meeting of the board of directors€¦ · meeting of the board of directors 10.00am to 12.05pm on...

Meeting of the Board of Directors

10.00am to 12.05pm on Thursday 26 November 2015

Boardroom A, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH

AGENDA – MEETING IN PUBLIC

1. 10.00 Welcome and Apologies for Absence Chair

2. 10.00 Declarations of Interests All

3. 10.00 Minutes of Board Meeting held on 29 October 2015 To approve

Enclosure Chair

4. 10.05 Matters Arising from the Minutes

To note Enclosure Chair

5. 10.10 Chief Executive’s Report

To receive and agree any necessary actions Enclosure MG

PATIENT SAFETY/EXPERIENCE ITEMS

6. 10.25 Quality Report To receive and agree any necessary actions

Enclosure AP/GF

7. 10.45 Nursing Staffing and Capacity Levels Report

To receive and agree any necessary actions Enclosure AP

OPERATIONAL ITEMS

8. 11.55 Performance Report To receive and agree any necessary actions

Enclosure JF

9. 11.10 Organisational Development and Workforce Performance

Report To receive and agree and necessary actions

Enclosure DF

10. 11.20 Financial Performance Report

To receive and agree any necessary actions Enclosure KG

STRATEGIC ITEMS

11. 11.30 Patient First Programme Update To receive and agree any necessary actions

Enclosure MG

OTHER ITEMS

12. 11.45 Other Business Chair

13. 11.50 Resolution into Board Committee To pass the following resolution: “That the Board now meets in private due to the confidential nature of the business to be transacted.”

Verbal Chair

14. 11.50 Date of Next Meeting

The next meeting in public of the Board of Directors is scheduled to take place at 10.00am on 28 January 2016 in Boardroom A, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH

Chair

15. 11.50 Close of Meeting Chair

16. 11.50

to 12.05

Questions from the Public Following the close of the meeting there will be an opportunity for members of the public to ask questions about the business considered by the Board

Chair

Andy Gray Company Secretary Tel: 01903 285288 / Mobile: 07785332416

1

MINUTES OF A MEETING OF THE BOARD OF DIRECTORS IN PUBLIC HELD AT 10:00 ON 29 OCTOBER 2015 IN THE BATEMAN ROOM, CHICHESTER MEDICAL EDUCATION CENTRE, ST RICHARD’S HOSPITAL, SPITALFIELD LANE, CHICHESTER, PO19 6SE

Present: Mike Viggers Chair

Bill Brown Non-Executive Director

Joanna Crane Non-Executive Director

Lizzie Peers Non-Executive Director

Mike Rymer Non-Executive Director

Marianne Griffiths Chief Executive

Denise Farmer Director of Organisational Development and Leadership

George Findlay Medical Director

Karen Geoghegan Director of Finance

Amanda Parker Director of Nursing and Patient Safety

In Attendance: Andy Gray Company Secretary

Mike Jennings Commercial Director

Carol Fenn Board Administrator (Minutes)

1. WELCOME AND APOLOGIES

1.1

1.2

The Chair welcomed everyone to the meeting. Apologies for absence were received from Jon Furmston and Jane Farrell.

2. DECLARATIONS OF INTERESTS

2.1 There were no interests to declare.

3. MINUTES

3.1

3.2

The Board received the minutes of the meeting held on 1 October 2015, copies of which had previously been circulated. A minor amendment to the questions from the public was agreed.

3.3 IT WAS RESOLVED THAT, subject to the above amendment, the minutes be approved for signature by the Chair.

4. MATTERS ARISING

4.1

A schedule of Matters Arising from the previous meeting held on 1 October 2015, copies of which had previously been circulated, was considered and noted.

5. CHIEF EXECUTIVE

5.1

Marianne Griffiths presented her report, copies of which had been previously circulated. The following were highlighted:

Staff Conference – more than 250 colleagues had attended the Staff Conference “Where Better Never Stops” at Fontwell Park Racecourse on 23 September 2015. The next Staff Conference was scheduled for 27 November 2015;

2

New ITU relatives’ room – a new ITU relatives’ room had been established at St Richard’s Hospital. Marianne Griffiths thanked Angela Fisher, Chair, and members of the Organ Donation and Transplant Committee and staff for leading the project;

National Older People’s Day – staff had marked National Older People’s Day with a variety of activities and offered patients afternoon tea and cake;

STARS Awards – the STARS Awards took place on 8 October 2015 at Fontwell Park Racecourse. 13 awards were presented. Marianne Griffiths thanked everyone for their submissions and congratulated the shortlisted nominees;

“Eat Well Eat Out” Awards – “Eat Out Eat Well” Awards had been developed to highlight catering businesses, which provide healthy food choices. Worthing Hospital received three awards. St Richard’s Hospital was granted two awards. Marianne Griffiths congratulated the Catering Team;

Eye Care at Southland’s – plans for the new eye care facilities at Southland’s Hospital would be on display at Worthing Hospital and at Southland’s Hospital during November; and

New Courtyard Garden – Marianne Griffiths thanked Rennie Wells and the Friends of Chichester Hospitals for the new courtyard garden at St Richard’s Hospital.

5.2

Marianne Griffiths gave an update on the recruitment of nurses:

local and national nurse shortages remained a challenge, however, the Trust was mitigating the risk;

domestic recruitment campaigns, including open days and “drop-in days”, were proving successful, however, there remained a gap;

international recruitment campaigns had been launched: o Philippines – the first cohort was expected to arrive by January 2016.

However, there was potential for slippage as the nurses’ English language test pass rates had been lower than anticipated. The Trust was working with the agency to improve the rates and mitigate any potential delay; and

o Europe – additional nurses were being recruited from Europe. A two-centre campaign had been launched in Portugal and Spain, which included targeting of specialty areas such as theatres. The nurses were expected to arrive in two cohorts during November and December; and

initiatives to improve retention, standardise approaches and release staff time had been implemented such as “stay” interviews, “transfer windows” to rotate staff, a pilot to develop Band 4 roles and the introduction of electric beds.

5.3 Marianne Griffiths thanked nursing staff who, despite the shortfall, continued to provide great care.

6. QUALITY

6.1

George Findlay and Amanda Parker presented the Quality Report for Month 6, copies of which had previously been circulated. The following were highlighted:

Effectiveness o the crude non-elective mortality rate fell from 3.15% in August to 2.70% in

September and was lower than the equivalent month in 2014 (2.83%). The 12 month mortality rate fell to 3.22%;

o the Dr Foster Hospital Standardised Mortality Ratio (“HSMR”) for the 12 months to July was 93.5 (100 being the level predicted by the Dr Forster model using the April 2015 benchmark); and

o there was one exception report relating to the caesarean section rate, which reached 30.3% in September. Detailed audits indicated that the vast majority of procedures had been completed for valid reasons and to ensure the safe delivery of the neonate;

3

Safety o there were:

five Serious Incidents Requiring Investigation (“SIRIs”); 42 falls resulting in harm (against a benchmark of 43); no cases of MRSA bacteraemia; five cases of C-difficile; 15 cases of Grade 2 hospital acquired pressure ulcers; two cases of hospital acquired Grade 3 pressure ulcers; and four exception reports relating to prescribing incidents and audits,

compliance with WHO checklist and the investigation findings of the “Never Event” reported in September;

Patient Experience o there were 44 complaints. The main themes were clinical treatment,

appointments and communication; o Friends and Family Test scores remained good against national

benchmarks; and o there were four exception reports relating to cancellations, a breach of

mixed sex accommodation arrangements and the MUST assessment.

6.2

6.3

Following an inquiry from Mike Rymer, it was agreed that the report on the visit to John Radcliffe, Oxford to consider alternative approaches to caesarean section management would be circulated to the Board once published. In response to a question from Bill Brown, George Findlay advised that the Dr Foster model had not identified any particular areas of concern regarding mortality. Renal failure was slightly higher than the baseline of 100 but not a cause for concern. Sepsis was a notable contributor to mortality nationwide. Considerable work had been undertaken to raise awareness and enable faster diagnosis and treatment of the condition. Fractured neck of femur rates had improved considerably. The crude non-elective mortality rate of 2.70% benchmarked well against the national average of 8.20%. This was particularly impressive given the age profile/frailty of the local population, for which the Dr Foster tool did not adjust.

GF

6.4

6.5

6.6

Following an inquiry from Lizzie Peers, it was agreed that Amanda Parker would give a presentation to the Board on the QUEST Falls Collaborative work. Following an inquiry from Lizzie Peers, it was agreed that additional information on the breach of mixed sex accommodation arrangements in September would be included in a future report. Following an inquiry from Joanna Crane, it was agreed that additional information on safer staffing scores would be included in the next Nursing Staffing and Capacity Levels Report to provide a more comprehensive picture/enhance triangulation.

AP

AP/GF

AP

7. PERFORMANCE

7.1

Marianne Griffiths presented the Performance Report for Month 6, copies of which had previously been circulated. The following were highlighted:

Activity o A&E attendances were marginally down on the same month last year; o emergency admissions were up. There was an increase in the age profile of

patients (up 0.6% for 65-85 years and up 8.1% for >=85 years) compared to September 2014; and

o delayed transfers of care (“DTC”) totalled 3.97%;

A&E o the Trust was non-compliant in September with 94.8% of patients waiting

less than four hours from arrival at A&E to admission, transfer or discharge (against a national target of 95%). However, the Trust was fully compliant in aggregation for Quarter 2 at 96.6%;

4

o compliance in September reflected the rapid rise in DTC combined with workforce capacity constraints, notably at St Richard’s Hospital. Business continuity actions were deployed alongside a recovery plan; and

o despite the difficulties in September, the Trust benchmarked well locally and nationally. Compliance across the south region was 90.2%, with Surrey/Sussex trusts (excluding the Trust) generating aggregate compliance of 91.2%. National compliance was 91.5%;

Cancer o the provisional position for September indicated that the Trust was

compliant in six out of seven cancer metrics as projected in the Month 6 report; and

o the Trust was non-compliant in the breast symptomatic metric in Quarter 2, with 91.2% of patients being seen within two weeks (against a target of 93%). This was set within the context of a 22.4% increase in demand for breast symptomatic patients and 25% increase in two week rule GP-referrals in September;

Referral to Treatment (“RTT”) o during September, the Trust completed 11,785 RTT patient pathways, 7.0%

above the planned recovery volume for the month. This was the second highest like-for-like volume in the Trust’s history (June 2015 being the highest); and

o cumulatively the Trust was 3.2% ahead of recovery plan commitments in the year-to-date and completed 6.9% more cases than the same period of 2014/15. During September, 17.6% of pathway completions were >18 weeks (backlog), which was a record high.

7.2 In relation to an inquiry from Bill Brown, Marianne Griffiths advised that there had been a rise in the number of patients fit for discharge but still within the hospital. Notable constraints included the reduced number of beds in the community, workforce capacity constraints in the local social care market and lengthy assessment processes. Considerable work was underway to address/mitigate the social care market issues as well as galvanise improvements across pathways and assessment processes.

8. ORGANISATIONAL DEVELOPMENT AND WORKFORCE PERFORMANCE

8.1

Denise Farmer presented the Organisational Development and Workforce Performance Report for Month 6, copies of which had previously been circulated. The following were highlighted:

the increase in the bank rates of pay for nurses, HCAs and housekeepers;

the Philippian and European nurse recruitment campaigns; and

the appraisal rates within Medicine, Surgery and Facilities and Estates, which required improvement.

8.2

8.3

8.4

In relation to a question from Joanna Crane, Denise Farmer advised that the nurses from the Philippines had a broad skills-set, which could be aligned to both Medicine and Surgery. The skills-set of the nurses from Europe was more specific to either Medicine or Surgery. Denise Farmer highlighted the planning underway to support the orientation and integration of nurses joining the Trust from overseas. Following an inquiry from Mike Rymer, it was agreed that a review of opportunities to speed up Medical consultant recruitment processes would be carried out and reported to the Board. In response to a question from Lizzie Peers, Denise Farmer advised that nurse appraisals were traditionally low risk. The main constraint was the ward sisters’ capacity to schedule appraisals. Ward sisters required more support with this. There might be scope to improve the process through the Nursing Transformation Programme.

DF

5

9. FINANCE

9.1

Karen Geoghegan presented the Financial Performance Report for Month 5, copies of which had previously been circulated. The following were highlighted:

the Trust reported a year-to-date deficit of £1,794k against a planned surplus of £88k. This was being driven by underperformance in income and operational costs being ahead of budget;

the Trust reported an overall Financial Sustainability Risk Rating (“FSRR”) of 3. However, the Capital Servicing Capacity Ratio and Income and Expenditure Margin delivered an FSRR of 2;

the cash balance reduced due to the capital loan and PDC dividend payment. Cash remained behind plan in the year-to-date, however, the overall variance improved following receipt of seasonal resilience and overperformance income;

income was £1.1m behind plan. Income for PbR excluded items and seasonal resilience offset activity underperformance. Private patient income and non-patient care contracts continued to underperform;

at the end of Quarter 2, operational costs were £721k above plan. Pay overspend was driven largely by Medical staff agency expenditure. Non-pay overspend was driven by PbR excluded items;

there was a small increase in agency expenditure in September, which continued to exceed the same period in 2013/14 and 2014/15, particularly in Medical and Nursing staff;

there was slippage of £3,814k against the capital programme in the year-to-date, notably in Endoscopy, Estates and Information Technology. This was being actively managed and the programme was forecast to be on plan by the year-end; and

the Efficiency Programme delivered cumulative savings of £7.9m against a plan of £8.1m.

9.2 In response to an inquiry from Joanna Crane, Karen Geoghegan advised that negotiations were ongoing with commissioners to agree a local tariff for the emergency floors at St Richard’s Hospital and Worthing Hospital.

10. PATIENT FIRST PROGRAMME

10.1

Marianne Griffiths presented the Patient First Programme Update Report, copies of which had previously been circulated. The following were highlighted:

three appointments had been made to the Kaizen Office. These would be supplemented by a number of internal staff who would be seconded on a part time and/or block release basis; and

the activity planned for November included the implementation of Patient First Improvement System training across four wards, the Nurse Resource Management Programme and a similar programme for Medical workforce.

11. BOARD GOVERNANCE

11.1

The Company Secretary presented the External Board Governance Review, copies of which had previously been circulated. The following were highlighted:

Monitor’s Risk Assessment Framework required all foundation trusts to carry out an external review of their governance based on Monitor’s Well-Led Framework every three years;

the Trust’s evaluation was scheduled to commence in February 2016 and culminate in a presentation of the final report to the Board in June 2016; and

learning from other trusts indicated that the evaluation may cost between £30k and £50k depending on scope/complexity.

11.2 In relation to an inquiry from Joanna Crane, the Company Secretary explained that the output from the CQC inspection might mitigate the cost of the evaluation.

6

11.3 IT WAS RESOLVED THAT the procurement of the evaluation, as set out in the

report, be approved.

12. OPERATIONAL PLAN OBJECTIVES AND BOARD ASSURANCE FRAMEWORK

12.1

Mike Jennings presented the Operational Plan Objectives and Board Assurance Framework for Quarter 2, copies of which had been previously circulated. The following were highlighted:

good progress had been made across the Operational Plan Objectives during Quarter 2;

there was no movement in the post-mitigated risk ratings for the Board Assurance Framework items; and

the highest risks continued to be around workforce, sustainability and maintaining the financial position.

13. MONITOR SUBMISSION

13.1

13.2

13.3

The Board considered the Monitor Submission for Quarter 2, copies of which had been previously circulated. The section relating to the Trust’s RTT performance was noted. IT WAS RESOLVED THAT the submission be approved.

14. RESOLUTION INTO BOARD COMMITTEE

14.1

IT WAS RESOLVED THAT the Board now meet in private due to the confidential nature of the business to be transacted.

15. NEXT MEETING

15.1 The next meeting would take place at 10.00am on Thursday, 26 November 2015 in

Boardroom A, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH.

………………………………………………….

Mike Viggers, Chair

Date:

7

QUESTIONS FROM MEMBERS OF THE PUBLIC ATTENDING THE MEETING

Member Topic Response

Margaret Bamford

CQC inspection preparation

Amanda Parker gave an update on the CQC inspection preparations. The following were highlighted:

the relevant submissions, including the self-assessments and statement of strengths and weaknesses, had been completed; and

mock inspections involving staff, governors, the Executive Team and Non-Executive Directors had been carried out.

Marianne Griffiths emphasised the considerable executive oversight and involvement in the preparations.

DTC Marianne Griffiths advised that the Trust collated and analysed its own data. The Trust could inquire about the collation and analysis of wider community data.

Vicki King Level of community beds

Marianne Griffiths confirmed that there would be approximately 58 less beds in the community during this winter period compared to last year. The Trust was engaging with the Health and Adult Social Care Committee to look into this and apply pressure to remedy the social care market issues.

Infection control – c-difficile

Amanda Parker confirmed that there were three cases of c-difficile during September, which related to lapses of care. Two cases were attributed to environmental factors and dirty commodes. Amanda emphasised the extensive and comprehensive audit and surveillance programme relating to commodes at the Trust. The scores of which were very reassuring/satisfactory.

Workforce capacity

Marianne Griffiths advised that the change in establishment of scientific and technical staff was part of the overall pathology review.

Katie Manning

DTC Marianne Griffiths confirmed that the main constraints were the reduced number of community beds, workforce capacity constraints in the local social care market and lengthy assessment processes. Considerable work was underway to address/mitigate the social care market issues as well as galvanise improvements across pathways and assessment processes.

HSMR George Findlay confirmed that the Dr Foster tool did not adjust for demographic variances such as the age profile/frailty of the local population.

John Thompson

CQC inspection preparation

John Thompson commented positively on the mock CQC inspections.

International recruitment

Denise Farmer highlighted the planning underway to support the orientation and integration of nurses joining the Trust from overseas.

Gillian Sedgewick

Discharge assessments

Marianne Griffiths confirmed that discharge assessments were carried out by multidisciplinary teams of health and social care professionals.

MATTERS ARISING Board in Public

Meeting Minute Ref

Action Person Responsible

Deadline Status

29 October 2015

6.2 Circulate report on the visit to John Radcliffe, Oxford (re caesarean section management). GF

Once report is available.

To be circulated once report is available.

6.4 Give a presentation to the Board on the QUEST Falls Collaborative work.

AP January 2016 Board Seminar scheduled for January 2016.

6.5 Provide additional information on the breach of mixed sex accommodation arrangements in a future Quality Report.

AP/GF November 2015 Action completed – see 6.4.3 of Quality Report.

6.6

Include additional information on safer staffing scores in the next Nursing Staffing and Capacity Levels report to provide a more comprehensive picture/enhance triangulation.

AP November 2015

Action completed – see Nursing Staffing and Capacity Levels Report.

8.3 Review of opportunities to speed up Medical consultant recruitment processes. DF December 2015

To form part of a future Organisational Development and Workforce Performance Report.

To: Trust Board

Date: 26 November 2015

From: Marianne Griffiths, Chief Executive Agenda Item: 5

FOR INFORMATION

CHIEF EXECUTIVE’S BOARD PAPER

1. Patient First

Investment at Worthing Bowel cancer screening and other endoscopy services at Worthing Hospital have benefited from a £7m investment in new facilities. Following months of works the new Endoscopy Department has more than doubled in size and now provides patients with new single-sex recovery areas, more treatment rooms, and new and improved reception and waiting areas. Five new endoscopy rooms have replaced the previous three, and, to improve access for patients, additional sessions can now be provided in the evening or at the weekend. Demand for endoscopy services is increasing, driven by the needs of an ageing population, as well as the requirements of the National Bowel Screening Programme for the over-50s. Over the next five years it is forecast demand for endoscopy procedures across the Trust will rise to more than 28,000, up from the 17,820 procedures carried out in 2013/14. Endoscopy facilities will be maintained at St Richard’s and Worthing, to provide a range of inpatient and outpatient endoscopic diagnostic and therapeutic procedures at both hospitals. A £400,000 redesign of the Bracklesham Suite at St Richard’s was completed last year, with an additional £686,000 spent on new medical equipment. New works have begun in the East Wing at Worthing to facilitate the replacement of interventional radiology (IR) equipment within the Radiology Suite, which is expanding into the Main Entrance. The existing IR fluoroscopy machine is over 18 years old and well beyond its expected lifespan. The ultrasound in the IR room is over 10 years old and also out of warranty and the Contrast Pressure Injector is past its usable date. New equipment is being procured, but this is too large to fit in the current IR Room, so construction works are underway in order to modernise. Chichester Emergency Floor (EF) The Acute Medical Unit (AMU) at St Richard’s has re-opened as a new 55-bedded unit, and is now named as the Chichester Emergency Floor. A recent refurbishment has combined the AMU with what has, until now, been Graffham ward. The new Emergency Floor will be split into three zones, EF1, EF2 and EF3 – which means that Graffham will no longer be a ward area.

of 5

The EF at Chichester will be a single point of access for all emergency and urgent medical and surgical admissions, whether referred by A&E or GPs, and will provide standardised acute care in a modern environment supported by highly skilled staff. We have increased the numbers of nurses on the new unit, as well as appointing five new acute care doctors. Training has been provided so that the clinical teams working on the floor have the range of skills required to ensure that our emergency admissions receive the best care as quickly as possible and, when necessary, are swiftly transferred to the most appropriate specialty ward. It builds on the significant benefits for patients already demonstrated at Worthing where, for example, the average length of stay of stay for surgical patients has reduced by 22% since the opening of the Emergency Floor last year. Increasing the number of beds from 43 to 55, 12 beds will be designated for the triage, assessment and immediate management of acute surgical patients. It means that surgical referrals from primary care will no longer rely on A&E to be the point of initial assessment and as a result, the current A&E Ward at St Richard’s will now become and be renamed the Chichester A&E Department ‘Clinical Decision Unit’.

2. Nursing recruitment and staff retention Open and Selection Days are continuing for Band 5 Qualified Nurses and the forthcoming dates are:

CMEC, St Richard’s, Monday 7th December 2015

Homefield, Worthing, Wednesday 13th January 2016

Homefield, Worthing, Tuesday 2nd February 2016

CMEC, St Richard’s, Wednesday 24th February 2016

CMEC, St Richard’s, Friday 11th March 2016

Homefield, Worthing, Wednesday 6th April 2016

We would like to hear from local people who may have spare rooms available for our new nurses who join us from December onwards. More than 100 nurses will be arriving from abroad in the coming months and will benefit from temporary accommodation for a period while they look for more permanent arrangements. An average rent is around £400 per month, including bills. I would ask anyone who is able to help to call Sue Villis, Accommodation Manager, on 01903 285115. Staff retention is a key improvement related to our ‘Delivery and Sustainability’ strategic theme and the Trust is committed to keeping skilled and motivated staff. Losing knowledgeable and trained colleagues is incredibly costly, both in terms of the intellectual property they take with them, as well the cost of re-hiring and the impact on productivity because of low morale. To reduce staff turnover it is important to learn what employees like and don’t like about their job and to highlight any potential triggers that may cause an individual to consider leaving the organisation; it for these reasons that ‘stay interviews’ are being launched for all staff working for the Trust. Stay interviews are an informal discussion between an individual and their line manager to establish many of the things an exit questionnaire would determine, but with retention in mind and will commence throughout the Trust with immediate effect.

of 5

3. Care Quality Commission (CQC) standard inspection 8 to 11 December 2015 It is now only a few weeks until we welcome the Care Quality Commission (CQC) to our Trust. While we want the CQC inspectors to see us on our best day, we have been reminding staff that that we are a high performing trust that provides excellent care every day. Our Friends and Family test results tell us that patients are happy with their care and would happily recommend us to their loved ones. We welcome the CQC inspection as an opportunity to show the world what we do well. Our mock inspections found great care and a real desire from staff to provide patients with the best possible experience. We know there are areas where we need to improve and we have plans in place to address these, like our plans to create a centre of excellence for eye care at Southlands and the changes we are making to our outpatients services and its booking systems, all aimed at improving care and patient experience. I believe our team has every right to be very proud of the wonderful work they do. It is that pride in what we do that we should all be looking to convey to the CQC inspectors next month.

I would like to thank members who have completed the Trust’s online survey about the care they have received and encourage recent patients and relatives to submit their feedback as there is still time. The survey is on our website http://www.westernsussexhospitals.nhs.uk/your-trust/members/getting-involved/cqc-survey/ The CQC is holding two public listening events where local people can meet the inspectors and share their experiences of our services and care provided in the last year.

Tuesday 1st December 2015 Time: 3pm – 6:30pm University of Chichester, College Lane, Chichester, P019 6PE

Wednesday 2nd December 2015 Time: 6pm – 7:30pm Chatsworth Hotel, Steyne, Worthing, BN11 3DU

Experiences can be shared anonymously at any time via www.cqc.org.uk/sye - [email protected] or 03000 616161

4. Welcome to new colleagues

Peter Basford – Consultant in Gastroenterology (Chichester) – start date to be confirmed, probably February 2015 Vinod Audimoolam – Consultant in Gastroenterology (Worthing) – start date 30th November 2015

5. Request to take part in local health survey Our main commissioner, NHS Coastal West Sussex Clinical Commissioning Group (CCG) - the organisation responsible for planning and purchasing health care services in our local area - has launched a brand new survey about the health services everyone uses, and people’s priorities for how they could be improved. The survey focuses on priorities for the services provided at GP practices and the care people receive when they need NHS help and support urgently. Anyone living locally is encouraged to take part in the survey which will be continuing through November. The feedback will be shared widely. The CCG wants this to be a real opportunity to hear views from across our area, and so we hope many people will take part. A link to the survey is available CCG’s website - www.coastalwestsussexccg.nhs.uk

http://www.westernsussexhospitals.nhs.uk/your-trust/members/getting-involved/cqc-survey/

http://www.westernsussexhospitals.nhs.uk/your-trust/members/getting-involved/cqc-survey/

mailto:[email protected]

http://www.coastalwestsussexccg.nhs.uk/

of 5

6. Events

Western Sussex Eye Care | Southlands We held two public events where more than 100 people took the opportunity to discuss our new

£7.5M eye care centre at Southlands with our eye care specialists. The new centre will be known as Western Sussex Eye Care | Southlands. Attendees could also question the Trust’s

project team, and discuss important issues such as parking provision and transport links. All the information from the public events is now available via the trust’s website – www.westernsussexhospitals.nhs.uk/EYECARE - and in the trust’s newsletter Eye Care Update, available from reception at Southlands Hospital and in the Ophthalmology Departments at Worthing and St Richard’s hospitals. Staff Conference This month we will be re-running our Staff Conference to enable even more staff to attend. In September we held the first event and more than 250 colleagues from across the Trust attended this year’s Where Better Never Stops staff conference at Fontwell Park Racecourse. I was delighted to open the event in September which gave me an opportunity to thank colleagues’ for their hard work over the past year. I also highlighted many of our achievements during this period – the fact that we are one of only 20 acute trusts to meet the A&E 4-hour target in 2014/15, that our mortality rate being the lowest it has ever been (Dr Foster HSMR), and the Trust Board won Governing Body of the Year 2014/15 (KSS NHS Leadership Awards). This month I will also have the opportunity to describe the benefits of our Patient First Programme which is helping us to refine the way we work in order to allow us more time for direct patient care, supporting that care and each other. The next phase of Patient First, the Patient First Improvement Programme, was also launched at the September event. The Programme will see staff given the skills to analyse what they do, identify opportunities for positive change and then make it happen. It has a strong focus on Lean management, which is widely employed in industry to eliminate waste and improve value for customers. Recognising long service This month we were delighted to host two every special events to recognise long service within the NHS. We have 13 staff within the Trust who achieved this milestone and we enjoyed sharing their career histories and chatting over afternoon tea. We are very grateful to Love Your Hospital charity who funded the celebratory gifts. Every year we enjoy listening to the career summaries and hearing ward names and places which hold so many memories. What always shines through is the dedication to patient care and support and commitment given to colleagues which makes this event so special and a pleasure to host. One member of staff this year had an extra surprise on the morning of the event. Angela Bridger, a nurse in A&E has worked her entire career at St Richard’s. Her team invited Fred Dineage from ITV Meridian to visit and present her award which he kindly did. Angela and the team were thrilled and I would like to offer my heartfelt thanks to Fred and the team at ITV for making her day extra special.

of 5

National Casting Day celebrated Orthopaedic practitioners and technicians at Worthing celebrated National Casting Day for the first time this year with a host of activities, including demonstrations of plaster application, brace application, and other appliances, as well as opportunities for staff and visitors to remove plaster using the plaster saw. On the day people were invited to find out more about the team and some of the equipment they use, such as the specialist plaster saw that does not rotate but cuts by oscillating so it will not cut skin which is free to vibrate with it.

Crohn’s and Ulcerative Colitis Carla Hookway, our Inflammatory Bowel Disease Specialist Nurse, hosted a patient support evening on the topic of Crohn’s and Ulcerative Colitis at St Richard’s. The event was well received by patients and I thank Carla for organising this useful session. Medicine for Members We held two Medicine for Members events on the topic of Sepsis at Worthing and St Richard’s. Sepsis arises when the body’s response to an infection damages its own tissues and organs and can lead to shock, multiple organ failure and death. Thank you to Simon Higgs and Zoe Blair who explained what steps are being taken to raise the awareness of Sepsis within the Trust which enables faster diagnosis and treatment. This was an excellent session which raised the profile of this least recognised disease and offered much reassurance on its treatment within the Trust. Chapel services Saturday 5 December, 2:30pm, St Pancras Church, Chichester, Children and Baby Remembrance Service Thursday 17 December, 3:00pm, Worthing Chapel, Carol Service Friday 18 December, 5pm, St Richard’s Hospital, Carol Singing around the wards Monday 21 December, 11:00am, Southlands Hospital, Carol Singing Monday 21 December, 3pm, Worthing Hospital, Carol Singing around wards and departments Tuesday 22 December, 6pm Worthing Hospital, Carol Singing around the wards Thursday 24 December, 2:30pm, Worthing Chapel Crib Service Friday 25th December, 8:30am, Worthing Chapel, Christmas Day Holy Communion

I will report back on the November Stakeholder Forum which is taking place on Tuesday 24 November, 12.30 to 2.30pm.

Title

Quality Report – Month 7

Responsible Executive Director

Dr George Findlay, Medical Director

Amanda Parker, Director of Nursing and Patient Safety

Prepared by

Jamie Cochrane, Planning and Performance Manager

Status

Disclosable

Summary of Proposal

N/A

Implications for Quality of Care

Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality.

Link to Strategic Objectives/Board Assurance Framework

This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the board and (if necessary) highlighting issues.

Financial Implications

Describes KPIs that have potential financial impact (e.g. CQUIN).

Human Resource Implications

Describes KPIs linked to workforce.

Recommendation

The Board is asked to NOTE the report.

Communication and Consultation

N/A

Appendices

Appendix I: Quality Scorecard

Appendix II: Ward Staffing Scorecard

Appendix III: Review of Health Services for Children Looked After and Safeguarding in West Sussex

To: Trust Board

Date of Meeting: 25 November 2015

Agenda Item: 6

2 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

1 INTRODUCTION

1.1 This report brings together key national, regional and local quality indicators relating to quality and

safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within

Western Sussex Hospitals Foundation Trust (WSHFT).

1.2 The paper describes performance on an exceptional basis determined by RAG (red/amber/green)

ratings based on national, regional or local targets. Further quality items are shown as dashboards in the

appendices.

2 2015/16 REFRESH

2.1 As part of the refresh of the Quality Strategy outlining key quality objectives for the next three years, this

report will be refreshed and redesigned. The Trust Quality Board has reviewed and approved a new

format with a view to making a recommendation to the Trust Board. A discussion took place at the last

Trust Board and this will be progressed in line with development of the Trust’s quality improvement

agenda.

2.2 As described in April, to provide assurance in the interim period, the format and metrics used for

2014/15 have been used. Targets for this interim period have been applied according to the following

hierarchy: 1. Where national targets are available these are applied; 2. Where specific local targets or

thresholds have been previously agreed these have been applied; 3. Where the 2014/15 targets were

based on 2013/14 levels, these have been refreshed to use the 2014/15 levels as a benchmark. (Any

exceptions to this are noted below).


3 KEY QUALITY OBJECTIVES

3.1 Dashboard Definitions

3.1.1 The full Clinical Quality Dashboard is presented as Appendix I. Figures are in-month figures (e.g. the

number of falls reported in October) unless otherwise stated. The dashboard shows 13 months to allow

trends to be identified, although some data items are reported retrospectively. Year to date

actuals/targets are based on financial years unless otherwise stated (e.g. standardised mortality ratios

are recorded as 12 month positions). A subset of the key measures from the report is presented at 3.3.

3.1.2 Exception reports are included under the relevant section of this report (i.e. under the broad headings

Effectiveness, Safety and Experience).

3.1.3 Only the current financial year and year to date values are RAG rated, with the exception of those

metrics reported in arrears with no data in the current financial year where the most recent data-point of

last year is RAG rated.

3.2 Domain scores

3.2.1 The domain score is an overall indication of the performance in relation to each of the three areas. The

score is calculated as follows: Each RAG rated indicator for a month is scored as follows: reds score 1,

ambers score 2, greens score 3. These scores are then totalled and divided by the total number of

indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score

can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red

score for the domain as a whole. For example if a domain had two greens and a red the calculation

would be as follows:

3 (green) + 3 (green) + 1 (red) = 7

7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.

3.2.2 Year to date domain scores are calculated based on the year to date RAG ratings for each metric.

Previous months are retrospectively updated to take account of any measures reported in arrears.

3.2.3 As with any aggregate indicator, it remains essential that the board retains sight of the individual

elements as well as the domain score as a whole.


3.3 Overview of Key Quality Objectives

3.3.1 The following table shows performance against key, top level quality objectives.

Indicator Aug

2015

Sep 2015

Oct 2015

2015/16

to date

2015/16

Target /

limit

Effectiveness Domain Score 2.57 2.57 2.73 2.48 2.5

Safety Domain Score 2.33 2.28 2.33 2.17 2.5

Experience Domain Score 2.13 2.13 2.23 2.27 2.5

E01 Trust crude mortality rate (non-elective) 3.15% 2.70% 2.97% 2.93% 3.27%

E02 Hospital Standardised Mortality Ratio for top

56 diagnoses (Dr Foster, based on rolling 12

months)

93.5

(12m to

Jul)

93.5

(12m to

Jul)

<92

S05 Number of Serious Incidents Requiring

Investigation (number reported in month)

12 5 5 45 60

S14 Numbers of hospital attributable MRSA 0 0 0 0 0

S28 Numbers of hospital C. diff where a lapse in

the quality of care was noted

0 3 4 11 18 (national

target = 39)

X01 The Friends and Family Test: Percentage

Recommending Inpatients

94.6% 94.0% 95.4% 94.8%

X02 The Friends and Family Test: Percentage

Recommending A&E

90.6% 90.6% 90.2% 91.3%

X15 Mixed Sex Accommodation breaches

(number of breaches)

0 1 0 1 0

X20 Number of complaints 56 44 72 365 570


4 EFFECTIVENESS

4.1 Crude Trust Mortality

4.1.1 Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to

non-elective activity. The Trust uses the previous year as a benchmark.

4.1.2 Crude non-elective mortality rose from 2.70% in September to 2.97% in October, higher than the

equivalent month in 2014 (October 2014 = 2.83%). The year to date level remains lower than the same

months in 2014. The 12 month mortality also rose slightly to 3.23%.

4.1.3 The 2.97% mortality in October related to 166 deaths for 5581 non-elective admissions.

4.2 Hospital Standardised Mortality Ratio (HSMR)

4.2.1 There is a delay in data being available in Dr Foster tools to allow for coding and processing by the

Health and Social Care Information Centre and Dr Foster. Due to the timing of data releases from Dr

Foster and WSHFT Board Meetings there has been no new data released since the previous board

report and the most recent data available is July 2015.

4.2.2 The Trust’s HSMR for the twelve months to July 2015 is 93.5 (where 100 is the level predicted by the Dr

Foster model using the April 2015 benchmark).


4.2.3 The twelve month HSMR to July 2015 split by site is lower for St Richards (90.5) than for Worthing

(95.8), however both are lower than 100.

4.2.4 This data is now rebased using the latest available benchmark (April 2015), this accounts for the

observable increase at April 2015.

