trust board meeting the boardroom ... - wye valley nhs trust · trust board meeting the boardroom,...

Trust Board Meeting The Boardroom, Trust Headquarters, Hereford

Thursday 1st December 2016, 10 a.m. – 12.45 p.m. Agenda – Part A (In Public)

Exclusion of the Press and Public ‐ Having resolved that representatives of the press and other members of the public be excluded from Part B of the meeting due to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. Section 1(2), Public Bodies (Admission to Meetings) Act 1960. *The Chairman should be advised of any matters to be raised under “Any Other Business” before the meeting.

FOR INFORMATION ONLY

The following matters are to be considered in Part B of the Board meeting held in private:

Declarations of Interest to items on the Agenda.

The minutes of the meeting in private of 3rd November 2016.

Matters Arising from the meeting in private of 3rd November 2016.

Confidential staff suspensions

Confidential Committee Reports

Page No: 10.00 1. Apologies for Absence RH 2. Quorum RH 3. Declarations of Interest RH 4. Minutes from the meeting held on 3rd November 2016 RH For approval 2‐12 5. Matters Arising from the meeting held on 3rd November 2016 RH For noting 13 Improve the quality and safety of care to our patients, their carers and families 10.10 6. Organisational Sustainability Plan GB Presentation 10.30 7. Chief Executive update report GB For noting 14‐16 10.40 8. CQC Report SG For noting 17‐5310.50 9. Quality Improvement Programme LF For discussion 54‐68 11.05 10. Board Assurance Framework NL For discussion 69‐100 Improve the responsiveness of our services for the benefit of our patients and their families 11.15 11.

Performance and Progress Summary Exception Reports:

a) Key Performance Indicators

b) Operational Performance

c) Workforce

d) Finance inc. Financial Recovery Plan

HO JB SS HO

For discussion For discussion For discussion For discussion

101‐107 108‐114 115‐127 128‐137

11.35 12. Acute Clinical Services Strategy – update on implementation SG For discussion 138‐141 Develop a highly skilled, motivated, healthy and engaged workforce

Develop first class facilities and technology to support the care we provide11.55 13. INFORM Electronic Patient Record Update Report HO For noting 142‐148 12.05 14. STP Submission GB For noting 149‐171 Enablers

Governance 12.20 15. Safety and Quality Committee Summary Report 24.11.2016 CH For noting To be tabled 12.25 16. Finance and Performance Committee Summary Report 22.11.2016 MW For noting Verbal 12.30 17. Any Other Business * RH 12.35 18. Questions from members of the Public RH

19. Date of Next Meeting – 5th January 2017 RH

of 171

MINUTES OF THE TRUST BOARD MEETING HELD ON 3rd NOVEMBER 2016

BOARDROOM, TRUST HEADQUARTERS, HEREFORD COUNTY HOSPITAL PART A – IN PUBLIC

Present:

Mr Mark Waller AC Acting Chairman Mr Richard Beeken CEO Chief Executive Officer Dr Susan Gilby MD Medical Director Revd Christobel Hargraves NED Non-executive Director Mr Andrew Cottom NED Non-executive Director Mr Frank Myers, MBE NED Non-executive Director Mr Howard Oddy DFI Director of Finance & Information Mrs Lucy Flanagan DN Director of Nursing In attendance:

Mrs Susan Smith DHR Director of Human Resources Ms Nicola Licence CS Company Secretary Mrs Lynne Kedward DCOO Deputy Chief Operating Officer Mrs Louise Gibson EA Executive Assistant (for the minutes) The Acting Chairman (AC) welcomed the Board and members of the public to the meeting.

A001/11.16 1. Apologies for Absence

Apologies were received from Jon Barnes, Chief Operating Officer and Richard Humphries, Non-executive Director.

A002/11.16 2. Quorum

The meeting was quorate.

A003/11.16 3. Declarations of Interest

There were no declarations of interest.

A004/11.16 4. Minutes of the Meeting held on 6th October 2016

• A Non-executive Director (NED) highlighted a typing error under the heading A009/10.16 of the minutes.

• The Director of Finance & Information (DFI) requested for a sentence to be removed under heading A023/10.16 as he did not feel it was an accurate reflection.

RESOLVED: The minutes of the Trust Board meeting held ‘in public’ on the 6th October 2016 were APPROVED subject to the agreed amendments.

A005/11.16 5. Matters Arising and Action Log

A016/09.16 – The Company Secretary (CS) advised that the Infection Prevention and Control Annual Report would be presented to the Board meeting

of 171

in February 2017 after being presented to the Safety and Quality Committee in January 2017.

A006/11.16 6. Chief Executive Update Report

The Chief Executive (CEO) advised that since the time of writing, the detail in his cover report had been superseded by the CQC inspection report, the discussions regarding South Warwickshire Foundation Trust (SWFT) and NHSI’s announcement regarding Special Measures. The CEO advised that a staff briefing had taken place on the 2nd November where he had given a presentation on all three matters. The CEO went on to represent the presentation for the benefit of the public who were in attendance at the meeting.

CQC Inspection Presentation

• Inspection outcomes – The presentation compared the outcome of the CQC inspection conducted in September 2015 with the outcome of the CQC inspection conducted in July 2016. In 2015 the CQC had great concerns around patient safety, the outcome of the 2016 inspection showed there had been significant improvements in Patient Safety and areas such as Critical Care and End of Life Care, which were both rated ‘good’ overall.

• Outstanding practice – The CQC had highlighted areas of outstanding practice including the ‘pathway bundle’ and Gilwern Assessment Unit.

