enc. 1 quality & safety committee held on 14 room k2, … · 2018-03-27 · page 1of 14 quality...

of 14Quality & Safety Committee meeting APPROVED minutes – 14 December 2017

Enc. 1Minutes of a meeting of the

QUALITY & SAFETY COMMITTEEHeld on 14th December 2017 at 9:30 am

Room K2, William Farr House, Shrewsbury.

Present: Rolf Levesley, Non-Executive Director & Committee Chair (RL) ChairJan Ditheridge, Chief Executive (JD)Nuala O’Kane, Non-Executive Director (NOK)Steve Gregory, Director of Nursing and Operations (SG)Julie Thornby, Director of Corporate Affairs (JT)Dr M Ganesh, Medical Director (MG)Alison Trumper, Associate Director of Quality (ATr)Sally-Anne Osborne, Deputy Director of Operations (SAO)Angela Cook, Head of Nursing & Quality – Adults (AC)Jo France, Head of Nursing & Quality – Children (JF)

Apologies: Mike Ridley, Chairman (MR)Steve Jones, Non-Executive Director (SJ)Andrew Thomas, Head of Nursing & Quality – Adults (AT)Rita O’Brien, Chief Pharmacist (ROB)

Minute taker: Nicola Dixon, PA to Associate Director of Quality (ND)Transcribed by: Jayne Williams, PA to Director of Nursing & Operations (JW)

Guests: Juliet Morris, HR Manager (JM)Mel Duffy, Executive Director of Strategy (MD)Ros Preen, Executive Director of Finance (RP)Andy Matthews, Service Delivery Group Manager (AM)

Minutenumber: Agenda Item title2017/12/01 Declarations of Interest (Agenda Item 3)

None.

2017/12/02 Minutes of the Previous Meeting held on 16th November 2017 (Agenda Item4)The minutes of the last meeting held on 16th November 2017 were agreed andapproved by the Quality & Safety Committee as a true and accurate record ofthe meeting.

2017/12/03 Matters arising not covered by the rest of the Agenda (Agenda Item 5)Action Log MonitoringThe action log was discussed and updated.

CPR Training was discussed in more detail; the Committee are still looking forassurance from ATr that our clinical staff; those who are required to undertakeCPR training, are compliant.

2017/12/04 Quality Performance Report (Agenda Item 6)The Quality & Performance executive summary was presented by ATr andoutlines the Trust’s performance for November 2017 and is aligned to the CQCdomains of quality – Safe, Effective, Caring, Responsive and Well-Led services.

NOTE: some of the metrics in the Quality Performance report were carriedover from the previous month due to the November data not being


available; this was mainly due to the December meeting being earlier in themonth because of Christmas and metrics not available at the time ofreporting.

Safe:Patient Safety Dashboard – this dashboard focusses on the ‘reds’ in the ‘Safe’domain and these were discussed:

Safeguarding compliance (MCA/SG Training)o Mental Capacity Act training % - 89.33%o Safeguarding Training Compliance Level 1 (Adults) – 88.72%o Safeguarding Training Compliance Level 2 (Adults) – 79.09%o Safeguarding Training Compliance (Children’s – New KPI) –

87.11%

Safeguarding Training: ATr informed the Committee that for both Adult andChildren’s safeguarding training the anticipated completion date has beenbrought forward from February 2018 to January 2018. Our OperationalManagers will ensure that clinical managers on duty are in date for safeguardingtraining; both Adult and Children’s’.

There were 2 reported Serious Incidents this month; 1 never event – wrong toothextraction and 1 grade 3 pressure ulcer – Telford South.

NHS to NHS Concerns: Telford & Wrekin CCG is looking to review the process,to ensure better effectiveness going forward.

SCHT have some out-of-date N2Ns which required our immediate attention; thiswork is being picked up by Yvonne Gough. T&W CCG have requested thatSCHT review the N2N issues; returning an update to the T&W CCG no laterthan 31st December 2017.

SG informed the Committee that once the N2N issues have been reviewed theywill be shared with the Quality & Safety Committee.

CQC Visit : ROB informed the Committee that the CQC Pharmacy Inspectorhad visited the Trust on 5th December 2017. The inspector was informed ofchanges that had been implemented since their last visit and was particularlyimpressed by:

Our system for dealing with medicines incidents and the resulting lessonslearnt and expressed that this is a positive move

Our work on covert use of medicines and when it is appropriate to do this

Caring: Patient Caring Dashboard – this dashboard focusses on the ‘reds’ inthe ‘Caring’ domain and these were discussed:What are our patients Saying:

% of discharged inpatients who complete the survey – 14.8% a drop fromthe previous month’s 17.6%

An internal improvement target of 20% return has been applied to thisindicator as a driver for improving the FFT process across our clinicalservices.The quality team will work with operational teams to ensure that FFT isregularly recorded. In those services where Observe and Act is notapplicable they will use other patient experience feedback methodsincluding patient stories and focus groups.


FIG Group have found that some teams have nothing in place for FFT.FIG currently analysing the FFT feedback.SG and ATr agreed to look at alternative methods of collecting thefeedback i.e. using staff that are already out and about to collect thefeedback.

Responsive: Patient Responsive Dashboard – this dashboard focusses onthe ‘reds’ in the ‘Responsive’ domain and these were discussed:

Delayed Transfer of Care (DTOC) – 6.26% against a target of 3.5% –The November position shows a decline on last month’s position. Thefigure is based on days delayed not patients – this has been recalculatedfrom April 2017 so in effect changes the figures reported to the Quality &Safety Committee since April 2017. The adjusted figures are:

o April 2017 – 9.91%o May 2017 – 9.23%o June 2017 – 11.1%o July 2017 – 10.76%o August 2017 – 7.47%o September 2017 – 10.45%o October 2017 – 4.76%

Basic Life Support training (Adult and Paediatric) – 81.6% against atarget of 95% - a slight improvement on last month

DN response times (same Day) and (Next Day) – ATr informed theCommittee that the DN data is being temporarily removed from thedashboard. Following a meeting with Yvonne Gough, ATr and YGagreed to remove this data as RiO is not showing all data and the DN’shave reverted back to paper diaries. DN’s are sitting on the triage deskopening/cancelling visits - patients are being seen but the data is notcoming through on the reports; we are working with the RiO team and willget IT involved.

AC suggested that when the Board do their clinical visits considermaking one of the visits a sit and observe visit with the DN’s on thetriage desk.

Feedback from external visitsShropshire CCG routine Quality Assurance visit to Whitchurch Hospital on 18th

September as part of contract monitoring for SCHT. Shropshire CCGrepresentative was Sue Aucutt (SA); interim Quality Manager.

The details of the visit were discussed as detailed within the QualityPerformance report and the Concerns and Actions noted:

The MIU has experienced ‘walk in’ referrals from GPs for ECGs due tochest pains. SA understood that this had been formally raised with theGP practice concerned and that discussions are in progress at a seniorlevel within the CCG to address the issues concerned. National guidancerequired GPs to refer patients with chest pain to A&E and not to walk ordrive to an MIU.

Effective:Patient Effective Dashboard – this dashboard focusses on the ‘reds’ in the

SG/ATr


‘Effective’ domain and these were discussed:

There were no ‘reds’ in the November data.

Clinical Audits Overdue: A new KPI is being introduced for January 2018.MG informed the Committee that MB sends out the NICE Guidance monthly toteams; NICE is also reviewed at the SDG Quality meetings where exceptionswould be recorded. Following a clinical audit; MB would send exceptions out tothe teams; the findings would also be record on the dashboard. JD expressedsome concern that it doesn’t always get to the Quality level; we need to beassured of learning.Q1; 16 projects have started on time. 4 projects have not been taken forward; 7due for completion but not yet complete. There are 18 projects in total which isgreat for the Trust – 16 of these are our own Audits and 2 are national Audits.

