

of

the

long te

rm r

equir

em

ents

fo

r m

edic

s, nurs

ing a

nd the

rapie

s in li

ne

with the

IT

Ro

adm

ap.

Clin

ica

l No

ting is a

long w

ay o

ff o

n the

IT

Ro

adm

ap a

nd s

o d

iscussio

ns a

re u

nde

rwa

y w

ith the

Me

dw

ay T

ea

m to

add thre

e k

ey

do

cum

ents

to

the

ele

ctr

onic

Me

dw

ay (

Pa

tie

nt A

dm

inis

tra

tio

n S

yste

m)

to

suppo

rt the

nurs

ing te

am

s w

ith the

co

mple

tio

n o

f

do

cum

enta

tio

n.

To

da

te, a

sco

pin

g s

essio

n to

loo

k a

t nurs

ing d

ocum

enta

tio

n to

ok p

lace

on the

16

th J

uly

with w

ard

ma

na

ge

rs a

nd s

taff

nurs

es

fro

m a

cro

ss U

rge

nt C

are

and P

lanne

d C

are

. to

re

vie

w n

urs

ing r

isk a

sse

ssm

ent bo

okle

ts a

nd c

are

pla

ns. F

ee

dba

ck f

rom

the

gro

up w

as tha

t tim

e to

co

mple

te d

ocum

enta

tio

n w

as the

ma

in b

locka

ge

.

RC

A

Actio

n 3

Publis

h a

nd r

egula

rly a

udit a

ga

inst a

gre

ed

sta

nda

rds f

or

clin

ica

l do

cum

enta

tio

n; to

inclu

de

the

co

mple

tio

n o

f pa

thw

ays o

f ca

re

for

ke

y m

edic

al c

onditio

ns a

nd le

gib

le

pre

scri

bin

g. T

his

sho

uld

fo

rm p

art

of

str

uctu

red f

ee

dba

ck to

me

dic

al s

taff

.

Ongo

ing

50

%G

The

Tru

st pa

rtic

ipa

tes in the

re

gio

na

l be

nchm

ark

ing e

xe

cis

e A

dva

ncin

g Q

ua

lity. E

ve

ry m

onth

we

co

llect in

form

atio

n o

n c

are

for

the

fo

llow

ing c

onditio

ns: A

KI, A

RL

D, P

ne

um

onia

, D

iabe

tes, H

ip a

nd K

ne

e r

epla

ce

me

nt a

nd S

epsis

, H

ospita

l acquir

ed

pne

um

onia

(pilo

t).

The

me

asure

s f

or

adva

ncin

g q

ua

lity a

re b

ase

d o

n N

ICE

guid

elin

es f

or

be

st pra

ctice

.

EM

R

Actio

n 6

Re

vie

w n

urs

ing a

nd A

HP

do

cum

enta

tio

n to

ensure

tha

t it is f

it f

or

purp

ose

in f

ocusin

g a

nd

pro

mo

ting e

sse

ntia

l ca

re, pa

rtic

ula

rly f

luid

ba

lance

and n

utr

itio

na

l ne

eds.

Ma

r-2

15

%R

Upda

te a

s p

er

'Re

vie

w S

tanda

rds o

f D

ocum

enta

tio

n' a

bo

ve

.

EM

R

Actio

n 7

Ensure

pre

scri

bin

g is le

gib

le, cle

arly s

igne

d

and in li

ne

with n

atio

na

l exis

ting g

uid

elin

es f

or

ca

re. F

ocus initia

lly o

n o

pia

te p

rescri

bin

g in

line

with r

ece

nt G

ospo

rt r

epo

rt.

Ma

r-2

01

5%

RT

he

Go

spo

rt a

udits c

om

ple

ted w

ithin

So

uth

po

rt a

nd O

rmskir

k H

ospita

l Tru

st sho

we

d s

ignific

ant le

ve

ls o

f a

ssura

nce

apa

rt f

rom

the

do

cum

enta

tio

n o

f clin

ica

l indic

atio

ns f

or

dru

gs (

apa

rt f

rom

tho

se

who

are

actu

ally

dyin

g w

hic

h is b

ette

r) a

nd the

hig

h

incid

ence

of

pne

um

onia

as c

ause

of

de

ath

.

The

Tru

st is

de

dic

ate

d to

a M

edic

ine

s M

ana

ge

me

nt Im

pro

ve

me

nt a

nd O

ptim

isa

tio

n P

roje

ct w

hic

h is c

urr

ently

be

ing d

rive

n b

y a

de

taile

d a

ctio

n p

lan w

hic

h is s

ubje

ct to

we

ekly

scru

tiny a

nd p

lannin

g m

ee

tings. C

lea

r a

nd le

gib

le d

ocum

enta

tio

n in li

ne

with

na

tio

na

l guid

elin

es is to

be

inco

rpo

rate

d into

the

Do

cum

enta

tio

n P

roje

ct.

RC

A

Actio

n 4

Ongo

ing a

udit o

f physio

logic

al o

bse

rva

tio

n

co

mplia

nce

and f

luid

ba

lance

co

mple

tio

n m

ust

be

re

po

rte

d to

CB

U a

nd c

entr

ally

. A

ll C

BU

s

must cle

arly d

em

onstr

ate

ho

w the

y w

ill

impro

ve

obse

rva

tio

n c

om

plia

nce

and f

luid

ba

lance

co

mple

tio

n o

n the

ir w

ard

s a

nd

de

mo

nstr

ate

tha

t th

is is o

ccurr

ing.

Ja

n-1

9M

ar-

20

40

%G

As p

art

of

the

NH

SI Q

ua

lity Im

pro

ve

me

nt P

rogra

mm

e, a

PD

SA

im

pro

ve

me

nt cycle

ha

s b

ee

n u

nde

rta

ke

n o

n W

ard

9A

(S

ho

rt

Sta

y U

nit);

to

re

vie

w a

nd im

pro

ve

the

wa

y tha

t o

bse

rva

tio

ns a

re ta

ke

n, do

cum

ente

d a

nd r

evie

we

d.

Wo

rk is c

ontinuin

g to

re

duce

obse

rva

tio

n b

rea

che

s a

nd to

im

pro

ve

obse

rva

tio

ns c

om

plia

nce

aga

inst th

e T

rust's

The

Tru

st's

NE

WS

2 P

olic

y (

CL

IN C

OR

P 8

1 E

arly W

arn

ing T

rack &

Tri

gge

r S

yste

m O

pe

ratio

na

l Po

licy.)

The

Tru

st ha

s inve

ste

d in a

Flu

id B

ala

nce

mo

dule

on V

ita

lPa

c (

Syste

m C

) w

hic

h w

ill e

lectr

onic

ally

re

co

rd f

luid

ba

lance

che

cks

and p

rovid

e r

epo

rtin

g b

y w

ard

to

me

asure

co

mplia

nce

leve

ls a

ga

inst sta

nda

rds. T

he

ro

ll o

ut o

f th

e p

roduct is

expe

cte

d in the

ne

ar

futu

re w

ith a

sta

rt d

ate

to

be

co

nfirm

ed.

Do

cto

rs’ R

ota

s t

o

be

Re

vie

we

d

(to

en

su

re

su

ffic

ien

t d

ail

y

se

nio

r c

ov

er

&

jun

ior

do

cto

r

su

pp

ort

)

Are

a R

eq

uir

ing

Imp

rov

em

en

t

On

go

ing

au

dit

of

ph

ys

iolo

gic

al

ob

se

rva

tio

n

co

mp

lia

nc

e a

nd

flu

id b

ala

nc

e

co

mp

leti

on

Senior Ownership

Cle

ar

Se

nio

r

Cli

nic

al

Le

ad

Re

vie

w S

tan

da

rds

of

Do

cu

me

nta

tio

n

Re

vie

w N

urs

ing

an

d A

HP

Do

cu

me

nta

tio

n

Documentation & Observations

En

su

re P

res

cri

bin

g

is l

eg

ible

, c

lea

rly

sig

ne

d a

nd

in

lin

e

wit

h n

ati

on

al

exis

tin

g g

uid

eli

ne

s

for

ca

re.

Cli

nic

al

Do

cu

me

nta

tio

n

Au

dit

s

Apr-

19

De

puty

Dir

ecto

r o

f

Nurs

ing

De

teri

ora

ting

Pa

tie

nt P

roje

ct

('S

enio

r

Ow

ne

rship

')

Do

cum

enta

tio

n'

Pro

ject

De

teri

ora

ting

Pa

tie

nt P

roje

ct

('O

bse

rva

tio

ns

&

Do

cum

enta

tio

n'

)

Page 56 of 210

17

Exte

rnal M

ort

ality

Acti

on

Pla

n, B

oard

Assu

ran

ce R

ep

ort

– P

ag

e 4

EM

BA

R

Th

e E

xte

rnal

Mo

rtali

ty A

cti

on

Pla

n (

Inclu

din

g 7

RC

A C

ases)

Bo

ard

Pro

gre

ss A

ssu

ran

ce R

ep

ort

2019-2

1

Ori

gin

Re

co

mm

en

da

tio

n D

eta

il

Pro

gra

mm

e /

Pro

jec

t

Le

ad

(s)

Sta

rt

Da

te

Pro

jec

ted

Co

mp

leti

o

n D

ate

Co

mp

leti

o

n %

BR

AG

U

pd

ate

21

st

Oc

tob

er

20

19

EM

R

Actio

n 7

Ensure

pre

scri

bin

g is le

gib

le, cle

arly s

igne

d

and in li

ne

with n

atio

na

l exis

ting g

uid

elin

es f

or

ca

re. F

ocus initia

lly o

n o

pia

te p

rescri

bin

g in

line

with r

ece

nt G

ospo

rt r

epo

rt.

Ma

r-2

01

5%

RT

he

Go

spo

rt a

udits c

om

ple

ted w

ithin

So

uth

po

rt a

nd O

rmskir

k H

ospita

l Tru

st sho

we

d s

ignific

ant le

ve

ls o

f a

ssura

nce

apa

rt f

rom

the

do

cum

enta

tio

n o

f clin

ica

l indic

atio

ns f

or

dru

gs (

apa

rt f

rom

tho

se

who

are

actu

ally

dyin

g w

hic

h is b

ette

r) a

nd the

hig

h

incid

ence

of

pne

um

onia

as c

ause

of

de

ath

.

The

Tru

st is

de

dic

ate

d to

a M

edic

ine

s M

ana

ge

me

nt Im

pro

ve

me

nt a

nd O

ptim

isa

tio

n P

roje

ct w

hic

h is c

urr

ently

be

ing d

rive

n b

y a

de

taile

d a

ctio

n p

lan w

hic

h is s

ubje

ct to

we

ekly

scru

tiny a

nd p

lannin

g m

ee

tings. C

lea

r a

nd le

gib

le d

ocum

enta

tio

n in li

ne

with

na

tio

na

l guid

elin

es is to

be

inco

rpo

rate

d into

the

Do

cum

enta

tio

n P

roje

ct.

RC

A

Actio

n 4

Ongo

ing a

udit o

f physio

logic

al o

bse

rva

tio

n

co

mplia

nce

and f

luid

ba

lance

co

mple

tio

n m

ust

be

re

po

rte

d to

CB

U a

nd c

entr

ally

. A

ll C

BU

s

must cle

arly d

em

onstr

ate

ho

w the

y w

ill

impro

ve

obse

rva

tio

n c

om

plia

nce

and f

luid

ba

lance

co

mple

tio

n o

n the

ir w

ard

s a

nd

de

mo

nstr

ate

tha

t th

is is o

ccurr

ing.

Ja

n-1

9M

ar-

20

40

%G

As p

art

of

the

NH

SI Q

ua

lity Im

pro

ve

me

nt P

rogra

mm

e, a

PD

SA

im

pro

ve

me

nt cycle

ha

s b

ee

n u

nde

rta

ke

n o

n W

ard

9A

(S

ho

rt

Sta

y U

nit);

to

re

vie

w a

nd im

pro

ve

the

wa

y tha

t o

bse

rva

tio

ns a

re ta

ke

n, do

cum

ente

d a

nd r

evie

we

d.

Wo

rk is c

ontinuin

g to

re

duce

obse

rva

tio

n b

rea

che

s a

nd to

im

pro

ve

obse

rva

tio

ns c

om

plia

nce

aga

inst th

e T

rust's

The

Tru

st's

NE

WS

2 P

olic

y (

CL

IN C

OR

P 8

1 E

arly W

arn

ing T

rack &

Tri

gge

r S

yste

m O

pe

ratio

na

l Po

licy.)

The

Tru

st ha

s inve

ste

d in a

Flu

id B

ala

nce

mo

dule

on V

ita

lPa

c (

Syste

m C

) w

hic

h w

ill e

lectr

onic

ally

re

co

rd f

luid

ba

lance

che

cks

and p

rovid

e r

epo

rtin

g b

y w

ard

to

me

asure

co

mplia

nce

leve

ls a

ga

inst sta

nda

rds. T

he

ro

ll o

ut o

f th

e p

roduct is

expe

cte

d in the

ne

ar

futu

re w

ith a

sta

rt d

ate

to

be

co

nfirm

ed.

EM

R

Actio

n 8

Re

vie

w e

sca

latio

n a

nd c

eili

ngs o

f ca

re

po

licie

s to

inclu

de

tim

ely

acce

ss to

cri

tica

l

ca

re a

nd e

nd o

f lif

e c

are

. In

clu

de

a f

ocus o

n

tra

inin

g o

f a

ll sta

ff in a

ccura

te c

alc

ula

tio

ns o

f

Ea

rly W

arn

ing S

co

res (

EW

S),

inte

rpre

tatio

n

and c

onte

xtu

alis

atio

n o

f E

WS

and a

sha

red

unde

rsta

ndin

g o

f w

he

n to

esca

late

ca

re a

nd

co

nsid

er

a s

tructu

red c

om

munic

atio

n

appro

ach s

uch a

s S

itua

tio

n, B

ackgro

und,

Asse

ssm

ent, R

eco

mm

enda

tio

n (

SB

AR

).

Ja

n-1

9Jun-1

98

0%

G

RC

A

Actio

n 5

Imple

me

nt th

e R

CP

/NIC

E N

EW

S2

physio

logic

al m

onito

ring p

roce

ss, w

ith c

lea

r

pa

thw

ays f

or

the

mo

nito

ring a

nd e

sca

latio

n o

f

ele

va

ted s

co

res to

se

nio

r de

cis

ion m

ake

rs.

This

must in

clu

de

a r

egula

r se

nio

r re

vie

w o

f

the

appro

pri

ate

ne

ss o

f e

sca

latio

n p

lans f

or

eve

ry inpa

tie

nt a

s a

n inte

gra

l pa

rt o

f e

ve

ry

wa

rd a

nd b

oa

rd r

ound. A

ll clin

ica

l sta

ff s

ho

uld

be

aw

are

of

the

NE

WS

2 s

co

re f

or

esca

latio

n, w

ho

to

, a

nd w

ha

t sho

uld

be

expe

cte

d f

rom

the

se

nio

r de

cis

ion m

ake

r.

Ja

n-1

9Jun-1

98

0%

G

Are

a R

eq

uir

ing

Imp

rov

em

en

t

On

go

ing

au

dit

of

ph

ys

iolo

gic

al

ob

se

rva

tio

n

co

mp

lia

nc

e a

nd

flu

id b

ala

nc

e

co

mp

leti

on

Asso

cia

te

Me

dic

al

Dir

ecto

r o

f

Pa

tie

nt

Sa

fety

Ph

ys

iolo

gic

al

Mo

nit

ori

ng

Pro

ce

ss

Appropirate Escalation

Re

vie

w E

sc

ala

tio

n

an

d C

eil

ing

s o

f

Ca

re P

oli

cie

s

Documentation & Observations

En

su

re P

res

cri

bin

g

is l

eg

ible

, c

lea

rly

sig

ne

d a

nd

in

lin

e

wit

h n

ati

on

al

exis

tin

g g

uid

eli

ne

s

for

ca

re.

Apr-

19

De

puty

Dir

ecto

r o

f

Nurs

ing

De

teri

ora

ting

Pa

tie

nt P

roje

ct

('A

ppro

pri

ate

Esca

latio

n')

Do

cum

enta

tio

n'

Pro

ject

De

teri

ora

ting

Pa

tie

nt P

roje

ct

('O

bse

rva

tio

ns

&

Do

cum

enta

tio

n'

)

The

Tru

st's

NE

WS

2 P

olic

y (

CL

IN C

OR

P 8

1 E

arly W

arn

ing T

rack &

Tri

gge

r S

yste

m O

pe

ratio

na

l Po

licy)

ha

s b

ee

n r

atifie

d is

live

in the

Tru

st's

inte

rna

l on-lin

e P

olic

y P

ort

folio

.

Lin

k N

urs

es (

on e

ach w

ard

) ha

ve

be

en tra

ine

d w

ith the

re

mit to

ca

sca

de

tra

inin

g. A

n e

lectr

onic

tra

inin

g m

odule

is b

ein

g

inve

stiga

ted. T

rain

ing m

ode

ls a

re b

ein

g r

evie

we

d to

ensure

appro

pri

ate

suppo

rt o

f th

e li

nk n

urs

e p

rogra

me

.

As d

eta

iled a

bo

ve

, a

min

i im

pro

ve

me

nt pro

ject is

be

ing u

nde

rta

ke

n o

n W

ard

9A

(S

ho

rt S

tay U

nit)

to

incre

ase

obse

rva

tio

ns in

line

the

po

licy to

95

% b

y S

epte

mbe

r 2

01

9. O

nce

the

blu

epri

nt fo

r be

st pra

ctice

ha

s b

ee

n e

sta

blis

he

d, th

is w

ill b

e r

olle

d o

ut

acro

ss the

Tru

st to

ensure

tha

t co

mplia

nce

leve

ls a

re m

ain

tain

ed to

eff

ective

ly s

uppo

rt e

sca

latio

n o

f th

e d

ete

rio

rating p

atie

nt.

TB

203_

19c

LfD

Rep

ort D

ec 1

9

Page 57 of 210

18

Exte

rnal M

ort

ality

Acti

on

Pla

n, B

oard

Assu

ran

ce R

ep

ort

– P

ag

e 5

EM

BA

R

Th

e E

xte

rnal

Mo

rtali

ty A

cti

on

Pla

n (

Inclu

din

g 7

RC

A C

ases)

Bo

ard

Pro

gre

ss A

ssu

ran

ce R

ep

ort

2019-2

1

Ori

gin

Re

co

mm

en

da

tio

n D

eta

il

Pro

gra

mm

e /

Pro

jec

t

Le

ad

(s)

Sta

rt

Da

te

Pro

jec

ted

Co

mp

leti

o

n D

ate

Co

mp

leti

o

n %

BR

AG

U

pd

ate

21

st

Oc

tob

er

20

19

EM

R

Actio

n 1

0

Ensure

tha

t in

div

idua

l end o

f lif

e c

are

pla

ns

are

co

mm

ence

d p

rom

ptly

and tha

t th

e c

are

pla

ns a

re w

ell

do

cum

ente

d inclu

din

g p

refe

rre

d

pla

ce

of

ca

re. C

onsid

er

wid

er

use

of

Em

erg

ency H

ea

lth C

are

Pla

ns to

pre

ve

nt

rea

dm

issio

n f

or

pa

tie

nts

appro

achin

g the

end

of

the

ir li

fe.

Se

p-1

8M

ar-

21

30

%G

Str

ata

He

alth

ca

re h

as p

rese

nte

d a

n e

lectr

onic

so

lutio

n to

suppo

rt the

de

live

ry o

f a

sin

gle

Pa

tie

nt A

nticip

ato

ry C

linic

al

Ma

na

ge

me

nt P

lan (

AC

MP

) a

cro

ss a

ll lo

ca

l he

alth

ca

re p

rovid

ers

.

A ta

rge

ted tra

inin

g p

rogra

mm

e is b

ein

g d

eve

lope

d a

s p

art

of

the

Futu

re C

are

Pla

nnin

g w

ork

str

ea

m o

f th

e O

lde

r P

eo

ple

s' C

are

Pro

gra

mm

e. T

he

fin

din

gs o

f th

e N

atio

na

l Audit o

f C

are

at E

nd o

f L

ife

are

info

rmin

g a

nd s

uppo

rtin

g the

ca

se

fo

r A

dva

nce

Ca

re

Pla

nnin

g a

nd the

Anticip

ato

ry C

linic

al M

ana

ge

me

nt P

lannin

g m

ode

l.

EM

R

Actio

n 1

1

Ensure

de

ve

lopm

ent o

f a

mo

re r

obust

mo

rta

lity r

evie

w p

roce

ss w

ith c

entr

al

repo

rtin

g. T

he

re s

ho

uld

be

an e

mpha

sis

on

dis

se

min

atio

n o

f le

arn

ing f

rom

de

ath

s a

cro

ss

all

spe

cia

ltie

s w

ith invo

lve

me

nt fr

om

me

dic

al,

nurs

ing a

nd a

llie

d h

ea

lthca

re p

rofe

ssio

na

ls.

and inclu

din

g c

olle

ague

s f

rom

Pri

ma

ry C

are

.

Jul-1

8M

ar-

20

50

%G

The

Scre

enin

g o

f de

ath

s incre

ase

d f

rom

32

.9%

in M

ay to

90

.5%

in S

epte

mbe

r. T

his

hig

h le

ve

l of

scre

enin

g w

as c

arr

ied

thro

ugh into

August w

he

n 8

4.6

% o

f de

ath

s w

ere

re

vie

we

d. T

he

incre

ase

d c

om

plia

nce

is a

ttri

bute

d to

im

pro

ve

d a

cce

ss to

IT

and e

ffe

ctive

co

mm

unic

atio

ns. T

he

AM

D f

or

pa

tie

nt sa

fety

ha

s b

ee

n m

ee

ting w

ith le

ads f

rom

ea

ch d

epa

rtm

ent to

dis

cuss

ba

rrie

rs to

the

co

mple

tio

n o

f S

JR

s.

Re

co

gnitio

n o

f th

ose

like

ly to

be

dyin

g incre

asin

g -

59

% h

ad a

n indiv

idua

l pla

n f

or

the

ca

re o

f th

ose

tho

ught lik

ely

to

be

dyin

g

de

ve

lope

d w

ith the

m a

nd tho

se

im

po

rta

nt to

the

m (

20

18

/19

). D

ocum

enta

tio

n o

f in

div

idua

l pla

ns f

or

ca

re o

f th

ose

tho

ught lik

ely

to b

e d

yin

g im

pro

vin

g, but still

a lo

ng w

ay to

go

- e

duca

tio

n is o

ngo

ing. 6

6%

pe

ople

who

die

in h

ospita

l ha

ve

do

cum

ente

d

pre

ferr

ed p

lace

of

ca

re a

nd f

or

the

se

70

% a

chie

ve

d it by d

yin

g in h

ospita

l (2

01

8/1

9).

12

7 p

eo

ple

who

PP

C w

as n

ot ho

spita

l

we

re tra

nsfe

rre

d in the

Ra

pid

End o

f L

ife

Tra

nsfe

r pro

ce

ss w

he

n d

yin

g w

as r

eco

gnis

ed a

nd a

che

ive

d the

ir P

PC

. (2

01

8/1

9).

Me

mbe

rs o

f th

e R

educin

g A

vo

ida

ble

Mo

rta

lity a

nd the

Old

er

Pe

ople

's C

are

Pro

ject G

roups a

re c

olla

bo

rating o

n F

utu

re C

are

Pla

nnin

g a

ctivity; in p

art

icula

r th

e c

ultu

ral s

hift to

wa

rds p

roa

ctive

Anticip

ato

ry C

linic

al M

ana

ge

me

nt P

lannin

g a

nd a

syste

m

wid

e a

ppro

ach to

Ca

re M

ana

ge

me

nt P

lans.

RC

A

Actio

n 6

Mo

rta

lity a

nd M

orb

idity r

evie

w m

ust o

ccur

in

de

pa

rtm

ents

with e

vid

ence

pro

duce

d o

f

agre

ed a

ctio

ns a

nd im

pro

ve

me

nt pro

jects

, a

s

de

fine

d b

y the

ca

se

s p

rese

nte

d. T

he

se

impro

ve

me

nts

, ge

ne

rate

d b

y c

linic

al t

ea

ms,

must ha

ve

evid

ence

of

revie

w b

y C

BU

and

se

nio

r m

ana

ge

me

nt to

de

mo

nstr

ate

ope

nly

ho

w c

ha

nge

is s

uppo

rte

d.

Jul-1

8M

ar-

20

50

%A

The

Tru

st's

Mo

rta

lity R

epo

rt h

as b

ee

n r

ede

sig

ne

d to

pro

vid

e m

onth

ly a

ssura

nce

aro

und L

ea

rnin

g f

rom

De

ath

s. L

ea

rnin

g f

rom

De

ath

s is a

lso

a s

tanda

lone

wo

rk s

tre

am

in the

ne

wly

re

vis

ed T

rust M

ort

alit

y P

roje

ct; R

eco

gnitio

n a

nd C

are

of

the

De

teri

ora

ting P

atie

nt. T

he

ove

rrid

ing o

bje

ctive

is to

ensure

the

mo

st e

ffe

ctive

dis

se

min

atio

n o

f le

sso

ns le

arn

ed w

ith

assura

nce

tha

t le

arn

ing h

as b

ee

n e

mbe

dde

d.

A s

tructu

re h

as b

ee

n a

gre

ed in p

rincip

le to

ide

ntify

a g

ove

rna

nce

lea

d c

linic

ian in e

ach C

BU

to

dri

ve

to

M&

M p

roce

sse

s a

nd

ide

ntify

the

ke

y w

ork

str

ea

ms f

or

impro

ve

me

nt w

hic

h w

ill in turn

be

re

po

rte

d to

the

Mo

rta

lity O

pe

ratio

na

l Gro

up. A

mo

nth

ly

lesso

ns le

arn

ed b

ulle

tin c

asca

de

s the

ge

ne

ral l

esso

ns f

rom

Le

ve

l 2 S

tructu

red J

udge

me

nt R

evie

ws tha

t a

re e

sca

late

d to

MO

G.

The

Asso

cia

te M

edic

al D

ire

cto

r fo

r P

atie

nt C

are

is w

ork

ing w

ith the

Clin

ica

l Le

ad f

or

Educa

tio

n to

inco

rpo

rate

lesso

ns

lea

rne

d d

isse

min

atio

n thro

ugh the

junio

r do

cto

rs tra

inin

g p

rogra

mm

e. T

he

AM

D f

or

Pa

tie

nt S

afe

ty, C

linic

al L

ea

d f

or

Educa

tio

n

and H

ea

d o

f R

isk a

re to

me

et to

dis

cuss the

de

ve

lopm

ent o

f be

st pra

ctice

.

RC

A

Actio

n 7

Re

vie

w a

nd u

pda

te the

tru

sts

po

licy a

nd

appro

ach to

the

ma

na

ge

me

nt o

f in

pa

tie

nt

dia

be

tes. E

nsure

ava

ilable

, cle

ar

guid

ance

exis

ts f

or

the

ma

na

ge

me

nt o

f dia

be

tic

Tbc

CD

Me

dic

ine

/

AM

D o

f

Urg

ent C

are

Apr-

19

Ma

r-2

15

0%

AR

ecru

itm

ent fo

r D

iabe

tes a

nd E

ndo

cro

no

logy C

onsulta

nt co

ve

r is

no

w u

nde

rwa

y a

nd w

ill a

ddre

ss the

long te

rm g

ap le

ft w

he

n

the

co

mm

unity s

erv

ice

s w

ere

co

ntr

acte

d o

ut in

20

17

. T

he

Me

dic

al D

ire

cto

r is

org

anis

ing a

re

vie

w o

f dia

be

tes s

erv

ice

.

RC

A

Actio

n 8

Re

vie

w a

nd u

pda

te the

tru

sts

appro

ach to

the

pro

vis

ion o

f a

cute

pa

in s

erv

ice

s, to

inclu

de

the

ava

ilable

guid

ance

to

no

n-s

pe

cia

list

do

cto

rs o

n a

ba

sic

pha

rma

co

logic

str

ate

gy,

Tbc

Acute

Pa

in

Le

ad / C

D

Ana

esth

etic

s

Apr-

19

Ma

r-2

13

0%

AT

he

Tru

st ha

s o

ne

Pa

in S

pe

cia

list N

urs

e w

ho

co

ve

rs b

oth

acute

and c

hro

nic

pa

in. D

r H

old

en, C

linic

al L

ea

d f

or

Educa

tio

n is

wo

rkin

g o

n a

ba

sic

sta

nda

rd f

or

the

adm

inis

tra

tio

n o

f a

na

lga

esic

s.

Are

a R

eq

uir

ing

Imp

rov

em

en

t

Mo

rta

lity

&

Mo

rbid

ity R

ev

iew

s

mu

st

oc

cu

r in

de

pa

rtm

en

ts w

ith

ev

ide

nc

e p

rod

uc

ed

of

ag

ree

d a

cti

on

s

an

d i

mp

rov

em

en

t

pro

jec

ts

Ma

na

ge

me

nt

of

Dia

be

tes

Ac

ute

Pa

in

Se

rvic

es

De

teri

ora

ting

Pa

tie

nt P

roje

ct

('F

utu

re C

are

Pla

nnin

g')

De

teri

ora

ting

Pa

tie

nt P

roje

ct

('F

utu

re C

are

Pla

nnin

g')

Specialist

En

su

re p

rom

pt

co

mm

en

ce

me

nt

of

we

ll d

oc

um

en

ted

ind

ivid

ua

l e

nd

of

life

ca

re p

lan

s

Learning from Deaths Future Care

Ro

bu

st

mo

rta

lity

rev

iew

pro

ce

ss

wit

h c

en

tra

l

rep

ort

ing

wit

h a

foc

us

of

dis

em

ina

tio

n o

f

lea

rnin

g f

rom

de

ath

s.

Asso

cia

te

Me

dic

al

Dir

ecto

r o

f

Pa

tie

nt

Sa

fety

with

Asso

cia

te

Dir

ecto

r o

f

Inte

gra

ted

Go

ve

rna

nce

Me

dic

al &

Educa

tio

n

Dir

ecto

r,

Que

ensco

ur

t H

ospic

e

Page 58 of 210

19

Ap

pen

dix

2 –

Re

co

gn

itio

n a

nd

Ca

re o

f th

e D

ete

rio

rati

ng

Pa

tien

t P

roje

ct

Hig

hlig

ht

Re

po

rt

Pro

gra

mm

e

Sta

rt D

ate

B

RA

G f

or

pro

gre

ss o

f acti

vit

y ag

ain

st

pro

jecte

d

tim

efr

am

es

A

En

d D

ate

31st

Marc

h 2

021

Pro

ject

Man

ag

er

Rach

el F

loo

d-J

on

es, P

roje

ct

Man

ag

er

Pro

gra

mm

e H

igh

lig

ht

Re

po

rt

Reco

gn

itio

n a

nd

Care

of

the D

ete

rio

rati

ng

Pati

en

t (R

CD

P)

(Form

erl

y 'R

ed

ucin

g A

void

ab

le M

ort

alit

y' P

roje

ct)

Re

co

gn

itio

n a

nd

Care

of

the

De

teri

ora

tin

g

Pati

en

tE

xe

cu

tiv

e S

po

nso

rD

r T

err

y H

an

kin

, M

ed

ical D

ire

cto

rB

RA

G f

or

KP

I actu

al v

ers

us in

mo

nth

targ

et

R

Info

rmati

on

Le

ad

M

ike

Lig

htf

oo

t, H

ead

of

Info

rmati

on

/

Am

an

da H

als

all In

form

ati

on

An

aly

st

Re

po

rtin

g T

oM

ort

ality

Op

era

tio

nal G

rou

p / Q

uality

& S

afe

ty

(Im

pro

ve

me

nt

Bo

ard

) G

rou

p

Re

po

rt D

ate

13th

No

ve

mb

er

2018 fo

r H

osp

ital M

an

ag

em

en

t B

oard

21st

No

ve

mb

er

2019

1st

Ap

ril 2019

Clin

ical L

ead

Dr

Ch

ris G

od

dard

, A

MD

Pati

en

t S

afe

ty

EX

EC

UT

IVE

SU

MM

AR

Y

(Wh

at

we

are

try

ing

to

ac

hie

ve

an

d w

he

re w

e a

re t

o t

arg

et)

The

Mo

nth

by M

onth

Ho

sp

ital S

tand

ard

Mo

rtalit

y R

atio

is inhe

rently u

nsta

ble

. It

is a

ffe

cte

d b

y the

num

be

r o

f d

eath

s in that m

onth

and

the

case

mix

, w

hic

h c

hang

es. It

do

es h

ow

eve

r allo

w a

naly

sis

of

what th

e u

nd

erlyin

g c

ontr

ibuto

rs a

re. T

he

se

are

the

cause

s o

f d

em

and

cap

acity m

ism

atc

h. T

his

mo

nth

(H

SM

R 6

1.5

) d

ischarg

e a

nd

AE

D f

low

im

pro

ve

d d

ram

atically

– thus the

syste

m c

ould

co

pe

be

tte

r w

ith d

em

and

.

The

Ro

lling

HS

MR

and

SH

MI

giv

e a

be

tte

r in

dic

atio

n o

f d

ire

ctio

n o

f tr

ave

l. T

he

tre

nd

of

bo

th is to

ward

s im

pro

ve

me

nt, a

gain

re

fle

cting

the

inve

stm

ent m

ad

e in q

ualit

y.

Cap

acity a

nd

De

mand

must b

e a

ctive

ly m

anag

ed

, sho

uld

de

mand

incre

ase

, co

mm

ensura

te incre

ase

s in c

ap

acity a

re r

eq

uire

d to

main

tain

safe

ty. T

his

is n

ot ju

st atte

nd

ance

at A

ED

, b

ut can b

e a

cro

ss d

iffe

rent p

art

s o

f th

e s

yste

m inclu

din

g inp

atie

nt

ward

s –

what is

our

surg

e p

lan a

nd

ho

w is it g

ove

rne

d / a

ctivate

d?

Mo

rtalit

y s

cre

enin

g r

ate

s r

em

ain

aro

und

90

%, 1

17

SJR

s w

ere

pe

rfo

rme

d in 2

01

8-2

01

9, w

hic

h is the

targ

et and

has b

ee

n m

et. T

he

challe

ng

e n

ow

is u

sin

g this

info

rmatio

n to

id

entify

and

pro

po

se

im

pro

ve

me

nt w

ork

. T

he

first are

as w

ill b

e e

nd

of

life

care

, A

KI

and

fra

ctu

red

Ne

ck o

f F

em

ur.

The

Bo

ard

is a

ske

d to

re

ce

ive

the

re

po

rt f

or

assura

nce

, th

e m

easure

s f

or

mo

rtalit

y a

long

sid

e d

eta

il o

f th

e a

ctivity s

up

po

rtin

g the

im

pro

ve

me

nt o

f q

ualit

y o

f care

and

pe

rfo

rmance

.

SM

AR

T O

BJ

EC

TIV

ES

(Sp

ec

ific

-Me

as

ura

ble

-Att

ain

ab

le-R

ele

va

nt-

Tim

e b

ou

nd

)

To

de

vis

e c

on

tin

uo

us

se

lf-

imp

rov

em

en

t s

tru

ctu

res

wh

ich

pro

ac

tiv

ely

id

en

tify

clin

ica

l d

ete

rio

rati

on

wit

hin

ou

r c

om

mu

nit

y s

o t

ha

t b

y M

arc

h 2

02

1:

Mo

rtalit

y ind

icto

rs s

it p

rem

ane

ntly w

ithin

co

nfid

ence

inte

rvals

(S

HM

I, H

SM

R &

Lo

cal S

MR

)

All

end

of

life

patie

nts

to

have

an A

nticip

ato

ry C

linic

al M

anag

em

ent P

lan

Ad

vance

Care

Pla

nnin

g is b

usin

ess a

s u

sual w

ith s

taff

co

nfid

ent to

have

co

nve

rsatio

ns w

ith p

atie

nts

and

fam

ilie

s

Jo

ine

d u

p w

ork

ing

and

se

em

less c

olla

bo

ratio

n b

etw

ee

n p

rim

ary

care

, acute

care

, co

mm

unity s

erv

ice

pro

vid

ers

and

care

ho

me

s to

de

live

r th

e m

ost ap

pro

priate

care

fo

r p

atie

nts

in lin

e w

ith A

CP

, A

CM

P a

nd

GS

F.

TB

203_

19c

LfD

Rep

ort D

ec 1

9

Page 59 of 210

20

MIL

ES

TO

NE

/ W

OR

K S

TR

EA

M / K

EY

AC

TIV

ITY

Sta

rt d

ate

En

d d

ate

Ow

ne

r /

Le

ad

Co

mp

leti

on

%

BR

AG

Se

nio

r O

wn

ers

hip

& A

pp

rop

ria

te E

sc

ala

tio

n

Ele

ctr

on

ic W

ard

Bo

ard

Ro

un

d

PD

SA

Pilo

t on G

astr

o W

ard

03/0

6/2

019

30/0

3/2

020

AM

D P

atie

nt

Safe

ty

20%

RT

he

re r

em

ain

s a

blo

ckag

e w

hic

h h

as c

au

se

d a

2 m

on

th d

ela

y to

date

: IT

fix

es r

eq

uir

ed

to

mo

ve

th

e p

ilo

t fo

rward

are

on

ho

ld a

t th

e t

ime

of

rep

ort

ing

du

e t

o s

taff

ing

le

ve

ls in

th

e IT

de

ve

lop

me

nt

team

. (

Cf

Ris

k L

og

).

A s

cre

en is

bein

g s

ecure

d for

the fin

al c

ycle

of th

e p

ilot on W

ard

11B

whic

h w

ill la

st fo

r a furt

her

2 w

eeks

. T

he p

ilot is

als

o to b

e

ext

ended to w

ard

14A

(O

rthopaedic

Ward

- S

urg

ery

). O

nce a

robust and a

ppro

ved m

odel h

as b

een d

eve

loped, th

e p

lan is

to r

oll

out

acro

ss w

ard

s in

line w

ith the w

ard

refu

rbis

hm

ent pro

gra

mm

e (

a p

riva

te r

oom

and s

cre

ens w

ill b

e r

equired o

n e

very

ward

).

LA

TE

ST

UP

DA

TE

FO

R H

IGH

LIG

HT

RE

PO

RT

Pro

jec

t R

es

co

pin

g

21/1

0/2

019

15/1

1/2

019

R F

lood-J

ones

85%

A5 o

f 6 r

equired r

e-s

copin

g s

essio

ns h

ave

now

been h

eld

and d

ocum

ente

d.

Drive

r D

iagra

ms a

re w

ith w

ork

str

eam

gro

ups for

feedback

ahead o

f second s

essio

n for

feedback.

Th

ere

is a

re

qu

ire

me

nt

for

the

Tru

st

Do

cu

me

nta

tio

n P

rog

ram

me

to

be

sco

pe

d in

lin

e w

ith

th

e O

pe

rati

on

al S

trate

gy

in lin

e

wit

h V

isio

n 2

020

Concern

s r

ais

ed a

t D

ete

riora

ting P

atie

nt O

pera

tional G

roup r

egard

ing id

entif

icatio

n o

f C

onsulta

nt re

view

in m

edic

al n

ote

s –

Consulta

nts

are

to b

e e

ncoura

ged to c

arr

y and u

se n

am

e s

tam

ps. A

n u

pdate

is e

xpecte

d a

t th

e n

ext

Gro

up M

eetin

g o

n 1

5th

Octo

ber.

The T

rust's

Docum

enta

tion P

roje

ct is

bein

g r

evi

site

d b

y a n

ew

Pro

gra

mm

e O

ffic

e L

ead.

OB

SE

RV

AT

ION

S &

ES

CA

LA

TIO

NS

:

Tim

ely

Ob

se

rva

tio

ns

(P

DS

A -

Wa

rd 9

A)

(95

% o

f p

atie

nts

on W

ard

9A

to

have

the

ir o

bse

rvatio

ns p

erf

orm

ed

as p

er

Tru

st P

olic

y b

y S

ep

tem

be

r 2

01

9 (

mo

de

l to

be

de

sig

ne

d,

tria

lled

and

the

n to

be

ro

lled

out acro

ss o

the

r w

ard

s)

12/0

6/2

019

30/0

9/2

019

Clin

ical Q

ualit

y

Lead

25%

RO

bse

rvati

on

Bre

ach

es f

or

the

Tru

st

req

uir

e im

me

dia

te a

tte

nti

on

. T

he

PD

SA

cyc

le o

n W

ard

9A

is b

ein

g e

xte

nd

ed

on

to W

ard

14B

The fin

din

gs o

f th

e P

DS

A c

ycle

on W

ard

9A

pre

sente

d a

t th

e N

HS

I QI E

vent 12th

Septe

mber

report

ed s

uccess thro

ugh the follo

win

g

changes:

Move

fro

m b

edsid

e d

iscussio

n o

f patie

nts

observ

atio

ns to o

rganis

ed g

roup

Handove

r m

eeitn

gs (

with

access to the e

lectr

onic

data

on Ip

ads).

Incre

ased e

ducatio

n a

nd v

isib

ility

of O

bserv

atio

ns c

om

plia

nce le

vels

for

the w

ard

to d

rive

corr

ect activ

ty.

Dis

cuss N

EW

S2 S

core

s in

R2G

Board

Rounds to in

cre

ase u

niv

ers

al a

ware

ness o

f hig

h s

coring p

atie

nts

.

Set tim

es for

observ

atio

ns to b

e take

n 6

tim

es e

very

24 h

ours

.

Co

ns

ult

an

t R

ev

iew

(D

oc

um

en

tati

on

)23/0

7/2

019

30/1

0/2

019

Lead T

bc

10%

A

Le

arn

ing

fro

m D

ea

ths

S

tru

ctu

re J

ud

ge

me

nt

Re

vie

w M

eth

od

01/0

4/2

019

30/0

3/2

020

AM

D P

atie

nt

Safe

ty

70%

RT

he S

cre

enin

g o

f death

s in

cre

ased to

90.7

% for

Octo

ber

2019

. There

is a

n in

cre

asin

g b

ackl

og o

f S

JR r

evi

ew

s in

surg

ery

and o

rthopaedic

s, m

edic

ine a

nd IC

U a

re c

urr

ently

perf

orm

ing w

ell.

This

is

main

ly b

ein

g d

rive

n b

y clin

ical c

apacity

(re

view

s take

1-2

hours

) and the im

passe c

aused b

y th

e la

ck

of cla

rity

ove

r jo

b p

lannin

g.

Revi

ew

ers

do n

ot have

this

work

recognis

ed in

the c

urr

ent jo

b p

lannin

g s

tructu

re. A

meetin

g o

f m

ort

alit

y le

ads is

to b

e a

rranged to

addre

ss the is

sues.

Fu

ture

Ca

re P

lan

nin

g

Ad

va

nc

e C

are

Pla

nn

ing

: s

up

po

rtin

g d

isc

us

sio

ns

wit

h

Pa

tie

nts

an

d F

am

ilie

s

01/0

4/2

019

30/0

9/2

020

Pro

ject M

anager

/

Fra

ilty

Pra

ctit

ioner

5%

RS

trata

Netw

ork

ing S

olu

tions h

ave

pro

posed a

paperless s

olu

tion for

a s

ingle

ele

ctr

onic

AC

MP

- there

are

issues w

ith the g

ove

rnance

and p

ace u

nder

whic

h S

trata

are

curr

ently

slo

wly

deliv

ering p

rogre

ss. T

here

is c

oncern

that th

ey

will

only

pro

vide a

basis

pro

of of

concept by

the e

nd o

f th

e c

ontr

acte

d p

eriod a

nd that th

ere

will

be c

onsid

era

ble

cost to

the T

rust to

purc

hase the fully

required p

roduct

in li

ne w

ith e

xpecta

tions.

The topic

for

the G

rand R

ound o

n the 2

9th

Nove

mber

2019 is

based u

pon the S

tructu

red J

udgem

ent R

evi

ew

fin

din

gs for

End o

f Life

Death

s. T

his

them

atic

appro

ach w

ill c

ontin

ue to u

nderp

in L

earn

ing fro

m D

eath

s le

ssons le

arn

ed.

The m

onth

ly M

ort

alit

y R

eport

to the Q

ualit

y and S

afe

ty C

om

mitt

ee a

nd the T

rust B

oard

is c

hangin

g to a

Learn

ing fro

m D

eath

s R

eport

whic

h w

ill d

em

onstr

ate

the in

cre

ased o

f fo

cus o

f Lessons L

earn

ed.

Clin

ical A

udit

Lead is

pro

ducin

g a

month

ly n

ew

sle

tter

from

the M

ort

alit

y O

pera

tional G

roup (

MO

G)

calle

d 'L

essons to b

e L

earn

ed'

whic

h is

bein

g c

ircula

ted to F

oundatio

n, S

pecia

lty a

nd G

P d

octo

rs in

tra

inin

g a

s w

ell

as b

ein

g p

oste

d o

n T

rust N

ew

s a

nd o

n the

Meetin

g P

lace (

the T

rust's

clo

sed F

acebook

page).

Le

ss

on

s L

ea

rne

d

01/0

4/2

019

30/0

3/0

20

AM

D P

atie

nt

Safe

ty / D

irecto

r of

Medic

al E

ducatio

n

/ A

DO

Inte

gra

ted

Gove

rnance

40%

A

PM

O h

ave

met w

ith M

Pin

nin

gto

n w

ho is

lead for

the r

edesig

n o

f th

e n

urs

ing tra

inin

g p

lan. T

here

are

no funds to s

upport

the

coord

inatio

n o

r deliv

ery

of tr

ain

ing. A

ris

k paper

is to b

e w

ritten for

escala

tion thro

ugh the T

rust's

gove

rnance a

rrangem

ents

,

Dis

cussio

n r

equired w

ith W

ork

Str

eam

Gro

up to c

onfir

m w

heth

er

this

is to b

e b

rought in

to the s

cope o

f th

e P

roje

ct,

Re

d D

ay &

AIM

S T

rain

ing

01/1

1/2

019

30/1

2/2

020

M P

innin

gto

n5%

Page 60 of 210

21

Cu

rre

nt

PD

SA

Cy

cle

s

Le

ad

D

eta

il

Ite

rati

on

En

d

Date

Ne

xt

Ste

ps

Ele

ctr

on

ic W

ard

Bo

ard

Pilo

t (W

ard

11

B)

AM

D P

atie

nt

Safe

ty

Ele

ctr

onic

sta

nd

ard

isa

tio

n o

f B

oa

rd R

ound

to

ensure

do

cum

ente

d s

enio

r in

put a

nd

co

nsis

tent p

ractice

. 17/1

0/2

019

Tri

al t

o jo

in u

p w

ith R

ed

to

Gre

en d

id n

ot w

ork

. T

ria

l ha

s o

vera

ll g

one

we

ll. A

wa

itin

g

IT fix

es a

nd

a s

cre

en. T

o s

tart

on w

ard

14

A.

95

% T

ime

ly O

bs

erv

ati

on

s P

DS

A (

Wa

rd 9

A)

Clin

ical Q

ualit

y

Lead

95

% o

f p

atie

nts

on W

ard

9A

to

ha

ve the

ir o

bse

rva

tio

ns p

erf

orm

ed

as p

er

Tru

st P

olic

y b

y S

ep

tem

be

r 2

01

9

(the

n to

be

ro

lled

out a

cro

ss o

the

r w

ard

s)

17/1

0/2

019

Up

da

tes to

co

me

fro

m the

PD

SA

Te

am

fo

r W

ard

9A

. M

ea

sure

s ta

ke

n a

s b

elo

w

fro

m V

ItalP

ac r

ep

ort

s. T

ime

line

fo

r ro

ll o

ut to

be

dis

cusse

d a

t 'O

bse

rva

tio

ns a

nd

Esca

latio

n' M

ee

ting

in O

cto

be

r.

RIS

KS

(Po

tentia

l ris

k w

hic

h w

ill im

pa

ct th

e p

roje

ct; h

as n

ot ye

t o

ccurr

ed

whic

h w

ill

RA

GM

itig

ati

on

Acti

vit

yR

AG

Aft

er

Mit

igati

on

Co

mm

en

ts

Ele

ctr

on

ic W

ard

Bo

ard

s -

IT

De

ve

lop

me

nt

RA

t tim

e o

f re

po

rtin

g a

ll IT

sup

po

rt fo

r th

e E

lectr

onic

Wa

rd B

oa

rd P

SD

A h

as b

ee

n p

ut o

n h

old

due

to

sta

ffin

g

leve

ls. D

iscussio

ns a

nd

w

ork

aro

und

s a

re the

ne

xt s

tep

s.

RC

onfe

rence

ca

ll b

oo

ke

d to

dis

cuss n

ext

ste

ps fo

r p

roje

ct te

am

3rd

Octo

be

r.