4.2.5 A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high

actual versus expected mortality and any mortality CuSum alerts.

4.3 Summary Hospital-Level Mortality Indicator (SHMI)

4.3.1 The latest data made available by the Health and Social Care Information Centre is for the period April

2014 to March 2015. The Trust value is 1.03 (where 1.00 is the national average), with the Trust banded

as ‘as expected’.

4.4 Exception Reports Relating to Effectiveness

4.4.1 None to report


5 SAFETY

5.1 Central Alert System (CAS) Safety Alerts

5.1.1 There are no outstanding alerts for the Trust relating to October 2015 or earlier.

5.2 Serious Incidents Requiring Investigation (SIRIs)

There were 5 incidents which occurred in October that have initially been graded as serious incidents

requiring investigation. A detailed SIRI report is provided to the Committee section of the Trust Board.

The Board should note there is a slight variation in the month by month numbers between the SIRI

report and the scorecard as the scorecard assigns incidents to the month in which they occur whereas

the latter assigns them to the month in which the SIRI was raised. (The SIRI report records 50 SIRIs

reported in April to October, compared to 45 occurring in these months).

Recent actions undertaken/planned following SIRIs include the use of anti-embolism stockings with grips

and slipper socks to reduce likelihood of falling, undertaking a review of the pathway for patients wearing

a collar (in relation to pressure damage) and development and implementation of the Procedural Safety

Checklist for Gynaecology Outpatient Procedures adapted from the WHO checklist for use in

Colposcopy, Hysteroscopy and all minor procedure clinics.

5.3 Infection control

5.3.1 There were zero cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia during

October.

5.3.2 There were 7 cases of hospital attributable Clostridium difficile during October; 5 at the Worthing site

and 2 at St Richards.

5.3.3 The 7 cases in October equate to a rate of 24.97 cases of C diff per 100,000 bed days compared the

national average for 2014/15 of 15.1 cases per 100,000 bed days (interquartile range 10.3 to 17.6)

(source: https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data).

5.3.4 Of the 7 cases in October, root cause analysis identified four cases related to lapses in care, relating to

environmental issues and issues relating to commodes and prompt isolation.

5.3.5 The year to date figures for both the overall hospital attributable C diff and C diff relating to lapses in

care are now marginally above trajectory.

https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data


5.4 Falls

5.4.1 In October there were 42 falls resulting in harm against a benchmark of 43.

5.4.2 There were no falls resulting in severe harm or death in October.

5.4.3 Of the 42 falls in October, in 14 instances the patient had previously fallen during the inpatient stay.

5.4.4 The trust continues to review whether falls identified as part of the safety thermometer audit were

avoidable (see indicator S24). The consistent themes identified in these cases were the level of staffing

and the lack of consistent intentional rounding.

5.5 Tissue Viability

5.5.1 As described previously, changes in the way the Trust reports pressure ulcers means that more grade 2

and grade 3 ulcers will be reported in 2015/16 than previous years.

5.5.2 Based upon the new reporting arrangements, during October the Trust reported 19 cases of grade 2

hospital acquired pressure ulcers.

5.5.3 In addition to this there were 3 hospital acquired grade 3 pressure ulcers. These related to deterioration

of existing skin damage. There were no grade 4 pressure ulcers.

5.5.4 The incidence of pressure ulcers (including those developing within 72 hours after admission) per 1000

bed days in October was 0.78.

5.5.5 Root cause analysis (RCA) of all of these cases identified in ten instances the harm was deemed

avoidable due to omissions in documentation of skin assessments and the frequency of repositioning.

The following actions are being undertaken as a result of this:

All wards are undertaking monthly SSKIN bundle audits.

Emergency Floor Worthing has planned a number of pop up sessions with Tissue Viability Nurse

to reinforce the importance of Skin assessment and the correct use of the intentional rounding form and

the new emergency floor at SRH included pressure ulcers as part of it preparatory team days.


Photography guidelines and cameras now in place, with teaching sessions planned for key staff

groups.

Purpose T pilot is extending to include a further ward.

5.5.6 All grade 3 pressure ulcers have a root cause analysis investigation and are subject to an executive

review.

5.5.7 There were 65 patients admitted to the Trust from the Community with pressure damage.

5.6 NHS Patient Safety Thermometer

5.6.1 The NHS Patient Safety Thermometer is used across all relevant acute wards. This tool looks at point

prevalence of four key harms (falls, pressure ulcers, urinary tract infections and deep vein thrombosis

(DVT) and pulmonary embolism (PE)) in all patients on a specific day in the month. A dashboard is

available to each ward showing Trust-wide and ward-level data for each individual harm as well as the

harm-free care score. These numbers are also shared via the new ward screens.

5.6.2 The harm-free care score for the Trust in October was 95.8% (indicator S02), better than the target of

93.8% (target based on national average for 2014/15).

5.6.3 The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to

admission. The actual number of patients with no new harms during their inpatient stay at WSHFT

(indicator S03) was 98.5%. A new target of 99% of patients suffering no new harms following admission

for 2015/16 has been set within the Trust Quality Account. This will prove a stretching target as it is

considerably higher than the national average of 97.7%.

5.6.4 National data relating to the NHS safety thermometer is available here:

http://www.safetythermometer.nhs.uk/

5.6.5 As part of the Trust’s 2015/16 CQUIN programme, WSHFT are rolling out the use of the Medication

Safety Thermometer – a separate, but complementary data collection focused on appropriate

prescription and administration of medicines – across all key wards during 2015/16. At the time of writing

the Medical Safety Thermometer is used on 21 wards across the Trust with additional ones added each

month.

http://www.safetythermometer.nhs.uk/


5.7 Exception Reports Relating to Safety:

5.7.1 Exception Report: Indicator S09 – Moderate and severe prescribing incidents: There was one moderate

incident relating to medication or prescribing in October. At the time of writing this incident is still under

review.

5.7.2 Exception Report Indicator S18: Full Compliance with WHO Checklist: Last month the scorecard showed

performance for this indicator as 97%. Detailed review of the elements of the checklist that were

supposedly ‘missed’ revealed these were not applicable for the procedure being undertaken. Teams

have been reminded of the importance of stating ‘Not applicable’ on the forms in such cases to ensure

easy audit. Taking this into account, performance for this indicator has not dipped below 100% during

the last 12 months. In addition the Director of Nursing undertook a review of practice within SRH

theatres and observed that the WHO was clearly an embed practice within the team observed.

5.7.3 Exception Report: Indicator S19 – Never events: Unfortunately the Trust reported a never event in

October in relation to a knee replacement. When a routine post-operative check x-ray was undertaken a

screw pin head was noted which subsequently required the patient to return to theatre for it to be

removed. A more detailed report will be made to the committee section of the board as part of the SIRI

report, however lessons learned include:

1. In the case of surgical instruments breaking, ensuring all broken parts must be visualised by

two people in order to account for them accurately.

2. In the event that it is not possible to retrieve and visualise the broken parts of an instrument

no assumptions as to the whereabouts of the pieces should be made and an intraoperative

x-ray should be undertaken to establish that the broken instrument parts have not been

retained within the patient

3. That the screw pins contained on the Nex Gen total knee replacement set are single use

only.

5.7.4 Exception Report: Indicator S29 – Percentage of patients with catheters and UTIs where best practice

protocol was not followed: This data is collected as part of the monthly safety thermometer audits and is

based on relatively small numbers. Performance in October related to two patients. In both cases the

catheter was felt to be justified, but there were lapses in the use of the care plan. This information has

been fed back to the wards to ensure learning. The Trust remains on trajectory for the year to date

performance for this measure.


6 PATIENT EXPERIENCE

6.1 PALS and Complaints

6.1.1 All complaints are responded to by the Trust Office. The process is administered by the Customer

Relations Team. The Quarterly Complaints Report provides an in-depth analysis of trends and lessons

learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the

Trust Board.

6.1.2 During October 2015 the Trust received 72 complaints. This is a significant increase against previous

months and the most received in any one month since 2011. The increase has been observable across

both main Trust sites.

6.1.3 The most significant theme noted is oral communication relating to Ophthalmology appointments (this

also accounts to the increase in indicator X20). Following a meeting between the Customer Relation

Team and the Care Group Manager and Divisional Director of Operations for the service, an

Ophthalmology Call Centre has been set up to provide a streamlined central service for appointment

queries. The contact numbers for the Call Centre have now been given to the PALS team and will be

advertised on the trust website and given out to patients in the outpatient clinic to improve

communication for patients requiring follow-up appointments or who have queries regarding follow-up.

6.2 Friends and Family Test (FFT)

6.2.1 Patients who access hospital services are asked whether they would recommend WSHFT to their

friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case,

A&E and maternity are all offered the opportunity to respond to the question (plus a number of other

areas outside the scope of the official friends and family data collection).

6.2.2 Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can

address problems or get positive feedback as quickly as possible. In addition to this a dashboard is

available giving wards access to their individual scores and a poster printed with ward performance to

display to the public. Ward recommend rates are also shown on the new screens installed on wards.

6.2.3 Friends and Family Test Response Rates: As described previously the criteria for inclusion in Friends

and Family changed significantly for 2015/16 to include paediatric patients, day-cases and short-stay

non-electives. As such the response rate fell considerably at the beginning of the year. Work is

underway in the new areas to increase the response rates.


6.2.4 Friends and Family Test Recommend Rates: In line with national guidance the Friend and Family test is

now reported as a ‘percentage recommending’ score (calculated as the percentage of respondents

indicating they were either ‘highly likely’ or ‘likely’ to recommend the service divided by the total

respondents including ‘don’t knows’). National performance is published on the NHS England website:

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

6.2.5 The table below shows the latest local scores against national benchmarks:

Percentage recommending

WSHFT in Oct (year to date in

brackets)

National median (April 2014 to

March 2015)*

Inpatient care 95.4% (94.8%) 94.1%

A&E 90.2% (91.2%) 86.8%

Maternity: Delivery care 96.4% (95.4%) 95.4%

Outpatient care 90.0% (89.2%) No benchmark

Maternity: Antenatal care 100% (95.8%) 94.6%

Maternity: Postnatal ward 96.4% (95.2%) 92.2%

Maternity: Postnatal community

care

100% (97.6%) 96.6%

* Some caution should be undertaken using this benchmark due to the changes to the eligible patients noted

above.

6.3 Feedback from Hospital Experience Questionnaires

6.3.1 Detailed results from the Real-Time Patient Experience (RTPE) project are routinely fed back to

divisions and wards. Information, including satisfaction levels for patient admitted both in and out of

hours, is also shown on the new ward information system. 332 inpatients gave their views on the Trust

using the RTPE system in October.

6.4 Exception Reports Relating to Experience

6.4.1 Exception Report: Indicator X12 – Patients cancelled on the day of surgery for non-clinical reasons:

There were 45 patients cancelled on the day of surgery during October. This was a direct result of

pressure on availability of beds. The year to date performance remains on target.

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/


6.4.2 Exception Report: Indicator X14 and X15 – MUST Assessment in 24 hours and 7 days: As reported

previously, the Trust has implemented this assessment on the electronic Patientrack system. This gives

a more robust and stringent monitoring system, capturing data continuously on all appropriate patients

rather than relying on once a month audit. Initial data from Patientrack shows reduced compliance for

October, particularly for the 24 hour measure. In some cases this will be the result of MUST scores

being recorded on paper first and then transferred to Patientrack subsequently. Work is underway with

ward in ensuring both the accurate capture of this data and compliance with this key patient safety and

experience indicator.

6.4.3 Exception Report: Indicator X13 – Breaches of mixed sex accommodation arrangements: Within last

month’s board report one mixed sex breach was reported following investigation this was due to the

unavailability of a ward bed for 16 hours and as a result 6 patients in total were affected. New processes

are being trialled that look to ensure that once patient is fit to go to a ward they are prioritised.

7 CARE QUALITY COMMISSION (CQC)

7.1 CQC Compliance

7.1.1 The CQC have informed the Trust that the Trust will be inspected on 8th to 11

th December. Preparations

for this are underway.

7.2 CQC Intelligent Monitoring Reports

7.2.1 The CQC have announced that they will not be producing any further Intelligent Monitoring Reports and

will rely on trust inspections.

7.3 CQC Reports

7.3.1 The CQC have announced that they will not be producing any further Intelligent Monitoring Reports and

will rely on trust inspections. On November 13th, the CQC published their Review of Health Services for

Children Looked After and Safeguarding in West Sussex. As a part of this WSHFT were inspected in

February 2015 by the CQC to ensure we were working in accordance with our responsibilities under

Section 11 of the Children Act 2004 and included the statutory guidance, Working Together to

Safeguard Children 2015. WSHFT have already been working on actions to address areas of weakness

identified and these are monitored through the children’s safeguarding operational group and assurance

sought by the safeguarding strategy group. The final report is attached as Appendix III.


8 NATIONAL AND LOCAL REPORTS

8.1.1 None to report

9 COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)

9.1 Since 2009/10 a proportion of the money the Trust receives has been payable on achievement of

agreed quality metrics.

9.2 Agreement has been reached in relation to 2015/16 CQUIN measures. National measures include care

for patients suffering acute kidney injury and sepsis, reducing urgent care admissions and continuation

of the national dementia screening measures. The local CQUIN programme for 2015/16 relates to seven

day services, care for patients with diagnosed dementia (in addition to the national screening project),

supporting patients during end of life care, increasing training in mental capacity assessment, and roll

out of the medication safety thermometer and ward accreditation. The Trust has provided information to

commissioners to demonstrate performance against these goals for quarter 2.

10 RECOMMENDATION

10.1 The Board is asked to note the contents of this report.

Operational Planning and Performance: Quality

OCTOBER 2015

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

Actual

YTD

TargetTarget Trend

EFFECTIVENESS

Effectiveness domain score 2.44 2.56 2.52 2.64 2.57 2.57 2.73 2.48

Trust-wide mortality

E01 Trust crude mortality rate (non-elective) 2.83% 2.74% 3.64% 4.24% 4.22% 3.44% 3.23% 2.82% 2.99% 2.66% 3.15% 2.70% 2.97% 2.93% 2.99% 3.27%

E02 Crude mortality rate (non-elective): 12 month rolling 3.16% 3.15% 3.17% 3.21% 3.25% 3.27% 3.30% 3.28% 3.28% 3.26% 3.23% 3.22% 3.23% 3.23% 3.27% 3.27%

E03 Trust Hospital Standardised Mortality Ratio (HSMR) 94.1 93.3 92.6 92.3 92.1 91.2 95.3 93.9 93.8 93.5 93.5 92 92

E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) 1 1

Improve mortality in specific conditions

E07 Crude non-elective mortality for Renal failure 23.8% 30.8% 23.8% 17.4% 19.4% 34.8% 13.8% 13.3% 30.0% 21.4% 14.8% 13.8% 9.8% 15.8% 19.9% 19.9%

Reduce mortality following hip fracture

E09 SMR for hip fracture (all diagnoses/procedures) 99.2 93.4 90.0 96.7 89.5 75.8 76.5 83.3 85.8 84.2 84.2 100 100

E09a Worthing SMR for hip fracture (all diagnoses/procedures) 125.9 121.8 118.9 122.5 115.6 105.7 109.0 115.7 116.4 109.6 109.6 100 100

E09b St Richard's SMR for hip fracture (all diagnoses/procedures) 64.6 59.0 53.4 64.7 58.8 40.1 38.8 43.8 46.9 51.0 51.0 100 100

E10 30 day mortaliy rate following hip fracture 6.2% 7.5% 11.1% 10.8% 8.0% 2.9% 2.5% 6.1% 8.3% 7.5% 5.8% 6.0% 8.2% 8.2%

Reduce the rate of readmission following discharge from the Trust

E11 Emergency readmissions within 30 days % 13.6% 12.9% 12.3% 12.9% 13.3% 12.3% 12.7% 13.7% 13.7% 13.1% 12.6% 12.7% 13.5% 13.4% 13% 13%

To improve maternity care by encouraging natural chilbirth

E13 C-Section Rate 28.7% 24.1% 29.9% 30.1% 26.3% 24.1% 29.4% 24.2% 27.6% 26.0% 24.9% 30.3% 27.8% 27.2% 26% 26%

E14 % Mothers requiring forceps for delivery 12.5% 12.6% 10.6% 10.4% 14.2% 13.4% 10.5% 11.1% 10.8% 11.3% 15.7% 10.2% 12.0% 11.7% <15% <15%

E15 % Deliveries complicated by post-partum haemorrhage 0.2% 0.5% 0.2% 0.5% 1.0% 0.9% 0.4% 0.2% 0.4% 0.0% 0.2% 1.1% 0.0% 0.3% 1% 1%

E16 Maternal deaths 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0

E17 Admission of term babies to neonatal care 2.9% 1.8% 2.0% 3.3% 2.4% 2.7% 1.8% 2.5% 3.1% 2.3% 1.0% 2.6% 3.6% 2.4% <10% <10%

Caring for the elderly patient

E18 % Emergency admissions staying over 72h screened for dementia 92.6% 90.8% 89.6% 96.0% 90.3% 93.4% 93.4% 94.9% 97.6% 92.1% 91.3% 92.4% 93.0% 93.5% 90% 90%

E19% Patients identified as at risk of dementia for whom further

investigations are carried out91.3% 91.3% 90.8% 94.2% 90.9% 87.1% 85.7% 96.5% 95.3% 91.7% 93.1% 91.2% 86.3% 91.4% 90% 90%

E20 % Patients with identified dementia referred to specialist services 100.0% 100.0% 96.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.3% 99.5% 90% 90%

E25 Number of admissions for patients with dementia flag 144 130 208 233 181 185 222 186 186 212 205 174 168 1353 tbc tbc

E39 Ward moves for patients flagged with dementia 59 71 130 190 124 105 132 107 118 137 107 119 127 847 tbc tbc

E42 Night-time ward moves for patients flagged with dementia 32 38 61 75 35 44 37 42 39 34 39 35 30 256 tbc tbc

E43Documentation Audit: % patients with dementia with Knowing Me

document75.4% 76.2% 72.8% 67.5% 74.8% 97.8% 95.4% 97.8% 99.4% 97.4% 99.7% 98.6% 98.2% 98.2% 75% 75%

QUALITY SCORECARD

1.03 1.03

6a. Quality Scorecard - M7.Quality Scorecard Page 1 of 6 Printed 20/11/2015 10:50


OCTOBER 2015


Actual

YTD

TargetTarget Trend

QUALITY SCORECARD

Stroke care

E26 % CT scans undertaken within 12 hours 80.6% 80.3% 89.2% 91.1% 97.4% 93.3% 89.3% 92.5% 91.8% 94.0% 89.1% 91.2% 95% 95%

E27 % Stroke thrombolysis within 60 minutes of hospital arrival 42.9% 83.3% 57.1% 77.8% 58.3% 77.8% 54.5% 83.3% 100.0% 85.7% 75.0% 76.2% 95% 95%

E28 % Swallow screen for stroke patients within 4 hours of admission 72.1% 80.4% 79.7% 73.8% 81.3% 82.4% 78.4% 75.5% 86.2% 85.0% 78.8% 80.7% 95% 95%

E29 % of stroke patients admitted to stroke unit within 4 hours of admission 72.6% 64.4% 63.4% 68.4% 76.3% 80.7% 84.7% 80.0% 74.3% 83.0% 71.4% 78.5% 90% 90%

E30 % high risk TIA patients seen within 24 hours 84.0% 69.2% 87.5% 60.0% 81.3% 80.0% 71.4% 61.1% 76.5% 62.5% 77.8% 52.2% 60% 60%

Ensure active engagement with research

E21 Patients recruited to interventional studies within CRN portfolio 8 6 12 24 15 9 15 7 17 14 14 15 25 107 n/a n/a

E22 Patients recruited to observational studies within CRN portfolio 103 269 60 65 115 100 44 39 31 38 27 26 55 260 n/a n/a

E23 Local Clinical Research Network (LCRN) Score 143 299 120 185 190 145 119 74 116 108 97 101 180 795 761 1305

Data Quality

E24 NHS IC Data validity summary (YTD) 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 96.1 96.1

E37 % inpatients with electronic discharge summaries produced 85.0% 83.0% 83.0% 84.0% 85.0% 84.0% 85.1% 83.0% 85.0% 84.0% 85.5% 84.3% 85.0% 86.0% tbc tbc



OCTOBER 2015


Actual

YTD

TargetTarget Trend

QUALITY SCORECARD

SAFETY

Safety domain score (Patient Aggregate Safety Score - PASS) 2.33 2.50 2.89 2.44 2.33 2.28 2.39 2.22

Safer staffing

S36 Safer Staffing: Average fill rate - registered nurses/ midwives (day shifts) 96.7% 97.1% 95.4% 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.3% tbc tbc

S37Safer Staffing: Average fill rate - registered nurses/ midwives (night

shifts)97.5% 98.0% 95.8% 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.6% tbc tbc

S38 Safer Staffing: Average fill rate - care staff (day shifts) 94.4% 93.3% 91.3% 90.5% 89.5% 91.7% 93.8% 93.0% 93.9% 91.0% 91.5% 88.9% 90.1% 91.7% tbc tbc

S39 Safer Staffing: Average fill rate - care staff (night shifts) 97.2% 95.3% 91.1% 93.3% 92.0% 92.9% 94.7% 93.3% 95.0% 93.3% 93.6% 90.1% 93.0% 93.3% tbc tbc

NHS safety thermometer

S02 Safety Thermometer: % of patients harm-free 94.4% 94.1% 95.5% 93.8% 94.5% 96.6% 96.3% 95.3% 97.3% 96.3% 95.6% 94.9% 95.8% 95.9% 93.82% 93.82%

S03 Safety Thermometer: % of patients with no new harms 97.6% 97.6% 98.6% 98.1% 98.5% 99.0% 98.6% 98.0% 99.0% 98.2% 97.6% 98.4% 98.5% 98.3% 99% 99%

S29% of patients with catheters and UTIs where best practice protocol was

not followed.0.23% 0.26% 0.21% 0.23% 0.11% 0.22% 0.44% 0.11% 0.00% 0.00% 0.00% 0.00% 0.23% 0.10% 0.2% 0.2%

Monitoring of clinical incidents

S04 Total incidents 810 709 839 789 726 755 722 758 741 819 875 853 916 56844738-

6410

8122 -

10988

S05 Total moderate, severe or death incidents 16 8 15 11 16 8 13 12 5 22 19 9 14 94 89 153

S06 Total serious incidents (SIRIs) 4 2 9 6 7 2 7 7 2 7 12 5 5 45 35 60

S07 Number of outstanding CAS alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Improve safety of prescribing

S08 Total incidents involving drug/prescribing errors 115 107 112 98 67 103 74 85 94 107 106 86 94 646 616-8331056 -

1428

S09 Moderate/severe incidents involving drug/prescribing errors 0 0 0 0 0 2 1 0 0 1 0 2 1 5 3 5

Reduce incidence of healthcare acquired infections

S14 Number of hospital attributable MRSA cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

S15 Number of hospital C.diff cases 2 3 5 3 1 2 0 5 2 3 3 5 7 25 23 39

S28 Number of C. diff cases where a lapse in the quality of care was noted 0 2 3 3 0 1 0 2 1 1 0 3 4 11 11 18

S16 Number of reportable MSSA bacteraemia cases 6 8 9 8 6 6 4 6 8 6 5 10 6 45 n/a n/a

S17 Number of reportable E.coli cases 19 25 29 27 25 37 21 23 25 34 23 35 26 187 n/a n/a



OCTOBER 2015


Actual

YTD

TargetTarget Trend

QUALITY SCORECARD

Improve theatre safety for patients

S18 Full compliance with WHO Surgical Safety Checklist 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

S19 NEVER events 0 0 0 0 0 0 0 0 0 0 1 0 1 2 0 0

S30 SSIs: Total hip replacement (YTD is rolling 12 months) tbc tbc

S33 SSIs: Total knee replacement (YTD is rolling 12 months) tbc tbc

S34 SSIs: Large bowel surgery (YTD is rolling 12 months) tbc tbc

S35 SSIs: Breast surgery (YTD is rolling 12 months) tbc tbc

Reduce number of falls in hospital

S21 Falls resulting in harm 44 38 46 42 32 45 42 34 28 35 38 44 42 263 299 513

S22 Falls resulting in severe harm or death 0 0 0 0 0 0 0 0 0 1 1 0 0 2 1 1

S23 Falls assessment within 24hrs of admission 92.0% 87.5% 85.0% 92.5% 92.0% 90.5% 92.0% 96.5% 85.0% 91.8% 88.3% 95.5% 83.5% 90.4% 80% 80%

S24 Avoidable falls identified on the Safety Thermometer 0.91% 1.15% 0.53% 1.35% 1.16% 0.77% 1.09% 0.55% 0.57% 0.69% 0.97% 0.94% 0.69% 0.79% 0.76% 0.76%

Pressure ulcers

S25 Grade 2 pressure ulcers 9 7 8 7 8 9 12 10 10 13 15 15 19 94 tbc tbc

S26 Grade 3 & 4 pressure ulcers 1 0 1 2 0 0 0 0 1 1 5 2 3 12 tbc tbc

Other safety metrics

S11 VTE Assessment Compliance 95.6% 96.2% 95.0% 95.9% 96.0% 95.2% 94.6% 94.0% 94.4% 93.7% 94.1% 92.2% 93.9% 93.8% 95% 95%

1.1%

1.2%

15.6%

3.4% 3.4%

4.7%

4.0%

15.4%



OCTOBER 2015


Actual

YTD

TargetTarget Trend

QUALITY SCORECARD

EXPERIENCE

Experience domain score 2.67 2.60 2.60 2.00 2.13 2.13 2.23 2.27

Friends and Family Test

X38 Trust Friends and Family Recommend %: Inpatient 90.1% 95.0% 93.7% 94.3% 93.4% 94.6% 94.0% 94.4% 95.3% 95.5% 94.6% 94.0% 95.4% 94.8% tbc tbc

X39 Trust Friends and Family Recommend %: A&E 88.9% 91.1% 89.3% 93.0% 91.7% 93.3% 91.7% 91.1% 91.1% 92.5% 90.6% 90.6% 90.2% 91.2% tbc tbc

X40Maternity Friends and Family Recommend %: Antenatal care

(36 weeks)95.8% 100.0% 95.2% 95.3% 98.4% 96.6% 100.0% 94.1% 100.0% 100.0% 92.0% 88.9% 100.0% 95.8% tbc tbc

X41 Maternity Friends and Family Recommend %: Delivery care 96.5% 95.8% 94.6% 97.0% 97.3% 97.9% 98.2% 95.0% 96.5% 93.0% 91.4% 95.3% 96.4% 95.4% tbc tbc

X42 Maternity Friends and Family Recommend %: Postnatal ward 92.6% 95.7% 95.1% 92.7% 94.4% 95.4% 96.7% 95.0% 96.5% 93.0% 91.4% 95.3% 96.4% 95.2% tbc tbc

X43 Maternity Friends and Family Recommend %: Postnatal community care 75.9% 100.0% 100.0% 76.5% 98.1% 93.9% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 100.0% 97.6% tbc tbc

X44 Trust Friends and Family Recommend %: Outpatient 91.2% 88.7% 84.7% 87.9% 87.9% 91.6% 90.0% 89.2% tbc tbc

Friends and Family Test response rates

X24 Trust Friends and Family Response Rate: Inpatient 33.0% 34.6% 28.5% 42.8% 39.8% 56.7% 47.3% 20.8% 19.0% 28.9% 25.2% 24.0% 23.9% 25.3% 30% 30%

X25 Trust Friends and Family Response Rate: A&E 34.0% 28.9% 24.7% 27.1% 25.4% 30.1% 26.1% 17.2% 18.4% 20.9% 16.6% 18.9% 18.8% 19.3% 25% 25%

X33 Maternity Friends and Family Response Rate: Delivery care 25.0% 33.3% 20.9% 30.0% 27.7% 36.3% 12.2% 13.8% 19.3% 9.0% 8.2% 9.6% 6.0% 11.1% tbc tbc

Reduction in patients suffering a bad experience dealing with the Trust

X08 Percentage of re-booked outpatient appointments 8.5% 7.6% 8.3% 7.7% 8.7% 9.4% 8.4% 7.8% 7.5% 7.8% 7.9% 7.0% 7.3% 7.7% 8.6% 8.6%

X09 Clinics cancelled with less than 6 weeks notice for annual/study leave 16 30 41 84 30 24 17 19 26 33 35 14 30 174 198 340

X11 PALS contacts relating to appointment problems (% of total appts) 0.09% 0.10% 0.07% 0.09% 0.08% 0.09% 0.09% 0.08% 0.08% 0.07% 0.09% 0.08% 0.08% 0.08% 0.09% 0.09%

X12 Reduce patients cancelled on the day of surgery for non-clinical reasons 25 45 56 75 32 18 18 11 30 20 17 40 45 181 233 399

X13 Breaches of mixed sex accommodation arrangements 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0

Nutritional Assessment

X14 Compliance with MUST tool after 24 hours 82.0% 80.0% 73.0% 78.5% 75.5% 79.5% 81.3% 82.5% 72.5% 80.5% 75.8% 44.1% 72.8% 80% 80%

X15 Compliance with MUST tool after 7 days 94.0% 95.3% 88.5% 94.0% 95.0% 94.0% 93.2% 97.8% 92.0% 94.0% 90.3% 87.4% 92.4% 95% 95%



OCTOBER 2015


Actual

YTD

TargetTarget Trend

QUALITY SCORECARD

Cleanliness / PLACE Survey

X16 Internal PLACE compliance : St Richard's Hospital 97% 98% 98% 98% 96% 99% 92% 98% 97% 84% 90% 96% 91% 93% 85% 85%

X17 Internal PLACE compliance : Worthing Hospital 98% 98% 92% 91% 97% 98% 98% 97% 94% 97% 95% 94% 94% 96% 85% 85%

Improve our customer service and become a more caring organisation

X18 Number of complaints 45 57 51 51 41 54 43 48 44 58 56 44 72 365 333 570

X19 Complaints where staff attitude or behaviour is an issue 2 5 8 5 6 10 6 2 3 11 6 4 3 35 39 67

X20 Complaints where staff communication is an issue 4 6 4 8 3 2 7 2 3 9 7 5 8 41 29 49

X21 Complaints about nursing 5 7 5 1 5 4 4 4 2 5 2 2 2 21 27 46



October 2015

Shift Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep OctYTD

ActualTrend

Day 97.1% 95.4% 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.4%

Night 98.0% 95.8% 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.6%

Day 98.0% 95.5% 93.2% 92.1% 94.5% 95.7% 96.1% 97.0% 97.4% 98.4% 96.7% 97.7% 97.0%

Night 99.2% 93.5% 96.8% 95.5% 91.1% 97.5% 97.6% 96.7% 97.6% 98.4% 93.3% 97.6% 97.0%

Day 94.0% 94.1% 94.8% 93.2% 92.5% 95.7% 97.2% 95.9% 93.9% 94.6% 95.7% 98.3% 95.9%

Night 95.9% 96.1% 96.1% 97.1% 93.0% 96.8% 97.8% 94.6% 94.7% 95.6% 94.1% 98.2% 96.0%

Day 98.1% 96.8% 97.8% 94.8% 97.8% 97.8% 96.8% 98.5% 99.3% 93.9% 95.6% 96.4% 96.9%

Night 98.3% 95.2% 93.5% 94.6% 90.3% 98.3% 93.5% 98.3% 98.4% 87.1% 88.3% 93.5% 93.9%

Day 100.0% 92.7% 92.7% 95.6% 97.2% 97.7% 96.6% 96.5% 97.2% 93.8% 92.4% 92.1% 95.2%

Night 100.0% 96.8% 93.5% 100.0% 98.4% 100.0% 98.4% 96.7% 100.0% 100.0% 98.3% 96.8% 98.6%

Day 99.4% 97.2% 92.1% 89.4% 95.5% 97.1% 95.5% 100.0% 100.0% 100.0% 100.0% 100.0% 98.9%

Night 98.3% 93.5% 96.8% 96.4% 90.3% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5%

Day 92.0% 96.8% 98.4% 94.6% 97.4% 98.0% 99.0% 97.3% 98.1% 98.7% 97.0% 99.4% 98.2%

Night 94.4% 96.8% 98.9% 96.4% 98.9% 100.0% 98.9% 97.8% 100.0% 100.0% 100.0% 100.0% 99.5%

Day 100.0% 100.0% 100.0% 100.0% 100.0% 98.9% 98.9% 100.0% 97.8% 100.0% 97.4% 100.0% 99.0%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.9% 100.0% 98.5% 98.8% 99.5%

Day 100.0% 96.7% 99.0% 95.7% 98.6% 99.0% 96.6% 97.0% 97.6% 100.0% 100.0% 100.0% 98.6%

Night 100.0% 96.8% 98.4% 94.6% 96.8% 96.7% 95.2% 98.3% 96.8% 100.0% 100.0% 100.0% 98.1%

Day 98.3% 96.0% 95.9% 100.0% 97.6% 99.2% 96.0% 100.0% 100.0% 98.9% 95.8% 94.0% 97.6%

Night 96.2% 96.0% 100.0% 95.5% 99.2% 99.2% 99.2% 97.8% 98.9% 100.0% 98.9% 99.1% 99.0%

Day 99.6% 99.2% 89.5% 92.0% 95.6% 97.1% 97.2% 99.6% 98.4% 96.0% 95.8% 97.2% 97.3%

Night 100.0% 96.8% 90.3% 91.1% 91.9% 95.0% 98.4% 100.0% 100.0% 95.2% 91.7% 98.4% 97.0%

Day 90.4% 88.9% 94.4% 85.7% 90.7% 94.7% 94.8% 93.1% 91.5% 92.9% 88.5% 93.7% 92.8%

Night 93.3% 92.5% 94.6% 86.9% 87.1% 94.4% 94.6% 93.3% 97.8% 91.4% 94.4% 98.9% 95.0%

Day 99.2% 93.1% 97.6% 97.8% 98.4% 97.9% 98.0% 97.5% 94.8% 96.4% 98.3% 99.6% 97.5%

Night 100.0% 91.9% 100.0% 98.2% 100.0% 95.0% 96.8% 98.3% 88.7% 91.9% 95.0% 98.4% 94.9%

Day 96.8% 95.3% 95.7% 91.3% 93.0% 95.1% 93.4% 96.0% 99.1% 90.4% 92.0% 98.3% 94.9%

Night 98.3% 100.0% 98.4% 96.4% 96.8% 96.7% 98.4% 100.0% 100.0% 95.2% 100.0% 100.0% 98.6%

WSHFT

Acute Medical Unit(Chichester)

Bluefin

Bosham

Botolphs

Birdham

Acute Cardiac Unit

Ashling

Barrow

Beacon

Beeding

Becket

Boxgrove

Broadwater

SAFER STAFFING SCORECARD - Registered Nurses and Midwives

6B. Safer Staffing Scorecard M7 SaferStaffingWardNurseScorecard 1 of 3 20/11/2015 10:52


October 2015


ActualTrend

Day 97.1% 95.4% 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.4%

Night 98.0% 95.8% 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.6%WSHFT

Acute Cardiac Unit


Day 96.0% 97.6% 94.2% 93.1% 94.2% 92.1% 93.7% 94.1% 94.7% 92.3% 83.2% 91.8% 91.7%

Night 98.3% 98.4% 95.2% 94.6% 95.2% 91.7% 96.8% 95.0% 100.0% 98.4% 96.7% 100.0% 97.0%

Day 99.5% 96.7% 99.0% 93.6% 96.6% 100.0% 99.0% 96.0% 96.7% 95.2% 85.1% 98.1% 95.8%

Night 98.3% 98.4% 96.8% 96.4% 95.2% 100.0% 98.4% 98.3% 100.0% 100.0% 98.3% 100.0% 99.3%

Day 96.8% 97.0% 94.8% 96.2% 96.5% 96.9% 99.6% 97.3% 97.0% 91.2% 94.6% 96.6% 96.2%

Night 98.6% 97.4% 97.4% 98.5% 97.3% 94.5% 100.0% 97.3% 100.0% 96.0% 98.6% 100.0% 98.1%

Day 99.0% 97.2% 99.5% 97.9% 96.7% 98.1% 99.1% 99.5% 100.0% 98.6% 97.6% 97.7% 98.6%