Some work is required around Clinical Audit, ensuring we pick up out-of-dateaudits and complete - there are clearly still some gaps in the programme; MGagreed to provide feedback to the Committee on a quarterly basis.

Well-Led:Well-led Dashboard this dashboard focusses on the ‘reds’ in the ‘Well-led’domain and these were discussed:

Sickness Absence – Total workforce – 6.04% Sickness Absence – Nursing Workforce – 7.88% Staff FFT % - Quarter 1 was 72.3%; Quarter 2 is 68.29%

JD asked ATr and SG whether they were assured that things are getting betterin the well-led domain. SG responded by saying that we are still too hard onourselves in terms of reporting against well-led - this we know, and it was fedback to us at the last CQRM.

Sickness Absence – Occupational Health have concluded that the high level ofsickness absence caused by stress are not only work related stress; it’s a 50/50split.

SG said we should be encouraging staff to come back to work with support. JTsaid that the view from some managers was that they would like extra supportwhen discussing sickness absence with staff – some managers find theseconversations very difficult and rely on HR support. The support is not onlyrequired for those who are off due to sickness but for the remaining teammembers who may struggle to cover for that sickness absence.

Well-Led was discussed in more detail under agenda item 9; Getting to GoodUpdate.

JD talked about a newspaper article relating to the RCN Pay Review and thewords ‘productivity to be up for a pay rise’. JD was very clear that we as anorganisation do not encourage working extra hours; we support teams to workonly their contracted hours but we know that on too many occasions this is nothappening; self-care is of the utmost importance - as a Board should we besending this message out to all staff again.

Number of Overdue Datix IncidentsFeedback on this item was that the Quality & Safety Committee only needs thethemes; this level of detail in the report is only required by the SDG’s.


ComplaintsComplaints were very briefly discussed as noted in the Quality Performancereport.

CQUINSNoted by the Committee. SAO confirmed that the Trust had met allrequirements; Q2 submission on time and awaiting feedback.

Flu Uptake; this is at 62%

QAASPhase 1 roll-out involved Inpatient Community Hospitals. The first self-assessments undertaken in July 2017 indicated huge progress against CQCdomains, this trend has continued through to November.

Adaption of the QAAS tool is currently in progress following changes to the CQCKLoE’s.

The Quality & Safety Committee discussed and accepted the content of theQuality Performance report noting the actions.

2017/12/05 Whistleblowing Update Report (Agenda Item 7)RL presented this report, the first report of this kind to come to the Quality &Safety Committee. The report is presented to make the Quality & SafetyCommittee aware of two ‘Freedom to Speak Up’ concerns raised with RL withpotential impact on service quality, associated investigations and actions andask the Committee to consider if any further action was required.

Summary of Key points: Two cases have been raised with RL as lead NED for Freedom to Speak Up

(whistleblowing) issues, one about the implementation of EPR in podiatry(especially poor connectivity and extended appointment times compromisingquality and safety) and the other about low staffing levels in a communityteam through sickness absence.

Both have implications for quality and safety. In both cases RL concluded that the issues have been investigated and

appropriate actions taken. In the case of the podiatry/EPR concerns, theDirectors of Finance and Nursing have indicated to RL that they believe theinvestigation is complete.

Detail of the concerns and their findings are contained within the report.

Comments/questions raised by the CommitteeNOK asked whether ‘whistleblowing’ was the correct channel/route for theseissues. RL felt that ideally other channels i.e. line management or if necessarythe Freedom to Speak up Guardian (or Champions) should act as the channelbut the role of the Whistleblowing NED was another useful channel if otherswere not felt suitable.

The Quality & Safety Committee discussed and considered the report. TheCommittee endorse the final position with regard to the two sets of issuesi.e. sign off of the investigation reports and completion of actionsidentified in the appendices and were in support of the request of a followup report to the Committee in March 2018 on progress on actions on theESR issues, especially connectivity and the overall impact on waitingtimes of 30 minute appointments.


Include in the March 2018 agenda.

CARING & RESPONSIVEEFFECTIVE

2017/12/06 Service Delivery Group Dashboards (Agenda Item 8)All three SDG dashboards are structured around the five CQC key lines ofenquiry; caring, responsive, effective, well-led and safe. The aim is to providevisual assurance in relation to our quality and safety compliance measures, withadditional detail by exception, to the committee.

Community Hospitals and Outpatients: AT presented this report.

Highlights from the report discussed at the meeting: FFT % recommended – 96.4% an increase from 94.1% in October Observe & Act – 1; Bridgnorth late November with several actions

identified. AT will discuss further with relevant CSM. Appraisals – 84% with a trajectory of 95% by January 2018. Sickness Absence – 8.48% Pressure Ulcers in Service – 2 MRSA Screening – 98.2% (target 97%) Highest Vacancy Rates:

o 47% - Bishops Castle (Nursing)50% down is a worrying position; SAO said that rotas are plannedin advance and we are managing to fill the gaps with bank/agencystaff (most days agency staff are being used). Sg said the fill rateis good and we are monitoring this. If we have staff shortages wemove staff from Ludlow to Bishop’s Castle.SG and JD will both arrange a visit to Bishop’s Castle now it hasre-opened.Some GP issues identified at Bishop’s Castle; Andy Matthews’ isworking alongside SAO to put a plan in place to support these GPissues.

o 20% - Whitchurch (Nursing)o 14% - Bridgnorth (Nursing)o 15.2% - Stoke Heath

CQUINS; Quarter 2 Agreed as complete and successful at CQRM on8/12/17

Risks scoring above 12Failure to comply with agency requirements of NHSI in relation to use of offframework agencies and above ‘cap’ costs – Score 16

Actions - Twice weekly conference calls and weekly reports. NHSI weeklyreports. Centralised bank have process to secure framework agencies andrequire Deputy/Director approval to go off framework as per SOP. Staffing andestablishments / skill mix under review.Centralised bank 7 day pilot completed in June and July. A business case forextended hrs centralised bank was presented at Adults Performance meeting on11th October; this was approved and funding has been sourced.A paper will go to JNP in regards to bank administrators working weekends.

JD asked AT and SG to discuss whether ShropDoc should be added to theRisk Register.


Community Services: AC presented this report.

Highlights from the report discussed at the meeting: FFT % recommended – 98.9% a decrease from 99.4% in October CQC Action Plan – 100%; 6 teams now using RiO as a full EPR.

Pressure ulcer KPI’s being introduced and audit planned againststandards.

Children’s Safeguarding Training Level 2 – 86% (target 85%) Adult Safeguarding Training Level 2 – 83% (target 85%) Appraisals – 91% Sickness Absence Rates – 5.49%

o Top absence reasons anxiety/stress/depression – 32.7% (13 staff) MSK 14.1% (9 staff) Cold & Coughs 9.8% (12 staff)

Innovation/celebrating Success – 4 services migrated to a full EPR usingRiO last month (Tissue viability, Continence, MSK OPD services andICS)

Pressure Ulcers developed in service - 7, a slight increase. (Grade 3: 1,Grade 2: 3 and Ungradable: 3)

Vacancy rates in Community Services are low

Children and Families: AT presented this report on behalf of JF.

Highlights from the report discussed at the meeting: FFT % recommended – 98.72% showing a 2% increase Staff FFT (Quarterly) – 70.15% CQC Action Plan – 100% Sally Crighton reported on the CCN CQC ‘Getting to Outstanding’ action

plan at the Q&S SDG meeting on 4th Dec 2017. Assurance received inrelation to sustaining their good rating. SC has shared the CQCprogramme with her teams.Examples of assurance gained:

o Proactive approach to NG tube risk alert. All C&YP were riskassessed in a timely way and appropriate action taken to ensureC&YP remain safe.

o Peer review to ensure all CCN records meet the requiredstandard

o Children’s EOL policy with staff training. Action plan reviewedquarterly the Q&S SDG.

o Safeguarding supervision offered and accessed by all staff acrossthe team. Register maintained.