Em

erg

en

cy

De

part

me

nt

Ph

arm

acis

t

(To id

entif

y m

orb

idity

and tim

ely

revi

ew

of A

KI P

atie

nts

)

RT

ria

ng

ula

tio

n o

f se

rio

us incid

ent re

vie

ws a

nd

lea

rnin

g fro

m d

ea

ths v

ia the

SJR

me

tho

do

log

y ha

s h

ighlig

hte

d the

ne

ed

fo

r a

n E

me

rge

ncy

De

pa

rtm

ent P

ha

rma

cis

t.T

his

po

sito

n m

ay

co

ntr

ibute

to

the

id

entifica

tio

n o

f p

atie

nt co

-

mo

rbid

ity

by

co

rre

latio

n o

f m

ed

ica

tio

n h

isto

ry w

ith d

iag

no

sis

, th

us c

ontr

ibuting

to

the

co

st o

f th

e p

ost. T

he

po

st

wo

uld

als

o im

pro

ve the

tim

elin

ess o

f p

ha

rma

cy

revi

ew

of p

atie

nts

with A

KI.

AA

busin

ess c

ase

whic

h inclu

de

s a

Pha

rma

cis

t fo

r A

&E

is b

ein

g s

ub

mitte

d thro

ug

h

the

Tru

st's

Go

vern

ance

ro

ute

fo

r co

nsid

era

tio

n c

om

me

ncin

g o

n 1

st O

cto

be

r.

Str

uctu

red

Ju

dg

em

en

t R

ev

iew

s

RT

he

re is a

n incre

asin

g b

acklo

g o

f S

JR

re

vie

ws in s

urg

ery

and

ort

ho

pa

ed

ics w

hic

h is a

ttri

buta

ble

in the

ma

in to

clin

ica

l ca

pa

city

(re

vie

ws ta

ke

1-2

ho

urs

) a

nd

the

im

pa

sse

ca

use

d b

y th

e la

ck o

f cla

rity

ove

r jo

b p

lannin

g.

Re

vie

we

rs d

o n

ot ha

ve this

wo

rk r

eco

gnis

ed

in the

curr

ent jo

b p

lannin

g s

tructu

re.

A m

ee

ting

of m

ort

alit

y le

ad

s is b

ein

g a

rra

ng

ed

to

ad

dre

ss the

issue

s.

AD

iscussio

ns w

ith s

taff to

em

be

d a

re o

ng

oin

g.

Mo

re info

rma

tio

n to

fo

llow

.

ISS

UE

S

(Issues h

ave

already

occurr

ed / a

re c

urr

ently

impactin

g u

pon the p

roje

ct)

RA

GA

cti

on

Take

nR

AG

Aft

er

Mit

igati

on

Co

mm

en

ts

Co

nsu

ltan

t E

ng

ag

em

en

t fo

r 'P

ne

um

on

ia a

s C

om

plicati

on

of

He

art

Failu

re'

Wo

rksh

op

.

RF

ace

to

fa

ce

dis

cussio

ns r

eq

uir

ed

with L

ea

d R

esp

ira

tory

and

Ca

rdia

c C

onsulta

nts

to

co

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TB

203_

19c

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ec 1

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Page 61 of 210

22

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thly

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Page 62 of 210

23

TB

203_

19c

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Rep

ort D

ec 1

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Page 63 of 210

24

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dix

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ce D

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tio

n f

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ne 2

019

Page 64 of 210

25

Appendix

5 Mortality Indicators June 2019

SHMI - Summary Hospital Level Mortality Indicator

HSMR - Hospital Standardised Mortality Ratio (Rolling 12 month)

HSMR - Hospital Standardised Mortality Ratio (Monthly)

TB

203_

19c

LfD

Rep

ort D

ec 1

9

Page 65 of 210

26

Local HSMR Bronchitis

Local HSMR Lower Respiratory Tract Infection

Local HSMR Pneumonia

Page 66 of 210

27

Local HSMR Septicemia

Local HSMR Stroke

Local HSMR Urinary Tract Infection

TB

203_

19c

LfD

Rep

ort D

ec 1

9

Page 67 of 210

28

Local HSMR Acute Renal Failure

Mortality Screens - % Deaths Screened

Crude Mortality Rate (Crude rate per 1000 discharges (excluding day cases))

Page 68 of 210


Agenda Item TB203/19d Report Title Monthly Safe Nurse & Midwifery

Staffing Report – October 2019

Executive Lead Juliette Cosgrove, Director of Nursing Midwifery Therapies and Governance

Lead Officer Claire Blackman-Deputy Director of nursing

Carol Fowler Assistant Director of Nursing – Workforce

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

The Trust Board safe staffing highlight report for October 2019 is set out below:

The purpose of this report is to provide the Board with the current position of nursing staffing in line with National Quality Board, National Institute of Health & Care Excellence and NHS Improvement guidance. The report includes as a comparable metric, Care Hours per Patient Day (CHpPD) which supports the recording and reporting of nursing and care staff deployment. This report presents the safer staffing position for the month of October 2019. Alert

• For the month of October 2019 the Trust reports safe staffing against the national average (90%) at 92.3%.

Advise

• Care Hours per Patient Day (CHpPD) reporting remains under review to support accuracy of data reporting. Trust CHpPD reports at 8.3

• The Nursing Safe Staffing report is under reconstruction with a revised report anticipated in January 2020. The review includes workforce dashboard reporting and triangulation against clinical outcomes.

• The Trusts reporting to UNIFY has been reviewed to assure the Safe Staffing reporting includes the staff allocated on arrival of shift to clinical areas from the flexible workforce pool. Retrospective review has identified slight uplift to the trust safe staffing % reporting and an application to resubmit this data to UNIFY has therefore been requested by the trust.

Assure

• No harm events have occurred to our patients due to staffing levels

Recommendation

The Board is asked to receive the report







TB

203_

19d

Saf

e N

urse

Sta

ffing

Rep

ort -

(O

ct d

ata)

Dec

19

Page 69 of 210










CQC KLOEs

GOVERNANCE





✓ Well Led



✓ Engagement and Communication ✓ Quality & Safety

✓ Equality ✓ Risk

✓ Finance ✓ Workforce



Policy

Service Change

Strategy

Next Steps (List the required Actions and Leads following agreement by Committee)





Committee ✓ Workforce Committee







Page 70 of 210

1. Introduction This report provides an overview of the staffing levels for October 2019. Overall fill rate for October 2019 was 92.3% (appendix 1).

• 91.01% Registered Nurses on days

• 86.04% Registered Nurses on nights

• 97.14% Care staff on days

• 98.72% Care staff on nights

The Board is advised the Trusts reporting to UNIFY has been reviewed to assure the Safe Staffing reporting includes the staff allocated on arrival of shift to clinical areas from the flexible workforce pool. Retrospective review has identified slight uplift to the trust safe staffing % reporting and an application to resubmit this data to UNIFY has therefore been requested by the trust. The Board will be kept appraised on this outcome and any change to the trusts Safe Staffing % reporting. The overall CHpPD for the Trust has remained static in month reporting at 8.3 hours (appendix 1) and remains slightly above the national average of 7 hours CHpPD, The Trust current reporting for CHpPD includes Registered Nurses/Registered Midwives. . Planned care clinical business unit (CBU) report overall 10.3, Urgent Care CBU 6.6 and Women’s and Children’s 13.0 overall. 2. October Safe Staffing Trust whole time equivalent (wte) funded establishment versus contracted for October 2019 below finance figures:

Funded WTE Contracted WTE Vacancy

Registered 950.41 791.46 158.95

Non-registered 447.71 367.03 80.68

Total 1,398.12 1,158.49 239.63

3. Staffing Related Reported Incidents October 2019

TB

203_

19d

Saf

e N

urse

Sta

ffing

Rep

ort -

(O

ct d

ata)

Dec

19

Page 71 of 210

27 staffing incidents/nursing red flags were reported in October, 12 less than the previous month. 13 of these incidents highlight insufficient nurses/midwives or nurse shortfalls, 16 less than September. 3 of these relate to Ward 14A (red flags) and a further 2 to Delivery Suite. No harm was caused to patients as a result of these incidents.

In October there were 4 nursing red flags reported in month, 3 on ward 14A, 1 on ward 7b. All incidents have been supported and managed through trust process and there has been no reported correlation with patient harm.

4. Non Framework Nurse Agency Usage

Page 72 of 210

The Trust continues to proactively review and consider options for additional staffing resource as an interim and longer term substantive position.

October reports a 3.7% increase in off framework agency usage compared to September.

5. Recommendations

The Board is asked to receive the content presented in this paper and support the on-going plans to

achieve and sustain compliance against Safe Staffing Plan.

Carol Fowler Assistant Director of Nursing – Workforce

TB

203_

19d

Saf

e N

urse

Sta

ffing

Rep

ort -

(O

ct d

ata)

Dec

19

Page 73 of 210

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Page 74 of 210


Agenda Item TB204/19 Report Title Integrated Performance

Report

Executive Lead Steve Christian, Chief Operating Officer

Lead Officer Anita Davenport, Interim Performance Manager

Action Required

(Definitions below)

To Approve To Note

✓ To Assure ✓ To Receive

For Information

Executive Summary

The report highlights the indicators that require discussion at the board. Some of these indicators require corrective action to be taken. Executive assurance and action plans have been provided in order to provide assurance that corrective measures are in place. The reporting forms part of the Trust’s Performance and Accountability Framework, where governance is in place to drive and monitor both operational performance improvement and delivery of the Vision 2020 Single Improvement Plan. Update on development: The development of the IPR has been an ongoing process over the last year. To date, several improvements have been made to both the structure and content of the report to enable ease of use and clarity of understanding. The improvements include:

• SPC charts for each indicator in line with NHSI recommendations

• The inclusion of targets where these were previously not included

• The addition of trajectories of performance where this is practicable and appropriate (blue line on graph)

• The division of the ‘red/green’ box on the detailed report to enable a clear picture of where the Trust is performing against both target and trajectory – a white box indicates ‘no trajectory’

• Executive sign off, for their respective KPIs

• Ongoing data cleansing and data quality audits – data quality group set up

• HR Trajectories have been agreed and will be included going forward

• Continued support to colleagues in developing good quality and useful narrative - Peer review of IPR introduced

• Results of MIAA audit of IPR recommended stability in design to enable documentation of the data collection process, and a focus on data quality

The Board is asked to receive the report and highlight any further assurance necessary in relation to areas of poor performance.




TB

204_

19 1

FS

IPR

Dec

19

Page 75 of 210














CQC KLOEs

GOVERNANCE





✓ Well Led


✓ Compliance ✓ Legal

✓ Engagement and Communication ✓ Quality & Safety

✓ Equality ✓ Risk

Finance ✓ Workforce



Policy

Service Change

Strategy


Continue to monitor complaints and compliments. Weekly complaints review meeting to review all complaints over 40 day response target.


Audit Committee ✓ Quality & Safety Committee


✓ Finance, Performance & Investment ✓ Workforce Committee

Page 76 of 210

Committee

TB

204_

19 1

FS

IPR

Dec

19

Page 77 of 210

Inte

grat

ed

Per

form

ance

Re

po

rt E

xecu

tive

Su

mm

ary

Sep

tem

be

r 2

01

9, S

teve

Ch

rist

ian

(C

hie

f O

per

atin

g O

ffic

er)

Go

vern

ance

Fra

me

wo

rk

The

Inte

grat

ed

Per

form

ance

rep

ort

is r

evie

wed

mo

nth

ly b

y th

e Tr

ust

Bo

ard

an

d s

pec

ific

ind

icat

ors

are

rev

iew

ed

by

the

sub

co

mm

itte

es o

f th

e B

oar

d w

hic

h

rep

ort

ass

ura

nce

, ale

rts

and

ad

vice

to

th

e B

oar

d.

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per

form

ance

rep

ort

incl

ud

es t

he

Tru

st in

dic

ato

rs r

elat

ing

to t

he

NH

S, C

on

stit

uti

on

al S

tan

dar

ds,

th

e 2

01

9/2

0 S

OF

and

inte

rnal

per

form

ance

ind

icat

ors

wh

ich

th

e Tr

ust

has

iden

tifi

ed a

s es

sen

tial

mea

sure

s o

f o

per

atio

nal

del

iver

y an

d a

ssu

ran

ce.

The

per

form

ance

ind

icat

ors

are

gro

up

ed a

cco

rdin

g to

th

e

do

mai

ns

use

d b

y re

gula

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in t

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ll Le

d F

ram

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rk.

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ind

icat

or

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tati

stic

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roce

ss C

on

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l Ch

art

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C)

and

co

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enta

ry. W

hils

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xecu

tive

su

mm

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vid

es a

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ll vi

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f th

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isat

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ris

ks, s

om

e in

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ato

rs a

re a

lso

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ud

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pro

vem

ent

mea

sure

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r th

e fo

ur

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rio

riti

es a

nd

are

co

vere

d in

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ail i

n t

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rele

van

t

rep

ort

s.

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uti

ve S

um

mar

y h

igh

ligh

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rust

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form

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pro

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KP

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ss t

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orm

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lity.

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inte

r P

lan

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rnal

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st h

as in

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du

ced

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eekl

y W

inte

r O

per

atio

nal

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up

to

su

pp

ort

imp

lem

enta

tio

n o

f th

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osp

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win

ter

sch

emes

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e sc

hem

es in

clu

de

the

op

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g o

f a

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bed

ded

po

st -

op

erat

ive

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pae

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w

ard

to

su

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ap

pro

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sfer

of

pat

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ts s

till

un

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are

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can

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ceiv

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reh

abili

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se 1

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TB

204_

19 2

IPR

Sum

mar

y D

ec 1

9

Page 78 of 210

a fi

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nu

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re b

ein

g in

tro

du

ced

to

su

pp

ort

wee

ken

d p

erfo

rman

ce.

Th

ese

incl

ud

e en

han

cin

g p

har

mac

y p

rese

nce

, op

enin

g u

p a

mb

ula

tory

car

e an

d in

crea

sin

g se

nio

r d

ecis

ion

mak

ers

acro

ss t

he

inp

atie

nt

war

ds.

Pat

ien

t Fl

ow

Imp

rove

men

t P

rogr

amm

e (P

FIP

) co

nti

nu

es t

o w

ork

on

its

acti

on

s to

imp

rove

eff

icie

ncy

an

d

lead

ersh

ip o

f p

atie

nt

man

agem

ent

on

th

e w

ard

wit

h a

n a

spir

atio

n o

f es

tab

lish

ed r

edu

ce a

ll Em

erge

ncy

ALO

S b

y 0

.5 d

ays.

Th

e b

asel

ine

at t

he

star

t o

f th

is w

ork

str

eam

was

set

at

aver

age

LOS

7.4

day

s. T

he

resu

lts

for

Oct

ob

er

sho

w a

n im

pro

vem

ent

of

alm

ost

1 d

ay n

ow

at

6.5

day

s.

Can

cer

Fort

nig

htl

y C

ance

r Im

pro

vem

ent

mee

tin

gs w

ith

Ch

ief

Op

erat

ing

Off

icer

allo

w

hig

h le

vel i

mp

acts

an

d b

arri

ers

to b

e d

iscu

ssed

wit

h C

ance

r Se

rvic

es.

The

mee

tin

g p

rovi

des

ass

ura

nce

an

d e

scal

atio

n o

f is

sues

, wit

h r

epo

rtin

g o

f so

luti

on

s th

e m

ain

fo

cus.

In a

dd

itio

n, i

nd

ivid

ual

tu

mo

ur

site

s ar

e in

vite

d t

o

atte

nd

th

is m

eeti

ng

to d

iscu

ss in

dep

th t

he

risk

s, b

arri

ers

and

go

od

pra

ctic

e w

ith

in t

hei

r o

wn

are

as, w

hic

h s

up

po

rt t

hei

r im

pro

vem

ent

pla

n.

Ro

bu

st c

ance

r im

pro

vem

ent

pla

ns

for

eac

h in

div

idu

al t

um

ou

r si

te a

nd

ser

vice

s th

at a

ffec

t th

e ca

nce

r p

ath

way

s, w

ith

cle

arly

def

ined

KP

Is a

re n

ow

in p

lace

.

Form

al d

iscu

ssio

ns

are

un

der

way

wit

h o

ther

pro

vid

ers

rega

rdin

g H

aem

ato

logy

an

d H

ead

& N

eck

serv

ices

. 1

8 W

eek

RTT

Per

form

ance

Th

e G

ynae

colo

gy p

osi

tio

n is

pre

dic

ted

to

re

cove

r fr

om

Jan

uar

y 2

02

0 a

s th

e Tr

ust

has

rec

en

tly

app

oin

ted

4 c

on

sult

ants

. Th

e C

om

mu

nit

y P

aed

iatr

ics

per

form

ance

will

co

nti

nu

e to

be

com

pro

mis

ed u

nti

l we

can

ap

po

int

into

th

e va

can

t co

mm

un

ity

Pae

dia

tric

ian

po

st.

Page 79 of 210

Dia

gno

stic

s P

erfo

rman

ce f

or

Oct

ob

er a

gain

st t

he

6 w

eek

wai

t ta

rget

w

as 2

.16

% a

n im

pro

vem

ent

of

0.5

% o

ver

the

Sep

tem

ber

p

osi

tio

n a

nd

in li

ne

wit

h t

raje

cto

ry.

End

osc

op

y re

cord

ed

the

mo

st n

um

ber

of

sco

pes

in a

mo

nth

(o

n r

eco

rd)

in

Oct

ob

er a

t 6

53

wit

h z

ero

ses

sio

ns

can

celle

d d

ue

to n

o

nu

rses

. Th

eat

re U

tiliz

atio

n

Orm

skir

k im

pro

ved

in m

on

th t

o 7

3%

fo

r O

cto

ber

by

1%

ag

ain

st t

he

pre

vio

us

mo

nth

. H

ow

ever

So

uth

po

rt u

tiliz

atio

n

reco

rded

a d

eclin

e in

per

form

ance

du

e to

hig

h n

um

ber

s o

f ca

nce

llati

on

s at

trib

ute

d t

o p

oo

r p

atie

nt

flo

w.

Dia

gno

stic

s (U

ltra

sou

nd

) Th

e U

ltra

sou

nd

bac

klo

g re

du

ctio

n w

ill b

e d

eliv

ered

th

rou

gh a

n a

gree

d S

LA

wit

h R

en

acre

s, a

nd

will

co

nti

nu

e to

be

sup

po

rted

by

PD

S M

SK S

on

ogr

aph

ers

and

ext

ra in

-ho

use

co

nsu

ltan

t ac

tivi

ty.

Th

eat

re U

tiliz

atio

n

The

imp

rove

men

t p

rogr

amm

e co

nti

nu

es t

o s

ho

w p

rogr

ess

(5%

imp

rove

men

t in

uti

lizat

ion

sin

ce A

pri

l) t

hro

ugh

a f

ocu

s o

n t

hre

e w

ork

are

as: S

ched

ulin

g,

Avo

idin

g o

n-t

he-

day

can

cella

tio

ns

and

sta

rtin

g se

ssio

ns

on

tim

e (

the

Go

lden

P

atie

nt)

.

Wel

l Le

d

The

key

risk

s re

late

to

wo

rkfo

rce

cap

acit

y an

d c

apab

ility

. A

nu

mb

er o

f m

etri

cs in

clu

din

g va

can

cy r

ate

and

tu

rno

ver

as

we

ll as

sic

knes

s ab

sen

ce a

nd

ap

pra

isal

are

co

nsi

sten

tly

bel

ow

th

e re

qu

ired

leve

l. Th

is is

imp

acti

ng

sign

ific

antl

y o

n

the

fin

anci

al p

erfo

rman

ce a

s th

e Tr

ust

has

bee

n r

elia

nt

on

te

mp

ora

ry a

nd

hig

h c

ost

so

luti

on

s in

ord

er t

o m

ain

tain

saf

e

staf

fin

g an

d t

he

CH

PP

D le

vels

.

On

e su

ch im

pro

vin

g m

etri

c is

th

e Tr

ust

’s r

olli

ng

year

to

dat

e si

ckn

ess

abse

nce

rat

e w

hic

h h

as c

on

sist

en

tly

red

uce

d

mo

nth

on

mo

nth

fo

r 1

1 m

on

ths

and

rem

ain

s o

n t

rack

to

at

tain

bel

ow

5%

by

Mar

ch 2

02

0.

Ho

wev

er, t

he

Tru

st h

as

no

t fe

lt t

he

ben

efit

of

the

red

uci

ng

sick

nes

s ab

sen

ce r

ate

, d

ue

to a

n in

crea

sin

g va

can

cy r

ate,

wh

ich

is a

ttri

bu

ted

to

an

in

crea

sin

g st

aff

turn

ove

r ra

te.

Pri

ori

ty h

as b

een

giv

en t

o e

stab

lish

ing

a n

um

ber

of

task

an

d f

inis

h g

rou

ps

to

enga

ge w

ith

key

sta

keh

old

ers

to c

entr

e o

n: R

ecru

itm

ent

and

Re

ten

tio

n a

nd

al

so P

erfo

rman

ce D

evel

op

men

t an

d R

evie

w (

PD

R).

Th

eref

ore

, wit

hin

th

e n

ext

fou

r w

eeks

, tw

o t

ask

and

fin

ish

gro

up

s w

ill b

e es

tab

lish

ed, o

ne

gro

up

will

fo

cus

on

rec

ruit

men

t an

d r

eten

tio

n a

nd

th

e o

ther

on

per

form

ance

d

evel

op

men

t re

view

. In

ad

dit

ion

th

e Tr

ust

is c

on

tin

uin

g w

ork

wit

h a

n e

xte

rnal

co

mp

any,

Lia

iso

n, o

n d

evel

op

ing

thei

r W

ork

forc

e D

ash

bo

ard

s in

ord

er t

o

uti

lise

arti

fici

al a

nd

bu

sin

ess

inte

llige

nce

, in

ord

er t

hat

ho

tsp

ot

area

s ca

n b

e q

uic

kly

and

eas

ily id

enti

fied

an

d t

imel

y in

terv

enti

on

s p

ut

into

pla

ce.

W

ork

co

nti

nu

es o

n t

he

inte

rven

tio

ns

to r

edu

ce a

gen

cy s

pen

d b

elo

w w

hic

h

incl

ud

es a

n a

gree

d f

orm

al p

artn

ersh

ip a

rran

gem

ent

wit

h t

hir

d p

arty

o

rgan

isat

ion

s th

at c

an a

ssis

t w

ith

in-s

ou

rin

g to

mit

igat

e th

e ri

sk r

egar

din

g ta

x b

ills

on

pen

sio

n; T

he

dev

elo

pm

ent

of

a “m

edic

al”

ban

k -

to g

o li

ve 1

st

Dec

emb

er; T

he

on

goin

g u

se o

f th

e n

urs

ing

“tie

r 2

” fr

amew

ork

to

era

dic

ate

agen

cy u

sage

; A

sys

tem

wid

e re

view

of

Frag

ile s

ervi

ces

is in

pla

ce w

ith

th

e co

nsi

der

atio

n o

f w

ho

le s

yste

m s

olu

tio

ns.

TB

204_

19 2

IPR

Sum

mar

y D

ec 1

9

Page 80 of 210

Safe

P

osi

tive

pro

gres

s h

as b

een

ach

ieve

d a

gain

st t

he

falls

in

dic

ato

r (k

ey e

lem

ent

of

the

Car

e o

f O

lder

Peo

ple

Im

pro

vem

ent

Pri

ori

ty)

and

FN

OF

ind

icat

or

for

tim

e to

th

eatr

e. T

hes

e K

PIs

hav

e b

een

pre

vio

usl

y ra

ised

as

a co

nce

rn a

t SO

IB.

Del

iver

y o

f th

e fa

lls a

spec

t o

f th

e O

lder

Peo

ple

s Q

I pro

gram

me

has

ach

ieve

m

ajo

r m

ilest

on

es f

or

intr

od

uci

ng

new

ris

k as

sess

men

t, d

ocu

men

tati

on

, tr

ain

ing

and

un

der

taki

ng

RC

A r

evi

ews.

Th

e Fa

lls S

trat

egy

is o

n t

rack

fo

r th

e la

un

ch b

y th

e en

d o

f N

ove

mb

er 2

01

9.

Th

e O

rth

op

aed

ics

team

co

nti

nu

e to

imp

lem

ent

the

FNO

F p

ath

way

an

d

‘Go

lden

Pat

ien

t’ a

pp

roac

h t

o e

xped

ite

acce

ss t

o t

hea

tre

and

is a

imin

g to

ac

hie

ve t

he

targ

et b

y D

ecem

ber

20

19

. In

ad

dit

ion

we

hav

e im

pro

ved

ort

ho

-ge

riat

ric

sup

po

rt (

3 d

ays

per

wee

k).

The

Tru

sts

con

tin

ues

to

dem

on

stra

te

imp

rovi

ng

FNO

F m

ort

alit

y ra

tes.

Effe

ctiv

e

Co

nti

nu

ed im

pro

vem

ent

in p

erfo

rman

ce a

gain

st S

tro

ke a

nd

Se

psi

s in

dic

ato

rs h

as b

een

ach

ieve

d s

up

po

rted

by

the

Det

erio

rati

ng

Pat

ien

t Q

I Pri

ori

ty a

nd

Pat

ien

t Fl

ow

Im

pro

vem

ent

Pro

gram

me

(PFI

P).

In

ad

dit

ion

, th

ere

hav

e b

een

imp

rove

men

ts in

scr

een

ing

dea

ths

and

SJR

pro

cess

es

wh

ich

un

der

pin

th

e Le

arn

ing

fro

m D

eath

asp

ects

of

the

pro

gram

me.

Th

e H

MSR

an

d S

HM

I tra

ject

ory

co

nti

nu

e to

im

pro

ve.

The

nex

t im

pro

vem

ent

focu

s w

ill b

e o

n A

KI a

nd

LR

TI w

ith

lin

ks/i

nte

rdep

end

ency

wit

h t

he

Car

e o

f O

lder

Peo

ple

p

rogr

amm

e.

Imp

lem

enta

tio

n o

f ip

ad f

acili

ty f

or

scre

en

ing

dea

ths

and

mo

rtu

ary

enga

gem

ent

has

imp

rove

d r

ates

. A

pre

sen

tati

on

of

less

on

s le

arn

ed f

rom

SJR

s is

sch

edu

led

at

the

No

vem

ber

G

ran

d R

ou

nd

. Th

e Tr

ust

is a

lso

su

pp

ort

ing

two

acu

te T

rust

on

th

e d

evel

op

men

t o

f le

arn

ing

fro

m d

eath

s as

an

imp

rove

men

t ap

pro

ach

.

Car

ing

Th

e ke

y fo

cus

in t

his

do

mai

n is

to

incr

ease

th

e re

spo

nse

ra

te a

nd

use

of

info

rmat

ion

fro

m t

he

Frie

nd

s an

d F

amily

te

st. T

his

is e

sse

nti

al if

th

e Tr

ust

is t

o id

enti

fy k

ey a

spec

ts o

f p

atie

nt

exp

erie

nce

wh

ich

can

be

imp

rove

d.

Wh

ilst

the

traj

ecto

ry f

or

the

ove

rall

nu

mb

er o

f w

ritt

en

com

pla

ints

is p

osi

tive

th

e fu

ture

fo

cus

will

be

on

imp

rovi

ng

the

pro

cess

, th

emat

ic a

nal

ysis

an

d e

valu

atin

g th

e o

utc

om

e fr

om

th

e p

atie

nt/

care

r p

ersp

ecti

ve.

SMS

Text

an

d In

tera

ctiv

e V

oic

e m

essa

gin

g w

ent

live

on

th

e 1

st O

cto

ber

to

A+E

D

epar

tmen

ts, O

utp

atie

nts

an

d D

ay c

ase

area

s. T

his

has

dem

on

stra

ted

an

in

crea

se in

res

po

nse

rat

es

and

qu

alit

ativ

e co

mm

ents

acr

oss

th

ese

sett

ings

. Th

is w

ill p

rovi

de

mo

re r

epre

sen

tati

ve f

eed

bac

k to

iden

tify

are

as t

o f

ocu

s im

pro

vem

ents

.

The

corp

ora

te n

urs

ing

team

is u

nd

erta

kin

g a

revi

ew o

f th

e co

mp

lain

ts p

roce

ss

and

will

be

lead

ing

an im

pro

vem

ent

pro

gram

me.

Page 81 of 210

TB

204_

19 2

IPR

Sum

mar

y D

ec 1

9

Page 82 of 210

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l-L

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arg

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ctu

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raj

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dour

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vide

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genc

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inan

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ruit

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66N

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Eff

icie

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Tar

get

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ual

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D

Act

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ien

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AG

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nd

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j R

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r D

isch

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Ave

rage

Num

ber

of

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ly B

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In M

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5073

6473

DT

OC

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umbe

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st p

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mon

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th O

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y6.

56.

57

N/A

New

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low

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2.64

2.5

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A (

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nd)

rate

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2%7.

1%18

37

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celle

d O

ps0.

61%

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8

The

atre

Util

isat

ion

- S

DG

H80

%64

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61.3

%N

/A

The

atre

Util

isat

ion

- O

DG

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69.8

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/A

Str

ande

d P

atie

nts

(>6

Day

s LO

S)

170

179

1247

179

Sup

er S

tran

ded

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ient

s (>

20 D

ays

LOS

)58

6948

669

Sou

thpo

rt A

&E

Con

vers

ion

Rat

e20

%21

%10

53

Saf

eT

arg

etA

ctu

alY

TD

A

ctu

alP

atie

nts

RA

GT

ren

dT

raj

RA

G

MR

SA

10

10

C-D

iff1.

335

195

Nev

er E

vent

s0

01

0

VT

E P

roph

ylax

is A

sses

smen

ts95

%96

.9%

97.7

%15

1

Har

m F

ree

(Saf

ety

The

rmom

eter

)95

%98

.9%

97.9

%4

Fal

ls -

Mod

erat

e/S

ever

e/D

eath

12

112

Pat

ient

Saf

ety

Inci

dent

s -

Low

, Nea

r M

iss

or N

o H

arm

814

5472

814

Saf

e S

taffi

ng90

%92

.3%

92%

N/A

Fra

ctur

ed N

eck

of F

emur

90%

79.3

%71

.4%

23

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ecti

veT

arg

etA

ctu

alY

TD

A

ctu

alP

atie

nts

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GT

ren

dT

raj

RA

G

Per

cent

age

of D

eath

s S

cree

ned

100%

88.9

%60

%7

SH

MI (

Sum

mar

y H

ospi

tal-l

evel

M

orta

lity

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cato

r)10

099

.610

0.7

N/A

HS

MR

- R

ollin

g 12

Mon

ths

(Hos

pita

l S

tand

ardi

sed

Mor

talit

y R

atio

)10

091

91N

/A

WH

O C

heck

list

100%

100%

100%

0

Str

oke

- 90

% S

tay

on S

trok

e W

ard

80%

94.1

%71

.8%

1

Sep

sis

- T

imel

y Id

entif

icat

ion

75%

100%

98.7

%N

/A

Sep

sis

- T

imel

y T

reat

men

t75

%80

%77

.9%

N/A

Car

ing

Tar

get

Act

ual

YT

D

Act

ual

Pat

ien

tsR

AG

Tre

nd

Tra

j R

AG

DS

SA

(D

eliv

erin

g S

ame

Sex

A

ccom

mod

atio

n) B

reac

hes

- T

rust

114

139

14

Writ

ten

Com

plai

nts

3530

151

30

Frie

nds

and

Fam

ily T

est -

% T

hat

Wou

ld R

ecom

men

d -

Tru

st O

vera

ll90

%91

.6%

92.7

%19

2

Boa

rd R

epor

t - O

ctob

er 2

019

RE

GU

LA

TO

RY

Tar

get

Act

ual

YT

D

Act

ual

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ien

tsR

AG

Tre

nd

Tra

j R

AG

CQ

C R

egis

trat

ion

-

Mon

itor

Gov

erna

nce

Rat

ing

Gre

en-

--

-

Res

po

nsi

veT

arg

etA

ctu

alY

TD

A

ctu

alP

atie

nts

RA

GT

ren

dT

raj

RA

G

Acc

iden

t & E

mer

genc

y -

4 H

our

com

plia

nce

94.9

9%84

.6%

86.5

%16

35

Acc

iden

t & E

mer

genc

y -

12+

Hou

r tr

olle

y w

aits

127

6227

Am

bula

nce

Han

dove

rs <

=15

Min

s99

%48

.2%

53.1

%79

0

Dia

gnos

tic w

aits

1.

01%

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61

14 d

ay G

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efer

ral t

o O

utpa

tient

s93

%96

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%30

31 d

ay tr

eatm

ent

96%

95.3

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3

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ay tr

eatm

ent (

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gery

)94

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ay tr

eatm

ent (

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i-can

cer

drug

s)98

%10

0%10

0%0

62 d

ay p

athw

ay A

naly

sis

85%

82%

78.6

%9

62 d

ay G

P r

efer

ral t

o tr

eatm

ent

85%

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%9

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erra

l to

trea

tmen

t: on

-goi

ng92

%93

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%75

0

Bed

Occ

upan

cy -

SD

GH

93%

90%

92.1

%N

/A

Bed

Occ

upan

cy -

OD

GH

60%

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48.3

%N

/A

Rep

ortin

g F

requ

ency

is m

onth

ly e

xcep

t for

SH

MI w

hich

is q

uart

erly

.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 1

of 1

TB

204_

19 3

IPR

Das

hboa

rd D

ecem

ber

2019

Oct

ober

Dat

a

Page 83 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

S

afe

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

MR

SA

The

num

ber

of M

ethi

cilli

n R

esis

tant

Sta

phyl

ococ

cus

Aur

eus

(MR

SA

) te

st s

ampl

es

that

wer

e po

sitiv

e.

The

thre

shol

d is

0.

The

re w

as z

ero

MR

SA

bac

tera

emia

in O

ctob

er -

Sin

ce th

e M

RS

A b

acte

raem

ia in

Aug

ust,

less

on

lear

ned

have

bee

n in

clud

ed in

Tru

st N

ews,

Man

dato

ry tr

aini

ng a

nd M

edic

al u

pdat

es. I

n ad

ditio

n th

e af

fect

ed w

ard

has

incl

uded

MR

SA

sup

pres

sion

Rxi

ng in

MD

T R

ed to

Gre

en r

evie

ws

and

hudd

les.

Als

o,

whe

n re

view

ing

MR

SA

pat

hway

s th

e IP

C te

am c

ross

ref

eren

ce th

e pa

tient

Rx

char

t and

adv

ise

clin

icia

ns to

con

side

r A

bxs

effe

ctiv

e ag

ains

t MR

SA

if th

e pa

tient

col

onis

ed w

ith M

RS

A a

nd is

bei

ng

trea

ted

for

an in

fect

ion.

C-D

iff

Num

ber

of C

lost

ridiu

m d

iffic

ile

(C. d

iff)

infe

ctio

ns fo

r pa

tient

s ag

ed 2

or

mor

e on

the

date

the

spec

imen

was

take

n.

Tru

st ta

rget

36

for

the

year

. G

ood

perf

orm

ance

is fe

wer

th

an 3

6 fo

r th

e ye

ar.

5 C

diff

cas

es in

Oct

ober

, how

ever

3 o

f the

se w

ill b

e ap

peal

able

as

no la

pses

in c

are

- R

egio

nally

C d

iff

rate

s ha

ve in

crea

sed

this

yea

r an

d S

outh

port

and

Orm

skirk

are

no

exce

ptio

n. T

he ta

rget

for

2019

/20

is

for

no m

ore

than

16

case

s an

d th

e T

rust

has

cur

rent

ly h

ad 2

0 ca

ses,

how

ever

7 o

f the

se c

ases

hav

e be

en s

ucce

ssfu

lly a

ppea

led

and

a fu

rthe

r 4

case

s ar

e el

igib

le fo

r ap

peal

.S

ome

of th

e is

sues

iden

tifie

d as

par

t of t

he R

CA

pro

cess

wer

e m

ultip

le p

resc

riptio

ns o

f Abx

s no

t onl

y in

th

e ho

spita

l but

als

o in

the

com

mun

ity p

rior

to a

dmis

sion

and

frai

l pat

ient

s w

ith fe

edin

g tu

bes

or lo

ng

term

cat

hete

rs.

The

Con

sulta

nt M

icro

biol

ogis

t and

the

Ant

imic

robi

al P

harm

acis

t are

rev

iew

ing

the

curr

ent A

ntim

icro

bial

gu

idel

ines

to r

ecom

men

d su

itabl

e al

tern

ativ

es to

the

freq

uent

use

of c

epha

losp

orin

's w

hich

hav

e an

in

crea

sed

risk

of C

diff

. O

ctob

er's

cas

es o

n w

ards

: SS

U, 1

4B, O

BS

, GP

and

FE

SS

(on

e on

the

FE

SS

cas

es w

as a

com

mun

ity

occu

rrin

g ho

spita

l ass

ocia

ted

case

- th

e ty

ping

of t

his

case

was

diff

eren

t to

the

othe

r F

ES

S c

ase)

Nev

er E

vent

s

Nev

er E

vent

s -

A p

artic

ular

ty

pe o

f ser

ious

inci

dent

that

is

who

lly p

reve

ntab

le a

nd h

as th

e po

tent

ial t

o ca

use

serio

us

patie

nt h

arm

or

deat

h.

The

re w

ere

no n

ever

eve

nts

in O

ctob

er -

The

Tru

st r

epor

ted

1 ne

ver

even

t in

the

last

12

mon

ths

- in

M

ay 2

019.

•

Sig

ns w

ere

imm

edia

tely

put

up

acro

ss a

ll T

heat

re a

reas

in th

e an

aest

hetic

Roo

ms,

follo

win

g th

e ev

ent

to a

lert

sta

ff to

’Sto

p B

efor

e Y

ou B

lock

’ •

The

inci

dent

was

dis

cuss

ed a

t dai

ly S

afet

y H

uddl

es•

Sta

ff aw

aren

ess

sess

ions

wer

e pu

t in

plac

e.•

Tra

inin

g ha

s no

w b

een

put i

n pl

ace

and

this

is in

clud

ed in

the

Clin

ical

Com

pete

ncy

trai

ning

pac

kage

s.•

We

have

a n

ew L

ocss

ip (

in th

e S

OP

tem

plat

e) ‘P

roce

dura

l Ver

ifica

tion

of S

ite M

arki

ng’ b

ased

on

Nat

ssip

s.•

We

have

com

men

ced

a m

onth

ly o

bser

vatio

nal a

udit

of S

top

Bef

ore

You

Blo

ck a

nd th

ere

have

bee

n no

oth

er e

piso

des.

• W

e ha

ve a

sec

tion

incl

uded

in In

duct

ion/

com

pete

ncy

pack

s ar

ound

Sto

p B

efor

e Y

ou B

lock

.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 1

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 84 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

S

afe

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

VT

E P

roph

ylax

is A

sses

smen

ts

VT

E r

isk

asse

ssm

ent:

all

inpa

tient

Ser

vice

Use

rs

unde

rgoi

ng r

isk

asse

ssm

ent f

or

VT

E.

Thr

esho

ld 9

5%. G

ood

perf

orm

ance

is h

ighe

r.

Com

plia

nt -

The

Tru

st c

ontin

ues

to a

chie

ve a

bove

the

thre

shol

d of

95%

Har

m F

ree

(Saf

ety

The

rmom

eter

)

Saf

ety

The

rmom

eter

-

Per

cent

age

of P

atie

nts

With

H

arm

Fre

e C

are.

Thr

esho

ld 9

8%. H

ighe

r is

be

tter.

Per

form

ance

rem

ains

abo

ve ta

rget

- P

erfo

rman

ce fo

r O

ctob

er r

emai

ns g

ood

and

in to

tal t

he T

rust

re

port

ed 5

har

ms

durin

g O

ctob

er's

mon

thly

cen

sus.

2

x ca

thet

er a

ssoc

iate

d ur

inar

y tr

act i

nfec

tions

( 7

b an

d 9b

) an

d 3

x ne

w V

TE

's w

hich

wer

e 2

x ne

w

DV

T's

( N

WR

SIU

and

9a

) an

d 1x

new

PE

( 9

a)

Fal

ls -

Mod

erat

e/S

ever

e/D

eath

The

tota

l num

ber

of fa

lls w

ithin

th

e T

rust

wer

e th

e se

verit

y of

th

e ha

rm w

as e

ither

mod

erat

e,

seve

re o

r re

sulte

d in

dea

th.

Thr

esho

ld:0

Per

form

ance

is d

emon

stra

ting

stab

le n

umbe

rs o

f fal

ls w

ith h

arm

but

ear

ly d

emon

stra

tion

of a

red

uctio

n fo

r al

l fal

ls C

BU

spe

cific

- T

he fa

lls w

ith h

arm

are

low

num

bers

and

dem

onst

rate

a r

elat

ivel

y st

able

pi

ctur

e, h

owev

er th

e to

tal f

alls

par

ticul

arly

in U

rgen

t Car

e ap

pear

s to

be

in th

e ea

rly s

tage

s of

sho

win

g a

redu

ctio

n an

d th

is c

ontin

ues

to b

e w

orke

d on

. The

impr

ovem

ent i

s ex

pect

ed to

be

seen

now

eac

h m

onth

.

Wor

k is

und

erw

ay to

dev

elop

a ta

rget

for

all f

alls

map

ped

agai

nst a

traj

ecto

ry w

hich

will

pro

vide

mor

e ob

viou

s ev

iden

ce o

f im

prov

emen

t aga

inst

the

falls

impr

ovem

ent p

lan.

In

add

ition

, 'ba

ckgr

ound

wor

k' in

clud

es in

crea

sing

the

abili

ty to

iden

tify

patie

nts

at r

isk

of fa

lls a

s pe

r N

ICE

Clin

ical

Gui

danc

e 16

, whe

re th

e tr

ust h

as a

lread

y im

prov

ed fr

om 5

6% in

qua

rter

1, t

o 89

% in

qu

arte

r 2.

In

add

ition

we

mon

itor

the

impl

emen

tatio

n of

car

e pl

ans

for

thos

e id

entif

ied

as b

eing

at r

isk.

Thi

s w

as

72%

in Q

1 ris

ing

to 8

7% in

Q2

and

we

cont

inue

to s

triv

e to

war

ds th

e 95

% ta

rget

.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 2

of 2

3

Page 85 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

S

afe

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

Pat

ient

Saf

ety

Inci

dent

s -

Low

, Nea

r M

iss

or N

o H

arm

The

num

ber

of in

cide

nts

rela

ting

to p

atie

nts

whe

re th

e se

verit

y w

as L

ow, N

ear

Mis

s or

N

o H

arm

cau

sed.

A h

ighe

r nu

mbe

r is

goo

d.

Incr

ease

in r

epor

ting

of N

o ha

rm/N

ear

mis

s/Lo

w h

arm

inci

dent

s by

71

- O

f thi

s in

crea

se 4

6 of

the

incr

ease

d in

cide

nts

are

attr

ibut

ed to

bed

man

agem

ent.

Thi

s re

late

s to

the

dela

y in

tran

sfer

of p

atie

nts

from

the

emer

genc

y ar

eas

to g

ener

al w

ards

and

from

thea

tre

and

Crit

ical

car

e to

gen

eral

war

ds to

en

able

new

pat

ient

s to

be

adm

itted

. Thi

s co

rrel

ates

with

the

pres

sure

on

A&

E/ E

AU

from

adm

issi

ons

thro

ugho

ut O

ctob

er.

Ano

ther

are

a sh

owin

g a

sign

ifica

nt in

crea

se is

Infe

ctio

n co

ntro

l with

an

incr

ease

of 1

5 re

latin

g to

the

batc

h im

port

of b

acte

raem

ia p

atie

nts

onto

dat

ix.

Saf

e S

taffi

ng

The

rat

io b

etw

een

the

prop

osed

num

ber

of n

ursi

ng

staf

f to

ensu

re a

saf

e st

affin

g le

vel a

nd th

e ac

tual

num

ber

of

nurs

es w

orki

ng th

ose

shift

s.

Thr

esho

ld: 9

5%, F

ail 9

0%.

The

Tru

st r

epor

ts a

n im

prov

ed p

ositi

on to

saf

e st

affin

g ag

ains

t the

nat

iona

l ave

rage

(90

%)

at 9

2.3%

. -

Sup

port

to im

prov

ed d

eliv

ery

agai

nst s

afe

staf

fing

perf

orm

ance

con

tinue

s th

roug

h fle

xibl

e w

orke

r op

port

uniti

es, c

onsi

dera

tion

of a

n ov

erse

as r

ecru

itmen

t pro

posa

l, lo

cal r

ecru

itmen

t ong

oing

.

Fra

ctur

ed N

eck

of F

emur

Per

cent

age

of F

NO

F o

pera

ted

on w

ithin

36

hour

s of

ad

mis

sion

.

Thr

esho

ld: 9

0%.

Per

form

ance

is s

how

ing

cont

inuo

us im

prov

emen

t fol

low

ing

bette

r us

e of

the

'gol

den

patie

nt' o

n th

e tr

aum

a lis

t - T

here

is n

ow b

ette

r us

e of

prio

ritis

ing

#NO

F p

atie

nts

as g

olde

n an

d si

lver

pat

ient

s on

the

thea

tre

list t

o en

sure

we

mee

t the

36h

rs to

thea

tre

targ

et.

Cur

rent

cap

acity

ena

bles

us

to o

pera

te o

n 3

NO

Fs

in 1

thea

tre

day.

Ofte

n th

ere

is m

ore

than

3 N

OF

pa

tient

s on

a th

eatr

e lis

t, as

wel

l as

othe

r pa

tient

s, th

eref

ore

whe

re o

ther

pat

ient

s ha

ve to

take

prio

rity,

th

is c

reat

es a

del

ay to

NO

F p

atie

nts

until

the

follo

win

g da

y.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 3

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 86 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

E

ffect

ive

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

SH

MI (

Sum

mar

y H

ospi

tal-l

evel

M

orta

lity

Indi

cato

r)

Sum

mar

y H

ospi

tal-l

evel

M

orta

lity

Indi

cato

r (S

HM

I) is

the

stan

dard

ised

mor

talit

y bo

th in

ho

spita

l and

with

in 3

0 da

ys o

f di

scha

rge.

Sou

rce

= D

r. F

oste

r.

Ple

ase

note

: Thi

s in

dica

tor

is

repo

rted

qua

rter

ly (

rolli

ng 1

2 m

onth

s) a

nd is

6 m

onth

s be

hind

due

to w

hen

Dr

Fos

ter

publ

ish

the

data

.

Per

form

ance

with

in to

lera

nce,

figu

re is

with

in s

tatis

tical

nor

ms.

- N

HS

Dig

ital n

ow r

elea

se th

e S

HM

I m

onth

ly. P

erfo

rman

ce is

gen

eral

ly im

prov

ed.

As

SH

MI a

nd H

SM

R a

re b

oth

risk

adju

sted

mor

talit

y fig

ures

, the

act

ions

des

crib

ed in

the

HS

MR

na

rrat

ive,

als

o ap

ply

to S

HM

I.

HS

MR

- R

ollin

g 12

Mon

ths

(Hos

pita

l S

tand

ardi

sed

Mor

talit

y R

atio

)

The

rat

io o

f the

obs

erve

d nu

mbe

r of

in-h

ospi

tal d

eath

s w

ith a

Hos

pita

l Sta

ndar

dise

d M

orta

lity

Rat

io (

HS

MR

) di

agno

sis

to th

e ex

pect

ed

num

ber

of d

eath

s, m

ultip

lied

by

100.

Ple

ase

note

: Thi

s in

dica

tor

is

repo

rted

mon

thly

and

is 3

m

onth

s be

hind

due

to w

hen

Dr

Fos

ter

publ

ish

the

data

.

Per

form

ance

is w

ithin

acc

epte

d to

lera

nce

- -

In-m

onth

ach

ieve

men

t:1.

4/5

wor

ksho

ps fo

r th

e re

-sco

ping

of t

he d

eter

iora

ting

patie

nt p

roje

ct a

re c

ompl

ete.

6th

wor

kstr

eam

to

be s

cope

d (in

form

atio

n / d

ocum

enta

tion)

. Com

plet

ed r

e-sc

opin

g ex

pect

ed b

y ne

xt m

onth

.2.

Tw

o fu

rthe

r pr

ojec

ts to

red

uce

harm

from

nos

ocom

ial i

nfec

tion

are

bein

g de

vise

d3.

Dra

ft re

port

of p

robl

ems

in h

ealth

care

bei

ng d

evis

ed fr

om th

e 11

7 S

JR r

evie

ws

com

plet

ed s

o fa

r in

th

e tr

ust t

o al

low

targ

eted

ana

lysi

s of

this

ric

h da

ta. d

raft

repo

rt fo

r D

ecem

ber

MO

G.

Ong

oing

wor

k on

UT

I - th

is is

now

an

AQ

faci

litat

ed p

roje

ct to

red

uce

urin

ary

cath

eter

isat

ion.

Thi

s is

pr

edic

ted

to h

ave

mul

tiple

ben

efits

incl

udin

g im

prov

ed m

obili

ty, i

mpr

oved

con

tinen

ce a

nd a

red

uctio

n in

U

TI a

nd g

ram

-ve

infe

ctio

n.

A n

ew p

roje

ct h

as b

een

initi

ated

to r

educ

e va

riatio

n in

IV c

annu

la c

are

aim

ing

to r

educ

e as

soci

ated

st

aphy

loco

ccal

infe

ctio

n.