Night 100.0% 96.8% 100.0% 98.2% 95.2% 96.7% 100.0% 98.3% 100.0% 96.8% 95.0% 95.2% 97.4%

Day 100.0% 96.7% 98.1% 93.1% 99.0% 96.0% 99.0% 98.0% 97.1% 95.2% 93.1% 97.1% 96.5%

Night 98.3% 98.4% 98.4% 94.6% 100.0% 98.3% 98.4% 100.0% 100.0% 98.4% 100.0% 100.0% 99.3%

Day 96.3% 98.8% 96.4% 93.3% 96.0% 96.7% 97.6% 95.0% 98.0% 96.4% 90.4% 96.8% 95.9%

Night 100.0% 100.0% 98.4% 94.6% 95.2% 96.7% 98.4% 96.7% 100.0% 98.4% 98.3% 98.4% 98.1%

Day 98.3% 98.8% 96.8% 97.8% 98.8% 97.9% 98.8% 98.3% 90.7% 92.3% 89.2% 96.0% 94.7%

Night 98.3% 96.8% 100.0% 98.2% 100.0% 98.3% 98.4% 100.0% 100.0% 98.4% 100.0% 100.0% 99.3%

Day 96.7% 94.8% 96.0% 96.9% 94.0% 98.3% 94.0% 96.3% 96.4% 94.8% 92.5% 95.6% 95.4%

Night 96.7% 96.0% 93.5% 94.6% 93.5% 96.7% 97.6% 89.2% 96.0% 96.0% 95.8% 99.2% 95.8%

Day 96.7% 94.0% 96.8% 94.4% 94.5% 97.6% 97.7% 99.5% 96.3% 95.9% 94.8% 97.7% 97.1%

Night 95.0% 93.5% 96.8% 96.4% 95.2% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5%

Day 97.6% 95.9% 95.4% 98.0% 96.3% 98.6% 99.5% 93.3% 96.3% 93.5% 92.4% 97.2% 95.9%

Night 100.0% 95.2% 96.8% 98.2% 95.2% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 98.4% 99.5%

Day 95.2% 94.0% 96.8% 94.4% 95.4% 97.6% 96.8% 97.1% 98.2% 95.9% 91.9% 97.7% 96.5%

Night 96.7% 93.5% 100.0% 92.9% 96.8% 100.0% 98.4% 98.3% 100.0% 100.0% 100.0% 100.0% 99.5%

Day 96.3% 96.0% 94.8% 92.4% 95.2% 96.3% 96.4% 97.5% 96.4% 94.0% 80.0% 95.6% 93.8%

Night 100.0% 98.4% 98.4% 94.6% 96.8% 96.7% 98.4% 100.0% 100.0% 96.8% 96.7% 98.4% 98.1%

Eartham

Eastbrook

Clapham

Coombes

Burlington

Brooklands

Courtlands

Ditchling

Durrington

Buckingham

Chilgrove

Chiltington



October 2015


ActualTrend

Day 97.1% 95.4% 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.4%

Night 98.0% 95.8% 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.6%WSHFT

Acute Cardiac Unit


Day n/a 89.4% 90.9% 90.0% 92.1% 95.4% 94.0% 90.6% 94.2% 92.3% 89.2% 95.8% 93.1%

Night n/a 90.0% 94.7% 95.1% 94.1% 97.0% 97.1% 94.2% 98.2% 95.0% 98.2% 98.2% 96.9%

Day 100.0% 99.2% 100.0% 100.0% 100.0% 99.2% 100.0% 99.2% 100.0% 100.0% 99.2% 100.0% 99.6%

Night 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 98.3% 100.0% 99.5%

Day 99.0% 98.2% 97.2% 96.9% 94.5% 97.1% 98.6% 97.6% 97.2% 93.5% 95.2% 99.1% 96.9%

Night 96.7% 98.4% 100.0% 96.4% 98.4% 100.0% 100.0% 98.3% 100.0% 100.0% 98.3% 100.0% 99.5%

Day 98.8% 95.6% 91.5% 94.6% 90.7% 97.9% 96.0% 95.8% 97.2% 98.8% 97.1% 96.8% 97.1%

Night 100.0% 95.2% 91.9% 96.4% 85.5% 100.0% 93.5% 96.7% 96.8% 98.4% 93.3% 95.2% 96.3%

Day 95.7% 95.2% 93.5% 94.6% 92.9% 96.7% 92.6% 95.7% 95.8% 98.4% 94.3% 96.1% 95.7%

Night 95.6% 92.5% 96.8% 95.2% 88.2% 96.7% 87.1% 95.6% 94.6% 97.8% 90.0% 96.8% 94.1%

Day 100.0% 98.7% 100.0% 96.4% 100.0% 99.3% 98.7% 100.0% 98.7% 100.0% 100.0% 100.0% 99.5%

Night 100.0% 100.0% 100.0% 96.4% 100.0% 100.0% 96.8% 100.0% 98.4% 100.0% 100.0% 100.0% 99.3%

Day 100.0% 98.4% 100.0% 96.5% 99.2% 99.2% 99.2% 100.0% 100.0% 100.0% 100.0% 93.5% 98.7%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 96.8% 100.0% 96.0% 98.7%

Day 98.1% 95.7% 94.3% 94.0% 97.1% 93.7% 91.0% 97.4% 96.8% 96.4% 95.9% 97.5% 95.5%

Night 100.0% 93.5% 90.3% 98.2% 96.8% 85.0% 91.9% 98.3% 95.2% 93.5% 90.0% 93.5% 92.5%

Day 98.8% 98.0% 98.0% 92.4% 96.0% 96.3% 98.8% 94.6% 99.6% 98.0% 100.0% 98.4% 98.0%

Night 100.0% 95.2% 95.2% 96.4% 100.0% 100.0% 100.0% 96.7% 98.4% 96.8% 98.3% 96.8% 98.1%

Day 100.0% 100.0% 100.0% 98.6% 100.0% 100.0% 100.0% 97.8% 98.9% 100.0% 100.0% 100.0% 99.5%

Night 100.0% 100.0% 100.0% 98.6% 100.0% 98.8% 100.0% 100.0% 98.8% 100.0% 100.0% 100.0% 99.6%

Day 98.3% 94.6% 94.6% 94.0% 97.3% 99.4% 99.5% 100.0% 98.4% 98.4% 98.9% 99.5% 99.1%

Night 100.0% 93.5% 96.8% 98.2% 100.0% 96.7% 100.0% 100.0% 100.0% 98.4% 98.3% 100.0% 99.1%

Day 98.3% 96.7% 95.8% 94.4% 93.3% 94.0% 97.1% 96.1% 96.7% 96.6% 95.7% 96.7% 96.1%

Night 100.0% 97.8% 96.8% 96.4% 96.8% 96.7% 96.8% 98.9% 95.7% 96.8% 96.7% 97.8% 97.0%

Day 96.7% 93.5% 97.2% 95.1% 94.8% 96.7% 96.0% 95.4% 97.6% 98.8% 96.7% 96.4% 96.8%

Night 98.3% 93.5% 96.8% 98.2% 90.3% 98.3% 95.2% 96.7% 95.2% 98.4% 93.3% 96.8% 96.3%Wittering

Ford

Graffham

Lavant

Neonatal Unit

Petworth

Enhanced Surgical Care Unit

Erringham

Fishbourne

Selsey

Emergency Floor

Howard Children's Unit

Middleton


Review of Health services for Children Looked After and Safeguarding in West Sussex Page 1 of 33

Review of health services for

Children Looked After and Safeguarding in

West Sussex


Children Looked After and Safeguarding The role of health services in West Sussex

Date of review: 9th February - 13th February 2015

Date of publication: 13th November 2015

Name(s) of CQC inspector: Lee McWilliam Jan Clark Lynette Ranson

Provider services included: Sussex Community NHS Trust Western Sussex Hospitals NHS Foundation Trust, Surrey and Sussex NHS Trust, Brighton and Sussex University hospitals Trust. Sussex Partnership NHS Foundation Trust CRI

CCGs included: NHS Coastal West Sussex CCG NHS Crawley & NHS Mid Sussex CCG

NHS England area: South of England

CQC region: South East

CQC Deputy Chief Inspector, Primary Medical Services and Integrated Care:

Ruth Rankine

Contents

Summary of the review 3 About the review 3 How we carried out the review 4 Context of the review 4 The report 6 What people told us 7

The child’s journey 8 Early help 8 Children in need 13 Child protection 16 Looked after children 19

Management 22 Leadership & management 22 Governance 25 Training and supervision 28

Recommendations 30

Next steps 33


Summary of the review This report records the findings of the review of health services in safeguarding and looked after children services in West Sussex. It focuses on the experiences and outcomes for children within the geographical boundaries of the local authority area and reports on the performance of health providers serving the area including Clinical Commissioning Groups (CCGs) and Local Area Teams (LATs). Where the findings relate to children and families in local authority areas other than West Sussex, cross-boundary arrangements have been considered and commented on. Arrangements for the health-related needs and risks for children placed out of area are also included. About the review The review was conducted under Section 48 of the Health and Social Care Act 2008 which permits CQC to review the provision of healthcare and the exercise of functions of NHS England and Clinical Commissioning Groups. • The review explored the effectiveness of health services for looked after children

and the effectiveness of safeguarding arrangements within health for all children.

• The focus was on the experiences of looked after children and children and their families who receive safeguarding services.

• We looked at: o the role of healthcare providers and commissioners. o the role of healthcare organisations in understanding risk factors, identifying

needs, communicating effectively with children and families, liaising with other agencies, assessing needs and responding to those needs and contributing to multi-agency assessments and reviews.

o the contribution of health services in promoting and improving the health and wellbeing of looked after children including carrying out health assessments and providing appropriate services.

• We also checked whether healthcare organisations were working in accordance with their responsibilities under Section 11 of the Children Act 2004. This includes the statutory guidance, Working Together to Safeguard Children 2015.

• Where we found areas for improvement in services provided by NHS but commissioned by the local authority then we will bring these issues to the attention of the local public health team in a separate letter.


How we carried out the review We used a range of methods to gather information both during and before the visit. This included document reviews, interviews, focus groups and visits. Where possible we met and spoke with children and young people. This approach provided us with evidence that could be checked and confirmed in several ways. We tracked a number of individual cases where there had been safeguarding concerns about children. This included some cases where children were referred to social care and also some cases where children and families were not referred, but where they were assessed as needing early help and received it from health services. We also sampled a spread of other such cases. Our tracking and sampling also followed the experiences of looked after children to explore the effectiveness of health services in promoting their well-being. In total, we took into account the experiences of 71 children and young people. Context of the review Most of West Sussex residents, 57.6% (485,090 residents) are registered with GP practices that are part of the NHS Coastal West Sussex Clinical Commissioning Group (CCG). There are 214,738 West Sussex residents (25.5%) that are registered with a GP practice that is part of NHS Horsham and Mid Sussex CCG and there are 117,773 residents (14.0%) that are registered with a GP practice that is part of NHS Crawley CCG. There are some West Sussex residents that are registered with GPs that are a part of further CCGs but these are much lower in number. The current 2014 West Sussex Child and Maternal Health Observatory (Chi Mat) profile identifies that children and young people make up 22.5 % of West Sussex population with 14.7 % of school age children being from a minority ethnic group. On the whole, the health and well-being of children in West Sussex is generally better than the England average. The infant and child mortality rates are similar to the England rates. The rate of looked after children under age 18 per 10,000 children as at March 2013, was significantly lower than the England average. This also corresponds with West Sussex having a significantly higher percentage of looked after children having up to date immunisations when compared to the England average.


Chi Mat reports that in 2013, the overall percentage of all West Sussex children having MMR vaccinations and other immunisations such as diphtheria, tetanus and polio by aged two was significantly better when compared against the England average. The indicator for the rate of A&E attendances for children under four years of age in 2011/12, was significantly better when compared to the England average rate. The rate of hospital admissions caused by injuries for children under 14 years of age was not significantly different when compared to the England average. However, the rate of hospital admissions caused by injuries for young people between the age of 15 and 24 years was significantly worse when compared to the England average. The rate of hospital admissions for mental health conditions was significantly better than the England average in 2012/13. The rate of hospital admissions as a result of self-harm in same time period however was significantly worse than that the England average. In 2011, the conception rate for under 18 year olds per 1000 females was significantly better to the England average. This corresponded with the significantly lower percentage of teenage mothers in 2012/13 when compared to the English average. In 2014, the DfE reported that West Sussex had 420 looked after children that had been continuously looked after for at least 12 months as at 31st March 2014, excluding those children in respite care. The DfE reported that 95.2% (400) of these children received their annual health assessments. This percentage is greater than the England average of 88.4%. The percentage of looked after children that had their teeth checked by a dentist in West Sussex was 92.9% (390), which is higher than the England average of 84.4%. As at 31st March 2014, there were 45 looked after children who were aged five or younger, the DfE reported that all of these looked after children had up to date development assessments. Commissioning and planning of most health services for children are carried out by NHS Coastal West Sussex CCG, NHS Crawley & NHS Horsham and Mid Sussex Clinical Commissioning Groups. Commissioning arrangements for looked-after children’s health are the responsibility of NHS Coastal West Sussex CCG on behalf of NHS Crawley & NHS Horsham and Mid Sussex Clinical Commissioning Groups and the looked-after children’s health team, designated roles and operational looked-after children’s nurses, are provided by Sussex Community NHS Trust.

Acute hospital services (including maternity services) are provided by Western Sussex Hospitals NHS Foundation Trust, Surrey and Sussex Healthcare NHS Trust, Brighton and Sussex University Hospitals Trust. Health visitor services are commissioned by the CCGs and provided by Sussex Community NHS Trust.


School nurse services are commissioned by West Sussex County Council and provided by Sussex Community NHS Trust. Contraception and sexual health services (CASH) are commissioned by West Sussex County Council and provided by Western Sussex Hospitals NHS Foundation Trust. Child substance misuse services are commissioned by West Sussex County Council and provided by CRI. Adult substance misuse services are commissioned by West Sussex County council and provided by CRI

Child and Adolescent Mental Health Services (CAMHS) are provided by Sussex Partnership Foundation Trust and the CAHMS LAAC service is commissioned by West Sussex County Council

Specialist facilities are provided by Sussex Partnership Foundation Trust Adult mental health services are provided by Sussex Partnership Foundation Trust The West Sussex integrated inspection of Safeguarding and Looked after Children’s Services took place in November 2010. Recommendations from that review will be covered in this report. The report This report follows the child’s journey reflecting the experiences of children and young people or parents/carers to whom we spoke, or whose experiences we tracked or checked. A number of recommendations for improvement are made at the end of the report.


What people told us We heard from children in care and care leavers: “My health check was really fine. She weighed and measured me. I got to pick the time and place and the nurse came to my house, I filled in a form that said I gave consent which I thought was good. I was seen on my own too, not with my (foster) mum and that was good.” “It was the first time I had met the nurse. She was friendly and open and easy to talk to, so I felt I could ask her questions.” “I got a copy of the assessment afterwards and was able to fill in a feedback questionnaire about how the health check went and it went into a sealed envelope” “I had a choice about where the health review happened. I preferred to have it at home as I didn’t want everyone knowing I was going out of school to meet the nurse.” “She (the looked-after child nurse) was really nice. Bubbly and nice. Very easy to talk to. We did this game when I first met her, with cards. It was so funny” “Since meeting the nurse and seeing her for a few times afterwards I have really changed. I would love to see her again. She has made such an impression on me. She told me all about safe sex and relationships and safety. I have a much healthier new relationship with a new boyfriend and I am much happier about things. She changed my life.” We heard positive feedback from parents we spoke to in East Surrey Hospital ED about the treatment they and their children received. “You get a great service here for children. The staff are very approachable and we are always very happy with the treatment our children get here. Keep up the good work! They have been really good with our son.”


The child’s journey This section records children’s experiences of health services in relation to safeguarding, child protection and being looked after. 1. Early help 1.1 Young expectant and new parents are well supported across West Sussex with access to the young parents group at health and family centres and peer support initiatives via social media. The Family Nurse Partnership is well established however the service is currently commissioned to meet the needs of only approximately 20% of young mothers who fulfil the criteria for the programme. 1.2 The early parenting group, weekly drop in sleep support clinic and post natal depression group, in conjunction with local MIND services, are recently established initiatives in some parts of West Sussex. Although it is too soon to see the impact of this on outcomes, the groups have been well received by new parents as a means to access advice and support on a regular basis from the health visiting teams.

1.3 Arrangements for expectant mothers with additional needs are variable across West Sussex. At East Surrey Hospital (ESH) and Western Sussex Hospitals there are no specialist services, aside from the counselling midwife and safeguarding midwife. However at Princess Royal Hospital (PRH), there is a “one stop” midwife who is part of a dedicated clinic involving a social worker and specialist nurse for substance misuse which specifically supports expectant mothers with substance misuse issues or that are homeless. Across all sites there is limited commissioned support available for mothers in the ante and post natal period with mental health issues and this is a gap. (Recommendations 1.2, 4.2, 5.3)

1.4 Arrangements for expectant mothers with low and moderate substance misuse are under developed. Drug and alcohol misuse commissioning arrangements do not address the special needs for supporting women who are pregnant, especially those with low level substance misuse. Practitioners we met with reported a lack of clarity about how to access support in these cases. This information will be brought to the attention of Public Health England.


1.5 Flexible maternity booking arrangements are in place to ensure newly expectant mothers have easy access to health advice. These are available online, via GP surgeries and at over 100 clinic sessions held at children’s centres, GPs or hospitals. The parent craft offer at ESH includes specialist sessions for the local Polish community alongside evening and weekend sessions to ensure everyone can easily access this valuable support. There is also a liaison midwife who links with the detention centre at Gatwick airport to ensure that expectant mothers arriving into the country can access health services. At PRH, specialist individualised sessions are available to support teenage parents and include support to visit the hospital and birthing unit, and help with transport to appointments to facilitate attendance.

1.6 Some cases we reviewed highlighted a lack of individualised birth plans being held on records. This was particularly at PRH where the ante-natal care is likely to be provided by community midwifery from a different health trust. There is more to do to ensure seamless planning and transition of care in the ante-natal and immediate post natal period for expectant mothers, especially those who are accessing various health organisations in the different phases of pregnancy, to ensure their needs are fully met. (Recommendation 5.1)

1.7 Following recent training at the midwifery study day, midwives at ESH have a heightened awareness of female genital mutilation (FGM) and are now routinely discussing this at the booking appointment. This ensures women who are victims are identified for support at the earliest opportunity. 1.8 Midwives across all sites we visited demonstrated good awareness of domestic violence (DV). At ESH, DV questions are routinely asked at booking and again at 28 weeks, and women are provided with opportunities to see the midwife alone. At Worthing, the teenage pregnancy midwives maintain their own separate record of DV questioning and responses, outside the hand held notes and these questions are repeatedly reviewed with the young person. 1.9 Multi-disciplinary “early help” and “special issues” midwifery liaison meetings are well valued and deemed as effective in ensuring vulnerable expectant mothers and unborn babies are well supported and safeguarded throughout pregnancy. There is robust liaison in place between midwifery and health visiting on a fortnightly basis at ESH. This is in addition to regular visits three times per week to the hospital from the liaison health visitor who collects post natal information and distributes it to the relevant health visiting team. In contrast however, there is limited liaison between PRH and Horsham health visitors, and this is compounded by the lack of commissioned paediatric liaison role in PRH. Cases sampled highlighted gaps in information exchange which were negatively impacting on both teams’ ability to support families. (Recommendation 5.2)

1.10 The comprehensive electronic “Eclipse” booking system at ESH automatically flags alerts on a pop-up screen if certain responses have been ticked as part of a midwifery consultation. This ensures all clinicians are fully aware of additional vulnerabilities and can offer ongoing support to vulnerable expectant mothers.


1.11 The named midwives at both ESH and PRH have good oversight of safeguarding cases and maintain a database of all “special issues” forms received from the midwifery team. Easily identifiable colour coded paperwork for safeguarding information is also in place which ensures all practitioners involved with the care of the woman can easily access the most up to date information. 1.12 We heard positive feedback about the “Partners welcome” initiative in place at both Worthing and PRH maternity unit. Fathers can stay overnight on the ward, with boundaries made clear to each family. Partners’ wishes are discussed routinely to ensure they are fully involved throughout labour and the immediate post natal period. However some staff raised concerns related to the lack of information currently collected about partner’s history both at booking and throughout pregnancy and the risks this may present to both staff and other patients on the ward. (Recommendations 1.4, 5.5)

1.13 Universal ante natal visits by the health visiting team are in place however the gaps in liaison between midwifery at PRH and the health visiting service mean that currently not all pregnancy bookings are received, therefore not all women in this part of the county are able to benefit from this enhanced support. (Recommendation 5.4)

1.14 The use of the health visiting family health and wellbeing assessment which includes maternal mood, is undertaken at the antenatal visit and again at the 6-8 week visit. Consequently, any areas of additional support are highlighted at an early opportunity and reviewed to ensure support is meeting the needs of the family.

1.15 Many health teams we visited do not routinely receive DV notifications and therefore health practitioners are unable to offer support, particularly at an early stage for families who are victims of domestic abuse. We heard of cases where the first time the health practitioner was aware that domestic violence was an issue was when the case was discussed at the Multi Agency Risk assessment conference (MARAC). This is a missed opportunity to ensure health staff are able to offer their unique contribution to supporting children and their families at an early stage. (Recommendation 7.1)

1.16 Midwifery services engagement with MARAC is well established however there is more to do to ensure that the trust safeguarding teams, particularly at ESH are fully involved. The named nurses report that they have made few referrals to the MARAC and that domestic violence incidents are referred to children's social care, therefore neither named nurse attends MARAC regularly. This means information is not informing risk assessments undertaken, particularly in the emergency department. (Recommendation 4.3)

1.17 The school nursing team work corporately because of ongoing capacity issues which can impact on visibility to young people and the strength of links with schools. As a result, school drop ins are operated on an ad hoc basis only where and when capacity allows, reducing the opportunity for young people to request health support.


1.18 Safeguarding risk assessment practice at ESH emergency department (ED) is robust. Assessment documentation is comprehensive and of good quality; using the CWILTED assessment model and there is a high level of compliance with good recording practice. Cases we reviewed in the ED demonstrated that all sections in the assessment documentation are routinely completed and that practitioners prioritise the safeguarding of children and young people. 1.19 Although there is no alert flagging system in use at ESH, in a number of cases reviewed in the ED, it was evident that the clinician had noted where there had been frequent or a high number of attendances and had interrogated the system to get further details of previous attendances. This information had informed their risk assessment of the current situation and is positive practice. 1.20 East Surrey Hospital has its own missing person policy which includes children that go missing or are likely to abscond. There is a high level of awareness among ED practitioners of the potential for adults and/or children to go missing from a busy ED, and all cases reviewed demonstrated that it is routine practice for clinicians to record the appearance and clothes of patients attending the ED. 1.21 We saw good awareness of the potential for hidden harm to children and appropriate risk identification demonstrated through cases we reviewed in the adult ED at ESH. The children’s assessment tool at Crawley Urgent Treatment Centre (UTC) includes question prompts about relationships and family and also records who accompanies the child. We saw an example of prompt recognition of safeguarding risk to a vulnerable young person who was present in ED with adults in her family. This link has since enabled the young person’s needs to be considered in a child in need meeting. 1.22 The Surrey & Sussex Healthcare trust has a robust did not attend (DNA) protocol in place. Where a child or young person fails to attend two or more times across the trust or where there is recurrent rescheduling of appointments; these cases are automatically discussed at the weekly safeguarding meeting. If a child or young person leaves the ED before being seen, notification for follow up is sent to community health services and primary care to ensure their needs are met. 1.23 Access to the mental health assessment team is rapid for patients who present at the UTC, as the mental health crisis team are located on site. As a result, in cases sampled where patients presented with clear mental health needs, initial triage by the UTC team was brief, without completion of the safeguarding questions. There was an assumption that the mental health team would take a more in depth history and identify any safeguarding concerns. As the two teams operate different IT systems, it is not possible for either team to ensure these prompts have been asked and that concerns have been identified and think family considered. (Recommendation 2.1)

1.24 At Worthing hospital, children’s needs are well met by the paediatric ED accommodation. Extension of paediatric opening times until midnight is currently being considered and would enhance the service at a time when there is often a peak in presentations.


1.25 The establishment of a young person’s drug & alcohol pathway at the EDs is a recognised area for improvement. Some work has been undertaken to develop a pathway, however, operational issues have yet to be resolved. The intended completion and launch of a robust pathway at Worthing is welcomed and its impact and reach will be monitored and reviewed to ensure that increased numbers of young people receive support at an early stage. There is no clear pathway for referrals of young people for substance misuse at ESH. Young people who present with substance misuse issues are given information and leaflets on support services only; therefore there is no assurance that they are being appropriately supported once they leave the ED. (Recommendation 4.1) 1.26 The health visiting and school nursing teams make good use of the Brearley risk assessment tool to help focus on case strengths and dangers, and this is updated regularly for families of concern to ensure support is increased if risks are escalating.

1.27 Young people have good access to full range of CASH and termination services around the county at three hub centres and a number of satellite clinics, all of which are well linked to the “Find it out” service for young people. Booked and walk in sessions are available, and all areas have some sessions up to 8pm across the week. Saturday morning clinics are a new development. Senior practitioners are based at the satellite clinics where there is a need for more autonomous decision making and interrogation of potential safeguarding risk.

One case seen highlighted the benefits of an ongoing risk assessment tool in the school nursing service to ensure children were well supported as their needs changed. The description of “dangers” on the tool clearly articulated and tracked the escalation of needs as the impact of the mother’s complex health issues led to neglect, and as the negative effect on the child’s development and socialisation increased over a number of visits. Additional home visits were undertaken which had a good focus on the child, leading to early revisits and intensive support to prevent the home situation deteriorating. The persistent work by the school nurses in maintaining contact to support both the child and her parents, alongside robust joint working with the school ensured positive outcomes were achieved and the situation did not continue to escalate.


2. Children in need 2.1 There is a well-established under 16 self-harm pathway in place at ESH and access to CAMHs assessment on the ward is reported to be good. Under 16’s who attend ED with self-harm are always admitted to the paediatric ward in line with NICE guidance. In one case we sampled involving a young person living outside the area and where there were complexities and barriers around access to their local services, this did not cause delay in the young person having their needs assessed. 2.2 Currently young people attending Worthing ED with mental health needs do not have prompt access to assessment leading to unnecessary delays or admissions. We are aware that the recent agreement of a new CAMHs post within the ED should greatly enhance the service and ensure young people’s needs are met in a more timely way. 2.3 We heard about and saw some CAMHS case examples where children and young people had experienced positive outcomes from the therapeutic intervention. However young people do not have prompt access to CAMHS services and performance on waiting times for specialist assessments such as Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) as well as the time taken for interventions to commence following assessment is an area of concern. An action plan is in place to address the backlog of young people awaiting intervention in Horsham in the short-term through the use of bank practitioners. However there is no clear plan in place to resolve the problem in the medium to long-term, particularly for young people with moderate mental health needs. (Recommendation 3.1) 2.4 Worthing CAMHS report a very positive and supportive relationship with the local paediatric ward where young people are admitted in mental health crisis. Individual plans are developed between the CAMHS duty worker attending the ward and ward staff to ensure the young person is supported effectively while in the paediatric ward. The CAMHS team leader also provides periodic mental health training to paediatric staff at Worthing hospital to ensure young people’s needs are being addressed appropriately. 2.5 The CAMHS team leader attends the weekly multi-agency safeguarding meeting at ED which facilitates efficient information sharing and prompt access to clinical information on young people known to the CAMHS service who may have presented at ED. This promotes effective multi-agency care planning and support to vulnerable young people. 2.6 The STEPS support programme operated by CAMHs is effective in providing positive outcomes for young people, and two young people who have benefited from the programme are now acting as facilitators to further develop young people’s engagement.


2.7 Adult mental health practitioners we met demonstrated that they understand their role in safeguarding children and that they prioritise the safety and wellbeing of children in their engagement with adult service users. We saw some case examples of good liaison between adult mental health practitioners and other professionals such as health visitors and school nurses. However managers acknowledged that there is scope to strengthen this to ensure this becomes routine practice rather than a reliance on practitioners only communicating at formal meetings and case conferences. 2.8 The perinatal mental health specialist service operating out of Worthing Hospital is identified on the intranet under complex care pathways but practitioners we met with were unable to access further information about the service and referral pathway through the intranet. As a result, there is a lack of clarity within adult mental health about the scope of and access to this specialist provision. (Recommendation 3.2) 2.9 Liaison between midwifery and GPs is an area of development. The midwife discharge letter sent to GPs from Worthing hospital has no section for detailing safeguarding concerns and only identifies that the safeguarding midwife is involved within the body of the letter. This is not easily distinguishable and leads to the risk that the GP, who will have ongoing contact with the family, may not be fully aware of any safeguarding concerns and therefore be unable to provide appropriate support. (Recommendation 1.1) 2.10 Bi-monthly ‘families of concern’ meetings held at GP practices we visited are routinely attended by the health visitor, the practice manager and a member of staff from the local family centre. Although the school nurse is invited they are currently unable to attend this forum due to capacity constraints. This meeting facilitates good information sharing and is able to direct vulnerable families into engagement with early help services. The new safeguarding lead GP at one practice is increasing the frequency of meetings to monthly to ensure that the follow-up on issues and actions by the professionals is robust and that families of concern are monitored carefully. This is a positive development in strengthening practice at the surgery. 2.11 In addition to the family of concern meeting, health visitors maintain good links with GPs by visiting practices on a regular basis to discuss and review all families on the health visiting caseload where safeguarding concerns have been highlighted. GP practices we visited were flagging children and young people on child protection plans or who were looked after, however there is no system in place to highlight children where there are other safeguarding concerns or additional needs that are not yet subject to formal child protection measures. In one case we sampled, this would have been beneficial to ensure the GP consultations were more fully informed and that cumulative issues were considered. (Recommendation 6.5) 2.12 Drug and Alcohol services (CRI) report that their liaison with midwifery at Western Sussex hospitals and ESH is improving and that they are now included in discharge planning for new mothers with ongoing substance misuse issues to ensure a holistic approach to care planning and longer term support is in place.


2.13 There is more to do within the school nursing service to clarify the role of practitioners outside formal child protection processes, where young people are vulnerable. Currently, there is a lack of clear expectations or criteria within the service about responding to identified risks. Cases sampled included a young person with a high level of attendances at ED; domestic violence identified within a family and young people with CAMHS involvement. There was a lack of clarity within the service as to when the school nurse should become involved. Some of these cases highlighted occasions where school nurses were not actively involved and there are no transparent criteria which triggers regular oversight and monitoring by school nurses, when they become aware of key information such as deliberate self-harm or domestic violence. This lack of cohesive multi-disciplinary working leads to the risk that children’s and young people’s needs are not being met. This information will be brought to the attention of Public Health England.

2.14 The CASH “vulnerable young people clinic” pilot enables better liaison and follow up for young people displaying risky behaviours. One case we sampled highlighted how it has successfully addressed the immediate health needs of a vulnerable young person and probed her circumstances which then identified additional safety concerns. The multi-disciplinary meeting component of this clinic has enabled CASH professionals to discuss the concerns and potential risks and make an onward referral to children’s social care in order to ensure the young person is safeguarded. 2.15 At present CASH work in isolation from other services and systems and have to go via the children’s access point (CAP) in children’s social care or their trust safeguarding team to make checks on people attending or ascertain more information. Accessing information via CAP can be a very slow process and impedes the team’s ability to fully risk assess when the young person is present in the clinic.


3. Child protection 3.1 There is significant variation in the method for practitioners across West Sussex to make referrals to Children’s’ Social Care (CSC) via the children’s access point (CAP). Referrals from Crawley UTC use their electronic discharge note as the CSC referral. This means that whilst the clinical history taken is consistently copied, the form may not always clarify the risks and the purposes of the referral. Forms sampled were not clear enough in identifying the nature of the referral, the risks the practitioner has identified and the outcome desired. There is no consistent method of making referrals to the CAP in either CAMHS or adult mental health and it the responsibility of individual practitioners as to how the written referral is set out; for example via e-mail, letter or through the use of the referral form. As a result, there is no effective method to quality assure safeguarding referrals and promote continuous improvement. (Recommendation 7.2)

3.2 Following recognition that the quality of the referrals CRI made to children's social care was a national area for development, CRI has introduced a standard template known as a Statement of Referral (SOR) and all its practitioners routinely use this to make referrals. This is facilitating ongoing improvement in the quality of referrals made by this provider which is also making good use of examples of poor, satisfactory and exemplar referrals as training tools. 3.3 Most East Surrey Hospital ED referrals made to children's social care (CSC) that we reviewed did set out the risks of harm to the child or young person clearly. In one case however, key information about the circumstances precipitating the child’s attendance at ED was recorded in the ED assessment documentation but not included on the children's social care referral. This could result in children's social care not having all relevant information to best inform their decision making about individual children. 3.4 Within all midwifery services, the quality of referrals to CSC and subsequent reports for conference was variable. In some cases, there was lack of clarity of the reason for the referral and the expected outcome. We did not see evidence of quality assurance of these referrals or reports by named midwives. (Recommendation 7.2) 3.5 We have seen and heard some good practice examples demonstrating effective risk assessment and prompt appropriate action taken by practitioners across a range of disciplines at ESH as a result of which, children were protected.


3.6 Surrey &Sussex Healthcare trust named nurses are linked in to child protection pathways and routinely attend strategy meetings. They are encouraging frontline practitioners to attend these with the named nurse where they may have the key information to best inform the decision making of the meeting and to ensure the child is supported at an appropriate level. 3.7 Health visitors and school nurses are well engaged with formal child protection processes including attendance at conferences and core groups, and both teams use a standard format to ensure a consistent contribution is made by all staff. 3.8 Where child protection plans are in place for children whose parent is supported by adult mental health, copies of the child protection plan are not routinely sought and obtained by mental health practitioners. Plans are not uploaded onto the case record so that they are easily available to practitioner and managers therefore workers are unclear what their role in the plan is. It is essential that the child protection plan informs the care plan or agreement made with the client. This ensures that the practitioner can monitor compliance with the plan and report back to conference to best inform ongoing safeguarding decision making (Recommendation 3.3) 3.9 There is a clear expectation in adult mental health services that practitioners working with parents where children are subject to child protection plans will be part of the core group and attend child protection case conferences, whenever possible, as well as submitting written reports. We saw one case example where the named psychiatrist and an adult mental health support worker had attended the initial child protection conference and made a significant contribution to the conference decision to place the children on a child protection plan. 3.10 While managers and practitioners in both adult mental health (AMH) and CRI teams agree that in principle they would share relapse indicators and crisis plans with health visitors and other professionals, this does not happen routinely in practice. Cases sampled did not spotlight strong liaison or joint working between the health visiting, substance misuse and AMH teams, therefore opportunities to provide support to families are being missed. (Recommendation 3.8)

Child A attended a dental practitioner in the community due to toothache. The dentist referred her to the hospital dental service where the hospital dentist, who had recently undertaken the trust’s level 3 safeguarding training, identified dental neglect, the child’s unkempt appearance and some unusual behaviour. These were immediately recognised as safeguarding concerns and the named nurse was consulted. The named nurse contacted the child’s GP who had not seen A for many years and through contact with the school nurse, it was ascertained that they had never attended any school and were illiterate .A strategy meeting was convened which was attended by the hospital dentist who had identified the concerns and the child was placed on a child protection plan at the subsequent ICPC. This case highlighted that A was protected promptly as the result of the dentist being trained at an appropriate level and therefore equipped to recognise indicators of safeguarding concern, taking swift and appropriate action.