Completed Clinical Audits – 1; Physiotherapy Clinical record keepingaudit.

Business cases/tenders:o Immunisation tender released on 6th November 2017. Alternative

model costed providing clinical leadership within SN submitted toexecutive team. Final submission to commissioners is dueDecember 2017.

o Implementation of the 0 – 19 Public Health Service continuesalongside the change management process. Staff are slotting into


their new roles and we have received some reassurances thatmorale is improving.

Zero Complaints received in November. Appraisals – 92.2% improving position. Children’s Safeguarding training Level 2 – 93.3% Children’s Safeguarding training Level 3 – 92.5% Five risks remain on the CF&YP register with a score of 12 and above. Highest vacancy rates – Health Visiting – South Shropshire – 16.4% Trust wide Staff Support and Supervision Policy was published in

November 2017 – this was developed by Hilary Griggs and Jo France.

JF agreed to include in the January 2018 CF&YP dashboard: 0-19 risk register 0-19 staffing levels

JF is currently looking at Datix following the sharing of information by the CCGDesignated Nurse. The Designated Nurse doesn’t feel that our Trust arereferring enough into the Local Authority.

The Quality & Safety Committee discussed and accepted the content of thethree SDG Dashboards and noted the actions and key risks.

WELL-LEDNo items pertaining to the well-led domain were presented at the DecemberQuality & Safety Committee meeting.SAFE

2017/12/07 Getting to Good update (Agenda Item 9)ATr presented this report which was to provide the Quality and SafetyCommittee with CQC updates.

ATr informed the Committee that there are two outstanding actions fromthe CQC action plan

Key points which were discussed:Well –Led

A Well -Led workshop to specifically support our clinical and operationalleaders in preparing for and evidencing the well–led KloE’s has beenscheduled for 19th January 2018.

Prior to the workshop, a senior team meeting has been scheduled by theDirector of Corporate Affairs to undertake a self- assessment/stock takeof evidence for the Trust as a whole against the well-led KLoES, todecide (1) evidence we have for compliance with ‘good’, (2) evidence forany areas where we exceed good or (3) any gaps.

Revised KloE’s The revised KloE’s have now been mapped across to the QAAS and will

be cascaded across our organisational teams for monthly self -assessments to take place from January 2018.

Service -areas of focus and support LAC processes and KPI dashboard reporting – this work is being

supported by Head of Nursing and Service Delivery Manager for C&F. TEMS – an internal supportive service review, with full engagement from

the TEMS team is in progress led by Associate Director of Quality


.Anticipated completion 21st December 2017. EoLC – implementation of the strategy is being led by the EoL Care lead,

supported by Associate Director of Quality.A clinical educator with an extensive EoL care clinical and educationalbackground has been allocated to a Trust Clinical Educator role and twostaff members with extensive EoL care skills have been allocated tocommunity Matron roles. This will further strengthen implementation ofthe strategy and support our clinical and operational teams in thedevelopment of necessary clinical skills and processes.

The Quality & Safety Committee discussed and noted the content of theGetting to Good Update Report.

THEMED REVIEW2017/12/08 Urgent Care within the Shropshire System (Agenda Item 10)

SAO presented a themed review; Urgent Care: Our Contribution 2017. AndyMatthews was in attendance to support with questions and answers.

A summary of the presentation slide by slide is followed by comments andquestions raised by the Quality & Safety Committee. There was a lot ofdialogue which took place, not all of which is noted, not for any particularreason other than to only pick out the most relevant points for theminutes:

The Challengeo Financial Squeezeo Front Door Demando Fragility of Primary and Social Careo Workforceo System Complexityo Relentless media attentiono More honesty than 2 years agoo DToC not resolved but progress being madeo Community Providers essential for system flow

Questions and Comments:SAO said nationally admissions are up, we are still having great difficulty inrecruiting, MIUs have to be closed when we can’t get staff, DToC improvedslightly with better planned discharges.

JD made a suggestion to the Committee - to undertake a ‘deep dive’ as aCommittee and a Board around the Urgent Care Pathway; mapping againstgood practice guidance.

What have we learned from last yearo Capacity – SaTH still have high occupancy levels >95%;

SCHT still below 90%o System Wide Solutions – Urgent Care Director appointedo Variation – clinicians, teams, hospitals and wardso Central demand

Questions and Comments:An Urgent Care Director is now in post as of 8/12/17 working across the System;Claire Old. Claire is employed by the CCG.

Current State - Performanceo System Performance 4 hr wait – 80.77%


o MIU – 2 breacheso Patients discharged In 48 hrs of FFA received (target 80%);

Shropshire 66%; Telford 69%o Bed Occupancy (target 95%); SaTH Med 99%, Surgery 101%,

SCHT 89%

Questions and Comments:JD has asked that the current performance is reported regularly via thedashboard.

4 Hour ED Performance – SaTH and MIU27/11/17 – 3/12/17 total attenders 2793; Total LOS >4hrs 537; SaTH %who did not breach 76.85%; SaTH <4hrs % inc MIU 80.77%

Our Contributiono MIU’so Admission Avoidanceo Early Supported Dischargeo Community Hospitals

Questions and Comments:Discussions took place about the graphs which related to the aboveperformance; MIU’s, AA, ESD and CHs and breaking down discharges; forexample, use the support of the ICS teams. Discharges are discussed daily onthe regular conference calls. SG said that Flow is the most importantrequirement across the System.

The Urgent Care Governance – local picture was discussed anddisplayed as a flow diagram within the presentation.

Solutions – The Principleso Critical for maintaining patient flowo Manage clinical risk in people’s homeso Innovative service designo Home Firsto Good links with social care and other providerso MDT approach to providing holistic careo Workforce expertise and knowledge of patients

What Community Services need to do?6 Essential Steps

o System-wide data sharingo Operational management of dischargeo Discharge hub and an integrated discharge teamo Effective patient choice policyo Well understood community serviceso Red2Green dashboard

and also…….resist the temptation to argue over a patient

Questions and Comments:JD’s comments: Not meeting Data Sharing on a daily basis; Discharge Hubdiscussions being made by people not involved in a full system; no proper robustDischarge to Access process. SAO to link in with Mel Duffy to discussDischarge.


SAO said that Sarah Robinson has made contact with AM to get a Grouptogether for the discharge and patients going into preferred Community Hospital(CH). A discussion took place around Choice Policy; if a patient refuses to go toanother CH then where at all possible we will always try to get that patient home.It was felt that where a patient sometimes refuses to be transferred to anotherhospital it is sometime just the way the discharge has been handles. It justneeds a little tact, encouragement and compassion; ‘we will be transferring youto XXXX hospital to meet your needs’.

Red2Green Dashboard - resist the temptation to argue over a patient; equipmentcan cause problems; pick up the phone rather than sending referrals back andforth.

Our Contributiono Home Firsto Providing daily capacity for AA & ESDo Frailty at the front dooro Community Matron at PRHo Daily discharge planning in the hubso Care Home Assessoro Care Home Admission Avoidance (MDT)

Questions and Comments:Community Matron is having an impact; discharges are down.Care Home Shropshire; we have to sign-up to this and ensure it is correct fromthe onset.Care Home Admissions Avoidance – Telford only - this is to support people inthe nursing homes who need to be in Hospital; this will be up and running byFebruary 2018.

Our Contribution – Winter Planningo System wide Winter Plan signed off by SAED Boardo SaTH at Homeo iBCF Schemeso Demand modeling and system KPIso System wide escalation processo Clinic capacity supported by community nursingo Falls team – no programs – community basedo CNRT – Ward basedo Specialist services supporting community provisiono Enhanced therapy over Christmaso Non-essential work deferred week before Christmas weeko Senior experienced managers on callo Senior cover BH and between Xmas and new yearo Planning started for post Xmas demando CH staffing numbers maintainedo Seasonable flu immunisation 58%o Bank staff availability reviewed for BH covero Staff resource management – Sickness up, vacancy down,

agency down

Questions and Comments:JD asked MD what capacity we are trying to create. MD responded, we know


that there are patients going into the Acute that shouldn’t be. 170 beds could beachieved with a shift of resources and modelling.