The

uni

fied

AC

MP

tem

plat

e to

sup

port

trai

ning

and

use

of A

CM

P to

rec

ord

deci

sion

s ab

out a

ppro

pria

te

ceili

ngs

of tr

eatm

ent i

s un

der

deve

lopm

ent.

Thi

s pr

ojec

t is

acro

ss m

ultip

le p

rovi

ders

in th

e he

alth

ec

onom

y an

d w

ill fa

cilit

ate

the

use

of A

ntic

ipat

ory

Clin

ical

Man

agem

ent P

lans

, pre

vent

ing

unw

ante

d ho

spita

l adm

issi

on a

nd im

prov

ing

the

achi

evem

ent o

f pre

ferr

ed p

lace

of d

eath

.

The

re is

dev

elop

men

t of a

pro

cess

to r

evie

w lo

wer

res

pira

tory

trac

t and

UT

I dea

ths

to e

nsur

e th

ese

are

in th

e co

rrec

t dia

gnos

tic g

roup

s. S

yste

m d

evis

ed to

allo

w c

o-m

orbi

dity

dat

a id

entif

ied

in c

odin

g re

view

s to

be

mad

e av

aila

ble

to c

linic

al s

taff

if pa

tient

Is r

e-ad

mitt

ed to

info

rm c

are

of th

e pa

tient

.

WH

O C

heck

list

WH

O C

heck

list.

W

HO

che

cklis

t com

plia

nce

cont

inue

s to

ach

ieve

100

% -

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 4

of 2

3

Page 87 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

E

ffect

ive

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

Per

cent

age

of D

eath

s S

cree

ned

Per

cent

age

of D

eath

s S

cree

ned

- D

AT

IX

Sig

nific

ant i

mpr

ovem

ent i

s m

aint

aine

d -

Thi

s im

prov

emen

t fol

low

s th

e im

plem

enta

tion

of th

e iP

AD

sy

stem

and

the

rem

inde

r po

ster

s. T

here

rem

ains

a fo

cus

on th

is a

rea

in o

rder

to m

aint

ain

and

impr

ove

perf

orm

ance

.

Scr

eeni

ng o

f mor

talit

y is

impo

rtan

t to

allo

w th

e tr

ust m

orta

lity

revi

ewer

s to

focu

s th

eir

atte

ntio

ns o

n th

e ap

prop

riate

cas

es fo

r S

JR. W

e ai

m fo

r 90

%+

scr

eeni

ng to

ass

ure

that

the

vast

maj

ority

of d

eath

s ha

ve

a cl

inic

al r

evie

w.

We

cont

inue

to m

onito

r to

ens

ure

the

proc

ess

beco

mes

em

bedd

ed.

Str

oke

- 90

% S

tay

on S

trok

e W

ard

Pro

port

ion

of s

trok

e pa

tient

s w

ho h

ave

90%

of t

heir

hosp

ital

stay

on

a de

dica

ted

stro

ke

war

d. T

hres

hold

80%

. Goo

d pe

rfor

man

ce is

hig

her.

Ple

ase

note

: Ind

icat

or m

ay c

hang

e as

a

resu

lt of

del

ayed

val

idat

ion.

Str

oke

perf

orm

ance

ach

ieve

d ab

ove

the

80%

targ

et in

Oct

ober

at 9

4.12

% -

The

Tru

st h

as

dem

onst

rate

d an

impr

ovem

ent t

rend

sin

ce F

ebru

ary

of th

is y

ear

Sep

sis

- T

imel

y Id

entif

icat

ion

Sep

sis

Tim

ely

iden

tific

atio

n of

se

psis

in e

mer

genc

y de

part

men

ts a

nd a

cute

in

patie

nt s

ettin

gs -

Nat

iona

l ea

rly w

arni

ng s

core

(N

EW

s)

reco

rded

with

in 1

hou

r of

ho

spita

l arr

ival

.

The

trus

t con

tinue

s to

ach

ieve

the

targ

et fo

r id

entif

icat

ion

of S

epsi

s -

The

tota

l num

ber

of a

ttend

ance

to

A&

E n

atio

nally

in J

uly

2019

was

2,2

66,9

13 a

n in

crea

se o

f 4%

from

the

prev

ious

yea

r an

d th

e hi

ghes

t nu

mbe

r of

atte

ndan

ces

ever

rec

orde

d si

nce

colle

ctio

n of

figu

res

star

ted.

Sep

sis

- T

imel

y T

reat

men

t

Sep

sis

Tim

ely

trea

tmen

t for

se

psis

in e

mer

genc

y de

part

men

ts a

nd a

cute

in

patie

nt s

ettin

gs-

the

rate

of

rapi

d ad

min

istr

atio

n of

an

tibio

tics

with

in o

ne h

our

of

diag

nosi

s of

sep

sis.

Our

rol

ling

perf

orm

ance

bet

wee

n Ja

nuar

y 20

19 to

Aug

ust 2

019

for

antib

iotic

s w

ith 1

hou

r is

cur

rent

ly

achi

evin

g 80

%. -

Thi

s is

aga

inst

a b

ackd

rop

of th

e to

tal n

umbe

r of

atte

ndan

ces

to A

&E

nat

iona

lly in

Ju

ly 2

019

whi

ch w

as 2

,266

,913

rep

rese

ntin

g 4%

from

the

prev

ious

yea

r. T

his

is t

he h

ighe

st n

umbe

r of

at

tend

ance

sin

ce n

atio

nal d

ata

colle

ctio

n st

arte

d. T

he to

tal n

umbe

r of

atte

ndan

ce to

A&

E n

atio

nally

in

Aug

ust 2

019

was

2,1

25,4

45.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 5

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 88 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

C

arin

gIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

DS

SA

(D

eliv

erin

g S

ame

Sex

A

ccom

mod

atio

n) B

reac

hes

- T

rust

Thi

s in

dica

tor

mon

itors

the

Tru

st's

par

t in

the

NH

S

com

mitm

ent t

o el

imin

ate

mix

ed

sex

acco

mm

odat

ion.

Eac

h pa

tient

bre

ache

s ea

ch 2

4 ho

urs.

Bre

ache

s re

mai

n at

a s

tabl

e le

vel -

The

maj

ority

of b

reac

hes

are

in H

DU

and

Obs

war

d. T

here

is a

re

view

of a

ll pa

tient

s fo

r st

epdo

wn

from

crit

ical

car

e at

all

bed

mee

tings

and

the

plan

is d

epen

dent

on

the

over

all T

rust

pos

ition

; The

Crit

ical

Car

e M

anag

er a

ttend

s th

e 13

:30

bed

mee

ting

daily

; Obs

War

d w

ill c

ontin

ue to

follo

w p

olic

y an

d w

ork

with

all

team

s, a

nd r

epor

t bre

ache

s if

they

occ

ur; n

ew s

ingl

e se

x br

each

for

criti

cal c

are

is to

be

revi

ewed

Writ

ten

Com

plai

nts

The

tota

l num

ber

of c

ompl

aint

s re

ceiv

ed.

A lo

wer

num

ber

is g

ood.

The

re w

ere

30

com

plai

nts

in O

ctob

er -

The

num

ber

of c

ompl

aint

s re

ceiv

ed s

ugge

sts

that

pat

ient

s ar

e aw

are

of th

e co

mpl

aint

s pr

oced

ure.

the

com

plai

nts

cont

inue

to b

e re

port

ed in

to th

e Q

ualit

y an

d S

afet

y re

port

s fo

r ea

ch C

linic

al B

usin

ess

Uni

t and

in th

e in

tegr

ated

Gov

erna

nce

Rep

ort p

rese

nted

at Q

&S

C

omm

ittee

for

com

plai

nts

anal

ysis

suc

h as

tren

ds, t

hem

es a

nd r

espo

nsiv

enes

s.

The

com

plai

nts

data

has

bee

n sp

lit in

to lo

w le

vel c

once

rns

and

form

al c

ompl

aint

s gr

aded

3 o

r ab

ove

usin

g th

e tr

ust g

radi

ng to

ol. T

he fo

rmal

com

plai

nts

ofte

n in

clud

e m

ore

than

one

are

a of

com

plai

nt.

Urg

ent C

are

rece

ived

16

com

plai

nts,

with

War

d 10

A (

EA

U)

acco

untin

g fo

r 4

and

A&

E 2

. Pla

nned

Car

e re

ceiv

ed 6

com

plai

nts,

in 3

diff

eren

t are

as. S

peci

alis

t Ser

vice

s re

ceiv

ed 7

com

plai

nts,

of w

hich

2

rela

ted

to M

ater

nity

. 1 c

ompl

aint

was

rec

eive

d by

Est

ates

and

Fac

ilitie

s an

d re

late

d to

Sec

urity

.T

he fo

llow

ing

them

es w

ere

iden

tifie

d:•

Clin

ical

Tre

atm

ent –

in p

artic

ular

ly c

o-or

dina

tion

of m

edic

al tr

eatm

ent

• S

taff

attit

ude/

beha

viou

r•

End

of l

ife•

Adm

issi

on/tr

ansf

ers/

disc

harg

e pr

oced

ure

• C

omm

unic

atio

n•

Dat

e fo

r ap

poin

tmen

t

All

com

plai

nts

are

revi

ewed

with

in th

e B

usin

ess

Uni

ts a

nd r

espo

nse

and

rele

vant

act

ions

are

put

into

pl

ace.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 6

of 2

3

Page 89 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

C

arin

gIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Frie

nds

and

Fam

ily T

est -

% T

hat

Wou

ld R

ecom

men

d -

Tru

st O

vera

ll

The

pro

port

ion

of p

atie

nts

over

all w

ho r

espo

nded

that

th

ey w

ould

be

likel

y or

ex

trem

ely

likel

y to

rec

omm

end

the

Tru

st to

Frie

nds

and

Fam

ily.

Per

form

ance

has

slig

htly

im

prov

ed o

n pr

evio

us m

onth

s da

ta b

ut r

emai

ls b

elow

targ

et o

f 94%

. -

Per

form

ance

impr

oved

on

prev

ious

mon

th b

ut r

emai

ns b

elow

targ

et o

f 94%

.

Oct

ober

was

the

first

mon

th im

plem

entin

g th

e E

NV

OY

sys

tem

and

the

Tru

st h

as s

een

a si

gnifi

cant

im

prov

emen

t in

resp

onse

rat

es (

6.48

% to

21.

18%

)an

d an

incr

ease

in q

ualit

ativ

e co

mm

ents

sup

port

ing

the

ratin

gs g

iven

.

Pla

nned

car

e -

thos

e th

at w

ould

rec

omm

end

has

incr

ease

d to

95.

81%

from

94.

34%

Urg

ent c

are-

thos

e th

at w

ould

rec

omm

end

has

incr

ease

d to

88.

96%

from

79.

67%

. (T

his

incl

udes

a

scor

e of

88%

that

wou

ld r

ecom

men

d fr

om th

e A

dult

Em

erge

ncy

Dep

artm

ent)

. .

Mat

erni

ty -

thos

e th

at w

ould

rec

omm

end

has

incr

ease

d to

100

% fr

om 9

7.09

.%.

Pae

diat

rics

- th

ose

that

wou

ld r

ecom

men

d ha

s de

crea

sed

to 9

2.24

% fr

om 9

3.33

% (

Thi

s in

clud

es a

sc

ore

of 9

1.92

% th

at w

ould

rec

omm

end

from

the

Pae

diat

ric E

mer

genc

y D

epar

tmen

t).

Fro

m q

ualit

ativ

e co

mm

ents

rec

eive

d al

ongs

ide

nega

tive

ratin

gs t

he to

p th

emes

iden

tifie

d w

ere

staf

f at

titud

e, c

omm

unic

atio

n, im

plem

enta

tion

of c

are

and

wai

ting

times

.

All

seni

or w

ard/

dept

sta

ff no

w h

ave

the

oppo

rtun

ity to

acc

ess

EN

VO

Y fo

r liv

e F

FT

dat

a to

ena

ble

timel

y ac

tion

to b

e ta

ken

at a

loca

l lev

el in

res

pons

e to

poo

r ra

tings

/com

men

ts a

nd th

e ab

ility

to id

entif

y po

sitiv

e/ne

gativ

e th

emes

to d

irect

loca

l im

prov

emen

ts. F

FT

dat

a is

als

o pr

esen

ted

on w

ard/

dept

da

shbo

ards

alo

ngsi

de th

e nu

mbe

r co

mpl

aint

s/co

ncer

ns to

sup

port

iden

tific

atio

n of

any

tren

ds.

Fro

m th

e 1s

t Nov

embe

r on

war

ds th

e m

atro

n fo

r pa

tient

exp

erie

nce

rece

ives

dai

ly a

lert

s fo

r ra

tings

of

unlik

ely

/ ext

rem

ely

unlik

ely

to m

onito

r th

emes

and

act

ion

any

resp

onse

s th

at r

equi

re im

med

iate

at

tent

ion

The

Tru

st h

as n

ow r

ecei

ved

resu

lts fr

om a

ll fo

ur N

atio

nal P

atie

nt E

xper

ienc

e S

urve

ys (

Mat

erni

ty

resu

lts a

wai

ting

rele

ase

from

CQ

C).

Loc

al a

ctio

n pl

ans

yet t

o be

dev

elop

ed b

y le

ads

with

in th

e P

aedi

atric

s, M

ater

nity

and

Adu

lt E

mer

genc

y C

are

depa

rtm

ents

. O

nce

deve

lope

d th

ese

will

be

pres

ente

d to

and

mon

itore

d th

roug

h th

e T

rust

Pat

ient

Exp

erie

nce

Gro

up.

The

202

0-20

21 T

rust

pat

ient

exp

erie

nce

stra

tegy

is c

urre

ntly

in d

raft

form

at. T

his

will

be

deliv

ered

for

cons

ulta

tion

at th

e Ja

n-20

pat

ient

exp

erie

nce

grou

p.

FF

T %

that

will

rec

omm

end

will

con

tinue

to b

e m

onito

red

and

repo

rted

to w

ards

/dep

ts. o

n a

mon

thly

ba

sis.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 7

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 90 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

R

espo

nsiv

eIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Acc

iden

t & E

mer

genc

y -

4 H

our

com

plia

nce

Per

cent

age

of p

atie

nts

spen

ding

less

than

4 h

ours

in a

A

&E

dep

artm

ent f

rom

arr

ival

to

disc

harg

e, tr

ansf

er o

r ad

mis

sion

.

95%

targ

et. G

ood

perf

orm

ance

is

hig

her.

The

Sou

thpo

rt s

ite c

ontin

ues

to e

xper

ienc

e ch

alle

nges

in m

aint

aini

ng p

atie

nt fl

ow. T

his

a co

mbi

natio

n of

a 9

.4%

incr

ease

in a

ttend

ance

s on

the

Sou

thpo

rt s

ite (

an e

xtra

418

pat

ient

s) a

nd s

igni

fican

t bed

pr

essu

res.

- A

s a

resu

lt, th

ere

was

an

incr

ease

in th

e nu

mbe

r of

pat

ient

s w

ho w

aite

d lo

nger

than

4

hour

s in

ED

(15

04 p

atie

nts

com

pare

d to

114

3 pa

tient

s la

st y

ear)

. Rev

iew

s ha

ve b

een

unde

rtak

en to

un

ders

tand

the

reas

ons

for

the

brea

ches

(65

.82%

of 4

-hou

r br

each

es w

ere

attr

ibut

able

to b

ed d

elay

s;

15.3

5% w

ere

due

to E

D d

elay

s, 9

% w

ere

due

to s

peci

alty

del

ays,

8%

wer

e du

e to

clin

ical

del

ays)

. ED

co

ntin

ues

to tr

y an

d st

reng

then

sta

ffing

leve

ls. E

D n

ow h

as 7

wte

con

sulta

nts

in p

ost (

the

high

est

num

ber

to d

ate)

. M

iddl

e gr

ade

leve

l sta

ffing

rem

ains

a c

halle

nge.

Lat

e sh

ift s

taffi

ng c

ontin

ues

to b

e en

hanc

ed w

here

pos

sibl

e as

this

is w

hen

activ

ity le

vels

freq

uent

ly e

xcee

d ca

paci

ty. A

vac

ant E

NP

pos

t is

cur

rent

ly o

ut to

adv

ert,

whi

ch w

ill e

nabl

e th

e cu

rren

t ava

ilabi

lity

of a

n E

NP

min

ors

serv

ice

to b

e ex

tend

ed. T

he P

atie

nt F

low

Impr

ovem

ent P

rogr

amm

e co

ntin

ues

to w

ork

thro

ugh

high

impa

ct a

ctio

ns.

AC

U is

pilo

ting

Sun

day

open

ing

acro

ss a

num

ber

of d

ates

. A s

ucce

ssfu

l pilo

t was

hel

d at

the

end

of

Oct

ober

with

15

patie

nts

stre

amed

from

ED

and

0 r

equi

ring

adm

issi

on. T

he c

ontin

ued

bed

pres

sure

s re

sult

in o

ngoi

ng u

se o

f esc

alat

ion

area

s, w

hich

neg

ativ

ely

affe

cts

the

abili

ty to

max

imis

e st

ream

ing.

A

PD

SA

is p

lann

ed in

ED

to te

st im

prov

emen

ts in

red

ucin

g tr

iage

tim

es (

wc

18/1

1/19

)

Acc

iden

t & E

mer

genc

y -

12+

Hou

r tr

olle

y w

aits

The

num

ber

of p

atie

nts

wai

ting

mor

e th

an 1

2 ho

urs,

for

an

emer

genc

y ad

mis

sion

via

A&

E,

from

the

poin

t whe

n th

e de

cisi

on is

mad

e to

adm

it to

the

time

whe

n th

e pa

tient

is

adm

itted

.

The

thre

shol

d is

0.

The

re w

ere

x27

12-h

our

brea

ches

acr

oss

the

mon

th. T

hese

wer

e al

l rel

ated

to in

patie

nt b

ed p

ress

ures

. -

All

brea

ches

occ

urre

d du

ring

and

imm

edia

tely

follo

win

g w

eeke

nd p

ress

ures

. ED

saw

a 9

.4%

incr

ease

in

atte

ndan

ces

acro

ss th

e m

onth

(ad

ditio

nal 4

18 p

atie

nts)

and

90

addi

tiona

l adm

issi

ons.

Acr

oss

the

maj

ority

of t

he m

onth

, the

Tru

st w

orke

d ag

ains

t the

12

hour

sta

ndar

d w

ith a

ll es

cala

tion

area

s op

en a

nd

in u

se, h

igh

num

bers

of p

atie

nts

bedd

ed o

vern

ight

in E

D e

ach

nigh

t aw

aitin

g a

bed

and

corr

idor

car

e in

us

e du

e to

lack

of c

linic

al c

apac

ity in

the

depa

rtm

ent.

Tim

elin

es h

ave

been

com

plet

ed fo

r al

l 27

patie

nts

with

ass

uran

ce p

rovi

ded

that

all

patie

nts

rece

ived

tim

ely

and

appr

opria

te c

linic

al c

are

whi

lst i

n th

e de

part

men

t. T

he s

yste

m is

pro

vide

d co

ntin

ually

with

upd

ates

on

the

Tru

st's

esc

alat

ion

posi

tion.

Dai

ly

hudd

les

cont

inue

to ta

ke p

lace

with

sys

tem

par

tner

s to

ena

ble

the

redu

ctio

n of

leng

th o

f sta

y. Is

sues

ar

ound

leng

th o

f sta

y, IC

B a

nd c

omm

unity

cap

acity

con

tinue

to b

e ad

dres

sed

and

regu

lar

disc

ussi

ons

take

pla

ce w

ith th

e P

rogr

amm

e D

irect

or fo

r U

npla

nned

and

Em

erge

ncy

Car

e. D

isch

arge

team

co

ntin

ues

to h

ave

a pr

esen

ce a

t wee

kend

s to

try

and

supp

ort d

isch

arge

s ac

ross

the

wee

kend

, and

st

affin

g is

rou

tinel

y se

cure

d fo

r th

e us

e of

esc

alat

ion

area

s. T

he A

cute

team

hav

e id

entif

ied

a nu

mbe

r of

Sun

days

ove

r th

e co

min

g m

onth

s th

at th

ey a

re a

ble

to o

pen

AC

U to

sup

port

str

eam

ing

from

ED

in

effo

rts

to r

educ

e th

e nu

mbe

r of

pat

ient

s id

entif

ied

as r

equi

ring

beds

who

are

clin

ical

ly a

ppro

pria

te fo

r ad

mis

sion

.

Am

bula

nce

Han

dove

rs <

=15

Min

s

All

hand

over

s be

twee

n am

bula

nce

and

A&

E s

taff

to

occu

r w

ithin

15

min

utes

. Thi

s m

easu

re lo

oks

at th

e pe

rcen

tage

of h

ando

vers

with

in

15 m

inut

es.

Am

bula

nce

hand

over

s co

mpl

eted

with

in 1

5 m

ins

drop

ped

to 4

8.23

% -

Thi

s is

a r

efle

ctio

n of

the

incr

ease

of 9

.4%

in o

vera

ll at

tend

ance

s an

d th

e ch

alle

nges

in in

patie

nt fl

ow, r

esul

ting

in h

igh

num

bers

of

pat

ient

s aw

aitin

g be

ds in

ED

and

del

ays

in ti

mel

y ac

cess

to E

D c

ubic

les.

83.

63%

of p

atie

nts

arriv

ing

by a

mbu

lanc

e w

ere

hand

ed o

ver

with

in 3

0 m

inut

es fr

om a

rriv

al, c

ompa

red

to 7

2.91

% la

st O

ctob

er. T

he

Tru

st a

ttend

ed th

e 1s

t NW

AS

Han

dove

r C

olla

bora

tive

on 2

5/10

/19

and

is n

ow o

n a

90 d

ay

impr

ovem

ent p

rogr

amm

e. P

DS

A c

ycle

s ar

e pl

anne

d fo

r F

it to

Sit

(led

by N

WA

S)

and

Con

sulta

nt b

ased

in

tria

ge (

plan

ned

for

wc

18/1

1/19

.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 8

of 2

3

Page 91 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

R

espo

nsiv

eIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Dia

gnos

tic w

aits

The

num

ber

of p

atie

nts

wai

ting

6 w

eeks

or

mor

e fo

r a

diag

nost

ic te

st e

xpre

ssed

as

a pe

rcen

tage

of a

ll pa

tient

s w

aitin

g.

Thr

esho

ld 1

%. G

ood

perf

orm

ance

is lo

wer

.

Per

form

ance

con

tinue

s to

impr

ove

for

the

four

th m

onth

in a

row

- B

reac

hes

are

as fo

llow

s:

Col

onos

copy

2 p

atie

nts

1.6%

ava

ilabi

lity/

patie

nt c

hoic

e

Com

pute

d T

omog

raph

y 1p

t 0.5

%

Cys

tosc

opy

13pt

s 12

.0%

Con

sulta

nt a

ctiv

ity -

spe

cial

ist s

ervi

ce -

spi

nal s

ervi

ce 2

pat

ient

cho

ice.

3

brea

ches

are

thea

tre

case

s du

e to

lack

of t

heat

re c

apac

ity d

ue to

the

incr

ease

in d

eman

d fo

r T

arge

t/Urg

ent c

ases

. 7 b

reac

hes

are

due

to E

mer

genc

y le

ave

take

n by

the

cons

ulta

nt in

Oct

ober

w

here

the

list h

ad to

be

canc

elle

d. 1

bre

ache

s ar

e du

e to

the

Uro

logy

/Spi

nal C

onsu

ltant

that

can

onl

y se

e th

e pa

tient

s. P

lan

to a

ccom

mod

ate

alte

rnat

e w

eekl

y se

ssio

n w

ith U

rolo

gy/S

pina

l Con

sulta

nt w

ithin

jo

b pl

an g

oing

forw

ard.

Cys

tosc

opy

(Gyn

aeco

logy

) 1p

t Cap

acity

issu

es. P

atie

nt h

as T

CI 2

0.11

.19

Fle

xi S

igm

oido

scop

y 2p

ts 2

.9%

2 p

atie

nt c

hoic

e 1

no in

terp

rete

r av

aila

ble.

G

astr

osco

py 2

pts

1.4%

1 p

atie

nt c

hoic

e 1

is d

ue to

pat

ient

dec

isio

n to

hav

e pr

oced

ure

unde

r G

A in

th

eatr

e.M

RI 2

pts

0.6%

2 b

reac

hes

both

at 6

wee

ks I

ssue

s co

ntac

ting

both

pat

ient

s N

on O

bs U

ltras

ound

34p

ts 3

.4%

cap

apci

ty is

sues

Uro

dyna

mic

s T

OT

AL

(S

PLI

T O

UT

BE

LOW

) 5p

ts 7

.5%

U

rody

nam

ics

(tre

atm

ent c

entr

e, U

rolo

gy)

17pt

s 1

Em

erge

ncy

leav

e ta

ken

via

spec

ialis

t nur

se -

on

the

day

8 pa

tient

cho

ice

Uro

dyna

mic

s (G

yn)

4pts

sta

ff si

ckne

ss

Inso

urci

ng h

as b

een

agre

ed b

y th

e tr

ust w

ith 'Y

our

Med

ical

' a c

ompa

ny w

ho a

re k

now

n to

the

trus

t and

ha

ve p

revi

ousl

y de

liver

ed w

ork

for

us. T

his

wor

k ha

s co

mm

ence

d an

d al

l pa

tient

s ha

ve b

een

offe

red

or

book

ed in

Nov

embe

r. N

umbe

rs h

ave

decr

ease

d an

d sh

ow c

ontin

ued

impr

ovem

ent g

oing

forw

ard.

14 d

ay G

P r

efer

ral t

o O

utpa

tient

s

Per

cent

age

of p

atie

nts

seen

w

ithin

two

wee

ks o

f an

urge

nt

GP

ref

erra

l for

sus

pect

ed

canc

er.

Tar

get 9

3%. G

ood

perf

orm

ance

is

hig

her.

Per

form

ance

has

rec

over

ed to

be

com

plia

nt in

Sep

tem

ber

- A

lthou

gh th

e de

man

d fo

r ap

poin

tmen

ts

rem

aine

d hi

gh in

som

e tu

mou

r gr

oups

, ove

rall

num

ber

of r

efer

rals

was

dow

n.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 9

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 92 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

R

espo

nsiv

eIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

31 d

ay tr

eatm

ent

Per

cent

age

of p

atie

nts

rece

ivin

g fir

st d

efin

itive

tr

eatm

ent w

ithin

one

mon

th (

31

days

) of

a c

ance

r di

agno

sis

(mea

sure

d fr

om 'd

ate

of

deci

sion

to tr

eat')

.

Tar

get 9

6%. G

ood

perf

orm

ance

is

hig

her.

3 br

each

es in

Aug

ust r

esul

ted

in fa

iled

targ

et -

Bre

ache

s w

ere

due

to c

apac

ity in

col

orec

tal t

heat

res

and

derm

atol

ogy

patie

nt c

hoic

e.

31 d

ay tr

eatm

ent (

Sur

gery

)

Per

cent

age

of p

atie

nts

rece

ivin

g fir

st d

efin

itive

sur

gica

l tr

eatm

ent w

ithin

one

mon

th (

31

days

) of

a c

ance

r di

agno

sis

(mea

sure

d fr

om 'd

ate

of

deci

sion

to tr

eat')

.

Per

form

ance

con

tinue

s to

be

mai

ntai

ned

at 1

00%

- T

hree

pat

ient

s w

ere

trea

ted

in th

e su

bseq

uent

su

rger

y ca

tego

ry in

Sep

tem

ber,

all

in ti

me.

31 d

ay tr

eatm

ent (

Ant

i-can

cer

drug

s)

Per

cent

age

of p

atie

nts

rece

ivin

g fir

st d

efin

itive

ant

i-ca

ncer

dru

g tr

eatm

ent w

ithin

on

e m

onth

(31

day

s) o

f a

canc

er d

iagn

osis

(m

easu

red

from

'dat

e of

dec

isio

n to

trea

t').

Com

plia

nce

mai

ntai

ned

at 1

00%

- O

nly

1 pa

tient

was

trea

ted

in th

is c

ateg

ory

in S

epte

mbe

r.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 10

of 2

3

Page 93 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

R

espo

nsiv

eIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

62 d

ay p

athw

ay A

naly

sis

All

Tru

st B

oard

s sh

ould

hav

e si

ght o

f tum

our

spec

ific

perf

orm

ance

aga

inst

the

62 d

ay

GP

ref

erra

l to

trea

tmen

t.

Som

e im

prov

emen

t see

n in

per

form

ance

- 5

0 ac

coun

tabl

e pa

tient

s w

ere

trea

ted

in S

epte

mbe

r. T

here

w

ere

9 br

each

es in

tota

l. th

is o

ccur

red

in th

e fo

llow

ing

tum

our

site

s;H

aem

atol

ogy

0.5

Hea

d &

Nec

k 0.

5C

olor

ecta

l 3O

ther

1U

rolo

gy 4

62 d

ay G

P r

efer

ral t

o tr

eatm

ent

Per

cent

age

of P

atie

nts

rece

ivin

g fir

st d

efin

itive

tr

eatm

ent f

or c

ance

r w

ithin

two

mon

ths

(62

days

) of

urg

ent G

P

refe

rral

for

susp

ecte

d ca

ncer

.

Tar

get 8

5%. G

ood

perf

orm

ance

is

hig

her.

Sep

tem

ber

clos

ed a

t 82%

- S

epte

mbe

r's p

erfo

rman

ce c

lose

d at

the

high

est p

ositi

on s

ince

Oct

ober

last

ye

ar. T

here

wer

e 50

acc

ount

able

trea

tmen

ts a

nd 9

bre

ache

s.

Ref

erra

l to

trea

tmen

t: on

-goi

ng

Per

cent

age

of p

atie

nts

on a

n in

com

plet

e pa

thw

ay w

ith a

cu

rren

t wai

t exp

erie

nce

of 1

8 w

eeks

or

less

.

Thr

esho

ld 9

2%. G

ood

perf

orm

ance

is h

ighe

r.

The

trus

t con

tinue

s to

mai

ntai

n co

mpl

ianc

e w

ith R

TT

- P

erfo

rman

ce is

cur

rent

ly b

eing

impa

cted

by

issu

es w

ithin

ana

esth

etic

s an

d va

rious

wor

kfor

ce is

sues

with

in s

peci

aliti

es. T

hese

wor

kfor

ce s

hort

falls

ha

ve h

isto

rical

ly b

een

addr

esse

d w

ith W

LIs.

Cur

rent

pen

sion

s ta

x is

sues

hav

e m

eant

this

is n

o lo

nger

a

solu

tion.

The

impa

ct is

bei

ng a

sses

sed

in o

rder

to a

ddre

ss th

is.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 11

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 94 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

R

espo

nsiv

eIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Bed

Occ

upan

cy -

SD

GH

Per

cent

age

bed

occu

panc

y at

th

e S

outh

port

site

.

A lo

wer

per

cent

age

is g

ood.

T

hres

hold

is 9

3%.

Oct

ober

saw

a s

light

incr

ease

in o

ccup

ancy

for

Sou

thpo

rt s

ite b

ut th

e tr

ust a

chie

ved

targ

et fo

r th

e fo

urth

m

onth

in a

row

- ta

rget

leve

l was

ach

ieve

d at

89.

99%

- D

aily

bed

occ

upan

cy is

mon

itore

d th

roug

h th

e es

cala

tion

mee

tings

and

impr

ovem

ent w

ork

to r

educ

e oc

cupa

ncy

bein

g un

dert

aken

and

mon

itore

d vi

a th

e P

atie

nt F

low

Impr

ovem

ent G

roup

Bed

Occ

upan

cy -

OD

GH

Per

cent

age

bed

occu

panc

y at

th

e O

rmsk

irk s

ite, b

ased

on

open

bed

s. A

hig

her

perc

enta

ge is

goo

d. T

hres

hold

is

60%

.

Occ

upan

cy h

as r

emai

ned

stab

le in

mon

th 5

2.04

% a

nd is

slig

htly

bel

ow tr

ajec

tory

- -

Ele

ctiv

e ac

tivity

is

curr

ently

bei

ng im

pact

ed b

y th

e lo

ss o

f ana

esth

etic

s an

d th

e as

soci

ated

red

uctio

n in

cas

es.

Rec

ruitm

ent o

f ana

esth

etis

ts is

ong

oing

. Can

cella

tions

are

dis

trib

uted

am

ongs

t the

spe

cial

ties.

The

or

der

of p

riorit

y is

: mai

ntai

ning

crit

ical

car

e, th

en a

cute

car

e, th

en th

e O

rmsk

irk s

ite. T

his

is m

onito

red

thro

ugh

the

thea

tre

sche

dulin

g m

eetin

g an

d w

eekl

y P

TL.

HB

S c

ontr

act h

as a

lso

been

neg

otia

ted

to

enab

le a

naes

thet

ic c

over

. Oct

ober

saw

can

cella

tion

of li

sts

as a

res

ult o

f the

atre

sta

ff si

ckne

ss.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 12

of 2

3

Page 95 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

W

ell-L

edIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Dut

y of

Can

dour

- E

vide

nce

of

Dis

cuss

ion

The

pro

port

ion

of p

atie

nts

who

ha

ve h

ad a

dis

cuss

ion

with

he

alth

care

pro

fess

iona

ls a

bout

so

met

hing

that

has

gon

e w

rong

w

ith th

eir

trea

tmen

t or

care

.

89%

com

plia

nce

- 1

brea

ch in

mon

th -

The

re w

as 1

bre

ach

of th

e D

uty

of C

ando

ur r

egul

atio

n in

S

epte

mbe

r. T

his

was

with

in th

e U

rgen

t Car

e C

BU

. The

har

m le

vel w

as in

cide

nt w

as in

corr

ectly

do

wng

rade

d by

the

CB

U. T

his

was

sub

sequ

ently

cha

nged

bac

k to

mod

erat

e ha

rm a

nd th

e pa

tient

was

co

ntac

ted,

but

afte

r th

e 10

day

tim

esca

le. T

here

has

bee

n a

revi

ew o

f the

dow

ngra

ding

pro

cess

and

an

amen

dmen

t has

bee

n m

ade

to D

atix

to c

aptu

re th

e ra

tiona

le w

hen

inci

dent

s ar

e do

wng

rade

d.

Dut

y of

Can

dour

- E

vide

nce

of L

ette

r

The

pro

port

ion

of p

atie

nts

who

ha

ve r

ecei

ved

a le

tter

of

apol

ogy

whe

n so

met

hing

that

ha

s go

ne w

rong

with

thei

r tr

eatm

ent o

r ca

re.

89%

com

plia

nce

- 1

brea

ch in

mon

th -

The

re w

as 1

bre

ach

of th

e D

uty

of C

ando

ur r

egul

atio

n in

S

epte

mbe

r. T

his

was

with

in th

e U

rgen

t Car

e C

BU

. The

har

m le

vel w

as in

cide

nt w

as in

corr

ectly

do

wng

rade

d by

the

CB

U. T

his

was

sub

sequ

ently

cha

nged

bac

k to

mod

erat

e ha

rm a

nd th

e le

tter

was

se

nt, b

ut a

fter

the

10 d

ay ti

mes

cale

. The

re h

as b

een

a re

view

of t

he d

owng

radi

ng p

roce

ss a

nd a

n am

endm

ent h

as b

een

mad

e to

Dat

ix to

cap

ture

the

ratio

nale

whe

n in

cide

nts

are

dow

ngra

ded.

I&E

sur

plus

or

defic

it/to

tal r

even

ue

The

pro

port

ion

of In

com

e &

E

xpen

ditu

re s

urpl

us/d

efic

it of

th

e to

tal r

even

ue g

ener

ated

by

the

Tru

st.

Per

form

ance

impr

ovin

g -

The

per

cent

age

defic

it ha

s im

prov

ed th

is m

onth

. How

ever

, thi

s ha

s be

en

driv

en b

y hi

gher

mon

thly

inco

me

in O

ctob

er (

as p

lann

ed)

resu

lting

in a

low

er d

efic

it th

an S

epte

mbe

r.

The

targ

et d

efic

it pe

rcen

tage

yea

r to

dat

e fo

r O

ctob

er is

-6.

4% a

nd th

e T

rust

ach

ieve

d -7

.1%

res

ultin

g in

the

Tru

st b

eing

adv

erse

ly a

way

from

pla

n.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 13

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 96 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

W

ell-L

edIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Liqu

idity

Liqu

idity

indi

cate

s w

heth

er th

e pr

ovid

er c

an m

eet i

ts

oper

atio

nal c

ash

oblig

atio

ns.

Dow

nwar

d tr

end

cont

inue

s -

Loan

s ar

e re

-cla

ssifi

ed a

s cu

rren

t lia

bilit

ies

whe

n th

ey a

re d

ue w

ithin

12

mon

ths.

Thi

s re

-cla

ssifi

catio

n ha

s oc

curr

ed in

Oct

ober

and

sig

nific

antly

affe

cts

the

calc

ulat

ion

of th

e m

etric

res

ultin

g in

a d

eter

iora

tion

in li

quid

ity.

Liqu

idity

day

s is

cal

cula

tes

as fo

llow

s:(C

urre

nt a

sset

s –

curr

ent l

iabi

litie

s –

inve

ntor

ies)

/(op

erat

ing

expe

nses

+ a

mor

tisat

ion

+ d

epre

ciat

ion)

X

num

ber

of d

ays

in th

e ye

ar to

dat

e re

port

ing.

Mon

th 7

liqu

idity

day

s is

-£6

9.25

8m /

£114

.573

m *

214

day

s =

-12

9.36

day

s

Dis

tanc

e fr

om C

ontr

ol T

otal

Dis

tanc

e fr

om C

ontr

ol T

otal

.

Per

form

ance

det

erio

rate

d in

Oct

ober

- T

he T

rust

ach

ieve

d th

e co

ntro

l tot

al a

t the

end

of Q

uart

er 2

with

no

n re

curr

ent s

uppo

rt. A

t mon

th 7

the

Tru

st is

cur

rent

ly b

ehin

d pl

an b

ut h

as p

lans

to m

itiga

te th

is r

isk

and

mee

t the

Qua

rter

3 c

ontr

ol to

tal.

Cap

ital S

ervi

ce C

apac

ity

The

leve

l of d

ebt t

he T

rust

is

requ

ired

to s

ervi

ce. T

his

indi

cato

r is

1 o

f 5 u

sed

to

deriv

e th

e 'U

se o

f Res

ourc

es

(Fin

ance

)' sc

ore.

Per

form

ance

impr

oved

in O

ctob

er -

The

mai

n re

ason

for

the

impr

ovem

ent i

n th

is m

etric

is th

at th

e T

rust

re

paid

DH

SC

loan

s fo

r £2

.741

mill

ion.

The

re's

no

chan

ge to

the

ratin

g of

this

met

ric w

hich

due

to it

be

ing

nega

tive

rem

ains

at a

4. P

erfo

rman

ce n

eeds

to b

e a

posi

tive

1.25

to a

chie

ve a

use

of r

esou

rces

sc

ore

of 3

for

this

asp

ect.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 14

of 2

3

Page 97 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

W

ell-L

edIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

% A

genc

y S

taff

(cos

t)

The

cos

t of a

genc

y st

aff a

s a

prop

ortio

n of

the

tota

l cos

t of

the

wor

kfor

ce.

Rel

iant

on

finan

ce s

yste

m to

m

onito

r sp

end

rath

er th

an th

e H

R s

yste

m.

Per

form

ance

det

erio

ratin

g -

Age

ncy

spen

d re

mai

ns h

igh

as a

per

cent

age

of to

tal p

ay c

ost.

Age

ncy

spen

d is

slig

htly

up

on S

epte

mbe

r (£

1.1m

aga

inst

£1.

05m

last

mon

th).

Tot

al p

ay s

pend

is a

lso

high

er

this

mon

th th

an la

st m

onth

. S

o bo

th th

e nu

mer

ator

and

den

omin

ator

in th

is c

alcu

latio

n ha

s in

crea

sed

but t

he o

vera

ll re

sult

is a

slig

ht r

educ

tion

in p

erce

ntag

e.P

erfo

rman

ce b

y st

aff g

roup

is:

Con

sulta

nts

16%

Oth

er m

edic

al 1

4%N

ursi

ng &

Mid

wife

ry 9

%S

cien

tific

/tech

/ther

apeu

tic 2

%O

ther

sta

ff 5%

Use

of R

esou

rces

(F

inan

ce)

Sco

re

A F

inan

cial

per

form

ance

sco

re

deriv

ed fr

om th

e N

HS

Im

prov

emen

t 'U

se o

f R

esou

rces

' ass

essm

ent

fram

ewor

k.

Per

form

ance

det

erio

rate

d in

Oct

ober

- O

vera

ll sc

ore

has

incr

ease

d fr

om a

3 la

st m

onth

to 4

this

mon

th.

The

mai

n ch

ange

has

bee

n on

the

dist

ance

from

pla

n m

etric

whi

ch is

now

a 2

(la

st m

onth

1)

as th

e T

rust

is a

dver

sely

aw

ay fr

om it

s pl

an a

t the

end

of O

ctob

er.

All

the

othe

r m

etric

s re

mai

n at

4-

Cap

ital

serv

ice

cove

r, L

iqui

dity

, I&

E m

argi

n an

d ag

ency

rat

ing.

Dis

tanc

e fr

om A

genc

y S

pend

Cap

Dis

tanc

e fr

om A

genc

y S

pend

C

ap.

Per

form

ance

det

erio

rate

d -

Alth

ough

the

Tru

st d

id n

ot a

gree

to th

e ag

ency

cap

the

targ

et fo

r m

onth

7

YT

D is

£2.

882

mill

ion.

The

act

ual m

onth

7 Y

TD

age

ncy

spen

d is

£6.

978

mill

ion.

Oct

ober

has

see

n th

e hi

ghes

t in

mon

th a

genc

y sp

end

with

mon

thly

nur

se a

genc

y at

its

high

est l

evel

. B

and

5 nu

rses

hav

e a

vaca

ncy

rate

of 2

5% a

nd n

ot a

ll th

ese

can

be fi

lled

with

ban

k st

aff w

hich

res

ults

in

the

Tru

st h

avin

g to

pay

a p

rem

ium

for

agen

cy n

urse

s.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 15

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 98 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

W

ell-L

edIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Sta

ff T

urno

ver

Sta

ff T

urno

ver

is c

alcu

late

d by

ta

king

the

num

ber

of le

aver

s di

vide

d by

the

aver

age

head

coun

t fro

m th

e st

art a

nd

end

of th

e m

onth

.

Oct

ober

saw

a m

onth

ly d

ecre

ase

in tu

rnov

er to

1.1

2% h

owev

er th

e ro

lling

rat

e is

stil

l inc

reas

ing

due

to

the

over

all i

ncre

ase

in s

taff

turn

over

. - T

he n

umbe

r of

leav

ers

redu

ced

slig

htly

in m

onth

to 3

4 fr

om 3

8 in

S

epte

mbe

r an

d A

ugus

t. T

he T

rust

had

est

ablis

hed

a N

ursi

ng R

ecru

itmen

t and

Ret

entio

n gr

oup

whi

ch

initi

ally

saw

a s

igni

fican

t dec

reas

e in

nur

sing

turn

over

how

ever

the

grou

p is

und

er r

evie

w fo

llow

ing

the

appo

intm

ent o

f the

New

Dep

uty

Dire

ctor

of N

ursi

ng fo

r W

orkf

orce

. D

ue to

the

dete

riora

ting

Tru

st

posi

tion

in r

elat

ion

to s

taff

turn

over

(in

crea

sed

rolli

ng fi

gure

) a

new

wor

kfor

ce d

ashb

oard

is b

eing

cr

eate

d. T

he d

ashb

oard

will

pro

vide

gre

ater

bus

ines

s in

telli

genc

e in

to s

taff

turn

over

to id

entif

y ho

tpot

s in

ord

er th

at a

ppro

pria

te in

terv

entio

ns c

an b

e pu

t int

o pl

ace.

Wor

k w

ill b

e re

port

ed a

t a w

eekl

y W

orkf

orce

Impr

ovem

ent w

ork

stre

am w

hich

will

rep

ort i

nto

the

Tru

st’s

Wor

kfor

ce Im

prov

emen

t Gro

up.

A d

raft

dash

boar

d w

ill b

e av

aila

ble

for

revi

ew fr

om J

anua

ry 2

020.

Sta

ff T

urno

ver

(Rol

ling)

Sta

ff T

urno

ver

(Rol

ling)

is

calc

ulat

ed b

y ta

king

the

num

ber

of le

aver

s ov

er th

e pa

st

12 m

onth

s di

vide

d by

the

aver

age

head

coun

t fro

m th

e la

st 1

2 m

onth

s.

The

rol

ling

staf

f tur

nove

r ha

s in

crea

sed

in O

ctob

er 2

019

at 1

2.6%

com

pare

d to

12.

3% in

Sep

tem

ber

2019

. -

The

num

ber

of le

aver

s re

duce

d sl

ight

ly in

mon

th to

34

from

38

in S

epte

mbe

r an

d A

ugus

t. T

he

Tru

st h

ad e

stab

lishe

d a

Nur

sing

Rec

ruitm

ent a

nd R

eten

tion

grou

p w

hich

initi

ally

saw

a s

igni

fican

t de

crea

se in

nur

sing

turn

over

how

ever

the

grou

p is

und

er r

evie

w fo

llow

ing

the

appo

intm

ent o

f the

New

D

eput

y D

irect

or o

f Nur

sing

for

Wor

kfor

ce.

Due

to th

e de

terio

ratin

g T

rust

pos

ition

in r

elat

ion

to s

taff

turn

over

(in

crea

sed

rolli

ng fi

gure

) a

new

wor

kfor

ce d

ashb

oard

is b

eing

cre

ated

. T

he d

ashb

oard

will

pr

ovid

e gr

eate

r bu

sine

ss in

telli

genc

e in

to s

taff

turn

over

to id

entif

y ho

tpot

s in

ord

er th

at a

ppro

pria

te

inte

rven

tions

can

be

put i

nto

plac

e. W

ork

will

be

repo

rted

at a

wee

kly

Wor

kfor

ce Im

prov

emen

t wor

k st

ream

whi

ch w

ill r

epor

t int

o th

e T

rust

’s W

orkf

orce

Impr

ovem

ent G

roup

. A

dra

ft da

shbo

ard

will

be

avai

labl

e fo

r re

view

from

Jan

uary

202

0.

Vac

ancy

Rat

e -

Med

ical

The

pro

port

ion

of p

lann

ed

med

ical

est

ablis

hmen

t tha

t is

curr

ently

vac

ant.

The

med

ical

vac

ancy

rat

e sa

w a

furt

her

incr

ease

in O

ctob

er to

16.

5% -

App

licat

ions

to m

edic

al p

osts

ha

ve in

crea

sed

sinc

e th

e im

plem

enta

tion

of th

e B

MJ

adve

rtis

ing

cam

paig

n. F

urth

er p

lans

are

in

deve

lopm

ent t

o sc

ope

incr

ease

d ut

ilisa

tion

of s

ocia

l med

ia to

pro

mot

e ca

mpa

igns

. Con

trac

ting

com

plet

ed w

ith fr

amew

ork

agen

cy. E

ngag

ed w

ith h

ard

to r

ecru

it sp

ecia

lties

incl

udin

g R

adio

logy

and

A

naes

thet

ics.

Ana

esth

etic

PA

s re

crui

tmen

t in

prog

ress

; offe

rs m

ade

to g

row

alte

rnat

ive

futu

re w

orkf

orce

with

pla

ns in

pl

ace

to c

omm

ence

in Q

3/4.

Det

aile

d pr

ojec

t pla

n in

pla

ce to

sup

port

red

uctio

n in

tim

e to

hire

man

aged

thro

ugh

mod

el

hosp

italp

rogr

amm

e bo

ard

and

Wor

kfor

ce Im

prov

emen

t Gro

up.

Med

ical

est

ablis

hmen

t con

trol

impl

emen

tatio

n -

Pro

cess

to b

e im

plem

ente

d to

iden

tify

recr

uitm

ent

area

s

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 16

of 2

3

Page 99 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

W

ell-L

edIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Vac

ancy

Rat

e -

Nur

sing

The

pro

port

ion

of p

lann

ed

nurs

ing

esta

blis

hmen

t tha

t is

curr

ently

vac

ant.

Nur

sing

Vac

ancy

rat

e re

mai

ns s

tatic

- A

lthou

gh th

e va

canc

y fig

ures

rem

ain

stat

ic th

e tr

ust h

as s

een

in

Oct

ober

25.

67 F

TE

new

sta

rter

s (R

N x

13 H

CA

x12

)Le

aver

s fo

r O

ct to

tals

13.

49 F

TE

(R

N X

6.8

HC

A X

6.69

). L

ocal

rec

ruitm

ent c

ontin

ues

to s

uppo

rt th

e tr

ust v

acan

cy p

ositi

on.

Sic

knes

s R

ate

The

pro

port

ion

of th

e su

bsta

ntiv

e W

TE

in m

onth

who

w

ere

unav

aila

ble

for

wor

k.