3.11 One practitioner in adult mental health told us that she regularly undertakes home visits to her clients and prioritises those where there are children in the household to ensure there are no additional environmental risks. This is not routine practice across the service however. 3.12 One GP we met was very aware of her safeguarding responsibilities and was able to demonstrate, through a case example, her diligence in following up concerns she had about a child with the ED and children's social care. Where she sees patients and children where there are known to be vulnerabilities or identified risk and child protection plans in place, she records her observations of the child’s behaviours and demeanour and observations of interactions between parent and child. This is exemplary practice, giving the practice the opportunity to submit more detailed reports to child protection conference and thereby inform the conference decision making to best effect. Not all practitioners in the surgery recorded in this way however. One report submitted to a child protection conference recently set out basic information only, citing when the children had attended the practice and some additional information about the GPs concerns about one child’s weight loss. The standardised template that is available for primary care contributions to child protection conferences is not universally used , which impacts on the consistency of these contributions. (Recommendation 6.1) 3.13 Whereas some GPs in the practices visited attend child protection conferences on occasions, there was a view that these are planned at short notice making it difficult to attend. Staff at the practice had not appreciated that the date of the next conference is recorded at the bottom of the minutes giving ample opportunity to plan how they can participate or attend. Heightening GP’s awareness of this is likely to lead to increased participation in conferences. There has been little or no consideration of use of teleconferencing or other technology based means of increasing GP participation. (Recommendation 6.2) 3.14 There is more to do to develop liaison processes between school nursing and GPs. One case we sampled highlighted diligent work by the school nurse in following up the health needs of two children on child protection plans where the GPs lack of responsiveness led to risks that their health needs were unmet. However there was no communication between school nursing and primary care to ensure a holistic approach to supporting the family. (Recommendation 6.3) 3.15 There is a lack of clarity for CASH practitioners on the referral and outcome process for safeguarding concerns. In one case sampled, after initial liaison and referral to CSC, the CASH service did not have an update about outcome of the referral or whether the young person is now on a child in need or child protection plan. The CASH team reported feeling unclear about whose responsibility it is to follow up CSC, and there are no current standards and protocols in place. This information will be brought to the attention of Public Health England.


4. Looked after children 4.1 Initial health assessments (IHA) are undertaken by appropriately qualified clinicians, including a GP with a special interest in unaccompanied asylum seeking children (UASC); however there are ongoing issues with timeliness of assessments, related to the notification process. IHAs are undertaken at the four child development centres ensuring that the setting is not overly clinical and therefore not likely to act as a deterrent to older children. 4.2 The support from the looked after children (LAC) nurse at IHA appointments when available facilitates immediate signposting for young people and their carers, alongside rapid follow up to ensure young people’s high priority health needs are addressed. 4.3 On the rare occasion where an IHA has been undertaken by the looked-after children’s lead nurse, this is subject to oversight and review by the designated doctor and subject to appropriate risk assessment. The service recognises that this is by exception only to ensure that a young person who will not engage in any other way, will consistently have their health assessed on entering care. 4.4 Overall the quality of IHAs and review health assessments (RHAs) sampled was good, with evidence that the nurse had taken time to engage and build a rapport with the child; this was particularly the case in the 0-5 years cases we looked at, where the LAC nurses are health visitor trained. The RHA’s undertaken by the specialist LAC nurse team gave a good sense of the child as an individual and it was clear that all practitioners gave time to the young people to ensure a thorough assessment. 4.5 The LAC named nurse works with the cohort of UASC and undertakes their RHAs. She undertakes individual work with some UASC on particular health issues and these young people benefit from developing a relationship with a consistent health practitioner. 4.6 Most health plans reviewed were SMART although there were some where it would be difficult to track progress and timescales and accountabilities were not always clear. There was also a lack of transfer of targets and checks on previous actions from one plan to the next, and as follow up of actions cannot be monitored at present this is an area of development to ensure increased positive health outcomes. (Recommendation 2.2) 4.7 Young people have choices about where they have their RHA and the LAC nurses are able to offer some flexibility about location and time of day to suit the needs and wishes of the young person. However those RHA’s currently undertaken by school nurses are not able to be conducted as flexibly, meaning there is inequity in the service as not all young people have this choice.


4.8 Birth histories were lacking in some cases but the LAC nurses demonstrated a high level of understanding of the importance of obtaining and securing parental birth history at the point the child becomes looked after. In one case the LAC nurse had challenged the view put forward by other professionals that as the child had been looked-after child previously, albeit 10 years previously in another area, there was no need to secure parental birth history. 4.9 The care leaver’s offer is weak and is in the process of being developed. The service is not commissioned to work with young people over 18 but do on occasions if a young person is deemed to be in particular need of the looked-after child health team’s support. Young people on leaving care are currently given a personalised health summary but the service is exploring how to strengthen this offer through the use of a health passport. We understand that the LAC nurse is consulting with the Children in Care (CIC) council on this. 4.10 Children who are looked after do not have access to specialist intervention services in CASH however the sexual health outreach worker nurse located within the CASH team is highly regarded and undertakes positive work with vulnerable young people and those in care particularly. 4.11 A specialist CAMHS service for looked-after children ( known as Looked after and Adopted children-LAAC -CAMHs) is in place, available to local children in care, although limitations on the scope of their work currently means many looked after children are seen in the generic service and are therefore subjected to standard waiting times. There are also issues with access to CAMHS for young people who are not deemed to be in a stable placement. This may mean that a highly vulnerable group of young people are not able to access the support offered by this service and therefore their needs are unmet. (Recommendation 3.4) 4.12 Within the LAAC CAMHs team, there is a 12 month wait for some LAAC interventions and this has been a stable waiting time for more than two years. While the young person is waiting for direct work to commence, LAAC identify an allocated practitioner who can be consulted by telephone for advice and support, however access to direct intervention is not timely. This information will be brought to the attention of the Local Authority. 4.13 Although CAMHs and LAAC CAMHS do report into statutory looked-after child reviews, there is no routine liaison with the LAC health team or submission of progress briefings or reports to inform young people’s review health assessments. This is a gap and we saw evidence of young people who are looked after with significant mental health concerns that are unknown to the LAC team and that are not part of their health plan. There is a significant risk that the RHA’s and subsequent health plans are therefore not fully representative of a child’s assessed emotional and wellbeing needs and that these needs are unmet. (Recommendation 3.5)


4.14 GPs, health visitors and school nurses are routinely contacted for information to inform the RHA however we did not see evidence of any contributions being received. This is a missed opportunity to ensure children’s needs are being met on an ongoing basis. GPs spoken to were unaware of being asked to contribute information. (Recommendations 2.5 and 6.4) 4.15 Foster carers are engaged in the RHA process and are asked to complete an age specific carer’s report. This has been recently redesigned by the looked-after child health team and is currently with foster carers for agreement. 4.16 GP practices we visited were flagging children who are looked after and all relevant documents were uploaded on System1. This included IHAs and RHAs with the health plan located on the front of the documentation to draw the GPs attention to its contents. This administrative change was at the suggestion of the previous named GP. However, GPs acknowledged they were not proactive in knowing this group of children and actively promoting health and wellbeing. The leadership of an overarching named GP would help safeguarding leads in practices to develop their roles and responsibilities in a consistent manner and ensure GPs are fully clear about their role in respect of LAC health.


Management This section records our findings about how well led the health services are in relation to safeguarding and looked after children. 5.1 Leadership and management 5.1.1 Safeguarding leadership, advice and guidance is provided by the designated nurse, however the ongoing recruitment difficulties in securing a designated doctor and named GP are significantly impacting on her ability to drive forward safeguarding practice, and provide effective governance. (Recommendation 6.6) 5.1.2 The current absence of a named GP role for the area is contributing to a lack of focused expectation setting in primary care and there is slow progress in ensuring effective primary care safeguarding arrangements. 5.1.3 The children’s programme boards in each CCG, alongside the pan Sussex approach in some health areas are a useful mechanism to look at cross county themes to inform strategic direction for commissioning services for children. 5.1.4 It is not clear that the designated nurse for looked-after children has sufficient capacity (one day per week) to undertake the full range of responsibilities and ensure effective governance under the current arrangements for the role. This is in addition to the potential conflict of interest issues due to her operational LAC nurse role. (Recommendation 8.1) 5.1.5 The NHS professional’s forum is well valued as a mechanism to discuss issues and for shared problem solving across the health economy. However there is more to do to develop contract specification and monitoring to ensure appropriate levels of scrutiny and accountability. 5.1.6 Workforce capacity, recruitment and retention across all providers are ongoing challenges and we did not see a robust proactive approach to overcoming these long term issues. There are capacity issues across named professionals in all midwifery services which is impacting on ability to quality assure and continually drive forward safeguarding practice under current capacity arrangements. 5.1.7 In order to ensure services learn from serious incidents and that practice is subject to continuous improvement, learning events and updated training has been developed. However we were unable to see the impact of this across many services we visited.


5.1.8 On the whole, the interface between health and CSC across West Sussex is working well. The plans in place to develop multi-agency strategies for LAC and care leavers; the Multi Agency Children Looked after improvement group (MACLAIG), and the Children’s Access Point (CAP) into a Family Support pathway incorporating more health aims will aid collaboration and cohesive working to achieve best outcomes and progress for young people. 5.1.9 There is more to do to develop staff awareness across the economy on the use of escalation on cases where there is professional dissent. Whilst an agreed policy is in place, many practitioners we met with were unaware of both the policy and their role in highlighting professional disagreements across agencies. (Recommendation 7.4) 5.1.10 Surrey & Sussex Healthcare NHS Trust have recently increased the named nurse capacity for children’s safeguarding by restructuring the full-time role into two part-time posts equivalent to a 1.3 whole time equivalent post. The named nurses report that this additional provision ensures sufficient capacity to meet the requirements of the role for the trust. 5.1.11 The re-build of the adult and paediatric EDs at East Surrey Hospital in the last two years has resulted in improved patient flow through the department. The paediatric waiting area is well equipped with a range of play and interactive equipment. The area is not directly observed by staff at the nurses’ station; however, children and young people are only directed to the area if they are accompanied by an adult. Young people are also directed to wait in private rooms where deemed appropriate by staff, for example if a young person was in mental health distress or needed a quieter area than the communal paediatric waiting area. 5.1.12 The LAAC practitioners and team leader we met were not aware of any multi-agency CSE strategy in place although they are currently working with a child at high risk of CSE. The multi-agency strategy does not appear to be directly informing the work in this instance. CAMHs are currently not represented as part of the Multi Agency Child exploitation (MACSE) forum and this is an important disconnect as they are unable to exchange important information about young people who are at significant risk and assist with keeping young people safe. (Recommendation 3.6) 5.1.13 In adult mental health the named professionals are highly visible and practitioners and operational managers told us that they were available and that their leadership, advice and guidance is valued. 5.1.14 Not all adult mental health practitioners and operational managers have access to Framework I electronic system. The use of two separate and non-interfacing electronic recording systems within one service does not facilitate effective information sharing or safeguarding practice to ensure all practitioners are able to offer families optimum support. (Recommendation 3.7)


5.1.15 CRI have set a significant improvement and development agenda for the local service in its first year of operation, working to change practices and build a new staff team. CRI has undertaken its second section 11 audit independently and submitted this to the West Sussex Safeguarding Children’s Board demonstrating the provider’s commitment to improvement in safeguarding practice. 5.1.16 Where young people are transitioning from CAMHs into adult mental health, the protocol in place is for shared care and co-working between the two services for 12 months prior to transition. This would constitute best practice but is not currently happening in the trust due to the capacity pressures. Cases are currently being handed over in a single point of transfer at the young person’s care programme approach review (CPA). As the result of a complaint, the general manager in adult mental health and the improvement manager are working to resolve this situation and an action plan is in place to address this and establish a more robust pathway with appropriate governance arrangements. 5.1.17 Monthly multi-disciplinary team meetings in CASH are part of a new strategy to strengthen oversight and decision making, with overview by the named nurse for safeguarding children, consultant, matron, lead health advisor and lead clinician to discuss and track the children most at risk to offer additional support to them. This is a positive development to ensure children and young people receive high levels of support. 5.1.18 The use of the Lillie IT system in all CASH service hubs ensures young people accessing sexual health services across the county are identified. However the system is stand alone and there is no linked systematic way to identify and flag those young people who are looked after, on a child protection plan or at risk of CSE. Information sharing arrangements across health teams and other agencies have not been developed. This impacts on the CASH team’s ability to undertake a thorough risk assessment as they may not be fully aware of the young person’s circumstances. It also highlights under developed partnerships to help safeguard young people who may be particularly vulnerable by failing to make connections across agencies. 5.1.19 The significant role for both CAMHs and CASH services in identifying and supporting young people at risk of CSE is not sufficiently recognised or represented in current partnerships and operational arrangements. Safeguarding practice and tracking in relation to young people who are vulnerable to CSE or victims of CSE is at an early stage, although it’s reported that general awareness and understanding about the issue has improved in the county. The CASH modern matron was invited recently to sit on the LSCB CSE sub group but having attended once, it was concluded that her attendance was less effective at this strategic forum. She has now been invited to join the MACSE forum which until now hasn’t had representation from CASH or CAMHs. The opportunity to track knowledge about young people across services who are engaging in risky behaviours is therefore less well developed than it could be. (Recommendation 3.6)


5.2 Governance 5.2.1 Safeguarding governance by the three CCGs is not robust. The bi-monthly update report on child safeguarding developed by the Designated nurses across Sussex does not constitute an effective safeguarding governance tool. The reports set out activity data only with no requirement for analysis or explanatory narrative. There is no reporting on outcomes which result from the activity. As a result it is not clear how the update gives the CCGs and WSSCB meaningful safeguarding performance information or robust assurance. 5.2.2 Governance and monitoring of provider activity and training compliance is underdeveloped. The limited capacity of the designated nurse means she cannot currently attend provider safeguarding and governance meetings and is less able to professionally challenge information reported. This has led to a stagnation of issues that are not being resolved in a timely manner. The recent recruitment of a deputy designated nurse will release additional resource to help resolve issues more promptly. 5.2.3 There is a robust process in place at the ESH ED whereby all under 18 presentations are reviewed by a senior practitioner to ensure safeguarding risk assessment has been comprehensive and any issues identified are acted upon appropriately. 5.2.4 The named nurses at ESH have developed a set of criteria to help support and guide ED staff in how to respond to any identified vulnerabilities or safeguarding concerns. This is in use at the nurse’s station, displayed throughout the ED and is subject to regular review and updating by the named nurses as a result of learning from local and national incidents and SCRs and national guidance. 5.2.5 The weekly multi-agency safeguarding meeting held in ESH ED attended by named nurses, paediatric liaison health visitor, ED senior practitioner and Surrey social worker ensures all cases where vulnerabilities or safeguarding concerns have been identified are reviewed and discussed. The meeting is seen as an essential and effective component of the trust’s safeguarding governance arrangements. There is no West Sussex children's social care presence however and this means that information sharing on West Sussex children and vulnerable families may be less well facilitated. 5.2.6 All notes seen in ESH ED were clearly legible, comprehensive and signed by the clinician making the record. This enables an effective audit trail and demonstrates that good accountability and recording practice is routine. Periodic audits are undertaken by the named nurses and there is continuous operational management oversight of practice as ED managers and senior practitioners check case records throughout the day.


5.2.7 Pre-populated text in some of the documentation in the ESH ED which states there are no safeguarding concerns could lead to contradictory or confusing information being shared across agencies. Practitioners are not deleting the pre-existing text in cases where it does not apply and this undermines the robustness of what is an overall sound approach to risk assessment, analysis and documentation reporting. 5.2.8 There is a high degree of risk that potential and known risks to children will not be appropriately alerted to other professionals and services where information systems across health do not interface. There is not due diligence paid to ensuring that flags and links to vulnerable or at risk children are entered onto all relevant systems. (Recommendation 7.5) 5.2.9 Operational governance in mental health for children’s safeguarding is underdeveloped. There is no mechanism in place through which adult mental health practitioners and managers can easily and promptly identify that there is a CIN or child protection plan in place in individual cases, or that these are obtained by the practitioner and uploaded on the case record. Similarly, managers are unable to identify what cohorts of cases held by their service or team have children with known vulnerabilities or who are subject to child protection plans. This does not support the establishment of the “Think Family” model the service is reporting to be working towards. It also undermines effective caseload management, weakens information available to inform the joint strategic needs assessment and does not facilitate operational safeguarding practice oversight. (Recommendation 3.9) 5.2.10 Sussex Partnership Foundation Trust general managers do not receive regular updates on their team performance on the uptake and competition of both mandatory and desirable training. This does not assist managers in ensuring that practitioners are best equipped to discharge their responsibilities, nor to ensure improved performance on training which the trust acknowledges has been a long standing area of challenge. Performance reporting to managers is beginning to be introduced but is at an early stage. (Recommendation 3.10) 5.2.11 The multi-agency children looked after improvement group, MACLAIG, meets quarterly as a governance body for looked-after children, with a focus on improving performance. However, within health, the approach to quality assurance within LAC could be stronger. The LAC named nurse undertakes all quality assurance of assessments on West Sussex children placed out of county and returns assessments with which she is not satisfied. There is no recognised benchmarking tool or criteria based on NICE guidance for this quality assurance however to ensure consistency or compliance with national good practice. (Recommendation 2.3) 5.2.12 CRI are taking action to ensure that lessons learnt from a recent IMR become established practice. The “over the threshold” training to staff promotes the benefits and impact of undertaking home visits and what to look for in the home environment. Operational managers are checking that these are becoming established practice through regular audit.


5.2.13 An audit tool has been developed within CAMHs to monitor the impact of outcomes where young people have not engaged with the service and further assess this risk. This is with a view to develop a more robust approach to developing services for young people subject to child protection plans or where there are identified risks associated with the young person. 5.2.14 The Worthing ED demonstrated examples of monitoring the quality of practitioners safeguarding work compared to national standards and a solution focused approach when issues were identified. Ensuring that all ED locum staff understand and comply with trust policies remains a challenge. (Recommendation 1.3) 5.2.15 Quality assurance processes in relation to safeguarding referrals to children's social care are underdeveloped. Referrals seen do not set out the risks of harm to the child with sufficient clarity, and mainly consist of a chronology of events or summary of contact records. The inconsistencies in documentation are not facilitating practitioners in making good quality referrals which clearly articulate the risks of harm to the child. (Recommendation 7.2)


5.3 Training and supervision 5.3.1 Formal scheduled supervision arrangements across most health services are underdeveloped, and although there is regular supervision by the designated nurse with all named nurses, this is not stringently monitored. Adhoc advice and guidance particularly with the safeguarding advice line for community trust staff and GPs is well established. 5.3.2 Formalised supervision arrangements for both health visiting and school nursing services and recording until recently were robust, with very clear plans held on records. However ,recent changes from regular individual supervision to group sessions has significantly impacted on some practitioner’s ability to discuss all cases that are of concern, particularly those that may sit outside the periphery of formal child protection measures. As a result, some practitioners reported feeling less well supported in their role and there is a lack of management oversight of vulnerable children and their families. Current arrangements, where there is an emphasis on the practitioner to raise risk and concerns, give inadequate oversight for the levels of risk and complexity of some cases, particularly those that practitioners may not have recognised as such. (Recommendation 2.4) 5.3.3 There is no formal safeguarding preceptorship which aims to nurture community staff into safeguarding work, however all staff we spoke with felt well supported via mentors and joint working on cases to ensure they are able to identify and respond appropriately to safeguarding and child protection concerns. 5.3.4 Within the LAC team, supervision arrangements are robust and practitioners told us they felt they had appropriate protected time on a monthly basis to allow for discussion and analysis of cases. 5.3.5 CAMHS practitioners have regular clinical supervision which includes safeguarding, however, cases that are discussed in 1:1s and any decisions resulting from it are not noted on the young person’s case record in line with best practice. Cases discussed in the multi-disciplinary meeting are being routinely recorded on the case notes. 5.3.6 Whilst most providers we visited had clear expectations for training and supervision, current arrangements and compliance is not meeting targets. Many staff we spoke with are not trained at levels commensurate with their roles and responsibilities. This review identified an issue at SPFT whereby there was a lack of clarity on the training level expected and a disparity between the online and paper policy. The SPFT training policy sets out that adult mental health practitioners will undertake level 3 children’s safeguarding training, however, the trust’s intranet policy sets the expectation at level 2. There is unsurprisingly, confusion among operational and strategic managers in the trust about what the expectation is. We understand this was being clarified as a matter of urgency following our visit.


5.3.7 Level 3 training arrangements across the county are not fully multi-agency in line with statutory guidance and best practice. While the LSCB multi-agency training is available to health practitioners, frontline staff, safeguarding professionals and operational managers told us of difficulties in accessing this training, therefore many health professionals reported they had attended single agency training only. There is no mechanism in place by which trusts can monitor health staff uptake and attendance at the multi-agency training effectively. (Recommendation 7.3) 5.3.8 Training and engagement of GPs in safeguarding remains a significant challenge. This is despite the development of specific in house training sessions within practices for level 3. We were told this is now being discontinued as uptake was low, and new approaches for level 3 training are being explored. 5.3.9 East Surrey Hospital staff have recently undertaken training on CSE delivered by the local police CSE lead, and one of the named nurses has been approved to deliver CSE training to trust practitioners to ensure all staff are fully informed on the risks and their responsibilities. 5.3.10 Children who attend ED at ESH are seen by appropriately trained practitioners. The provision of paediatric trained staff in the paediatric ED at ESH is in line with guidance with two paediatric trained nurses on each shift and an emergency practitioner on duty until midnight, after which the paediatric ward staff can be consulted.

5.3.11 The quarterly safeguarding professionals’ network chaired by the designated nurse is described by named nurses as a very useful training forum and valuable to them in developing their role and safeguarding practice in settings. 5.3.12 The need for more focused safeguarding training for CASH services has been recognised by the trust as current training levels are insufficient for the role demands. A more service specific approach to training is being put into place by the Trust to be rolled out in April 2015. 5.3.13 In summary, practitioners across health services in West Sussex prioritise the safeguarding needs of children in their day to day work. However, capacity issues and transitional arrangements are significantly impacting on the pace of operational change and improvements in safeguarding and LAC services. There is more to do to further develop consistency, quality assurance and training across the health economy, to help deliver optimal outcomes for children and young people.


Recommendations 1. Coastal West Sussex, Crawley and Horsham and Mid Sussex CCG’s

with Western Sussex Hospitals NHS Foundation Trust should ensure

1.1 That the discharge letter between midwifery and GP’s clearly sets out safeguarding risks and involvement of specialist midwife

1.2 That specialist midwifery services are reviewed to include expectant mothers with perinatal mental health and substance misuse issues

1.3 That processes are established to ensure that locum staff in ED are

compliant with trust policies.

1.4 That detailed partner information is captured at booking at updated throughout pregnancy

2. Coastal West Sussex, Crawley and Horsham and Mid Sussex CCG’s

with Sussex Community NHS trust should ensure

2.1 That liaison between the emergency treatment centre and mental health assessment team at Crawley is strengthened with clear responsibilities for safeguarding assessment set out for practitioners

2.2 That actions from review health assessments are reviewed routinely as part of next health assessment, with a process for monitoring follow up actions from health plans to ensure children and young people’s needs are being met

2.3 That a quality assurance process and use of a benchmarking tool for initial

and review health assessments is established in the looked after children’s team

2.4 That supervision arrangements within health visiting and school nursing

services are monitored and new styles of supervision are evaluated with frontline staff for effectiveness and quality

2.5 That health visitors and school nurses contribute to information for review health assessments


with Sussex Partnership NHS Foundation Trust should ensure

3.1 That a long term plan to address capacity and waiting times for young people awaiting CAMHs intervention is established across the county


3.2 That arrangements for peri-natal mental health support is clarified for practitioners in the adult mental health team

3.3 That practitioners in the AMH team are proactive in their approach to

ensuring attendance at child protection meetings and that written plans are secured on client records

3.4 That access to CAMHS interventions for children who are looked after is

reviewed to ensure timely access to support

3.5 That the CAMHs team routinely liaise with the LAC health team and contribute information to inform review health assessments

3.6 That the CAMHs team are represented at the MACE forum

3.7 That access to the Framework I system in adult mental health is reviewed

for all practitioners

3.8 That a process for liaison around relapse indicators between adult mental health and health visiting teams is formalised

3.9 That a process is established for management oversight of children on child

in need and child protection plans known to the Adult mental health team

3.10 That a system to allow training compliance reporting is developed


with Surrey and Sussex NHS Trust should ensure

4.1 That a young person’s drug and alcohol pathway is established at East Surrey Hospital emergency department

4.2 That specialist midwifery services are reviewed to include expectant mothers with perinatal mental health and substance misuse issues

4.3 That engagement with the MARAC by named professionals at East Surrey Hospital is established

5. Coastal West Sussex, Crawley and Horsham and Mid Sussex CCG’s with Brighton Sussex University Hospital Trust should ensure

5.1 That individualised birth plans are developed in a consistent format in conjunction with Horsham community midwifery team

5.2 that robust liaison arrangements are established between Princess Royal midwifery service and the Horsham community team


5.3 That specialist midwifery arrangements for expectant mothers with perinatal mental health needs are reviewed.

5.4 That robust arrangements are in place to ensure all maternity bookings at

Princess Royal Hospital are reported to health visiting service for antenatal visits.

5.5 That detailed partner information is captured at booking and updated

throughout pregnancy with particular reference to ongoing assessment of risk related to “partners welcome” initiative at Princess Royal Hospital.

6. Coastal West Sussex, Crawley and Horsham and Mid Sussex CCG’s with NHS England should ensure

6.1 That a standard format for GP written contribution to child protection conferences is used consistently

6.2 That methods of increasing GP participation and attendance at child protection conferences are explored, including the use of technology.

6.3 That robust arrangements are established to increase GP and school nursing team liaison

6.4 That GP’s contribute information to the review health assessment process

6.5 That a method of flagging vulnerable families in GP practices is explored

6.6 That the recruitment of a designated doctor and named GP is prioritised as a matter of urgency with clear action plans in place if recruitment is not successful

7. Coastal West Sussex, Crawley and Horsham and Mid Sussex CCG’s with Western Sussex Hospitals NHSFT, Sussex community NHS trust, SPFT, Surrey and Sussex NHS Trust, Brighton Sussex University Hospital trust should ensure

7.1 That an agreed process to ensure all teams are informed of domestic

violence notifications is established

7.2 That an agreed format for health teams to make referrals to children’s social care is established, with clear articulation of risk set out and management oversight developed as part of a quality assurance process

7.3 That uptake of level 3 training is monitored to ensure all practitioners are

trained in accordance with their level of role and responsibility.

7.4 That staff awareness of professional dissent and escalation policy and local process is developed across all teams


7.5 That a standardised process is developed to ensure all relevant safeguarding flags and alerts are present across IT systems

8. Coastal West Sussex, Crawley and Horsham and Mid Sussex CCG’s should ensure

8.1 That the capacity and job description of the designated nurse for looked

after children is reviewed to ensure it reflects appropriate resources and in light of potential conflict of interest with operational duties

Next steps An action plan addressing the recommendations above is required from West Sussex CCGs within 20 working days of receipt of this report. Please submit your action plan to CQC through [email protected]. The plan will be considered by the inspection team and progress will be followed up through CQC’s regional compliance team.



This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

To: Trust Board

Date of Meeting: 26 November 2015 Agenda Item: 7

Title:

Nursing Staffing and Capacity Levels Report



Prepared by:


Status:

Disclosable

Summary of Proposal:

The purpose of this 6 monthly report is to provide details of the nursing staffing and capability levels for adult inpatient wards, midwifery and children’s wards across the Trust as required by the National Quality Board directive.

Implications for Quality of Care:

To consider areas of concern and provide assurance of safe nursing staff levels.

Financial Implications:

1. Financial penalties may be incurred.

2. Subsequent patient litigation claims may occur.

3. Loss of Commissioner confidence may result in loss of Trust business.

Human Resource Implications:

1. Professional performance management issues for individuals.

2. Learning and development requirements.

3. Organisational, behavioural and cultural issues.

Recommendation


Consultation:

This paper will be provided to divisions for review at their relevant meetings.

Appendices:

Appendix A – Ward assessments

Appendix B – Ward moves

Appendix C – Safer staffing – contact hours


1

Report to the Board of Directors

Nurse Staffing and Capacity Levels Report for Adult Inpatient wards,

Midwifery and Children’s Wards across Western Sussex Hospitals Foundation Trust

Executive Summary

The purpose of this report is to present to the board a review of ward establishments as directed by the National Quality Board (NQB). The NQB has

stipulated that; ‘Boards must take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective

responsibility for nursing, midwifery and care staffing capacity and capability’. Within their recommendations it states that every six months the board of directors

should receive and discuss at a public board meeting a report on staffing capacity and capability. This was requirement came following a number of national

reports.

The Francis report on Mid Staffordshire (2013) resulted in the publication of a number of documents focussing on the importance of safe nurse staffing

levels.

Keogh review into the quality of care and treatment provided in 14 hospital trusts in England (2013)

Cavendish review (2013), an independent enquiry into healthcare assistants and support workers in the NHS and social care setting.

Berwick report on improving the safety of patients in England (2013)

‘How to ensure the right people, with the right skills, are in the place at the right time. A guide to nursing, midwifery and care staffing capacity and capability’ (National Quality Board 2013).

‘Hard truths. The journey to putting patients first’ (DH, 2013)

As a result of the recommendations ‘Safe staffing for Nursing in adult inpatient wards in acute hospitals’ (NICE 2014) was developed, this provides detail on the methodology for undertaking a staffing review and, processes requirements for escalation including the introduction of ‘red flags’ which were a series of incidents that NICE identified should be reported by ward staff. These are reported through datix and reviewed each month at the triangulation meeting.

The board currently receives monthly information on the percentage of staff shifts filled. Ward staff display publicly daily information shift by shift the staff available versus those that were planned for the shift.

In November 2014 Safer staffing: A guide to care contact time was released this recommends that a contact time assessment is undertaken that would provide a baseline for each ward on the amount of contact time staff have with patients or on other nursing activities versus time that is unproductive. WSHT were a pilot for this using Boxgrove as the pilot ward, there are plans to roll out and complete an annual assessment on each ward. The initial finding can be found in Appendix C

2

The board is reminded that registered nurse workforce capacity across the local region and nationally is a challenge to all health providers. WSHT has a recruitment campaign that is focussed on national and international recruitment to reduce the current shortfall. Bank and agency staff are utilised to maintain safe staffing of wards.

This report provides information on all adult inpatient wards at WSHT and information on children wards and maternity department staffing. The Director of

Nursing is satisfied staffing in midwifery, children and neonatal care meet safe staffing requirements and is satisfied with adult wards, with one ward rated

amber this due to changes in bed numbers related to bed reconfiguration. In light of the challenges faced in recruiting to substantive posts the DN would like

to assure the board that she has confidence in the executive teams focus on the quality of care delivered and that there is no element of complacency around

ensuring patient safety is considered a priority on a day to day basis. This is evidenced by the delayed opening of areas related to the bed reconfiguration

with Birdham (WH) and Apuldram (SRH) currently remaining closed.

Adult Inpatient wards

Assessment Methodology & Findings – Current staffing data on establishments and current staff in post was provided by the Heads of Nursing with

information also taken from the rostering system. Calculating staffing requirements is not straight forward and is dependent upon a number of factors. These

include; the dependency (acuity) of patients on nursing care and factors such as skill mix of staff available and others including the culture and leadership of

the team. Training was previously undertaken by the DN and DDN with HEKSS and their staffing tools were used to undertake the safe staffing assessment.

Ward establishments have been reviewed during the bed reconfiguration programme and as ward moves related to this have occurred over the period of the

staffing review some wards are now no longer located in the same ward environment. For example Graffam patients are now located in Ford and Eartham

patients are now located in Castle. The last staffing review was presented to the board in March 2015. The methodologies used then included; ward level

engagement, triangulation, comparison, standardisation and review of safety metrics. This has been repeated for this report with additional information

provided on shift fill rates of registered nurses and triangulation against safety and quality metrics.

Presented within Appendix A are the overall planned establishments alongside the acuity assessment staffing, each ward is rated against their current staffing and the assessment undertaken in February 2015. Presented alongside are; the vacancy factor, and information on harm incidents and complaints for each ward during September. Additionally information on Friends and family feedback and staff appraisals are provided. Together these provide a picture of how safe, effective, responsive, caring and well led each ward is. Through the recent months some wards have been moved and have therefore taken on a new name, these are summarised in Appendix B. One ward is flagged as amber; Barrow, this is because the ward is currently 19 beds with a further 19 used for escalation that had started to be opened during September. Staffing therefore will need to reflect the full number of beds in use.

Vacancy Rates and Recruitment

The vacancy factor for all areas was managed by the use of bank and agency staff and the board receive a monthly dashboard summarising the

percentage of filled shifts by ward and role (registered / non registered staff) every month within the quality report. The Director of Nursing would remind

the board that during September activity had increased and a number of escalation areas within the bed reconfiguration programme were opened earlier

3

than anticipated. Therefore some wards had staff moved to ensure substantive staff supported newly opened areas and they were not totally reliant on

bank and agency staff.

WSHT is currently focussing on recruiting to both registered and non-registered staff posts.

Registered staff are being recruited through a domestic campaign which sees us now interviewing staff every two weeks. International recruitment from

the Philippines is progressing and first recruits should join WSHT in January and Staff from a European campaign where we are aiming for 40 recruits and

have seen the first nurses arriving in November.

To further support staffing we have commenced the pilot of the role that Assistant Practitioners can play in supporting the delivery of excellent care.

Assistant Practitioners are defined as; “...a worker who competently delivers health and social care to and for people. They have a required level of

knowledge and skill beyond that of the traditional healthcare assistant or support worker. The Assistant Practitioner would be able to deliver elements of

health and social care and undertake clinical work in domains that have previously only been within the remit of registered professionals. The Assistant

Practitioner may transcend professional boundaries. They are accountable to themselves, their employer, and, more importantly, the people they serve.”

(Skills for Health (2009 pg 1) - Core Standards for Assistant Practitioners). We are currently evaluating the progress on the pilot wards and taking into

consideration feedback from research and the views of the Royal College of Nursing.

Safety Metrics

Appendix A provides information by ward on safety metrics including pressure ulcers, falls with harm and clostridium difficile incidents that occurred in

September. It is acknowledged nationally that the increased use of agency staff can lead to poor patient safety and experience. This is not evidenced

during September, on reviewing the patient harm statistics presented to the board during October.

The total falls with harm in September was 42 compared to 43 in March. Pressure ulcers grade 2 - 4 there were 17 in September compared to 9 in March,

it should be noted that significant work on pressure harm has been undertaken over the recent months and this has resulted in what is believed to be

higher reporting rather than a higher incidence. This is reflected in our safety thermometer scores with a no new harms scores in September of 98.4%

compared to 99% in March. The harm free score for September was 94.9% compared to 96.6% in March. The national average harm free care score was

93.8% for 2014/15.

Further Assessment

In addition to this information the Director of Nursing undertook a review of establishments using three different methodologies for calculating staffing

requirements each includes 1WTE supervisory management role and 22% uplift for sickness, annual leave and study leave. The three methodologies are

calculated using spreadsheet calculation sets from HEKSS and the methodologies used are;

Professional judgement method.

o This reflects the staff staffing templates of each ward as set by their ward manager, matron and Head of Nursing. Standard ward

templates are attached within Appendix C though these will be augmented if patient acuity determines additional staff are required.

4

Occupied bed methodology

o This method is based on the ward speciality, ward bed numbers and assumes occupancy of 95%.

Acuity methodology

o During September ward leads collected data Monday – Friday on the acuity of patients and calculations use this and ward occupancy

during September, it should be noted this was a snapshot in time at 3 pm each day.

This information was used to give the Director of Nursing an insight into where budgeted establishments were considered sufficient to provide the care

required for patients.

Review of wards and triangulating the results from these methodologies has informed the DN assessment contained within Appendix B. In previous

reports the emergency floor was identified as having a significant discrepancy, their current funded establishment model would appear to be sound and

currently the leadership support is being evaluated. Areas where staffing numbers appeared to sit outside the methodologies previously are now better

understood have been reviewed and bar Barrow sit within recognised model establishment calculations. Barrow is flagged amber as it is staffed for 19

beds however its capacity is 38 due to 19 escalation beds and staffing needs to be recognised within their establishment for this.