• Improvement required – There were areas where improvement was required such as access to outpatient services, identifying risks on the risk register and Trust staff needing to be better at completing mandatory training.

• Special measures – The CEO stated that Professor Sir Mike Richards, Chief Inspector of Hospitals, had recommended for Wye Valley NHS Trust (WVT) to be removed from Special Measures, and he went on to confirm that following this, WVT had been taken out of Special Measures.

• Next steps – The Trust needed to continue its improvement journey and aim for a ‘good’ rating as a minimum. The Trust needed to work to improve its financial position and would be working towards a strategic partnership with South Warwickshire NHS Foundation Trust (SWFT) to improve this along with sustainability and governance.

• SWFT partnership – Russell Hardy, Chairman of South Warwickshire NHS Foundation Trust (SWFT) would be appointed as Chairman of WVT on Monday 7th November. Discussions were ongoing to agree how the WVT and SWFT partnership would work, however it was likely the CEO of SWFT would also be the CEO of WVT, the Trusts would have shared leadership but individual Boards would remain. It was felt that the partnership would improve clinical practice by sharing and adopting best practice. The CEO stressed that the partnership was not a merger,

of 171

acquisition or takeover, as the media had reported, and that the legal construct of WVT would remain. The CEO commented that the Health Service Journal (HSJ) stated that one third of NHS Trusts planned to form a strategic alliance with each other.

• A NED asked whether the presentation had been presented to Trust staff. The CEO confirmed that it had and advised that there had been a large turnout with over two hundred staff present, he also advised that it had been filmed and was available to view on the Intranet. The CEO stressed the importance of delivering a consistent message and reiterating that the partnership between WVT and SWFT was not a merger. The Deputy Chief Operating Officer (DCOO) commented that the media coverage had heightened anxiety and she felt the CEO’s message was strong and would hopefully reduce any anxiety that may have been felt.

• The AC advised the Board that the CEO had received a round of applause following his presentation at the CQC summit and felt this should be acknowledged, the AC went on the pay tribute to the CEO on behalf of the NEDs and Executive Team. The AC also acknowledged the clinical staff who had consistently portrayed caring and empathetic care.

Chief Executive Update Report

• The CEO confirmed that WVT Medical Director (MD) had been appointed as the MD at the Wirral University Teaching Hospital Foundation Trust, he went on to congratulate her and thank her for all her hard work, particularly in relation to the mortality and serious incidents culture which she had led in an exemplary fashion.

• The next iteration of the STP had been submitted on the 21st October, the Trust was waiting for clear guidance on how the plans would be shared with the public.

• WVT was currently within segment four of the NHSI segmentation of NHS Trusts. Following the CQC inspection results and Special Measures being lifted. The CEO stated that he expected the Trust to move to segment three.

• WVT had been selected for a costing assurance audit, the AC questioned this and the DFI advised that it was specifically related to reference costs and advised that a selection of Trusts, large/small, acute/community are audited. A NED asked who paid for this audit, the DFI confirmed that the Trust did not have to pay for it and it was paid for by the NHS.

• The AC asked for an update on the business case for the hutted wards, the DFI advised that the business case was planned for the next financial year.

of 171

RESOLVED: The Board NOTED the Chief Executive’s CQC inspection presentation and update report.

A007/11.16 7. Quality Improvement Programme (QIP)

The CEO provided the Board with an update on the delivery of the Quality Improvement Programme (QIP). The following points were noted:

• QIP 2 had received Board sign off and would be implemented.

• There had been a very successful Star Chamber for the Tissue Viability project. A NED emphasized the importance of maintaining a focus on Star Chamber sessions.

• The Programme Team had managed the collation of comments from service leads for factual accuracy following the CQC inspection, the CEO confirmed that over 75% were accepted. The Service Transformation Lead had been the key contact for the CQC however this would now be the new Associate Director of Quality Governance.

• Ian Hall, Improvement Director had now left the Trust however NHSI continued to provide support.

RESOLVED: The Board DISCUSSED the Quality Improvement Programme.

A008/11.16 8. Board Assurance Framework (BAF)

The CS presented the monthly BAF update for the Board to discuss and note the risks. The following points were noted:

• The CS advised that she hoped to reduce risk ref 411, risk to the Trust’s credibility and reputation due to remaining in Special Measures. A NED questioned why this was not removed already with Special Measure being lifted, the CS stated that it needed to be fully reviewed before removing.

• The CS advised that she and the MD would review risk ref 544, risk to health, safety and welfare of service users due to ineffective quality governance systems and processes. This would reduce the overall number of risks on the BAF from nine to seven.

RESOLVED: The Board DISCUSSED the Board Assurance Framework.

A009/11.16 9. Performance and Progress Summary Exception Reports

The AC stated that the exception reports had been presented to the relevant Committees and therefore suggested for questions only to be dealt with under

of 171

the appropriate sub-heading.

A010/11.16 a) Key Performance Indicators

The report was taken as read and there were no questions in relation to the Key Performance Indicators (KPI’s).

A011/11.16 b) Integrated Quality Governance Report

The MD presented the integrated quality governance summary report and advised that it was a dashboard of the full report, which is presented to the Safety and Quality Committee (S&QC). The following points were noted:

• The MD highlighted an error within the report and advised that there had been ‘never’ event, which was not reported; she went on to confirm that Duty of Candour had taken place.

• Mortality reports were improving and four out of five outliers had been closed down. There were sufficient action plans in place therefore reports were no longer required, this was a significant milestone. The remaining outlier was fracture neck and femur.