Capacity within District Nursing (DN); ATr said that DN’s need clinical admin tosupport them.

JD asked when Systems were last leaned; Meridian saved time etc., RiO shouldhelp. RP said that if everyone works at getting excellent then the process wouldbe better.

JD asked the Committee what they felt were the key things as a Communityprovider:

Frailty – Front Door Patients in the right place in Community; easy access into services Ensure what capacity (model) Red2Green OOHs Provision Information (lack of intelligence) Keep flow in the Hospitals – early timely discharges

What Nexto Workforce alignment with primary Care in localitieso New roles to release and create capacityo Develop, embed 6 essential stepso Community Offer (LTC, Proactive Response and Supported

Discharge)o Outcome of MIU, DAART and Beds reviewo Ambulatory care pathways

The Quality & Safety Committee thanked SAO and AM for a comprehensivereview of the Urgent Care System.

2017/12/09 Policies (Agenda Item 11)for Noting:

Multi-Resistant Gram Negative Bacteria Policy

The above policy was noted by the Quality & Safety Committee.

for Approval: NoneItems for Information: None

2017/12/10 Risks/Assurances: (Agenda Item 12)Risks:

ShropDocAssurances:

2016/12/11 Any Other Business (Agenda Item 13)

Update and target setting for the Friends and Family Test for Staff andNational NHS Staff Survey – update on timescales for reporting.

In summary; the purpose of the report:Juliet Morris from HR joined the meeting to present this report the purpose of


which was to update the Quality and Safety Committee on Friends and FamilyTest for Staff and the 2017 National Staff Survey.

The report included results from the last three Friends and Family test for Staffsurveys which were undertaken during March, July and September 2017.

The report also asked for discussion around the targets we should set forFriends and Family Test for Staff.

NHS Staff Survey 2017 – initial reporting scheduleMonitoring of response rates for 2017 has shown uptake to be slightlylower than in 2016. On Monday 27th November 2017 with one week stillto run the response rate was at 44.5%. The final response rate was notavailable at the time of writing the report.

A timetable of reporting is currently being developed. In outline, it islikely to cover:

o Quality and Safety Committee in January 2018 (subject to Pickerreports arriving as stated above)

o Board, Part 2 in January 2018o Community Trust Leadership Group – to be confirmedo Board, Public in March 2018

Friends and Family Test for StaffFrom March 2017 we started to use the Meridian Reporting System toundertake our quarterly Friends and Family Test for staff. We have threesets of results so far which show that response rates are fairly goodinitially at 353 in March, 336 in July but then declined in September to154.

Staff satisfaction scores are calculated from the number of ‘likely’ or‘extremely likely’ responses’ to the two core questions.The two questions are:

o “How likely are you to recommend this organisation tofriends and family if they needed care or treatment?”

o “How likely are you to recommend this organisation tofriends and family as a place to work?”

Our overall staff satisfaction score in September 20017 was 68.29%.

In addition to the core staff satisfaction questions, we have recentlyadded questions around health and wellbeing:

o Have you experienced MSK problems in the last 12 months?- The CQUIN requires us to reach 80.8% ‘no’ responses at aminimum; we are currently at 73.47%.

o Have you felt unwell due to work related stress in the last 12months? - The CQUIN requires us to meet 64.2% minimum forour ‘no’ scores; we are currently at 55.92%.

o My immediate Manager takes a positive interest in my Healthand Wellbeing –The positive score in the national staff survey2016 was 71%; we are currently at 81.43%

o The Organisation takes a positive interest in my health andwellbeing – The CQUIN requires us to reach 33.7% minimumpositive score for this question; we are currently at 68.83% inSeptember.


Friends and Family Test for Staff – Target SettingResults from FFT for staff are reported to the Resource and PerformanceCommittee. The FFT for staff asks two questions of staff on a quarterlybasis – these are asking whether they would recommend the Trust as aplace to work and to receive treatment.The initial proposal to the group was that we should have one target forour Organisation which is the overall staff satisfaction score and makeour target 80%.

Taking all of the above into consideration, a proposal was made toCulture Working Group that we therefore set our targets asrecommendation to receive care at 85% and to work at our Trust at65% which is in line with the West Midlands average. This was acceptedby the group. JD said her ambition would be for both targets to be set at95%. JM agreed to feed this back to RPC.

The Quality & Safety Committee noted the timescales for receiving theresults for the 2017 National NHS Staff Survey and agreed the targetsshould be set for our Friends and Family Test for Staff for‘recommendation to receive care at 85%’ and ‘work at our Trust at 65%’.

2016/12/12 Date of Next Meeting

Thursday 18th January 2018, 9:30 – 12:30, K2, William Farr House, Shrewsbury

Forthcoming Themed Reviews: January 2018 – Palliative and End of Life Care – CM/SC February 2018 – New model of working for Diabetes – looking at a 3 tier

model of care – Fiona Smith April 2018 – Best Interest Assessment and Covert Medicines –

ROB/AT/JR

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Enc 1

Minutes of a meeting ofPART I - RESOURCE & PERFORMANCE COMMITTEE

Held on 22 January 2018 at 1:00pmRoom B, William Farr House

Present: Steve Jones, Non-Executive Director (Chair) (SJ)Peter Philips, Non-Executive Director (PP)Rolf Levesley, Non-Executive Director (RL)Jan Ditheridge, Chief Executive (JD)Ros Preen, Director of Finance (RP)Mel Duffy, Director of Strategy (MD)Steve Gregory, Director of Nursing and Operations (SG)Sally-Anne Osborne, Deputy Director of Operations – Adults (SAO)Yvonne Gough, Deputy Director of Operations (YG)Andy Turnock, Head of Financial Management (AT)Trish Finch, Head of Business Development (TF)Julie Southcombe – Patient Representative (JS)

In Attendance: Jan Cox, PA to Director of Finance (Secretary) (JC)Karen Taylor, Head of TeMS and Outpatient Services (KT) (Item 7.2)Robert Graves, Director of Facilities and Estates SSSFT (RG) (Item 8.1)Andrew Crookes, Head of Informatics (AEC) (Item 9.1)Angela Cooke, Head of Nursing & Quality for Adults (AC) (Item 9.1)

Apologies: Sarah Lloyd, Deputy Director of Finance (SL)Mike Ridley, Chairman (MR)Phil Stringer – Patient Representative (PS)

Minutenumber:

Agenda Item title Action

2018/1/281 Declarations of Interest (Agenda Item 3)

None recorded.

2018/1/282 Minutes of the Previous Meeting held on 27 November 2017(Agenda Item 4)

Part I Minutes of the meeting held on 27 November 2017 were agreedas a correct record.

2018/1/283 Matters arising not covered by the rest of the Agenda (Agenda Item5.)

None recorded.

2018/1/284 Monitoring of Action Log from the previous meeting (Agenda Item5.1)

To contact Neil Nisbett, Director of Finance at SaTH to escalate thesigning of the sub-contract – No further communication from SATHhas been received since the end of November on this matter. Afurther review has been undertaken with the new management ofthe service and a verbal update will be given at the January

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Committee. RP reported that the action was specific to the TeMSservice which would be discussed later on the agenda. It was notedthere had been no communication from SaTH and there had notbeen time to follow this up during January. KT had produced ananalysis on SaTH as a service provider and a meeting would bearranged to determine renegotiation. If a response from SaTH hadnot been received at that point it would be escalated to CEs – Open.