Registered Nurse – Patient Ratio

Whilst there are no national recommendations on the number of patients per nurse. The Safe Staffing Alliance recommends a staffing ratio of greater than

1 registered nurse to 8 patients during the day and a ratio of 1 to 11 at night, the correlation that this is evidenced to have a direct impact on patient care

and safety. All wards with WSHFT have a budgeted established that ensures during the day the ratio of 1:8 is met. At night the funded establishment aims

to support 1:11 at night. On the Worthing site all wards bar two meet this however the 2 that do not have 23 or 24 patients therefore are considered to be

safe. On the Chichester site the ward bed numbers range from in the main from 25-27 and therefore they meet on average 1:13 at night, however

currently establishments have been reviewed and require further review once bed reconfiguration is completed as at the time of the review wards were in

transition.

There are no set recommended standards for skill mix. The Royal College of Nurses (RCN) recommended a minimum 65:35 registered nurse to non-

registered nurse split during the daytime shifts. Overall the nursing ratio for the trust is 70:30 with a range of percentages across wards in order to meet

patients dependency needs.

In the interest of safety, with regard to the patient population, wards that receive and manage highly complex patients will appropriately roster a skill mix

level greater than that i.e. the haemo-oncology wards across both sites and this is in line with the increasing complexity of care relating to intravenous

medication and chemotherapy. Alternatively some wards may have a higher establishment and lower skill mix to provide a greater level of

care/observation by support staff.

5

Escalation

Currently the Trust produces an acute site operation plan which is reported 4 times daily the site team. This is cascaded to the Chief Executive, Chief

Operating Officer, Director of Nursing and Executive Director on call together with key operational staff across the Trust. Within the body of the report

staffing levels and shortfalls are reported and mitigation plans are updated.

Ward staff display publicly daily information shift by shift the staff available versus those that were planned for the shift. An escalation process is available

for staff to follow when staffing does not meet the planned numbers and a process for recording red flag incidents is in place (Appendix A).

Summary - The Director of Nursing has triangulated the findings of the assessments and discussed them with the heads of nursing and matrons. Wards

identified as green are considered to have staffing establishment that meets the recommendations following triangulation and discussion regarding

rationale to support a differential. This includes for example; turnover of patients (number of admissions / discharges per day), specialised care and single

rooms.

Those documented as amber require a further review to consider more broadly ward layout, patient acuity and staff ratios. These wards will be prioritised

for undertaking contact hour assessments during the next 3 months prior to repeating the staffing audit in September. This next step approach is

supported by national recommendations that state that no change should be based on one data set.

6

Maternity

Introduction

Historically, the maternity dashboard is used to review the monthly number of births that have gone through the service so that any large increases seen

month-on-month can be monitored to identify fluctuation in numbers/percentage increase or fall in annual births. The total births are compared with the

number of staff in post using the Birthrate Plus standards to assess the midwife to birth ratio. The births include all viable and non-viable births that

midwives are required to give one-to-one care during the labour and directly after birth.

The Department of Health has endorsed the use of Birth Rate Plus as the definitive workforce planning tool for midwifery services. The Birth Rate Plus tool

has been used to benchmark existing establishments for midwifery and support staff within the Dartford & Gravesham NHS Trust and this is supported by

the documents of the Royal Colleges who highlight the need for a ratio of midwives to deliveries ratio to be 1.28 for safe staffing levels for the expected

birth rate (hospital births). The Birthrate Plus audit was last undertaken in December 2012, using data from both Worthing and St. Richards births to

establish the number of midwives needed in the provision of safe care to women and their babies as detailed in the recommendations of Safer Childbirth

(Royal College of Obstetricians and Gynaecologists 2007). It is recognised as good practice to conduct a full Birthrate Plus audit every few years, this is

worthy of consideration in 2016, to assess the changing needs in acuity levels.

Where the recommended numbers of staff are not in place, business and contingency plans should be implemented and their effectiveness monitored in

order to manage the situation (CNST 2012).

In February 2015, the National Institute for Health and Care Excellence published the ‘Safe Midwifery Staffing for Maternity Settings. This guideline makes

recommendations on safe midwifery staffing requirements for maternity settings, based on the best available evidence. The guideline focuses on the pre-

conception, antenatal, intrapartum and postnatal care provided by midwives in all maternity settings, including: at home, in the community, in day

assessment units, in obstetric units, and in midwifery-led units (both alongside hospitals and free-standing). This document seeks to consider this work in

line with the operational requirements at Western Sussex Hospitals NHS Trust.

Both NICE and Western Sussex Hospitals NHS Trust believes in the importance of individually assessing the care needs of each woman/newborn when

making decisions about safe midwifery staffing requirements. The assessments should take into account individual preferences and the need for holistic

care and contact time between the midwife and the woman and baby.

This guideline further outlines a description of:

The midwifery, nursing and support staff within the Maternity Service.

The recommended staffing levels.

Process for conducting audit on a twice yearly basis.

Process for the development of a business plan to address staffing shortfalls.

7

Process for the development of a contingency plan to address short term and ongoing staffing shortfalls. This staffing guidance applies to all care settings in which the Maternity Service provides care to women and their babies.

6 month audit review

A systematic process to calculate the midwifery staffing establishment is used and this is supported by the use of:

- Historical data about the number and care needs of women who have accessed Maternity Services over a sample period (for example, the past 6-12 months or longer).

- The total maternity care hours estimated to be needed over the period based on a risk categorization of women and babies in the service. - Risk factors, acuity and dependency, and the estimated time taken to perform all routine maternity care

Currently the Maternity Services does not use the calculation methodology provided by NICE (2015) and this will be considered further in the 2016

establishment planning. However, using the principles of a review every 6 months has been used comparatively which shows similar birthing data and

projected data.

Table: Total Births 2014= 2697 2015= 2680

350

400

450

500

April May June July August September

2014 2015

8

Table: Total Bookings 2014= 2841 2015= 2853

Midwifery Funded Establishment

Total funded establishment for midwives

188.2

Total number of B3 MSW’s in community supporting midwifery care

10.0

Total number of staff undertaking midwifery care

198.2

Less non clinical specialist roles (see below for explanation)

- 8.0

Less 8% (Birthrate Plus calculation for supervision and management)

-16.0

Total number of midwifery staff for clinical care

174.2

Ratio of births per clinical midwife 1:30 births 1:30 births

Specialist Roles

The specialist midwifery roles identified in Birth Rate Plus as being essential to maternity but not to be included in the clinical workforce include:

Patient Safety 2.00wte

Practice Development 1.00wte

Child Protection 1.00wte

350

400

450

500

550

April May June July August September

2014

2015

9

Antenatal Screening specialists 2.00wte

Parent Education 1.00wte

Lead Midwife for Diabetes 1.00wte

Midwife Counsellor 1.00wte

9.00wte

Minimum Staffing Levels for all clinical areas

NICE (2015) describe assessing differences in the number and skill mix of midwives needed and the number of midwives available. It recommends that

registered midwives in charge of assessing the number of midwives needed on a day-to-day basis ensure that the minimum number of midwives is

assessed in all settings.

Inpatient Services staff requirements per site

Midwives

2 shifts per 24 hour period (2x11.5hr shifts) to cover 7 day week services 161.0hrs

Midwifery template n= 9 per day shift n=8.5 per night shift

Midwifery Wte required 39.0wte

2 ward managers x 1 per site 2.0wte

+ 25% for sickness cover/AL/SD/supervision etc. 10.0wte

Midwives required for inpatient services 50.0wte per site 100.0wte

Maternity Assistants Hours for each site 4 per shift 24/7 +22.5% =823hrs

Total support workers required for each site n=22 44.0wte

Ward clerk hours provided for 2 per shift for both clinical areas equates to 5.5wte per site

Total ward clerk support each site 11.0wte

Housekeeper services per site (2 wte per site) 4.00wte

Secretarial Support band 3 (1wte per site) 2.00wte

Nursery Nurses 1.5wte per site. Review of increase in postnatal acuity, 3.00wte

skill mix on the ward and enhanced relations with neonatal unit

10

Community services

Total caseload based on 5200+ births to take into account out of area work

Community caseloads of 100 per annum per midwife requires n= 54 wte or 44wte and 10 Maternity Support Worker posts)+ 25% for sickness

cover/AL/SD/supervision 14.0wte

Total midwives required for community services (using n=10 MSW’s) 68.0wte

Ward clerk hours 2 clerks for community cover 2.0wte

Antenatal clinic including DAU both sites 12.0wte

Obstetric Theatre

Discussions with main theatre are taking place to enable St Richards’s site to have compatible services as Worthing site, 24 hour main theatre cover of

scrub nurse and OPD cover, to meet the standards set by The Association for Perioperative Practice (AfPP).

Maternity Conclusion

The midwifery staffing ratio is therefore calculated at 1:30. However, staffing has been challenging over the last 5 months, recruitment has taken place but

there has been a time deficit whilst waiting for newly qualified midwives to start thus affecting the ratio on a month by month basis. Midwifery staffing levels

are also reviewed via the Local Supervising Authority audit of staffing levels which is undertaken annually.

Maternity services are awaiting the outcome of the national Maternity Review that is due at the end of December 2015. There is likely to be due

consideration to a wider range of service delivery models which could form part of a service redesign for the future. Maternity services reviewing how

continuity of care(r) can be improved for women as well as providing a responsive and flexible approach to respond to fluctuations in activity.

11

Paediatrics

Last year’s comprehensive paediatric nursing review was undertaken to consider compliance with the new RCN 2013 guidance, defining staffing levels for

children’s healthcare.

Recommendations made from the review centred on the need to:

Increase the night nursing establishment.

Increase seniority on all shifts over the period of the next 12 months by way of the provision of a band 6 deputy sister

To consider the role of the ward sister/manager over the next 18 months, in line with that of the acute hospitals Trust.

The standards aligned to the neonatal nursing workforce are the DH Neonatal toolkit standards 2012 and the British Association of Perinatal Medicine

2011. WSHT provides compliance data through the neonatal networks and measures progress through monthly workforce audits using a nationally

validated tool.

Progress - Paediatrics

There is now sufficient senior cover at band 6/ band 6 development posts for each 24 hour period. The paediatric band 6 nurse development programme,

designed by Matron Sue Nicholls as part of the Trust Senior Nurse Development programme has continues to progress with three senior band 5’s close to

completion. This exciting development provides senior band 5 nurses the opportunity to undertake a year long programme with set objectives and

outcomes, which prepares them well for the next stages of their career. The programme was designed in acknowledgement that there is little currently

available to support the career pathway at this level, and it is envisaged that this will provide a perfect platform for those who want to take the next

substantive steps in to clinical leadership roles.

The ward sisters currently undertake 1 – 2 supernumerary shifts per week, not unlike their colleagues on general wards. It is acknowledged that this can

leave the role of the ward sister with significant competing demands in terms of the day to day running of the ward and importantly providing the required

support for his/her team.

Current models and audit - Paediatrics

The current model has a seasonal variation recognising the changes in both activity and acuity. However, the last couple of years has not shown

evidence of the seasonal variation traditionally seen in our hospitals, with additional pressures seen in terms of activity and dependency. Table’s 1 and 2

shows the reasonably constant demand in terms of admissions in the two hospitals. In addition the increased activity seen suggests a significant increase

of 8.64% increase on the Worthing site and 18.6% on the St Richards Hospital site

12

Table 1 Worthing

Table 2 St Richards

Audits undertaken in the winter of 2014 and summer of 2015, have shown areas of concern in with meeting 2013 standards. On occasions compliance

has been achieved by providing flexibility across the child health clinical areas from both clinical sites, particularly when there is sudden, unexpected

sickness or high acuity.

Although the RCNs guidance recommends the use of validated tools to audit the workforce requirements, currently the only one available (PANDA) has

not been used on general paediatric wards, and is more aligned to tertiary centres. However, NICE are expected to publish their guidance on staffing

levels for children’s wards in the next year.

0

100

200

300

400

500

August September October November December January February March April May June July

2012/13

2013/14

2014/15

0

100

200

300

400

500

August September October November December January February March April May June July

2012/13

2013/14

2014/15

13

The audits look to see compliance by measuring our ability to provide a nurse to patient ratio of:

1:3 for under 2’s

1: 4 for over 2’s

1:2 for HDU care

1:1 for specialling CAMHs

1: 3 for ‘Intensification of treatment ie Oncology/CF’

Tables 3 and 4 illustrate the difficulties we have experienced in the summer months to meet the required standards: Green = compliant/Amber =

compliant, with staff moved from other areas/Red= non-compliant (i.e. escalation failed)

Table 3 Worthing Table 4 St Richards

74.0%

17.0%

8.0%

1

2

3

23%

16% 61%

Red

Amber

Green

14

Conclusions

There is sufficient evidence to suggest the Nurse to patient ratio recommended is compromised, particularly during the summer months analysed. In

order to rectify this, the ward model will be adjusted within budget to ensure there is a year round model.

Areas not managed by Women and Child Health

One area of concern relates to their being insufficient children’s nurses in A & E on the SRH site. Currently this is an area of non-compliance to the

intercollegiate standards required, and the medical division has been supported in developing a business case to take regard of this.

In order to fully explore areas across the Trust where children form a part of the workload, a Children’s Board has been launched to look at how we can

develop the best pathways for children, so that their care is child centred and delivered or supported by those with the right skill set and knowledge.

Progress – Neonatal Nursing

The DH toolkit sets out the standards for the training and staffing requirements for Neonatal units, dependent on their intended level of acuity, and activity

levels. There has been some difficulty largely on the St Richards site in training and maintaining sufficient nurses ‘qualified in speciality’. These nurses

qualified in speciality are highly regarded, and strategies to retain them are always sought. These might include enhanced career pathways, rotations

through tertiary care, and or leadership opportunities.

Audits of our compliance with current standards are undertaken routinely, with no current concerns being obvious.

REF: Defining staffing levels for Children and young people’s Services – 2013

Neonatal Toolkit Standards DH 2012

15

APPENDIX A

Metric Apr May Jun Jul Aug Sep Safe - Effective - Responsive Caring - Well led

FFT 95.6% 96.2% 95.9%

Complaints 0 0 0

Appraisal Rate 78.80% 76.00% 78.60%

Funded Est 34.64 34.64 34.64 34.64 34.64 35.86

Actual Est 29.17 29.17 29.17 29.17 29.17 29.24

Vacancy 5.47 5.47 5.47 5.47 5.47 6.62

RN Day Fill 95.7% 96.1% 97.0% 97.4% 98.4% 96.7%

RN Night Fill 97.5% 97.6% 96.7% 97.6% 98.4% 93.3% 94

P Ulcers 0 1 0

Falls - harm 0 3 0

C Diff 0 0 0

FFT 94.6% 94.4% 94.5%

Complaints 0 0 0

Appraisal Rate 97.70% 97.70% 93.00%

Funded Est 69.45 69.45 69.45 69.45 69.45 69.45

Actual Est 67.75 67.75 67.75 67.75 67.75 66.01

Vacancy 1.70 1.70 1.70 1.70 1.70 3.44

RN Day Fill 95.7% 97.2% 95.9% 93.9% 94.6% 95.7%

RN Night Fill 96.8% 97.8% 94.6% 94.7% 95.6% 94.1% 94

P Ulcers 0 0 0

Falls - harm 0 0 0

C Diff 0 0 0

FFT 100.0% 86.7% 100.0%

Complaints 0 0 0

Appraisal Rate 67.50% 66.70% 36.60%

Funded Est 35.19 35.19 35.19 35.19 34.33 34.30

Actual Est 32.68 32.68 32.68 32.68 30.74 30.74

Vacancy 2.51 2.51 2.51 2.51 3.59 3.59

RN Day Fill 97.8% 96.8% 98.5% 99.3% 93.9% 95.6%

RN Night Fill 98.3% 93.5% 98.3% 98.4% 87.1% 88.3% 94

P Ulcers 0 0 0

Falls - harm 0 1 1

C Diff 0 0 0

Acute Cardiac Unit

Medical SRH

25 beds

Occupancy 100%

Staffing

Assesment v Acuity

35.4 WTE

Feb Sept

Acute Medical Unit

Medical SRH

43 beds

Occupancy 96%

Staffing

Assesment v Acuity

62.2 WTE

Feb Sept

Ashling

Medical SRH

26 beds

Occupancy 96%

Staffing

Assesment v Acuity

34.6WTE

Specials x 1/2

Feb Sept

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill 0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill 0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill 90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

16

FFT 100.0% 100.0% 50.0%

Complaints 1 0 0

Appraial Rate 80.0% 83.9% 63.6%

Funded Est 25.27 25.27 25.27 25.27 25.27 26.91

Actual Est 23.04 23.04 23.04 23.04 23.04 21.29

Vacancy 2.23 2.23 2.23 2.23 2.23 5.62

RN Day Fill 97.7% 96.6% 96.5% 97.2% 93.8% 92.4%

RN Night Fill 100.0% 98.4% 96.7% 100.0% 100.0% 98.3%

P Ulcers 0 0 0

Falls - harm 0 1 1

C Diff 0 0 0 0 0 1

FFT 94.7% 90.9% 85.7%

Complaints 0 1 0

Appraisal Rate 63.0% 50.0% 65.2%

Funded Est 25.27 25.27 25.27 25.27 25.27 29.36

Actual Est 23.5 23.5 23.5 23.5 23.5 20.99

Vacancy 1.77 1.77 1.77 1.77 1.77 8.37

RN Day Fill 98.0% 99.0% 97.3% 98.1% 98.7% 97.0%

RN Night Fill 100.0% 98.9% 97.8% 100.0% 100.0% 100.0%

P Ulcers 0 0 0

Falls - harm 5 4 0

C Diff 0 0 0

FFT

Complaints

Appraisal Rate

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill

P Ulcers

Falls - harm

C Diff

Birdham

Medical WH

Beds reconfiguration

currently closed

Becket

Medical WH

22 beds

Occupancy 98.8%

Staffing

Assesment v Acuity

29.9 WTE

Feb Sept

Barrow*

Medical WH

19 beds

Occupancy 66%

+19 beds

Staffing

Assesment v Acuity

28.1 WTE

Specials x 1/2

Feb Sept88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1 2 3 4 5 6

Complaints

Appraisal Rate

FFT

Funded Est

Actual Est

Vacancy

17

FFT 87.50% 96.30% 100.00%

Complaints 0 0 0

Appraisal Rate 35.50% 30.00% 28.10%

Funded Est 36.02 36.02

Actual Est 20.9 20.9

Vacancy 15.12 15.12

RN Day Fill 97.1% 97.2% 99.6% 98.4% 96.0% 95.8%

RN Night Fill 95.0% 98.4% 100.0% 100.0% 95.2% 91.7%

P Ulcers 0 0 1

Falls - harm 0 1 0

C Diff 0 0 0

FFT 97.7% 96.2% 93.9%

Complaints 0 0 0

Appraial Rate 94.7% 86.8% 94.9%

Funded Est 40.35 40.35 40.35 40.35 40.35 40.33

Actual Est 34.9 34.9 34.9 34.9 34.9 32.07

Vacancy 5.45 5.45 5.45 5.45 5.45 8.26

RN Day Fill 94.7% 94.8% 93.1% 91.5% 92.9% 88.5%

RN Night Fill 94.4% 94.6% 93.3% 97.8% 91.4% 94.4%

P Ulcers 0 0 2

Falls - harm 2 0 2

C Diff 0 0 0

FFT 91.70% 78.60% 93.80%

Complaints 1 0 0

Appraisal Rate 66.70% 61.50% 59.50%

Funded Est 33.89 33.89 33.89 33.89 33.89 32.89

Actual Est 31.14 31.14 31.14 31.14 31.14 33.51

Vacancy 2.75 2.75 2.75 2.75 2.75 0

RN Day Fill 97.9% 98.0% 97.5% 94.8% 96.4% 98.3%

RN Night Fill 95.0% 96.8% 98.3% 88.7% 91.9% 95.0%

P Ulcers 1 2 1

Falls - harm 2 1 6

C Diff 0 0 0

Bosham #

Surgical SRH

26 beds

Occupancy 96%

Feb staffed as escalation

only

Staffing

Assesment v Acuity

29.4 - 34.4WTE

Specials x 1/2

Feb Sept

Botolphs

Medical WH

28 beds

Occupancy 87.8%

Staffing

Assesment v Acuity

28.4 WTE

excludes thrombo RN

Feb Sept

Boxgrove

Medical SRH

27 beds

Occupancy 100%

Staffing

Assesment v Acuity

29.4 - 34.4WTE

Specials x 1/2

Feb Sept

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill 0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

18

FFT 90.50% 80.00% 92.30%

Complaints 0 0 0

Appraial Rate 69.00% 77.80% 84.60%

Funded Est 29.61 29.61 29.61 29.61 29.61 29.61

Actual Est 24.8 24.8 24.8 24.8 24.8 24.8

Vacancy 4.81 4.81 4.81 4.81 4.81 4.81

RN Day Fill 95.1% 93.4% 96.0% 99.1% 90.4% 92.0%

RN Night Fill 96.7% 98.4% 100.0% 100.0% 95.2% 100.0%

P Ulcers 0 2 1

Falls - harm 0 2 2

C Diff 0 0 0

FFT 97.00% 84.20% 72.70%

Complaints 0 0 0

Appraisal Rate 95.70% 95.70% 95.00%

Funded Est 30.54 30.54 30.54 30.54 30.54 27.94

Actual Est 23.2 23.2 23.2 23.2 23.2 21.99

Vacancy 7.34 7.34 7.34 7.34 7.34 5.95

RN Day Fill 92.1% 93.7% 94.1% 94.7% 92.3% 83.2%

RN Night Fill 91.7% 96.8% 95.0% 100.0% 98.4% 96.7%

P Ulcers 1 0 0

Falls - harm 0 0 0

C Diff 0 0 0

FFT 100.00% 83.30% 88.90%

Complaints 0 0 0

Appraial Rate 88.90% 88.90% 80.80%

Funded Est 27.89 27.89 27.89 27.89 27.89 31.32

Actual Est 24.6 24.6 24.6 24.6 24.6 24.55

Vacancy 3.29 3.29 3.29 3.29 3.29 6.77

RN Day Fill 100.0% 99.0% 96.0% 96.7% 95.2% 85.1%

RN Night Fill 100.0% 98.4% 98.3% 100.0% 100.0% 98.3%

P Ulcers 0 4 0

Falls - harm 1 0 3

C Diff 0 0 0

Broadwater

Medical WH

22 beds

Occupancy 100%

Staffing

Assesment v Acuity

28.1 WTE

Specials x 1/2

Feb Sept

Brooklands

Medical WH

22 beds

Occupancy 100%

Staffing

Assesment v Acuity

28.1 WTE

Specials x 1/2

Feb Sept

Buckingham

Medical WH

22 beds

Occupancy 100%

Staffing

Assesment v Acuity

32 WTE

Specials x 1/2

Feb Sept

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

19

FFT 100.00% 100.00% 90.60%

Complaints 0 0 0

Appraisal Rate 96.60% 96.40% 85.70%

Funded Est 33.76 33.76 33.76 33.76 33.76 29.37

Actual Est 27.8 27.8 27.8 27.8 27.8 26.8

Vacancy 5.96 5.96 5.96 5.96 5.96 2.57

RN Day Fill 96.9% 99.6% 97.3% 97.0% 91.2% 94.6%

RN Night Fill 94.5% 100.0% 97.3% 100.0% 96.0% 98.6%

P Ulcers 0 0 2

Falls - harm 0 0 0

C Diff 0 0 0

FFT 94.50% 92.90% 98.10%

Complaints 0 2 0

Appraial Rate 100.00% 100.00% 97.60%

Funded Est 22.12 22.12 22.12 22.12 22.12 24.83

Actual Est 18.95 18.95 18.95 18.95 18.95 26.56

Vacancy 3.18 3.18 3.18 3.18 3.18 0

RN Day Fill Not required

RN Night Fill

P Ulcers 0 0 2

Falls - harm 0 0 0

C Diff 0 0 0

FFT 97.80% 100.00% 94.40%

Complaints 0 0 0

Appraial Rate 91.70% 94.10% 97.10%

Funded Est 25.98 25.98 25.98 25.98 25.98 29.32

Actual Est 30.23 30.23 30.23 30.23 30.23 5.07

Vacancy 0 0 0 0 0 24.25

RN Day Fill 98.1% 99.1% 99.5% 100.0% 98.6% 97.6%

RN Night Fill 96.7% 100.0% 98.3% 100.0% 96.8% 95.0%

P Ulcers 0 0 2

Falls - harm 0 0 1

C Diff 1 0 0

Chichester Suites

Private SRH

16 +10 beds

Occupancy 62%

Staffing

Assesment v Acuity

23.5 WTE

Feb Sept

Chilgrove

Surgical SRH

22 beds

Occupancy 91%

Staffing

Assesment v Acuity

28.7 WTE

Feb Sept

Burlington

Medical WH

18 beds

Occupancy 96%

Staffing

Assesment v Acuity

29.4 WTE

Specials x 1/2

Feb Sept

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

105.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

20

FFT 94.40% 95.90% 99.10%

Complaints 0 0 0

Appraisal Rate 97.10% 94.10% 91.20%

Funded Est 28.31 28.31 28.31 28.31 28.31 29.81

Actual Est 25.9 25.9 25.9 25.9 25.9 25.35

Vacancy 2.41 2.41 2.41 2.41 2.41 4.47

RN Day Fill 96.0% 99.0% 98.0% 97.1% 95.2% 93.1%

RN Night Fill 98.3% 98.4% 100.0% 100.0% 98.4% 100.0%

P Ulcers 1 0 0

Falls - harm 0 1 1

C Diff 0 0 0

FFT 92.90% 95.00% 94.40%

Complaints 2 0 0

Appraial Rate 16.10% 50.00% 58.60%

Funded Est 21.2 21.2 21.2 21.2 21.2 30.02

Actual Est 25.5 25.5 25.5 25.5 25.5 25.04

Vacancy 0 0 0 0 0 4.98

RN Day Fill 96.7% 97.6% 95.0% 98.0% 96.4% 90.4%

RN Night Fill 96.7% 98.4% 96.7% 100.0% 98.4% 98.3%

P Ulcers 0 0 1

Falls - harm 0 0 0

C Diff 0 0 0

FFT 96.80% 90.50% 92.90%

Complaints 0 0 0

Appraisal Rate 82.80% 73.30% 74.10%

Funded Est 28.8 28.8 28.8 28.8 28.8 28.89

Actual Est 25.1 25.1 25.1 25.1 25.1 21.59

Vacancy 3.7 3.7 3.7 3.7 3.7 7.3

RN Day Fill 97.9% 98.8% 98.3% 90.7% 92.3% 89.2%

RN Night Fill 98.3% 98.4% 100.0% 100.0% 98.4% 100.0%

P Ulcers 0 0 1

Falls - harm 0 0 0

C Diff 0 0

Chiltington

Surgical WH

21 beds

Occupancy 95%

Staffing

Assesment v Acuity

31.7 WTE

Feb Sept

Clapham

Surgical WH

27 beds

Occupancy 93%

Staffing

Assesment v Acuity

31.7 WTE

Feb Sept

Coombes

Surgical WH

21 beds

Occupancy 96%

Staffing

Assesment v Acuity

30 WTE

Recognises special use

Feb Sept

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

21

FFT 100.00% 97.90% 100.00%

Complaints 0 0 0

Appraial Rate 100.00% 96.70% 96.60%

Funded Est 28.57 28.57 28.57 28.57 28.57 28.01

Actual Est 22.7 22.7 22.7 22.7 22.7 26.23

Vacancy 5.87 5.87 5.87 5.87 5.87 1.78

RN Day Fill 98.3% 94.0% 96.3% 96.4% 94.8% 92.5%

RN Night Fill 96.7% 97.6% 89.2% 96.0% 96.0% 95.8%

P Ulcers 0 0 0

Falls - harm 1 0 0

C Diff 0 0 0

FFT 91.70% 75.00% 89.50%

Complaints 2 0 0

Appraisal Rate 96.20% 96.20% 91.70%

Funded Est 29.8 29.8 29.8 29.8 29.8 29.32

Actual Est 20.5 20.5 20.5 20.5 20.5 20

Vacancy 9.3 9.3 9.3 9.3 9.3 9.32

RN Day Fill 97.6% 97.7% 99.5% 96.3% 95.9% 94.8%

RN Night Fill 98.3% 98.4% 100.0% 100.0% 100.0% 100.0%

P Ulcers 1 0 0

Falls - harm 2 0 0

C Diff 0 0 0

FFT 100.00% 100.00% 100.00%

Complaints 0 0 0

Appraial Rate 92.30% 92.30% 92.60%

Funded Est 21.89 21.89 21.89 21.89 21.89 21.89

Actual Est 20.65 20.65 20.65 20.65 20.65 20.65

Vacancy 1.24 1.24 1.24 1.24 1.24 1.24

RN Day Fill Not available

RN Night Fill

P Ulcers 0 0 0

Falls - harm 0 0 1

C Diff 0 0 0

Courtlands

Medical WH

17 beds

Occupancy 88%

Staffing

Assesment v Acuity

28.7 WTE

Feb Sept

Ditchling

Medical WH

24 beds

Occupancy 100%

Staffing

Assesment v Acuity

29.38 WTE

Feb Sept

Donald Wilson House

Medical SRH

12 beds

Occupancy 83.3%

Staffing

Assesment v Acuity

20.7 WTE

Feb Sept

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill94.00%

95.00%

96.00%

97.00%

98.00%

99.00%

100.00%

101.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

102.00%

0.0

5.0

10.0

15.0

20.0

25.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

22

FFT 100.00% 100.00% 87.50%

Complaints 0 0 0

Appraial Rate 98.40% 93.80% 97.70%

Funded Est 12.92 12.92 12.92 12.92 12.92 15.46

Actual Est 9.9 9.9 9.9 9.9 9.9 13.62

Vacancy 3 3 3 3 3 1.84

RN Day Fill Not required

RN Night Fill

P Ulcers 0 0 0

Falls - harm 0 0 1

C Diff 0 0 0

FFT 100.00% 100.00% 87.50%

Complaints 0 0 0

Appraial Rate 96.60% 92.60% 88.90%

Funded Est 24.56 24.56 24.56 24.56 24.56 29.32

Actual Est 28.7 28.7 28.7 28.7 28.7 25.82

Vacancy 0 0 0 0 0 3.5

RN Day Fill 98.6% 99.5% 93.3% 96.3% 93.5% 92.4%

RN Night Fill 100.0% 100.0% 100.0% 100.0% 98.4% 100.0%

P Ulcers 0 1 1

Falls - harm 0 1 1

C Diff 0 0 0

FFT 88.70% 81.80% 87.90%

Complaints 0 1 0

Appraisal Rate 74.10% 70.40% 63.00%

Funded Est 29.56 29.56 29.56 29.56 29.56 28.59

Actual Est 25.4 25.4 25.4 25.4 25.4 24.98

Vacancy 4.16 4.16 4.16 4.16 4.16 3.61

RN Day Fill 97.6% 96.8% 97.1% 98.2% 95.9% 91.9%

RN Night Fill 100.0% 98.4% 98.3% 100.0% 100.0% 100.0%

P Ulcers 0 0 0

Falls - harm 0 1 0

C Diff 0 0 0

Durrington

Medical WH

23 beds

Occupancy 100%

Staffing

Assesment v Acuity

28.7 WTE

Feb Sept

Eartham

Medical WH

23 beds

Occupancy 100%

Staffing

Assesment v Acuity

28.6 WTE

Feb Sept

Downlands

Private WH

9 beds

Occupancy 67%

Staffing

Assesment v Acuity

14.2 WTE

Feb Sept

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill80.00%

85.00%

90.00%

95.00%

100.00%

105.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill80.00%

85.00%

90.00%

95.00%

100.00%

105.00%

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

1 2 3 4 5 6

Complaints

FFT

Appraial Rate

Funded Est

Actual Est

Vacancy

23

FFT 98.10% 95.10% 87.80%

Complaints 0 0 0

Appraisal Rate 64.30% 64.30% 60.70%

Funded Est 30.26 30.26 30.26 30.26 30.26 28.59

Actual Est 24.7 24.7 24.7 24.7 24.7 22.61

Vacancy 4.6 4.6 4.6 4.6 4.6 5.98

RN Day Fill 96.3% 96.4% 97.5% 96.4% 94.0% 80.0%

RN Night Fill 96.7% 98.4% 100.0% 100.0% 96.8% 96.7%

P Ulcers 1 1 0

Falls - harm 2 3 0

C Diff 0 0 0

FFT 95.40% 100.00% 87.80%

Complaints 1 0 0

Appraisal Rate 29.60% 31.60% 30.20%

Funded Est 121.22 121.22 121.22 121.22 121.22 116.81

Actual Est 105.7 105.7 105.7 105.7 105.7 97.35

Vacancy 15.5 15.5 15.5 15.5 15.5 19.46

RN Day Fill 95.4% 94.0% 90.6% 94.2% 92.3% 89.2%

RN Night Fill 97.0% 97.1% 94.2% 98.2% 95.0% 98.2%

P Ulcers 1 1 0

Falls - harm 0 0 0

C Diff 0 0 0

FFT 100.00% 100.00% 100.00%

Complaints 0 0 0

Appraisal Rate 93.30% 80.00% 80.00%

Funded Est 15.21 15.21 15.21 15.21 15.21 15.21

Actual Est 14.15 14.15 14.15 14.15 14.15 14.15

Vacancy 1.06 1.06 1.06 1.06 1.06 1.06

RN Day Fill 99.2% 100.0% 99.2% 100.0% 100.0% 99.2%

RN Night Fill 100.0% 100.0% 98.3% 100.0% 100.0% 98.3%

P Ulcers 0 0 0

Falls - harm 0 0 0

C Diff 0 0 0

Enhanced Surgical Care

Unit

Surgical WH

5/6 beds

Occupancy

Staffing

Assesment v Acuity

14.8 WTE

Feb Sept

Eastbrook

Medical WH

23 beds

Occupancy 96%

Staffing

Assesment v Acuity

28.8 WTE

Feb Sept

Emergency Floor

Medical WH

67 beds

Occupancy 82%

Staffing

Assesment v Acuity

115 WTE

assumes 20% 1a /2 &

60% 1b

Feb Sept

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

100.5%

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

24

FFT 86.80% 84.60% 89.50%

Complaints 0 0 0

Appraisal Rate 92.00% 88.00% 76.00%

Funded Est 28.54 28.54 28.54 28.54 28.54 29.86

Actual Est 25.7 25.7 25.7 25.7 25.7 25.34

Vacancy 2.3 2.3 2.3 2.3 2.3 4.62

RN Day Fill 97.1% 98.6% 97.6% 97.2% 93.5% 95.2%

RN Night Fill 100.0% 100.0% 98.3% 100.0% 100.0% 98.3%

P Ulcers 2 0 0

Falls - harm 3 0 1

C Diff 0 0 1

FFT 86.10% 97.40% 100.00%

Complaints 0 0 0

Appraisal Rate 78.90% 65.00% 66.70%

Funded Est 23.93 23.93 23.93 23.93 23.93 33.00

Actual Est 28.68 28.68 28.68 28.68 28.68 28.56

Vacancy 0 0 0 0 0 4.44

RN Day Fill 97.9% 96.0% 95.8% 97.2% 98.8% 97.1%

RN Night Fill 100.0% 93.5% 96.7% 96.8% 98.4% 93.3%

P Ulcers 0 1 0

Falls - harm 1 2 3

C Diff 0 0 0

FFT 9.60% 100.00% 6.00%

Complaints 1 1 0

Appraisal Rate 83.80% 81.60% 70.30%

Funded Est 34.65 34.65 34.65 34.65 34.65 31.6

Actual Est 33.67 33.67 33.67 33.67 33.67 25.69

Vacancy 0.8 0.8 0.8 0.8 0.8 5.91

RN Day Fill 96.7% 92.6% 95.7% 95.8% 98.4% 94.3%

RN Night Fill 96.7% 87.1% 95.6% 94.6% 97.8% 90.0%

P Ulcers 0 0 1

Falls - harm 3 0 1

C Diff 0 0 0

Erringham

Medical WH

23 beds

Occupancy 95%

Staffing

Assesment v Acuity

28.8 WTE

Feb Sept

Fishbourne

Medical SRH

26 beds

Occupancy 100%

Staffing

Assesment v Acuity

34.4 WTE

Feb Sept

Ford

Medical SRH

26 beds

Occupancy 82%

Staffing

Assesment v Acuity

32 WTE

Feb Sept

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

25

FFT 100.00% 95.00% 0.00%

Complaints 1 0 0

Appraisal Rate 0.00% 0.00% 0.00%

Funded Est 29.39 29.39 29.39 29.39 29.39 29.39

Actual Est 28.94 28.94 28.94 28.94 28.94 28.94

Vacancy 0.45 0.45 0.45 0.45 0.45 0.45

RN Day Fill 99.3% 98.7% 100.0% 98.7% 100.0% 100.0%

RN Night Fill 100.0% 96.8% 100.0% 98.4% 100.0% 100.0%

P Ulcers 0 0 0

Falls - harm 0 0 0

C Diff 0 0 0

FFT 92.90% 90.70% 94.60%

Complaints 1 0 0

Appraisal Rate 84.20% 94.60% 83.80%

Funded Est 33.82 33.82 33.82 33.82 33.82 35.49

Actual Est 30.48 30.48 30.48 30.48 30.48 30.75

Vacancy 5.39 5.39 5.39 5.39 5.39 4.74

RN Day Fill 93.7% 91.0% 97.4% 96.8% 96.4% 95.9%

RN Night Fill 85.0% 91.9% 98.3% 95.2% 93.5% 90.0%

P Ulcers 0 0 0

Falls - harm 0 2 1

C Diff 0 0 0

FFT 93.30% 96.70% 94.70%

Complaints 2 0 0

Appraisal Rate 57.90% 83.80% 75.00%

Funded Est 31.84 31.84 31.84 31.84 31.84 36.78

Actual Est 26.64 26.64 26.64 26.64 26.64 32.28

Vacancy 5.2 5.2 5.2 5.2 5.2 4.58

RN Day Fill 96.3% 98.8% 94.6% 99.6% 98.0% 100.0%

RN Night Fill 100.0% 100.0% 96.7% 98.4% 96.8% 98.3%

P Ulcers 1 2 2

Falls - harm 1 1 1

C Diff 0 0 0

Middleton

Medical SRH

26 beds

Occupancy 100%

Staffing

Assesment v Acuity

30.7 WTE

Feb Sept

Graffham

Medical SRH

12 beds

Occupancy

Staffing

Assesment v Acuity

ward now closed

Feb Sept

Lavant

Medical SRH

26 beds

Occupancy 94%

Staffing

Assesment v Acuity

30.7 WTE

Feb Sept

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill78.00%

80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

26

FFT 72.70% 100.00% 100.00%

Complaints 0 0 0

Appraisal Rate 69.00% 64.30% 64.30%

Funded Est 33.44 33.44 33.44 33.44 33.44 26.35

Actual Est 22.37 22.37 22.37 22.37 22.37 28.36

Vacancy 11.01 11.01 11.01 11.01 11.01 0

RN Day Fill 99.4% 99.5% 100.0% 98.4% 98.4% 98.9%

RN Night Fill 96.7% 100.0% 100.0% 100.0% 98.4% 98.3%

P Ulcers 0 2 1

Falls - harm 0 1 1

C Diff 0 0 0

FFT 97.90% 95.80% 89.30%

Complaints 0 0 0

Appraisal Rate 48.40% 66.70% 62.10%

Funded Est 33.56 33.56 33.56 33.56 33.56 33.21

Actual Est 24.19 24.19 24.19 24.19 24.19 26.13

Vacancy 9.37 9.37 9.37 9.37 9.37 7.08

RN Day Fill 94.0% 97.1% 96.1% 96.7% 96.6% 95.7%

RN Night Fill 96.7% 96.8% 98.9% 95.7% 96.8% 96.7%

P Ulcers 0 0 0

Falls - harm 1 1 0

C Diff 0 0 0

FFT 89.50% 100.00% 95.90%

Complaints 0 0 0

Appraisal Rate 81.50% 80.00% 80.50%

Funded Est 32.43 32.43 32.43 32.43 32.43 36.02

Actual Est 25.39 25.39 25.39 25.39 25.39 32.83

Vacancy 7.04 7.04 7.04 7.04 7.04 3.19

RN Day Fill 96.7% 96.0% 95.4% 97.6% 98.8% 96.7%

RN Night Fill 98.3% 95.2% 96.7% 95.2% 98.4% 93.3%

P Ulcers 0 0 0

Falls - harm 0 0 1

C Diff 0 0 0

Petworth*

Medical SRH

20 beds

Occupancy %

Staffing

Assesment v Acuity

30.7 WTE

Feb Sept

Selsey

Surgical SRH

26 Beds

Occupancy 73%

Staffing

Assesment v Acuity

28.7 WTE

Feb Sept

Wittering

Surgical SRH

26 beds

Occupancy 92%

Staffing

Assesment v Acuity

28.7 WTE

Feb Sept

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

101.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

C Diff

Falls - harm

P Ulcers

Funded Est

Actual Est

Vacancy

RN Day Fill

RN Night Fill0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 2 3 4 5 6

Complaints

FFT

Appraisal Rate

Funded Est

Actual Est

Vacancy

27

APPENDIX B

Ward Moves

Worthing

November Eartham moved to Castle acute medicine ( general medicine and endocrine)