• The Chair of the S&QC recognised that the dashboard was developing but stated that she did not feel assured by it; she did however feel more assured by the full report which was presented to the S&QC.

• The CEO requested for a commentary to be included alongside the dashboard and also suggested that patient experience be removed as this was already included within the Chief Operating Officer’s (COO) report.

• The DFI stated that the NEDs had previously requested a full integrated report and he felt it was an appropriate time to do this. The AC asked if it could be in place for the next financial year and the DFI confirmed that he felt it was achievable. In addition to this the CEO reminded the Board that the COO had agreed to pick this action up at the AQuA Board Development session.

A012/11.16 ACTION: To include a commentary alongside the integrated quality governance summary dashboard. MD – December 2016

A013/11.16 ACTION: To remove patient experience detail from the integrated quality governance summary dashboard. MD – December 2016

A014/11.16 ACTION: To create a full integrated report by the next financial year. COO – April 2017

A015/11.16 c) Operational Performance

The DCOO provided a summary of the operational performance report and answered questions from the public.

of 171

Q. A&E Standard - It is encouraging to read that the Trust is following the advice from NHSI and will run a pilot called "Red/Green Day" in an effort to tackle poor patient flow. What exactly is "Red/Green Day"? An explanation would be welcomed.

A. The DCOO advised that she had already provided a detailed response to this question offline but went on to explain that a red day was a day of no value for a patient, for example, when a patient was waiting for an action to progress their care and/or this action could take place out of the current setting. A green day was a day of value for a patient, for example, when a patient received an intervention that supported their pathway of care through to discharge. The DCOO stated that the initiative had proved worthwhile in other hospitals and WVT had planned to run a week long pilot. The AC stated that the initiative sounded positive for inpatients but questioned whether there was a risk to the waiting lists for outpatients. The DCOO stated that she did not expect it to have an impact on outpatients.

RTT 18 week standards – the DCOO advised that specialist plans were in place for the revised recovery trajectory and they were being monitored on a weekly basis.

Cancer standards – the DCOO advised that WVT were continuing to work closely with Cheltenham Hospital and their gynecology department.

Q. Stroke - The figures on page 69 of the papers continue to show that the TIA standard repeatedly falls below the threshold standard.

On page 31 of the October papers it states, “Discussions with Gloucester to provide cover for high risk TIA referrals at weekends. Developing a longer term SLA with Stroke to provide out of hours support across the week including telemedicine and Thrombolysis support.”

What progress has been made in this area?

A. The DCOO advised that the weekend service had only commenced in November and a date for when out of hours support would be confirmed soon. There was ongoing use of telemedicine to support options being drawn up. Delayed transfers of care were deteriorating and this was linked to A&E performance. Delays were predominately around packages of care and community bed base. Currently nine patients were waiting for out of community placements.

Q. On pages 40 to 41 of the papers refer to strategic risk 5. Risk of the Trust failing to achieve the NHS Constitutional targets.

This risk would seem to be very real with:-

Gaps in control:- 1. Don’t have the capacity in all specialities to deliver activity and achieve plans.

of 171

and Gaps in Assurance:-

1. Non achievement of National Standards by the Trust on a consistent basis.

2. Recovery trajectories were not met last month with exception of A & E.

3. Delayed transfers of care not getting better.

This would seem to be confirmed by the Activity Summary for September 2016, on page 65 of the papers.

“Day case saw the highest level of monthly activity.... but remained down on plan in the month for the 3rd month in a row........with a new recovery plan identified by each division”.

“Elective activity increased in the month and behind behind plan....”

“Outpatient Activity continues to be down on plan for both new and follow ups......Both Divisions have developed recovery plans to reduce the shortfall at the year end”.

What assurances can the Board give that these new recovery plans will succeed and allow the Trust to achieve its Constitutional target?

A. Responses detailed answered this question.

A016/11.16 d) Workforce

The AC welcomed the new substantive Director of Human Resources (DHR) to her first Board meeting, which was her third week in post. The DHR provided a summary of the workforce report and the following points were noted:

• Vacancies – The Trust’s vacancy rate was down to 8.5%. The DHR advised that she was looking to develop a detailed recruitment and retention (R&R) plan, which she would present to the Board with initiatives.

• Agency spend – The DHR stated that she would be held to account for the agency reducing spend plan.

• Statutory and mandatory training – The DHR advised that she was reviewing the shortfalls.

• Appraisals – The DHR responded to a question from a member of the public.

Q. On page 15 of the October papers, referring to the Actions from the September meeting, (also repeated in the November papers, page 13), it states,

“To develop an action plan for preventing incremental increases in pay where appraisal and statutory and mandatory training have not been undertaken.” Due November 2016.

of 171

Has this plan been completed?

Does it differentiate between staff failure to complete and management failure to complete?

Are staff given appropriate working time to complete appraisal and training?

Have the relevant Trade Unions been consulted upon this plan?

A. The DHR advised that a pay progression policy was already in place within the Trust that contained very clear criteria in support of incremental pay progression for both employees and their managers. The intention of this policy was to support the delivery the best possible patient care by staff with the right skills to do so. The purpose of such a policy was not to prevent pay progression but to engender a culture of performance. The AC stated that he felt reassured by the DHR’s plans and emphasized the importance of cultural change rather than it being a ‘tick box’ exercise.

A017/11.16 e) Finance

The finance summary report which was taken as read and the DFI highlighted key points of the report.