Thr

esho

ld: 4

%. L

ower

is b

ette

r.

Oct

ober

s 20

19's

mon

thly

sic

knes

s ab

senc

e ra

te h

as in

crea

sed

in m

onth

to 4

.94%

how

ever

rem

ains

un

der

the

5% tr

ajec

tory

for

the

year

- T

he r

ollin

g ye

ar to

dat

e si

ckne

ss a

bsen

ce r

ate

high

light

s pr

ogre

ss

mad

e to

dat

e an

d th

at th

ere

has

been

a m

onth

on

mon

th r

educ

tion

of th

e T

rust

’s r

ollin

g si

ckne

ss

abse

nce

rate

sin

ce D

ecem

ber

2018

whi

ch h

as b

een

sust

aine

d fo

r 11

mon

ths:

D

ec-1

8 -

5.95

%Ja

n-19

- 5

.89%

Feb

-19

- 5.

82%

Mar

-19

- 5.

76

Apr

-19

- 5.

72%

M

ay-1

9 -

5.70

%Ju

n-19

- 5

.65%

Ju

l-19

- 5.

61%

Aug

-19

– 5.

54%

Sep

t-19

– 5

.35%

Oct

-19

– 5.

20%

The

Tru

st m

onito

rs a

ttend

ance

leve

ls o

n a

mon

thly

bas

is a

nd r

emai

ns c

omm

itted

to s

uppo

rtin

g st

aff’s

at

tend

ance

to w

ork

to b

e ‘H

appy

, Hea

lthy

Her

e’. T

he T

rust

con

tinue

s to

be

part

of t

he N

HS

i Hea

lth a

nd

Wel

lbei

ng (

HW

B)

prog

ram

me

and

rece

ntly

atte

nded

the

NH

Si H

ealth

and

Wel

lbei

ng S

umm

it (R

educ

ing

sick

ness

abs

ence

) in

Nov

embe

r, w

here

all

trus

ts o

n th

e pr

ogra

mm

e sh

ared

thei

r ex

perie

nce

and

prog

ress

to d

ate.

Con

sequ

ently

the

HW

B a

ctio

n pl

an w

ill b

e re

view

ed in

ord

er to

eva

luat

e an

d co

nsid

er

the

good

pra

ctic

e an

d id

eas

that

wer

e sh

ared

at t

hat e

vent

. T

his

will

sup

port

the

Tru

sts

ongo

ing

assu

ranc

e to

del

iver

ing

the

HW

B a

ctio

n pl

an.

Per

form

ance

aga

inst

the

actio

n pl

an is

mon

itore

d at

W

orkf

orce

Com

mitt

ee a

nd W

orkf

orce

Impr

ovem

ent G

roup

to e

nsur

e pr

ogre

ss a

nd g

ive

assu

ranc

e.In

add

ition

to th

e ab

ove

The

Tru

st h

as e

mba

rked

upo

n a

6 m

onth

rev

iew

of t

he S

uppo

rtin

g A

ttend

ance

po

licy

with

sta

ff si

de a

nd k

ey s

take

hold

ers

with

in th

e T

rust

. An

initi

al m

eetin

g ha

s ta

ken

plac

e, w

ith a

fu

rthe

r m

eetin

g pl

anne

d be

fore

the

end

of th

e ye

ar to

agr

ee th

e re

view

of t

he p

olic

y. P

artn

ersh

ip h

as

flour

ishe

d du

ring

this

pie

ce o

f wor

k an

d di

scus

sion

s ha

ve b

een

wel

l str

uctu

red,

pro

duct

ive

and

mea

ning

ful.

Con

sequ

ently

ther

e is

a b

elie

f tha

t we

can

get t

o a

posi

tion

whe

re b

oth

staf

f sid

e an

d m

anag

emen

t sid

e co

nsid

er th

e T

rust

has

a p

olic

y in

pla

ce th

at s

uppo

rts

all s

taff.

Per

sona

l Dev

elop

men

t Rev

iew

Per

cent

age

of s

taff

with

an

up

to d

ate

Per

sona

l Dev

elop

men

t R

evie

w (

PD

R).

Rol

ling

12 m

onth

figu

re.

PD

R c

ompl

ianc

e in

crea

sed

slig

htly

in m

onth

to 7

0.56

% in

Oct

ober

. - C

BU

’s c

ontin

ue to

set

traj

ecto

ries

to in

crea

se a

ppra

isal

rat

es to

85%

but

hav

e be

en u

nabl

e to

mee

t the

m. O

ver

the

last

few

mon

ths

a ta

rget

ed a

ppro

ach

by th

e O

D te

am h

as b

een

take

n to

impr

ovin

g th

e qu

ality

of a

ppra

isal

s an

d a

myt

h bu

ster

has

bee

n de

velo

ped

and

shar

ed a

t dep

artm

enta

l/war

d vi

sits

in o

rder

to tr

y to

tack

le th

is is

sue.

T

his

wor

k ha

s se

en a

slig

ht im

prov

emen

t in

the

com

plia

nce

rate

by

near

ly 1

% s

ince

last

mon

th.

Mul

tiple

fact

ors

have

bee

n id

entif

ied

thro

ugho

ut th

e ye

ar in

und

erst

andi

ng th

e ba

rrie

rs to

impr

ovin

g co

mpl

ianc

e an

d su

bseq

uent

inte

rven

tions

hav

e be

en e

stab

lishe

d to

add

ress

the

mat

ter.

A c

olle

ctiv

e ta

rget

ed a

ppro

ach

is b

eing

take

n to

look

at h

ow b

est t

o ad

dres

s th

is K

PI i

n D

ecem

ber’s

Wor

kfor

ce

Impr

ovem

ent G

roup

.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 17

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 100 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

W

ell-L

edIn

dic

ato

r N

ame

(Co

lou

r -

Per

f | T

raj)

Des

crip

tio

nN

arra

tive

Mo

nth

Tre

nd

Man

dato

ry T

rain

ing

The

per

cent

age

of s

taff

with

up

to d

ate

Man

dato

ry T

rain

ing.

Thr

esho

ld: 8

5%.

Rol

ling

12 m

onth

figu

re.

Cor

e m

anda

tory

trai

ning

rem

ains

abo

ve th

e T

rust

's 8

5% a

t 88.

34%

- A

Tas

k &

Fin

ish

Gro

up in

N

ov/D

ec20

19 w

ill fo

cus

on a

rev

iew

of c

ore

man

dato

ry tr

aini

ng w

ith a

spe

cific

focu

s on

Res

usci

tatio

n T

rain

ing

at a

ll le

vels

.

Car

e H

ours

Per

Pat

ient

Day

(C

HP

PD

)

Num

ber

of n

ursi

ng c

are

hour

s w

orke

d pe

r pa

tient

day

. Thi

s in

dica

tor

is u

sed

to m

easu

re

nurs

e st

affin

g le

vels

.

The

ove

rall

CH

pPD

for

the

Tru

st h

as r

emai

ned

stat

ic i

n m

onth

rep

ortin

g at

8.3

hou

rs -

Cur

rent

re

port

ing

rem

ains

slig

htly

abo

ve th

e na

tiona

l ave

rage

of 7

hou

rs C

HpP

D, T

he T

rust

cur

rent

rep

ortin

g fo

r C

HpP

D in

clud

es R

egis

tere

d N

urse

s/R

egis

tere

d M

idw

ives

. .

Pla

nned

car

e cl

inic

al b

usin

ess

unit

(CB

U)

repo

rt o

vera

ll 10

.3, U

rgen

t Car

e C

BU

6.6

and

Wom

en’s

and

C

hild

ren’

s 13

.0 o

vera

ll.

Tim

e to

Rec

ruit

The

num

ber

of w

orki

ng d

ays

from

Adv

ert C

lose

to S

tart

D

ate.

Ple

ase

note

that

ca

ndid

ates

req

uirin

g a

Vis

a ar

e in

clud

ed.

-

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 18

of 2

3

Page 101 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

E

ffici

ency

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

MO

FD

(M

edic

ally

Opt

imis

ed fo

r D

isch

arge

) -

Ave

rage

Num

ber

of D

aily

B

eds

Lost

In M

onth

Ave

rage

Num

ber

of D

aily

Bed

s Lo

st In

Mon

th.T

aken

from

A

Dai

ly S

naps

hot O

f Pat

ient

s M

edic

ally

Fit

For

Dis

char

ge.

Low

er is

bet

ter.

Incr

ease

in m

onth

- im

prov

emen

ts in

rec

ordi

ng o

f dat

a on

med

way

is g

ivin

g a

mor

e co

rrec

t mea

sure

to

wor

k w

ith. W

e co

ntin

ue to

wor

k w

ith c

omm

unity

and

LA

team

s to

sup

port

mov

emen

t of p

atie

nts

from

ac

ute

care

onc

e m

edic

ally

fit.

The

re r

emai

ns a

pro

port

ion

of p

atie

nts

who

req

uire

on-

goin

g th

erap

y w

hich

can

not

be

supp

orte

d in

the

com

mun

ity d

ue to

the

leve

l of d

epen

denc

y. D

aily

hud

dles

con

tinue

w

ith in

form

atio

n fr

om th

e di

scha

rge

faci

litat

ors

from

Red

2Gre

en b

oard

rou

nds;

SA

FE

R e

ngag

emen

t ev

ents

hav

e oc

curr

ed a

t war

d le

vel.

new

wee

kly

DT

OC

mee

ting

com

men

ced

to fo

rmal

ise

repo

rts;

ci

rcul

atio

n of

new

boa

rd r

ound

SO

P a

nd r

ed2g

reen

pos

ter

is h

elpi

ng to

focu

s al

l sta

ff on

flow

DT

OC

- N

umbe

r of

Bed

s lo

st p

er

mon

th

The

num

ber

of b

eds

lost

per

m

onth

from

pat

ient

s w

ho h

ave

expe

rienc

ed a

Del

ayed

T

rans

fer

of C

are

(DT

OC

).

The

se p

atie

nts

will

hav

e be

en

Med

ical

ly O

ptim

ised

for

Dis

char

ge (

MO

FD

) an

d th

e de

lay

conf

irmed

by

the

loca

l au

thor

ity.

218

bed

days

lost

- T

here

is c

ontin

ued

wor

k w

ith p

artn

ers

from

Com

mun

ity a

nd L

A s

uppo

rtin

g di

scha

rges

thro

ugh

daily

hud

dle

and

wee

kly

long

sta

y re

view

. Fro

m O

ctob

er o

f for

mal

DT

OC

mee

tings

ta

ke p

lace

with

bot

h LA

s to

agr

ee d

elay

s;

Leng

th O

f Sta

y

The

ave

rage

am

ount

of t

ime

in

days

that

pat

ient

s sp

ent a

s an

in

patie

nt fr

om a

n em

erge

ncy

adm

issi

on. E

xclu

des

ZE

RO

Le

ngth

of S

tay.

sust

aine

d at

<6.

5 da

ys -

wor

kstr

eam

s re

port

ing

thro

ugh

to P

atie

nt F

low

Impr

ovem

ent P

rogr

amm

e to

su

ppor

t util

isat

ion

of a

sses

smen

t are

as (

wor

k st

ream

1)

and

redu

cing

LoS

(w

orks

trea

m 2

);

enga

gem

ent e

vent

s w

ith a

ll in

-pat

ient

war

ds to

sup

port

SA

FE

R a

t war

d le

vel h

ave

been

com

plet

ed;

intr

oduc

tion

of b

oard

rou

nd S

OP

to s

uppo

rt im

plem

ent i

mpr

oved

red

2gre

en; c

ontin

ued

daily

rev

iew

th

roug

h di

scha

rge

hudd

le w

ith s

yste

m p

artn

ers

with

del

ays

iden

tifie

d th

roug

h w

ard

red2

gree

n bo

ard

roun

ds o

n al

l in-

patie

nt w

ards

; hea

d of

pat

ient

flow

and

CC

G fo

r S

efto

n w

orki

ng c

lose

ly to

geth

er to

su

ppor

t red

ucin

g Lo

S w

ith fo

cus

on s

uper

str

ande

d an

d st

rand

ed p

atie

nts

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 19

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 102 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

E

ffici

ency

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

New

:Fol

low

Up

The

Tru

st's

ove

rall

ratio

be

twee

n ne

w o

utpa

tient

ap

poin

tmen

ts a

nd fo

llow

-up

outp

atie

nt a

ppoi

ntm

ents

.

Thr

esho

ld: m

onito

r.

The

trus

t con

tinue

s to

con

sist

ently

ach

ieve

targ

et -

DN

A (

Did

Not

Atte

nd)

rate

The

pro

port

ion

of p

atie

nts

of a

ll th

ose

offe

red

appo

intm

ents

or

trea

tmen

t dat

es th

at d

o no

t giv

e no

tice

of n

on-a

ttend

ance

irr

espe

ctiv

e of

how

sho

rt th

at

notic

e is

.

Low

er is

bet

ter.

Whi

lst t

he D

NA

rat

e re

mai

ns b

elow

targ

et, t

he tr

ust c

ontin

ues

to lo

ok fo

r so

lutio

ns to

impr

ove

- T

he

Tru

st is

cur

rent

ly r

evie

win

g el

ectr

onic

sol

utio

ns to

ass

ist i

n th

e m

anag

emen

t of t

his

and

the

asso

ciat

ed

prob

lem

s of

late

can

cella

tions

Can

celle

d O

ps

Can

celle

d E

lect

ive

Ope

ratio

ns

(with

in 2

4 ho

urs

of o

pera

tion)

-

% o

f Tot

al E

lect

ives

&

Day

case

s in

Mon

th

Dat

a re

port

ed is

in r

efer

ence

to c

ance

lled

emar

genc

y ca

ses

with

in 2

4hrs

. - O

n da

y ca

ncel

latio

ns o

f el

ectiv

e pa

tient

s is

45

at O

DG

H a

nd 1

3 at

SD

GH

.Is

sues

at S

DG

H a

re a

roun

d oc

cupa

ncy

on th

is s

ite a

nd e

lect

ive

adm

issi

ons

bein

g ca

ncel

led

due

to b

ed

pres

sure

s.A

t OD

GH

, the

issu

es a

re a

mix

of c

ance

llatio

ns w

ith 6

0% b

eing

due

to u

navo

idab

le c

linic

al r

easo

ns. 4

w

ere

due

to th

e ca

ncel

latio

n of

a li

st d

ue to

sur

geon

sic

knes

s. R

evie

w o

f can

cella

tions

due

to la

ck o

f th

eatr

e tim

e is

und

er r

evie

w a

nd is

gen

eral

ly a

s a

resu

lt of

the

late

sta

rt o

f afte

rnoo

n lis

ts.

KP

I for

can

celle

d el

ectiv

es b

eing

dev

elop

ed to

incl

ude

with

in IP

R

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 20

of 2

3

Page 103 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

E

ffici

ency

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

The

atre

Util

isat

ion

- S

DG

H

The

pro

port

ion

of e

lect

ive

The

atre

slo

ts u

sed

over

the

tota

l ele

ctiv

e pl

anne

d ca

paci

ty

on th

e S

outh

port

site

.

Thi

s m

atrix

rep

orts

on

over

all t

heat

re u

tilis

atio

n at

SD

GH

incl

udin

g em

erge

ncy

and

trau

ma

lists

. -

Em

erge

ncy

and

trau

ma

list u

tilis

atio

n is

by

the

natu

re o

f the

term

var

iabl

e de

pend

ant o

n de

man

d.

Impr

ovem

ent o

f the

trau

ma

list c

ontin

ues

to b

e se

en w

ith th

e im

plem

enta

tion

of th

e go

ld a

nd s

ilver

pa

tient

pro

cess

intr

oduc

ed in

the

thea

tre

effic

ienc

y pr

ogra

mm

e. E

xclu

ding

trau

ma

and

emer

genc

y th

e th

eatr

e ut

ilisa

tion

is 6

8.37

%. T

his

was

impa

cted

with

13

on th

e da

y ca

ncel

latio

ns d

ue to

lack

of b

eds.

The

atre

Util

isat

ion

- O

DG

H

The

pro

port

ion

of e

lect

ive

The

atre

slo

ts u

sed

over

the

tota

l ele

ctiv

e pl

anne

d ca

paci

ty

on th

e O

rmsk

irk s

ite.

Slo

w im

prov

emen

t in

utili

satio

n w

hich

is c

urre

ntly

bei

ng im

pact

ed b

y on

day

can

cella

tions

. - T

heat

re

utili

satio

n w

as 7

3.06

%. T

his

was

impa

cted

by

45 o

n th

e da

y ca

ncel

latio

ns. F

ollo

win

g su

cces

sful

pilo

t of

the

48hr

pre

adm

issi

on c

alls

, the

se h

ave

now

com

men

ced

acro

ss a

ll sp

ecia

litie

s. C

ance

llatio

ns fo

r cl

inic

al r

easo

ns h

ave

incr

ease

d to

app

rox.

60%

, how

ever

, the

re is

a c

lear

impa

ct o

f lat

e ru

nnin

g af

tern

oon

lists

whi

ch is

und

er in

vest

igat

ion.

HB

S a

re o

fferin

g a

solu

tion

to th

e la

ck o

f ana

esth

etic

cov

er,

how

ever

sta

ff si

ckne

ss in

thea

tre

has

also

impa

cted

dur

ing

Oct

ober

.

Str

ande

d P

atie

nts

(>6

Day

s LO

S)

Pat

ient

s w

ho s

pend

7 d

ays

or

mor

e as

an

inpa

tient

.

Incr

ease

d no

ted

in s

tran

ded

in O

ctob

er -

The

SA

FE

R r

oll o

ut h

as b

een

revi

ewed

and

alth

ough

re

d2gr

een

com

plia

nce

has

impr

oved

it is

rec

ogni

sed

that

mor

e w

ork

is r

equi

red

to s

uppo

rt S

AF

ER

. S

OP

to s

uppo

rt r

ed2g

reen

boa

rd r

ound

s co

mpl

eted

and

pos

ter

deve

lope

d to

be

circ

ulat

ed;

red2

gree

n m

onito

ring

is im

prov

ing

and

wee

kly

audi

ts id

entif

y ar

eas

for

addi

tiona

l sup

port

. T

he d

evel

opm

ent o

f flo

w a

ctiv

ity r

epor

ts fo

r w

ards

is in

the

early

sta

ges

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 21

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 104 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

E

ffici

ency

Ind

icat

or

Nam

e (C

olo

ur

- P

erf

| Tra

j)D

escr

ipti

on

Nar

rati

veM

on

th T

ren

d

Sup

er S

tran

ded

Pat

ient

s (>

20 D

ays

LOS

)P

atie

nts

who

spe

nd 2

1 da

ys o

r m

ore

as a

n in

patie

nt.

incr

ease

in m

onth

con

tinue

s -

The

re r

emai

ns o

n-go

ing

wor

k w

ith #

long

stay

tues

day

with

the

com

mun

ity

and

LA a

t war

d le

vel a

nd c

ontin

ued

prog

ress

thro

ugh

the

Pat

ient

Flo

w Im

prov

emen

t pro

gram

me,

in

clud

ing

the

revi

ew o

f cur

rent

pro

cess

at w

ard

leve

l for

SA

FE

R,

enga

gem

ent e

vent

s w

ith M

DT

and

clin

icia

ns to

pro

mot

e S

AF

ER

, ac

ute

wor

king

to s

uppo

rt c

ompl

ex d

isch

arge

s in

to c

omm

unity

bed

s; r

elau

nch

of r

ed2g

reen

in

Nov

embe

r w

ith S

OP

to s

uppo

rt w

ards

; add

ition

al r

evie

ws

of s

tran

ded

patie

nts

to id

entif

y up

stre

am a

ny

com

plex

pat

ient

s

Sou

thpo

rt A

&E

Con

vers

ion

Rat

e

Pro

port

ion

of S

outh

port

A&

E

Atte

ndan

ces

that

are

mov

ed to

a

base

war

d. P

atie

nts

who

onl

y st

ay o

n an

Ass

essm

ent W

ard

are

not i

nclu

ded.

The

trus

t was

not

com

plia

nt in

Oct

ober

at 2

1.05

% -

The

Tru

st h

as w

orke

d ha

rd to

ens

ure

that

al

tern

ativ

e pa

thw

ays

to a

dmis

sion

whe

reve

r cl

inic

ally

app

ropr

iate

are

ado

pted

. Oct

ober

saw

an

addi

tiona

l 90

adm

issi

ons

via

ED

com

pare

d to

last

yea

r ag

ains

t an

incr

ease

of 4

18 a

ttend

ance

s.

Dem

and

for

side

roo

ms

durin

g O

ctob

er w

as h

igh

resu

lting

in p

atie

nts

adm

itted

str

aigh

t to

war

ds w

ithou

t go

ing

thro

ugh

asse

ssm

ent a

reas

. Thi

s w

as in

add

ition

to p

atie

nts

requ

iring

adm

issi

on to

ded

icat

ed

war

ds to

mee

t the

ir cl

inic

al n

eed

(par

ticul

arly

res

pira

tory

war

d fo

r N

IV, c

ardi

ac m

onito

ring

beds

on

SS

U

and

war

d 7A

). E

D c

ontin

ues

to h

ave

spec

ialty

in-r

each

into

ED

. Thi

s en

sure

s th

at p

atie

nts

iden

tifie

d as

re

quiri

ng a

bed

clin

ical

ly n

eed

adm

issi

on a

nd a

re n

ot s

uita

ble

for

alte

rnat

ive

path

way

s. T

he u

se o

f st

ream

ing

to C

DU

, SA

U a

nd A

CU

con

tinue

s. T

he m

odel

s ar

e in

line

with

bes

t pra

ctic

e an

d ha

ve b

een

desi

gned

in c

onju

nctio

n w

ith E

CIS

T (

natio

nal i

n-ho

use

NH

S e

xper

t con

sulta

ncy

for

UE

C).

Acr

oss

Oct

ober

, the

re w

as h

eavy

rel

ianc

e on

esc

alat

ion

bed

usag

e to

try

and

brid

ge th

e ga

p be

twee

n ad

mis

sion

s an

d di

scha

rges

, and

AC

U w

as u

sed

as a

n es

cala

tion

area

for

the

maj

ority

of t

he m

onth

, re

duci

ng o

ppor

tuni

ties

to m

axim

ise

stre

amin

g. A

s w

eeke

nds

are

a pa

rtic

ular

pre

ssur

e po

int,

AC

U h

as

open

ed o

n 3

Sun

days

str

eam

ing

a to

tal o

f 32

patie

nts

and

only

1 b

eing

adm

itted

. SA

U h

as p

rese

nted

a

mod

el to

red

esig

n th

e pa

thw

ay fo

r G

P r

efer

rals

and

are

look

ing

into

wee

kend

wor

king

, whi

ch w

ould

co

ntrib

ute

to r

educ

ing

the

conv

ersi

on r

ate

from

ED

.

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 22

of 2

3

Page 105 of 210

Boa

rd R

epor

t - O

ctob

er 2

019

Pag

e 23

of 2

3

TB

204_

19 4

IPR

Det

ail D

ecem

ber

2019

Oct

ober

Dat

a

Page 106 of 210

Ind

icat

or

Nam

eO

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r2

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er

20

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er 2

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,87

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E A

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02

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ll A

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770

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232

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197

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y Su

mm

ary –

Oct

ob

er2

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9

TB

204_

19 5

IPR

Act

ivity

Sum

mar

y D

ec 1

9

Page 107 of 210

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icat

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20

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tem

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01

9

Page 108 of 210


Agenda Item TB205/19 Report

Title

Director of Finance Report – Month 7

2019/20

Executive Lead Steve Shanahan, Director of Finance

Lead Officer Kevin Walsh, Deputy Director of Finance

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

In the latest System Financial Recovery Plan the Trust is forecasting a year end overspend of £3.6

million against the deficit plan of £26.6 million (excluding PSF/FRF), after achieving the plan at the

end of Quarter 2 with non- recurrent assistance thus securing £3.654 million PSF/FRF funding.

The Month 7 financial plan was not achieved with expenditure higher than the trajectory allowed to

achieve the forecast outturn. The main reasons for this are; pay spend with both monthly agency

and bank levels at their highest levels; CIP delivery to date and a forecast gap at the end of the year

of £2.0 million (previous month was £1.7 million).

The overall System financial position is forecasting an over spend of £24.53 million against the

£25.6 million deficit control total (excluding PSF/FRF)

The Board is asked to receive the Finance Report – Month 7 2019/20.












SO5 Enable all staff to be patient-centred leaders building


TB

205_

19 F

inan

ce R

epor

t Mon

th 7

Dec

19

Page 109 of 210

on an open and honest culture and the delivery of the Trust values




CQC KLOEs

GOVERNANCE




Safe Service Change

Well Led


Compliance Legal


Equality Risk

Finance Workforce



Policy

Service Change

Strategy







Page 110 of 210

Director of Finance Report – Month 7 2019/20

1. Purpose

1.1. This report provides the Board with the financial position for Month 7 (October 2019) and the

progress on delivery of the Trust’s control total.

1.2. It also provides an update on the Trusts’ forecast outturn alongside the overall System

position.

1.3. The Trust signed up to its 2019/20 deficit control total of £8.296 million (£26.567 million deficit

before non-recurrent funding of £18.271 million).

1.4. The non-recurrent funding consists of Provider Sustainability Funding (PSF) of £3.464 million

and Financial Recovery Fund (FRF) of £14.807 million.

2. Executive Summary

2.1. The month 7 (YTD) position is a deficit after PSF/FRF of £8.106 million against a plan of

£7.235 million resulting in £869,000 worse than plan. Before PSF/FRF the YTD deficit is

£16.328 million.

2.2. The month 7 (in month) positon is a deficit after PSF/FRF of £0.545 million against a surplus

plan of £0.315 million resulting in £0.861 million worse than plan. Before PSF/FRF the in-

month deficit is £2.372 million.

2.3. The Trust’s forecast outturn, based on month 6 performance and shared with NHSI/E on 1

November 2019, is £3.6 million overspend against the deficit plan.

2.4. Month 7 expenditure is higher than the trajectory used to achieve this forecast outturn.

2.5. The 2019/20 CIP programme is £1,350,000 behind plan at month 7; the forecast outturn is

£4.3 million against the £6.3 million plan leaving an unidentified gap of £2.0 million.

2.6. If material cash reducing CIP schemes cannot be transacted during the remainder of the year

then any pressure on the expenditure run rate will not be mitigated.

2.7. The table below is the I&E statement for October:

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ANNUAL

I&E (Including R&D) Budget

£000

Budget

£000

Actual

£000

Variance

£000

Budget

£000 Actual £000

Variance

£000

Commissioning Income 165,513 97,340 97,208 (131) 14,463 14,279 (184)

PP, Overseas & RTA 1,094 640 453 (187) 92 53 (39)

Other Income 12,174 7,271 7,662 391 1,030 1,026 (3)

PSF & FRF 18,271 8,222 8,222 0 1,827 1,827 0

Total Operating Income 197,052 113,473 113,545 72 17,411 17,185 (226)

PAY (140,012) (82,273) (82,544) (271) (11,610) (11,961) (351)

NON PAY (53,220) (31,355) (32,032) (677) (4,453) (4,775) (322)

Total Operating Expenditure (193,232) (113,628) (114,577) (948) (16,064) (16,735) (673)

EBITDA 3,820 (155) (1,032) (876) 1,348 450 (899)

Net Financing Costs (12,149) (7,109) (7,112) (3) (1,019) (999) 20

Retained Surplus/Deficit (8,329) (7,264) (8,144) (879) 329 (549) (879)

Technical Adjustments 33 28 38 10 (14) 4 18

Break Even Surplus/(Deficit) (8,296) (7,235) (8,106) (869) 315 (545) (861)

Less PSF/FRF Funding (18,271) (8,222) (8,222) 0 (1,827) (1,827) 0

SURPLUS/(DEFICIT)

excluding PSF/FRF (26,567) (15,457) (16,328) (869) (1,512) (2,372) (861)

YEAR TO DATE IN MONTH

2.8. The YTD deficit in the above table (£16.328 million) equates to a monthly average of £2.3

million.

2.9. As previously highlighted a number of non recurrent items were actioned in Quarters 1 and 2.

2.10. It is estimated that the current underlying deficit remains in the region of £2.7 million per month

excluding PSF/FRF which is an underlying annualised deficit of £32.0 million.

3. 2019/20 Contract Position

3.1. The value of the Southport & Formby CCG contract is £74.9 million.

3.2. The contract is a “Cost based contract” which has a number of “conditional income” elements.

3.3. These conditional elements, and performance to date, are shown in the table below:

Annual M7 YTD M7 YTD M7 YTD

Plan Plan Actual Var

£ £ £ £

Repatriation 600,000 350,000 0 (350,000)

Business Cases 1,300,000 758,333 402,027 (356,306)

CQC Contingency 300,000 175,000 7,200 (167,800)

BPT 850,000 495,833 23,732 (472,101)

Contingency - Other Conditional 450,000 262,500 0 (262,500)

Total 3,500,000 2,041,667 432,959 (1,608,707)

3.4. The Trust is assuming that it will achieve the £3.5 million at the year end and, therefore, is

accruing the full £2.041 million in the above table in the month 7 YTD position.

3.5. An additional £200,000 has been accrued in the month 7 YTD position (current expected year

Page 112 of 210

end contract over performance of £1.1 million results in a contract payment of £76.0 million).

This is based on expected year end contract performance and is reviewed monthly.

3.6. Latest projections indicate that if Southport & Formby CCG was on a PbR contract value the

year end projection is in the region of £78.8 million.

3.7. Apart from the Sefton CCGs, all other CCG contracts are on a PbR type contract.

3.8. The commissioning income annual budget in the above table includes:-

• £51.0 million for West Lancashire CCG; based on month 7 activity performance, and

planned recovery of the elective plan, this is forecast to be achieved.

• £74.9 million for Southport & Formby CCG; the Trust is currently underperforming against

the conditional elements of the contract but the contract is expected to overachieve.

4. Income

4.1. Elective activity performance has been improving over the last few months. It should be noted

that this improvement has had an adverse impact on outpatient activity as cancelled elective

sessions were previously replaced with outpatient work.

4.2. Non elective activity has once again overperformed in month.

4.3. Trust activity and income performance at month 7 YTD is as follows:

• Elective – activity is 3.9% below plan; £435,000 loss of income.

• A&E – activity 5.5% above plan; £353,000 of additional income.

• Non Elective – activity is 2.4% below plan; £2,567,000 additional income due to case mix

• Outpatients – activity is 3.9% above plan; £627,000 of additional income

4.4. Not all of the above activity performance is payable in 2019/20 due to:

• the application of the “blended tariff” adjustment means that only a proportion of the non-

elective value is payable

• Sefton CCG’s contract applies the “blended tariff” to all points of delivery.

4.5. The Trust’s commissioning income for month 7 YTD position assumes the following:

• Southport & Formby CCG will overperform against the contract at the year end (full year

contract value is £74.9 million; overperformance of £1.1 million).

• £200,000 of this overperformance was bought into the month 6 income position and this

has also been accrued at month 7.

• All other commissioning income is paid in line with the agreed contract.

5. Expenditure

5.1. Please refer to attached appendices for more detailed information regarding expenditure and

Whole Time Equivalent (WTE).

5.2. Underlying expenditure levels over the last few months have been fairly consistent but have

increased in month 7.

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5.3. The Board will recall that a number of non-recurrent expenditure reductions were applied in

month 3 in order to achieve the Quarter 1 control total.

5.4. No reductions were applied in months 4 and 5 but in month 6 a number of further adjustments

(mostly non-recurrent) were made which contributed to the achievement of the Quarter 2

control total.

5.5. In month 7 no adjustments have been made and this has contributed to a deteriorating

performance.

5.6. The most material increase in expenditure is within nursing staff with October 2019 seeing the

largest monthly nurse expenditure and WTE date. Although the substantive WTE has seen a

welcome increase this month (from 1,102 to 1,121 WTE) both bank and agency have also

increased.

5.7. It is important that substantive staff increase and vacancies reduce from both a quality and

finance perspective. Whilst bank is financially preferable to agency staff it is apparent that the

premium associated with bank is also significant as the majority of shifts covered are evenings

and weekends.

5.8. Further review of this will take place alongside the 2020/21 budget process.

5.9. Non pay areas have also seen a slight increase with some of this attributable to the additional

elective work now taking place.

6. Bank/agency spend

6.1. The Trust spent £2.052 million in October on bank and agency staff.

6.2. Monthly agency spend has increased in October to £1,109,000 (9.3% of the pay bill); Medical

staff £511,000; Nursing staff £458,000

6.3. Month 7 YTD agency spend is £6.978 million (8.4% of the pay bill); Medical staff £3.717

million; Nursing staff £2.619 million

6.4. The agency target cap of £4.891 million set by NHSI for 2019/20 was breached in month 6.

6.5. Bank spend is consistent with previous months; October is £944,000 (8.3% of the total pay bill)

bringing YTD spend to £6.533 million (7.9% of the total pay bill).

6.6. As referred to above both bank and agency attract a considerable premium element and is a

key area of focus for the Trust to improve its financial position.

7. Cost Improvement Plan (CIP)

7.1. The Trust’s I&E plan assumes a £6.3 million CIP is delivered in 2019/20 from both increased

income and reduced expenditure.

7.2. Following contract discussions the plan is mainly dependent on expenditure reduction.

7.3. The table below illustrates the targets with performance to date.

19/20 Plan - Expenditure (pay) 2,465 3,965 355 118 (237) 2,094 959 (1,135) 1,377 1,015

19/20 Plan - Expenditure (non pay) 1,724 1,724 160 83 (77) 910 737 (173) 1,143 996

19/20 Plan - Income (other op income) 325 325 39 25 (14) 128 242 114 343 66

19/20 Plan - Income (BPT) 1,800 300 26 (26) 156 (156)

19/20 Plan - Total 6,314 6,314 580 226 (354) 3,288 1,938 (1,350) 2,863 2,077

Annual

Plan

£000

Annual

Budget

£000

Month 6 YTD

CYE

£000

FYE

£000

Budget

£000

Actual

£000

Var

£000

Budget

£000

Actual

£000

Var

£000

Page 114 of 210

7.4. The forecast outturn against the £6.314 million target has reduced to is £4.359 million leaving

an unidentified gap of £1.955 million.

8. Forecast Outturn

8.1. The Trust has been signalling that it will not achieve its financial plan based on current

financial performance.

8.2. Despite the achievement of the Quarter 2 plan a large element of the income and expenditure

adjustments will impact in Quarter 4.

8.3. The Trust’s expenditure levels in the first half of the year, together with assumptions on CIP

delivery and future impact of agreed business cases, derived a predicted £5.1 million

overspend against the plan.

8.4. This was included in the System Recovery plan submitted to NHSI/E on 18th October 2019

and discussed at this Board’s October meeting.

8.5. Following review the System was instructed to find further schemes to reduce the forecast gap

from control totals.

8.6. The Trust has identified a further improvement of £1.49 million and is now predicting an

overspend of £3.61 million against the £26.6 million deficit plan. NHSI/E is monitoring the

Trust’s performance against this forecast on a weekly basis.

8.7. The table below shows the control total and current forecast for all System partners:

S&O

NHST

SS CCG SF CCG Winter Total

£m £m £m £m £m

2019/20 Control Total (excl PSF/FRF) (26.60) 1.00 0.00 0.00 (25.60)

Winter 0.00 0.00 0.00 (1.10) (1.10)

Forecast overspend (3.61) (9.12) (10.70) 0.00 (23.43)

Forecast Outturn (excl PSF/FRF) (30.21) (8.12) (10.70) (1.10) (50.13)

8.8. Month 7 expenditure levels were in the region of £0.2 million above the Trust’s trajectory to

achieve £3.61 million adverse against plan.

8.9. The pressure on the expenditure run rate as vacancies are filled (including agreed business

cases) is not being mitigated by real expenditure reductions form the CIP programme.

8.10. Based on current expenditure levels and CIP performance it is highly likely that the Trust will

not achieve the Quarter 3 deficit plan without significant CCG support and, therefore, will not

be in receipt of the PSF/FRF for that quarter (£5.481 million).

9. Cash

9.1. The previous large cash balance (October’s opening balance was £7 million) has now been

fully utilised with November closing cash balance £1.1million which is in line with the terms

and conditions of our revenue support loans..

9.2. Performance against the cash plan in October 2019 was on target overall, however, cash

outflows needed controlling to ensure the target was met.

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9.3. Quarter 2 FRF funding of £2.961 million was received on 15th November 2019; it was not

forecast to be received until December 2019.

9.4. The uncertainty of timing around PSF and FRF funding has made forecasting a challenge

9.5. The Trust is not achieving the Better Payment Practice Code (BPPC) target, however, a focus

on delivering the e-invoicing target will help with both the BPPC and reduce the risk of

additional contractual penalty charges by NHS Shared Business Services.

10. Debtors

10.1. Debt levels have increased from £3.8 million at the end of September 2019 to £4.9 million at

the end of October 2019.

10.2. Greater than 90 day debt has increased from £1,466,998 last month to £2,021,405 this month.

10.3. The majority of this increase is in NHS debt and is linked mostly to a revoked credit note to

NHS England for -£364,000.

10.4. There has been some increase in non NHS debt and this is entirely due to Local Authority

invoices (Lancashire County Council) which are on SBS (Shared Business Services) dunning

levels.

10.5. A monthly debt management call takes place with SBS and this includes a review of the top 10

debtors (NHS and non-NHS) over 31 days and by dunning responsibility.

10.6. The majority of >90 day debt is NHS related (as per table above) and it can be difficult to

chase as this debt can’t be referred to external debt recovery.

11. Capital

11.1. Actual spend in month 7 was higher than month 6, at £535,000 bringing the cumulative actual

spend to date to £2,098,000 against a planned spend year to date of £4,027,000.

11.2. The low spend is more a reflection of an optimistic plan that schemes such as the ward

upgrades and library extension would have progressed further by this point in the year.

11.3. Commitments have increased in the month to £1,137,000, partly IT, but mainly Medical

Equipment on order which has recently been approved at Capital Investment Group (CIG).

11.4. Medical Equipment has the highest level of commitments, closely followed by IT which is

mostly connected with the Windows 10 rollout and Careflow Connect.

11.5. Taking actual and committed spend together at £3,087,000 (excluding donated and GE

radiology assets) and comparing this against the annual plan, £5,103,000, then the Trust is at

60.5% of the plan at the end of October 2019.

11.6. The first 5 wards of the Southport ward upgrade project will be completed before Christmas

with a 6th planned for completion before the end of the financial year.

11.7. Work is near completion in the Spinal Injuries Unit on the Isolation work and the bathroom

upgrades which were required as a result of the Klebsiella outbreak.

11.8. IM&T contingency scheme at £450,000 was originally intended for the datacentre, however,

this is unlikely to be implemented in 2019/20 and a re-utilisation of these monies to other IT

projects planned for next year is reflected in the revised plan.

11.9. The Trust has been successful in receiving £700,000 funding for ePMA (Electronic Prescribing

Page 116 of 210

and Medicines Administration) system.

11.10. NHSE/I has supported the Trust to apply for a capital loan of £935,000 to address the high risk

items identified in the six facet survey. This could be received in 2019/20.

11.11. The Board approved a revised capital plan on 6th November and included the authorisation to

proceed with the development of additional bed capacity at Ormskirk hospital as part of the

winter plan at a forecast cost of £350,000.

11.12. However, the full cost of these works is now £495,000 which includes backlog maintenance.

11.13. Under the new scheme of delegation Finance Performance and Investment Committee

approved the additional cost of the scheme.

11.14. This week confirmation was received that capital funding for winter planning of £500,000 had

been awarded; the relevant paperwork is awaited (Memorandum of Understanding) and once

signed off an application will be made to draw down public dividend capital.

11.15. Based on current information the MRI scanner project is back on track in and this scheme will

be delivered by the end of March 2020 as originally planned.

12. Recommendations

12.1. The Board is asked to receive the Finance Report – Month 7 2019/20.

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Page 118 of 210

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4)

(1,5

77

)(1

,67

5)

(1,6

08

)(1

,49

4)

(1,6

15

)(1

,58

7)

(1,5

00

)(1

,70

8)

(1,5

66

)(1

,81

2)

(1,6

30

)

Oth

er

Me

dic

al

Su

bsta

nti

ve

(1,2

43

)(1

,20

2)

(1,2

63

)(1

,31

9)

(1,3

07

)(1

,25

6)

(1,3

37

)(1

,30

5)

(1,3

27

)(1

,29

7)

(1,3

13

)(1

,43

1)

(1,3

28

)

Ba

nk

(12

9)

(16

3)

(14

2)

(13

7)

(11

5)

(16

7)

(16

5)

(16

7)

(19

5)

(15

5)

(17

4)

(17

1)

(14

6)

Ag

en

cy

(22

6)

(21

7)

(20

8)

(24

4)

(27

3)

(31

6)

(25

6)

(25

7)

(27

7)

(28

8)

(25

5)

(23

5)

(24

7)

Oth

er

Me

dic

al

To

tal

(1,5

97

)(1

,58

1)

(1,6

12

)(1

,69

9)

(1,6

95

)(1

,73

9)

(1,7

58

)(1

,73

0)

(1,7

99

)(1

,74

0)

(1,7

42

)(1

,83

7)

(1,7

22

)

Nu

rse

s &

Mid

wiv

es

Su

bsta

nti

ve

(3,6

28

)(3

,60

4)

(3,5

71

)(3

,70

4)

(3,6

72

)(3

,38

8)

(3,9

54

)(3

,81

8)

(3,7

97

)(3

,74

5)

(3,7

22

)(3

,77

1)

(3,7

49

)

Ba

nk

(52

9)

(56

5)

(54

3)

(59

5)

(58

8)

(68

4)

(60

9)

(63

7)

(64

5)

(63

2)

(67

1)

(65

6)

(68

4)

Ag

en

cy

(36

7)

(29

4)

(26

2)

(42

7)

(41

5)

(43

6)

(37

2)

(39

7)

(31

9)

(30

3)

(40

0)

(37

0)

(45

8)

Nu

rse

s &

Mid

wiv

es T

ota

l(4

,52

4)

(4,4

63

)(4

,37

5)

(4,7

26

)(4

,67

5)

(4,5

08

)(4

,93

5)

(4,8

52

)(4

,76

1)

(4,6

80

)(4

,79

3)

(4,7

96

)(4

,89

1)

Scie

nti

fic,

Te

ch

nic

al

&

Th

era

pu

tic

Su

bsta

nti

ve

(1,3

31

)(1

,33

0)

(1,3

07

)(1

,32

0)

(1,3

19

)(1

,26

0)

(1,4

37

)(1

,34

9)

(1,3

29

)(1

,32

3)

(1,3

48

)(1

,37

2)

(1,3

84

)

Ba

nk

(11

)(1

3)

(12

)(9

)(1

2)

(12

)(7

)(7

)(7

)(8

)(6

)(5

)(5

)

Ag

en

cy

(16

)(2

0)

(15

)(1

2)

(8)

(14

)(4

)(8

)(2

0)

(35

)(2

6)

(72

)(2

8)

Scie

nti

fic,

Te

ch

nic

al

& T

he

rap

uti

c T

ota

l(1

,35

8)

(1,3

63

)(1

,33

4)

(1,3

41

)(1

,33

9)

(1,2

86

)(1

,44

8)

(1,3

64

)(1

,35

5)

(1,3

66

)(1

,38

0)

(1,4

49

)(1

,41

7)

Oth

er

Sta

ffS

ub

sta

nti

ve

(2,0

10

)(2

,04

0)

(1,9

81

)(1

,96

5)

(2,0

08

)(1

,73

1)

(2,2

84

)(2

,15

6)

(2,1

47

)(2

,09

0)

(2,1

15

)(2

,15

0)

(2,1

20

)

Ba

nk

(31

)(7

)(2

8)

(27

)(1

9)

(34

)(3

8)

(17

)(2

7)

(34

)(4

0)

(28

)(2

4)

Ag

en

cy

(63

)(5

1)

(58

)(5

9)

(50

)(5

4)

(59

)(5

4)

(48

)(6

4)

(78

)(3

4)

(11

2)

Oth

er

Sta

ff T

ota

l(2

,10

5)

(2,0

98

)(2

,06

7)

(2,0

51

)(2

,07

7)

(1,8

18

)(2

,38

1)

(2,2

27

)(2

,22

3)

(2,1

88

)(2

,23

2)

(2,2

13

)(2

,25

6)

Pa

y R

ese

rve

sS

ub

sta

nti

ve

0

35

1

84

2

32

7

98

(1

76

)(5

7)

(56

)1

49

(1

91

)(5

4)

91

4

(0)

Pa

y R

ese

rve

s T

ota

l0

3

5

18

4

23

2

79

8

(17

6)

(57

)(5

6)

14

9

(19

1)

(54

)9

14

(0

)

Pa

y C

IPS

ub

sta

nti

ve

0

0

0

0

0

0

0

0

0

0

0

0

0

Pa

y C

IP T

ota

l0

0

0

0

0

0

0

0

0

0

0

0

0

Ap

pre

nti

ce

sh

ip L

ev

yS

ub

sta

nti

ve

(39

)(4

4)

(39

)(4

1)

(40

)(4

7)

(44

)(4

2)

(38

)(5

0)

(36

)(4

3)

(46

)

Ap

pre

nti

ce

sh

ip L

ev

y T

ota

l(3

9)

(44

)(3

9)

(41

)(4

0)

(47

)(4

4)

(42

)(3

8)

(50

)(3

6)

(43

)(4

6)

PA

Y T

ota

l(1

1,1

02

)(1

1,0

08

)(1

0,8

20

)(1

1,3

01

)(1

0,6

36

)(1

1,0

68

)(1

2,2

39

)(1

1,8

57

)(1

1,5

27

)(1

1,9

24

)(1

1,8

03

)(1

1,2

35

)(1

1,9

61

)

NO

N-P

AY

Su

pp

lie

s &

Se

rvic

es C

lin

ica

l(2

,31

7)

(2,2

90

)(2

,22

8)

(2,2

49

)(2

,22

7)

(2,4

13

)(2

,26

3)

(2,3

25

)(2

,25

9)

(2,4

20

)(2

,26

4)

(2,2

27

)(2

,38

2)

Su

pp

lie

s &

Se

rvic

es G

en

era

l(2

04

)(2

14

)(2

00

)(2

03

)(1

99

)(2

12

)(1

86

)(1

72

)(1

73

)(1

64

)(1

89

)(2

19

)(2

11

)

No

n-E

xe

cu

tiv

e D

ire

cto

rs(6

)(6

)(6

)(8

)(4

)(6

)(6

)

Esta

bli

sh

me

nt

Ex

pe

nse

s(2

88

)(3

52

)(2

95

)(2

98

)(2

92

)(2

68

)(1

91

)(2

26

)(2

32

)(2

21

)(2

45

)(2

42

)(2

37

)

Pre

mis

es &

Fix

ed

Pla

nt

(99

0)

(94

3)

(99

3)

(95

3)

(91

7)

(77

5)

(1,0

18

)(1

,03

5)

(99

1)

(98

5)

(1,0

55

)(9

48

)(1

,06

1)

Mis

ce

lla

ne

ou

s(6

16

)(6

32

)(6

59

)(6

38

)(6

54

)(5

95

)(7

17

)(7

20

)(7

16

)(7

35

)(7

17

)(6

66

)(7

40

)

Se

rvic

es F

rom

Oth

er

NH

S B

od

ies

(27

9)

(29

3)

(20

9)

(28

7)

(25

3)

(32

8)

(10

3)

(61

)(6

9)

(14

5)

(18

8)

(13

6)

(13

7)

No

n P

ay

Re

se

rve

0

0

0

0

0

0

(7)

7

0

0

0

0

0

No

n P

ay

CIP

0

0

0

0

0

0

0

0

0

0

0

0

0

NO

N-P

AY

To

tal

(4,6

95

)(4

,72

5)

(4,5

83

)(4

,62

8)

(4,5

43

)(4

,59

0)

(4,4

91

)(4

,53

8)

(4,4

46

)(4

,67

8)

(4,6

62

)(4

,44

3)

(4,7

75

)

NO

N-O

PE

RA

TIN

G E

XP

EN

DIT

UR

E(9

20

)(9

39

)(9

42

)(9

39

)(9

40

)(4

79

)(1

,03

1)

(1,0

23

)(1

,03

7)

(1,0

06

)(1

,04

2)

(1,0

16

)(9

98

)

Gra

nd

To

tal

(16

,71

7)

(16

,67

2)

(16

,34

6)

(16

,86

8)

(16

,11

9)

(16

,13

7)

(17

,76

1)

(17

,41

8)

(17

,00

9)

(17

,60

8)

(17

,50

6)

(16

,69

4)

(17

,73

3)

PA

Y S

UM

MA

RY

BY

ST

AF

F T

YP

E

PA

YS

ub

sta

nti

ve

(9,5

70

)(9

,48

5)

(9,2

96

)(9

,51

1)

(8,8

71

)(8

,97

5)

(10

,35

1)

(9,9

64

)(9

,72

3)

(10

,01

6)

(9,8

22

)(9

,24

8)

(9,9

08

)

Ba

nk

(74

9)

(78

8)

(79

5)

(86

9)

(81

3)

(1,0

01

)(9

18

)(8

98

)(9

40

)(9

42

)(9

56

)(9

36

)(9

44

)

Ag

en

cy

(78

2)

(73

5)

(73

0)

(92

0)

(95

2)

(1,0

92

)(9

70

)(9

95

)(8

64

)(9

66

)(1

,02

4)

(1,0

50

)(1

,10

9)

PA

Y T

ota

l(1

1,1

02

)(1

1,0

08

)(1

0,8

20

)(1

1,3

01

)(1

0,6

36

)(1

1,0

68

)(1

2,2

39

)(1

1,8

57

)(1

1,5

27

)(1

1,9

24

)(1

1,8

03

)(1

1,2

35

)(1

1,9

61

)

Page 121 of 210

4.