Quarterly Contracting Report - To ensure the Committee was keptup to date on progress with regards to the SLA with SATH – SLreported on a meeting to progress the SLA around the terms ofreference of both organisations. A series of actions had been takenaway to progress and another meeting had been arranged forDecember. Assurance had been received that accommodationcharges would be reviewed. It had been agreed that the issueswould be progressed and reported back prior to the Decembermeeting – It was noted that if no progress had been made byDecember this would be escalated to RP. An update would bepresented to the January Committee – It was noted that theDecember meeting did not go ahead due to the amount of apologiesreceived. An e-mail had been sent to SaTH regarding theaccommodation charges in particular. RP would contact NN on theoutstanding issues and report back to the next Committee – Open.

To undertake an independent review of the TeMS Service to see if itwould be viable for the Trust to continue to run the service in thefuture. It was noted the internal, independent review hadcommenced, which was being led by Alison Trumper. It has,however, proved more time consuming than envisaged, as the teamtry to get to grips with the short term recovery. Therefore the termsof reference are presented to the Committee with a progress reportagenda item 7.3 enclosure 11 – Open.

To consider the contents of the Performance Report to enable theCommittee to receive a high level view. It was noted that an initialreview to help focus the Committee was undertaken for theNovember meeting and changes were made to the summary sheet.The action would remain open to monitor further modifications to thereport – Open.

There was a work stream focussing on EPR benefits realisation ledby Paul Devlin but as he leaves the organisation a replacement andplan needs to be agreed and it was requested that this be closelymonitored and reported back to the Committee – To be discussedunder EPR Board Summary report – Closed

To look at the stranded cost of the 0-19 services going forward andreport back to the next Committee – Work progresses on the plan tomitigate the stranded costs for both Shropshire and TelfordServices. The impact of some aspects of this plan were currentlybeing assessed and a further, firm view would be reported to theFebruary Committee via the Service Transformation and BusinessDevelopment report - Open.

Members approved the recommendation that the Referral toTreatment Incomplete 52+ Week Waiters indicator would be ragrated on current performance not on previous months. As themeeting was not quorate Members are required to ratify this decisionat this Committee – It was noted that the update to this KPI hadbeen made for the January Performance Report. The Committeeratified this action – Closed.

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2018/1/285 Work Plan (Agenda item 5.2)

The Work Plan was noted by the Committee.

2018/1/286 CIP Delivery Group Terms of Reference (Agenda Item 6.1)

RP presented the Committee with the updated CIP Delivery GroupTerms of Reference incorporating agreed amendments as follows:

4. Membership (include Service Delivery Group Managers)

7. Handling Conflicts of InterestIf any member has an interest, financial or otherwise, in any matter andis present at the meeting at which the matter is under discussion,he/she will declare that interest as early as possible and shall notparticipate in the discussions. The Chair will have the power to requestthat member to withdraw until the Committee’s consideration has beencompleted.

The Resource & Performance Committee approved the updatedTerms of Reference.

2018/1/287 Finance Report Month 9 (Agenda Item 6.2)

RP presented the Financial Performance for the period ended 31December 2017 (Month 9 2017/18) and the following key points werenoted:

The Trust was reporting an Adjusted Financial Position surplus of£441k at month 9, against a planned surplus of £350k, which was afavourable variance of £91k.

The Trust had agreed to a control total of £855k surplus inclusive ofexpected Sustainability & Transformation Funding (STF) of £596k.

The forecast outturn as at month 9 was consistent with the agreed‘Control Total’ of £855k surplus however NHSI have requested thatthis was reviewed with a view to increasing the forecast surplus.

The Trust’s cash balance as 31 December 2017 was £11,469k. The Capital Resource Limit of £2,516k had been confirmed by NHS

Improvement however due to the delay with the RiO modulesscheme the EPR initial implementation has been postponed until2018-19 resulting in a forecast CRL underspend of £360k.

On a year to date basis CIP savings delivered and validated totalled£1,991k, against a target of £1,859k. £1,237k savings had beendelivered non-recurrently and this remained the most significant riskto address through action taken before the year-end and 18/19planning. The Trust continued to forecast delivery of the fullprogramme (£3,960k) and had identified potential schemes todeliver the full value in-year.

SJ referred to a question received from MR, Trust Chairman, relatingto flexibility on capital carry forward for next year. NHSI werelooking for capital underspends nationally to balance the positionhowever there were no guarantees when requesting carry forward orextra capital for next year.

PP referred to the centrally held budgets and the aim to have nocentrally held CIP however £380k was still to be cleared. RP statedthat this would be resolved prior to year end.

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PP referred to reference costs index where the Trust’s RCI had beenidentified as 109 which means 9% higher than the national averageand queried why that much higher. RP stated that it was a relativepositon against the current national average. This would be lookedat in more detail over the forthcoming months and a view wouldcome back to this Committee in due course.

SG commented that it was interesting to compare the Trust againstother local Trusts, with SSOTP being significantly higher at 133.

The Resource & Performance Committee considered the year todate adjusted financial position at 31 December 2017 of £441ksurplus which reflects a favourable variance to plan of £91k; notedthat the report had been prepared based on delivery of a £855kyear-end surplus, which was in line with the NHSI key data returndue to be submitted on 16 January 2018, and considered this inrelation to the identified financial risks and the potential for theseto impact positively and negatively in the coming months;recognised that the cash position remained healthy with a balanceof £11,469k as at 31 December 2017; referred back to this reportand its content when further discussing CIP under a separate partof the Committee agenda.

2018/1/288 CIP Report (Agenda Item 6.3)

AT updated the Committee on progress with regards to thedevelopment and delivery of the Trust’s Cost Improvement Plan and thefollowing points were noted:

AT reported that delivery and progress had been maintainedhowever there was still the issue of the significant element beingdelivered non-recurrently and the impact next year.

It was noted that the level of risk associated with current yearschemes had reduced from £197k in month 8 to £112k in month 9.

SJ referred to increasing concerns received from MR over thefinancial implications of the CCG Reviews, Community Offer, 18/19target and the implications for our bids and bidders. RP replied thatthe CCG and community offer would be discussed in Part II of themeeting. The implications regarding bidders in CIP delivery nextyear showed that both in their presentations would seek to secureCIP delivery however both had also put CIP delivery as 1 of 3 highrisks. The Trust needed delivery in place for this year however wedo not have recurrent solutions. The key focus would be benefitsrealisation of EPR, rationalisation work on estates and procurement.There has not been the opportunity to build additional contribution tobids and the only other place would be developing bids withcommissioners around our Community Offer.

SJ sought clarification about estimating the value of efficiencyrequirement for 2018/19. AT explained that the Trust’s estimate wasbased on tariff assumptions as part of 17/19 planning round whichmay be subject to change when 2018/19 planning guidance wasissued.

The Resource & Performance Committee noted the delivery to dateand that CIP delivery exceeded planned levels at this stage of theyear with a significant proportion currently delivered nonrecurrently; noted that the Trust continued to forecast delivery ofthe full requirement in 2017/18 and that further schemes were

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being sought to address the recurrent shortfall; recognised thattransactional opportunities were being taken to support the leadtime for operational plans to be assessed and contribute todelivery later in the year and fully in 2018/19; noted that theestimated value of the efficiency requirement for 2018/19 wasbeing progressed, prior to the release of national planningassumptions.

2018/1/289 Budget Setting Process and Timetable (Agenda Item 6.4)

AT presented to the Committee the Trust’s Budget Setting Process forthe financial year 2018/19 and the following points were noted:

AT reported on the Trust’s budget setting process highlighting theprinciples and issues for the financial year 2018/19 and the budgetsetting timetable in Appendix 1.

It was noted that a draft report showing the position would bepresented to the February Committee with the final report to theMarch Committee prior to Trust Board approval on 29 March 2018.

AT asked the Committee to note the process around the CIP plansand the 1% contingency an incease from the 0.5% currently held.

The Committee supported the 1% contingency in principle.

The Resource & Performance Committee considered the contentsof the report and the issues outlined with the process.