• If the current trend didn’t stop and if all the risks came to fruition the financial position would deteriorate to £40m deficit.

• The Financial Recovery Plan would be incorporated into the summary report from December.

• The Trust had been given access to cash to fund the capital programme in its entirety. An extra cash bid had also been submitted which would increase the monthly bid for cash, this had not yet been approved however it was expected to be.

• Referring to the Single Operating Framework table included in the report, the DFI advised that the Trust had a rating of four in all of the following areas, financial sustainability, financial efficiency and financial controls; he stated that this was a clear indication of the Trusts financial difficulties. A NED advised that he did not have a good understanding of the table, in response the DFI advised he was happy to explain it in detail at the F&PC meeting and would also bring a summary to a future Board meeting. Further to this, the AC questioned whether four was an appropriate rating for the Trust, the DFI confirmed that it was.

• The CEO raised a question on control totals, the DFI advised that the NHS as a whole had financial challenges and all Trusts were issued with a control total for the current financial year and WVT were one of thirteen Trusts who had did not accept it. It was understood that the NHS did need to set targets however the control total for 2017/18 for WVT was felt to be unachievable, the gap between the current budget plan and the proposed control total was £14m. The Trust had to decide whether to

of 171

accept or reject the control total by November. The CEO and DFI agreed to decide offline how to respond to reject the control total.

• The AC asked the DFI to convey appreciation on behalf of the Board to the finance team.

A018/11.16 ACTION: To provide a summary on the Single Operating Framework. DFI – November 2016

A019/11.16 ACTION: To decide how to respond and reject the control total. CEO/DFI – November 2016

RESOLVED: The Board DISCUSSED the performance summary Reports.

A020/11.16 10. INFORM Electronic Patient Record Update Report

The DFI provided the Board with the monthly update on the Electronic Patient Record (EPR) programme. He advised that the system was due to ‘go live’ at the end of March 2017 and welcomed questions.

• A NED stated that she felt uncomfortable with the key risk detailed within the report; the DFI advised that it was being managed closely.

• The Chair of the Finance and Performance Committee (F&PC) requested for an EPR Programme update to be provided to the next F&PC meeting. He suggested that the EPR Programme Director and EPR Programme Manager to attend. The DFI agreed and advised that he felt the programme should have had a higher profile however the focus had been on the CQC Inspection and Special Measures.

• The DFI responded to two questions from the public which related to the EPR programme.

Q. Would the Board clarify how widely the EPR will be used when it comes on stream next spring, i.e. will it interface with GP Surgeries, WMAS etc. or will it be used solely within the Hospital?

A. The DFI advised that the first phase was focused on merging the two current Patient Administration Systems (PAS) and five departmental systems, the second phase would look closely at how it could be integrated with GP surgeries, this however wouldn’t be until mid-2018.

Q. In view of the low mandatory training rates amongst staff, is the Board confident that the month allocated to training will be sufficient to ensure staff will be competent to operate the EPR effectively?

A. The DFI advised that training was critical and it needed to be close to the system going live to stay fresh in users memories but also in a timeframe to provide notice for rostering, which was challenging to find the right balance. He advised that training would be conducted over a six week period and would be role based, he also confirmed that training was high on the agenda of the

of 171

programme board. In addition the DCOO commented that there would also be a number of ‘super users’ trained. Further to this, the DHR advised that she had been approached by the EPR team in relation to low mandatory training rates and she had agreed to feedback.

A NED raised concerns over cyber security and asked whether the Trust was protected from cyber-attacks. The DFI stated that he had been given reassurance from Hoople however due to recent news it was going to be closely reviewed to ensure the system was protected. The DFI advised that he would provide a further update at the next meeting.

A021/11.16 ACTION: EPR Programme Director to provide an update on the EPR programme to the next Finance & Performance Committee meeting.

DFI – December 2016 A022/11.16 ACTION: To provide an update on cyber security protection.

DFI – December 2016 RESOLVED: The Board NOTED the update on the electronic patient record

programme.

A023/11.16 11. Safety and Quality Committee Summary Report

The Chair of the Safety and Quality Committee (S&QC) advised the Board that the meeting, which was due to be held on the 27th October, had unfortunately been cancelled. This was due to the clash of an unplanned staff briefing session which was being held following media coverage in the Hereford Times regarding the Trust’s future. The Chair of the S&QC went on to advise that she had used the meeting time effectively to discuss the Committee work plan and governance.

RESOLVED: The Board NOTED the Safety and Quality Committee summary report.

A024/11.16 12. Finance and Performance Committee Summary Report

The Chair of the Finance and Performance Committee (F&PC) provided a verbal summary of the meeting held on the 25th October. The Chair advised that the Committee had reviewed the business case for the Second CT scanner, six months after ‘going live’ and also the Gilwern Assessment Unit, which was now almost fully established.

RESOLVED: The Board NOTED the Finance and Performance Committee summary report from the meeting held on the 25th October 2016.

A025/11.16 13. Any Other Business

There was no other business to be discussed.

A026/11.16 14. Questions from Members of the Public

of 171

The AC asked the public if they had any questions following the CEO’s presentation.

Q. A member of the public expressed concern over the shared CEO role and asked what was envisaged for the role of the CEO. He went on to discuss the STP and questioned how WVT would provide community care when commercial companies had declined this work.

A. In response to the first part of the question, the AC advised that the Trust were still in discussions regarding the role however, it was likely that the CEO from SWFT would work alongside another leadership role at WVT. In response to the second part of the question, the CEO advised that this was part of the five year forward view (5YFV), he went on to state that WVT had not yet decided whether to bid for the work.