WT

E r

un

ra

te b

y m

on

th

WTE

wo

rke

dA

s at

31s

t O

cto

be

r 20

19

STA

FF G

RO

UP

STA

FF T

YP

EO

ct-1

8N

ov-

18D

ec-

18Ja

n-1

9Fe

b-1

9M

ar-1

9A

pr-

19M

ay-1

9Ju

n-1

9Ju

l-19

Au

g-19

Sep

-19

Oct

-19

Co

nsu

ltan

tsSu

bst

anti

ve

100

103

102

9

4

9

9

9

7

9

6

9

5

9

4

9

4

9

5

9

5

9

5

Ban

k

2

2

4

4

5

5

5

5

3

5

3

3

4

Age

ncy

25

8

9

8

10

12

12

12

9

12

12

13

14

Co

nsu

ltan

ts T

ota

l

127

114

115

107

114

114

114

111

106

111

110

111

113

Oth

er

Me

dic

alSu

bst

anti

ve

207

207

215

218

224

225

225

226

217

228

225

217

216

Ban

k

1

0

1

1

1

0

1

0

1

0

1

1

1

3

1

1

9

1

2

1

2

9

1

2

Age

ncy

65

19

18

21

24

28

20

23

24

22

20

20

21

Oth

er

Me

dic

al T

ota

l

281

236

242

249

258

264

258

260

250

263

257

246

249

Nu

rse

s &

Mid

wiv

es

Sub

stan

tive

1,0

97

1,1

01

1,0

98

1,0

94

1,1

01

1,1

10

1,1

06

1,1

21

1,1

10

1,1

09

1,1

07

1,1

02

1,1

21

Ban

k

161

171

161

172

176

208

178

185

186

189

196

187

197

Age

ncy

48

44

42

62

59

69

63

60

54

57

66

65

75

Nu

rse

s &

Mid

wiv

es

Tota

l

1

,305

1

,315

1

,302

1

,329

1

,336

1

,387

1

,347

1

,367

1

,350

1

,355

1

,369

1

,354

1

,394

Pay

Re

serv

es

Sub

stan

tive

-

-

-

-

-

-

-

-

-

-

-

-

-

Pay

Re

serv

es

Tota

l

-

-

-

-

-

-

-

-

-

-

-

-

-

Scie

nti

fic,

Te

chn

ical

& T

he

rap

uti

cSu

bst

anti

ve

410

403

402

402

407

402

405

400

387

395

400

408

406

Ban

k

3

2

2

2

3

2

2

2

1

2

2

1

1

Age

ncy

13

4

3

3

2

2

1

1

4

6

5

6

5

Scie

nti

fic,

Te

chn

ical

& T

he

rap

uti

c

Tota

l

426

410

407

406

411

407

408

403

392

403

407

415

412

Oth

er

Staf

fSu

bst

anti

ve

775

774

771

760

772

773

810

802

805

797

803

804

824

Ban

k

1

2

1

4

1

2

9

1

1

1

4

1

5

1

3

1

0

1

4

1

4

1

3

1

2

Age

ncy

11

15

11

7

10

8

8

10

13

10

12

9

11

Oth

er

Staf

f To

tal

7

99

8

03

7

93

7

77

7

93

7

95

8

33

8

25

8

28

8

21

8

29

8

26

8

48

Gra

nd

To

tal

2,9

38

2,8

78

2,8

60

2,8

68

2,9

12

2,9

67

2,9

59

2,9

66

2,9

26

2,9

52

2,9

72

2,9

52

3,0

15

SUM

MA

RY

BY

STA

FF T

YP

E

PA

YSu

bst

anti

ve

2

,589

2

,589

2

,588

2

,569

2

,603

2

,608

2

,642

2

,643

2

,613

2

,623

2

,630

2

,626

2

,663

Ban

k

187

200

190

198

205

240

213

215

210

222

227

213

226

Age

ncy

1

62

90

82

1

01

1

04

1

19

1

03

1

08

1

03

1

07

1

15

1

13

1

26

Gra

nd

To

tal

2,9

38

2,8

78

2,8

60

2,8

68

2,9

12

2,9

67

2,9

59

2,9

66

2,9

26

2,9

52

2,9

72

2,9

52

3,0

15

TB

205_

19 F

inan

ce M

onth

7 R

epor

t App

endi

ces

Page 122 of 210

5.

Sta

tem

en

t o

f F

ina

nc

ial

Po

sit

ion

(B

ala

nce

Sh

ee

t)

Op

en

ing

ba

lan

ce

Clo

sin

g

ba

lan

ce

Mo

ve

me

nt

Mvt

in

mo

nth

01/0

4/2

019

31/1

0/2

019

£'0

00s

£'0

00s

£'0

00s

£'0

00s

NO

N C

UR

RE

NT A

SS

ETS

Pro

pert

y p

lant

and e

quip

ment/

inta

ngib

les

123,0

67

121,0

87

(1,9

80)

(38)

Oth

er

assets

966

1,5

37

571

(31)

TO

TA

L N

ON

CU

RR

EN

T A

SS

ETS

124,0

33

122,6

24

(1,4

09)

(69)

CU

RR

EN

T A

SS

ETS

Inve

nto

ries

2,3

82

2,3

15

(67)

105

Tra

de a

nd o

ther

receiv

able

s11,6

78

13,8

68

2,1

90

2,7

33

Cash a

nd c

ash e

quiv

ale

nts

1,0

42

1,1

19

77

(6,1

00)

Non c

urr

ent

assets

held

for

sale

00

00

TO

TA

L C

UR

RE

NT A

SS

ETS

15,1

02

17,3

02

2,2

00

(3,2

62)

CU

RR

EN

T L

IAB

ILIT

IES

Tra

de a

nd o

ther

payable

s(2

2,7

71)

(22,3

58)

413

(1,9

31)

Pro

visio

ns

(199)

(212)

(13)

0

PF

I/F

inance lease lia

bilitie

s(1

,153)

(1,1

53)

00

DH

reve

nue loans

(20,4

87)

(53,5

47)

(33,0

60)

(2)

DH

Capital lo

an

(411)

(400)

11

0

Oth

er

liabilitie

s(1

,025)

(6,5

75)

(5,5

50)

1,1

08

TO

TA

L C

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RE

NT L

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ILIT

IES

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46)

(84,2

45)

(38,1

99)

(825)

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T C

UR

RE

NT A

SS

ETS

/(LIA

BIL

ITIE

S)

(30,9

44)

(66,9

43)

(35,9

99)

(4,0

87)

TO

TA

L A

SS

ETS

LE

SS

CU

RR

EN

T L

IAB

ILIT

IES

93,0

89

55,6

81

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56)

NO

N C

UR

RE

NT L

IAB

ILIT

IES

Pro

visio

ns

(207)

(160)

47

20

DH

reve

nue loans

(82,9

53)

(55,0

26)

27,9

27

2,7

43

PF

I/F

inance lease lia

bilitie

s(1

3,8

31)

(12,9

38)

893

645

DH

Capital lo

an

(1,0

00)

(600)

400

200

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TA

L N

ON

CU

RR

EN

T L

IAB

ILIT

IES

(97,9

91)

(68,7

24)

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67

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L A

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ETS

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PLO

YE

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(548)

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AN

CE

D B

Y T

AXP

AY

ER

S E

QU

ITY

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ivid

end C

apital

98,2

14

98,2

14

00

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ined e

arn

ings

(112,4

32)

(120,5

73)

(8,1

41)

(548)

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luation r

eserv

e9,3

16

9,3

16

00

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TA

L T

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AY

ER

S E

QU

ITY

(4,9

02)

(13,0

43)

(8,1

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(548)

In m

onth

mate

rial

move

ments

are

as follow

s:

Cash h

as r

educed by £

6.1

million a

s it has b

een utilised

to p

ay d

ow

n som

e o

f th

e D

HS

C l

oans (

£2.7

43 m

illion)

and c

ope w

ith less m

onie

s f

rom

the C

om

mis

sio

ners

as

they a

re c

law

ing b

ack p

revi

ously

paid

monie

s o

ver

the

last 6 m

onth

s o

f th

e y

ear.

The in

cre

ase i

n t

rade a

nd o

ther

receiv

able

s is

a

com

bin

ation in

an incre

ase i

n a

ged debt

(£1.1

million)

and a

n incre

ase in

incom

e a

ccru

als

.

Tra

de and o

ther

payable

s h

as a

lso incre

ased w

ith t

he

majo

rity

(appro

x.

£1.5

million)

associa

ted w

ith u

npaid

purc

hase in

voic

es.

Page 123 of 210

6.

Ca

pit

al

CA

TEG

OR

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CA

PIT

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CR

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Page 124 of 210

CA

TEG

OR

Y

CA

PIT

AL

SCH

EME

DES

CR

IPTI

ON

S SC

HEM

E C

OD

ES

20

19

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ers

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ceiv

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ed

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lett

er

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s an

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Page 125 of 210

7.

Ca

sh

flo

w F

ore

ca

st – 2

019

/20

Actu

al

Actu

al

Actu

al

Actu

al

Actu

al

Actu

al

Actu

al

Pla

nP

lan

Pla

nP

lan

Pla

n

Ap

r-19

Ma

y-1

9Ju

n-1

9Ju

l-19

Au

g-1

9S

ep

-19

Oct-

19

No

v-1

9D

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n-2

0F

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-20

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r-20

To

tal

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

£'0

00s

Ca

sh

Flo

ws f

rom

Op

era

tin

g A

cti

vit

ies

Opera

ting S

urp

lus/(

Deficit)

(1,5

93)

(1,0

05)

(26)

(1,0

93)

(1,3

91)

126

(122)

482

(89)

612

(15)

912

(3,2

02)

Incom

e r

ecognis

ed in r

espect

of capital donations (

cash a

nd n

on-c

ash)

(9)

10

(34)

00

(8)

0(3

3)

00

(17)

(100)

Depre

cia

tion a

nd A

mort

isation

594

593

601

571

572

572

573

581

581

598

598

599

7,0

33

Impairm

ents

and R

eve

rsals

00

00

0

(Incre

ase)

in Inve

nto

ries

59

(86)

200

(143)

(74)

216

(105)

(50)

30

25

18

30

120

(Incre

ase)

in T

rade a

nd O

ther

Receiv

able

s(9

49)

(2,0

96)

(1,1

15)

1,1

43

1,9

47

1,0

11

(2,7

02)

(2,4

54)

1,2

00

(2,7

58)

(2,7

58)

3,1

36

(6,3

95)

Incre

ase in T

rade a

nd O

ther

Payable

s3,5

17

(1,1

23)

(1,8

71)

(1,8

87)

5,8

22

(512)

514

(1,5

59)

(2,8

94)

(3,8

65)

170

(1,1

65)

(4,8

53)

Incre

ase in P

rovi

sio

ns

1(8

)(3

)10

0(1

4)

14

(25)

(42)

(67)

Ne

t C

ash

In

flo

w/(

Ou

tflo

w)

fro

m O

pe

rati

ng

Acti

vit

ies

1,6

20

(3,7

24)

(2,2

14)

(1,4

33)

6,8

76

1,3

99

(1,8

36)

(3,0

00)

(1,2

30)

(5,3

88)

(1,9

87)

3,4

53

(7,4

64)

Ca

sh

Flo

ws f

rom

In

ve

sti

ng

Acti

vit

ies

Inte

rest

Receiv

ed

34

55

817

(1)

66

66

772

(Paym

ents

) fo

r In

tangib

le A

ssets

(57)

0(2

)(1

52)

127

0(2

)(9

2)

(112)

(83)

(80)

(237)

(690)

(Paym

ents

) fo

r P

PE

and inve

stm

ent

pro

pert

y(1

90)

(117)

(186)

40

(1,1

44)

(325)

(189)

(391)

(570)

(667)

(291)

(1,0

70)

(5,1

00)

Receip

ts fro

m d

isposal of fixed a

ssets

00

00

0

Receip

t of cash d

onations t

o p

urc

hase c

apital

assets

9(1

)0

34

833

17

100

Ne

t C

ash

In

flo

w/(

Ou

tflo

w)

fro

m I

nve

sti

ng

Acti

vit

ies

(235)

(114)

(183)

(73)

(1,0

09)

(308)

(184)

(477)

(643)

(744)

(365)

(1,2

83)

(5,6

18)

Ca

sh

Flo

ws f

rom

Fin

an

cin

g A

cti

vit

ies

Public d

ivid

end c

apital re

ceiv

ed

00

00

0

Public d

ivid

end c

apital re

paid

00

00

0

Loans r

eceiv

ed fro

m D

H2,4

56

1,4

58

2,3

86

2,1

79

00

03,6

93

3,1

55

6,4

34

3,0

81

24,8

42

Loans r

epaid

to D

H(2

00)

00

00

0(2

,941)

(697)

(1,2

36)

(5,0

74)

Capital ele

ment

of finance leases

(8)

(8)

(8)

(8)

(8)

(8)

(596)

(24)

(240)

(24)

(932)

Capital ele

ment

of P

FI, L

IFT

(16)

(15)

(118)

(16)

(15)

(119)

(15)

(16)

(118)

(16)

(15)

(119)

(598)

Inte

rest

Paid

(190)

(234)

(225)

(195)

(228)

(545)

(207)

(238)

(234)

(205)

(236)

(540)

(3,2

77)

Inte

rest

ele

ment

of finance lease

00

00

(240)

(158)

(398)

Inte

rest

ele

ment

of P

FI, L

IFT

(80)

(81)

(209)

(80)

(81)

(209)

(81)

(81)

(209)

(81)

(80)

(209)

(1,4

81)

PD

C d

ivid

end (

paid

)/re

funded

00

00

0

Ne

t C

ash

In

flo

w/(

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tflo

w)

fro

m F

ina

ncin

g

Acti

vit

ies

1,9

62

1,1

20

1,8

26

1,8

80

(332)

(881)

(4,0

80)

3,3

58

1,8

73

6,1

32

2,3

52

(2,1

28)

13,0

82

NE

T I

NC

RE

AS

E/(

DE

CR

EA

SE

) IN

CA

SH

3,3

47

(2,7

18)

(571)

374

5,5

35

210

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042

0

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- B

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rio

d1,0

42

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1,0

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Ca

sh

- E

nd

of

the

Pe

rio

d4,3

89

1,6

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1,1

00

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1,0

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TB

205_

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inan

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7 R

epor

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endi

ces

Page 126 of 210


Agenda Item PB206/19 Report Title Risk Register

Executive Lead Juliette Cosgrove, Director of Nursing, Midwifery and Therapies

Lead Officer Katharine Martin, Interim Head of Risk

Mandy Power, Assistant Director of Integrated Governance

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

Since the last meeting, one new risk has been added onto the risk register.

• 2122 – Medicines Management (15). This risk has been added as a result of concerns raised by CQC. A Medicines Management Improvement Plan has been developed with actions underway.

Discussions have taken place at Risk & Compliance Group to add an additional two risks onto this risk register. These relate to ‘Fragile Services’ and ‘Medical Staffing’. These will be drafted for approval at Risk & Compliance Group in December. Since the last meeting, no risks have been removed from the risk register. There are currently 8 risks on the High Level Risk register. These are:

• 1688 - Inadequate Staffing Levels in Anaesthetic Department (will be consolidated into Medical Staffing risk)

• 1902 - Failure to comply & improve governance of services in relation to the areas of non-compliance identified by CQC

• 2052 - Older Peoples Care

• 1862 - Maintaining safe quality nursing care with current level of nursing & HCA vacancies

• 1942 - Eradicating the Trust’s deficit by 2023/24

• 2072 - Failure to achieve 2019/20 financial control total

• 2056 - Missing Patient appointments/admissions

• 2122 – Medicines Management



TB

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Page 127 of 210















CQC KLOEs

GOVERNANCE

✓ Caring Statutory Requirement




✓ Well Led




Equality ✓ Risk

✓ Finance ✓ Workforce



Policy

Service Change

Strategy


This is a dynamic document and its structure and content may be updated as necessary.






Page 128 of 210







TB

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Page 129 of 210

of 14

NOVEMBER 2019 – SUMMARY OF HIGH LEVEL RISK REGISTER AS AT 26/11/2019

Risk ID Principle Objective(s) Risk Executive Lead Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19

1688

SO1 - Improve clinical outcomes and patient safety to ensure we deliver high quality

services

SO3 - Efficiently and productively provide care within agreed financial limits

SO4 - Develop a flexible, responsive workforce of the right size and with the right skills

who feel valued and motivated

SO6 - Engage strategic partners to maximise the opportunities to design and deliver

sustainable services for the population of Southport, Formby and West Lancashire

Inadequate Staffing Levels in

Anaesthetic Department

Chief

Operating

Officer

=15 20 =20 =20 =20 =20

1902


services

SO2 - Deliver services that meet NHS constitutional and regulatory standards




SO5 - Enable all staff to be patient-centered leaders building on an open and honest

culture and the delivery of the Trust values



Failure to comply & improve

governance of services in

relation to the areas of non

compliance identified by CQC

Director of

Nursing &

Quality

=16 =16 =16 =16 =16 =16

1862

SO1 Improve clinical outcomes and patient safety to ensure we deliver high quality

services


Maintaining safe quality

nursing care with current level

of nursing & HCA vacancies

Director of

Nursing &

Quality =16 =16 =16 =16 =16 =16

1942 SO3 - Efficiently and productively provide care within agreed financial limitsEradicating the Trust's deficit

by 2023/24

Director of

Finance =16 =16 =16 =16 =16 =16

1987


services









Haem / Oncology, reduction in

medical capacity following

resignation of consultant

Executive

Medical

Director

=16 =16 =16 12 =12 =12

2052


services





Older Peoples Care

Director of

Nursing &

Quality

!16 =16 =16 =16 =16 =16

2056


services


Missing Patient

appointments/admissions

Chief

Operating

Officer !16 20 =20 =20

2021


services








In Hospital Mortality

Executive

Medical

Director

!15 =15 =15 10 10

1977


services






Peadiatric Dietetics Band 6

Director of

Nursing &

Quality

!15 =15 16

Risk to be

amalgama

ted into

overarchi

ng Fragile

Services

risk

2072 SO3 - Efficiently and productively provide care within agreed financial limitsFailure to achieve 2019/20

financial control total

Director of

Finance !16 =16 =16

2122SO1 Improve clinical outcomes and patient safety to ensure we deliver high quality

servicesMedicines Management

Executive

Medical

Director !15

TB

206_

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Page 130 of 210

Pa

ge

2 o

f 1

4

TR

US

T R

ISK

PR

OF

ILE

AS

AT

26

/11

/20

19

C

ON

SEQ

UEN

CE

(im

pac

t/se

veri

ty)

LIK

ELIH

OO

D

(fre

qu

ency

) In

sign

ific

ant

(1)

Min

or

(2)

Mo

de

rate

(3

) M

ajo

r (4

) C

atas

tro

ph

ic (

5)

Alm

ost

Cer

tain

(5

)

Like

ly (

4)

194

2 –

Era

dic

atin

g th

e T

rust

’s d

efic

it b

y 2

023/

24

207

2 -

Fai

lure

to

ach

ieve

20

19/2

0 fi

nan

cial

co

ntr

ol t

ota

l 2

052

- O

lder

Pe

op

les

Car

e 1

862

- M

ain

tain

ing

safe

qu

alit

y n

urs

ing

care

wit

h c

urr

en

t le

vel o

f n

urs

ing

& H

CA

va

can

cies

1

902

- F

ailu

re t

o c

om

ply

& im

pro

ve

gove

rnan

ce o

f se

rvic

es in

rel

atio

n t

o t

he

area

s o

f n

on

-co

mp

lian

ce id

enti

fied

by

CQ

C

16

88

- In

adeq

uat

e

Staf

fin

g Le

vels

in

An

aest

het

ic D

ep

artm

ent

20

56

– M

issi

ng

Pat

ien

t ap

po

intm

ents

/ad

mis

sio

ns

Po

ssib

le (

3)

21

22

– M

edic

ines

M

anag

eme

nt

Un

likel

y (2

)

Rar

e (

1)

Page 131 of 210

Pa

ge

3 o

f 1

4

Board

/Sub-B

oard

C

om

mitte

e:

Tru

st

Board

R

isk R

eg

iste

r

Str

ate

gic

Ob

jecti

ve

SO

1 -

Im

pro

ve c

linic

al outc

om

es a

nd p

atie

nt safe

ty to e

nsure

we d

eliv

er

hig

h q

ualit

y s

erv

ices

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

14/1

1/2

019

2122

Executive M

edic

al D

irecto

r John W

illia

ms

Me

dic

ines M

anagem

ent

Descri

pti

on

If the tru

st cannot

guara

nte

e S

afe

and S

ecure

Handlin

g o

f M

edic

ines a

nd

Clin

ical P

harm

acy S

erv

ice then t

here

is a

ris

k o

f patie

nt harm

thro

ugh la

ck o

f tim

ely

me

dic

ines r

econcili

atio

n, supply

of

critical m

edic

ines t

o p

atie

nts

, corr

ect pre

scrib

ing a

nd a

dm

inis

tratio

n o

f m

edic

ines a

nd r

isk o

f patie

nts

goin

g h

om

e w

ithout th

e c

orr

ect ta

ke h

om

e m

edic

atio

n.

Co

ntr

ols

P

harm

acis

t clin

ical check f

or

all

non

-sto

ck ite

ms d

urin

g o

penin

g h

ours

. Late

nig

ht ro

ta for

Pharm

acy s

taff a

nd o

n-c

all

serv

ice.

Access t

o E

me

rgency S

tore

out of hours

W

eekend o

penin

g tim

es lim

ited t

o a

n e

me

rgency s

erv

ice

E

lectr

onic

dis

charg

e, in

clu

din

g lin

ks to P

harm

Ou

tcom

es

Locum

cover

for

som

e v

acancie

s

Patie

nts

ow

n m

edic

ines s

tore

d in b

ed s

ide lo

ckers

S

elf a

dm

inis

tratio

n of m

edic

ines, C

ontr

olle

d D

rug a

nd M

edic

ines O

ptim

isatio

n P

olic

ies

Weekly

top u

p a

nd d

ate

checkin

g fro

m p

harm

acy s

taff in

cupboard

s for

mo

st clin

ical are

as;

Ele

ctr

onic

Checklis

t fo

r re

sus t

rolle

ys t

o e

nsure

ite

ms a

re in

date

Gap

s i

n C

on

tro

ls

Insuffic

ient S

taff w

ithin

Pharm

acy D

epart

me

nt to

pro

vid

e

me

dic

ines r

econcili

atio

n w

ithin

24 h

ours

. U

nable

to e

nsure

tim

ely

dis

charg

e m

edic

atio

n d

ue t

o in

suff

icie

nt

sta

ff r

esultin

g in in

suff

icie

nt

openin

g t

ime

s

Imp

act

on p

atie

nt

flo

w d

ue to d

ela

yed d

ischarg

es a

s a

result o

f dela

yed d

ischarg

e m

edic

atio

n n

ot bein

g p

rescrib

ed in

a t

ime

ly

fashio

n

Insuffic

ient re

sourc

e f

or

in-p

atie

nt/dis

charg

e c

ounselli

ng

impactin

g p

oor

in-p

atie

nt surv

ey r

esults, and a

bili

ty for

patie

nts

to

self-a

dm

inis

ter.

R

isk o

f patie

nts

mis

sin

g c

ritical m

edic

ines/t

hera

py.

Unable

to e

nsure

contin

uity o

f supply

of critical m

edic

ines d

ue to

insuffic

ient

ward

based s

erv

ices inclu

din

g w

ard

based p

harm

acy

technic

ians.

Me

dic

ines T

rolle

ys u

nfit fo

r purp

ose.

Inadequate

syste

m for

pre

-pack m

edic

ines c

ontr

ol in

all

are

as

Lack o

f C

D d

estr

uctio

n a

t w

ard

level due t

o la

ck o

f w

ard

based

technic

ians.

Aseptic u

nit Q

CN

W e

xte

rnal audit n

ote

d m

ajo

r concern

s

regard

ing Q

ualit

y R

evie

w s

yste

ms

Lim

ited o

penin

g h

ours

of P

harm

acy M

onday-

Frid

ay 9

-5,

and

reduced s

erv

ice a

nd s

taff

ing 3

hours

Sat

and S

un.

Eff

ect

on P

harm

acy s

taff w

ell-

bein

g a

nd s

ickness r

ate

s d

ue t

o

work

load p

ressure

. Lack o

f centr

al w

irele

ss m

onitorin

g s

yste

m f

or

tem

pera

ture

s in

dru

g s

tora

ge a

reas.

Lack o

f E

PM

A (

ele

ctr

onic

pre

scrib

ing)

trust w

ide.

Anti-c

oagula

nt clin

ics r

un o

n m

inim

al sta

ffin

g

Unable

to u

pdate

to D

rug L

ibra

ry for

IV p

um

ps in a

tim

ely

ma

nner

Poor

upta

ke o

f m

edic

ines m

anagem

ent tr

ain

ing to

mu

ltid

iscip

linary

team

. P

oor

com

ple

tion o

f docum

enta

tio

n.

TB

206_

19 R

isk

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iste

r D

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9

Page 132 of 210

Pa

ge

4 o

f 1

4

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Rev

iew

D

ate

of

Next

Revie

w

P

ossib

le (

3)

Cata

str

ophic

(5)

20

15

Extr

em

e r

isk

4

Mo

dera

te r

isk

21/1

1/2

019

12/1

2/2

019

Assu

ran

ce

Dru

g a

nd T

hera

peutic C

om

mitte

e p

rovid

es M

edic

ines G

overn

ance

and m

eets

mo

nth

ly

Me

dic

ines S

afe

ty C

om

mitte

e m

eets

mo

nth

ly. R

evie

w o

f dru

g a

lert

s a

nd m

edic

ines in

cid

ents

. M

ost lo

w/n

o

harm

. P

harm

acis

t in

terv

entio

n m

onitoring

P

harm

acy G

overn

ance m

onth

ly m

eetin

g. R

evie

w o

f D

ispensin

g e

rrors

S

OC

CA

S w

ard

accre

ditatio

n s

yste

m h

ighlig

hts

are

as o

f good p

ractice a

nd a

reas for

imp

rovem

ent

in

me

dic

ines m

anagem

ent

CD

audits

Gap

s i

n A

ssu

ran

ce

Out

of date

me

dic

ines,

poor

dru

g s

tora

ge a

nd t

em

pera

ture

m

onitorin

g w

ithin

exis

tin

g t

reatm

ent

room

s.

Poor

me

dic

ines r

econcili

atio

n w

ithin

24 h

ours

. C

D P

olic

y r

equires r

evie

w

Poor

attendance a

t M

edic

ines M

anagem

ent

train

ing

Acti

on

Pla

n

PM

O s

upport

pro

vid

ed to the M

edic

al D

irecto

r, C

hie

f P

harm

acis

t, P

harm

acy a

nd N

urs

ing s

taff to c

om

ple

te

the M

edic

ines M

anagem

ent

Develo

pm

ent P

roje

ct

in lin

e w

ith N

HS

I, C

QC

and in

tern

al assessm

ents

to

clo

se t

he G

aps in

assura

nce

Acti

on

Pla

n D

ue

Date

01/1

1/2

021

A

cti

on

Pla

n R

ati

ng

Mo

dera

te

Pro

gre

ss M

ade

La

test

Mo

nth

P

rog

ress

Th

e p

harm

acy b

usin

ess c

ase for

work

forc

e w

as a

ppro

ved a

t th

e t

rust board

7th

Novem

ber2

019 (

for

exte

nded w

eekend w

ork

ing, A

ED

Consultant

pharm

acis

t and w

ard

pharm

acy a

ssis

tants

). A

ny

changes to w

ork

ing h

ours

will

be s

ubje

ct to

sta

ff c

onsultatio

n w

ith s

upport

of

HR

. T

he t

rust

has b

een s

uccessfu

l in

securin

g £

700k o

f fu

ndin

g f

rom

NH

S E

ngla

nd I

nte

gra

ted D

igital C

are

Fu

nd t

o

imple

me

nt an e

lectr

onic

pre

scrib

ing a

nd m

edic

ines a

dm

inis

tratio

n (

EP

MA

) syste

m o

ver

the n

ext

18 m

onth

s w

hic

h w

ill s

upport

patie

nt safe

ty a

nd t

he

dis

charg

e p

rocess.

Page 133 of 210

Pa

ge

5 o

f 1

4

Str

ate

gic

Ob

jecti

ve

SO

1 -

Im

pro

ve c

linic

al outc

om

es a

nd p

atie

nt safe

ty to e

nsure

we d

eliv

er

hig

h q

ualit

y s

erv

ices S

O2 -

Deliv

er

serv

ices t

hat m

eet N

HS

constitu

tio

nal

and r

egula

tory

sta

ndard

s

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

27/0

6/2

019

2056

Chie

f O

pera

tin

g O

ffic

er

Hele

n B

ayth

orp

e

Mis

sin

g P

atie

nt

appoin

tme

nts

/adm

issio

ns

Descri

pti

on

If w

e f

ail

to h

ave a

robust

pro

cess in

pla

ce t

o m

anage O

utp

atie

nt C

linic

and W

ard

outc

om

es then t

here

is a

ris

k w

e w

ill c

ause

harm

to p

atients

due t

o n

ot

pro

vid

ing a

ppro

priate

tre

atm

ent in

a t

ime

ly

ma

nner.

Co

ntr

ols

2 N

on R

TT

valid

ato

rs h

ave c

om

menced in

Tru

st

to r

evie

w h

igh r

isk p

ath

ways in

Uro

logy a

nd

Ophth

alm

olo

gy

Report

re m

issin

g o

utc

om

es in

suite o

f P

TL

report

s to allo

w m

onitoring

S

OP

's in

pla

ce for

ma

nagem

ent

of clin

ic o

utc

om

es

Patie

nt's

giv

en a

dvic

e a

nd c

onta

ct num

ber

to c

all

if n

ot

heard

within

a c

ert

ain

perio

d w

ithin

Uro

logy

GP

lett

ers

ale

rtin

g t

o loss t

o f

ollo

w u

p

Clin

ic o

utc

om

e s

heets

now

reta

ined a

nd o

utc

om

ed o

n t

he d

ay

Clin

ic o

utc

om

e s

heets

now

reta

ined a

nd o

utc

om

ed o

n t

he d

ay

Gap

s i

n C

on

tro

ls

No a

udit o

f pro

cess in p

lace f

or

bookin

g a

ppoin

tme

nts

and lis

tin

g

patie

nts

for

pro

cedure

s

Paper

based p

rocess w

hic

h is f

ragm

ente

d

Lack o

f ele

ctr

onic

syste

m

Logis

tical is

sues o

f clin

ics b

ein

g h

eld

acro

ss s

ites c

ausin

g issues

transfe

rrin

g p

aper

form

s in v

ario

us m

odes

Non R

TT

tra

ckers

la

ck c

apacity to r

evie

w p

ath

ways.

Th

e p

rocess p

uts

the o

nus o

n the p

atie

nt

GP

's m

ay n

ot

ale

rt the loss t

o f

ollo

w u

p in

all

cases.

Sta

ff c

om

ple

te tra

inin

g p

ackage E

nd D

ec 2

019 w

hic

h m

eans

pote

ntia

l fo

r fu

rther

issues c

urr

ently o

ngoin

g.

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Cata

str

ophic

(5)

20

20

Extr

em

e r

isk

5

Mo

dera

te r

isk

18/1

1/2

019

18/1

2/2

019

Assu

ran

ce

Hig

hlig

hte

d t

o t

he B

oard

. P

atie

nts

lo

st to

follo

w-u

p r

eport

ed w

hen id

entifie

d v

ia D

atix

Gap

s i

n A

ssu

ran

ce

Lik

ely

to h

ave a

sig

nific

ant

dela

y p

rio

r to

gain

ing t

he r

ight solu

tio

n

As a

t 11/0

7/1

9 -

12 S

I's r

eport

ed r

ela

tin

g t

o U

rolo

gy a

nd

Ophth

alm

olo

gy

Acti

on

Pla

n

Deliv

ery

again

st th

e T

rust overa

rchin

g lo

st to

follo

w u

p a

ctio

n p

lan

A

cti

on

Pla

n D

ue

Date

31/0

1/2

020

A

cti

on

Pla

n R

ati

ng

Mo

dera

te

Pro

gre

ss M

ade

La

test

Mo

nth

P

rog

ress

Weekly

me

etin

gs c

ontin

ue to take p

lace to u

pdate

on t

he a

ctio

n p

lan w

ith C

CG

repre

senta

tio

n f

ort

nig

htly a

t th

ese m

eetin

gs.

CC

G c

onfirm

that

update

d a

ctio

n p

lan is p

resente

d a

t th

e J

oin

t Q

ualit

y a

nd

perf

orm

ance m

eetin

g.

SO

Ps h

ave b

een a

gre

ed a

nd c

ircula

ted.

Sta

ge 1

of tr

ain

ing h

as n

ow

been c

om

ple

ted w

ith S

tage 2

to b

e c

om

ple

ted b

y e

nd o

f D

ecem

ber

2019.

This

is r

ecord

ed o

n E

RS

to

enable

mo

nitorin

g.

Second tra

cker

is n

ow

tra

ined a

nd t

rackin

g r

eport

as a

bove is a

liv

e d

ocum

ent, w

ith d

aily

update

s.

Busin

ess c

ase h

as b

een w

ritt

en for

substa

ntive p

osts

and w

ill g

o to B

DIS

C D

ec

12th

.In lig

ht of curr

ent C

CG

engagem

ent

and r

eport

ing, T

rust re

quest

report

ing into

contr

act m

eetin

g b

y e

xceptio

n o

nly

.

TB

206_

19 R

isk

Reg

iste

r D

ec 1

9

Page 134 of 210

Pa

ge

6 o

f 1

4

Str

ate

gic

Ob

jecti

ve

SO

1 -

Im

pro

ve c

linic

al outc

om

es a

nd p

atie

nt safe

ty to e

nsure

we d

eliv

er

hig

h q

ualit

y s

erv

ices S

O2 -

Deliv

er

serv

ices t

hat m

eet N

HS

constitu

tio

nal

and r

egula

tory

sta

ndard

s

Lin

k t

o B

AF

SO

2

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

20/0

6/2

018

1862

Directo

r of N

urs

ing &

Qualit

y

Caro

l F

ow

ler

Ma

inta

inin

g s

afe

qualit

y n

urs

ing c

are

with c

urr

ent

level of

nurs

ing &

HC

A v

acancie

s

Descri

pti

on

If le

vels

of

Regis

tere

d N

urs

e &

HC

A s

taff

ing r

em

ain

s b

elo

w funded e

sta

blis

hm

ent

due to v

acancie

s then p

atie

nts

ma

y e

xperie

nce

poor

qualit

y o

f care

(safe

ty &

patie

nt

experie

nce).

Co

ntr

ols

S

afe

Care

mo

nitore

d d

aily

M-F

ri

Daily

sta

ffin

g h

uddle

s w

ith M

atr

ons &

Senio

r nurs

e

Revie

w H

ealth r

oste

r P

olic

y &

com

plia

nce r

atifie

d J

uly

2019

N

HS

P c

ontr

act

Nurs

ing e

sta

blis

hm

ents

ratifie

d a

t T

rust B

oard

Ma

y 2

019

Sta

ffin

g d

ata

revie

ws

See r

isks 1

132 , 2

78 a

nd h

igh r

isk 1

368

D

atix s

yste

m t

o id

entify

if th

ere

has b

een a

harm

of

patie

nts

due to s

taffin

g levels

D

atix s

yste

m in

pla

ce t

o id

entify

if th

ere

has b

een a

harm

of

patie

nts

due t

o s

taff

ing le

vels

in

accord

ance

with N

ICE

're

d' f

lags

Safe

sta

ffin

g r

eport

to W

Fo

rce C

om

m. &

Tru

st B

oard

on a

mo

nth

ly b

asis

T

ier

2 n

urs

e a

gency in p

lace

R

ete

ntio

n g

roup w

ith a

focus o

n R

ecru

itm

ent, s

upport

ed b

y N

HS

I C

ontr

act bookin

g for

RN

agency t

o s

upport

fill

rate

on d

ay s

hifts

during w

inte

r pre

ssure

d m

onth

s

Gap

s i

n C

on

tro

ls

No f

orm

al S

afe

ty H

uddle

at

w/e

nds

Esta

blis

hm

ent re

vie

w n

ot

undert

aken o

n a

6 m

onth

ly b

asis

with

recom

mendatio

ns t

o the T

B

NH

SP

contr

act fo

r re

vie

w in 6

mo

nth

s

Clin

ical w

ork

forc

e P

lan to b

e d

evelo

ped f

ollo

win

g E

sta

blis

hm

ent

revie

w

See r

isks 1

132, 278 a

nd h

igh r

isk 1

368.

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Ma

jor

(4)

20

16

Extr

em

e r

isk

8

Hig

h R

isk

18/1

1/2

019

16/1

2/2

019

Assu

ran

ce

Mo

nth

ly s

taff

ing r

eport

C

QC

in

spectio

n

Qualit

y a

nd s

afe

ty r

eport

s

Com

pla

ints

In

cid

ent re

port

ing

Bi annual sta

ffin

g r

eport

s

ma

ndato

ry tra

inin

g

Work

forc

e d

ata

(sic

kness &

AL)

D

edic

ate

d H

roste

r Lead f

or

N&

M

Esta

blis

hm

ent re

vie

w p

rocess S

OP

ratifie

d b

y H

MB

- M

ay 2

019

Mo

nth

ly E

roste

r m

eetin

gs &

dashboard

in

pla

ce

E-R

oste

r polic

y

QI m

eth

odolo

gy in

pla

ce to s

upport

E-R

oste

r perf

orm

ance

Gap

s i

n A

ssu

ran

ce

Work

forc

e P

lan (

inclu

din

g R

ete

ntion &

Recru

itm

ent)

U

pdate

d E

roste

r polic

y

Ma

trons d

ashboard

/Clin

ical m

etr

ics n

eeds t

o b

e d

evelo

ped

furt

her

Ma

ndato

ry tra

inin

g n

ot

bein

g a

t T

rust re

quired s

tandard

M

anagin

g P

erf

orm

ance F

ram

ew

ork

pro

cess

Acti

on

Pla

n

Fu

ll deta

ils in

sm

art

-sheets

- E

roste

r com

plia

nce

P

rio

ritise tem

pla

te u

plo

ad

Cla

rify

capacity to u

plo

ad t

em

pla

tes for

new

NE

R

Contin

ue 2

weekly

me

etin

g w

ith H

oN

/M &

Ma

trons

NE

R -

deta

iled p

lans o

n s

ma

rt s

heets

- M

odel H

ospital

Unders

tand c

urr

ent data

su

bm

issio

n

Revie

w M

odel hospital fo

r S

&O

data

A

ssess o

pport

unity for

savin

gs b

ased o

n n

ew

data

S

ma

rt s

heets

has d

eta

iled p

lan -

Fin

ance.

Uplo

ad b

udgets

In

form

Wd m

anagers

/Matr

ons o

f final e r

oste

r ro

ta

Acti

on

Pla

n D

ue

Date

27/1

2/2

019

27/1

2/2

019

31/1

2/2

020

31/1

2/2

020

31/1

2/2

020

29/0

6/2

018

31/0

1/2

019

29/0

3/2

019

31/0

5/2

019

Acti

on

Pla

n R

ati

ng

Com

ple

ted

Mo

dera

te

Pro

gre

ss M

ade

Com

ple

ted

Mo

dera

te

Pro

gre

ss M

ade

Mo

dera

te

Pro

gre

ss M

ade

Com

ple

ted

Com

ple

ted

Com

ple

ted

Com

ple

ted

Page 135 of 210

Pa

ge

7 o

f 1

4

Uplo

ad n

ew

tem

pla

tes

Sm

art

sheets

has d

eta

iled p

lan -

Recru

itm

ent

Identify

HR

recru

itm

ent te

am

to s

upport

recru

itm

ent pro

cess

Advert

ise r

ele

vant posts

(R

N,

HC

A, B

4)

Mo

nth

ly r

evie

w o

f vacancie

s, tu

rnover

& p

rogre

ss t

hro

ugh R

&R

Ste

erin

g g

roup

R

evie

w w

ork

forc

e d

ashboard

s to a

ssure

again

st positio

n

Ta

ble

top e

sta

blis

hm

ent re

vie

w O

ct/

Nov 2

019

Sm

art

sheets

have d

eta

iled p

lan -

New

Role

s (

tNA

) P

rocess m

ap c

urr

ent

path

way

Confirm

JD

& P

spec

Cla

rify

tra

inin

g p

rogra

mm

e

Cla

rify

QIA

role

s &

Responsib

ilities

Senio

r nurs

ing s

taff d

eplo

yed t

o identifie

d a

reas to r

evie

w c

urr

ent

nurs

ing p

ractice a

nd c

are

deliv

ery

. D

eplo

ym

ent of senio

r sta

ff t

o w

ard

s id

entifie

d.

Qualit

y im

pro

vem

ent

appro

ach o

f th

e t

hem

es to a

ddre

ss a

ctio

ns f

orm

CQ

C inspectio

n, com

pla

ints

and

incid

ents

C

om

ple

te N

urs

e E

sta

blis

hm

ent

revie

w b

ased o

n n

atio

nal guid

ance

La

test

Mo

nth

P

rog

ress

Contr

act bookin

g for

RN

agency t

o s

upport

fill

rate

on d

ay s

hifts

during w

inte

r pre

ssure

d m

onth

s s

tart

ed w

/c 1

8/1

1/1

9-

appro

xim

ate

ly 2

0 W

TE

. T

able

top e

sta

blis

hm

ent

revie

ws h

ave c

om

menced.

TB

206_

19 R

isk

Reg

iste

r D

ec 1

9

Page 136 of 210

Pa

ge

8 o

f 1

4

Str

ate

gic

Ob

jecti

ve

SO

1 -

Im

pro

ve c

linic

al outc

om

es a

nd p

atie

nt safe

ty to e

nsure

we d

eliv

er

hig

h q

ualit

y s

erv

ices S

O2 -

Deliv

er

serv

ices t

hat m

eet N

HS

constitu

tio

nal

and r

egula

tory

sta

ndard

s S

O3 -

Effic

iently a

nd p

roductively

pro

vid

e c

are

within

agre

ed fin

ancia

l lim

its S

O4 -

Develo

p a

fle

xib

le,

responsiv

e

work

forc

e o

f th

e r

ight siz

e a

nd w

ith t

he r

ight skill

s w

ho feel valu

ed a

nd m

otivate

d S

O5 -

Enable

all

sta

ff t

o b

e p

atie

nt-

cente

red le

aders

build

ing o

n

an o

pen a

nd h

onest culture

and t

he d

eliv

ery

of

the T

rust valu

es S

O6 -

Engage s

trate

gic

part

ners

to m

axim

ise t

he o

pport

unitie

s to d

esig

n a

nd

deliv

er

susta

inable

serv

ices for

the p

opula

tio

n o

f S

outh

port

, F

orm

by a

nd W

est Lancashire

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

19/0

9/2

018

1902

Directo

r of N

urs

ing &

Qualit

y

Brid

get

Lees

Fa

ilure

to c

om

ply

& im

pro

ve g

overn

ance o

f serv

ices in

rela

tio

n to t

he a

reas o

f non-c

om

plia

nce id

entified b

y

CQ

C

Descri

pti

on

If w

e f

ail

to c

om

ply

with r

egula

tory

fra

me

work

then t

his

will

result in

bre

ach o

f th

e T

rust re

gula

tio

n a

nd p

ote

ntia

l le

gal

actio

n,

poor

patie

nt

experie

nce, unsafe

and p

oor

qualit

y o

f care

, and lack o

f public

confid

ence in t

he T

rust

Co

ntr

ols

enhanced t

eam

to s

upport

DoN

deliv

er

expecta

tio

ns

Imp

rovem

ent

pla

ns d

evelo

ped a

nd a

gre

ed w

ith tru

st B

oard

Im

pro

vem

ent

gro

ups d

evelo

ped a

cro

ss T

rusts

, in

clu

din

g C

BU

s

Identifie

d E

xecutive a

nd m

anagem

ent

leads f

or

Perf

orm

ance, qualit

y, people

and u

se o

f re

sourc

es

develo

pm

ent of a s

hare

d d

rive t

o e

nable

evid

ence t

o b

e u

plo

aded

develo

pm

ent of aw

are

ness r

ais

ing a

nd p

repara

tion

for

key le

aders

at B

oard

and C

BU

level

identifie

d s

upport

fro

m P

MO

with p

roje

ct m

anagem

ent

Well-

led w

ork

ongoin

g w

ith A

QU

A

PIR

com

ple

ted a

nd s

ubm

itte

d 0

3.0

5.1

9

Board

Info

rma

tio

n P

acks d

evelo

ped a

nd E

xecutive a

nd N

on-E

xecutive C

oachin

g p

lanned

Sta

ff a

ware

ness b

ookle

ts d

istr

ibute

d

Depart

me

nta

l aw

are

ness s

essio

ns p

lanned f

or

all

sta

ff

Use o

f R

esourc

es p

lannin

g p

repara

tio

n le

t by I

nte

rim

Tu

rn A

round D

irecto

r

Fa

ctu

al A

ccura

cy C

heckin

g C

om

ple

ted a

nd s

ubm

itte

d w

ithin

tim

escale

s a

nd s

igned o

ff b

y I

nte

rim

Chie

f E

xecutive

Gap

s i

n C

on

tro

ls

CQ

C id

entifie

d 9

6 M

US

T A

ND

SH

OU

LD

DO

actio

ns f

ollo

win

g

Novem

ber

and D

ecem

ber

2017 inspectio

n

Lack o

f pace a

nd a

ssura

nce r

egard

ing p

rogre

ss o

f actio

n p

lan

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Ma

jor

(4)

16

16

Extr

em

e r

isk

12

Hig

h R

isk

18/1

1/2

019

23/1

2/2

019

Assu

ran

ce

com

mitte

e s

tructu

re

regula

r engagem

ent

me

etin

gs

assura

nce a

t qualit

y a

nd s

afe

ty &

com

mitte

e

CB

U m

onth

ly g

overn

ance m

eetin

gs

develo

pm

ent of a s

ingle

qualit

y im

pro

vem

ent

actio

n p

lan

engage a

nd g

ain

support

for

valid

atio

n f

rom

HealthW

atc

h,

CC

G a

nd o

ther

regula

tors

C

ore

serv

ice r

evie

w id

entifie

d s

om

e a

reas o

f im

pro

vem

ent

inclu

din

g o

penness o

f sta

ff, S

taff a

re c

arin

g,

com

passio

nate

and there

are

exam

ple

s o

f good p

ractice, sta

bili

ty o

f le

aders

hip

and n

o a

reas w

ere

consid

ere

d to b

e ‘in

adequate

’ on b

oth

days

Inte

rnal assura

nce p

anels

F

ollo

win

g s

ubm

issio

n o

f P

IR -

Pre

para

tio

n P

lan U

pdate

d a

nd K

LO

Es id

entifie

d

QID

Me

etin

g re

-esta

blis

hed

First unannounced inspectio

n w

/c 0

8.0

7.1

9

Second u

nannounced in

spectio

n w

/c 3

0.0

7.1

9

Me

dic

ines m

anagem

ent im

pro

vem

ent

pla

n d

evelo

ped &

agre

ed w

ith N

HS

E &

I &

share

d w

ith C

QC

Lett

er

subm

itte

d to C

QC

id

entify

ing im

pro

vem

ents

ma

de s

ince in

spectio

ns

Fa

ctu

al A

ccura

cy C

heckin

g C

om

ple

ted a

nd s

ubm

itte

d w

ithin

tim

escale

s a

nd s

igned o

ff b

y I

nte

rim

Chie

f E

xecutive

Gap

s i

n A

ssu

ran

ce

Engagem

ent

of key le

aders

fro

m 'w

ard

to b

oard

' re

duced u

nders

tandin

g o

f expecta

tio

ns o

f re

gula

tor

prio

r, d

urin

g

and a

fter

inspectio

ns

A n

um

ber

of

gaps id

entifie

d d

urin

g c

ore

serv

ices r

evie

w, th

ese

are

bein

g a

ddre

ssed t

hro

ugh Q

ualit

y Im

pro

vem

ent P

lan.