November Broadwater (DoME) moved to Eartham now acute medicine (H/F, respiratory and gastro)

SRH

Aug/Sept Ford moved to Ashling (respiratory)

Ashling – Middleton (#NOF)

Graffham – Ford (oncology/haematology

Graffham – Emergency Floor

AMU – now Emergency Floor

28

APPENDIX C

Safer Staffing: Contact Hours

This paper aims to provide an update about the ward review of nurse care contact time conducted between June and September 2015 in response to the recommendations

set out in the NHS England Safer Staffing: A Guide to Care Contact Time which was published in November 2014. This guidance sits alongside the national quality board

guidance for safe staffing.

The Trust already publishes ward level staffing information and has a process in place for evidenced based review of baseline staffing levels every six months. The new

guidance states an expectation that all acute Trusts will undertake a baseline assessment of care contact time by summer 2015 and repeat on a six monthly basis or

following a change in ward circumstances. The addition of care contact monitoring is to ensure that staffing reviews focus on the delivery of safe patient care rather than

the number of available staff. The care contact assessment does not replace the current staffing level reviews but should be used alongside them to provide a clear picture

for local and strategic review.

Methodology

There is no recommendation from NHS England about the best tool for contact hours review, however it is important that the same tool is used for each review as there is

considerable variation in methodology. The Trust used the activity clock approach when taking part in the national pilot during the summer 2014 and therefore continued

with this approach for the 2015 review. This is far less demanding of clinical staff time than other methods for activity monitoring.

The approach is summarised as follows:

Each ward conducts a review of one night shift and one day shift

On the chosen shift all ward staff (RN and HCAS) will carry a paper based “clock” and used this to record the activities that they are carrying out throughout the

shift.

The activity recorded is summarised as either direct, indirect care time or non- patient focussed activity. The table below summarises the categories used:

29

Direct Care(Nursing) Direct Care(Process) Indirect Care(Nursing) Non patient activities

Meals

Medications

Patient Communication

Nursing Procedures

Patient hygiene

Patient Observations

Off ward with Patient

Ward Round

Admissions

Discharges

Shift Handover

Nursing Documentation

Face to face /telephone

professional discussion

Relative communication

Environmental/cleanliness

Ordering patient tests

Student support

Break

Ordering stocks

Search for items

Staff training

Off ward without patient

The clocks were submitted to the patient experience team for data entry and analysis.

The ward sister/matron received a summary of the RN and HCA activities showing the proportion of nursing time spent on direct care, indirect care, associated

work and unproductive time.

The ward sister/matron will review the types of activity undertaken. Where there are higher than expected levels of non-patient activities, these should be explored

to identify what proportion are “do not add value” activities and what proportion are legitimate and important non-contact activities.

The matrons/heads of nursing will review the contact hours data alongside the Safer Nursing Care measurement of acuity and dependency, patient flow and patient

experience and outcome measures when setting ward establishments.

Results

Nineteen wards gathered data during this time period; the remaining wards will complete their contact hours reviews in the Spring 2016 following ward reconfiguration

changes.

The table below summarises the overall contact time spent in direct /indirect and non- patient activity.

30

DAY

Direct Care Indirect Care Non- patient activity

RN HCA RN HCA RN HCA

Overall 59% 67% 29% 20% 12% 12.5%

Range 52% to 74% 52% to 82% 16% to 37.5% 8% to 39% 6% to 21.5% 7% to 22%

NIGHT

Direct Care Indirect Care Non- patient activity

RN HCA RN HCA RN HCA

Overall 63.5% 65.5% 27% 22% 9.7% 13%

Range 46% to 88% 50% to 80% 12% to 42% 10% to 30% 0% to 15% 7% to 32%

As can be seen there is a wide range of recorded contact time, this compares with the national pilot results showed RN direct care time ranging between 38% to 61% and

HCA direct care time ranging between 64% and 86%.

Data Quality

Direct comparison from an overall contact time perspective must be treated with caution. The value of this exercise is the local scrutiny of activity by ward sisters and

matrons to understand where there are opportunities to reviews ways of working and to understand the differences between wards with similar a patient group. It must

also be noted that for many staff this was the first time they had used this tool which will lead to inevitable data quality challenges.

Recommendations

There are a number of opportunities already identified for further exploration. These include:

Interruptions to care/medication rounds in the evening when there is no ward clerk cover.

Amount of time spent cleaning items by HCAs and the possibility of this being carried out by another staff group

31

Time spent accompanying patients off the ward to investigations( there are different portering guidelines on each site)

Review of the ward coordinator role

Review of the involvement of RNs at mealtimes and review of patient observations.

Review of impact of EPMA and increasing use of electronic recording of nursing assessments contact time.

Lisa Ekinsmyth

Head of Patient Experience

November 2015

1

Title

Performance Report – Month 7


Jane Farrell, Chief Operating Officer/Deputy Chief Executive

Prepared by

Adam Creeggan, Director of Performance

Giles Frost, Assistant Director, Operational Planning and Performance

Status

Disclosable

Summary of Proposal

The paper sets out organisational compliance against national and local key performance metrics. The report summarises both in year and projected year end performance for Western Sussex Hospitals NHS Foundation Trust, as detailed in dedicated performance scorecards relating to Quality Board indicators aligned to the Quality Strategy, the Monitor Risk Assessment Framework and, when relevant, other efficiency indicators. This paper describes performance on an exceptional basis determined by RAG rating, national significance, or in year trend analysis.


Describes Quality Outcome KPIs


Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing on a range of measures to improve clinical effectiveness.

Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial performance and investing in appropriate infrastructure and capacity.

Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation.


Describes KPIs linked to financial performance.


Describes KPIs linked to workforce.

Recommendation



N/A

Appendices

Appendix 1: Key Performance Deliverables, Operational Performance Scorecard, Monitor Risk Assessment Framework Scorecard.

To: Trust Board


2

To: Trust Board Date: 26 November 2015

From: Jane Farrell, Chief Operating Officer/Deputy Chief Executive Agenda Item: 8

FOR INFORMATION

WSHFT PERFORMANCE REPORT: MONTH 7, 2015/16 1. INTRODUCTION

1.1 This report summarises both in year and projected year end performance for Western Sussex

Hospitals NHS Foundation Trust, detailed in dedicated performance scorecards relating to:

The Monitor Risk Assessment Framework

Other efficiency indicators, where relevant.

1.2 This paper describes performance on an exceptional basis determined by RAG rating, national

significance, or in year trend analysis.

1.3 In addition to the performance exception narrative, each exception is examined in detail in the

Key Performance Deliverables section of this report. Each metric under review examines detailed

trending, prevailing cause and effect, and summarises recovery programme actions.

2. SUMMARY PERFORMANCE

2.1 Based on provisional Month 7 positions, the Monitor Risk Assessment Framework performance is

notionally two points. This relates to continued ‘managed fail’ in Referral to Treatment (RTT) as

part of an agreed recovery planning process, and provisional under-performance for cancer 62

day referral to treatment patients.

2.2 The Trust had 6 cases of C.difficile in October. This generates an aggregate volume of 25 cases

in the year to date against a full year target of no greater than 39 cases.

3

2.3 Key indicators of operational pressure during October include:

11,651 A&E attendances compared to 11,161 in October 2014 (+4.4%).

4,551 emergency admissions compared to 4,140 in October 2014 (+9.9%). When

scrutinised by age group there was a 10.9% increase in 65-84 years and a 13.5%

increase in >=85 years October 2015 compared to October 2014.

Formally reportable delayed transfers of care totalled 3.41% for October 2015. This

excludes patients who are medically fit for discharge but have not been classified as

delayed transfers under national guidance as a multi-disciplinary case review had

not taken place.

Occupancy of funded bed stock was 95.4% for October 2015.

3. PERFORMANCE EXCEPTIONS 3.1 A&E Compliance

3.1.1 The Trust was fully compliant in October with 95.47% of patients waiting less than four hours

from arrival at A&E to admission, transfer, or discharge, against a national target of 95%.

3.1.2 Latest national data relates to September 2015 and shows National compliance to be 90.1%.

Regional compliance for South of England was 89.5%, with Surrey/Sussex Trusts (excluding

WSHFT) generating aggregate compliance of 90.6%. Excluding WSHFT, only Surrey & Sussex

Hospitals NHS Trust delivered compliance among Surrey/Sussex Trusts.

3.1 Cancer

3.1.1 The provisional position for October shows the Trust to be compliant against 6 out of 7 Cancer

metrics as projected in the Month 6 Board report.

3.1.2 The Trust is provisionally below target for 62 day referral to treatment patients in October, with

84.6% of patients seen within 62 days against a target of 85%. Board members are reminded that

data is provisional at the point of writing, and subject to both reporting of external partners and

the outcome of pathology reporting post procedure. Inclusive of the provisional October position,

Quarter 2 is fully compliant at the point of writing at 85.7%.

3.1.3 Compliance is set within the context of a 27.7% increase in treatment activity, and a 21.8%

increase in 2 week urgent referrals July – October 2015 compared to the same period 2014.

3.1.4 For context, latest nationally published data relating to September 2015/16 shows national

aggregate compliance for cancer attendance to be 93.3% for 2 week rule (target 93%), 92.8% for

symptomatic breast (target 93%), and treatment within 62 days to be 81.5% (target 85%).

4

3.2 Referral to Treatment (RTT/18 Weeks) 3.2.1 The Trust completed 11,435 RTT patient pathways in October and remains 1985 (2.5%) cases

ahead of planned recovery volumes.

3.2.2 Cumulative referrals exceed recovery plan levels by 4,010 cases (3.7%). The subset of referrals

that are suspected as having cancer or are urgent has increased by 9.6% on the same period of

the previous year.

3.2.3 In conjunction with the over-performance of pathway completion at WSHFT, redeployment of

Independent Sector capacity through the WSHFT hosted RTT Programme Management Office

(PMO) has increased backlog completion to drive compliance and offset in year referrals above

plan.

3.2.4 Coupled with closer alignment of referrals to plan since Month 5, additional throughput has

improved incomplete compliance from 85.7% in September to 86.6% in October as forecast in

the Month 6 Performance Report. The latter is inclusive of a negative effect of changes to

national guidance from 1st October 2015 regarding the removal of pauses in the waiting time

calculation. The effect of this change is equivalent to -0.4%, therefore the like for like position for

October would have been 87.1%.

3.2.5 Despite improved performance in recent months, referral demand remains a critical risk to

sustained delivery of the RTT recovery programme. As part of actions agreed with

Monitor/NHSE, WSHFT will support Coastal West Sussex CCG in working with secondary and

primary care clinicians to develop refreshed demand management plans that support genuine

and sustained reduction in referral to secondary care. An initial task group meeting is scheduled

for early December with senior clinical and management representation from both organisations.

3.2.6 Latest national data relates to September 2015 and shows National compliance to be 92.2%.

Across the South of England Region compliance was 90.6%, with Surrey/Sussex Trusts

(excluding WSHFT) generating aggregate compliance of 90.8%.

3.3 Fractured Neck of Femur (#NOF) operation within 36 hours of admission

3.3.1 During October, 93.22% of medically fit Fractured Neck of Femur (#NoF) patients were operated

on within 36 hours of admission against a target of 90%.

3.4 Diagnostic Test Waiting Times

3.4.1 Restricted access to diagnostic capacity provided by organisations outside WSHFT, and excess

demand for diagnostics, generated a rapid decay in compliance during Quarter 2, peaking at

6.28% in September against a target of 1%. During the month 248 of 5,837 patients waited over 6

weeks, a reduction of 33.9% in the peak volume of 375 observed in September.

5

3.4.2 Extensive recovery actions have been implemented across five key diagnostic procedure types:

MRI: 1,870 tests undertaken in September 2015 compared to 1,432 September 2014

(+30.6%). 2001 tests were undertaken in October (+23.7%), and compliance has been

restored to 0.5% in October in this test modality via this additional throughput.

NOUS: reallocation of sonographer and radiologist resources implemented in August, and

additional sessions in September creating an additional 181 slots. As planned, these

actions have significantly reduced breach volumes and compliance to 0.1% in October.

Gastroscopy/Flexi-sigmoidoscopy/colonoscopy– a combination of atypical demand and

unplanned consultant vacancies generated a rapid increase in scoping breaches.

Extensive actions taken to increase scoping capacity, and October breaches reduced to

75 from 185 in Sept.

DEXA scans – additional external capacity has been secured at Sussex Medical

Chambers, and existing capacity restored at BMI Goring Hall Hospital. These solutions

now provide surplus capacity above demand that will facilitate compliance restoration by

January 2016.

Neurophysiology – this service is provided via visiting clinicians from PHT/BSUH, and

recovery actions have been agreed to commence in October that extend existing capacity

through premium rate out of hours sessions. These actions support restoration of

compliance by January 2016.

3.4.3 The Trust continues to run significantly ahead of planned levels to meet demand. During October,

a total of 14,439 tests/procedures were carried out in comparison to 13,256 in October 2014

(+8.9%). As per planned compliance recovery actions, activity levels continue to exceed planned

levels in key modalities:-

Imaging Tests: 10,617 October 2015 compared to 9,750 October 2014 (+8.9%)

Diagnostic Scoping: 2,280 scopes October 2015 compared to 1,756 October

2014 (+29.8%)

3.4.4 For comparative purposes, the most recent national data (September 2015) shows compliance

across England to have deteriorated from 2.2% to 2.3%. For Trusts in the South of England

Region aggregate compliance was 2.4%, with the Surrey/Sussex acute Trusts (excluding

WSHFT) generating aggregate compliance of 4.5%. With the Surrey/Sussex patch, Brighton and

Sussex University Hospitals (10.2%) and Royal Surrey County Hospitals (7.1%) reported the

highest levels of non-compliance.

6

4 RECOMMENDATION

4.1 The Board is asked to receive the Month 7 positions, and note the notional compliance score of 2

points (Amber/Green) against the Monitor Risk Assessment Framework.

Adam Creeggan, Director of Performance

Giles Frost, Assistant Director - Operational Planning and Performance

20th November 2015

Mark Dennis, Head of Information Servicest: 01903 285273 (ext 5273)

OCTOBER 2015

Description / Comments / Actions

Month YTD Projected O/T

95.47% 96.81% >95%

Actions:

1. Enhanced discharge planning arrangements

2. Augmented patient flow arrangements in conjunction with external partners

3. Dedicated operational delivery plan in place under the leadership of the Chief

Operating Officer



97.82% 92.96% >93%

Actions:

1. Dedicated weekly action focused delivery meeting under the leadership of the Chief

Operating Officer

2. Mitigation actions agreed with health partners including enhanced advice and

guidance for GP's from WSHT consultant staff prior to referral, improved feedback

mechanism for GP on appropriateness of referral, and real time access to referral data

by GP practice, conversion to a cancer pathways and volumes receiving definitive

treatment for malignancy.



97.85% 89.25% >93%

Actions:


Operating Officer

2. Mitigation actions agreed with health partners including enhanced advice and

guidance for GP's from WSHT consultant staff prior to referral, improved feedback

mechanism for GP on appropriateness of referral, and real time access to referral data

by GP practice, conversion to a cancer pathways and volumes receiving definitive

treatment for malignancy.

Cancer - 62 days from referral to treatment following screening contact Description / Comments / Actions


92.86% 95.33% >90%

Actions:

1. Transitional leadership for MDT/tracking supported by GM - Access.

2. Augmented pathway management/tracking with enhanced oversight through DCS

led Cancer Delivery Group

3. Close working with the screening service to maximise the time available to the Trust

to secure capacity


Operating Officer

Patients with cancer can expect to commence treatment within 62 days following

referral after a positive screening test.Target

90%

Delays in receipt of onward referral from screening which reduces the time to secure

capacity to treat patients.

Cancer - Two weeks from urgent GP referral to first appt - Breast symptoms

Significant increases in demand level observed from Q1 2013/14.

Cancer - Two weeks from urgent GP referral to first appointment

Target

Target Patients with breast symptoms can expect to be seen within 2 weeks following an

urgent GP referral.93%

Significant increases in demand level observed from Q1 2013/14.

Key Performance Deliverables ReportA&E 4-hour waiting time target

Target

95%

Patients can expect to be admitted, transferred or discharged in 4 hours from arrival in

A&E

Significant increase in underlying acuity observed from early 2013/14

93.0%

Patients can expect to be seen within 2 weeks following an urgent GP referral for

suspected cancer.

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

70%

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Actual Target

8a. Key Deliverables Report - M7.Exception Report Page 1 of 2 Printed 20/11/2015 10:33

Mark Dennis, Head of Information Servicest: 01903 285273 (ext 5273)

OCTOBER 2015Key Performance Deliverables Report



84.62% 86.63% >85%

Actions:

1. Transitional leadership for MDT/tracking supported by GM - Access.

2. Augmented pathway management/tracking with enhanced oversight through DCS

led Cancer Delivery Group

3. Close working with the screening service to maximise the time available to the Trust

to secure capacity


Operating Officer



86.61% 0.00% < 92%

Actions:

1. Short term increase in internal capacity


Operating Office



93.94% 90.13% >90%

Actions:

1. Improved tracking and escalation processes in place to manage fluctuations in

demand on daily basis

% Medically fit hip fracture patients going to theatre within 36 hours

Target

Increased levels of demand have impacted sustained compliance. Mitigating actions

implemented by the Surgical Division have significantly improved performance.

To ensure the best possible outcomes, hip fracture patients who are medically fit

should be operated on within 36 hours of admission. This standard is part of the 'Best

Practice Tariff' payment process under PbR.90%

Non-compliance an expected outcome of planned RTT recovery programme.

85%

Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity

to treat patients.

92.0%

Cancer - 62 days from referral to treatment following urgent referral by a GP.

Target

Referral to treatment - Incomplete Pathways

Target All patients can expect to commence treatment within 18 weeks of a referral to

consultant.

Patients with cancer can expect to commence treatment within 62 days following

urgent referral by a GP.

70%

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

8a. Key Deliverables Report - M7.Exception Report Page 2 of 2 Printed 20/11/2015 10:33

Mark Dennis, Head of Information Services

t: 01903 285273 (ext 5273)

OCTOBER 2015

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

2015/16

YTD

2015/16

Target Trend

NATIONAL AND OPERATIONAL PERFORMANCE TARGETS

O01A&E : Four-hour maximum wait from arrival to admission, transfer

or discharge95.96% 95.39% 94.47% 85.99% 94.09% 95.73% 97.73% 98.22% 96.82% 97.39% 97.71% 97.28% 94.80% 95.47% 96.81% 95%

O02 Cancer: 2 week GP referral to 1st outpatient1

96.04% 95.35% 95.06% 95.12% 94.15% 93.09% 89.63% 85.30% 92.13% 94.14% 93.68% 93.21% 94.00% 97.82% 92.96% 93%

O03 Cancer: 2 week GP referral to 1st outpatient - breast symptoms1

96.82% 97.27% 93.41% 92.41% 92.41% 97.02% 84.88% 74.32% 85.51% 92.27% 96.55% 93.18% 83.24% 97.85% 89.25% 93%

O04 Cancer: 31 day second or subsequent treatment - surgery1

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00% 94%

O05 Cancer: 31 day second or subsequent treatment - drug1

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98%

O06 Cancer: 31 day diagnosis to treatment for all cancers1

98.21% 99.57% 100.0% 99.50% 98.85% 100.0% 98.93% 99.18% 99.57% 98.84% 99.59% 99.57% 100.00% 98.52% 99.3% 96%

O07 Cancer: 62 day referral to treatment from screening 1

88.10% 85.71% 86.84% 100.0% 93.75% 89.47% 91.94% 100.0% 81.82% 100.00% 94.44% 97.96% 100.00% 92.86% 95.3% 90%

O08 Cancer: 62 day referral to treatment from hospital specialist 1

91.30% 85.71% 80.00% 82.35% 100.0% 81.82% 93.75% 100.0% 85.3% 85.7% 78.1% 86.2% 81.5% 75.0% 83.25% N/A

O09 Cancer: 62 days urgent GP referral to treatment of all cancers 1

89.70% 85.27% 86.77% 87.61% 87.24% 91.23% 84.80% 89.10% 86.94% 84.72% 87.50% 87.60% 88.00% 84.62% 86.63% 85%

O12 RTT - Admitted - 90% in 18 weeks 88.18% 88.80% 87.22% 88.57% 88.45% 85.30% 85.88% 85.49% 86.05% 85.26% 84.88% 85.69% 85.63% 87.50% 0.00% 90%

O13 RTT - Non-admitted - 95% in 18 weeks 88.37% 88.13% 86.30% 86.83% 86.06% 86.04% 84.50% 85.28% 86.45% 86.60% 84.74% 85.78% 81.32% 82.62% 0.00% 95%

O14 RTT - Incomplete - 92% in 18 weeks 92.48% 90.27% 90.05% 89.64% 88.18% 87.71% 87.79% 87.87% 88.24% 87.66% 85.81% 84.99% 85.70% 86.61% 0.00% 92%

O15RTT delivery in all specialties

(Incomplete pathways)3 7 7 10 12 12 10 12 11 12 11 11 10 11 11 0

O16 Diagnostic Test Waiting Times 0.93% 0.92% 1.66% 3.07% 1.46% 0.99% 1.17% 0.86% 1.43% 1.44% 3.43% 4.56% 6.28% 4.28% 0.00% <1%

O17 Cancelled operations not re-booked within 28 days 1 1 2 3 10 2 0 1 1 0 2 0 1 1 1 -

O18 Urgent operations cancelled for the second time 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -

O19Clinics cancelled with less than 6 weeks notice for annual/study

leave23 16 30 41 84 30 24 17 19 26 33 35 14 30 30 -

O20 Mixed Sex Accommodation breaches 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0

O33 Delayed transfers of care2

3.22% 2.97% 2.45% 3.40% 3.55% 3.69% 3.69% 3.77% 3.08% 3.43% 3.42% 3.17% 3.97% 3.41% 3.5% 3.5%

IMPROVING CLINICAL PROCESSES

O23 % hip fracture repair within 36 hours 98.1% 84.0% 86.3% 90.3% 100.0% 98.5% 90.6% 98.5% 92.7% 93.7% 95.5% 90.6% 84.0% 93.9% 90.1% 90%

O24Patients that have spent more than 90% of their stay in hospital on

a stroke unit+

194.3% 97.2% 95.7% 98.2% 85.7% #N/A #N/A 93.7% 80%88.3%

OPERATIONAL PERFORMANCE

SCORECARD

91.3% 89.2%

8b. Operational Performance Scorecard M7.SCORECARD Page 1 of 2 Printed 20/11/2015 10:36


t: 01903 285273 (ext 5273)

OCTOBER 2015

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

2015/16

YTD

2015/16

Target Trend

OPERATIONAL PERFORMANCE

SCORECARD

OPERATIONAL EFFICIENCY

O36 Average length of stay - Elective 2.96 2.97 2.96 3.12 3.00 3.48 3.36 3.28 3.09 3.09 3.12 2.87 3.05 3.07 3.08 3.72

O37 Average length of stay - Non-elective Surgery 5.95 5.77 6.52 5.58 5.65 5.28 5.84 5.84 5.41 5.06 5.44 4.96 5.49 6.01 5.45 6.07

O38 Average length of stay - Non-elective Medicine 7.50 7.30 7.42 7.31 7.92 8.24 7.60 7.83 7.25 7.59 7.34 7.20 7.70 7.28 7.45 7.80

O39Day case rate - CQC basket of procedures

source: Dr Foster (reported 2-3 months in arrears)87.77% 87.96% 86.98% 88.73% 85.93% 86.47% 86.77% 86.50% 85.32% 85.31% 84.93% #N/A #N/A #N/A 85.50% 75.0%

O40 Elective day of surgery rate (DOSR) 97.6% 97.9% 97.2% 97.7% 98.1% 97.9% 98.5% 99.0% 97.5% 98.0% 97.1% 98.7% 99.1% 98.8% 98.3% 90.0%

O41 Did not attend rate (outpatients) 6.72% 6.65% 6.47% 6.45% 6.62% 6.61% 6.60% 6.50% 6.54% 6.59% 6.46% 6.76% 7.18% 6.87% 6.65% 7.65%

SUSTAINABILITY

O43 Bank staff - % of all staff pay 6.47% 6.08% 5.63% 6.59% 6.99% 6.44% 6.73% 6.57% 6.33% 6.20% 8.82% 6.76% 6.31% 6.51% 6.79% 7%

O44 Agency staff - % of all staff pay 5.65% 6.27% 4.87% 5.76% 6.45% 5.99% 5.82% 6.62% 5.61% 6.48% 5.61% 8.54% 9.03% 10.36% 7.46% 2%

O45 Nurse : occupied bed ratio 2.062 2.047 2.026 1.913 1.791 1.785 1.866 1.846 1.846 1.944 1.949 1.982 1.875 1.844 1.898 -

O46 % nurses who are registered 72.71% 72.70% 72.62% 72.50% 72.40% 72.18% 71.87% 71.64% 71.56% 71.65% 71.69% 71.64% 71.56% 71.42% 71.59% -

O47 % Staff appraised 78.80% 78.97% 78.98% 77.75% 77.09% 77.54% 76.58% 77.61% 77.33% 76.69% 77.40% 78.70% 78.29% 79.41% 79.41% 90%

O48Sickness Absence: % Sickness

(reported one month in arrears)

34.18% 4.61% 4.33% 4.51% 4.91% 4.34% 3.85% 3.56% 3.82% 3.65% 3.93% 3.86% 3.74% #N/A 4.09% 3.3%

O49 Staff Turnover: Turnover rate (YTD position) 7.03% 7.32% 7.74% 7.83% 8.00% 8.12% 8.39% 8.57% 8.73% 8.87% 9.01% 9.16% 9.51% 9.37% 9.37% 11%

ACTIVITY

A01 Day Cases 4,773 4,811 4,576 4,543 4,911 4,571 5,168 4,879 4,562 5,395 5,518 4,950 5,242 5,478 36,024 35,583

A02 Elective Inpatients 733 760 811 688 661 722 686 659 660 819 836 671 671 680 4,996 5,696

A03 Non-elective inpatients 5,012 5,182 4,867 5,334 5,267 5,012 5,290 5,246 5,370 5,174 5,441 5,062 5,112 5,573 36,978 36,437

A04 Outpatient First attendances 16,089 15,715 14,907 14,564 15,704 14,240 16,425 16,443 15,321 17,861 16,981 14,319 17,070 16,300 114,295 112,400

A05 Outpatient Follow-up attendances 25,587 27,325 25,386 24,503 26,826 25,386 27,718 27,341 26,048 29,938 28,932 24,129 28,177 28,353 192,918 187,297

A06 Outpatients with procedure 4,853 5,020 4,787 4,581 5,146 4,527 4,707 5,046 4,935 6,095 5,878 5,095 5,761 5,308 38,118 32,540

A07 A&E Attendances 11,383 11,162 10,786 11,101 9,885 9,459 11,059 11,010 11,599 11,508 12,068 11,682 11,276 11,651 80,794 84,239

1 National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification.

2 Data are provisional best estimates and will be amended to reflect the position signed-off in the relevant statutory returns in due course.

3 Staff sickness is reported one month in arrears.

Notes

8b. Operational Performance Scorecard M7.SCORECARD Page 2 of 2 Printed 20/11/2015 10:36


t: 01903 285273 (ext 5273)

OCTOBER 2015

Threshold Apr May Jun Q1Weighted

Score Jul Aug Sep Q2Weighted

Score Oct Nov Dec Q3Weighted

Score Jan Feb Mar Q4

Weighted

Score

(Forecast)

ACCESS

M1Maximum time of 18 weeks from point of referral to treatment in

aggregate – admitted90% 85.49% 86.05% 85.26% 85.26%


aggregate – non-admitted95% 85.28% 86.45% 86.60% 85.28%


aggregate – patients on an incomplete pathway92% 87.87% 88.24% 87.66% 87.66% 85.81% 84.99% 85.70% 84.99% 1.0 86.61% 86.61% 1.0

M5A&E: maximum waiting time of four hours from arrival to

admission/transfer/discharge95% 98.22% 96.82% 97.39% 97.46% 0.0 97.71% 97.28% 94.80% 96.63% 0.0 95.47% 95.47% 0.0

M6a All cancers : 62-day wait for first treatment following urgent GP Referral 85% 89.10% 86.94% 84.72% 86.96% 87.50% 87.60% 88.00% 87.58% 84.62% 84.62%

M6bAll cancers : 62-day wait for first treatment following consultant screening

service referral90% 100.00% 81.82% 100.00% 94.12% 94.44% 97.96% 100.00% 95.35% 92.86% 92.86%

M7aAll cancers : 31-day wait for second or subsequent treatment - surgery

treatments94% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 98.48% 100.00% 100.00%

M7bAll cancers : 31-day wait for second or subsequent treatment - drug

treatments98% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

M8 All cancers : 31-day wait from diagnosis to first treatment 96% 99.18% 99.57% 98.84% 99.21% 0.0 99.59% 99.57% 100.00% 98.76% 0.0 98.52% 98.52% 0.0

M9a Cancer : two week wait from referral to date first seen - All patients 93% 85.30% 92.13% 94.14% 90.47% 93.68% 93.21% 94.00% 93.59% 97.82% 97.82%

M9bCancer : two week wait from referral to date first seen - Symptomatic

breast patients93% 74.32% 85.51% 92.27% 84.08% 96.55% 93.18% 83.24% 91.15% 97.85% 97.85%

OUTCOMES

M17 Clostridium Difficile – meeting the Clostridium Difficile objective 39 0 5 2 7 0.0 3 3 5 11 0.0 7 7 0.0

M27Certification against compliance with requirements re access to healthcare

for people with a learning disabilityYES YES YES YES YES 0.0 YES YES YES YES 0.0 YES YES 0.0

3.0 2.0 2.0

Notes

i From 1 October 2013 MRSA was removed from the Monitor Risk Assessment Framework

ii Targets for admitted and non-admitted completed RTT pathways have been removed from Monitor's risk assessment framework with effect from 24 June 2015.

Monitor Risk Assessment Framework

0.0 0.0

2.0

Monitor Compliance Framework Score

0.0

1.0

0.0

1.0

Green : 0 Amber/Green : 1 Amber : 2 Amber/Red : 3 Red : 4 or more

0.0

1.0

0.0

9c. Monitor Scorecard M7.SCORECARD Page 1 of 1 Printed 20/11/2015 10:37


To: Trust Board


Title:

Organisational Development and Workforce Performance Report


Denise Farmer, Director of Organisational Development and Leadership

Prepared by:

Jennie Shore, Deputy Director of Human Resources

Status:

Disclosable

Summary of Proposal:

This report details the Trust’s performance in relation to the supply, development and engagement of its workforce and the organisations culture.

Implications for Quality of Care:

Provision of high quality, engaged staff has a direct impact on the quality of care.

Financial Implications:

Supports good financial performance.

Human Resource Implications:

As described.

Recommendation


Consultation:

N/A

Appendices:

1: Workforce Scorecard


To: Trust Board

Date: 26 November 2015

From: Denise Farmer, Director of Organisational Development

and Leadership

Agenda Item: 9

FOR INFORMATION

ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT 1.00 INTRODUCTION 1.01 This sets out the key performance indicators relating to the Trust’s workforce at 31 October

2015. 2.00 SUMMARY OF PROPOSAL 2.01 Workforce Capacity During October the amount of FTE used increased by 90 wte, representing total workforce

capacity of 98.6%. The number of substantive staff increased by 36 wte and substantive staff accounted for 85% of overall capacity.