A027/11.16 15. Date of next meeting

Thursday 1st December 2016.

of 171

Wye Valley NHS Trust Board Meeting Action Log for meeting held on 1st December 2016

Part A, held in Public

Minute Ref September 2016

Action Deadline per minutes

Action by Outcome

A006/09.16

To develop an action plan for preventing incremental increases in pay where appraisals and statutory and mandatory training have not been undertaken.

November 2016 IDHR This links to actions on the BAF therefore delivery date is March 2017.

A008/09.16 To present evidence on how the Clinical Services Strategy was being implemented to the Trust Board.

November 2016 MD Complete – on agenda 1.12.16.

A012/09.16 To have a discussion offline in relation to what NEDs would attend the two Star Chambers.

Offline AC Verbal update.

A016/09.16 To include actions from Quality and Safety Committee within the cover report of Infection Prevention and Control Annual Report.

September 2017 DN IPC Annual Report due December 2016.

Minute Ref October 2016

Action Deadline per minutes

Action by Outcome

A008/10.16 To present an analysis and list of ten Carter products to Finance and Performance Committee

November 2016 DFI Ten products not yet released.

A012/10.16 To present the BAF to TMB prior to Trust Board in the future. November 2016 CS Complete. Will commence from January 2017 – on work plan for TMB and Risk Committee.

A013/10.16 To share structure diagrams with the Board. November 2016 COO Complete A014/10.16 Request feedback from NHSI following deep dive review. December 2016 DFI Due December 2016 A018/10.16 To follow up on suggestion regarding the Trust working alongside the

Armed Forces. November 2016 CEO To be further investigated.

A019/10.16 To review and ensure appraisals are conducted within Trust Headquarters.

November 2016 CEO Review to be undertaken.

A024/10.16 Share the planning priorities 2017-2019 with Trust staff. December 2016 CEO Due December 2016

of 171

TRUST BOARD MEETING

Report to: Trust Board ‘in public’ Agenda item: 7

Date of Meeting: 1st December 2016

Title of Report: Chief Executive’s Update Report

Status of report: (Approval, position statement, information, discussion)

For information

Report Approval Route: N/A

Lead Executive Director: Chief Executive

Author: Chief Executive

Appendices: N/A

1. Purpose of the report

1.1 To provide Members of the Trust Board with an update from the Chief Executive.

2. Recommendations

2.1 To note the update report from the Chief Executive

3. Executive Director Assurance

3.1 To provide assurance to the Board on;

- progress towards agreeing financial plans for the next two years

- publication of system Sustainability and Transformation Plans

- the need to reduce agency staff expenditure

- the development of new models of care outside of hospital

4. Summary of Key Issues for discussion

4.1 My First Meeting

I couldn't let the first meeting pass without commenting on how welcome everyone has made me feel since I

joined the Trust on 22nd November. I write this piece having just delivered two staff briefings where I explained

the nature of the partnership and identified some of the initial challenges that we all face. There is clearly a strong

culture in the organisation, a culture which resulted in the Trust being removed from special measures last month

and one which will hopefully provide the momentum to tackle our sustainability challenges.

I also talked about how we want to be open with staff and to understand their concerns and ideas. To help us with

this we have introduced the 'Rumour Mill' on our intranet. This is a place where staff can post questions totally

anonymously, which will be answered by the senior team and then the question and the answer are published for

all to see. This has already generated quite a bit of activity.

of 171

Wye Valley and our partner organisation South Warwickshire Foundation Trust have much in common and both

Boards are keen to use this partnership to share best practice and improve services for our patients and service

users.

4.2 One Herefordshire

I have been impressed by the vision expressed in the One Herefordshire strategy. We definitely need to create a

new model of care which engages all key health and social care providers in some form of risk share. By doing so

we will be more incentivised to integrate, deliver more care outside of hospital and focus on the health and

wellbeing rather than simply treating illness.

As part of these discussions there has been a suggestion that community services might transfer to our partner

organisation 2gether NHS Foundation Trust. Whilst I am keen to not slow down this work I am concerned that

international evidence demonstrates that vertical integration has delivered much more benefit than horizontal

integration. The success of integration in South Warwickshire has predominantly come from encouraging the Out

of Hospital division to lead on developing capacity and transferring acute services into the community setting in

partnership with primary care. I would very much like to take the same approach here.

I have informed colleagues at 2gether, the CCG and Taurus GP Federation of my initial thinking on this. I have

been particularly impressed with the approach of Taurus who share my desire to focus on patient pathways and

joint working rather than organisational form. Organisational form is clearly something that we will need to focus

on at some point soon, but we should be able to draw upon emerging findings form national Vanguard sites. Any

proposed changes would of course need Board approval. But in the mean time I would like to see much more

organisational focus on our community services as they will be key to delivering a sustainable future.

4.3 Agency Expenditure

NHSI in Midlands and East have recently started to publish monthly league tables showing levels of agency

expenditure by provider. These show distance from reduction targets alongside the overall agency expenditure

expressed as a percentage of the total pay bill. Wye Valley performs badly in the first report which covers the

period up to the end of September. The figures show that the Trust spent around 69% of its pay bill on agency and

locum staff. This is one of the highest levels in the Midlands and East region.

Tackling this issue is paramount as agency staff not only represents a waste of resources, they also present quality

and safety risks in the delivery of healthcare. But the waste of resources is quite shocking - by way of an example,

the highest rate the Trust would pay for a specialist nurse on a Bank Holiday would be just under £30 per hour.