C

QC

Inspectio

n J

uly

id

entifie

d issues w

ith M

edic

ines

Ma

nagem

ent, M

CA

/ D

oLs a

nd o

ther

are

as f

or

furt

her

impro

vem

ent

F

eedback r

eceiv

ed fro

m C

QC

facili

tie

s f

ocus g

roup h

ighlig

htin

g

dis

conte

nt

in team

and issues w

ith c

ulture

and c

om

mu

nic

atio

n

Acti

on

Pla

n

Incorp

ora

te a

ny R

ed M

ust

Do A

ctions into

CB

U R

isk R

egis

ter

M

onitor

facili

ties f

ocus g

roup a

ction p

lan t

hro

ugh q

ualit

y a

ssura

nce p

anels

A

cti

on

Pla

n D

ue

Date

17/0

7/2

019

28/0

2/2

020

A

cti

on

Pla

n R

ati

ng

Com

ple

ted

Little o

r N

o

Page 137 of 210

Pa

ge

9 o

f 1

4

Fa

ctu

al accura

cy t

o b

e c

om

ple

ted w

ithin

agre

ed tim

e s

cale

s o

f 10 d

ays.

w

ork

with c

om

munic

atio

ns team

to e

ngage w

idely

with s

taff

develo

p t

rain

ing f

or

sta

ff a

cro

ss t

he o

rganis

atio

n

Key le

aders

to a

ccess tra

inin

g w

ith le

ad C

QC

executive/m

anager

Esta

blis

h c

onfirm

and c

halle

nge s

essio

ns for

each a

ctio

n a

nd c

ore

serv

ice t

o e

xpedite p

rogre

ss a

gain

st

actio

n P

lan,

and lo

ok a

t re

-esta

blis

hin

g t

he Q

ualit

y Im

pro

vem

ent D

evelo

pm

ent

(QID

)Gro

up

To

deliv

er

again

st th

e 9

6 M

US

T a

nd S

HO

ULD

DO

CQ

C r

ecom

me

ndatio

ns o

utlin

ed in

the o

vera

rchin

g

CQ

C A

ctio

n P

lan.

29/1

1/2

019

30/0

9/2

019

28/0

6/2

019

22/1

0/2

019

29/1

1/2

019

Pro

gre

ss M

ade

Com

ple

ted

Com

ple

ted

Com

ple

ted

Actio

ns A

lmost

Com

ple

ted

Mo

dera

te

Pro

gre

ss M

ade

La

test

Mo

nth

P

rog

ress

Th

e T

rust

is c

urr

ently a

waitin

g the C

QC

report

whic

h is e

xpecte

d b

y the e

nd o

f N

ovem

ber.

Th

is r

isk w

ill b

e u

pdate

d o

n r

eceip

t of th

is r

eport

.

TB

206_

19 R

isk

Reg

iste

r D

ec 1

9

Page 138 of 210

Pa

ge

10

of

14

Str

ate

gic

Ob

jecti

ve

SO

1 -

Im

pro

ve c

linic

al outc

om

es a

nd p

atie

nt safe

ty to e

nsure

we d

eliv

er

hig

h q

ualit

y s

erv

ices S

O2 -

Deliv

er

serv

ices t

hat m

eet N

HS

constitu

tio

nal

and r

egula

tory

sta

ndard

s S

O3 -

Effic

iently a

nd p

roductively

pro

vid

e c

are

within

agre

ed fin

ancia

l lim

its S

O6 -

Engage s

trate

gic

part

ners

to

ma

xim

ise t

he o

pport

unitie

s to d

esig

n a

nd d

eliv

er

susta

inable

serv

ices for

the p

opula

tio

n o

f S

outh

port

, F

orm

by a

nd W

est

Lancas

hire

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

13/0

6/2

019

2052

Directo

r of N

urs

ing &

Qualit

y

Me

gan L

angle

y

Old

er

People

s C

are

Descri

pti

on

If there

is c

ontin

ued p

oor

qualit

y c

are

deliv

ere

d in p

art

icula

r to

old

er

people

in

South

port

& O

rmskirk N

HS

Tru

st, c

ontin

ue t

hen h

arm

may b

e c

aused to o

ur

old

er

patie

nts

im

pactin

g n

egatively

on their

qualit

y o

f lif

e, fu

nctio

n a

nd e

xperience. T

he a

reas o

f concern

rela

te to s

pecific

pra

ctices:

•Deconditio

nin

g o

f patie

nts

•T

he in

appro

pria

te u

se o

f bed r

ails

•P

oor

mo

uth

care

•P

oor

nutr

itio

n a

ssessm

ent

and m

anagem

ent

•Poor

hydra

tio

n m

anagem

ent

•Poor

contin

ence a

ssessm

ent

and m

anagem

ent

•Lack o

f in

tera

ctio

n a

nd s

ocia

l/cognitiv

e s

tim

ula

tion in

cre

asin

g c

onfu

sio

n a

nd d

elir

ium

•

A lack o

f educatio

n a

nd tra

inin

g s

pecific

ally

in c

arin

g f

or

old

er

people

•

A lack o

f end o

f lif

e c

are

education s

trate

gy w

ithin

the T

rust

•Lim

ited a

vaila

bili

ty o

f G

eria

tric

ians to p

rovid

e h

olis

tic c

om

pre

hensiv

e a

ssessm

ent

and a

dvanced c

are

ma

nagem

ent

pla

ns for

pa

tie

nts

in a

dditio

n t

o lim

ited c

linic

al support

for

the F

railt

y P

ractitio

ners

•I

nabili

ty to d

ischarg

e p

atie

nts

hom

e d

ue to lack o

f re

sourc

e t

o s

upport

at hom

e p

art

icula

rly c

are

and r

ehabili

tatio

n p

rovis

ions in t

he c

om

mu

nity

•Poorly e

sta

blis

hed p

ath

way for

patie

nts

with s

pin

al fr

actu

res

•An e

nvironm

ent

not conduciv

e to s

tim

ula

ting p

eople

and e

nablin

g t

hem

to m

ain

tain

and m

axim

ise their f

unctio

n

•Th

e la

ck o

f a form

ally

agre

ed f

railt

y p

ath

way a

nd m

odel

Co

ntr

ols

R

ed2G

reen r

olle

d o

ut

- T

hera

py d

evelo

pin

g a

com

pete

ncy a

nd t

rain

ing f

or

sta

ff to b

e e

quip

ped t

o c

hair a

nd

challe

nge in a

consis

tent

way s

usta

inin

g t

he R

ed2G

reen p

rincip

les a

t board

rounds a

cro

ss t

he T

rust.

N

utr

itio

n -

New

polic

y a

ppro

ved, N

ew

E-le

arn

ing m

odule

pro

vid

ed to R

Ns o

n w

ard

10B

with n

ew

care

pla

ns

bein

g t

este

d -

in

additio

n t

o t

his

, additio

nal D

iete

tic s

upport

is b

ein

g o

ffere

d t

o t

his

ward

while

they

imple

me

nt th

e n

ew

pra

ctices. B

usin

ess I

nte

llig

ence a

re w

ork

ing o

n a

new

colle

ctio

n o

f K

PIs

to m

easure

and m

onitor

impro

vem

ent.

Mo

uth

Care

- 5 s

taff c

om

ple

ted M

outh

Care

Matt

ers

Tra

in t

he T

rain

er

pro

gra

mm

e-

curr

ently d

evelo

pin

g

new

polic

y, care

pla

ns a

nd p

roduct

availa

bili

ty.

Dem

entia

& D

elir

ium

- N

ew

cognitiv

e r

isk a

ssessm

ent and c

are

pla

n b

ein

g t

ria

led o

n 6

ward

s w

ith n

ew

patie

nt

info

rma

tio

n le

afle

ts a

nd r

eport

ing o

f F

AIR

natio

nally

on a

new

pro

form

a a

s t

he s

cre

enin

g t

ool has

been c

hanged. T

his

is b

ein

g r

evie

wed a

fter

1 m

onth

(end o

f June)

for

any a

me

ndm

ents

and f

urt

her

roll

out.

F

alls

- 6

ward

s u

sin

g n

ew

ris

k a

ssessm

ent, c

are

pla

n a

nd d

aily

checklis

t w

ith n

ew

e-le

arn

ing m

odule

accessib

le to s

taff f

or

com

ple

tio

n. T

his

is b

ein

g r

evie

wed a

fter

1 m

onth

(end o

f June)

for

any a

me

ndm

ents

and f

urt

her

roll

out.

B

edra

ils-

6 w

ard

s tria

ling n

ew

ris

k a

ssessm

ent, c

are

pla

n a

nd d

aily

check -

bein

g r

evie

wed a

fter

1 m

onth

(e

nd o

f June)

for

any a

me

ndm

ents

and f

urt

her

roll

out. (

Educatio

n inclu

ded in

falls

e-le

arn

ing m

odule

) F

railt

y T

eam

deliv

erin

g s

erv

ice M

-F in

AE

D a

nd in

-reachin

g -

contin

uin

g t

o w

ork

on c

om

pete

ncie

s

part

icula

rly a

round C

GA

com

ple

tion.

As p

art

of th

e R

ed2G

reen, E

ndP

Jpara

lysis

Get

Up,

Get

Dre

ssed, K

eep M

ovin

g w

as in

troduced -

this

will

be f

orm

ally

la

unched a

s a

pro

ject

in J

uly

as p

art

of th

e T

rust's

QI

work

.

Gap

s i

n C

on

tro

ls

Care

pla

ns n

ot alw

ays u

sed a

ppro

pria

tely

and n

ot all

care

pla

ns

are

appro

pria

te -

these a

re b

ein

g r

evie

wed b

y t

he d

ocum

enta

tio

n

gro

up

F

alls

and b

ed r

ails

new

ris

k a

ssessm

ent and c

are

pla

ns in 6

w

ard

s b

ein

g t

riale

d -

need to c

ontinue r

oll-

out.

Inabili

ty to c

onsis

tently s

taff a

dditio

nal care

bay

Tra

inin

g f

or

sta

ff r

e:

old

er

people

ris

ks n

ot curr

ently p

rovid

ed -

N

ew

Tra

inin

g P

rogra

mm

e t

o b

e launched e

nd o

f July

. E

nvironm

ent

not conduciv

e to r

eablin

g p

atie

nts

and m

ain

tain

ing

functio

n, socia

l in

tera

ctio

n o

r orie

nta

tio

n.

Environm

ent

not

wholly

adapte

d f

or

additio

nal/enhanced c

are

needs e

g d

em

entia

Lack o

f unders

tandin

g o

f th

e im

pact of

patie

nts

rem

ain

ing in b

ed,

in p

ads, w

ith c

ot sid

es, not eatin

g/d

rin

kin

g -

New

Tra

inin

g

Pro

gra

mm

e to b

e la

unched e

nd o

f July

. Lack o

f path

way/s

erv

ice a

vaila

bili

ty to s

upport

patie

nts

with

enhanced n

eeds r

etu

rnin

g h

om

e-

i.e. la

ck o

f 24hour

care

in

com

mu

nity to s

tep d

ow

n -

Work

underw

ay w

ith C

CG

, C

om

mu

nity

and L

A c

olle

agues t

o r

edesig

n p

ath

way,

Hom

efirs

t and

Delir

ium

/Dem

entia

. N

ot

yet com

me

nced m

outh

care

roll-

out

Docum

enta

tio

n n

ot conduciv

e to p

rovid

ing p

ers

on

-centr

ed c

are

, th

is is to b

e r

evie

wed a

s a

n e

ntity

July

2019 (

part

icula

rly c

are

pla

ns a

nd r

isk a

ssessm

ents

) C

linic

al superv

isio

n f

or

the fra

ilty team

lackin

g-

explo

rin

g u

se o

f Leeds B

uddy a

rrangem

ent to

support

. C

ontin

ence p

roje

ct not yet com

menced

- scopin

g s

essio

n 2

5/6

/19

to p

lan im

pro

vem

ent

work

Page 139 of 210

Pa

ge

11

of

14

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Ma

jor

(4)

16

16

Extr

em

e r

isk

8

Hig

h R

isk

18/1

1/2

019

18/1

2/2

019

Assu

ran

ce

CQ

C R

evie

w

G

ap

s i

n A

ssu

ran

ce

Need t

o d

evelo

p in

tern

al assura

nce o

f im

pro

ved q

ualit

y a

round

all

dom

ain

s lis

ted in t

he h

azard

. N

eed t

o d

evelo

p a

ctio

n p

lan a

nd

RA

G r

ate

, id

entify

pro

jects

and le

ads for

the im

pro

vem

ents

whic

h

have b

een id

entifie

d.

Need t

o c

om

mence a

udits o

f old

er

people

incid

ents

, harm

, im

pact

of

adm

issio

n, causes o

f 'red d

ays' and d

ela

ys b

etw

een

bein

g f

it t

o le

ave a

nd le

avin

g h

ospital.

Acti

on

Pla

n

Esta

blis

h a

nd d

evelo

p s

taff k

now

ledge,

focus a

nd e

ducatio

n o

n p

atient

functio

n. E

nsu

re a

ppro

pria

te

equip

me

nt

availa

ble

, develo

p r

esourc

e b

oxes s

pecific

ally

for

patie

nts

with c

ognitiv

e im

pairm

ent, d

evelo

p

actio

n p

lanners

for

engagin

g a

nd s

tim

ula

tin

g a

ctivitie

s o

n the w

ard

s.

Fa

lls p

olic

y e

xpired.

Fa

lls E

ducatio

n n

ot

esta

blis

hed/p

rovid

ed.

Falls

docum

enta

tio

n r

evie

w.

Fa

lls r

eport

ing a

nd K

PIs

to b

e r

evie

wed.

Fa

lls s

trate

gy to b

e d

evelo

ped.

Pre

vio

us p

olic

y for

nutr

itio

n s

cre

enin

g d

id n

ot com

ply

with b

est

pra

ctice o

r natio

nal guid

ance. P

ractices

there

fore

did

not alig

n e

ither.

E

sta

blis

h T

rain

ing P

rogra

mm

e f

or

Old

er

People

s C

are

M

outh

Care

pro

vis

ion o

f care

- r

evie

w o

f polic

y, care

pla

n,

educatio

n a

nd c

are

pro

vis

ion r

equired.

Esta

blis

h a

clin

ical path

way a

nd p

ractice for

the a

ssessm

ent and m

anagem

ent

of contin

ence f

or

patie

nts

. T

his

will

in

volv

e w

ritin

g a

path

way/p

olic

y, care

pla

ns, educatio

n p

ackage a

nd c

ham

pio

ns o

n t

he w

ard

s w

ith

a r

oll

out pla

n for

the n

ew

pra

ctices.

To

esta

blis

h a

path

way f

or

adults in t

he a

cute

sett

ing t

o p

rovid

e tim

ely

scre

enin

g f

or

delir

ium

/dem

entia

, ask

the c

ase fin

din

g q

uestio

n,

ensure

appro

pria

te f

urt

her

assessm

ent, c

are

, fo

llow

-up a

nd s

upport

for

the

patie

nt, c

are

r and f

am

ily. T

o e

nable

this

- p

rovid

e s

taff t

he a

ppro

pria

te e

ducatio

n.

Acti

on

Pla

n D

ue

Date

28/0

2/2

020

31/0

1/2

020

30/0

4/2

020

31/1

2/2

019

31/0

3/2

020

31/0

3/2

020

28/0

2/2

020

Acti

on

Pla

n R

ati

ng

Mo

dera

te

Pro

gre

ss M

ade

Actio

ns A

lmost

Com

ple

ted

Actio

ns A

lmost

Com

ple

ted

Com

ple

ted

Mo

dera

te

Pro

gre

ss M

ade

Mo

dera

te

Pro

gre

ss M

ade

Mo

dera

te

Pro

gre

ss M

ade

La

test

Mo

nth

P

rog

ress

Date

s h

ave b

een s

et fo

r 2020 f

or

the O

lder

People

’s C

are

Tra

inin

g P

rogra

mm

e.

Falls

ris

k a

ssessm

ent and c

are

bundle

on a

ll w

ard

s e

xcept

Inte

nsiv

e C

are

and w

ill b

e in

Inte

nsiv

e C

are

by t

he e

nd o

f N

ovem

ber,

when the o

ld c

are

pla

ns w

ill b

e r

em

oved fro

m t

he in

tranet. T

he n

ew

post-

falls

assessm

ent

is s

till

bein

g t

este

d o

n 2

ward

s w

ith the in

tentio

n o

f la

unchin

g o

n a

ll w

ard

s a

t th

e e

nd o

f N

ovem

ber.

A F

alls

report

ing d

ashboard

is b

ein

g d

evelo

ped, fo

llow

ing t

his

the d

ata

will

need t

o b

e r

evie

wed a

nd t

hen c

leansed.

Th

e F

alls

Str

ate

gy w

as r

evie

wed a

t N

MG

and f

ollo

win

g a

few

am

endm

ents

will

be a

ppro

ved a

nd la

unched in

the f

orm

of an 'I

mp

rovem

ent P

lan' by the e

nd o

f N

ovem

ber.

Th

e D

em

entia

resourc

e b

oxes a

re b

ein

g d

iscussed w

ith p

rocure

me

nt

and in

fectio

n c

ontr

ol,

once a

gre

ed a

charita

ble

funds b

id w

ill b

e c

reate

d t

o m

ake the p

urc

hases.

Th

ese w

ill then b

e u

sed in c

onju

nctio

n w

ith the a

ctivity p

lanners

and the e

ndP

Jpara

lysis

in

itia

tive to

get patie

nts

up,

dre

ssed

and m

ovin

g. T

his

pie

ce o

f w

ork

has b

een initia

ted o

n o

ne w

ard

and a

roll

out pla

n is b

ein

g d

evelo

ped.

Dem

entia

and D

elir

ium

Te

am

appro

ved in b

usin

ess c

ase,

one m

em

ber

in p

ost, A

dm

iral N

urs

e t

o

sta

rt 1

6/1

2/1

9 a

nd fin

al post to

com

mence b

efo

re e

nd o

f F

ebru

ary

2020.

Te

am

com

mencin

g im

media

te w

ork

on id

entify

ing c

ognitiv

e im

pairm

ent, a

nd r

olli

ng o

ur

risk a

ssessm

ent and c

are

pla

n -

this

is

in a

ll are

as w

ith t

he e

xceptio

n o

f In

tensiv

e C

are

and w

ill b

e in

all

are

as b

y the e

nd o

f N

ovem

ber

2019. 8 M

em

bers

of sta

ff h

ave n

ow

com

ple

ted t

he H

ealth E

ducatio

n E

ngla

nd T

rain

the T

rain

er

cours

e

for

Mo

uth

Care

. T

he p

roje

ct te

am

are

testin

g the n

ew

assessm

ent, e

ducatio

n, care

pla

n a

nd p

roduct

range o

n w

ard

14B

with a

roll-o

ut

pla

n e

sta

blis

hed for

the r

em

ain

ing w

ard

s. E

ducatio

n b

ein

g

pro

vid

ed a

t w

ard

le

vel durin

g w

ard

out

and a

lso m

onth

ly o

n t

he O

lder

People

s C

are

Tra

inin

g P

rogra

mm

e.

Refr

esh o

f th

e C

ontin

ence p

roje

ct is

underw

ay w

ith n

ew

focus o

f ta

rgetin

g o

ne w

ard

(7A

&B

)

to t

est new

range o

f pro

ducts

, assessm

ent, c

are

pla

n a

nd o

nw

ard

refe

rral/path

way.

Dem

onstr

able

im

pro

vem

ent on d

ashboard

for

MU

ST

scre

enin

g feedback to the w

ard

. F

urt

her

roll-

out

now

bein

g

schedule

d a

s t

he n

ew

Die

tetic le

ad h

as c

om

me

nced in

post and is p

rio

ritisin

g t

his

pie

ce o

f w

ork

. P

rio

r to

furt

her

roll-o

ut how

ever

their inte

ntio

n is to tw

eak the c

are

pla

n to a

lign a

gain

to b

est

pra

ctice

and t

he n

ew

tem

pla

tes b

ein

g u

sed o

n t

he w

ard

s c

urr

ently. S

taff a

re r

eceiv

ing e

ducatio

n o

n t

he O

lder

People

s C

are

Tra

inin

g P

rogra

mm

e a

nd a

TN

A is u

nde

rway to a

dd t

he e

-le

arn

ing m

odule

for

BA

PE

N N

utr

itio

n t

o a

ppro

pria

te p

rofile

s f

or

sta

ff t

o c

om

mence c

om

ple

tio

n.

TB

206_

19 R

isk

Reg

iste

r D

ec 1

9

Page 140 of 210

Pa

ge

12

of

14

Str

ate

gic

Ob

jecti

ve

SO

1 -

Im

pro

ve c

linic

al outc

om

es a

nd p

atie

nt safe

ty to e

nsure

we d

eliv

er

hig

h q

ualit

y s

erv

ices S

O3 -

Effic

iently a

nd p

roductively

pro

vid

e c

are

w

ithin

agre

ed fin

ancia

l lim

its S

O4 -

Develo

p a

fle

xib

le,

responsiv

e w

ork

forc

e o

f th

e r

ight siz

e a

nd w

ith the r

ight skill

s w

ho feel valu

ed a

nd

mo

tivate

d S

O6 -

Engage s

trate

gic

part

ners

to m

axim

ise t

he o

pport

unitie

s t

o d

esig

n a

nd d

eliv

er

susta

inable

serv

ices for

the p

opula

tio

n o

f S

outh

port

, F

orm

by a

nd W

est

Lancashire

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

13/1

1/2

017

1688

Chie

f O

pera

tin

g O

ffic

er

Ma

ndy M

ars

h

Inadequate

Sta

ffin

g L

evels

in A

naesth

etic D

epart

me

nt

Descri

pti

on

Sta

ffin

g L

evels

of

anaesth

etic d

epart

me

nt

aff

ectin

g c

apacity a

nd s

afe

ty o

f em

erg

ency/IC

U/M

ate

rnity c

over.

Lack o

f em

erg

ency c

over

for

on c

all

/ IC

U / m

ate

rnity b

oth

sites. T

his

would

result in t

he c

losure

of

hig

h r

isk p

atie

nts

pre

sentin

g to A

&E

for

both

adult a

nd c

hild

ren a

nd the inabili

ty t

o s

taff IT

U.

Co

ntr

ols

In

tern

al/exte

rnal Locum

s a

naesth

etists

to c

over

short

fall

caused b

y v

acancie

s

People

to w

ork

additio

nal hours

to fill

extr

a s

essio

ns

Ele

ctive lis

ts c

ancelle

d to e

nsure

cover

when n

eeded

Change t

o o

n-c

all

syste

m to e

nsure

full

covera

ge;

1st on c

all

onsite &

2nd o

n c

all

support

ing w

ithin

core

hours

In

terim

support

fro

m s

taff p

ain

managem

ent short

fall

Agency locum

s b

ein

g s

ought to

support

gaps

Gap

s i

n C

on

tro

ls

Availa

bili

ty o

f sta

ff t

o c

over

vacant shifts

at a m

inim

um

due to

burn

out/

sic

kness/a

nnual le

ave

Lack o

f agency s

taff

within

capped r

ate

10 v

acancie

s r

em

ain

in s

erv

ice

1 c

onsultant taken o

ut of core

theatr

e s

essio

ns t

o r

un p

ain

activity;

back fill

ing those s

essio

ns w

ith W

LI's

whic

h h

as b

een

appro

ved t

o the e

nd o

f th

e y

ear

by S

S

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Cata

str

ophic

(5)

20

20

Extr

em

e r

isk

5

Mo

dera

te r

isk

13/1

1/2

019

13/1

2/2

019

Assu

ran

ce

Mo

nth

ly P

lanned C

are

govern

ance m

eetin

gs

PC

ris

k r

evie

w m

eetin

g w

ith A

DO

/HoN

Gap

s i

n A

ssu

ran

ce

Acti

on

Pla

n

Revie

win

g jo

b d

escrip

tio

ns to b

e in lin

e w

ith n

atio

nal re

quirem

ents

. C

ontin

ue t

o a

dvert

ise to r

ecru

it t

o p

osts

. W

ork

forc

e s

trate

gy m

eetings s

et up w

ith C

OO

& M

D in

support

to

addre

ss. 1st m

eetin

g h

eld

on 0

6/1

1/1

8 w

ith t

he n

ext m

eetin

g s

chedule

d f

or

29/1

1/1

8. T

eam

are

actively

seekin

g s

olu

tio

ns t

o a

ddre

ss g

aps in

the w

ork

forc

e a

nd lo

okin

g a

t new

ways o

f w

ork

ing t

o b

oth

the o

n c

all

rota

(s)

and s

taff

ing e

sta

blis

hm

ent.

Update

29.0

1.1

9 -

Busin

ess c

ase c

urr

ently w

ith f

inance follo

win

g w

ork

forc

e r

evie

w.

Imp

lem

ent

new

ways

of

work

ing u

sin

g s

upport

sta

ff to m

ain

tain

safe

sta

ffin

g levels

and r

obust successio

n p

lan in

vie

w o

f extr

em

e r

ecru

itm

ent and r

ete

ntio

n issues.

12.0

2.1

9 -

Busin

ess C

ase p

resente

d a

t B

DIS

C, fo

r H

MB

next w

eek. If

appro

ved,

recru

itm

ent

drive to

advert

ise/a

ppoin

t to

posts

- f

ore

cast 6 m

onth

s t

o r

ecru

it -

full

qualif

icatio

n o

f som

e s

taff in

post w

ill b

e 2

years

. A

wait o

utc

om

e o

f H

MB

next w

eek.

17.0

4.1

9 S

till

aw

aitin

g fin

al appro

val

Update

;16.0

5.1

9 -

Busin

ess c

ase for

fin

al sig

n o

ff a

t H

MB

on 2

2.0

5.1

9

Update

01.0

7.1

9 -

still

aw

aitin

g f

inal sig

n o

ff -

back t

o H

MB

B

usin

ess c

ase a

ppro

ved a

nd a

ll advert

s w

ill g

o o

ut.

Acti

on

Pla

n D

ue

Date

18/1

2/2

017

13/1

2/2

019

Acti

on

Pla

n R

ati

ng

Com

ple

ted

Mo

dera

te

Pro

gre

ss M

ade

La

test

Mo

nth

P

rog

ress

Recru

ited to 1

substa

ntive C

onsultant

and 2

Tru

st

locum

Consultant fixed term

posts

. S

ubsta

ntive c

om

me

nced 1

1.1

1.1

9 a

nd 1

of th

e T

rust lo

cum

s c

om

menced o

n 0

4.1

1.1

9.

Th

e 3

rd T

rust

locum

was

only

appoin

ted 1

2/1

1 (

inte

rnal),

but

this

will

cre

ate

a furt

her

SA

S D

r post. W

e h

ave a

ppoin

ted 3

x S

AS

Dr's a

nd p

re -

em

plo

ym

ent checks u

nderw

ay.

We s

till

have 3

x I

CU

Consultant and 1

Pain

M

anagem

ent vacancie

s, 3 x

SA

S D

r V

acancie

s a

nd 1

Clin

ical F

ello

w.

Th

e r

isk is t

o r

em

ain

extr

em

e u

ntil all

posts

are

recru

ited

to a

s the I

CU

ele

me

nt is

still

extr

em

e.

Page 141 of 210

Pa

ge

13

of

14

Str

ate

gic

Ob

jecti

ve

SO

3 -

Effic

iently a

nd p

roductively

pro

vid

e c

are

within

agre

ed f

inancia

l lim

its

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

15/0

1/2

019

1942

Directo

r of F

inance

Ste

ve S

hanahan

Era

dic

atin

g t

he T

rust's

deficit b

y 2

023/2

4

Descri

pti

on

If the T

rust does n

ot re

config

ure

serv

ices a

nd in

vest in

its

infr

astr

uctu

re t

hen it w

ill n

ot m

ake s

ignific

ant fin

ancia

l im

pro

vem

ents

again

st th

e c

urr

ent

deficit. It w

ill then b

e u

nable

to c

om

ply

with N

HS

O

pera

tio

nal P

lannin

g a

nd C

ontr

actin

g G

uid

ance 2

019/2

0 w

hic

h s

tate

s that

all

Tru

st deficits s

hould

be e

radic

ate

d b

y 2

023/2

4.

Co

ntr

ols

S

yste

m B

oard

set

up t

o m

anage fin

ancia

l re

covery

of th

e h

ealth e

conom

y

Mo

nth

ly r

un r

ate

report

s,

Tru

st and C

BU

T

urn

aro

und D

irecto

r re

vie

w o

f fin

ancia

l govern

ance

PM

O in

pla

ce to a

ssis

t th

e d

rive f

or

inte

rnal effic

iencie

s id

entifie

d thro

ugh M

odel H

ospital

GIR

FT

pro

gra

mm

e c

om

me

nced w

ith f

utu

re r

oll

out to

oth

er

specia

ltie

s p

roposed

Gap

s i

n C

on

tro

ls

Fu

ture

clin

ical m

odel still

to b

e fin

alis

ed a

nd c

oste

d

Accura

cy o

f P

LIC

S a

nd M

odel H

ospital data

F

ive y

ear

fin

ancia

l re

covery

pla

n (

NH

SI to

publis

h g

uid

ance)

not

in p

lace

No W

ave 4

Capital fu

ndin

g

West Lancs C

CG

me

mb

er

of

Healthie

r Lancashire a

nd S

C

um

bria

ST

P

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Ma

jor

(4)

16

16

Extr

em

e r

isk

8

Hig

h R

isk

16/0

9/2

019

18/1

1/2

019

Assu

ran

ce

Acute

Susta

inabili

ty P

rogra

mm

e B

oard

-curr

ently fort

nig

htly

Fin

ance P

erf

orm

ance &

Investm

ent

Com

mitte

e a

nd T

rust B

oard

-month

ly

Hospital M

anagem

ent B

oard

-mo

nth

ly

Perf

orm

ance R

evie

w B

oard

-mo

nth

ly

People

and A

ctivitie

s G

roup (

PA

G)

pro

cess in p

lace -

me

etin

g w

eekly

S

ubm

it m

onth

ly w

ork

forc

e a

nd f

inance d

ata

to N

HS

Im

pro

vem

ent

Cost Im

pro

vem

ent P

rogra

mm

e d

ata

subm

itte

d f

ort

nig

htly to N

HS

Im

pro

vem

ent

Gap

s i

n A

ssu

ran

ce

Agency s

pend/v

acancy r

ate

s

Acti

on

Pla

n

Revie

w o

f M

odel H

ospital data

to e

nsure

its

accura

cy a

nd r

ele

vance in

drivin

g T

rust effic

iency

impro

vem

ents

Update

20/8

/19 fort

nig

htly M

H m

eetin

gs in

tra

in,

with k

ey e

ffic

iency p

rogra

mm

es a

ligned

with le

ads id

entifie

d a

cro

ss t

he T

rust to

test th

e a

ssum

ptio

ns a

nd t

ake forw

ard

recom

mendatio

ns. a

s a

re

sult s

om

e d

ata

cle

ansin

g h

as take

n p

lace, specific

ally

in

pro

cure

ment

and E

SR

F

inance team

to m

odel th

e im

pact of

the p

roposed c

hange t

o t

he f

inance a

rchitectu

re to a

ssess t

he

impro

vem

ent to

the T

rust's

underlyin

g fin

ancia

l deficit.

Tru

st and C

CG

to w

ork

togeth

er

to e

sta

blis

h a

fin

ancia

l m

odel fo

r th

e r

evis

ed F

railt

y p

ath

way; th

is c

ould

th

en b

e u

sed t

o r

oll

out fo

r oth

er

serv

ices that have a

n e

lem

ent

of serv

ice p

rovis

ion o

uts

ide t

he T

rust.

O

bta

inin

g r

ele

vant in

form

atio

n, financia

l and a

ctivity fro

m the T

rust

Confirm

atio

n o

f S

cenario

s

Initia

l A

ssum

ptio

ns D

evelo

pm

ent

and C

onfirm

atio

n w

ith t

he T

rust

Agre

e s

pecia

lty c

ost str

uctu

re f

or

scenario

develo

pm

ent

Pro

duce D

em

and a

nd C

apacity (

Activity)

mo

del

Pro

duce d

eta

iled T

ravel A

naly

sis

P

roduce F

inancia

l and E

conom

ic m

odels

A

lignm

ent

of m

odels

P

repare

and s

hare

dra

ft r

eport

F

inal R

eport

Acti

on

Pla

n D

ue

Date

31/1

2/2

019

31/0

1/2

019

30/0

9/2

019

28/1

0/2

019

Acti

on

Pla

n R

ati

ng

Actio

ns A

lmost

Com

ple

ted

Com

ple

ted

Com

ple

ted

Mo

dera

te

Pro

gre

ss M

ade

La

test

Mo

nth

P

rog

ress

Work

ed w

ith t

he s

yste

m t

o p

rovid

e N

HS

E/I a

n u

pdate

on o

ur

2020/2

1 p

lan. T

he m

odelli

ng s

how

s t

hat th

e T

rust

would

need a

n £

8.5

M C

IP if

it c

ontin

ued t

o c

ontr

act w

ith t

he S

eft

on C

CG

’s o

n a

cost

basis

and a

£3.5

M C

IP if

it w

as o

n a

PbR

contr

act.

TB

206_

19 R

isk

Reg

iste

r D

ec 1

9

Page 142 of 210

Pa

ge

14

of

14

Str

ate

gic

Ob

jecti

ve

SO

3 -

Effic

iently a

nd p

roductively

pro

vid

e c

are

within

agre

ed f

inancia

l lim

its

Lin

k t

o B

AF

Op

en

ed

ID

AD

O/E

xec L

ead

Ris

k L

ead

Tit

le

22/0

7/2

019

2072

Ste

ve S

hanahan

Ste

ve S

hanahan

Fa

ilure

to a

chie

ve 2

019/2

0 f

inancia

l contr

ol to

tal

Descri

pti

on

If the T

rust fa

ils t

o a

chie

ve its

2019/2

0 f

inancia

l contr

ol (a

deficit o

f £8.2

96 m

illio

n)

then t

he T

rust could

be p

ut

into

fin

ancia

l specia

l m

easure

s a

nd it

would

lo

se n

on

-recurr

ent

PS

F (

Pro

vid

er

Susta

inabili

ty F

und)

and F

RF

(F

inancia

l R

ecovery

Fu

nd)

fundin

g o

f up t

o £

18.2

71 m

illio

n.

Th

is r

isk is lin

ked t

o R

isk I

D 1

942 -

era

dic

atin

g t

he T

rust's

deficit b

y 2

023/2

4. T

his

new

ris

k is the s

hort

-term

ris

k a

nd 1

942 is t

he lo

ng

-term

ris

k.

Co

ntr

ols

P

eople

and A

ctivitie

s G

roup (

PA

G)

Hospital M

anagem

ent B

oard

(H

MB

) P

roje

ct M

anagem

ent

Offic

e (

PM

O)

South

port

& F

orm

by C

CG

contr

act sig

ned w

ith m

axim

um

earn

ings o

f £74.9

mill

ion

Gap

s i

n C

on

tro

ls

Sig

ned c

ontr

act

with W

est Lancashire C

CG

outs

tandin

g follo

win

g

outc

om

e o

f arb

itra

tio

n

Late

st S

yste

m R

ecovery

Pla

n (

18.1

0.1

9)

show

s a

£5.0

mill

ion

unm

itig

ate

d r

isk f

or

the T

rust again

st its d

eficit c

ontr

ol to

tal of

£26.5

67m

(befo

re P

SF

and F

RF

)

Ris

k L

evels

L

ikelih

oo

d

Co

ns

eq

ue

nce

Ris

k R

ati

ng

(I

nit

ial)

Ris

k R

ati

ng

(C

urr

en

t)

Ris

k L

evel

(Cu

rren

t)

Ris

k R

ati

ng

(T

arg

et)

R

isk L

evel (T

arg

et)

D

ate

of

La

st

Revie

w

Date

of

Next

Revie

w

Lik

ely

(4)

Ma

jor

(4)

16

16

Extr

em

e r

isk

8

Hig

h R

isk

21/1

0/2

019

18/1

1/2

019

Assu

ran

ce

People

and A

ctivitie

s G

roup (

PA

G)

pro

cess in p

lace -

me

etin

g w

eekly

H

ospital M

anagem

ent B

oard

(H

MB

) m

onth

ly

Fin

ance P

erf

orm

ance &

Investm

ent

Com

mitte

e a

nd T

rust B

oard

- m

onth

ly

Subm

it m

onth

ly w

ork

forc

e a

nd f

inance d

ata

to N

HS

Im

pro

vem

ent

Cost Im

pro

vem

ent P

rogra

mm

e d

ata

subm

itte

d f

ort

nig

htly to N

HS

Im

pro

vem

ent

Acute

Susta

inabili

ty P

rogra

mm

e B

oard

- c

urr

ently fort

nig

htly

Perf

orm

ance R

evie

w B

oard

- m

onth

ly

Gap

s i

n A

ssu

ran

ce

Agency s

pend c

ontin

ues s

ignific

antly in

excess o

f N

HS

Im

pro

vem

ent

agency c

eili

ng

Recru

itm

ent

and r

ete

ntio

n issues r

esultin

g in

hig

h v

acancy r

ate

s

Unid

entifie

d C

ost Im

pro

vem

ent P

lans

Non-r

ecurr

ent

me

asure

s u

sed t

o d

eliv

er

Q1 p

ositio

n n

ot

susta

inable

goin

g in

to f

urt

her

quart

ers

.

Acti

on

Pla

n

Regula

tor

will

require m

onth

ly u

pdate

s o

n d

eliv

ery

of th

e s

yste

m r

ecovery

pla

n.

Fin

ance team

to m

odel th

e im

pact of

the p

roposed c

hange t

o t

he f

inance a

rchitectu

re to a

ssess t

he

impro

vem

ent to

the T

rust's

underlyin

g fin

ancia

l deficit.

Tru

st and C

CG

to w

ork

togeth

er

to e

sta

blis

h a

fin

ancia

l m

odel fo

r th

e r

evis

ed F

railt

y p

ath

way; th

is c

ould

th

en b

e u

sed t

o r

oll

out fo

r oth

er

serv

ices that have a

n e

lem

ent

of serv

ice p

rovis

ion o

uts

ide t

he T

rust.

R

evie

w o

f M

odel H

ospital data

to e

nsure

its

accura

cy a

nd r

ele

vance in

drivin

g T

rust effic

iency

impro

vem

ents

Update

20/8

/19 fort

nig

htly M

H m

eetin

gs in

tra

in,

with k

ey e

ffic

iency p

rogra

mm

es a

ligned

with le

ads id

entifie

d a

cro

ss t

he T

rust to

test th

e a

ssum

ptio

ns a

nd t

ake forw

ard

recom

mendatio

ns. A

s a

re

sult s

om

e d

ata

cle

ansin

g h

as taken p

lace, specific

ally

in

pro

cure

ment

and E

SR

A

Syste

m R

ecovery

Pla

n s

ubm

itte

d o

n 0

2.0

8.1

9 t

o t

he R

egula

tors

. It

was d

iscussed w

ith N

HS

I/N

HS

E o

n

06.0

8.1

9

Acti

on

Pla

n D

ue

Date

31/0

3/2

020

31/0

3/2

019

30/0

9/2

019

31/1

2/2

019

02/0

8/2

019

Acti

on

Pla

n R

ati

ng

Mo

dera

te

Pro

gre

ss M

ade

Com

ple

ted

Com

ple

ted

Actio

ns A

lmost

Com

ple

ted

Com

ple

ted

La

test

Mo

nth

P

rog

ress

Subm

itte

d a

n im

pro

vem

ent pla

n to r

educe the c

urr

ent

deficit g

ap b

y £

1.5

M in Q

3/Q

4.

Page 143 of 210


Agenda Item TB207/19 Report Title Vision 2020 and the Single

Improvement Plan

Executive Lead Therese Patten, Deputy Chief Executive/Director of Strategy

Lead Officer Donna Lynch, Head of PMO

Action Required

(Definitions below)

To Approve To Note

To Assure X To Receive

For Information

Executive Summary

Vision 2020 describes a number of strategic objectives which have been refined and agreed by the

Trust Board during winter 2019.

The Trust Single Improvement Plan (SIP) is the consolidated plan for all the improvement activities

that are being conducted during the year. The SIP sets out the priorities, actions and timescales that

the Trust needs to deliver to achieve its Vision. The priorities for 2019/20 are:

Quality: September rating - Amber

▪ Recognition and care of the deteriorating patient

▪ Care of the older person

▪ Infection prevention and control

▪ Medicines management

Operations: September rating - Amber

▪ Achievement of quality targets for ED, RTT, cancer and diagnostics

▪ Clinical documentation focus on accuracy, completion and safe storage

Workforce: September rating – Amber

▪ Culture – organisational development, staff engagement and Freedom to Speak Up

▪ Clinical workforce strategy to ensure the right numbers of skilled staff

Finance: September rating – Amber

▪ Deliver our control total

▪ Maximize capacity using transformative efficiency and productivity tools

Strategy: September rating - Amber

▪ Engage with partners to develop opportunities for joint working

▪ Develop an affordable, sustainable acute services model

TB

207_

19 S

ingl

e Im

prov

emen

t Pla

n D

ec 1

9

Page 144 of 210

There are nine risks rated as red with a further six rated as amber, after mitigation is in place.

The executive assurance reports are included in the paper for information purposes.




x SO1 Improve clinical outcomes and patient safety to ensure we deliver high quality services


x SO2 Deliver services that meet NHS constitutional and regulatory standards


x SO3 Efficiently and productively provide care within agreed financial limits


x SO4 Develop a flexible, responsive workforce of the right size and with the right skills who feel valued and motivated


x SO5 Enable all staff to be patient-centred leaders building on an open and honest culture and the delivery of the Trust values


x SO6 Engage strategic partners to maximise the opportunities to design and deliver sustainable services for the population of Southport, Formby and West Lancashire



CQC KLOEs

GOVERNANCE




Safe Service Change

Well Led


Compliance Legal


Equality Risk

Finance Workforce



Policy

Service Change

Strategy


This report will come to Trust Board on a monthly basis.

Page 145 of 210












TB

207_

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ingl

e Im

prov

emen

t Pla

n D

ec 1

9

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of 210

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ingl

e Im

prov

emen

t Pla

n D

ec 1

9

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of 210

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ingl

e Im

prov

emen

t Pla

n D

ec 1

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of 210

TB

207_

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ingl

e Im

prov

emen

t Pla

n D

ec 1

9

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of 210

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207_

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ingl

e Im

prov

emen

t Pla

n D

ec 1

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of 210

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207_

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ingl

e Im

prov

emen

t Pla

n D

ec 1

9

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of 210

TB

207_

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ingl

e Im

prov

emen

t Pla

n D

ec 1

9

Page 158 of 210

of 210

Sin

gle

Im

pro

vem

en

t P

lan

Bo

ard

Up

date

Decem

ber

2019

So

uth

po

rt a

nd

Fo

rmb

y D

istr

ict

Ge

ne

ral H

os

pit

al

Orm

sk

irk

an

d D

istr

ict

Ge

ne

ral H

os

pit

al

No

rth

We

st

Re

gio

na

l S

pin

al

Inju

rie

s C

en

tre

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 160 of 210

Sin

gle

Im

pro

ve

me

nt

Pla

n -

Ba

ck

gro

un

d

Page 161 of 210

Sin

gle

Im

pro

ve

me

nt

Pla

n –

Pri

ori

tie

s &

T

raje

cto

rie

s

we

have

a d

ream

wha

t is

impo

rtan

tho

w w

e w

ill d

o it

Tru

st V

isio

nP

rio

riti

esSt

rate

gic

Ob

ject

ives

Qu

alit

y P

rio

rity

1 -

Rec

ogn

itio

n an

d ca

re o

f th

e

dete

rio

rati

ng p

atie

nt

Qu

alit

y P

rio

rity

2 -

Car

e o

f th

e o

lder

per

son

Qu

alit

y P

rio

rity

3 -

Infe

ctio

n pr

even

tio

n an

d co

ntro

l

Qu

alit

y P

rio

rity

4 -

Med

icin

es m

anag

emen

t

SO 1

- Im

pro

ve c

linic

al o

utco

mes

and

pat

ien

t

safe

ty t

o e

nsu

re w

e de

liver

hig

h qu

alit

y

serv

ices

Op

erat

ion

s P

rio

rity

1 -

Ach

ieve

men

t o

f qu

alit

y

targ

ets

for

ED, R

TT, c

ance

r an

d di

agno

stic

s

Op

erat

ion

s P

rio

rity

2 -

Clin

ical

do

cum

enta

tio

n fo

cus

on

accu

racy

, co

mpl

etio

n an

d sa

fe s

tora

ge

SO 2

- D

eliv

er s

ervi

ces

that

mee

t N

HS

cons

titu

tio

nal a

nd r

egul

ato

ry s

tand

ards

Fin

ance

Pri

ori

ty 1

- D

eliv

er o

ur c

ont

rol t

ota

l

Fin

ance

Pri

ori

ty 2

- M

axim

ize

capa

city

usi

ng

tran

sfo

rmat

ive

effi

cien

cy a

nd p

rodu

ctiv

ity

too

ls

SO 3

- Ef

fici

entl

y an

d pr

odu

ctiv

ely

pro

vide

care

wit

hin

agre

ed f

inan

cial

lim

its

Wo

rkfo

rce

Pri

ori

ty 1

- C

ultu

re –

org

anis

atio

nal

deve

lopm

ent,

sta

ff e

nga

gem

ent

and

Free

do

m t

o

Spea

k U

p

Wo

rkfo

rce

Pri

ori

ty 2

- C

linic

al w

ork

forc

e st

rate

gy t

o

ensu

re t

he r

ight

num

bers

of

skill

ed s

taff

SO 4

- D

evel

op

a fl

exib

le, r

espo

nsiv

e

wo

rkfo

rce

of

the

righ

t si

ze a

nd w

ith

the

righ

t

skill

s w

ho f

eel v

alue

d a

nd m

oti

vate

d

SO 5

- E

nabl

e al

l sta

ff t

o b

e pa

tien

t-ce

ntr

ed

lead

ers

build

ing

on

an o

pen

and

ho

nest

cult

ure

and

the

deliv

ery

of

the

Trus

t va

lues

Stra

tegy

Pri

ori

ty 1

- E

ngag

e w

ith

part

ners

to

dev

elo

p

opp

ort

unit

ies

for

join

t w

ork

ing

Stra

tegy

Pri

ori

ty 2

- D

evel

op

an a

ffo

rdab

le,

sust

aina

ble

acut

e se

rvic

es m

ode

l

SO 6

- E

ngag

e st

rate

gic

part

ners

to

max

imis

e

the

opp

ort

unit

ies

to d

esig

n an

d de

liver

sust

aina

ble

serv

ices

fo

r th

e po

pula

tio

n o

f

Sout

hpo

rt, F

orm

by a

nd W

est

Lanc

ashi

re

Bec

om

e a

dist

rict

gen

eral

hosp

ital

wit

h sp

ecia

list

skill

s

in t

he c

are

of

old

er p

eopl

e

Be

part

of

an in

tegr

ated

care

sys

tem

del

iver

ing

seam

less

ho

spit

al-t

o-h

om

e

care

tha

t w

ork

s fo

r pa

tien

ts

Inve

st in

our

ho

spit

als,

mak

ing

them

fit

fo

r th

e 21

st

Cen

tury

Cre

ate

a hu

b fo

r ro

utin

e

plan

ned

car

e ru

n fr

om

a

ded

icat

ed h

osp

ital

We

will

bec

om

e an

empl

oye

r o

f ch

oic

e th

at

attr

acts

the

bes

t st

aff

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 162 of 210

Pro

gre

ss

to

da

te –

No

ve

mb

er

20

19

Key

Blu

e

Act

ivit

y co

mp

lete

d

Re

dSi

gnif

ican

tly

del

ayed

an

d/o

r o

f h

igh

risk

- n

ot

exp

ecte

d t

o r

eco

ver

Gre

en

P

rogr

essi

ng

on

sch

edu

le

Am

be

rSl

igh

tly

del

ayed

an

d /

or

of

low

ris

k -

can

be

reco

vere

d

Page 163 of 210

Pro

gre

ss

to

da

te –

Ris

ks

No

ve

mb

er

20

19

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 164 of 210

QU

ALI

TY &

SA

FETY

RA

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atin

g

Key

Ach

ieve

me

nts

/Pro

gre

ss

QU

ALI

TY S

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DA

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S

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ft C

QC

Insp

ecti

on

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rec

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act

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l acc

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om

ple

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nd

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bm

itte

d t

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QC

on

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in o

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rs. E

xpec

ted

pu

blic

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on

da

te N

ove

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er /

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emb

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Med

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Th

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om

ref

urb

ish

men

t n

eari

ng

co

mp

leti

on

-

Do

mes

tic

ho

urs

incr

ease

d t

o c

orr

esp

on

d w

ith

na

tio

na

l gu

idel

ines

-P

HE

Ass

ura

nce

vis

it o

f n

ati

on

al e

xper

ts s

ched

ule

d f

or

12

No

vem

ber

20

19

to

pro

vid

e a

dvi

ce a

nd

ver

ify

ad

equ

acy

of

pro

cess

es u

nd

erta

ken.