2018/1/290 Quarterly Procurement Report (Agenda Item 6.5)

RP presented the Quarterly Procurement report which updated theCommittee on the Trust’s procurement activity for 2017/18 (April-December) and the following points were noted:

RP reported that Procurement were on track to deliver the savingsidentified within the CIP programme

It was noted that Procurement were engaging on the nationalagenda and there were opportunities on the National ContractedProducts (NCP) which identified items that had been launched andthose planned for 2018. There will be updates on the process of thenew model giving comparative prices on items procured on anational basis. RJAH had already seen a substantial gain ononeprosthetic.

PP referred to the Procurement Product Evaluation Group held on18 January and confirmed that there was good evidence.

The Resource & Performance Committee received and reviewedthe aspects of expenditure which were being targeted byProcurement on behalf of the Trust.

2018/1/291 Monthly Performance Report (Agenda Item 7.1)

RP presented the Performance report which provided the Committeewith a focussed assessment of the key areas relating to risk arisingacross the Integrated Dashboard metrics at 31 December 2017 and thefollowing key points were noted:

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RP reported that there had not been a significant movement inmonth and there was no material risk on the Trust’s financialperformance however there were a residue of performanceindicators that were not improving. It was noted that the majority ofthese had been discussed in detail at Quality & Safety Committee.

SG suggested that at the Clinical Away Day being held on 23January a strong reminder of the importance of completingappraisals should be given to attendees.

SJ referred to the report where it stated that appraisalunderperformance was being addressed by Operational Managerswith HR input and asked how and when this was being done. SGreplied that over the last four years the culture of the Trust hadpositively changed and in his opinion did not think the Trust shouldtolerate apathy or non-compliance of appraisals. SG commentedthat he expected managers to lead and HR to support and had sentan e-mail out to staff last week as a reminder.

RL agreed with SG’s points and commented that it was about middlemanagers managing with support and training however they need tobe held to account and performance managed over a range ofissues if they are not taking place.

RP referred to the four top teams reported in the papers that neededto address a shortfall in their appraisal rate one of which was TeMSwith a rate of 55%. It was noted that KT would be attending for theTeMS Update report and her view on the impact to the service withonly half the staff receiving appraisals could be questioned in themeeting.

JD commented that Oswestry and Ludlow had reported for somemonths a number of staff with outstanding appraisals. These shouldbe targeted as a matter of urgency with assurance given at the nextCommittee that they were being dealt with.

ACTION: SG

The Resource & Performance Committee considered the currentperformance in relation to KPIs; reviewed the actions being takenwhere performance required improvement; discussed the actionsbeing taken to mitigate any risks arising to either the resourcesavailable to the Trust or the Trust’s financial performance;discussed the content to ensure appropriate assurance was inplace; approved the change to the Referral to TreatmentIncomplete 52+ Week Waiters Measure the Proportion of DelayedTransfers of Care (Days) and the addition of Seasonal FlueVaccine Uptake.

2018/1/292 Monthly TeMS Update Report (Agenda Item 7.2)

KT joined the meeting and presented the monthly TeMS update reportwhich included how the service would mitigate the impact ofimplementing RiO, reduce cost of delivery, return to contracted levels ofactivity, ensure financial viability and address estate issues particularlyrelocating the Booking Team from Deercote. The following points werenoted:

It was noted that there were no financial gains in month howeverthere had been considerable improvements operationally around theTeMS Service. The governance structure had been refreshed; thefirst Service Delivery Group meeting had been held in mid-January

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and the sub contract meetings were all in place and commence nextweek with partners.

It was noted that the unutilised capacity relating to clinic physios hadimproved however SaTH had capacity problems which had impactedon the service. The process of booking out and DNA’s had improvedand benefits would be realised once full capacity was achieved.

KT reported that the systems around TeMS had started to tighten upand the typing horizons had improved, they were some weeksbehind however the longest now was 2 weeks for rheumatology.

The booking process had improved but the impact of Rio was notinsignificant in this part of the process where previously you wouldexpect 60 appointments to be booked in a day now looking aroundthe 30 mark.

It was noted that the response to queries and complaints hadimproved.

From an operational point of view it was very positive however froma financial point of view it was disappointing. KT did not expect thefinancial position to deteriorate but also did not expect improvementbetween now and April however there may be some gains aroundcost for example oracle and prescribing.

KT commented that the model going forward as it stands was notsustainable. The price per pathway was incorrect so no matter howefficient the service became it would not breakeven. Also thesphere of influence the Community Trust has within the TeMS modelwas quite small with only 13% of the staff sitting within the Trust ofwhich the majority were administrators which highlights it was aboutinfluencing partners. The sub-contracting meetings had not been inplace and the model with SaTH had not been robust. Goingforward the model could be modified for example if therapy could sitinside the Community Trust it would be 25% cheaper and wouldmean the Trust would have some flexibility.

SJ queried with the Trust going through a process of acquisitionwould this be beneficial to the service. KT said one of the problemsthat TeMS has from a Trust point of view is not being able to provideand sits more in a commissioner role. SSSFT commission quite alot and you would expect their RTT and commissioning side to berobust in holding partners to account.

SJ referred to a question from MR who commented on the £1m lossthis year and questioned next year’s projected balance. KT replied itdepended on how much latitude we would be allowed to change themodel. MR also asked if the Trust would have to withdraw from thecontract. SAO commented that some of the work underway wasaround that discussion and would be reported back to theCommittee next month.

In answer to RL’s question RP confirmed that the Trust was undercontract with a notice period.

RP commented that views needed to reflect the content of themedium term view and suggested the Committee spend time at theFebruary Committee to fully discuss the content of the report.

RP referred to MR’s question ‘how was the deficit funded’ andexplained whilst there was an overrun, the Trust was supporting thisthrough underspends elsewhere however it was possible towithdraw from the contract if there were no other options.

RP queried the relationship with commissioners and asked wasthere freedom to act or were they tying the Trust into sub-contractorrelationships that were difficult to move away from. KT referred to

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previous meetings with commissioners where they were set with theoriginal model it was difficult with a partnership as there was noflexibility. RP queried if commissionres were committed to theservice model or service provider? KT replied that they would beopen to suggestion and there could be more scope now.

JD referred to the strategic setting in relation to Shropshire changesand the ambition of RJAH and queried if there were opportunities tomove to a better model with RJAH as the lead provider. KT repliedthat the interface between RJAH and TeMS would be better thanbetween SaTH and TeMS there would be flexibility. Working withRJAH either as lead provider and providing the consultant side or ifthey were the main provider and we the provided therapy side couldwork. JD asked if there had been any local conversations withcommissioners do you think they are considering having a similarservice to Shropshire given many of the patients are the same or doyou think they will keep it separate. KT’s opinion would be to keep itseparate.

MD referred to discussions held in Telford last week as part of theneighbourhood work. Telford were keen to move to Physio First andwere interested in how that would integrate with TeMS. They see itvery much as out of hospital rather than acute led so from a Telfordpoint of view there is a different direction of travel. JD we need toinclude this in our strategic considerations.

The Resource & Performance Committee challenged andconfirmed the content of the report; endorsed the approach andactions relating to the revised recovery plan; noted the financialposition at the end of December 2017 a loss of £687k compared toplanned contribution of £166k which reflected an adverse varianceof £853k to date; considered the full year outturn of £780k losswhich included £136k contribution from the revised recovery plan(January-March 2018) and that this was still £1002k worse thanplan.

2018/1/293 TeMS Medium Term Review Terms of Reference (Agenda Item 7.3)

A briefing paper outlining the background of the reviews was presentedto the Committee giving an initial briefing on the issues being reviewedand a request that the Committee ratify the Terms of Reference of theinternal review of Telford Musculoskeletal Service. The following pointswere noted:

RP referred back to the action log and subsequent discussionsrelating to the internal review of the TeMS service.