The equivalent rate for one of the agencies which the Trust regularly uses is over £171 per hour. Whilst this is an

extreme example, the relative costs of all grades are of a similar magnitude.

4.4 Single Oversight Framework

I am pleased to report that the Trust has moved from segment 4 to segment 3 in the Framework. We are

however fortunate that we have not remained in segment 4 by being placed in financial special measures by our

regulator as our deficit represents one of the largest as a percentage of any NHS provider.

4.5 Contract Sign-Off and 2017/18 Financial Plans

We are working to a much tighter timeline this year to sign contracts with commissioners. There are two

important milestones regarding next year’s financial plans. By the time the Board meets, the first milestone

of 24th November will have past. This is the deadline by which providers are requested to accept their control total

offers. By 23rd December we are expected to have signed contracts for the next two financial years with our main

of 171

x-apple-data-detectors://0/






commissioners.

In parallel to this we are attempting to negotiate a realistic control total offer with NHSI as the initial offer is not

deliverable as it would require a level of cost reduction never seen in any provider in the NHS previously. The

agreement of a control total would secure a contribution from the national Sustainability and Transformation

Fund. Such support is non-interest bearing and as a consequence would significantly help in our recovery

trajectory. I therefore hope to agree something workable.

To achieve the December deadline we have now had our initial contract offer from Herefordshire CCG. Sadly this

falls short of our requirements and will be the subject of further detailed discussion over the coming weeks. We

currently have different perspectives on this year’s forecast outturn, which forms the basis of next year’s offer.

The differing assumptions relate mainly to QUIP delivery.

4.6 Sustainability and Transformation Plans

The system has now published our initial plans see STP draft submission report later on the agenda.

5. Please state which Corporate Objective your report relates to:

Strategic Objective Risk Appetite

1. Improve the quality and safety of care to our patients, their carers and families

High

2. Improve the responsiveness of our services for the benefit of our patients and their families.

Moderate

3. Provide more productive and better value care that improves the sustainability of our services

Low

4. Develop a highly skilled, motivated, healthy and engaged workforce

High

5. Develop first class facilities and technology to support the care we provide

High

6. Transform health and wellbeing through working with our partners

High

7. Play our role as an important asset to the people of Herefordshire and the surrounding areas

Low

6. Reference to the Risk Register or Board Assurance Framework

6.1 The following risks upon the Board Assurance Framework are relevant to this report:

Ref: 386 – Risk to the financial sustainability of Wye Valley NHS Trust Ref: 400 – Risk of the Trust failing to achieve the NHS Constitutional Targets.

of 171

Wye Valley Trust Board

Report to: Trust Board Agenda item: 8


Title of Report: Care Quality Commission Wye Valley NHS Trust Hereford Hospital Quality Report (November 2016)


For noting

Report Approval Route: Medical Director

Lead Executive Director: Medical Director

Author: Associate Director of Quality Governance

Appendices: 1


For the Trust Board to formally receive the CQC Quality Report following publication in November 2016.

2. Recommendations

Trust Board members are asked to receive the CQC report.


The report provides assurances in relation to organisation wide improvements following the inspection in

July 2016. The Trust has been lifted out of special measures and is now rated as requires improvement.


Following the multi‐stakeholder Quality Summit held on the 2 November 2016 the final report of the Hereford County Hospital inspection was published on the 3 November 2016.

Agenda item 9 includes our response to the report and next steps in our improvement journey.

The full report can be accessed on the CQC website:

www.cqc.org.uk

of 171


Strategic Objective Risk Appetite 1. Improve the quality and safety of care to our patients, their carers

and families High


Moderate


Low


High


High


High


Low


Board Assurance Framework references 544: Quality Governance 411: Reputation

of 171

Wye Valley NHS Trust Quality Report July 2016 1

Wye Valley NHS Trust Hereford Hospital Quality report County Hospital Union Walk Hereford HR1 2ER Tel: 01432 355444 www.wyevalley.nhs.uk

Date of inspection visit: 5, 6, 7, 8, 11, 17, 18 July 2016 Date of publication: <xxxx> 2016

This report describes our judgement of the quality of care at this trust. It is based on a combination of what we found when we inspected and information given to us from patients, the public and other organisations.

Overall rating for this trust Requires improvement

Are services at this trust safe? resident and emergency

Requires improvement

Are services at this trust effective? Requires improvement

Are services at this trust caring? Good

Are services at this trust responsive? Inadequate

Are services at this trust well-led? Planning


Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of 186,000 people in Herefordshire and a population of more than 40,000 people in mid-Powys, Wales. The trust also provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham. During this inspection we only inspected the services provided by Hereford Hospital. We did not inspect community services provided by the trust. Therefore, the overall rating for community services remains as requires improvement, as per the September 2015 inspection. There are approximately 236 beds of which 208 are general and acute, 22 maternity and six critical care beds within Hereford Hospital. The trust employs 2,601 whole time equivalent staff as of June 2016. We carried out this inspection as part of our comprehensive programme of re-visiting trusts which are in special measures. We undertook an announced inspection from 5 to 8 July 2016 and unannounced inspections on 11, 17 and 18 July 2016.