Old

er P

eop

le’s

Pro

gra

mm

e -

The

tra

inin

g p

rog

ram

me

for

Ca

re o

f O

lder

Peo

ple

ha

s co

nti

nu

ed t

o b

e d

eliv

ered

wit

h e

xcel

len

t fe

edb

ack

. 17

0 p

eop

le a

re b

oo

ked

to

un

der

take

th

e p

rog

ram

me

by

the

end

of

20

19

.-T

he

firs

t m

emb

er o

f th

e D

emen

tia

an

d D

elir

ium

Tea

m in

po

st 0

4.1

1.1

9 a

nd

th

e A

dm

ira

l Nu

rse

du

e in

po

st 1

6.1

2.1

9

SAFE

STA

FFIN

G

Ove

rall

fill

rate

fo

r Se

pte

mb

er 2

01

9 w

as

91

.83

%(a

ga

inst

th

e n

ati

on

al a

vera

ge

of

90

%),

an

incr

ease

on

pre

vio

us

mo

nth

.Th

e Tr

ust

co

nti

nu

es t

o p

roa

ctiv

ely

sou

rce

nu

rse

ag

enci

es t

ha

t a

re

wit

hin

th

e fr

am

ewo

rk t

o s

up

ple

men

t N

HSp

an

d T

ier

3 a

gen

cies

to

su

pp

ort

wit

hd

raw

ing

of

hig

h c

ost

off

fra

mew

ork

ag

enci

es.

This

incl

ud

es b

lock

bo

oki

ng

op

po

rtu

nit

ies

tosu

pp

ort

co

nti

nu

ity

of

care

to

ou

r p

ati

ent

gro

up

s a

nd

fu

rth

er r

efle

ctiv

e o

f th

e w

inte

r co

nti

ng

enci

es f

or

the

tru

st.

QU

ALI

TY&

SA

FETY

GO

VER

NA

NC

E

Co

mp

lain

ts p

roce

ss m

ap

pin

g r

evie

w a

nd

inci

den

t p

roce

ss m

ap

pin

g e

xerc

ise

com

ple

ted

wit

h s

ub

seq

uen

t a

ctio

ns

dev

elo

ped

, a f

urt

he

r co

mp

lain

ts r

evie

w in

corp

ora

tin

g p

ati

ent

exp

erie

nce

le

d b

y th

e D

epu

ty D

irec

tor

of

Nu

rsin

g h

as

com

men

ced

in N

ove

mb

er 2

01

9, a

ny

ad

dit

ion

al

act

ion

s w

ill b

e b

uilt

into

th

e In

teg

rate

d G

ove

rna

nce

Imp

rove

men

t P

lan

. N

um

ber

s o

f co

mp

lain

ts

an

d c

on

cern

s a

re d

ecre

asi

ng

, th

e re

spo

nse

s w

ith

in 4

0 d

ays

is im

pro

vin

g –

this

wa

s 3

5.7

6%

Ap

ril 2

01

9 -

Oct

ob

er 2

01

9 c

om

pa

red

to

23

.08

% i

n A

pri

l 20

18

-O

cto

ber

20

18

6

Page 165 of 210

7

Key

Ris

ks/I

ssu

es

Mit

igat

ing

Act

ion

sR

AG

Inab

ility

to

rel

ease

clin

ical

sta

ff t

o p

arti

cip

ate

in M

ou

th C

are

Mat

ters

pro

ject

s Se

cure

d 3

ad

dit

ion

al p

lace

s fo

r M

ou

th C

are

Mat

ters

pro

gram

me

in L

on

do

n 1

5th

N

ove

mb

er 2

01

9A

Win

ter

pre

ssu

res

-C

lear

imp

act

acce

ss a

nd

flo

w o

n Q

ual

ity

& S

afet

y W

inte

r p

ress

ure

s -

Cle

ar im

pac

t ac

cess

an

d f

low

on

Qu

alit

y &

Saf

ety

Par

tici

pat

e in

th

e d

evel

op

men

t o

f th

e sy

stem

win

ter

pla

n

R

Key

Ach

ieve

me

nts

/Pro

gre

ss in

Mo

nth

–Q

ual

ity

& S

afet

y

CQ

C In

spec

tio

n c

om

ple

ted

, aw

ait

ing

fin

al r

epo

rt

Wo

rk r

ela

tin

g t

o t

he

4 q

ua

lity

pri

ori

ties

co

nti

nu

es t

o m

ove

fo

rwa

rd

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 166 of 210

1.1

Op

era

tio

nal

Pe

rfo

rman

ce (

Exe

cLe

ad: S

teve

Ch

rist

ian

)R

AG

Rat

ing

Pro

gre

ss

8

Can

cer

62

Day

Per

form

ance

fo

r Se

pte

mb

er 2

01

9 w

as 8

2%

an

incr

ease

on

th

e A

ugu

st p

osi

tio

n o

f 7

5.3

% a

nd

th

e b

est

per

form

ance

sin

ce O

cto

ber

20

18

. Th

ere

are

just

fiv

e tr

ust

s n

atio

nal

ly t

hat

are

del

iver

ing

an im

pro

vem

ent

in c

ance

r p

erfo

rman

ce, w

ith

in t

he

regi

on

we

are

the

on

ly s

ervi

ce s

ho

win

g im

pro

vem

ents

in

per

form

ance

.

18

We

ek

RTT

Pe

rfo

rman

ceSe

pte

mb

er 1

8-w

eek

RTT

per

form

ance

was

93

.4%

P

red

icti

on

s fo

r O

cto

ber

sh

ow

per

form

ance

will

rem

ain

aro

un

d 9

3%

an

d c

on

tin

ue

to b

e ab

ove

th

e 9

2%

th

resh

old

.Th

ere

are

curr

entl

y 7

pat

ien

ts w

aiti

ng

ove

r 4

0 w

eeks

, a s

ligh

t in

crea

se ,

ho

wev

er t

he

nu

mb

er o

f 3

0+

wee

k w

aite

rs h

as d

rop

ped

fro

m 9

9 t

o 8

8 o

ver

the

pas

t 4

wee

ks, t

hes

e lo

ng

wai

ters

are

la

rgel

y d

ue

to t

he

con

tin

uin

g ch

alle

nge

s in

Co

mm

un

ity

Pae

dia

tric

s an

d G

ynae

colo

gy.

The

Gyn

aeco

logy

po

siti

on

is p

red

icte

d t

o r

eco

ver

fro

m J

anu

ary

20

20

as

the

Tru

st a

hs

rece

ntl

y ap

po

inte

d 4

co

nsu

ltan

ts

The

Co

mm

un

ity

Pae

dia

tric

s p

erfo

rman

ce w

ill c

on

tin

ue

to b

e co

mp

rom

ised

un

til w

e ca

n a

pp

oin

t in

to t

he

vaca

nt

com

mu

nit

y P

aed

iatr

icia

n p

ost

Dia

gno

stic

sP

erfo

rman

ce f

or

Oct

ob

er a

gain

st t

he

6 w

eek

wai

t ta

rget

was

2.1

6%

an

imp

rove

men

t o

f 0

.5%

ove

r th

e Se

pte

mb

er p

osi

tio

n a

nd

in li

ne

wit

h t

raje

cto

ry s

et w

ith

NH

S I /

CC

GN

on

-ob

stet

ric

Ult

raso

un

d a

nd

Cys

tosc

op

y re

mai

n t

he

area

s o

f m

ost

co

nce

rn, w

ith

34

an

d 1

3 w

aite

rs o

ver

6 w

eeks

, all

oth

er m

od

alit

ies

hav

e si

ngl

e fi

gure

wai

ters

.En

do

sco

py

reco

rded

th

e m

ost

nu

mb

er o

f sc

op

es in

a m

on

th (

on

rec

ord

) in

Oct

ob

er a

t 6

53

wit

h z

ero

ses

sio

ns

can

celle

d d

ue

to n

o n

urs

es.

Len

gth

of

Stay

Len

gth

of

stay

fo

r fu

ll em

erge

ncy

ad

mis

sio

ns,

wh

ich

do

es n

ot

incl

ud

e p

atie

nts

bei

ng

adm

itte

d t

o a

sses

smen

t w

ard

s, w

as r

eco

rde

d a

t 6

.3 d

ays

in O

cto

ber

an

imp

rove

men

t fr

om

th

e Se

pte

mb

er p

osi

tio

n, w

ith

pat

ien

ts o

n a

sses

smen

t w

ard

s st

ayin

g an

ave

rage

of

8 h

ou

rs, w

hic

h is

th

e sa

me

as S

epte

mb

er.

Ther

e w

ere

18

5 s

tran

ded

pat

ien

ts in

Oct

ob

er 2

01

9, a

n in

crea

se f

rom

th

e p

revi

ou

s m

on

th.

Sup

er S

tran

ded

pat

ien

ts a

lso

incr

ease

d t

o 7

0Th

e ke

y in

-mo

nth

pro

gres

s is

th

e re

intr

od

uct

ion

of

the

sen

ior

lead

su

pp

ort

ing

R2

G a

nd

th

e in

tro

du

ctio

n o

f a

Bo

ard

Ro

un

d S

OP

A&

E 4

Ho

ur

Pe

rfo

rman

ceTh

e Tr

ust

s re

po

rted

4 h

ou

r A

&E

per

form

ance

in O

cto

ber

was

84

.6%

a 4

% d

ecre

ase

fro

m t

he

Sep

tem

ber

po

siti

on

of

88

.6%

Th

is is

du

e to

a s

ign

ific

ant

dec

reas

e in

So

uth

po

rt p

erfo

rman

ce w

hic

h h

as d

rop

ped

fro

m 7

7.6

% in

Sep

tem

ber

to

70

% in

Sep

tem

ber

20

19

.Th

e So

uth

po

rt it

sit

e is

exp

erie

nci

ng

sign

ific

ant

dem

and

pre

ssu

res

wit

h a

tten

dan

ces

and

ad

mis

sio

ns

up

by

17

% a

gain

st t

he

sam

eti

me

per

iod

of

last

yea

r.

Win

ter

pla

nn

ing

The

Tru

st h

as in

tro

du

ced

a w

eekl

y W

inte

r O

per

atio

nal

Gro

up

to

su

pp

ort

imp

lem

enta

tio

n o

f th

e h

osp

ital

win

ter

sch

emes

. Th

e sc

hem

es in

clu

de

the

op

enin

g o

f a

16

bed

ded

po

st o

per

ativ

e O

rth

op

aed

ic w

ard

to

su

pp

ort

ap

pro

pri

ate

tran

sfer

of

pat

ien

ts s

till

un

der

acu

te c

are

that

can

rec

eive

th

eir

reh

abili

tati

on

at

Orm

skir

k. T

his

in e

ffec

t w

ill r

elea

se 1

6b

eds

at S

ou

thp

ort

as

this

cu

rren

t co

ho

rt o

f p

atie

nts

rem

ain

on

th

e So

uth

po

rt s

ite

un

til f

it f

or

dis

char

ge.

The

Tru

st B

oar

d h

as s

ign

ed o

ff t

he

bu

sin

ess

case

wit

h r

ecru

itm

ent

and

est

ates

wo

rk c

om

men

ced

wit

h a

tar

get

dat

e o

f o

pen

ing

in t

he

firs

t w

eek

of

Jan

uar

y.

The

atre

Uti

lizat

ion

O

rmsk

irk

imp

rove

d in

mo

nth

to

73

% f

or

Oct

ob

er b

y 1

% a

gain

st t

he

pre

vio

us

mo

nth

. H

ow

ever

So

uth

po

rt u

tiliz

atio

n r

eco

rded

a d

eclin

e in

per

form

ance

du

e to

hig

h n

um

ber

s o

f ca

nce

llati

on

s (1

5.6

6%

mai

nly

att

rib

ute

d t

o p

atie

nt

flo

w is

sues

(i.e

. no

bed

s av

aila

ble

)

Page 167 of 210

9

Ke

yR

isks

Mit

igat

ing

Act

ion

sR

AG

Ach

ievi

ng

Co

nst

itu

tio

na

l St

and

ard

s

The

key

issu

es b

ein

g:

•W

ork

forc

e –

gap

s in

acu

te m

edic

ine

ph

ysic

ian

s, r

adio

logi

sts,

an

aest

het

ics

and

ger

iatr

icia

ns

are

clea

rly

imp

acti

ng

on

cu

rren

t p

erfo

rman

ce a

nd

bei

ng

able

to

su

stai

n a

co

nsi

sten

t le

vel o

f p

erfo

rman

ce (

acro

ss 4

ho

ur

stan

dar

d, d

iagn

ost

ic

and

can

cer

in p

arti

cula

r)

•Th

e So

uth

po

rt &

Orm

skir

k sy

stem

bei

ng

able

to

imp

lem

ent

win

ter

sch

emes

an

d d

eliv

er a

gain

st t

he

assu

mp

tio

ns

the

CC

G h

ave

sign

ed o

ff.

The

assu

mp

tio

ns

form

ed t

he

bas

is in

th

e sy

stem

bei

ng

able

to

mit

igat

e th

e ga

p id

enti

fied

by

Ven

n p

arti

cula

rly

wit

hin

th

e o

ut

of

ho

spit

al p

rovi

sio

n (

40

b

eds)

.

The

intr

od

uct

ion

of

the

“Wo

rkfo

rce

Imp

rove

men

t G

rou

p”

mu

st f

ocu

s o

n t

he

tim

ely

recr

uit

men

t o

f th

e cr

itic

al

po

sts

that

co

nti

nu

e to

pro

vid

e ch

alle

nge

s to

mai

nta

in a

n e

ffec

tive

an

d r

elia

ble

ser

vice

off

er.

The

Tru

st h

as r

efer

ence

d p

revi

ou

sly

the

con

cern

s th

at t

he

sch

emes

pu

t fo

rwar

d b

y th

e sy

stem

will

no

t ad

dre

ss t

he

gap

iden

tifi

ed b

y V

enn

du

e to

th

e as

sum

pti

on

s b

ein

g am

bit

iou

s gi

ven

tim

esca

les

set

wit

hin

th

e im

ple

men

tati

on

pla

ns.

Th

e sy

stem

has

set

up

a w

eekl

y U

EC S

yste

m L

ead

ers

mee

tin

g w

hic

h is

ch

aire

d b

y th

e U

EC P

rogr

amm

e D

irec

tor

and

th

is m

eeti

ng

no

w m

on

ito

rs p

rogr

ess

of

each

win

ter

sch

emes

rep

ort

ing

thro

ugh

to

th

e SM

B.

R

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 168 of 210

20

19

/20

FIN

AN

CIA

L P

LAN

(1

)R

AG

Rat

ing

Key

Ach

ieve

me

nts

/Pro

gre

ssFI

NA

NC

IAL

CO

NTR

OLS

-co

nti

nu

e to

co

ntr

ol s

pen

d a

nd

del

iver

CIP

Cu

rre

nt

pe

rfo

rman

ceTh

e m

on

th 7

YTD

po

siti

on

bef

ore

Pro

vid

er S

ust

ain

abili

ty F

un

din

g (P

SF)

and

Fin

anci

al R

eco

very

Fu

nd

(FR

F) is

a d

efic

it o

f £

16

.32

8 m

illio

n w

hic

h is

£8

69

,000

wo

rse

than

pla

n.

The

in-m

on

th p

osi

tio

n b

efo

re P

SF/F

RF

is a

def

icit

of

£2

.37

2 m

illio

n,

£0

.86

1 m

illio

n w

ors

e th

an p

lan

.

The

Tru

st’s

fo

reca

st o

utt

urn

, bas

ed o

n m

on

th 6

per

form

ance

an

d s

har

ed w

ith

NH

SI/E

on

1 N

ove

mb

er 2

01

9, i

s £

3.6

mill

ion

ove

rsp

en

d a

gain

st t

he

def

icit

pla

n.

Mo

nth

7 e

xpen

dit

ure

is

hig

her

th

an t

he

traj

ecto

ry a

llow

ed t

o a

chie

ve t

his

fo

reca

st o

utt

urn

.Th

e 2

01

9/2

0 C

IP p

rogr

amm

e is

£1

,35

0,0

00 b

ehin

d p

lan

at

mo

nth

7; t

he

fore

cast

ou

ttu

rn is

£4

.3 m

illio

n a

gain

st t

he

£6

.3 m

illio

np

lan

leav

ing

an u

nid

enti

fied

gap

of

£2

.0 m

illio

n.

If m

ater

ial c

ash

red

uci

ng

CIP

sch

emes

can

no

t b

e tr

ansa

cted

du

rin

g th

e re

mai

nd

er o

f th

e ye

ar t

hen

an

y p

ress

ure

on

th

e ex

pen

dit

ure

run

rat

e w

ill n

ot

be

mit

igat

ed.

Tru

st a

ctiv

ity

and

inco

me

per

form

ance

at

mo

nth

7 Y

TD is

as

follo

ws:

•El

ecti

ve –

acti

vity

is 3

.9%

bel

ow

pla

n;

£4

35

,00

0 lo

ss o

f in

com

e.•

A&

E –

acti

vity

5.5

% a

bo

ve p

lan

; £

35

3,0

00

of

add

itio

nal

inco

me.

•N

on

Ele

ctiv

e –

acti

vity

is 2

.4%

bel

ow

pla

n;

£2

,56

7,0

00

add

itio

nal

inco

me

du

e to

cas

e m

ix•

Ou

tpat

ien

ts –

acti

vity

is 3

.94

% a

bo

ve p

lan

; £6

27

,00

0 o

f ad

dit

ion

al in

com

e

No

t al

l of

the

abo

ve a

ctiv

ity

per

form

ance

is p

ayab

le in

20

19

/20

du

e to

:•

On

ly a

pro

po

rtio

n o

f th

e n

on

-ele

ctiv

e va

lue

is p

ayab

le d

ue

to t

he

app

licat

ion

of

the

“ble

nd

ed t

arif

f” a

dju

stm

ent.

•Se

fto

n C

CG

’s c

on

trac

t ap

plie

s th

e “b

len

ded

tar

iff”

to

all

po

ints

of

del

iver

y.

The

Tru

st’s

to

tal i

nco

me

pla

n is

on

sch

edu

le t

o b

e ac

hie

ved

.

Un

der

lyin

g ex

pen

dit

ure

lev

els

in m

on

th 7

hav

e ri

sen

mai

nly

du

e to

ad

dit

ion

al s

taff

hav

ing

bee

n e

mp

loye

d c

om

par

ed t

o p

revi

ou

s m

on

ths.

Th

e Tr

ust

sp

ent

abo

ve £

2.0

mill

ion

in O

cto

ber

on

b

ank

and

age

ncy

sta

ff w

hic

heq

uat

es t

o a

n a

nn

ual

sp

end

of

£2

4 m

illio

n o

n p

rem

ium

rat

e st

aff.

Mo

nth

7 Y

TD a

gen

cy s

pen

d is

£6

.97

8 m

illio

n (

8.4

5%

of

the

pay

bill

); M

edic

al s

taff

£3

.71

7 m

illio

n;

Nu

rsin

g £

2.6

19

mill

ion

.Th

e Tr

ust

bre

ach

ed t

he

NH

SI a

gen

cy t

arge

t ca

p o

f £

4.8

91

mill

ion

in

Sep

tem

ber

.M

on

thly

age

ncy

sp

end

has

incr

ease

d a

gain

in O

cto

ber

to

£1

,10

9,0

00

(9.3

% o

f th

e p

ay b

ill);

Med

ical

sta

ff £

51

1,0

00;

Nu

rsin

g £

45

8,0

00.

Tota

l Ban

k sp

end

is c

on

sist

ent

wit

h p

revi

ou

s m

on

ths;

Oct

ob

er is

£9

44

,000

(7.9

% o

f th

e to

tal p

ay b

ill)

bri

ngi

ng

YTD

sp

end

to

£6

.53

3 m

illio

n (

7.9

% o

f th

e to

tal p

ay b

ill).

Ke

y ac

tio

ns

Wee

kly

mee

tin

gs n

ow

est

ablis

hed

wit

h t

he

Exec

uti

ve t

eam

fo

r C

IP a

nd

th

e w

ider

fin

anci

al r

eco

very

pla

n w

ith

a f

ocu

s o

n t

he

op

era

tio

nal

det

ail b

ehin

d b

oth

of

thes

e ar

eas

(del

iver

y o

f £

1.5

m

illio

n r

eco

very

pla

n s

chem

es r

equ

ired

wef

No

vem

ber

20

19

bu

t th

is w

ou

ld s

till

resu

lt in

th

e Tr

ust

£3

.6 m

illio

n a

way

fro

m t

he

year

en

d p

lan

).El

emen

ts o

f th

e fi

nan

cial

rec

ove

ry p

lan

in

clu

de;

Red

uct

ion

in h

igh

co

st t

emp

ora

ry s

pen

d (

this

will

co

ver

ban

k, a

gen

cy, i

nte

rim

sta

ff a

nd

wai

tin

g lis

t in

itia

tive

s);

Pla

n o

f ac

tio

n o

n h

ow

th

e w

ork

on

fra

gile

ser

vice

s w

ill b

e d

eliv

ered

alo

ng

wit

h u

nfu

nd

ed/u

nd

er f

un

ded

ser

vice

s; M

ake

bes

t u

seo

fN

HSI

su

pp

ort

on

off

er s

uch

as

the

Mo

del

Ho

spit

al.

Co

st Im

pro

vem

en

t P

rogr

amm

eTr

ust

ori

gin

al C

IP p

lan

of

£6

.3 m

illio

n (

excl

ud

ing

£3

72

,000

of

FYE

of

20

18

/19

sch

emes

) w

as t

o b

e d

eliv

ered

by

£4

.5 m

illio

n e

xpen

dit

ure

red

uct

ion

s an

d a

dd

itio

nal

inco

me

of

£1

.8 m

illio

n f

rom

B

PT.

Fo

llow

ing

con

trac

t ag

reem

ent

wit

h o

ur

mai

n c

om

mis

sio

ner

th

e Tr

ust

nee

ds

to d

eliv

er £

6.3

mill

ion

of

exp

end

itu

re r

edu

ctio

ns.

Pro

gre

ss r

e p

lan

A

t m

on

th 7

, th

e Tr

ust

had

tra

nsa

cted

£2

.86

3 m

illio

n o

f C

IPs.

Th

e Tr

ust

is f

ore

cast

ing

del

iver

y o

f £

4.3

mill

ion

, ga

p o

f £

2.0

mill

ion

.

10

Page 169 of 210

20

19

/20

FIN

AN

CIA

L P

LAN

(2

)R

AG

Rat

ing

Key

Ach

ieve

me

nts

/Pro

gre

ss

CA

PIT

AL

PLA

N –

del

iver

pla

nn

ed in

vest

men

t p

rog

ram

me

focu

sin

g o

n IT

, med

ica

l eq

uip

men

t a

nd

imp

rove

men

ts t

o w

ard

en

viro

nm

ents

The

pla

n f

or

20

19

/20

is a

gro

ss c

apit

al s

pen

d t

ota

l of

£5

.1 m

illio

n (

this

exc

lud

es I

FRIC

12

ad

dit

ion

s an

d d

on

ated

ass

ets

of

£1

.3m

illio

n,

£1

.2 m

illio

n o

f w

hic

h is

fo

r th

e G

E R

adio

logy

eq

uip

men

t re

pla

cem

ent

pro

gram

me

). T

her

e co

nti

nu

es t

o b

e si

gnif

ican

t in

vest

men

t in

IT w

ith

£1

.7 m

illio

n in

vest

ed in

20

19

/20

, w

hic

h in

clu

des

pro

ject

s d

esig

ned

to

imp

rove

pat

ien

t fl

ow

an

d p

atie

nt

reco

rds,

alo

ng

wit

h w

ork

on

IT in

fras

tru

ctu

re a

nd

sec

uri

ty. T

he

rolli

ng

pro

gram

me

of

rep

laci

ng

and

up

dat

ing

Med

ical

Eq

uip

men

t co

nti

nu

es w

ith

inve

stm

ent

of

£1

.0 m

illio

n in

2

01

9/2

0.T

he

Esta

tes

cap

ital

pla

n in

clu

des

a 6

Fac

et S

urv

ey t

o h

elp

ste

er f

utu

re in

vest

men

t an

d s

up

po

rt s

trat

egic

inte

nt.

Oth

er e

stat

es

imp

rove

men

t sc

hem

es a

re d

esig

ned

to

imp

rove

ex

isti

ng

pro

per

ties

an

d e

nab

le s

ervi

ce d

eliv

ery

targ

ets

to b

e ac

hie

ved

, in

crea

sin

g p

atie

nt

safe

ty a

nd

imp

rovi

ng

pat

ien

t ex

per

ien

ce.

Tota

l pla

nn

ed s

pen

d f

or

Esta

tes

and

Fac

iliti

es in

20

19

/20

is

£1

.7 m

illio

n.

Pro

gre

ss r

e p

lan

Act

ual

sp

end

YTD

is £

2.0

98

mill

ion

(p

lan

ned

sp

end

yea

r to

dat

e o

f £

4.0

27

mill

ion

) w

ith

a f

urt

her

£1

.13

7 m

illio

n c

om

mit

ted

exp

end

itu

re.

Co

mp

arin

g th

is a

gain

st t

he

ann

ual

pla

n, £

5,1

03

,000

excl

ud

ing

do

nat

ed a

nd

GE

rad

iolo

gy a

sset

s, t

hen

th

e Tr

ust

has

sp

ent/

com

mit

ted

63

.4%

of

the

pla

n a

t th

e en

d o

f O

cto

ber

20

19

.

The

Sou

thp

ort

war

du

pgr

ade

pro

ject

has

star

ted

and

the

firs

t5

war

ds

will

be

com

ple

ted

bef

ore

Ch

rist

mas

.Th

e6

thw

ard

isp

lan

ned

for

com

ple

tio

nb

efo

reth

een

do

fth

efi

nan

cial

year

.

Wo

rkis

pro

gres

sin

gw

ellw

ith

inth

eSp

inal

Un

ito

nth

eIs

ola

tio

nw

ork

san

dth

ew

ork

req

uir

edas

are

sult

of

the

Kle

bsi

ella

ou

tbre

akw

ith

com

ple

tio

nex

pec

ted

inth

eve

ryn

ear

futu

re.

IM&

Tco

nti

nge

ncy

sch

eme

at£4

50

,000

was

ori

gin

ally

inte

nd

edfo

rth

ed

ata

cen

tre,

ho

wev

er,

this

loo

ked

un

likel

yto

be

imp

lem

en

ted

in2

01

9/2

0an

da

re-u

tilis

atio

no

fth

ese

mo

nie

sto

oth

erIT

pro

ject

sis

refl

ecte

din

the

revi

sed

pla

n.

On

a p

osi

tive

no

te t

he

Tru

st h

as b

een

su

cces

sfu

l in

bid

din

g fo

r eP

MA

(Ele

ctro

nic

Pre

scri

bin

g an

d M

edic

ines

Ad

min

istr

atio

n)

and

has

bee

n a

war

ded

£7

00

,00

0 in

20

19

/20

.

The

Bo

ard

ap

pro

ved

a r

evis

ed c

apit

al p

lan

on

6th

No

vem

ber

20

19

an

d a

uth

ori

sati

on

was

giv

en t

o p

roce

ed w

ith

th

e w

inte

r p

lan

at

£3

50

,00

0. H

ow

ever

, co

sts

are

no

w c

lear

er a

nd

an

a

req

ues

t to

incr

ease

th

e sc

hem

e va

lue

to £

49

5,0

00

will

be

dis

cuss

ed a

t Fi

nan

ce, P

erfo

rman

ce &

Inve

stm

ent

Co

mm

itte

e o

n 2

5th

No

vem

ber

20

19

.

TRA

NSF

OR

MA

TIO

N -

dri

ve d

eliv

ery

of

pro

gra

mm

es in

clu

din

g G

IRFT

, M

od

el H

osp

ita

l, th

eatr

e a

nd

ou

tpa

tien

t ef

fici

ency

GIR

FT–

incr

ease

in p

rod

uct

ivit

y; c

on

sist

ent

qu

alit

y; b

ette

r p

ati

ent

exp

erie

nce

; red

uce

d c

ost

of

join

ts

Mo

de

l Ho

spit

alFo

cus

wit

h t

he

NH

SI M

od

el H

osp

ital

tea

m•

Pro

cure

men

t•

Med

ical

Jo

b P

lan

nin

g -

app

rop

riat

e m

edic

al jo

b p

lan

s; r

edu

ctio

n in

WLI

’s

•N

urs

ing

–e-

Ro

ster

ing

and

revi

ew o

f C

linic

al N

urs

e Sp

ecia

lists

•H

R -

imp

rove

men

t in

“ti

me

to r

ecru

it”;

imp

rove

d r

eten

tio

n r

ates

; red

uci

ng

relia

nce

on

age

ncy

•Fa

cilit

ies

Man

agem

ent

car

par

kin

g te

nd

er a

nd

cat

erin

g; p

ort

erin

gca

pac

ity

and

dem

and

an

alys

is;

cate

rin

g ef

fici

ency

•

Med

icin

es M

anag

emen

t

The

atre

Eff

icie

ncy

–p

rod

uct

ivit

y im

pro

vem

ent;

red

uce

late

sta

rts

and

can

cella

tio

ns;

imp

rove

pat

ien

t ex

per

ien

ce

Ou

tpat

ien

t Ef

fici

en

cy –

red

uce

DN

A r

ates

; red

uce

wai

tin

g ti

mes

; o

pp

ort

un

ity

to r

edu

ce n

um

ber

of

clin

ics

11

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 170 of 210

20

19

/20

FIN

AN

CIA

L P

LAN

(3

)R

AG

Rat

ing

Key

Ach

ieve

men

ts/P

rogr

ess

12

Key

Ris

ks/I

ssu

esM

itig

atin

g A

ctio

ns

RA

G

Un

der

lyin

g e

xpen

dit

ure

leve

ls w

ill n

ot

red

uce

to

pre

Q4

20

18

/19

leve

ls,

wh

ich

is

the

ba

sis

of

the

exp

end

itu

re p

lan

.

Nu

rse

esta

blis

hm

ent

bu

sin

ess

case

fu

nd

ing

wa

s a

lloca

ted

in m

on

th 1

an

d w

ill e

na

ble

a

mo

re m

ean

ing

ful a

na

lysi

s ca

n t

ake

pla

ce o

f n

urs

e o

vers

pen

ds

an

d m

itig

ati

ng

act

ion

s

to b

rin

g b

ack

into

ba

lan

ce.

An

aly

sis

of

oth

er o

vers

pen

din

g a

rea

s (m

ain

ly m

edic

al s

taff

) th

at

are

co

ntr

ibu

tin

g a

nd

reco

nci

liati

on

to

det

erm

ine

wh

ere

curr

ent

bu

sin

ess

case

s w

ill r

eso

lve

the

issu

e.

R

Inco

me

pla

n h

as

bee

n r

evis

ed d

ow

n f

ollo

win

g c

on

tra

ct d

iscu

ssio

ns.

Ther

e is

a r

isk

tha

t th

e B

PT

an

d r

epa

tria

tio

n o

f a

ctiv

ity

will

no

t b

e a

chie

ved

.

Dev

elo

pm

ent

of

Tru

st F

ina

nci

al R

eco

very

pla

n (

pa

rt o

f o

vera

ll Sy

stem

Rec

ove

ry P

lan

).

6 k

ey a

rea

s o

f fo

cus

are

:➢

Esta

blis

hm

ent

con

tro

ls

➢M

edic

al b

an

k (P

atc

hw

ork

)➢

Dig

ita

lisa

tio

n o

f o

utp

ati

ents

➢R

epa

tria

tio

n

➢U

nfu

nd

ed s

ervi

ces

➢Fr

ag

ile s

ervi

ces

Each

are

a h

as

an

exe

cuti

ve le

ad

an

d t

he

Tru

st C

EO r

evie

ws

pro

gre

ss o

n t

hes

e p

roje

cts

on

a w

eekl

y b

asi

s.O

cto

ber

20

19

-p

erfo

rma

nce

is b

elo

w p

lan

an

d f

ore

cast

to

be

£2

mill

ion

aw

ay

at

yea

r-en

d. S

chem

es id

enti

fied

ab

ove

will

no

t m

itig

ate

th

e sh

ort

fall

on

oth

er s

chem

es.

A

New

CIP

ta

rget

fo

r ex

pen

dit

ure

red

uct

ion

of

£6

.3 m

illio

nR

Page 171 of 210

WO

RK

FOR

CE

AM

BER

Key

Ach

ieve

men

ts/P

rogr

ess

(1

)W

OR

KFO

RC

E EF

FIC

IEN

CY

•C

hes

hir

e &

Mer

seys

ide

colla

bo

rati

on

on

nu

rsin

g a

nd

mid

wif

ery

ag

ency

ca

ll o

ff c

on

tra

ct a

nd

ra

te c

ard

–Tr

ust

en

ga

ged

wit

h im

ple

me

nta

tio

n f

rom

1 N

ove

mb

er f

ollo

win

g C

art

er a

t Sc

ale

sig

n o

ff.

•Ti

er 2

ag

ency

ca

sca

de

imp

lem

ente

d w

ith

fu

rth

er e

nh

an

cem

ents

for

nu

rsin

g w

ith

a 3

% o

ff f

ram

ewo

rk im

pro

vem

ent

ach

ieve

d in

Sep

tem

ber

an

d m

on

th t

o d

ate

Oct

ob

er t

rack

ing

at

a

13

% im

pro

vem

ent.

•A

lloca

tio

n w

ard

sh

ift

mo

del

ling

in p

rog

ress

to

ass

ess

are

as

an

d p

att

ern

s w

her

e h

igh

er d

ema

nd

s w

ill s

up

po

rt r

edu

ctio

n in

off

fra

mew

ork

nu

rsin

g u

tilis

ati

on

. •

Sup

po

rtin

g A

tten

da

nce

Po

licy

(sic

knes

s a

bse

nce

) la

un

ched

fro

m 2

8th

Jan

ua

ry 2

01

8 w

ith

gu

ida

nce

, tra

inin

g a

nd

su

pp

ort

to

en

sure

a s

ust

ain

ed r

edu

ctio

n in

sic

knes

s a

bse

nce

ra

tes.

Th

e P

olic

y is

un

der

go

ing

a 6

mo

nth

rev

iew

wit

h t

he

firs

t a

nd

sec

on

d r

evie

w s

essi

on

s co

mp

lete

d.

YTD

Sic

knes

s a

bse

nce

ra

tes

ha

ve c

on

sist

entl

y d

ecre

ase

d s

ince

Dec

emb

er 2

01

8 a

nd

co

nti

nu

e to

do

so

in S

epte

mb

er 2

01

9.

Th

e Y

TD r

olli

ng

sic

knes

s a

bse

nce

ra

te h

as

red

uce

d b

y 0

.53

% s

ince

Dec

emb

er 2

01

8 t

o 5

.35

% in

Sep

tem

ber

20

19

. M

on

thly

sic

knes

s a

bse

nce

ra

te

for

Sep

tem

ber

20

19

wa

s a

red

uct

ion

to

4.3

2%

th

e lo

wes

t m

on

thly

sic

knes

s a

bse

nce

ra

te s

ince

20

14

. Th

e Tr

ust

will

co

nti

nu

e to

mo

nit

or

leve

ls c

lose

ly a

nd

co

nti

nu

e th

e fo

cuse

d w

ork

a

rou

nd

imp

rovi

ng

an

d s

up

po

rt s

taff

’s a

tten

da

nce

to

wo

rk.

•P

DR

co

mp

lian

ce d

ecre

ase

d in

mo

nth

to

69

.58

% f

or

Sep

tem

ber

20

19

.All

CB

U’s

ha

ve p

rese

nte

d t

hei

r re

vise

d P

DR

imp

rove

men

ta

t P

erfo

rma

nce

Rev

iew

Bo

ard

s. F

urt

her

su

pp

ort

m

eeti

ng

s p

lan

ned

to

loo

k a

t te

am

ob

ject

ives

.•

Eng

ag

emen

t w

ith

alt

ern

ati

ve m

edic

al b

an

k p

rovi

der

co

mm

ence

d –

Oct

ob

er 2

01

9•

Esta

blis

hm

ent

of

Emp

loye

e R

ela

tio

ns

rep

ort

to

be

pre

sen

ted

at

Wo

rkfo

rce

Co

mm

itte

e o

n a

mo

nth

ly b

asi

s.•

Sco

pin

g e

xerc

ise

un

der

wa

y to

imp

lem

ent

an

Em

plo

yee

Rel

ati

on

s el

ectr

on

ic s

yste

m t

his

will

pro

vid

e a

n a

rtif

icia

l in

telli

gen

ce e

lem

ent

to t

he

pro

cess

an

d a

lso

su

pp

ort

th

e re

com

men

da

tio

ns

follo

win

g t

he

Ba

ron

ess

Did

o H

ard

ing

Rep

ort

•W

ork

forc

eEf

fici

enci

es Im

pro

vem

ent

pro

gra

mm

e sc

op

ed a

nd

go

vern

an

ce a

rra

ng

emen

ts p

rop

ose

d v

ia P

MO

.•

Dev

elo

pm

ent

of

ag

ency

ra

te a

pp

rova

l pro

cess

giv

ing

mo

re a

cco

un

tab

ility

to

div

isio

ns

an

d c

linic

al d

irec

tors

; to

be

fin

alis

ed a

nd

imp

lem

ente

d in

No

vem

ber

.•

Enh

an

cem

ent

to n

urs

e ro

ster

ing

da

shb

oa

rd in

pro

gre

ss w

ith

en

ha

nce

d s

up

po

rt b

ein

g p

rovi

ded

to

ch

eck

an

d c

ha

llen

ge

pro

cess

es.

CLI

NIC

AL

WO

RK

FOR

CE

PLA

N

•Th

e C

linic

al W

ork

forc

e P

lan

–to

be

revi

ewed

fo

llow

ing

cu

rren

t cy

cle

of

bu

sin

ess

pla

nn

ing

.

REC

RU

ITM

ENT

AN

D R

ETEN

TIO

N

•R

edu

ctio

n in

Tim

e to

Hir

e p

rog

ram

me

rep

ort

ing

to

Mo

del

Ho

spit

al a

nd

Wo

rkfo

rce

Imp

rove

men

t G

rou

p•

QI p

rio

rity

fo

r Tr

ust

•Fo

cuss

ed p

iece

s o

f re

cru

itm

ent

bei

ng

un

der

take

n t

o f

ill m

edic

al v

aca

nci

es. E

spec

ially

ha

rd t

o f

ill a

rea

s su

ch a

s R

ad

iolo

gy

an

d O

bst

etri

cs a

nd

Gyn

aec

olo

gy.

•

Sco

pin

g o

f in

tern

ati

on

al r

ecru

itm

ent

op

tio

ns

for

nu

rses

. •

Co

nti

nu

ed r

ecru

itm

ent

to f

ully

est

ab

lish

th

e Tr

ust

rec

ruit

men

t te

am

. •

Wo

rkin

g t

o s

up

po

rt C

BU

s re

cru

itm

ent,

alo

ng

sid

e co

rpo

rate

nu

rse

lea

der

s.

13

TB

207_

19 S

IP P

rese

ntat

ion

Dec

19

Page 172 of 210

WO

RK

FOR

CE

AM

BER

Key

Ach

ieve

men

ts/P

rogr

ess

(2

)LE

AR

NIN

G A

ND

DEV

ELO

PM

ENT

•C

BU

’s c

on

tin

ue

to w

ork

wit

h H

R t

o s

et t

raje

cto

ries

to

incr

ease

ma

nd

ato

ry t

rain

ing

ra

tes

to s

tret

ch t

arg

et o

f 9

5%

. Iss

ue

hig

hlig

hte

d in

rel

ati

on

to

res

usc

ita

tio

n c

om

plia

nce

wh

ich

is

bei

ng

tre

ate

d a

s a

pri

ori

ty b

y th

e o

rga

nis

ati

on

to

ad

dre

ss t

he

issu

e a

nd

incr

ease

co

mp

lian

ce.

•C

BU

’s c

on

tin

ue

to w

ork

wit

h H

R t

o s

et t

raje

cto

ries

to

incr

ease

ap

pra

isa

l ra

tes

to 8

5%

. PD

R c

om

plia

nce

co

nti

nu

es t

o b

e ch

alle

ng

e fo

r th

e o

rga

nis

ati

on

an

d is

cu

rren

tly

on

a d

ow

nw

ard

tr

aje

cto

ry. I

ssu

e d

ue

to b

e a

dd

ress

ed in

Wo

rkfo

rce

Imp

rove

men

t G

rou

p t

o d

iscu

ss w

ith

key

sta

keh

old

ers

ho

w t

o m

ove

fo

rwa

rd w

ith

incr

easi

ng

co

mp

lian

ce. I

n a

dd

itio

n t

o c

om

plia

nce

b

ein

g c

ha

llen

ged

, qu

alit

y o

f a

pp

rais

als

is a

n is

sue

for

the

org

an

isa

tio

n a

nd

th

e O

D t

eam

is c

urr

entl

y ca

rryi

ng

ou

t a

myt

h b

ust

erin

ord

er t

o t

ry t

o in

crea

se c

om

plia

nce

an

d a

dd

ress

th

e is

sue

aro

un

d q

ua

lity.

•

Lea

der

ship

Str

ate

gy

ap

pro

ved

at

Bo

ard

Sep

t 2

01

9

•Sh

ad

ow

Bo

ard

Pro

gra

mm

e co

mm

ence

d in

Sep

t 2

01

9. t

he

pro

gra

mm

e h

as

bee

n w

ell a

tten

ded

, rec

eive

d a

nd

is c

on

tin

uin

g

•Tr

ium

vira

te D

evel

op

men

t P

rog

ram

me

du

e to

co

mm

ence

13

th/1

4th

No

v –

focu

ssed

co

nve

rsa

tio

ns

for

9 x

tri

um

vira

te le

ad

s (A

DO

/AM

D/H

oN

) &

3 x

Exe

c Le

ad

s•

‘Fo

un

da

tio

ns

of

Lea

der

ship

Pro

gra

mm

e’ –

co-d

esig

n w

ith

Asp

ire

for

lau

nch

in F

eb 2

02

0 –

to e

sta

blis

h t

he

‘So

uth

po

rt &

Orm

skir

k W

ay’

of

lea

der

ship

fo

r a

ll st

aff

(2

02

0)

•N

ew C

on

sult

an

ts/S

AS

Do

cto

rs p

rog

ram

me

(20

20

) -

sco

pin

g e

xerc

ise

com

ple

ted

, sp

ecif

ica

tio

n d

ocu

men

t w

ith

Med

ica

l Dir

ecto

r•

Ap

pre

nti

cesh

ip L

evy

–sc

op

ing

exe

rcis

e to

ga

in f

eed

ba

ck o

n t

he

Tru

st’s

pro

po

sal t

o s

pen

d 2

5%

of

ap

pre

nti

cesh

ip le

vy w

ith

pa

rtn

ero

rga

nis

ati

on

s (P

ap

er t

o H

MB

No

v 2

01

9)

•Le

ad

ing

Hea

lth

y W

ork

pla

ces

–b

esp

oke

tra

inin

g d

ay

un

der

dev

elo

pm

ent

wit

h a

fo

cus

on

su

pp

ort

ing

att

end

an

ce t

o b

e p

ilote

d in

Q4

•

Cu

sto

mer

Ser

vice

tra

inin

g u

nd

er c

on

sid

era

tio

n f

or

roll

ou

t st

art

ing

Q4

HEA

LTH

AN

D W

ELLB

EIN

G

•H

ealt

h &

Wel

lbei

ng

Str

ate

gy

ap

pro

ved

at

Wo

rkfo

rce

Co

mm

itte

e Se

pte

mb

er.

•R

evie

wed

an

d u

pd

ate

d t

he

Hea

lth

an

d W

ellb

ein

g (

sick

nes

s a

bse

nce

) act

ion

pla

n f

or

NH

SI p

roje

ct•

To le

ad

on

th

is y

ear’

s F

lu c

am

pa

ign

–2

01

9/2

020

CQ

UIN

N is

fo

r 8

0%

of

fro

ntl

ine

hea

lth

care

wo

rker

s to

be

vacc

ina

ted

. Th

e Tr

ust

rea

ched

th

e 8

0%

ta

rget

on

th

e w

eek

com

men

cin

g

11

/11

/20

19 a

hea

d o

f th

e ca

mp

aig

n s

ched

ule

•

Pro

vid

e ‘m

enta

l hea

lth

fir

st a

id’ t

o s

taff

, ‘M

enta

l Hea

lth

Fir

st A

id T

rain

ing

’ co

nsi

der

ati

on

giv

en o

n h

ow

to

pro

mo

te t

he

role

inlin

e w

ith

th

e H

ealt

h &

Wel

lbei

ng

ag

end

a.

•Tr

ust

Att

end

an

ce a

t N

HSi

Hea

lth

an

d W

ellb

ein

g S

um

mit

–7

thN

ove

mb

er 2

01

9 –

sha

re le

arn

ing

an

d e

xper

ien

ces

wit

h o

ther

pro

vid

ers

on

Hea

lth

& W

ellb

ein

g im

pro

vem

ent

pro

gra

mm

e

14

Page 173 of 210

15

WO

RK

FOR

CE

AM

BER

Key

Ach

ieve

men

ts/P

rogr

ess

(3

)O

D, C

ULT

UR

E A

ND

STA

FF E

NG

AG

EMEN

T

•So

Pro

ud

Big

Co

nve

rsa

tio

ns

con

tin

ue

acr

oss

th

e o

rga

nis

ati

on

–d

ata

ga

ther

ing

fo

r b

eha

vio

urs

th

at

un

der

pin

ou

r SC

OP

E va

lues

, fo

cus

gro

up

to

be

hel

d N

ov/

Dec

20

19

•St

aff

En

ga

gem

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Stra

teg

y a

pp

rove

d a

t B

oa

rd S

ept

20

19

•In

-ho

use

co

ach

ing

ser

vice

lau

nch

ed O

ct 2

01

9. P

urc

ha

se o

f o

nlin

e co

ach

ing

mo

du

les

for

all

sta

ff t

o a

cces

s fo

r a

12

mo

nth

per

iod

(2

02

0)

•St

aff

FFT

–in

crea

se in

co

mp

leti

on

s fr

om

2.1

% (

Q1

) to

13

.7%

(Q2

) -

CB

U in

fog

rap

hic

s ci

rcu

late

d e

arl

y N

ov

20

19

•St

aff

Su

rvey

lau

nch

ed O

ct 2

01

9 –

incr

ease

in c

om

mu

nic

ati

on

s vi

a e

-co

mm

s a

nd

so

cia

l med

ia.

Cu

rren

t re

spo

nse

ra

te 3

1%

. C

losi

ng

Da

te 2

9th

No

vem

ber

•Ta

len

t M

an

ag

emen

t Se

lf-D

iag

no

stic

To

ol –

curr

entl

y o

ut

for

con

sult

ati

on

–o

nlin

e re

po

rt e

xpec

ted

Dec

20

19

•C

on

tin

ued

bes

po

ke O

D In

terv

enti

on

s to

su

pp

ort

th

e ro

ll o

ut

of

SON

AA

S &

tea

m d

evel

op

men

ts f

or

spec

ific

ho

t sp

ot

are

as

•C

orp

ora

te In

du

ctio

n r

evie

w t

ake

n p

lace

, rep

ort

to

be

tab

led

at

HM

B in

No

vem

ber

20

19

.•

Bo

ard

Vis

ibili

ty i

nit

iati

ves

on

go

ing

–w

ill b

e re

view

ed w

hen

new

Ch

ief

Exec

uti

ve c

om

men

ces

in p

ost

. •

Mo

nth

ly V

alu

ing

Ou

r P

eop

le G

rou

p m

eeti

ng

s to

del

iver

Wo

rkfo

rce

& O

D P

lan

•SO

Pro

ud

Co

nve

rsa

tio

ns

–fo

cuss

ed c

on

vers

ati

on

s o

n t

he

beh

avi

ou

rs t

o u

nd

erp

in o

ur

SCO

PE

Va

lues

–N

ov

& D

ec 2

01

9

•R

elo

cati

on

of

HR

co

nsu

lta

tio

n h

as

con

clu

ded

. Fu

rth

er c

ab

ling

, net

wo

rkin

g a

nd

infr

ast

ruct

ure

wo

rk h

as

beg

an

to

be

un

der

take

n i

n o

rder

to

su

pp

ort

th

e a

dd

itio

na

l wo

rkst

ati

on

s,

con

tra

cto

rs h

ave

bee

n s

ou

rced

an

d h

ave

beg

an

to

un

der

take

th

is p

iece

of

wo

rk.