With the exception of the Core and Women and Children’s Divisions, the use of bank reduced in month to 7%, although the use of agency staff increased by 1% to 5%. This was experienced in all divisions and medical agency in particular continues to drive high spend.

We await the outcome of the consultation by Monitor and the NHS TDA regarding a proposal

to cap prices for agency staff at 55% above NHS rates from April 2016. In the meantimire Monitor has required the Trust to secure nursing agency staff via approved framework agreements. Reporting on the occasions when we override this rule is now in place with the first return due on 25 November. We welcome any national support in reducing the cost of agency to the Trust and driving out non-framework agencies.

As part of the range of specific measures to reduce the reliance on agency staff, the Trust

aligned its bank pay rate for nursing staff to that at BSUH. Overall fill rates over the last 4 weeks (to w/e 15.11.15) for RN’s is 83%, with 42% capacity from bank and 58% capacity met by agency (including 19% from non-framework agency). This compares to fill rates for the preceeding 4 weeks (to w/e 18.10.15) for RN’s of 80.6%, with 45% capacity from bank and 55% by agency (including 18% from non-framework agency).

2.02 Recruitment activity Increasing workforce capacity remains a priority across the Trust and during October 21

registered nurses joined the Trust. There are another 27 scheduled to join during November, including 7 from Spain and this will be supplemented by a further 19 during December. We have been advised that the first 23 nurses will be joining from the Philippines during January, in an unregistered capacity in the first instance.

Volumes of recruitment activity remains high and between 1 April and 31 October 2015, there

were 229 new joiners to the Trust, including 86 medical staff. A further 79 staff joined the staff bank. This does not reflect internal recruitment activity.

of 6

The recruitment KPI’s show that against a standard of 72 days, the Time to Hire is 62 days for Medical Staff and 68.1 days for Nursing staff. Actions that will drive improvement are:

Review of the authorisation process

Widening membership of ACCEA panel to improve availability

Increase capacity of the recruitment team following benchmarking exercise in order to support compliance against team KPI’s increases

Reduce shortlisting time through improved diary planning at outset

Additional training to managers in the use TRAC Progress of actions will be monitored through the Workforce Transformation Board.

2.03 Flu campaign Despite promotion through workplace vaccinators and occupational health, at 31%, uptake of

this year’s influenza vaccine remains 8% lower than at the same time last year. 1235 staff healthcare workers with direct patient care have received the vaccine. Promotion will continue.

2.04 Junior Doctors dispute

The BMA has announced proposed dates for industrial action following a 98% vote in favour by its membership in protest against the Government’s proposal to change the junior doctors’ contract and pay. The BMA has said that action would begin with an emergency care-only model, which would see junior doctors provide the same level of service that happens in their given specialty, hospital on Christmas Day: Emergency care only – from 8am Tuesday 1 December to 8am Wednesday 2 December The industrial action would then be escalated to a full walk-out by junior doctors: Full walk out – from 8am to 5pm, Tuesday 8 December and Wednesday 16 December. A letter has been sent to all junior doctors urging them to carefully consider the effect and impact on patients at the Trust of any action that they may take. Nothwithstanding the response by the Government, contingency plans are now being urgently advanced in the event that negotiations with the BMA are unsuccessful.

2.05 Staff Survey 2015 The national staff survey 2015 closes on Friday 27 November. At 19 November, 3,121 staff

had completed and returned their survey, representing a response rate of 48% (compared to the final response rate of 56% in 2014). This compares to an average of 33% for acute trusts. Final reminders have been distributed to all areas, and contain a further copy of the questionnaire included. It is hoped that this will boost response rates by 10-15%. The league tables are:

Division:

Trust 48%

Core 59%

Corporate 66%

Medicine 41%

Surgery 40%

Staff Group:

Add Prof Scientific and Technic 61%

Additional Clinical Services 46%

Administrative and Clerical 63%

Allied Health Professionals 59%

Estates and Ancillary 44%

of 6

Facilities & Estates 43%

W&C 46%

Healthcare Scientists 58%

Medical and Dental 29%

Nursing and Midwifery Registered 45%

Those areas with low response rates are being encouraged to support staff to complete their surveys. Promotion of the 2014 response has continued during October through Headlines, Staffnet, posters and loo media and a number of divisions have incorporated briefing events for staff to meet the senior team and hear about the actions taken since last year. Resources relating divisional action plans have been uploaded onto StaffNet.

2.06 Equality and Diversity A community engagement event to inform the Trust’s EDS 2 objectives has been arranged for

8 December in Bognor Regis. The venue is very popular with a number of hard to reach groups and attendance is expected to be good.

I am also pleased to advise the Board that since the last Diversity Matters Group, Nick McEvoy

has been appointed to the chair of the LGBT forum. Nick’s local knowledge of issues affecting our community will strengthen the work of the forum.

In preparation for this year’s annual monitoring report, the E&D team is currently collating

examples of good practice and initiatives undertaken across the Trust during 2015. The Board will be asked to approve this report in January.

2.07 Long Service Awards A number of long service awards for 2015 have been held within the Trust with over 100 staff

celebrating 25, 30 and 40 years in the NHS. 13 staff reached their 40 year milestone with recognition from members of the Board.

2.08 Staff Benefits During October and November the range of staff benefits available through salary sacrifice

arrangements has been extended from bikes to mobile phones and home electronics (including computers, TV’s, game consoles and kitchen equipment). Uptake for delivery by Christmas is expected to be popular with staff.

2.09 Employee Partnership Forum Away Day Our fourth EPF away day was held during October as part of our work to strengthen

relationships with staff side colleagues. It was agreed that a toolkit would be developed to support managers to manage their change processes to include early engagement with staff and their representatives prior to subsequent consultation processes. Staff side colleagues also agreed to support the dissemination of the response to the Staff Survey and continue to encourage completion of the 2015 questionnaire.

2.08 Workforce Efficiency

Sickness absence during September reduced to 3.7% with the rolling 12 month position remaining at 4.1%. The proportion of staff on long term sickness reduced in month, with the exception of Women and Children. Short term sickness increased in the majority of Divisions across the Trust and this is reflected in the increased number of episodes.

of 6

The management of absence within the Facilities and Estates divisions continues to yield improved productivity and at the end of September the rolling 12 month position was 5.9%. In the last year, absence rates have reduced by 1%, with an annual saving of circa. £120k. During September the in-month position was 4.6% absence.

2.09 Staff Retention During October, the rolling 12 month turnover rate held broadly steady at 9.4%. With the

exception of Core and Women and Children, the number of staff leaving the Trust fell. Whilst it is too soon to assess the impact of the recently introduced Stay Interviews, this is encouraging.

In the meantime we are determining the number of staff who are eligible to retire (from aged 55

years onwards) over the next 5 years, and modeling against the age of actual retirees during the last 2 years. This will help to more accurately predict our likely retirees.

2.10 Appraisals The number of appraisals undertaken increased in month to 79.4% and reflects the focused

attention from all Divisions. Facilities and Estates has the lowest compliance but action plans are in place to address this in the next 3 months.

2.11 Workforce Skills and Development

Statutory and Mandatory Training The percentage of staff undertaking statutory and mandatory training increased in month to

80.4% with an improvement across all modules.

DNAs The DNA rate for training is currently 7.3% (an decrease of 1% since last month

Progress re staff who have never attended any mandatory training The number of staff who have never attended any mandatory training, or have not attended any mandatory training for more than a year has decreased again this month and is currently as follows: Not attended any training for more than 12 months 0 (figure for last month was 0)

Never attended any Mandatory training (and started in the Trust more than 3 months ago) 6 (figure for last month was 7)

We will continue to work with Divisions to ensure that these individuals completed their training as soon as possible.

Apprenticeships

Activity is slowly growing in the Trust with both existing staff beginning apprentice programmes and managers converting existing posts into apprentice posts.

The Rotational Apprentices (joint project with West Sussex County Council) have started their new placements and the project was presented at the National Skills Academy for Health ‘Working Together’ Conference on the 11th November. The presentation was met with much

of 6

interest and we are pleased to be one of the first, and to date the most successful pilots to have run across the HEKKS region.

We have recently recruited 9 new HCA’s apprentices to work across the medical division, 4 of these will be in Worthing and 5 in St Richards. It is hoped that clinical apprentices will become integral to the skill mix on the wards.

In the first 3 quarters of the year we have 50 apprentices starts planned. This is a long way of our predicted trust target of 77 starts and way below the 113 starts that Health Education Kent, Surrey and Sussex have tasked us with completing this year. Managers need to be encouraging their existing staff to undertake apprenticeship qualifications, which are funded by learning and development, and also looking at whether band 1-4 posts vacancies could be converted into apprenticeships.

Supported Internships

The supported internship programme (aimed at young people aged 16-25 who have special educational needs) is now underway. They have spent around 3 weeks on placement and have been told by the tutors that they have settled in well, we hope that it will continue this way.

The students who are on placement from Northbrook and Chichester College will be fully supported in the workplace. .

Work Experience

Dates have been set for the 2016 work experience weeks aimed at year 10 and 11 students. The week will run both at SRH and Worthing. It is anticipated that we will also run 2 large career events in the trust during the summer of 2016. It is hoped that we will run this in partnership with other local NHS trusts and West Sussex County Council

2.12 Communications and Engagement The communications team has continued to provide support for the Trust’s nursing recruitment

campaign and specifically the Open and Selection Days held throughout the summer:

• Wednesday 25 November at St Richard’s Hospital • Monday 7 December at St Richard’s Hospital This has included promotion of the event both on and offline as well as the creation of resources promoting the organisation as an employer. Details can be found at www.westernsussexhospitals.nhs.uk

Two public exhibitions were held this month regarding the development of the Trust’s new

ophthalmology outpatients department at Southlands. The service will be called Western Sussex Eye Care | Southlands and is designed to enable more patients to receive all tests, results and diagnosis in one visit, with many treatments also available on the same day. More than 100 patients, visitors and staff attended the events which included detailed plans for the new department. Visitors took the opportunity to meet the Eye Care team and share their thoughts about the £7.5m project.

of 6

The information is also available to view at www.westernsussexhospitals.nhs.uk/eyecare, where people can also give their views. Western Sussex Eye Care | Southlands is due to open in early 2017, with all ophthalmology outpatients services moving from Worthing Hospital at this time, as agreed following the Service Redesign for Quality public consultation in 2011.

Two Medicine for Members events also took place this month at St Richard’s and Worthing on

the topic of Sepsis - the most common, but least recognised disease. On Monday 2 November in Worthing and Tuesday 10 November at St Richard’s Hospital, members heard about the signs of Sepsis as well as how to seek help. Sepsis arises when the body’s response to an infection damages its own tissues and organs and can lead to shock, multiple organ failure and death.

The next Stakeholder Forum will take place at St Richard’s Hospital, on Tuesday 24

November, 12.30 to 2.30pm. Positive media coverage over the past month achieved by the Communications team includes:

• New vision for Southlands Hospital – multi-million pound plans for new ophthalmology services at Southlands Hospital and dates for public engagement events were promoted. A post-event press release also provided follow-up information.

• Lead Governor ‘a difficult act to follow’ – Margaret Bamford stands aside after two years’ service, commended by her successor Vicki King.

• CQC survey – members of the public were urged to provide feedback to the Care Quality Commission about their care at Western Sussex Hospitals in an online survey run by the health watchdog.

• Cancer Health and Wellbeing event – the next in a series of events in the community for people living with cancer run by Trust health professionals was promoted.

• Wanted: Antibiotic Guardians – the Trust participates in the first annual worldwide antibiotic awareness week, with pharmacists asking patients, visitors and staff to make a pledge and safeguard the health of future generations by using antibiotics appropriately.

3.0 RECOMMENDATION


WSHFT WORKFORCE SCORECARD OCT 2015

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

2015/16

YTD

Target/

Ceiling Amber Limit Trend

1) WORKFORCE CAPACITY NB

Budgeted FTE 6179.0 6274.2 6286.8 6287.2 6287.2 6287.2 6431.3 6437.3 6437.3 6439.3 6520.1 6537.5 6538.4 6477.3 N/A N/A

Total FTE Used 6298.8 6227.1 6349.7 6329.4 6357.1 6393.3 6356.1 6249.6 6339.3 6337.6 6524.3 6362.1 6451.8 6374.4 N/A N/A

Total FTE Used Variance from Budget 119.8 -47.0 62.9 42.2 69.8 106.1 -75.2 -229.7 -98.1 -101.8 4.3 -175.4 -86.5 N/A N/A N/A

Total FTE Used Vacancy Factor -1.9% 0.7% -1.0% -0.7% -1.1% -1.7% 1.2% 3.6% 1.5% 1.6% -0.1% 2.7% 1.3% 1.6% N/A N/A

Substantive Contracted FTE 5700.1 5644.9 5668.6 5687.6 5693.5 5701.8 5665.0 5664.3 5646.9 5627.8 5797.8 5641.8 5677.9 5674.5 N/A N/A

Substantive FTE Worked 5606.3 5515.1 5582.8 5592.1 5586.6 5599.8 5612.7 5571.4 5540.3 5531.8 5547.4 5496.1 5540.4 5548.6 N/A N/A

Substantive FTE Used Vacancy Factor 7.8% 10.0% 9.8% 9.5% 9.4% 9.3% 11.9% 12.0% 12.3% 12.6% 11.1% 13.7% 13.2% 12.4% N/A N/A

Bank Usage As % Of Total FTE Used 6.9% 7.3% 8.2% 7.2% 7.8% 7.8% 7.8% 6.4% 7.9% 7.2% 7.3% 7.3% 7.0% 7.3% N/A N/A

Agency Usage As % Of Total FTE Used 2.6% 2.1% 2.5% 3.0% 2.6% 3.0% 3.1% 3.0% 3.0% 4.0% 3.8% 4.0% 5.0% 3.7% N/A N/A

2) WORKFORCE EFFICIENCY NB

Rolling 12 Month Sickness Absence 1 3.9% 3.9% 4.0% 4.0% 4.1% 4.1% 4.1% 4.1% 4.1% 4.1% 4.1% 4.1% N/A 3.3% 3.3%

In Month Sickness Absence % 4.6% 4.3% 4.5% 4.9% 4.3% 3.8% 3.6% 3.8% 3.7% 3.9% 3.8% 3.7% 3.7% 3.3% 3.3%

In Month Maternity Leave % 2.6% 2.7% 2.8% 2.8% 2.6% 2.5% 2.6% 2.6% 2.5% 2.5% 2.5% 2.6% 2.5% N/A N/A

In Month Other Absence % 1.5% 1.5% 1.2% 1.2% 1.2% 1.3% 1.4% 1.3% 1.3% 1.3% 1.0% 1.5% 1.3% N/A N/A

In Month Total Absence % 8.7% 8.5% 8.5% 8.9% 8.2% 7.6% 7.5% 7.7% 7.5% 7.7% 7.3% 7.8% 7.6% N/A N/A

Sickness Episodes 1489 1232 1652 1568 1295 1324 1134 1214 1170 1168 1095 1220 N/A

Maternity Heads 186 185 193 203 191 184 187 197 193 179 183 186 N/A N/A N/A

In Month Long Term Sickness Absence % (28 Days Or More) 2.3% 2.4% 2.1% 2.1% 1.9% 1.8% 1.8% 1.8% 1.9% 2.1% 2.0% 1.9% 1.9% N/A N/A

In Month Short Term Sickness Absence % (<28 days) 2.3% 1.9% 2.4% 2.8% 2.4% 2.0% 1.8% 2.0% 1.7% 1.8% 1.7% 1.9% 1.8% N/A N/A

In Month Stress Related Sickness Absence % 0.8% 0.7% 0.7% 0.7% 0.7% 0.7% 0.6% 0.7% 0.7% 0.7% 0.6% 0.6% 0.7% N/A N/A

In Month Musculo Skeletal Sickness Absence % 0.9% 0.8% 0.8% 0.8% 0.8% 0.7% 0.7% 0.9% 0.7% 0.9% 0.8% 0.8% 0.8% N/A N/A

Number of Staff breaching Management Triggers for sickness absence 976 1002 999 1032 1034 1024 990 994 1003 1025 1011 989 N/A

% of Staff (headcount) 14.6% 15.0% 15.0% 15.4% 15.4% 15.3% 14.8% 14.9% 15.1% 15.4% 15.2% 14.9% N/A

Rolling 12 Month Turnover 7.3% 7.7% 7.8% 8.0% 8.1% 8.4% 8.6% 8.7% 8.9% 9.0% 9.2% 9.5% 9.4% N/A 11.0% 11.0%

3) TRAINING & PERSONAL DEVELOPMENT NB

% Appraisals Up To Date 78.1% 79.0% 77.7% 77.1% 77.5% 76.6% 77.6% 77.3% 76.7% 77.4% 78.7% 78.3% 79.4% N/A 90.0% 80.0%

% In Date - All Mandatory Training 2 79.4% 79.3% 76.9% 77.6% 78.5% 78.0% 80.0% 81.1% 82.9% 81.5% 80.5% 79.6% 80.4% N/A 90.0% 80.0%

% In Date - Fire 87.4% 87.4% 86.4% 86.6% 88.4% 87.6% 89.3% 90.5% 90.9% 89.1% 89.8% 89.8% 90.2% N/A 90.0% 80.0%

% In Date - Infection Control (Role Specific) 87.5% 87.2% 86.4% 86.7% 88.2% 87.5% 89.2% 90.0% 91.3% 89.0% 89.5% 88.4% 89.2% N/A 90.0% 80.0%

% In Date - Back Training (Role Specific) 90.8% 90.5% 90.4% 90.7% 90.7% 90.3% 90.8% 90.4% 92.0% 91.3% 91.7% 91.5% 92.3% N/A 90.0% 80.0%

% In Date - Child Protection (Role Specific) 96.9% 97.0% 96.9% 96.9% 97.0% 96.8% 96.6% 97.5% 97.5% 96.1% 96.2% 96.0% 96.1% N/A 90.0% 80.0%

% In Date - Information Governance 87.5% 87.2% 86.0% 86.6% 88.3% 87.5% 89.1% 90.1% 90.7% 88.3% 87.5% 87.3% 87.7% N/A 90.0% 80.0%

% In Date - Adult Protection 69.1% 69.0% 75.5% 77.1% 80.3% 81.8% 85.3% 87.6% 90.2% 89.6% 90.9% 92.2% 93.6% N/A 90.0% 80.0%

Number of Staff with no mandatory training 14 11 11 19 20 19 12 14 9 6 8 7 6 N/A

Number of Staff > 12 months since any mandatory training 1 0 0 1 1 0 0 2 0 0 0 0 0 N/A

4) REAL-TIME STAFF FEEDBACK NB

Total Respondents To Survey 109 95 108 76 122 382 109 99 158 52 91 112 80 701 N/A N/A

% Respondents who would recommend this trust as a place to work 76.1% 73.7% 73.1% 65.8% 76.2% 61.0% 62.4% 76.8% 69.8% 63.5% 83.5% 83.0% 71.3% 73.2% N/A N/A

% Respondents happy with standard of care if a friend/relative needed treatment 86.2% 85.3% 88.0% 78.9% 82.0% 78.0% 87.2% 92.9% 83.0% 80.8% 89.0% 91.1% 88.8% 87.6% N/A N/A

Notes:

1 Absence data is available one month in arrears

2 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection amd Information Governance training is up to date.


To: Trust Board


Title

Financial Performance Report – Month 7

Presented by

Karen Geoghegan, Director of Finance

Prepared by

Alison Ingoe, Deputy Director of Finance

David Lowe, Assistant Director of Finance

Status

Confidential

Summary of Proposal

At the end of October, the Trust is reporting a £2.0m deficit against a planned surplus of £1.71m. The Trust delivered a Financial Sustainability Rating of '3' in the month. The forecast for 2015/16 is to deliver a surplus of £0.99m and a financial sustainability risk rating of '3' in line with the plan approved by the Trust Board in April. The attached report provides further commentary and analysis of the financial position.


Financial planning principles have been established to ensure that expenditure budgets reflect anticipated activity levels and that agreed staffing levels are maintained.

Support for/integration with Corporate Objectives and Strategies

G1. Maintain an acceptable financial risk rating.


These are noted within the report.


N/A

Recommendation

The Trust Board is asked to NOTE the report.

Consultation

N/A

Appendices

N/A


Finance Report Month 7 2015-16

Summary

Financial Sustainability Risk Rating G Surplus £k R Cash £k A

Plan Actual / Forecast Plan Actual / Forecast Plan Actual

Year to Date 3 3 Year to Date £k 1,710 (2,038) Year to Date £k 14,155 8,688

Year End Forecast 3 3 Year End Forecast £k 992 992 Year End Forecast £k 11,729 11,729

Income £k A Operating Costs £k A Agency Expenditure RExpenditure as % of Total Paybill

(monthly) 2013/14 2014/15 2015/16

Plan Actual / Forecast Plan Actual / Forecast Medical 9.0% 12.0% 15.9%

Year to Date £k 235,094 233,320 Year to Date £k (219,717) (221,851) Nursing 5.4% 4.0% 10.7%

Year End Forecast 400,087 401,850 Year End Forecast £k (375,685) (376,924) Other Staff Groups 3.2% 4.0% 5.4%

All Agency 5.7% 6.3% 10.4%

Capital £k A Efficiency and Transformation Programme £k A Indicators of Forward Financial Risk A

Plan Actual / Forecast Plan Actual / Forecast Actual Forecast

Year to Date £k 10,841 6,753 Year to Date £k 9,718 9,191 Number of Indicators Breached 3 1

Year End Forecast £k 15,070 15,070 Year End Forecast £k 19,108 18,375 Number of Indicators 10 10

Key Risks:

1. Management of patient flow to ensure that activity is able to be delivered within funded capacity and that numbers of patients medically fir for discharge are minimised. The Trust is working closely with health economy partners to ensure that the levels of

fit for discharge patients and community bed capacity is managed.

2. Delivery of savings within the efficiency programme. As in 2014/15 the Trust has a significant efficiency requirement in order to deliver its planned surplus. The savings profile increases in Q3 in order to deliver the total programme. The Programme

Management Office is now fully established and governance around the programme has been strengthened. Pipeline schemes are continuing to be developed to provide head-room within the programme.

3. The affordability for commissioners to pay in full for over-performance above contracted activity levels. Activity levels in year and being closely monitored and escalation triggers for significant variances to plan have been agreed with commissioners

4. Ability to exit premium rate workforce arrangements. Vacancies and long-term sickness in key staff groups are driving signficiant increases in agency expenditure. The Workforce Transformation Group is overseeing action plans to increase recruitment,

redesign workforce roles and manage sickness, rostering and retention issues.

At the end of October, the Trust is reporting a £2.0m deficit against a planned surplus of £1.71m. The Trust delivered a Financial Sustainability Rating of '3' in the month. The forecast for 2015/16 is to deliver a surplus of £0.99m and a financial sustainability

risk rating of '3' in line with the plan approved by the Trust Board in April.

The Trust is reporting a Financial Sustainability Risk Rating (FSRR) of '3' for

October.

In October the Trust reported an in month deficit of £245k, to bring the cumulative

deficit to £2m. There is continued under-performance in income from activities,

however, to manage operational pressures some additional bed capacity has been

opened which has increased the level of pay expenditure in addition to on-going

agency spend to cover vacancies.

The cash balance held has reduced between September and October due to the in month

deficit and cash remains behind plan for the year to date. The variance to plan is due to

the adverse income and expenditure variance and an increase in the level of accrued

income. These have been offset by slippage on the capital programme and an increase

in the overall level of creditors.

At the end of October, income is £1.7m less than plan. Income from activities is

favourable in year to date although income for PbR excluding items and

seasonal resilience are offseting activity under-performance. Private patient

income continues to be less than plan.

Operating costs are adverse to plan primarily due to overspends in pay. Although

the level of pay expenditure has remained consistent between September and

October, planned capacity reductions were not delivered and the proportion of the

paybill spent on agency staff has increased.

There is slippage against the capital plan of £4.1m year to date, mainly in

Endoscopy, Estates and Information Technology. Areas where slippage has

occurred are being actively managed and the programme is forecast to be on

plan by the year-end.

At the end of October, the Efficiency Programme delivered cumulative savings of

£9.2m against a plan of £9.7m (94.6%). The forecast out-turn is less than plan and

mitigating schemes are being developed to offset the shortfall.

Indicators breached are (i) more than 5% of debtors > 90 day, (ii) quarter end cash

balance less than 10 days, (iii) capital expenditure < 75% of plan for the year to date

There was an increase in agency expenditure in October to £2.3m in the month. This

continues to exceed the same period in 2013/14 and 2014/15, particularly in Medical and

Nursing areas.

Finance Report Month 7 2015-16 G

Financial Sustainability Risk Rating Plan Plan Actual Actual

YTD Metric Rating Metric Rating

Liquidity Ratio (0.35) 3 (3.42) 3

Capital Servicing Capacity Ratio 2.48 3 1.75 3

Income and Expenditure Margin 1.0% 2 (0.7%) 2

Variance in I&E margin as a % of income 0.0% 4 (1.8%) 2

Financial Sustainability Rating 3 3

Financial Criteria SFP Weight Metric to be Definition Rating categories

4 3 2 1

Liquidity Ratio 25% Liquidity ratio (days) Working capital balance x 360 0.0 (7.0) (14.0) <(14.0)

Annual operating expenses

Revenue available for capital service

Capital Servicing Capacity Ratio 25% Capital servicing capacity (times) Annual debt service 2.5x 1.75x 1.25x <1.25x

Surplus/(Deficit) before exceptional items 1% 0% (1.0%) <(1.0%)

Income and Expenditure Margin 25% I&E Margin (%) Total Operating and Non Op Income

Actual Surplus/(Deficit) - Planned Surplus/(Deficit) 0% (1.0%) (2.0%) <(2.0%)

I&E Plan Variance 25% Operating Income

The Trust is reporting a Financial Sustainability Risk Rating (FSRR) of '3'. There has been a 1.22 day deterioration in the liquidity metric from September due to the in-month deficit. The capital service metric has increased to

1.75 (1.70 in September). The income and expenditure margin as a percentage of income has improved to 0.7%, whilst the variance in planned I&E margin has declined from (1.0%) to (1.8%) due to the phaisng of the income

and expenditure plan and the impact of the in month performance.

Variance in I&E margin as a % of

income

Finance Report Month 7 2015-16 Surplus R

Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k

(Surplus) Deficit 1,710 (2,038) (3,750) (Surplus) Deficit 992 992 (0)

Prev Yr Actual Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k £k

Income 227,248 235,094 233,321 (1,774) Income 400,087 401,850 1,763

Pay (150,316) (153,684) (154,658) (974) Pay (264,504) (262,533) 1,971

Non-Pay (65,244) (66,033) (67,193) (1,160) Non-Pay (111,181) (114,391) (3,210)

EBITDA * 11,689 15,377 11,470 (3,908) EBITDA * 24,402 24,926 523

EBITDA % 5.1 6.5 4.9 EBITDA % 6.1 6.2

Profit / Loss on Disposal of Fixed Assets (47) - 3 3 Profit / Loss on Disposal of Fixed Assets - - -

Interest Payable (644) (533) (522) 11 Interest Payable (914) (882) 32

Interest Receivable 20 19 26 7 Interest Receivable 32 32 -

Depreciation (8,346) (8,357) (8,220) 137 Depreciation (14,288) (14,282) 7

Impairments (461) - - - Impairments - - -

Public Dividend Capital Dividend (4,037) (4,068) (4,442) (374) Public Dividend Capital Dividend (6,974) (7,614) (640)

Net Surplus / (Deficit) (1,826) 2,438 (1,685) (4,124) Net Surplus / (Deficit) 2,259 2,180 (78)

Reverse Impairment 461 - - - Reverse Impairment - - -

Donated Assets (306) (1,183) (824) 359 Donated Assets (2,028) (2,028) -

Donated Asset Depreciation and Amortisation 550 455 470 15 Donated Asset Depreciation and Amortisation 762 840 78

Performance against Control Total (1,121) 1,710 (2,038) (3,750) Performance against Control Total 992 992 (0)

Surplus % (0.5) 0.7 (0.9) Surplus % 0.2 0.2

* EBITDA Earnings before Interest Taxation Depreciation and Amortisation

In October, the Trust reported an underlying deficit of £245k due to underperformance against income from acitivities and increased pay spending above planned levels. As a result, the Trust is reporting a £2.0m deficit against a planned surplus of £1.71m at

the end of October.

Year To Date Year Forecast

Income from activities is under-performing year to date, however, this position includes £2m over-performance on PbR excluded drugs and devices. The overspend in pay is largely driven by agency costs. Additional medical beds above the current plan have

had to be opened in month and to enable staffing of these beds additional agency staff are being utilised. The adverse variance within non pay continues to be driven by PbR excluded drug and device usage which is offset by additional income.

Year to Date Full Year

(1,500)

(1,000)

(500)

0

500

1,000

1,500

2,000

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

£0

00

s

Surplus by Month

Budget

Actual

(2,500)

(2,000)

(1,500)

(1,000)

(500)

0

500

1,000

1,500

2,000


£0

00

s

Cumulative Surplus by Month

Budget

Actual

Finance Report Month 7 2015-16 Income A

Year To Date Year End Forecast

Prev Yr. Actual Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k £k

Total Income 227,248 235,094 233,320 (1,774) Total Income 400,087 401,850 1,763


Income £k £k £k £k Income £k £k £k

Clinical Commissioning Groups 162,594 174,198 174,881 683 Clinical Commissioning Groups 292,695 295,240 2,545

Specialist LAT 18,929 27,409 26,963 (446) Specialist LAT 46,719 47,177 458

WSCC - Sexual Health 4,657 4,557 3,897 (660) WSCC - Sexual Health 7,734 6,506 (1,228)

NCA 2,405 4,307 4,461 154 NCA 7,984 8,172 188

Other Trust Income 15,187 211 188 (23) Other Trust Income 3,000 5,976 2,976

Income From Activities 203,773 210,681 210,389 (292) Income From Activities 358,131 363,071 4,940

Private Patients 3,699 7,592 6,297 (1,295) Private Patients 6,657 6,320 (337)

Education, Training and Research 5,988 5,985 5,921 (64) Education, Training and Research 10,251 9,998 (253)

Donated Asset Income 306 1,183 824 (359) Donated Asset Income 1,916 762 (1,154)

Other Income 13,483 9,654 9,890 236 Other Income 23,132 21,699 (1,433)

Other Operating Income 23,476 24,414 22,932 (1,482) Other Operating Income 41,956 38,779 (3,177)

Total Income 227,248 235,094 233,320 (1,774) Total Income 400,087 401,850 1,763

of which : PbR Drugs/Devices 14,217 16,319 2,102


At the end of October, income is £1.7m less than plan. Income from activities is favourable in the year to date although income for PbR excluding items and seasonal resilience are offseting activity under-performance. Private patient income

continues to under-perform.

At the end of October income from activities is £292k below the Trust operational plan. Performance has reduced below plan in month due predominantly to under-performance in outpatient first attendances, elective and day case activity.

Non-elective activity continues to exceed the year-to-date plan, with increased activity in October compared to previous months. PbR excluded drugs cumulatively exceed plan by £1,654k - the largest variances are the Cancer Drugs Fund

and CCG funded home delivery drugs. The reported income position includes £2,449k of seasonal resilience monies to reflect the initiatives agreed for the year to date with the CCG and the costs of continued provision of community beds.

As in previous months, Private Patient income has underperformed. Clinical Excellence awards are lower than planned this year impacting on other income variances and there remains no further agreement on provider contract uplifts.

Additional donated income has been reported in month to reflected agreed funding from Love Your Hospital charity.

29000

30000

31000

32000

33000

34000

35000

36000


£'0

00

Monthly Income

Budget Actual

29000

30000

31000

32000

33000

34000

35000

36000

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

£'0

00

Monthly Income Yearly Comparison

2014-15

2015-16

Finance Report Month 7 2015-16 Contract Performance A

Table 2. Activity and Income by Point of Delivery

Point of Delivery YTD Plan YTD Actual YTD Var YTD Plan YTD Actual YTD Var

FYE Plan YTD Plan YTD Actual YTD Var Daycases 35,583 36,024 441 22,843 22,003 (840)

Coastal West Sussex (and associate CCGs) 294,985 174,198 172,129 (2,069) Elective Spells 5,750 5,044 (706) 17,810 15,897 (1,913)

NHS England 46,719 27,409 26,963 (446) Elective Excess Bed days 594 1,101 507 131 247 115

Integrated Sexual Health Services 7,734 4,557 3,897 (660) Non Elective Spells 30,219 30,431 212 55,229 55,610 381

Non Contract Activity 8,336 4,307 4,661 354 Non Elective short-stay 6,217 6,547 330 5,158 5,354 196

Reciprocal Overseas 358 211 188 (23) Non Elective Excess Bed days 11,578 14,383 2,805 2,576 3,392 817

Total 358,131 210,681 207,837 (2,844) Outpatients 332,237 345,331 13,094 35,504 35,334 (170)

A&E 84,239 80,794 (3,445) 8,957 8,912 (44)

NB: Variances are reported against Western Sussex Hospitals Planned Income Levels PbR exclusions 14,217 16,319 2,102

Critical Care 8,732 7,925 (807)

Maternity Pathway 7,320 6,521 (799)

OP Diagnostic Imaging 4,850 4,862 11

Sexual Health 4,120 3,806 (315)

Direct Access Pathology 4,564 4,295 (269)

Other Direct Access (Imaging and Dietetics) 1,727 1,655 (72)

Breast Screening 2,002 1,954 (48)

Other 10,250 9,165 (1,085)

CQUIN 4,691 4,803 112

Total 210,681 208,054 (2,627)

Table 3. - Reconciliation to Income Reporting Table 4. Contract Income by CCG and NHS England

£000s

Contract Monitoring Performance -(unadjusted ) 203,034 SUSSEX CCGs and NHS ENGLAND

CQUIN 2.4% 4,803 YTD Plan YTD Actual YTD Var

NHS COASTAL WEST SUSSEX CCG 164,949 162,056 (2,893)

Total Contracted Income 207,837 NHS HORSHAM AND MID SUSSEX CCG 2,702 2,598 (104)

NHS BRIGHTON AND HOVE CCG 2,226 2,660 434

Income Recharged non-contract NHS HIGH WEALD LEWES HAVENS CCG 136 120 (16)

NHS CRAWLEY CCG 241 406 165

Seasonal Resilience funding 2,449 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 86 126 40

Maternity pathway payment (60) NHS HASTINGS AND ROTHER CCG 37 68 31

Cystic Fibrosis 188 NHS SOUTH EASTERN HAMPSHIRE CCG 3,367 3,297 (71)

Risk Share and NCA Credit Notes (200) NHS PORTSMOUTH CCG 122 344 222

Change to deferred Income for Maternity pathway 175 NHS GUILDFORD AND WAVERLEY CCG 255 149 (106)

NHS FAREHAM AND GOSPORT CCG 76 230 154

Total Income from Activities 210,389 NHS CROYDON CCG - 75 75

Subtotal CCG Acute Contracts 174,198 172,129 (2,069)

NHS England 27,409 26,963 (446)

Total 201,606 199,091 (2,515)

£'000

Estimated Values for YTD (incl CQUIN)

The Trust reports income based on the contract monitoring position for prior months and an estimate of income for the current month based on priced and coded activity in the month as available. An estimate is made for the value of uncoded spells and missing days and included within the reported income

position.

1) Context

The Trust and the CCGs are required to complete monthly financial reconcilliations. The reconcilliations for Coastal West Sussex and Associate CCGs have been completed for the period April - July. There are a number of outstanding data challenges which are being resolved through the escalation

process. The August reconcilliation is due to be signed-off mid-November.

The Quarter 1 reconcilliaton for NHSE has been delayed due to staff absence at NHSE. The Assistant Director of Finance has escalated this with NHSE (as contract lead for the associcate CCGs), and the Trust has invoiced based on the unreconciled position.

2) YTD Report

Trust internal monitoring information shows underperformance agains the internal plan for Coastal West Sussex and for NHSE, with outpatient first atendances and elective activity lower than planned, and with non-elective performed at a lower casemix than planned,as outlined in the income report. PbR

excluded drugs and devices exceed plan.