Letter from the Chief Inspector of Hospitals

of 171


Overall, we rated Hereford Hospital as requires improvement with three of the five questions we ask with safe, effective and well led being judged as requiring improvement. We rated Hereford Hospital as inadequate for being responsive as patients were unable to access all services in a timely way for initial assessments, diagnoses and/or treatment. We rated caring as good. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support. Our key findings were as follows: Safe

There was a high vacancy rate which meant an increased use of agency and bank staff. The safer nurse staffing levels were planned in line with the national recommendations. The average trust fill rate for registered nurses remained below 95%, ranging from 74.5% on Wye ward to 109.4% on Monnow ward for June 2016. The trust strategy was to cover unfilled registered nurse shifts with a health care assistant where appropriate, to help mitigate staffing level risk. For June 2016 the hospital health care assistant fill rate was 116% for day shifts and 122% for night shifts. We found actual staffing levels met planned staffing levels on most wards during our inspection. We found no incidents relating to staff shortages directly affecting patient care at ward level.

Mandatory and statutory training compliance for June 2016 was at 86% which although had improved from 78% in July 2015, did not meet the trust target of 90%.

Patients’ weight was not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of the medicine.

In maternity, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby.

Staff were aware of their responsibilities regarding safeguarding procedures. Staff understood their responsibility to report concerns, to record safety incidents and near

misses. Staff received feedback on all incidents. Staff had an awareness of the duty of candour process, however just prior to the inspection

the trust had identified that it was not following all the requirements of the regulation in that it was not confirming their discussions with patients in writing and had put actions in place to address this.

Ward and clinical areas were visibly clean and staff were observed following infection control procedures.

There were systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.

Effective

The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated more patients were dying than would be expected. This had been reported to the trust board and an action plan was in place to understand and improve results.

The caesarean section rate was significantly higher (worse) than the national average and the deteriorating rate was not recorded on the risk register.

Most care was delivered in line with legislation, standards and evidence-based guidance. However, some trust guidelines needed updating.

The service had a series of care bundles in place, based on the appropriate guidance for the assessment and treatment of a series of medical conditions. However, there was no hip fracture pathway within the hospital although we were told that this was being drafted.

of 171


The trust had processes in place to monitor some patient outcomes and report findings through national and local audits and to the trust board. Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.

Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Caring

Staff were observed being polite and respectful during all contacts with patients and relatives. Staff protected patients’ privacy and dignity.

Patients felt involved in planning their care.

Responsive

The emergency department consistently failed to meet standards in terms of the amount of time patients spent in the department and waited for treatment.

Bed occupancy was consistently worse than the national average. Patients were unable to access the majority of outpatient services in a timely way for initial

assessments, diagnoses and/or treatment. The trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.

The trust did not consistently meet all cancer targets for referral to treatment times. Overall referral to treatment indicators within 18 weeks for admitted surgery patients was

worse than the England average. The percentage of patients that had cancelled operations was worse than the England

average. Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on

the intensive care unit each month. The trust did not have an electronic system in place to identify patients living with dementia

or those that had a learning disability. Staff adapted care and treatment to meet patient’s individual needs. We saw examples of services planning and delivering care to meet the needs of patients. Systems and processes were in place to provide advice to patients and relatives on how

to make a complaint.

Well-led

The trust had governance oversight of incident reporting and management. The board assurance framework and corporate risk register identified most of the keys risks.

The executive team could demonstrate good understanding of the risks, issues and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.

The trust implemented a new organisational structure in June 2016, with three service units reduced to two divisions, medical and surgical. Although staff felt the reconfiguration was positive and provided more support we were unable to assess the sustainability and effectiveness of the restructure as this had not yet been fully embedded into the trust.

The trust had a vison, their mission and their values. However, these were not fully embedded or understood by staff.

There was no equality and diversity strategy. Following the trust being placed into special measures in October 2014, a comprehensive

quality improvement plan was developed, which included a number of projects and actions. We saw that the action plans were reviewed regularly, with monitoring of compliance

of 171


against targets and details of completed actions. There was a sense of pride amongst staff towards working in the hospital and they felt

respected and valued. We were assured that appropriate steps had been taken to manage the ‘Fit and Proper

persons’ legislation implementation. We saw several areas of outstanding practice including:

Services for children and young people were supported by two play workers (one was on maternity leave at the time of inspection). The play workers regularly made arrangements for long term patients to have days out to different places, including soft play areas or bowling. An activity was arranged most months and the play workers sourced the activities from local businesses who donated their good and/ or services. This meant that patients with long term conditions could meet peers who also regularly visited the hospital. Patients found this valuable and liked the opportunity to meet patients who had shared experiences.

There was a children’s and young people’s ambassador group which was made up of patients who used or had used the service. We spoke with some members of the ambassador group who told us that they were involved in the service redesign when developments took place and improving the service for other patients.

The respiratory consultant lead for non invasive ventilation had developed a pathway bundle, which was used for all patients requiring ventilator support. The pathway development was based on a five-year audit of all patients using the service and the identification that increased hospital admissions increased patient mortality. The information gathered directed the service to provide an increased level of care within the patient’s own home. Patients were provided with pre-set ventilators and were monitored remotely. Information was downloaded daily and information and advice feedback to patients by the medical team. This allowed treatments to be altered according to clinical needs. The development had achieved first prize in the trust quality improvement project 2016.

The newly introduced clinic for patients with epilepsy had enlisted the support of a patient with epilepsy; their views had helped the clinic develop so that the needs of patients were met.

Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and twiddle mittens provided as patient activities. The unit provided regular activities for patients, which included monthly tea parties and games.

However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must:

The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the emergency department.

The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment.

The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps.

The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine.