It was noted that KT focusses on the day to day operation of theservice which links into the medium term review.

Alison Trumper had already commenced work on the review and thisreport was a result of initial investigations. It was noted that aformal report would be presented to the February.

SJ queried what information the formal report would contain. RPreplied consolidated views on issues impacting on the medium term.There were a range of ways to look at this and the Committee needto conclude what action should be taken. Members need to decide ifmore needs to be done if it is a strategic contractual requirement toagree a set of actions to mitigate or avoid the risk.

RL referred to the briefing paper and commented on the overspend

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on the contract, low cost high cost pathway split instead ofpredicated on 75/25% which turned out at 65/35% and asked if thatwas the single cause for the ovespend. RP confirmed that this wasone of the reasons however thought that the testing of the currentpayment relationship would probably not get the cost down.

PP referred to the 20/80% split between lower and higher costpathways and the reality of 35/65% and the number of referralsgoing up from 311 to 349 and commented that there was a volumeissue as well as a cost issue.

RL referred to the table on page 5 and was concerned with the highnumber of patients (2,025) without an appointment. KT explainedthat there was a caveat around this figure and the reports werebeing discussed with informatics outside the meeting. It was notedthat when the reporting changed from Lorenzo to RiO the servicegained about 600 patients waiting for an appointment. They werereal paitents and when backtracked it was found that a number hadappointments or appointments arranged. One of the issues was therelationship with TeMS and informatics which was not as tight as itshould and this was being addressed. It was noted that the RTTposition was more accurate.

It was noted that the Committee ratified the Terms of Reference ofthe internal review of Telford Musculoskeletal Service.

The Resource & Performance Committee ratified the Terms ofReference and supported the extended time required to undertakethe review.

2018/1/294 Quarterly Estates Report (Agenda Item 8.1)

RG joined the meeting to provide the Committee with an update on keyfacilities and estates matters and the following points were noted:

RG reported that compliance continues to improve and there wereno elements where patient safety was put at risk.

Non Trust responsibility properties – a schedule was being collatedfor non freehold properties and letters had been sent to 26 landlordswhere tenancy information was known however there were shortfallsof infomaiton for 77 properties.

RL questioned the unknown responsibilities and the element of risk.RG confirmed that work was continuing on drilling down theinformation to evaluate the level of risk and they were 6 months intoa 18 month timescale for the completion of this work.

RG reported that the work done to reduce legionella in the watersystem at Whitchurch Hospital was generally improving the situationand the risk was effectively being managed still with no harm topatients.

It was noted that NHSPS had completed the remedial itemsidentified on the water risk assessment at Ludlow Hospital and afurther water risk assessement was due to take place earlyFebruary.

SG referred to the legionella remedial work and asked what was thelikelihood that the hospitals would will be legionella free. RGconfirmed that Ludlow and Whitchurch would eventually be clear ofthe bacteria but was not prepared to commit to a timescale.

Ludlow NHSPS improving building better relationship however theyare commencing another reorganisation moving to two areas based

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in north and south. Reference was made to an issue with NHSPS and Oswestry. The

heating system had been defective and although a new pump andcontrol component had been fitted there were still issues with thesystem. Also the external lighting was still outstanding andnegotiations are ongoing. This was being kept under review.

It was noted that the Estates rationalisation was impacting on thedelivery of the capital programme however progress was beingmade.

Capital works now trying to absorb some of the IT slippage c £400k. The Committee noted the progress with regards to asset

management. The appointment of Authorised Engineers was progressing with

orders and letters of intent issued from the Trust. MD reported on the capital resource limit and the extent of the work

being undertaken at Whitchurch Community Hospital: roofing;emergency lighting; water services and storeroom conversion all ofwhich are due for completion by 31 March 2018.

RL referred to assurances sought at Quality & Safety Committeeand said the key points were not putting anyone at risk.

SG referred to the lighting at Oswesty as an example andquestioned if we could undertake the work and bill NHSPS. Ameeting had been arranged with the property owner next week andthese matters were to be followed up.

JD made reference to information received this morning of a randomspot inspection by the Fire Service of Coral House on 2 February.RG was aware of work required at Coral House and would be ableto confirm to the Fire Service that a review had been undertaken.

MD was unable at the meeting, to provide assurance on peoplecompliance of fire knowledge and evacuation procedures howeverthis would be determined before the inspection. It was confirmedthat there were not items that needed including on the risk register.SG had alerted SAO to the situation and it was noted that there wasover a week for remedial work to be completed.

RG commented on the need to check fire marshals are in place andwho was responsible for the building.

The Committee were assured that the building would be compliantbefore the visit.

The Resource & Performance Committee receive the progressreport about the compliance work completed to date and the on-going programmes; accepted that estates compliance reportingwas continuing to improve; supported the day to day activities ofthe estate management function and the focus on efficiency;considered the progress being made on estate rationalisation andthe requirement to focus on service areas and geographic areasset in context of the risks without clarity on the STP outcomes;accepted the improving position with NHSPS and the responsesmade to issues.

2018/1/295 EPR Project Board Summary (Agenda Item 9.1)

Andrew Crooks (AEC) and Angela Cooke (AC) joined the meeting topresent the update on the EPR programme with regard to the keyactivities, risks and issues arising from the EPR implementation re-calibration and programme sustainability. The following points were

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noted:

RP reminded the Committee of the context prior to AEC goingthrough the key issues of the project. RP said that Members whoattended the December Trust Board would be aware that there weresome significant delivery risks around the implementation of Phase 4(Inpatient Phase). A number of risks were raised at the initialassessment which had caused significant clinical concern and quitea few issues needed to be looked at again as they would impact onthe timeframe for delivery. It was noted that the Project Team hadbeen monitoring these in greater detail and the report beingpresented to the Committee was a summary position as of now not afully worked up plan. It was noted that this had also been fullydiscussed at EPR Project Board and a full project plan would beproduced for the February Committee.

SJ was concerned about the recalibration and questioned if it meantthe whole of Phase 4.

AEC explained that Phase 4 would now require to be replanned anda solution was being sought on a read only basis for CommunityHospitals which would allow ward based staff to see how RiO worksand view community records. There were a number of ways ofachieving this for example SSSFT had developed a portal so staffcould read only records and it had yet to be agreed whether we godown that route or apply Rio to ward managers which would givethem full access. In terms of milestones this would be the first stage.

It was noted that there were a number of issues to address thatspecifically related to Community Hospitals clinical working and theinterface in place. These were more complex than communityservices for example outpatient services linking with SaTH andWolverhampton from a consultant view point.

There would be a process in place to work through the issues andthe intention at this time was to split community hospitals intooutpatient and inpatient services. Outpatient services with TeMSand inpatient services which have a number of clinically significantareas in terms of risk.

RP commented that the original plan for Phase 4 was now notrobust or sufficient for what was required and that part of the planneeded to be rewritten as there were more elements to this phaseincluding implementing an EPMA.

SJ queried the commitment of clinicians. AC commented thatclinicians were committed however due to the complexity of theprocess they were concerned and their issues needed to beaddressed.

RL asked if the system in relation to Phase 4 implementation was inuse elsewhere and if so were there opportunities for learning. AECreferred to a visit to a Community Hospital in Taunton where thesystem had been deployed in a ward based setting. There was alsoa process in place to contact other organisations who had deployedRiO however it was becoming clear there were different views. AECcommented that the Trust appeared to be on the forefront ofdeployment into inpatient services. It was noted that a visit wasbeing arranged to a Foundation Trust in Berkshire where the systemwas being implemented on their ward based services.

JD asked what progress had been made since the December TrustBoard where it was noted more time was required to finalise the planand questioned the timeframe to resolve the issues. AEC replied

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there was an understanding around the technical issues andmilestones and confirmed conversations had taken place withServelec the primary supplier and SSSFT about features in theirproduct that would support our deployment process.