•W

ork

forc

eEf

fici

enci

es Im

pro

vem

ent

pro

gra

mm

e sc

op

ed a

nd

go

vern

an

ce a

rra

ng

emen

ts p

rop

ose

d v

ia P

MO

.•

Ag

reem

ent

ob

tain

ed t

o im

ple

men

t re

visi

on

s to

sa

lary

sa

crif

ice

veh

icle

s sc

hem

es t

o a

dd

ress

issu

es a

nd

ga

in im

pro

vem

ents

an

d e

ffic

ien

cies

•R

ost

erin

g p

olic

y d

evel

op

men

t –

att

ain

ed f

ina

l sig

n o

ff a

t p

olic

y ra

tifi

cati

on

gro

up

. •

Rev

iew

of

form

at

an

d b

eha

vio

ura

l co

ntr

act

of

the

Wo

rkfo

rce

Co

mm

itte

e

HR

IMP

RO

VEM

ENT

PR

IOR

ITIE

S

•W

ork

forc

e Im

pro

vem

ent

Gro

up

-h

eld

mo

nth

ly–

dri

ver

dia

gra

ms

& a

ctio

n p

lan

s in

pla

ce –

rep

ort

s in

to H

osp

ita

l Im

pro

vem

ent

Bo

ard

•C

ore

ma

nd

ato

ry t

rain

ing

rem

ain

s a

bo

ve t

he

Tru

st t

arg

et a

t 8

8.3

4%

(31

/10

/19

)•

Co

nti

nu

ed r

edu

ctio

n o

f Y

TD s

ickn

ess

ab

sen

ce r

ate

–0

.53

% r

edu

ctio

n s

ince

Dec

emb

er 2

01

8•

Sup

po

rtin

g A

tten

da

nce

Po

licy

Rev

iew

•Em

plo

yee

Rel

ati

on

s P

olic

y re

view

•In

crea

se P

DR

co

mp

lian

ce•

Incr

ease

sta

ff s

urv

ey r

esp

on

se r

ate

•R

edu

ce T

ime

to H

ire

•In

crea

se f

lu v

acc

ina

tio

n r

ate

fo

r cl

inic

al s

taff

•A

pp

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207_

19 S

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rese

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19

Page 174 of 210

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TB

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Page 176 of 210



Title

Charity Name Change


Lead Officer Mark Wilson, Assistant Director of Finance

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

This paper requests the renaming of the Charity from “Southport and Ormskirk Hospital NHS Trust Charitable Fund” to “Southport and Ormskirk Hospitals Charity”. A Board resolution is required so that a formal application to the Charity Commission can be made to change the name. R e c o m m e n d a t i o n s :

The Board is asked to approve the change of name for the charity.














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CQC KLOEs

GOVERNANCE




Safe Service Change

Well Led


Compliance Legal


Equality Risk

Finance Workforce



Policy

Service Change

Strategy


An on line submission to the Charity Commission will be made and the Board resolution attached.






Page 178 of 210

Charity name change

1 Introduction 1.1 As part of the charity re-launch strategy a minor amendment is required to the charity name.

1.2 To formalise this, the Charity Commission require a Board resolution authorising the name

change.

2 Name change

2.1 The name change is from “Southport & Ormskirk Hospital NHS Trust Charitable Fund” to “Southport and Ormskirk Hospitals Charity”.

2.2 The Board should note that the marketing materials have already been prepared under the new proposed name.

2.3 Logo is shown below:

3 Recommendation

3.1 It is recommended that the Board approve the change of name of the charity.

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Page 179 of 210



Title

Charity Investment Policy


Lead Officer Mark Wilson, Assistant Director of Finance

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

The majority of the charity’s monies are invested in a portfolio of shares and gilts. The Investment policy provides a framework for this investment together with ethical constraints. A number of changes to the existing policy are contained in this report and the final policy for approval is shown in appendix 1. R e c o m m e n d a t i o n s :

It is recommended that the Trust Board acting as the Corporate Trustee approve the charity’s

investment policy.














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CQC KLOEs

GOVERNANCE




Safe Service Change

Well Led


Compliance Legal


Equality Risk

Finance Workforce



Policy

Service Change

Strategy


Policy to be sent to Investment advisors.






Page 181 of 210

Charity Investment Policy

1 Introduction 1.1 The purpose of the investment policy is to ensure that the charitable fund portfolio is effectively

managed by providing a framework to the Investment advisors that sets out the allocation to each asset class within the constraints set by the charity.

1.2 This policy covers the framework allocation and the ethical constraints.

2 Policy changes

2.1 UK and overseas equity should be combined rather than listed separately with a limited risk of 75%.

2.2 Upper limit on alternatives (now that it encompasses a wider range of assets) should be lifted to 15%.

2.3 Include a comment on capacity for loss in our investment policy statements – see below.

2.4 ‘The Charity has a moderate ability to bear investment losses which means that in extreme circumstances falls in the value of the portfolio of up to 35% would not have a material impact on the overall financial ability to carry out its function. Under the current structure and based on historic data, the investment manager estimates this strategy has the potential to fall up to 23% peak to trough in an investment cycle.’

2.5 On ethical investments include the point that the charity will not invest in no win no fee medical claims companies.

3 Charitable Fund Committee

3.1 The above changes have been agreed by the Charity Committee and appendix 1 sets out the final investment policy.

3.2 The Investment advisors also provided a comparison with other charities in terms of risk

appetite which has been shared with the Committee members. 4 Risk appetite 4.1 Based on other charities, this investment policy in general is slightly on the cautious side of the

‘average’ charity, with a marginally lower equity content. 4.2 The reason for this is due to the ongoing potential that the portfolio may need to help meet

short term requirements when there are cash flow issues and investments need to be liquidated.

4.3 With the charity relaunch and the prospect of a significant increase in donations, then a further

review in 6 months may be required to re-assess risk appetite. 5 Conclusion 5.1 The final investment policy satisfies the charity’s objectives and has been through the

appropriate review and governance. 6 Recommendation 6.1 It is recommended that the Trust Board acting as the Corporate Trustee approve the charity’s

investment policy.

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Page 182 of 210

Appendix 1 – Charity Investment policy

Introduction The purpose of the investment policy is to ensure that the charitable fund portfolio is effectively managed by providing a framework to the Investment advisors that sets out the allocation to each asset class within the constraints set by the charity. Allocation

Asset Class Allocation Tactical Variance

Total range

UK Sovereign Debt 30% +/-10% 20% to 40%

Cash 0% +15% 0% to 15%

Equity Investments 65% +/-10% 55% to 75%

Alternative Assets (hedge, commercial property, commodities)

5% +/- 10% 0% to 15%

In terms of the risk profile and time horizon a medium risk strategy should be adopted with an indefinite time horizon. Ethical constraints The following ethical investment constraints have been set by the Trustees, which means that investments in those companies involved wholly or substantially in the following are excluded:

1. Tobacco. 2. Armaments. 3. Alcohol. 4. Betting/gaming. 5. Payday loans. 6. No win no fee medical claims companies.

Wholly or substantially is defined as more than two thirds of the business. Equity constraint No individual direct equity holding should account for more than 10% of the equity exposure of the fund. Portfolio transfers Transfers of cash into and out of the portfolio should be managed between the Charity and the Investment advisors to ensure there is sufficient notice period to make informed decisions. Where the Trust foresees that it will require funds to be liquidated from the portfolio, the Charity should inform the Investment advisors with details of the value to be liquidated and the required liquidation date.

Page 183 of 210

Surplus funds in the charity’s bank account over and above the current requirements should be transferred to the Investment advisors. The Assistant Director of Finance has delegated authority to transfer monies into the portfolio and to request transfers out. Reserves The value of the portfolio must always be greater than the charity’s reserve target. The reserve is made up of the unrestricted funds (general). Targets Income generation from the portfolio is from dividends on equity shares and UK sovereign debt. The target income generation is reviewed annually and currently stands at 3.5% of the average annual portfolio value. Capacity for loss The Charity has a moderate ability to bear investment losses which means that in extreme circumstances falls in the value of the portfolio of up to 35% would not have a material impact on the overall financial ability to carry out its function. Under the current structure and based on historic data, the investment manager estimates this strategy has the potential to fall up to 23% peak to trough in an investment cycle. Monitoring The Investment advisors will report each quarter to the Charitable Fund Committee. The report will include the following:

1. Full details of the portfolio. 2. Comparison of returns against an appropriate industry benchmark. 3. Income generation for the quarter. 4. A table showing the actual allocation percentages by asset class.

Review An annual performance review will take place at the end of each financial year. This in turn will feed into the investment policy review where the allocation of the portfolio can be considered together with the income generation target.

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Agenda Item TB210/19a Report Title Learning lessons to improve

Our People Practices

Executive Lead Jane Royds, Director of HR and OD

Lead Officer Laura Hilton, Head of HR

Action Required

(Definitions below)

To Approve To Note

✓ To Assure ✓ To Receive

For Information

Executive Summary

The Committee’s highlight report for September 2019 is set out below:

Alert N/A Advise There are a number of recommendations in the attached paper that need to be agreed in order to strengthen the Trusts compliance with investigation findings and recommendations. Further timescales were requested following presentation of this paper, at board in October 2019 in relation to the implementation of the Employee Relations Tracker system (Empactis). The timescales have been set out in the revised paper. Full implementation of the Employee Relations Tracker system (Empactis) is expected by May 2020. Assure

The board can take assurance that many of the recommendations set out by Baroness Harding are

already in place at S&O.

Recommendation: This paper is to assure the Board.










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Lear

ning

Les

sons

to Im

prov

e ou

r P

eopl

e P

ract

ices

Rep

ort

- U

pd...

Page 185 of 210








CQC KLOEs

GOVERNANCE



Responsive ✓ Best Practice


✓ Well Led




Equality Risk




Policy

Service Change

Strategy


A further update paper to be provided to Workforce Committee in October 2019.





Committee ✓ Workforce Committee







Page 186 of 210

Learning lessons to improve our people practices 1. Introduction

This paper is to advise the Trust Board about the content of a letter sent to Provider chief executives and chairs on the 24th May 2019 from Baroness Dido Harding, Chair, NHS England and NHS Improvement about why Trusts need to learn lessons to improve our people practices. The letter shares the outcomes of an important piece of work recently undertaken in response to a very tragic event that occurred at a London NHS trust three years ago. This paper will provide details of the case of Amin Abdullah who was the subject of an investigation and disciplinary procedure in late 2015 and includes additional guidance relating to the management and oversight of local investigation and disciplinary procedures. 2. Background In the case of Amin Abdullah the protracted procedure culminated in Amin’s summary dismissal on the grounds of gross misconduct. Tragically, in February 2016 just prior to an arranged appeal hearing, Amin took his own life. This triggered the commissioning of an independent inquiry undertaken by Verita Consulting, the findings of which were reported to the board of the employing Trust and to NHS Improvement in August 2018. The report concluded that, in addition to serious procedural errors having been made, throughout the investigation and disciplinary process Amin was treated very poorly, to the extent that his mental health was severely impacted. Verita’s recommendations were accepted by the Trust, in full, and have largely been implemented. Subsequently, NHS Improvement established a ‘task and finish’ advisory group to consider to what extent the failings identified in Amin’s case are either unique to that Trust or more widespread across the NHS, and what learning can be applied. Comprising of multi-professional stakeholders and subject matter experts representing both the NHS and external bodies, together with an advocate for Amin’s partner, the Group conducted an independent analysis of both the Verita findings and several historical disciplinary cases, the outcomes of which had attracted criticism in Employment Tribunal proceedings and judgements. HR directors of provider organisations were advised of the Group’s activity and invited to share details of any local experiences and/or examples of measures being taken to improve the management of employment issues. The analysis highlighted several key themes associated with the Verita inquiry which were also common to other historical cases considered. Principal among these were: poor framing of concerns and allegations; inconsistency in the fair and effective application of local policies and procedures; lack of adherence to best practice guidance; variation in the quality of investigations; shortcomings in the management of conflicts of interest; insufficient consideration and support of the health and wellbeing of individuals; and an over-reliance on the immediate application of formal procedures, rather than consideration of alternative responses to concerns. This paper aims to outline where S&O’s current processes and procedures are against the 7 areas of focus set out in Baroness Harding’s guidance and the Business HR team’s commitment to further improve and strengthen our people practice in relation to the management of employee relations cases. 3. Guidance relating to the management and oversight of local investigation and disciplinary

procedures 3.1. Adhering to best practice The Trusts key disciplinary and grievance policies are in the process of being significantly reviewed to ensure that they maintain keeping in line with current best practice as advised in the Arbitration Conciliation Advisory Service (ACAS) Code of practice on disciplinary and grievance procedures. The Trusts Managing High Professional Standards policy applicable to the management of our medical workforce has also recently been reviewed.

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The recommendation of Baroness Harding suggests that procedures should also follow the principles of the NMCs best practice guidance on local investigations (when published). The Business HR team in partnership with staff side will ensure review of this once published and make any amendments to our process if required. All formal employee relations cases have an assigned HR representative to advise and support the management of procedures. Through this the Business HR team ensure that independence and objectivity is applied throughout the process and action is taken to prevent any perceived conflicts of interest. This is supported by our policies and procedures and also applicable to the HR representative assigned to the differing steps of the process. Where required advisors to disciplinary and appeal panels may also be assigned as subject matters experts to ensure objectivity. All employee relations policies and procedures ‘owned’ by the Business HR team have recently been reviewed or are currently going through review and will be reviewed in accordance with the recommendations following this independent investigation. 3.2. Applying rigorous decision making Trust processes can be considered to be in line with the application of just culture principles. Policies have been drafted to ensure that preliminary investigative work is undertaken before any process progresses to a formal procedure. Within the Trusts revised disciplinary policy the usage of the NHS Incident Decision tree (Just Culture Guide) is proposed to be used on the outset of any employee relations case to guide and inform the appropriate next steps, for example when considering the suspension of an employee where a serious allegation has come to light. If following a preliminary investigation the senior manager in possession of the allegation recommends suspension, the Business HR team ensure that this is escalated to the respective Director of the Trust, Deputy Director, Assistant Director of Operations, Head of Nursing or equivalent. By adopting this practice ensures plurality and informed decisions are made on the outset. The Trust has significantly invested into their mediation service within the last 3 years and now has 27 trained mediators available throughout the Organisation. Where mediation is deemed appropriate, this is an enabler for cases to be managed at a local and informal stage of the process.

3.3. Ensuring people are trained and competent to carry out their role The appointment of investigating officers is decided in collaboration of the case manager/commissioning manager (revised policy) and the assigned HR representative. When appointing investigating officers this will be dependent on the seniority, neutrality and experience of the individual. As all employee relations cases will be assigned a HR representative, it is their role to guide, advise and coach that investigating officer as the process progresses. To support the competence of investigating officers, hearing and appeal boards, the Trust has guides and training established which are available on the Trusts intranet. The Business HR team will also review those guides and training programmes to ensure consistency with the revised policies. 3.4. Assigning sufficient resources Within the Business HR team monthly case reviews are held as a team which allows capacity and demand oversight and appropriate delegation to ensure the timeliness of investigations internal to the Business HR team. Any concerns regarding resource will be escalated to the appropriate senior member of the management team to ensure resolution. Additionally the Trust has invested in the development and resourced a bank of investigating officers to ensure that the Trust has access to independent investigating officers should resourcing be of concern.

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The Business HR team have scoped out and requested as part of the HR Business Case Investment in an Employee Relations Tracker system (Empactis) which is recommended by NHSI and will automate some of the processes associated with ER cases and ensure timely responses/reminders in line with the policy timescales. The system will enable timescales in relation to cases to be reported on easily and the identification of any hotspots areas in order to ensure effective and timely interventions. A HR Business Partner – Project Lead has been appointed to lead on the roll out of the implementation of this system and will commence in post on 9th December 2019. Timescales in relation to this policy are as follows:

• Detailed Project Initial Document and Project Plan to be drafted December 2019

• ESR Data cleanse to commence December 2019 – January 2020

• Procurement and Information Governance process to commence December 2019

• Contract and Information Governance sign off by mid-January 2020

• Project to initiate February 2020

• Phase 1 will focus on Case Management and include Disciplinary, Grievance, MHPS, Dignity at Work case types.

o This phase will include ESR interfacing. o The 1st Case Type to go-live as a full workflow for manager use will be Disciplinary. o Other case types will initially be tracked using the platform i.e. not as a workflow and

so will continue to be managed by HR; workflow for the remaining case types will introduced in a staged way during 2020.

• The Trust would like to be live by 31st May 2020 with Case Management. 3.5. Decisions relating to the implementation of suspensions / exclusions When a suspension is likely, the Business HR team ensure that the decision to suspend is escalated to the Director of the Trust, Deputy Director, Assistant Director of Operations, Head of Nursing or equivalent. The revised policy will ensure that the escalation of a decision to suspend ensures preliminary investigative work has been undertaken, that decisions to suspend are informed, safe and alternatives to suspensions are considered. 3.6. Safeguarding people health and wellbeing On the outset of an employee relations case the individual is reminded of the support services available to them through the Trusts health and wellbeing service and employee assistance provider. The individual is advised that a self-referral to those services can be made or alternatively a management referral will be made on their behalf. In some circumstances a case manager/commissioning manager may automatically refer an individual to support services dependent on the nature of the allegations or individuals circumstances. Once an employee relations case has been commissioned a terms of reference will be drafted by the case manager/commissioning manager that includes timeframes for the completion of the investigatory process and also when the individual will be informed of the outcome of the process. This timeframe will be shared with the individual by the investigating officer through the course of their investigation. The case manager/commissioning manager is responsible for keeping the individual informed on the progress of the investigation and any delays to the originally anticipated timeframe of completion. 3.7. Board level oversight Going forward the board will receive data relating to employee relations cases via a dashboard presented at Workforce Committee held on a monthly basis. This group is chaired via the Director of HR and OD and the minutes and papers of that group are shared with the Board via the Corporate Governance structure. The board will also receive data relating to employee relations cases directly via the CBU Performance Review meetings chaired by the Chief Executive Officer.

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Detailed discussions relating to employee relations cases are shared during the monthly one to one meetings held between the Head of HR and HR Business Partners. 4. Recommendations It is recommended that the board can take assurance that many of the recommendations set out by Baroness Harding are already in place at S&O. There are however areas that can be strengthened and the Business HR team will commit to improve those in the coming months, and will provide an assurance at regular intervals. . Actions to be taken:

• Review the contents of the NMCs ‘best practice guidance on local investigations’ when published, making any necessary amendments to process where needed.

• The team will develop a suspension pro-forma in order to record the process of escalation and informed decisions when the need to suspend arises. Whilst this can be evidenced at present this will ensure consistency and a central record of this information. Once developed a recommendation for this suspension pro-forma to be added as an appendices within the disciplinary policy to encourage its usage.

• The Business HR team to ensure evidence that a preliminary investigation has been undertaken prior to commencement of a formal process. Currently this can be difficult to evidence the separation of a preliminary and formal process.

• The Business HR team to will refresh a local training programme for investigations of employee relation cases.

• Continue to develop and review toolkits and guides to ensure they are fit for purpose.

• Add to terms of reference templates that the requirement for the commissioning manager to ensure wellbeing support is offered at regular intervals and a communication plan is established on the outset of an employee relations process.

• Develop and establish a governance framework in relation to the reporting of cases.

• Business Case funding will implement an employee relations case management system to ensure timeliness of case management. This system has shown much improvement when implemented in other Trusts.

• Investment in Employee Relations Tracker system – to automate some of the process and ensure timely responses in line with the policy timescales.

This paper is to assure the Board that an action plan is in place.

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Appendix 1

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PUBLIC TRUST BOARD 4 November 2019

Agenda Item TB210/19b Report Title Workforce Disability Equality

Standard Report

Executive Lead Jane Royds: Director of Human Resources and OD

Lead Officer Bob Davies: Equality Lead

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

The Committee’s highlight report for August 2019 is set out below:

Alert

• 30.48% of the workforce have not disclosed if they do or do not have a disability. The Trust

needs to promote to staff the purpose of self-reporting and self-reporting process on ESR.

Advise

• The WDES report highlights that staff with a disability have poorer experiences in areas such

as bullying and harassment and attending work when ill.

• Paper has been reformatted as per action following October’s Board meeting. New formatted

report was accepted at Workforce Committee in November 2019.

Assure

• The WDES action plan will be monitored and updated. Updates will be provided to the various

Trust groups / committees and the report and updates are also a requirement of the equality

section of the quality contract with the CCG’s.

Recommendation

The Workforce Committee is asked to receive the report.







If the Trust cannot meet its financial regulatory standards and operate within agreed financial resources the sustainability of services will be in

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question.








CQC KLOEs

GOVERNANCE





✓ Well Led


Compliance ✓ Legal


✓ Equality Risk




Policy

Service Change

Strategy


The Trust has compiled a WDES report and action plan that will be monitored at various Trust committees and groups i.e. Workforce Committee Valuing Our People Group, reporting is also a requirement in the CCG equality section of the quality contract, the Trust will set up a disability staff network to obtain the views of staff with a disability or long-term medical condition, the WDES action plan highlights areas for development i.e. Reporting a disability on ESR, Recruitment, Staff Bandings, Bullying and Harassment






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Southport and Ormskirk Hospital NHS Trust Workforce Disability Equality Standard Information Report April 2019 – March 2020

1. Executive Summary This paper provides a general overview of the Workforce Disability Equality Standard (WDES) and the metrics against the nine indicators within the Workforce Disability Equality Standard (WDES). It also provides analysis of the metrics and outlines actions (Appendix 1 WDES Action Plan) to address the gaps between the experience of Disabled and Non-disabled staff.

2. Introduction The Workforce Disability Equality Standard (WDES) is mandated by the NHS Standard Contract and will apply to all NHS Trusts and Foundation Trusts from April 2019. The WDES is a data-based standard that uses a series of measures (Metrics) to improve the experiences of Disabled staff in the NHS. The WDES comprises ten Metrics. All of the Metrics draw from existing data sources (recruitment dataset, ESR, NHS Staff Survey, HR data) with the exception of one; Metric 9b asks for narrative evidence of actions taken, to be written into the WDES annual report The Metrics have been developed to capture information relating to the experience of Disabled staff in the NHS. Research has shown that Disabled staff have poorer experiences in areas such as bullying and harassment and attending work when feeling ill, when compared to non-disabled staff. The ten Metrics have been informed by research by Middlesex and Bedford Universities, conducted on behalf of NHS England, and by Disability Rights UK on behalf of NHS Employers. The annual collection of the WDES Metrics will allow NHS Trusts and Foundation Trusts to better understand and improve the employment experiences of Disabled staff in the NHS. The WDES Metrics have been designed to be as simple and straightforward as possible. The development of the WDES owes a great deal to the consultation and engagement with NHS key stakeholders, including Disabled staff, trade unions and senior leaders.

3. WDES Highlights The information below provides highlights from the WDES report for 2018-19, the information also provides the Trust figures compared to the average for combined acute and community hospital. Please note this is the first year the WDES report have been compiled so there are no comparisons available. Q/ Do you have any physical or mental health conditions, disabilities or illnesses that have lasted or are expected to last for 12 months or more? (NHS staff survey 2018) Southport Ormskirk Hospital NHS Trust response is 19.8% other Trusts average is 17.1%, therefore SOHT is 2.7% above the national average response. The 2018-19 Trust ESR figures for staff highlighting they have a disability is 2.55% although19.8% of staff highlighted they have a disability in the NHS staff survey 2018. The Trust are in the process of promoting to staff the process they should follow to register having a disability on ESR, staff are also informed in a letter after supporting attendance meetings that they can record their disability on ESR or there manager can support them with updating ESR. The Trust is also looking at introducing a Reasonable Adjustment / Disability Passport for staff with a disability.

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The Trust is aiming to set up a Disability staff network group which will look at why 30.48% of Trust staff have not disclosed if they do or don’t have a disability. Metric 2/ Relative likelihood of Disabled staff compared to non-disabled staff being appointed from shortlisting 432 disabled staff were shortlisted and 16 were hired this is a success rate of 3.70% compared to 2515 non-disabled staff shortlisted and 150 who were successful which is a 5.96% success rate. Metric 3/ Relative likelihood of disabled staff compared to non-disabled staff entering the formal capability process For the purposes of Year 1 WDES report, capability is defined as capability on the grounds of performance, not ill health. The figures highlight that no disabled or non-disabled staff entered the formal capability process on the grounds of performance in 2018-19. Metric 4/ Percentage of Disabled staff compared to non-disabled staff experiencing harassment, bullying or abuse from:

i/ Patients/service users, their relatives or other members of the public in the last 12 months Disabled staff = 37.3% Non-disabled 26.7% Difference = 10.6% ii/ Managers Disabled staff = 24.4% Non-disabled 11.5% Difference = 12.9% iii/ Other colleagues Disabled staff = 30.8% Non-disabled 15.9% Difference = 14.9% Metric 5,6,7/ Staff with a disability highlighted in metric 5, 6, 7 of the report a score / response that is worse than staff without a disability, the responses highlight that appropriate actions need to be complied to address the issues raised. Metric 8/ Has your employer made adequate adjustment(s) to enable you to carry out your work?(NHS staff survey) The Trust response rate is 77% other Trusts average is 72%, SOHT is 5% above the national average response.

4. Staff Profile As of March 2019 Southport and Ormskirk Hospital NHS Trust employed 2986 people of which 2.55% disclosed they have a disability. Disability – Non Disabled Staff Information: 2.55% of the Workforce have disclosed that they consider themselves to have a Disability, 66.97% of staff have told us they don’t consider themselves to have a Disability with the remainder 30.48% either not declaring, preferring not to say and the others unspecified

Disability Headcount Percentage %

No 2000

66.97% of staff don’t consider themselves to have

a disability

Not Declared 127

30.48% not disclosed

Prefer Not To Answer 1

Unspecified 782

Yes 76

2.55% of staff consider themselves to have a

disability

Grand Total 2986 100%

5. Workforce Metrics Three workforce Metrics, compares the data for both Disabled and non-disabled staff.

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Note: Definitions for these categories are based on Electronic Staff Record occupation codes with the exception of medical and dental staff, which are based upon grade codes. Workforce Disability Equality Standard Indicators: For each of workforce indicators, the standard compares the metrics for disabled and non-disabled staff were the figures don’t equate to 100% this is due to the information not stated / not given Workforce Metrics

For the following three workforce Metrics, compare the data for both Disabled and non-disabled staff.

Metric:

Data for reporting year

Non – Clinical

1

Percentage of staff in AfC pay bands or medical and dental subgroups and very senior managers (including Executive Board members) compared with the percentage of staff in the overall workforce. Organisations should undertake this calculation separately for non-clinical and for clinical staff. Cluster 1 (Bands 1 - 4) Cluster 2 (Band 5 - 7) Cluster 3 (Bands 8a - 8b) Cluster 4 (Bands 8c - 9 & VSM Cluster 5 (Medical & Dental Staff, Consultants) Cluster 6 (Medical & Dental Staff, Non-Consultants career grade) Cluster 7 (Medical & Dental Staff, Medical and dental trainee grades) Note: Definitions are based on Electronic Staff Record occupation codes with the exception of Medical and Dental staff, which are based upon grade codes.

2018-19

Cluster Cluster 1 Cluster 2 Cluster 3 Cluster 4

Disabled

4% 4% 0% 0%

Non-Disabled

58% 67% 69% 89%

Clinical

2018-19

Cluster Cluster 1 Cluster 2 Cluster 3 Cluster 4

Disabled

2% 2% 3% 0%

Non-Disabled

70% 71% 64% 86%

Cluster 5: Med & Dental Consultant

2018-19

Disabled

0%

Non-Disabled

58%

Cluster 6: Med & Dental Consultant Non –Consultant

Career Grade

2018-19

Disabled

2%

Non-Disabled

64%

Cluster 7: Medical & Dental Trainee Grades

2018-19 2017-18

Disabled

1%

Non-Disabled

94%

Metric 2:

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2 Relative likelihood of Disabled staff compared to non-disabled staff being appointed from shortlisting across all posts. Note: i) This refers to both external and internal posts. ii) If your organisation implements a guaranteed interview scheme, the data may not be comparable with organisations that do not operate such a scheme. This information will be collected on the WDES online reporting form to ensure comparability between

organisations.

Recruitment: The information below highlights the ratio of Disabled and Non-Disabled staff being appointed from short listing; please note this refers to both internal and external posts 2018-19

Head Count Ratio

WDES Category

Shortlisted Hired Shortlisted Ratio

Disabled 432 16 0.96 0.04

Non-Disabled

2515 150 0.94 0.06

NULL 31 8 0.79 0.21

Not Stated / Not Given

49 1 0.98 0.02

Relative likelihood of Disabled staff compared to non-disabled staff being appointed from shortlisting across all posts: 1.6, A figure below 1:00 indicates that Disabled staff are more likely than Non-Disabled staff to be appointed from shortlisting

Metric 3:

3

Relative likelihood of Disabled staff compared to non-disabled staff entering the formal capability process, as measured by entry into the formal capability procedure. Note: i) This Metric will be based on data from a two-year rolling average of the current year and the previous year. ii) This Metric is voluntary in year one.

Relative likelihood of Disabled staff compared to non-disabled staff entering the formal capability process 2018-19

WDES Category

Head Count

Disabled 0

Non-Disabled 0

Not Stated 1

Total 1

Figure for disabled and none disabled staff is the same 0%

National NHS Staff Survey Metrics For each of the following four Staff Survey Metrics, compare the responses for both Disabled and non-disabled staff

Metric 4:

4 a/ Percentage of Disabled staff compared to non-disabled staff experiencing harassment, bullying or abuse from:

i/ Patients/service users, their relatives or other members of the public in the last 12 months

i/ Patients/service users, their relatives or other members of the public: Disabled Non-Disabled : 37.3 % 26.7%

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5

ii/ Managers iii/ Other colleagues b/ Percentage of Disabled staff compared to non-disabled staff saying that the last time they experienced harassment, bullying or abuse at work, they or a colleague reported it.

ii/ Managers: Disabled Non-Disabled 24.4% 11.5%

iii/ Other colleagues: Disabled Non-Disabled 30.8% 15.9 %

b/ % of Disabled staff compared to non-disabled staff saying that the last time they experienced harassment, bullying or abuse at work, they or a colleague reported it. Disabled Non-Disabled 52.8% 46.5%

Metric 5: Q14

5 Percentage of Disabled staff compared to non-disabled staff believing that the Trust provides equal opportunities for career progression or promotion.

Disabled Non-Disabled 78.5% 80.9 %

Metric 6: Q11

6 Percentage of Disabled staff compared to non-disabled staff saying that they have felt pressure from their manager to come to work, despite not feeling well enough to perform their duties

Disabled Non-Disabled 31.8% 19.7%

Metric 7: Q5

7 Percentage of Disabled staff compared to non – disabled staff saying that they are satisfied with the extent to which their organisation values their work

Disabled Non-Disabled 26.9% 37.8%

The following NHS Staff Survey Metric only includes the responses of Disabled staff

Metric 8: Q28b

8 Percentage of Disabled staff saying that their employer has made adequate adjustment(s) to enable them to carry out their work.

Disabled 76.2%

NHS Staff Survey and the engagement of Disabled staff For part a) of the following Metric, compare the staff engagement scores for Disabled, non-disabled staff and the overall Trust’s score For part b) add evidence to the Trust’s WDES Annual Report

Metric 9:

9 a) The staff engagement score for Disabled staff, compared to non-disabled staff and the overall engagement score for the organisation. b) Has your Trust taken action to facilitate the voices of Disabled staff in your organisation to be heard? (Yes) or (No) Note: For your Trust’s response to b) If yes, please provide at least one practical example of current action being taken in the relevant section of your WDES annual report. If no, please include what action is planned to address this gap in your WDES annual report. Examples are listed in the WDES technical guidance.

Disabled Non-Disabled 6.2 6.6 Yes: Staff & Family Friends Test NHS Staff Survey Big Brew / Conversation Setting Up of a Disability Staff Network So Proud Pulse Check

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Board Representation Metric For this Metric, compare the difference for Disabled and non-disabled staff

Metric 10:

10

Percentage difference between the organisation’s Board voting membership and its organisation’s overall workforce, disaggregated:

• Trust board headcount

• Executive and Non-executive

• Workforce

• Please note were figures don’t equate to 100% this is due to staff responses unknown or null response

Non-Disabled Disabled

Trust board members – Headcount:

14 0

of which: Voting Board Members 11 0

:Non-Voting Board Members 3 0

Trust Board Members

of which: Exec Board Members 11 0

:Non Exec Board Members 3 0

Workforce

Overall workforce % by disability 67% 2%

Differences

Total Board –overall workforce 33% -2%

Voting membership –Overall workforce

33% -2%

Executive-Overall Workforce 33% -2%

5. Trust Actions taken to be compliant with the WDES

• WDES Reporting template completed and sent to NHS England

• WDES Report completed and will be uploaded onto the Trust website

• WDES Action plan completed and to be reviewed and updates to be provided at each Valuing Our Peoples Assurance Group and Workforce Committee meeting

6. Recommendations

• WDES paper to be presented to the appropriate Trust Valuing Our Peoples Assurance Group and Workforce Committee meeting

The Valuing Our Peoples Assurance Group and Workforce Committee meeting to:

• Note that the NHS Workforce Disability Equality Standard (WDES) came into effect on the 1st April 2019 and will be completed by the Trust on an annual basis.

• Note that the Trust will put in place WDES action plan and agree that the performance against the plan will be reported through the various Trustwide Valuing Our Peoples Assurance Group and Workforce Committee meeting

• An annual report will be complied for submission to the NHS England Co-ordinator, Commissioner outlining progress on the Workforce Disability Equality Standards.

• Workforce Disability Equality Standard report will be published on the Trust website

• A copy of the WDES Indicators has been sent to NHS England Appendix 1: Workforce Disability Equality Standard (WDES) Action Plan

WDES ACTION PLAN 2019-20 Final.doc

Appendix 2: WDES Technical guidance

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wdes-technical-guidance-v1.pdf

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PUBLIC TRUST BOARD 4 November 2019

Agenda Item TB210/19c Report Title

Workforce Race Equality Standard Report

Executive Lead Jane Royds: Director of Human Resources and OD

Lead Officer Bob Davies: Equality Lead

Action Required

(Definitions below)

To Approve To Note


For Information

Executive Summary

The Committee’s highlight report for August 2019 is set out below:

Alert

• To highlight the Trusts compliance to NHS England to complete the Workforce Race Equality

Standard (WRES) report and action plan, the report highlights the comparisons between BME

and white staff across a number of indicators.

Advise

• Ensure that the Trust data for the WRES has been uploaded onto NHS England site and will

be published on the Trust website and sent to the CCG as part of the equality section of the

quality contract.

• Paper has been reformatted as per action following October’s Board meeting. New formatted

report was accepted at Workforce Committee in November 2019.

Assure

• The WRES action plan will be monitored and updated. Updates will be provided to the various

Trust groups / committees and the report and updates are also a requirement of the equality

section of the quality contract with the CCG’s.

Recommendation

The Workforce Committee is asked to receive the report







If the Trust cannot meet its financial regulatory standards and operate within agreed financial

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resources the sustainability of services will be in question.








CQC KLOEs

GOVERNANCE





✓ Well Led


Compliance ✓ Legal


✓ Equality Risk




Policy

Service Change

Strategy


The Trust has compiled a WDES report and action plan that will be monitored at various Trust committees and groups i.e. Workforce Committee Valuing Our People Group, reporting is also a requirement in the CCG equality section of the quality contract, the Trust will set up a disability staff network to obtain the views of staff with a disability or long-term medical condition, the WDES action plan highlights areas for development i.e. Reporting a disability on ESR, Recruitment, Staff Bandings, Bullying and Harassment






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1

Southport and Ormskirk Hospital NHS Trust Workforce Race Equality Standard Information Report April 2018 – March 2019 1. Executive Summary This paper provides a general overview of the Workforce Race Equality Standard (WRES) and the Trust’s metrics against the nine indicators within the Workforce Race Equality Standard (WRES). It also provides analysis of the metrics and outlines actions (Appendix 1 WRES Action Plan) to address the gaps between the experience of BME and White staff. 2. Introduction The NHS Equality and Diversity Council agreed in July 2014 that action across the NHS needs to be taken to ensure employees from black and ethnic minority (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace. The move follows recent reports which have highlighted disparities in the number of BME people in senior leadership positions across the NHS, as well as lower levels of wellbeing amongst the BME population. Following a period of consultation, the NHS Equality and Diversity Council agreed two measures that compliment each other whilst being distinct to improve equality across the NHS and these would be mandatory requirements embedded within the NHS Contract from April 2015. 1. The Workforce Race Equality Standard (WRES) 2. NHS Equality Delivery System 2 (EDS2) There are nine metrics. Four of the metrics are specifically on workforce data and four of the metrics are based on data derived from the national NHS Staff Survey indicators. The latter will highlight any differences between the experience and treatment of White staff and BME staff in the NHS, with a view to closing the gaps highlighted by those metrics. The final metric requires provider organisations to ensure that their Boards are broadly representative of the communities they serve. The CQC will take this into account within the ‘Well Led’ domain. 3. Drivers for WRES implementation The research Snowy White Peaks by Roger Kline (2013) showed:

• Unfair treatment of BME staff adversely affects the care and treatment of patients

• Talent is being wasted through unfairness in the appointment, treatment and development of a large section of the NHS workforce

• Precious staff resources are being wasted through the impact of such treatment on morale and discretionary effort

• Diverse teams and leaderships are more likely to show the innovation and increased organisational effectiveness the NHS needs.

• Organisations whose leadership composition bears little relationship to the communities they serve will be less likely to deliver the patient focussed care that is needed

• Nationally there has been a decrease in the proportion of BME Board members, Senior Managers and Nurse Managers in recent years; there are less BME Leaders and Managers in 2013 than in 2003 (Kline 2015).

• Statistically White staff are 1.74 times more likely to be appointed once shortlisted than BME staff (Kline, 2013);

• BME staff are twice as likely to enter formal disciplinary processes and be disciplined for similar offences than white staff (Archibong et al, 2010);

• Black nurses take 50% longer to be promoted and are less likely to access national training programmes (NHSLA);

• BME staff experiences correlate to the staff survey results on bullying, career progression, promotion and discrimination.

• 2014 Francis found BME Whistle-blowers are treated less favourably than white whistle-

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blowers. 4. Staff Profile As of March 2019 Southport and Ormskirk Hospital NHS Trust employed 2986 people of which Workforce

Ethnicity: The Trust workforce consists of 10.95% from Black Minority and Ethnic groups 82.65% White staff and 6.40% not stated unspecified prefer not to answer. 5. WRES Highlights: The information below provides a comparison for the WRES reports for 2017-18 and 2018-19, the information also provides the Trust figures compared to the average for combined acute and community hospital. BME staff in clinical and non–clinical bands 8a-9 Non Clinical: The 2018-19 WRES report highlights that there has been no increase in non-clinical BME staff in bands 8b to 9 and there are no BME staff in band 8b 8c 9 these figures are the same in the 2017-18 WRES report. Clinical: The WRES report highlights that there has been no increase in clinical BME staff in bands 8b – 8d and there are no BME staff in band 8b, 8c. 8d these figures are the same in the 2017-18 WRES report. Relative likelihood of BME and white staff being appointed from shortlisting across all posts 3.70% of BME staff were hired from those shortlisted compared to 5.96% of white applicants hired from shortlisting in 2018-19. The 2018-19 WRES data highlights that there has been an increase in BME staff being successful at interview and being hired by the Trust. 2018-19 = 3.70% compared to 1.78% in 2017-18 this is an increase of 1.78% Relative likelihood of BME and white staff entering the formal disciplinary process The number of BME staff (1) entering the disciplinary process in 2018-19 is the same as the 2017 -18 WRES figures, the figure for white staff has decreased to 23 in 2018-19 compared to 38 in 2017-18. NHS staff survey responses that are specific to WRES questions: Q1/ The percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months. In the last 12 months Trust figures for white staff has seen a decrease of 0.1% and a 9.2% increase for BME staff. The Trust figures compared to the average combined acute and community Trusts is 0.2% higher for white staff and 0.4% lower for BME staff. Q2/ Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months. Experiences of Trust staff experiencing harassment; bullying or abuse from staff in last 12 months has seen a 1.8% increase for white staff and a decrease of 6.5% for BME staff. The Trust figures compared to the average combined acute and community Trusts is 0.7% lower for white staff and 2.1%% lower for BME staff. Q3/ Percentage of Trust staff believing that Trust provides equal opportunities for career progression or promotion. Experiences of white staff have seen an increase of 1.2% and an increase of 5.4% for BME staff. The Trust figures compared to the average combined acute and community Trusts is 6% lower for white staff and 8.2% higher for BME staff.

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Q4/ In the last 12 months have you personally experienced discrimination at work from any of the following manager/team leader or other colleagues? Experience of white staff has seen a 0.3% increase from 2017 and there has been an increase of 3.5% from 2017 for BME staff The Trust figures compared to the average combined acute and community Trusts is 0.4% higher for white staff and 1% lower for BME staff. 6. Workforce Race Equality Standard Indicators: 6.1 Workforce: For each of these four workforce indicators, the standard compares the metrics for White and BME staff were the figures don’t equate to 100% this is due to the information not stated / not given.

Indicator Data for reporting year

2018-19 2017-18

1

Percentage of staff in each of the AfC Bands 1-9 or Medical and Dental subgroups and VSM (including executive Board members) compared with the percentage of staff in the overall workforce disaggregated by: • • Non-Clinical staff • • Clinical staff - of which • - Non-Medical staff • - Medical and Dental staff Note: Definitions are based on Electronic Staff Record occupation codes with the exception of Medical and Dental staff, which are based upon grade codes.

Non - Clinical

Band Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8a Band 8b Band 8c Band 8d Band 9 2017-18 VSM CQIR IRPM WCOO

BME 7.17% 1.29% 4.0% 0.61% 1.96% 1.96% 3.45% 4.76% 0.00% 0.00%

14.29% 0.00%

16.67% 0.00% 0.00% 0.00%

White 84.75% 93.89% 86.40% 95.09% 90.20% 94.12% 86.21% 90.48% 100% 100%

85.71% 100%

83.33% 100% 100% 100%

BME 7.0% 1.3% 4.3% 0.6% 1.9% 2.2% 3.3% 5.0% 0% 0%

14.3% 0%

33.3% 0% 0% 0%

White 84.7% 93.7% 84.5% 95.8% 90.4% 93.5% 90.0% 95.0% 100% 100% 66.7% 100%

66.7% 100% 100% 100%

Clinical

2018-19 2017-18

Band Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8a Band 8b Band 8c Band 8d VSM FMWC MT02 WHO3 WHO7

BME 9.68% 2.97% 0.00% 7.10% 5.32% 1.35% 8.62% 0.00% 0.00% 0.00%

0.00% 0.00% 80% 0.00% 16.67%

White 80.24% 91.82% 96.08% 87.33% 90.05% 91.89% 86.21% 91.30% 100% 100%

100% 100% 0.00% 100%

66.67%

BME 9%

3.2% 0%

7.5% 4.8% 2.0% 8.9% 0.00% 0.00% 0.00%

0.00% 0.00%

N/A 0.00%

16.67%

White 80.2% 92.2% 98.1% 87.2% 90.6% 91.2% 85.7% 90.5% 100% 100%

100% 100% N/A

100% 66.67%

Med & Dental Consultant

2018-19 2017-18

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BME 42.06%

White 42.99%

BME 45.9%

White 40.5%

Med & Dental Consultant Non –Consultant Career Grade

2018-19 2017-18

BME 56.38%

White 28.72%

BME 54.2%

White 30.1%

Medical & Dental Trainee Grades

2018-19 2017-18

BME 23.91%

White 66.30%

BME 24.7%

White 65.6%

Board- Ex- Non Exec

BME 18.18%

White 84.62%

BME 33.3%

White 66.67%

2

Relative likelihood of staff being appointed from shortlisting across all posts Note: This refers to both external and internal posts

Recruitment: The information below highlights the ratio of BME and White Staff being appointed from short listing; please note this refers to both internal and external posts 2018-19 & 2017-18 2018-19

Head Count Ratio

WRES Category


BME 432 16 0.96 0.04

White 2515 150 0.94 0.06

NULL 31 8 0.79 0.21


49 1 0.98 0.02

2017-18

Head Count Ratio

WRES Category


BME 393 7 0.98 0.02

White 2289 98 0.96 0.04

NULL 10 2 0.83 0.17


47 1.00

3 Relative likelihood of staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation Note: This indicator will be based on data from a two year rolling average of the current year and the previous year. For consistency, organisations should use the same methodology as they have always used.

Disciplinary Process: Overall breakdown of cases by ethnic origin categorised in line with WRES requirements as at 31.3.2019 2018-19

WRES Category

Head Count

BME 1

White 23

Not Stated 1

Total 25

2017-18

WRES Category

Head Count

BME 1

White 38

Not Stated 4

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Total 43

4 Relative likelihood of staff accessing non-mandatory training and CPD

Training: The information below highlights the ratio of BME and White staff accessing training in 2018-19 and 2017-18 2018-19

WRES Category

Head Count Enrolment Headcount

Ratio

BME 244 226 0.93

White 2551 2219 0.87

NULL 12 8 0.67


178 160 0.89

2017-18

WRES Category

Head Count Enrolment Headcount

Ratio

BME 242 223 0.92

White 2603 2447 0.94

NULL 12 10 0.83


206 191 0.93

6.2 NHS Staff Survey: The 2018 NHS Staff Survey was completed by 1,147 staff this is a response rate of 40% which is average for combined acute and community trusts in England (43%) and compares with a response rate in the Trust in 2017 of (45%) , For each of these four staff survey indicators, the Standard compares the metrics for each survey question response for White and BME staff. Key Findings KF25, KF26, and KF21, split between White and Black and Minority Ethnic (BME) staff, as required for the Workforce Race Equality Standard. Note that for question Q17, the percentage featured is that of “Yes” responses to the question. Key Finding and question numbers are the same in 2018 as 2017. Figures in bold highlight BME figures

Indicator Data for reporting year 2018

Data for previous year 2017

5 15a: Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months Experiences of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months has seen the figures for white staff decrease by 0.1% and a 9.2% increase for BME staff.

White staff 28.4 % BME staff : 29.4% Average (median) for combined Acute and Community Trusts White staff– 28.2% BME staff- 29.8%

White staff: 28.5% BME staff: 20.2%

6 Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months Experiences of experiencing harassment, bullying or abuse from staff in last 12 months has seen a 1.8% increase for white staff and a decrease of 6.5% for BME staff.

White staff: 25.7% BME staff: 26.5% Average (median) for combined Acute and Community Trusts White staff– 26.4% BME staff- 28.6%

White staff: 23.9% BME staff: 33%

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7 Percentage believing that trust provides equal opportunities for career progression or promotion Experience of white staff has seen an increase of 1.2% for white staff and an increase of 5.4% for BME staff.

White staff: 80.5% BME staff: 80.4% Average (median) for combined Acute and Community Trusts White staff: 86.5% BME staff: 72.3%

White staff:79.3% BME staff: 75%

8 In the last 12 months have you personally experienced discrimination at work from any of the following? b) Manager/team leader or other colleagues Experience of white staff has seen a 0.3% increase from 2017 and there has been a increase of 3.5% from 2017 for BME staff.

White staff: 7% BME staff: 13.6% Average (median) for combined MH/LD and Community Trusts White staff: 6.6% BME staff: 14.6%

White staff: 6.7% BME staff: 10.1%

6.3 Board Representation Indicator: For this indicator, compare the difference for white and BME staff

Indicator Data for reporting year

9 Percentage difference between the organisations’ Board membership and its overall workforce disaggregated:

• By voting membership

of the Board

• By executive

membership of the Board Note: This is an amended version of the previous definition of Indicator 9

The information below provides information on the headcount and percentage difference between the organisations board membership and its overall workforce for BME and White Staff By executive and non-executive board membership = BME: 14.29% White:78.57% Not Stated: 7.14% 2018-19

WRES Category

Head Count

Head count %

Board Head Count

Board Headcount %

BME 258 8.18% 2 14.29%

White 2679 84.97% 11 78.57%

Null 23 0.73% 0 0.00

Not Stated /Not Given

193 6.12% 1 7.14%

2017-18

WRES Category

Head Count

Head count %

Board Head Count

Board Headcount %

BME 242 7.9% 3 30%

White 2603 85.01% 6 60%

Null 12 0.39% 0 0.00

Not Stated /Not Given

206 6.7% 1 10%

7. Trust Actions taken to be compliant with the WRES

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• WRES Reporting template completed and sent to NHS England

• WRES Report completed and will be uploaded onto the Trust website

• WRES Action plan completed and to be reviewed and updates to be provided at each Valuing Our Peoples Assurance Group and Workforce Committee meeting

8. Recommendations

• WRES paper to be presented to the appropriate Trust Valuing Our Peoples Assurance Group and Workforce Committee meeting

The Valuing Our Peoples Assurance Group and Workforce Committee meeting to:

• Note that the NHS Workforce Race Equality Standard came into effect on the 1st April 2015 and is completed by the Trust on a annual basis.

• Note that the Trust has put in place WRES action plan and agree that the performance against the plan will be reported through the various Trustwide Valuing Our Peoples Assurance Group and Workforce Committee meeting

• An annual report will be compiled for submission to the NHS England Co-ordinator, Commissioner outlining progress on the Workforce Race Equality Standards.

• Workforce Race Equality Standard report will be published on the Trust website

• A copy of the WRES Indicators has been sent to NHS England Appendix 1: Workforce Race Equality Standard (WRES) Action Plan

WRES ACTION PLAN 2019-20 Final.doc

Appendix 2:

wres-technical-guidance-2017 (1).pdf

Appendix 3:

wres-nhs-board-bulletin.pdf

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