It is important to note that the performance indicated is compared to the Trust's plan and does not reflect the over-performance against commissioner contracts. The Trust is over-performing against the Coastal West Sussex CCG contract. The affordability of this level of performance to the CCG will need to

be closely monitored.

£'000

Activity Volumes £'000

Table 1. Total Financial Values by Contract

This table represents the Trusts assessment of the performance against commissioners only with whom a Contract SLA has been agreed. There are some differences between the Trust's income plan and the agreed contract values due to QIPP assumptions

Page 5

Finance Report Month 7 2015-16 Operating Costs A


£k £k £k £k £k £k

Pay (150,316) (153,684) (154,658) (974) Pay (264,504) (262,533) 1,971

Non Pay (65,244) (66,033) (67,193) (1,160) Non Pay (111,181) (114,391) (3,372)

Operational Costs (215,560) (219,717) (221,851) (2,134) Operational Costs (375,685) (376,924) (1,401)


£k £k £k £k £k £k £k

Pay Pay

Management & Admin (19,948) (22,069) (21,137) 931 Management & Admin (38,239) (36,371) 1,868

Medical and Dental Staff (43,452) (42,595) (44,807) (2,211) Medical and Dental Staff (72,891) (75,885) (2,994)

Nursing & Midwifery (56,449) (57,366) (57,803) (437) Nursing & Midwifery (98,634) (98,334) 300

Other Healthcare (21,147) (22,012) (21,511) 501 Other Healthcare (38,183) (36,108) 2,075

Estates (9,306) (9,354) (9,400) (46) Estates (16,068) (15,695) 373

Other Staff (14) (288) (0) 288 Other Staff (489) (140) 349

Total Pay (150,316) (153,684) (154,658) (974) Total Pay (264,504) (262,533) 1,971

Non-Pay Non-Pay

Services from Other NHS Bodies (2,096) (2,195) (2,185) 10 Services from Other NHS Bodies (3,708) (3,241) 467

Purchase of Healthcare from Non NHS Bodies (1,672) (2,527) (2,556) (30) Purchase of Healthcare from Non NHS Bodies (3,186) (4,148) (962)

Drugs & Medical Gases - tariff (6,382) (7,566) (7,220) 346 Drugs & Medical Gases (15,787) (15,289) 498

Drugs & Medical Gases - PbR excluded (13,095) (12,920) (14,574) (1,654) Drugs & Medical Gases - PbR excluded (19,078) (21,832) (2,754)

Supplies and Services - Clinical (19,587) (19,804) (19,816) (12) Supplies and Services - Clinical (33,794) (35,165) (1,533)

Supplies and Services - Clinical PbR Excluded (1,196) (1,297) (1,746) (448) Supplies and Services - Clinical Pbr Excluded (2,078) (2,135) (57)

Supplies and Services - General (2,582) (2,791) (2,445) 347 Supplies and Services - General (4,696) (4,348) 348

Establishment Expenses (4,413) (3,623) (3,658) (35) Establishment Expenses (5,979) (6,112) (132)

Premises (8,446) (8,859) (8,655) 204 Premises (14,978) (14,738) 240

Education and Training (414) (675) (510) 165 Education and Training (1,278) (1,074) 204

Clinical Negligence Premium (3,129) (3,026) (3,026) 0 Clinical Negligence Premium (5,187) (5,187) -

Other Non-Pay (2,233) (751) (804) (53) Other Non-Pay (1,432) (1,122) 310

Total Non-Pay (65,244) (66,033) (67,193) (1,160) Total Non-Pay (111,181) (114,391) (3,372)

Total Expenditure (215,560) (219,717) (221,851) (2,134) Total Expenditure (375,685) (376,924) (1,401)

Year To Date Year Forecast

Pay: Pay continues to be overspent due to the continuing use of Medical and Nursing agency to cover vacancies and sickness. The position reported in September has continued with high levels of vacancies across junior medical staff and additional pressures in A&E and the

emergency floor leading to increased staffing levels at premium rates in both medical and Nursing staff. Additional beds have been opened above those stated as being required in the bed reconfiguration plan, and these are being staffed using higher levels of agency staff due to

vacancy pressures. Favourable variances in Management & Admin and Other healthcare staff partially reduce this overspend.

Non Pay: Drugs continue to be the most significant area of overspend against the year to date budget with £1,654k of the overspend being due to the usage of high cost PbR excluded drugs. This includes £871k of additional spend on specialist cancer drugs which are funded by the

Independent Cancer Drugs Fund.

At the end of October, operational costs are £2,134k above plan. Pay is being driven by the significant adverse variance on Medical staff with premium rate agency costs being utilised to fill both vacancies and additional posts required for increased acuity cover and sickness. Non Pay

continues to be driven by expenditure on PbR excluded drugs and devices.


20500

21000

21500

22000

22500


£0

00

s

Monthly Pay

Budget Actual

0

5000

10000

15000


£0

00

s

Monthly Non Pay

Budget Actual

29000

30000

31000

32000

33000

34000


£0

00

s

Monthly Operating Costs

Budget Actual

20000

20500

21000

21500

22000

22500


£0

00

s

Monthly Pay Yearly Comparison

2014-15 2015-16

Finance Report Month 7 2015-16 R

Agency Agency by Division

2013/14 2014/15 Plan Actual Variance Plan Actual Variance

£k £k £k £k £k £k £k £k

Medical and Dental Staff (3,591) (5,198) (2,998) (5,959) (2,962) Surgery (1,157) (2,284) (1,127)

Nursing & Midwifery (2,000) (2,142) (1,330) (4,367) (3,037) Medicine (2,131) (6,626) (4,495)

Other Healthcare (961) (1,265) (996) (1,429) (433) Core (1,986) (2,371) (385)

Management & Admin (302) (90) (8) (233) (226) Women & Children (184) (531) (347)

Estates (182) (382) (173) (285) (112) Corporate (46) (461) (415)

Other Staff - - - - -

Total

(7,036) (9,077) (5,504) (12,273) (6,769) (5,504) (12,273) (6,769)

Payroll Staff in post incl Bank Year To Date

Prev Yr Actual Plan Actual Variance Prev Yr Actual Plan Actual Variance

£k £k £k £k WTE WTE WTE WTE

Medical and Dental Staff (38,254) (39,598) (38,847) 750 693 762 705 (56)

Nursing & Midwifery (54,307) (56,036) (53,437) 2,599 2,585 2,738 2,493 (245)

Other Healthcare (19,882) (20,817) (20,083) 734 944 1,044 937 (107)

Management & Admin (19,859) (22,061) (20,904) 1,157 1,172 1,259 1,197 (62)

Estates (8,924) (9,180) (9,114) 66 648 737 659 (78)

Other Staff (14) (488) (0) 488 - (1) - 1

(141,239) (148,180) (142,385) 5,795 6,042 6,538 5,991 (548)

Year To Date

Payroll & Agency Costs

Year To Date Year to Date

500

1,000

1,500

2,000

2,500

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

£0

00

s

Agency Expenditure Comparison

2014-15 2015-16

0

1,000

2,000

3,000

4,000

5,000

6,000

Medical andDental Staff

Nursing &Midwifery

OtherHealthcare

Management& Admin

Estates

£0

00

s

Agency Type Comparison

2014-15

2015-16

Finance Report Month 7 2015-16 Divisional Performance R

Year To Date Year To Date Year To Date

PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG

£k £k £k £k £k £k £k £k £k £k £k £k

Contract Income 53,865 66,460 64,843 (1,617) R Contract Income 75,724 80,891 83,658 2,767 G Contract Income 13,264 23,419 23,967 549 G

Other Income 1,225 1,253 1,290 37 G Other Income 2,056 1,654 1,717 63 G Other Income 5,958 6,969 6,795 (175) R

Total Income 55,089 67,713 66,133 (1,580) R Total Income 77,781 82,545 85,375 2,830 G Total Income 19,222 30,388 30,762 374 G

Pay (31,365) (36,894) (36,313) 581 G Pay (38,856) (45,564) (47,454) (1,891) R Pay (23,380) (29,688) (29,318) 370 G

Non Pay (10,790) (12,230) (13,340) (1,110) R Non Pay (15,056) (16,258) (18,984) (2,726) R Non Pay (9,654) (13,341) (13,462) (121) R

Total Expenditure (42,155) (49,124) (49,653) (529) R Total Expenditure (53,912) (61,821) (66,439) (4,617) R Total Expenditure (33,034) (43,029) (42,780) 249 G

EBITDA Surplus/(Deficit) 12,935 18,589 16,480 (2,109) R EBITDA Surplus/(Deficit) 23,869 20,723 18,936 (1,787) R EBITDA Surplus/(Deficit) (13,812) (12,641) (12,018) 623 G

Year To Date Year To Date

PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG

£k £k £k £k £k £k £k £k £k £k £k £k

Contract Income 29,734 36,961 34,914 (2,047) R Contract Income - - - - - Contract Income 4 - - - G

Other Income 567 653 544 (109) R Other Income 2,939 3,086 3,197 111 G Other Income 2,423 10,105 9,052 (1,053) R

Total Income 30,301 37,614 35,458 (2,156) R Total Income 2,939 3,086 3,197 111 G Total Income 2,423 10,105 9,052 (1,053) R

Pay (15,156) (17,603) (17,992) (390) R Pay (9,086) (9,163) (9,577) (414) R Pay (8,031) (14,396) (14,152) 244 G

Non Pay (4,939) (5,830) (5,724) 106 G Non Pay (8,441) (8,395) (8,576) (182) R Non Pay 3,042 (7,961) (7,725) 236 G

Total Expenditure (20,094) (23,433) (23,716) (283) R Total Expenditure (17,527) (17,558) (18,153) (596) R Total Expenditure (4,989) (22,358) (21,877) 481 G

EBITDA Surplus/(Deficit) 10,206 14,181 11,742 (2,439) R EBITDA Surplus/(Deficit) (14,588) (14,472) (14,957) (484) R EBITDA Surplus/(Deficit) (2,567) (12,253) (12,825) (572) R

Year To Date

Women & Children: The Division continues to be impacted by high levels of consultant sickness, which

has been driving an adverse variance within Medical expenditure since the begining of the year. This is

reflected in both an overspend on pay and an underperformance on outpatient and elective activity due

to consultant absence. Pay expenditure is also high due to on-call services being covered at premium

rates. During October, the Division incurred increased expenditure on agency nursing as a result of

paediatric patients requiring mental health nurse specialling on both sites and outliers and overnight

escalation in the Gynaecology Day Unit at Worthing. Non pay remains favourable to plan, but is

predominantly as a result of PbR excluded drug expenditure which has an opposite adverse variance on

income.

Facilities & Estates: Income continues to deliver a favourable variance to plan and has increased in

month with increased activity volumes being seen in the restaurants, accommodation and car parking

services. it is anticipated these levels will continue throughout the quarter. Pay is lower than the previous

month, although it remains adverse, to plan reflecting the impact of more out of hours work. Ad hoc

maintenance costs have increased in month and there has also been investment in replacement linen

and cleaning equipment this month. The Division is still forecasting a breakeven year end outturn,

although utility price rises could be a risk to the position being achieved.

Surgery: Despite improving the activity run rate since the Q1, the ability to deliver the planned levels of

activity across all points of delivery and all specialties is compromised due to staffing constraints-most

significantly in Theatres and Anaesthetics. Expenditure on nursing agency staff increased this month

compared to September, due to higher levels of vacancy cover, sickness cover and dependency. Pay is

underspent overall as difficulties in recruiting to cover vacancies continue. A review of accruals for

outstanding waiting list initiative payments has contributed to an improved expenditure position for the

Division. The Theatre stock take at end of Q2 has been completed and did not indicate higher than

normal levels of stock-holding.

Core: Overall the core division continues to over-perform against the main commissioner contracts.

This is predominantly in chemotherapy activity and therapies. The favourable year to date variance in

pay has deteriorated marginally in the month due to increases in agency spend in both Pathology and

Therapies, this premium expenditure is only partially offset by savings in substantive posts. Although

cover requirements for sickness and vacancies will necessitate agency usage continuing in these areas

to the end of the financial year, the rate of expenditure is expected to drop in future months. Use of the

mobile scanner for MRI scans has increased in October in Worthing and remains the major contributor

to the adverse non-pay position. Work is ongoing to secure this service at a lower rate as demand is

continuing.

Corporate: As in prior months Private Patient activity continues to deliver an adverse income variance

to plan, with NHS activity pressures imapcting on the Division's ability to recover the planned activity

levels. Reductions in planned levels of Clinical Excellence Award income are reported within the other

income. Favourable variances continue in both pay and non pay with vacancies continuing in a number

of departments. With controls still in place on non-essential expenditure, non pay continues to remain

favourable to plan.

Medicine: Non elective excess bed days have increased significantly in month, creating pressure on

bed requirements especially at Worthing. Outpatient activity is underperforming year to date, particularly

within General Medicine and Gastroenterology. Planned reductions in bed capacity and efficiency

savings were expected during October, however, the division has been unable to flex bays in line with

the bed capacity plan. Pay continues to over spend due to pressures within Medical staffing. Vacancies,

long term sickness and maternity leave have led to an increased use of agency staff, causing an

adverse variance to plan. There have also been a number of operational pressures, most notably within

A&E and the Emergency Floor which have resulted in additional staffing requirements. Nursing bank and

agency spend increased significantly following the opening of ward capacity. Non-Pay costs remained

above plan for drugs and clinical supplies with increased income relating to PbR excluded drugs and

devices offsetting this expenditure.

Finance Report Month 7 2015-16 Statement of Financial Position

Plan Actual Variance Notes Plan Forecast Variance Notes

£k £k £k £k £k £k

Property, Plant and Equipment 272,595 270,791 (1,804) 1 Property, Plant and Equipment 272,958 272,958 -

Intangible Assets 389 292 (97) Intangible Assets 389 389 -

Other Assets - - - Other Assets - - -

Non Current Assets 272,984 271,083 (1,901) Non Current Assets 273,347 273,347 -

Inventories 6,122 6,207 84 Inventories 6,052 6,052 -

Trade and Other Receivables 19,949 27,964 8,015 2 Trade and Other Receivables 20,248 20,248 -

Cash and Cash Equivalents 14,155 8,688 (5,466) Cash and Cash Equivalents 11,729 11,729 -

Non Current Assets Held for Sale - - - Non Current Assets Held for Sale - - -

Current Assets 40,226 42,859 2,633 Current Assets 38,029 38,029 -

Trade and Other Payables (32,481) (37,653) (5,173) 3 Trade and Other Payables (31,977) (31,977) -

Borrowings (1,079) (2,214) (1,135) Borrowings (2,122) (2,122) -

Other Financial Liabilities - - - Other Financial Liabilities - - -

Provisions (907) (403) 504 Provisions (1,034) (1,034) -

Other Liabilities - - - Other Liabilities - - -

Current Liabilities (34,467) (40,270) (5,803) Current Liabilities (35,132) (35,132) -

Borrowings (27,205) (26,118) 1,087 Borrowings (25,047) (25,047) -

Trade and Other Payables - - - Trade and Other Payables - - -

Provisions (2,831) (3,007) (176) Provisions (2,704) (2,704) -

TOTAL ASSETS EMPLOYED 248,707 244,547 (4,159)

TOTAL ASSETS EMPLOYED

248,493 248,493 -

Financed by: Financed by:

Public Dividend Capital 239,091 239,090 (1) Public Dividend Capital 239,091 239,091 -

Retained Earnings (37,151) (37,308) (158) Retained Earnings (37,365) (37,365) -

Surplus/(Deficit) for Year - - - (Surplus)/Deficit for Year - - -

Revaluation Reserve 46,767 42,765 (4,002) Revaluation Reserve 46,767 46,767 -

TOTAL TAXPAYERS EQUITY

248,707 244,547 (4,160)

TOTAL TAXPAYERS EQUITY

248,493 248,493 -

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values, as well as movement in liabilities.


1. The variance on Property, Plant and Equipment is due to slippage of the capital plan and the

phasing of the expenditure, which the Trust expects to come back on plan during the year

2. Within trade and other receivables, accrued income (£4.4m) is higher than the planned amount due

to the timing of payments from the Trust's main commissioner in relation to seasonal resilience

invoicing and CQUIN and other trade receivables are £3.6m higher including £2.2m in prepayments.

3. The trade and other payables relates to a £3.2m higher than expected trade creditors balance than

plan, which is due to extended payment timescales and an increase in deferred income relating to the

SaCP (South Acute Programme) Information Technology project of £1.7m

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values,

as well as movement in liabilities. The plan is the Monitor plan submitted in May.

Finance Report Month 7 2015-16 Cash A

.


£k £k £k £k £k £k

Cash Balance 14,155 8,688 (5,466) 11,729 11,729 -


£k £k £k £k £k £k

EBITDA 15,412 11,469 (3,942) EBITDA 24,402 24,402 -

Non Cash I&E Items - (824) (824) Non Cash I&E Items - - -

Movement in Working Capital (10,352) (13,553) (3,200) Movement in Working Capital (10,401) (10,401) -

Provisions (177) (130) 47 Provisions (304) (304) -

Cashflow from Operations 4,882 (3,038) (7,919) Cashflow from Operations 13,697 13,697 -

Capital Expenditure (8,776) (6,743) 2,033 Capital Expenditure (15,070) (15,070) -

Cash receipt from asset sales - - - Cash receipt from asset sales - - -

Cashflow before financing (3,894) (9,781) (5,887) Cashflow before financing (1,373) (1,373) -

PDC Received - - - PDC Received - - -

PDC Repaid - - - PDC Repaid - - -

Dividends Paid (3,487) (4,037) (550) Dividends Paid (6,974) (6,974) -

Interest on Loans and leases (562) (496) 66 Interest on Loans and leases (991) (991) -

Interest received 29 26 (3) Interest received 77 77 -

Donations received in cash - 824 824 Donations received in cash - - -

Drawdown on debt - - - Drawdown on debt - - -

Repayment of debt (1,079) (997) 82 Repayment of debt (2,158) (2,158) -

Cashflow from financing (5,099) (4,679) 420 Cashflow from financing (10,046) (10,046) -

Net Cash Inflow / (Outflow) (8,993) (14,460) (5,467) Net Cash Inflow / (Outflow) (11,419) (11,419) -

Opening Cash Balance 23,148 23,148 - Opening Cash Balance 23,148 23,148 -

Closing Cash Balance 14,155 8,688 (5,468) Closing Cash Balance 11,729 11,729 -

Year To Date Full Year

The cash balance held has reduced in October and cash remains behind plan for the year to date. The income and expenditure position has contributed £3.9m to the adverse cash variance against plan. The movement in

working capital includes an increase above planned levels in trade receivables, accrued income and prepayments of £8.1m. This relates to contractual overperformance and CQUIN payments which are invoiced and paid in

arrears. An increase in the level of creditors and deferred income along with the phasing of the capital programme has offset the impact of the accrued income increase.


Finance Report Month 7 2015-16 Aged Debtors

Invoiced Debtors

1-30 days31-60

days

61-90

days> 90 days

£k £k £k £k £k £k

CCG's 614 393 446 138 89 1,679

NHS England 1,126 1,541 37 87 150 2,940

NHS Trusts 251 661 547 152 845 2,456

Foundation Trusts 86 417 258 38 365 1,165

Other NHS (3) 18 12 10 35 71

Non-NHS 194 377 179 86 773 1,608

Total 2,268 3,407 1,478 511 2,256 9,920

23% 34% 15% 5% 23%

Provision for Bad Debts (including RTA Provision) (992)

Accrued Income (including Work in Progress) 11,081

Prepayments 3,919

Other Debtors 4,037

Total Trade & Other Receivables 27,964

The Trust debtors is a mixture of invoiced debtors, accrued income and prepayments as set out in the table below. It shows that the Trust has outstanding debtors of 31 days or more of £4,244k. The

most significant component of outstanding debtors greater than 90 days relates to other NHS trusts income of £0.85m. NHS debt has increased by £2.9m predominantly due to invoices raised to NHS

England for overperformance in M1-3, drugs expenditure and funding for the Clinical Portal raised at the end of October. Non NHS debt has remianed broadly static in the month.

Other debtors consists of £1.9m of RTA debtors, £1.2m of Private Patients, £0.7m relates to Love Your Hospital (this includes £0.4m of capital items due for payment in November). The balance is

made up of VAT and other miscellaneous debtors

Accrued income consists of £5.9m of commissioner income, £0.7m of provider to provider income, £0.4m of medical training income, non-contracted activity £0.8m, drugs/pharmacy £0.6m, private

patients £0.2m, work-in-progress £2.4m and £0.1m of other miscellaneous including radiology, catering and clinical excellence awards.

OverdueWithin

TermsTotal

3,407k

1,478k

511k

2,256k

Debtors

1-30 days

31-60 days

61-90 days

> 90 days

Finance Report Month 7 2015-16 Capital A

Year To Date Year End Forecast


£k £k £k £k £k £k

Total Capital 10,841 6,753 4,088 Total Capital 15,070 15,070 1

Capital Full Year

Budget Actual Variance Plan Forecast Variance

Source of Funds £k £k £k Source of Funds £k £k £k

Depreciation (net of IFRIC 12) 8,357 8,220 137 Depreciation (net of IFRIC 12) 13,920 13,920 -

Technology Fund 2 for Inpatient Documentation - - - Technology Fund 2 for Inpatient Documentation 110 110 -

Loan Repayments (579) - (579) Loan Repayments (1,158) (1,158) -

Health Education England Funding 170 0 170 Health Education England Funding 170 170 -

Charitable Funds 1,014 0 1,014 Charitable Funds 2,028 2,028 -

Donation/Grants - 824 (824) Donation/Grants - 304 (304)

8,962 9,045 (83) 15,070 15,374 -

Application of Funds Application of Funds

Endoscopy 4,235 3,077 1,158 Endoscopy 4,311 3,534 777

Interventional Radiology Room 606 106 500 Interventional Radiology Room 1,814 1,814 -

RTT - Pre Assessment 192 340 (148) RTT - Pre Assessment 627 580 47

A&E Door - 0 (0) A&E Door 50 59 (9)

Infection Control Isolation Room - - - Infection Control Isolation Room 450 - 450

Haemotology - - - Haemotology 200 160 40

IT Support - Ante Natal Care 59 - 59 IT Support - Ante Natal Care 118 118 -

Bed Capacity 109 112 (3) Bed Capacity 100 401 (301)

Cardiology & Respiratory - 0 (0) Cardiology & Respiratory 40 52 (12)

Other Service Developments not prioritised - - - Other Service Developments not prioritised 773 - 773

Southlands Ophthalmology - 328 (328) Southlands Ophthalmology 2,000 1,920 80

Medical Equipment (including EBME) 1,058 693 365 Medical Equipment (including EBME) 1,972 1,190 782

Facilities & Estates 2,175 690 1,485 Facilities & Estates 4,230 4,348 (118)

Information Technology 2,378 1,101 1,277 Information Technology 3,216 2,604 612

Donated Funds 29 283 (254) Donated Funds 28 245 (216)

Misc - 24 (24) Misc - 181 (181)

Overprogramming Overprogramming (4,859) (2,135) (2,723)

Total Expenditure 10,841 6,753 4,088 Total Expenditure 15,070 15,070 1

The main areas of underspend year to date relate to the endoscopy project, information technology,

Estates and Interventional Radiology Room. Endoscopy equipment spend has been deferred to

recognise apporpriate lead in times for procurement without compromising th eprogramme overall. The

Information Technology and Esates schemes that have slipped will be recovered in full within the year.

The forecast assumes the following:-

- in agreement with the service that the Endoscopy equipment for Chichester and Room 5 in Worthing is deferred

to 2016/17

- service developments not already underway remain unspent for the current year

- remainder of funds for equipment replacement programme remain uncommitted

- a detailed action plan for those schemes currently behind schedule is being completed and will be shared with

the Capital Investment Group on a monthly basis

Year to Date

There is slippage against the capital programme of £4,088k year to date, mainly in Endoscopy, Estates, Information Technology and the Interventional Radiology Room. A monthly capital forecast has been completed, with

input from the divisions, which has identified slippage of £2.7m to offset against the over-programming. A detailed review of the forecast has been undertaken and subject to monthly review at the Capital Investment Group

meeting.

Finance Report Month 7 2015-16 Efficiency and Transformation Programme A

Workstream Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k

Back Office & Corporate Support 2,323 2,382 59 3,999 3,977 (22)

Business Case Benefits Realisation 8 8 (0) 50 50 -

Commercial Opportunities 1,422 1,200 (222) 2,766 2,759 (7)

Clinical Support Services 240 238 (2) 556 551 (5)

Facilities & Estates 485 439 (46) 862 844 (18)

IM&T 109 21 (88) 157 102 (54)

Medical Workforce 1,810 1,692 (117) 3,248 2,821 (427)

Medicines Management 215 267 52 367 390 24

Nursing Workforce 473 360 (113) 1,854 1,665 (189)

Operational Productivity 1,494 1,459 (36) 2,225 2,190 (35)

Terms & Conditions 274 260 (14) 274 274 (0)

Elective Patient Flow - - - 543 543 -

Non Elective Patient Flow 864 865 0 2,208 2,208 -

Efficiency Plan Total 9,718 9,191 (527) 19,108 18,375 (733)

Month 7 Cumulative (October) Plan vs Actual

At the end of October, the Efficiency Programme delivered cumulative savings of £9.2m against a plan of 9.7m (94.6%). Risks within the Medical & Nursing Workforce workstreams have been recognised in month which have reduced the forecast out-turn

position. Mitigating schemes are being developed across all work-streams.

Year to Date Forecast Out-turn

0

500

1,000

1,500

2,000

2,500

3,000

Back Office &Corporate Support

Business Case BenefitsRealisation

CommercialOpportunities

Clinical SupportServices

Facilities & Estates IM&T Medical Workforce MedicinesManagement

Nursing Workforce OperationalProductivity

Terms & Conditions Elective Patient Flow Non Elective PatientFlow

£0

00

s

Plan

Actual

MONITOR FINANCIAL RISK INDICATORS Indicators of Forward Financial Risk AYTD Forecast Q4

Number of Indicators Breached 3 1

MONITOR FINANCIAL RISK INDICATORS YTD RAG Forecast Qtr

RAG

Position Explanation if Risk

Unplanned decrease in EBITDA margin in two consecutive quarters

G G

EBITDA is behind plan in

quarter but was on plan at

end of Q1

The Trust is behind plan for the quarter, but is

forecasting to meet its financial forecast in the

year

Financial risk rating (FRR) may be less than 3 in the next 12 monthsG G

FRR 2 for any one quarter

G G

Debtors > 90 days past due account for more than 5% of total debtor

balances R ROver 5%. Debtors over 90

days account for 22.8% of

the total invoiced debts.

Performance due to some slow NHS payments.

This is under constant review.

Creditors > 90 days past due account for more than 5% of total

creditor balancesG G

Over 5%. Creditors over 90

days account for 4.9% of

the total invoiced creditors.

NHS creditors account for 39.4% of the 90 day

balances, the remaining material balances relate

to specific non NHS creditors.

Two or more changes in Finance Director in a 12 month period

G GNot applicable Not applicable

Interim Finance Director in place over more than one quarter-end

G GNot applicable Not applicable

Quarter end cash balance <10 days of operating expenses

R G

Cash balance at end of

month is slightly below 10

days operating expenses

Movement in cash position against plan is

summarised on cash sheet

Capital expenditure < 75% of plan for the year to date

R G

Capital Expenditure is 62%

of plan year to date due to

the phasing of the

overprogramming

Capital expenditure reviewed by the Finance &

Investment committee, including forecast

Any particular occurrences that could have an impact on the

operation of the business of the Trust G G No plans to undertake a major acquisition,

investment or divestment. No plans for a major

change in capital structure.

YTD RAG Forecast Qtr

RAG

IMPACT MITIGATION

A A

Adverse financial

performance will impact on

the EBITDA margin and

CoS rating.

Performance across operational budgets will need

to improve and agency spend reduce. This will be

managed by exception through the director-led

deep dive reviews

A A

Non-delivery of efficiency

programmes will adversely

affect EBITDA and CoS

rating.

Enhanced infrastructure to support programmes

and enable delivery. Identification of new pipeline

schemes to enable headroom. Delivery of each

workstream is formally reviewed weekly by the

Programme Steering Group

A A

Non-recovery of income will

adversely affect will

adversely affect EBITDA

and CoS rating.

Regular discussions with the CCG Finance

Directors over system finances and affordability.

The anticipated level of income from commissioners may be in

excess of local health economy available funds.

Work through the local Contract Management

Group to validate and agree current levels of

activity and secure income

NEXT STEPS

Trust financial performance is adverse to plan and operational

performance is currently highlighting underlying cost pressures.

Slippage against efficiency and transformation programme. The Trust

must identify and deliver 'pipeline' schemes to ensure sufficienct

headroom so potential slippage on schemes is recovered in full

Formal risk assessment of plans supported

through external review. Additional support for

'high risk' work streams in place for 10 weeks to

mobilise delivery. Substantive PMO team

recruited in order to facilitate delivery

The Capital Investment Group, chaired by the

Director of Finance, continues to meet monthly to

oversee the 2015/16 plan and out turn. A

monthly forecast is now being produced, with

input from the divisions and an action plan is

being completed relating to those areas that are

currently behind plan but are forecasting to hit

this budget by March 2016

The indicators below have previously been identified by Monitor as indicators of forward financial risk against financial performance.

Although the new Monitor Risk Assessment Framework is now in place the indicators below still provide a helpful indication of

operational financial performance. The Trust will monitor performance against these as a helpful indicator of emerging risks in

addition to the Continuity of Service Rating and delivery against the control total surplus.

Action if Risk

A financial trajectory to deliver the year-end

position is in place and will be monitored by the

Finance and Investment Committee

FRR in 3 for the YTD FRR has remained a 3 The Trust must deliver its planned savings as

part of the efficiency programme and control the

costs of over-performance in order to achieve its

forecast financial position.

Comprehensive formal review of debtors and in

particular NHS partner organisations

Work is ongoing to clear the major non NHS

creditors

Not applicable

Not applicable

Review of accrued income and conversion to

debtors to enable cash to be collected. Work

continues on agreeing over-performance with the

Trusts Main Commissioners

To: Trust Board


Title

Patient First Programme Update


Marianne Griffiths, Chief Executive

Prepared by

Jenny Procter, Programme Director PMO

Status

Discloseable

Summary of Proposal

The purpose of this paper is to provide the Trust Board with an update on the implementation of the Trust’s Patient First Programme, our trust-wide approach to improving the experience and quality of care we offer patients. The Patient First Programme Board will oversee and assure delivery of all improvement and transformation work in the Trust.


The Patient First Programme’s key aim is to improve the quality of care for patients and improve patient experience and outcome.


Links across all of the Trust’s Strategic Objectives.


A number of workstreams within the Patient First Programme have resource implications and savings targets. These are now consolidated into and tracked through the Trust Efficiency and Transformation Programme.


A Workforce Transformation Workstream and an Organisational Development Workstream are now in place. Workforce impact will be assessed through these groups.

Recommendation

The Board is asked to NOTE progress on the development of the Patient First Programme.


Communication Strategy has been approved by the Patient First Programme Board.

Appendices

N/A

Patient First Programme – Update Report November 2015

1. Introduction

The Patient First Programme in November saw the launch of the first wave of the

Patient First Improvement System (PFIS), which included leadership teams from four

wards and welcomed into post the first Patient First Improvement Practitioners. There

has been continued focus on the Transformation Workstreams, all of which are well into

the delivery phase, which for some requires highly complex change management.

The Programme continues to be supported by a range of communication and

engagement activities. The second of two staff conferences is eagerly anticipated and

is scheduled for 27th November.

This report provides a summary update of progress against key objectives and outlines

the priorities for December.

2. Context

Introduced in November 2014, Patient First is the Trust’s approach to ensuring safe,

high quality care for patients. The philosophy behind the programme is centred on:

The patient being at the heart of every decision

Empowering staff to build on existing high standards

Continuous improvement of services through small steps of change

Standardising practices to ensure consistency of service.

Patient First has a strong focus on safety and we have prioritised changes that directly support that focus. For example the introduction of daily Safety Huddles, where everyone working on a ward comes together at the same time each day to discuss how they will provide a safe service that day, including ensuring they have the right staff and resources.

3. Patient First Themes

a. Sustainability: The Workforce Transformation Programme will deliver in year

efficiency schemes, improve business as usual processes and strengthen the

baseline from which more complex, larger scale change can be delivered. The

principal focus of the Programme is the development of a sustainable workforce that

reduces our reliance on temporary staffing and enables access to services that are

safe for patients.

Alongside realisation of the financial benefits as part of the Efficiency Programme,

non-financial benefits are being realised as a result of improvement actions. For

example, in October as a result of a prolonged period of intense domestic and

international recruitment activity, the number of qualified nurses joining the Trust

exceeded the numbers leaving and there can be some optimism that this is the start

of a new trend as we are expecting this to repeat in November and December.

Detailed work is underway to more accurately forecast the arrival of new overseas

nurses and to align this with the Trust’s activity plan and aim to eliminate

non-framework agency usage. This recruitment, alongside a focus on improving

retention is the key to creating a sustainable nursing workforce.

The Nurse Resource Management Programme is now being rolled out to all wards,

beginning with the Surgical wards. It is expected that temporary staffing usage will be

reduced by maximising the use of nursing establishments. Improvements will be

realised through more planned staff attendance that will result from allocation of

unallocated hours, proportionate annual leave throughout the year, proactive

sickness management and fair allocation of work hours.

It will be important to learn from the experience in the Nursing Efficiency Programme

and apply this in the Medical Workforce Workstream to accelerate the pace of

change in medical workforce management. This is the next focus of work.

b. Our People: The Trust is making good progress to establish a Kaizen Office. A

Director of Continuous Improvement has been appointed and the Kaizen Office is

fully established. The first two Improvement Practitioners joined the Kaizen Office on

the 2nd November and further people will take up post on 1st December and 1st

January 2016. Two other people will be seconded into the Kaizen Office and will

work part-time from February 2016 and a further nine people will be offered Green

Belt training, which will run from February 2016.

The first wave of training in the Patient First Improvement System (PFIS) began on

22nd October. Four wards are included in the first wave and will be used to tailor the

improvement method to Western Sussex to support subsequent waves. The first four

PFIS units are Botulphs, Fishbourne, Clapham and Wittering wards. Subsequent

training modules will be run monthly until completion of the first wave of training in

February 2016. The training has been well attended by the ward leadership teams

and there is very high participation and enthusiasm for the training and application of

the method in their ward areas.

In December, attention will focus on developing a lean training plan (to include green

belt, yellow belt and awareness training), identification of the six improvement

projects, selection of units to participate in the next PFIS waves and implementation

of the Strategy Deployment Room.

c. Quality Improvement: A review of the improvement projects and alignment with the

Quality Board objectives is currently underway to ensure focus on the right quality

improvement objectives. Work progresses in all current quality improvement

projects.

d. Systems and Partnerships: The Non-Elective and Elective Transformation

Programmes are now well into the delivery phase. The scope and timeline for these

programmes and critical dependence on the Workforce Transformation projects

makes delivery highly complex and challenging. Nonetheless, good progress is being

made in a number of patient flow improvement projects, including elimination of the

pre-assessment backlog, implementation of senior daily review, implementation of

bed reconfiguration proposals and agreement of a new theatre schedule. A stocktake

that refreshes delivery plans and ensures full alignment of transformation activity will

be undertaken in December and this will confirm efficiency values for 2015/16 and

set a baseline for 2016/17 improvement plans.

4. Planned Activity in December

Work will continue to support delivery of all improvement work within the Programme.

Specific actions include:

Review and alignment of all transformation workstreams

Continued implementation of Patient First Improvement System training in

four wards

Continued establishment of the Kaizen Office as more Patient First

Improvement Practitioners come into post

Agreement of True North metrics and full establishment of the Strategy

Deployment Room

Development of a lean training plan to include green belt, yellow belt and

awareness training

Identification of improvement projects and next PFIS units to confirm focus of

improvement activity for the Patient First Improvement Programme

Continued focus on domestic and international recruitment to ensure access

to safe services for patients

Trust wide communications to raise awareness of the Patient First

Improvement Programme and System roll out.

meeting of the board of directors€¦ · meeting of the board of directors 10.00am to 12.05pm on...

Documents