SG was concerned that there was no date for the commencement ofPhase 4 implementation, was not clinically assured there was paceand would like to see a timeline. SG recognised the good work todate however felt we were letting clinicians down by not driving atpace and this should be included in the plan.

JD referred to the issues raised at Trust Board and requestedweekly progress against the actions including solutions. She feltFebruary was too long to wait for an update unless the EPR ProjectBoard could give assurance they were closely monitoring the issues.

JD questioned if there had been research locally in acute trusts thatuse RiO on their wards. AEC replied it depended on whether it wasbeing used as a PAS on the wards because we were looking to useit as an EPR. Some organisations were using part of thefunctionality where the Trust’s aspiration was to make it entirelydigital.

AEC confirmed that a user list of organisations who hadimplemented the observation package had been requested fromServelec and in the meantime the team were making contactsoutside that route with other organisations.

JD requested assurance that the team are working through theseissues methodically and in a timely way and finding solutions.

SG commented on the time line for phase 4, the elements whichwere challenging especially EPMA and the work being undertaken atSSSFT. If the Trust was committed to a start date of the end ofMarch we could live with these issues for a period of time but with atimeframe built around them.

RL made reference to the resourcing issue in the report. RP referred to pace which was predicated to the amount of resource

available for the clinical side and technical resource side; clinicalleadership; and the need to reshape governance around the project.

RP referred to the EPR benefits realisation action and commentedon the work stream for benefits realisation and transformation group.Following discussions this morning at the EPR Project Board theneed to define different roles and responsibilities was identifiedwhich would determine pace. Before Christmas we were reportingthat the consultancy brought in to add pace had ceased to providethe expected support. It was noted that AEC’s additional task was tomake sure the project resources were correct and back on streamhowever this was further complicated because there were someshort term contracts coming to an end.

SJ referred to the recommendation to determine the time line tocomplete the implementation of Phase 4 by the end of March 2019.RP explained that the plan would determine the time line and wouldbe presented to the February Committee.

AEC referred to assurance in commencing Phase 4 and said thatPhase 4 would start when we enable read access into communityhospitals which would be the first milestone. It was noted that therewas an EPR Project Board expectation of end of March.

SJ asked what could jeopardise the end of March date. AEC repliedresource issues and unknowns that the Trust has no control over. Atthis point in time AEC believed it was achievable however could notgive full assurance to the Committee.

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SJ queried the implication of slippage. AEC did not think it would bethat significant as at this stage.

SG referred to the discussion about the BAF and corporate risk thatneeded to be worked through. We need to be very clear on the riskif we fail to meet the strategic objective or from a patient safety pointof view we are not creating a patient safety issue however equallywe are not improving our processes in line nationally. In winter wewould have no line of sight across our services and be no furtherforward. There was an issue on when it starts and when it would befully realised to benefit patients and staff within the system. SGwould like to see key milestones being worked through and theresource required.

SJ asked when this would be available. AEC replied that the nextEPR Project Board was schedule for 18 February and theinformation would be presented to the next Committee.

RL said that high quality clinical resource was critical and he wouldlike to see a clear comprehensive plan at the February meeting.

ACTION: AEC - Robust comprehensive report for February Committeeto include a plan and timescale. The Committee noted the requirement to appoint of a Chief Clinical

Information Officer but this had not been determined to date. JD asked if senior clinical leadership would make a difference to the

project and if so how would this be achieved. RP thought it was asignificant factor in delivery and was key to drive the project. JDqueried if this was key then why was this not already in place. SGcommented in terms of benefits realisation having a person in postwas critical in terms of the project as a whole they would not beacceptant of the delay.

RL questioned the impact of the delay on CIP. RP confirmed thatCIP would be revisited however depending on the timeline of theplan there could be a significant impact.

The Resource & Performance Committee recognised the intentionof the Project Team to focus on: the re-calibration plan: finishPhase 1- 3 in line with the timeline which would be approved at theFebruary Project Board;• provide “read only” access toCommunity Hospitals as soon as practicable; complete theimplementation of Phase 4 by the end of March 2019.Noted that the RiO programme would not deliver a “fully digital”environment; some services may need to operate in a mixedeconomy of paper and digital for a period of time.Recognised the need to put in place a sustainable programmesupport function.Recognised the need to appoint a Chief Clinical InformationOfficer (CCIO) to provide the necessary clinical leadership to thetransformation processes that are core to the RiO benefitsrealisation.

2018/1/296 EPR Project Board Minutes (Agenda Item 9.2)

The Minutes of the EPR Project Board held on 22 November 2017 andthe draft minutes from the meeting held on 13 December 2017 werenoted by the Committee.

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2018/1/297 BAF Risks (Agenda Item 10.1)

The Committee reviewed the risk for Trust Sustainability. The purposeof the review was to ensure that risk description and controls(mitigation) were current, to add any additional controls or gaps incontrols, verify assurances and ensure any identified actions to addressgaps in control or assurance were on track. The following were noted bythe Committee:

RP referred to the risks that related to this Committee and thespecific request raised at Trust Board that the Committee review inthe light of delays in EPR delivery the Transformation Systems BAFentry. RP updated the meeting on discussions held at the EPRProject Board where the group review and monitor BAF risks andforward recommendations to this Committee. It was discussed atthe group and agreed that the delivery risk was different to theTransformation Systems entry and wouldn’t seek to take this risk offthe BAF framework however we need to look at how we build up adifferent risk at corporate risk level. At the EPR Project Group arequest was made to the Project Team to write up a corporate riskregister entry with mitigations so that the level of risk could beassessed at that stage. It would stay on the corporate risk registeror be included on the BAF depending on the level of risk. Thiswould be presented to the Committee for approval once agreed.

ACTION: AEC

2018/1/298 Annual Meeting Check List (Agenda item 11.1)

The Committee fully discussed the annual meeting evaluation checklist.

SJ questioned were the papers circulated in sufficient time and werethey of sufficient quality to allow preparation for members prior to themeeting. Some reports were felt to be data rich and information poorand especially for NED’s the high level issues, opportunities andtimelines were required not the granular information. SJ felt anexecutive summary with supporting papers was all that was requiredand referred to the Performance Report which he thought was going tobe hyperlinked. RP commented that Boardpad did not have the facilityto hyperlink.

RP reminded the Committee that there was no expectation to gothrough all the detail which was included for Members to access ifrequired however it was agreed to look at the content of the summaryreports outside the meeting and it was a useful reminder to authors tofocus on the high level strategic issues rather than detailed information.

PP commented that during his time on the Committee he had seensteady progress in the presentation and content of reports howeverthere were still improvements to be made.

RL said it was important to avoid duplication between the Quality andSafety Committee and Resource & Performance Committee and forauthors to concentrate on the content and level of information relevantto the Committee.

The challenge in compiling the papers for this monthly Committee due

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to timeliness of information, complex reports and multiple authors wasnoted as a critical factor on the Checklist.

2018/1/299 Risks/Assurances: (Agenda Item 12)

Risks Identified at the Meeting (Agenda Item 12.1)

ERP TEMS Medium Term

Assurances given at the meeting of internal control/riskmitigation effectiveness, either positive or negative (AgendaItem 12.2)

Limited assurane of ESR Phase 4 delivery.

Any Comments on the Committee’s effectiveness (AgendaItem 12.3)

None to record.

2018/1/300 Any Other Business: (Agenda Item 13)

AT informed the Committee on the availability of papers for the 19February meeting. Due to the timeliness of receiving the financialinformation it would not be possible to provide the reports 5 days inadvance of the meeting and these would be uploaded later in the weekcommencing 12 February.

The Committee agreed to the deletetion of all Resource & PerformanceCommittee papers stored on Boardpad with the exception of the lastmeeting.

Date and time of next Meeting:

Monday 19 February 2018, Room B, William Farr House from 1pm – 4pm.

………………………………. ……….……………….Chair – Steve Jones Date

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