The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a patient has been given the paracetamol orally or

of 171


intravenously. The trust must ensure all medicines are stored in accordance with trust polices and national

guidance, particularly in outpatients. The trust must ensure that all patients receive effective management of pain and there are

enough medicines on wards to do this. The trust must ensure all staff have received their required mandatory training to ensure

they are competent to fulfil their role. The trust must ensure all staff are supported effectively via appropriate clinical and

operational staff supervisions systems. The trust must ensure staff receive appraisals which meet the trust target. The trust must ensure that patients are able to access surgery, gynaecology and outpatient

services in a timely way for initial assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets.

The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the waiting list.

The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded accurately.

The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children and young people’s services.

The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy. The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

Please refer to the location report for details of areas where the trust SHOULD make improvements. The trust was placed into special measures in October 2014. Due to the improvements seen at this inspection, I have recommended to NHS Improvement that the special measures are lifted. Professor Sir Mike Richards Chief Inspector of Hospitals

Background to Wye Valley NHS Trust

Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of 186,000 people in Herefordshire and a population of more than 40,000 people in mid-Powys, Wales. The trust also provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham. During this inspection we only inspected the services provided by Hereford Hospital. We did not inspect community services provided by the trust. Therefore, the overall rating for community services remains as requires improvement, as per the September 2015 inspection. There were approximately 236 beds of which 208 were general and acute, 22 maternity and six critical care beds within Hereford Hospital. The trust employs 2,601 whole time equivalent staff as of June 2016. For 2016/17 the trust’s predicted revenue was £184,377m. The trusts forecast deficit was £31.5m. At the end of June 2016, the trust reported a deficit of £8,154k, this was £1,132k worse than plan. There was a cost improvement programme in place, the trust was cumulatively £587k behind the programme at the end of June 2016.

of 171


We inspected Hereford Hospital as part of our programme to re-visit acute trusts that are in special measures. We held focus groups, drop in sessions and held a stall within the reception area of the hospital to capture feedback from patients, family members and representatives visiting the hospital. We spoke with a range of staff, including black and minority ethnic staff, nurses, junior doctors, consultants, midwives, healthcare assistants, student nurses, administrative and clerical staff, allied health professions, porters and the estates team. We also spoke with staff individually as requested. The inspection team inspected the following eight core services at Hereford Hospital

Urgent and emergency services Medical care (including older people’s care) Surgery Critical care Maternity and gynaecology Services for children and young people End of life care Outpatients and diagnostic imaging

Our inspection team Our inspection team was led by: Chair: Dr Peter Turkington, Medical Director, Salford Royal NHS Foundation Trust Head of Hospital Inspections: Bernadette Hanney, Care Quality Commission (CQC) The team included 11 CQC inspectors, two assistant inspectors, one CQC pharmacist inspector and a variety of specialists including governance leads, a safeguarding lead, a critical care consultant and nurse, a midwife, a consultant obstetrician and gynaecologist, medical consultants and nurses, a surgical nurse, allied health professionals, a junior doctor, a palliative care nurse, a consultant neonatologist and an expert by experience who had experience of using services.

How we carried out this inspection To get to the heart of patients’ experiences of care, we always ask the following five questions of every service and provider:

Is it safe? Is it effective? Is it caring? Is it responsive of people’s needs? Is it well-led?

We carried out this inspection as part of our comprehensive programme of re-visiting trusts which are in special measures. We undertook an announced inspection from 5 to 8 July 2016 and unannounced inspections on 11, 17 and 18 July 2016. Before visiting, we reviewed a range of information we held about Wye Valley NHS Trust and asked other organisations to share what they knew about the trust. These included the clinical commissioning group, NHS Improvement, the General Medical Council, the Nursing and Midwifery Council, the royal colleges and the local Health Watch.

of 171


We talked with patients and staff from all inpatient areas and outpatients departments. We held an engagement stand within the reception area of Hereford Hospital where people shared their views and experiences of services provided by Wye Valley NHS Trust. Some people also shared their experience by email, telephone or completing comment cards We held focus groups and drop in sessions with a range of staff. The focus groups included nurses, junior doctors, consultants, health care assistants, allied health professionals, administrative and clerical staff, porters and the estates team, and black and minority ethnic staff. We also spoke with staff individually as requested. We would like to thank all staff, patients, carers and other stakeholders for sharing their balanced views and experiences of the quality of care and treatment at Wye Valley NHS Trust.

What people who use the trust’s services say The trust results from the 2014 National Cancer Patient Experience Survey (published 2015) showed little variances from their 2013 results. Areas which had deteriorated included: patient’s rating of care, emotional support and pain management. However, patients said the trust had improved in controlling the side effects of chemotherapy, they had received clear information about what they should/should not do post discharge and they felt there were enough staff on duty. The trust scores in the Patient Led Assessment of the Care Environment (PLACE) were mostly in-line with the England averages for both 2014 and 2015. The CQC Inpatient Survey was sent to 1,250 inpatients between August 2015 and January 2016 within the Wye Valley NHS Trust. We received responses from 674 patients. The responses showed that the trust was “about the same” as other trusts for all 12 selected questions with the exception of the emergency department which was worse in comparison with other trusts. The percentage of friends and family that would recommend the trust as a place to receive treatment was in-line with England averages for the period March 2015 to March 2016.

Facts and data about this trust Wye Valley NHS Trust employs 2,601 whole time equivalent staff as of June 2016. The trust had a planned nursing staffing level of 2,844 for this period. This meant there was a shortfall of 224 whole time equivalent staff as of June 2016. For 2016/17 the trust’s predicted revenue was £184,377m. The trusts forecast deficit was £31.5m. At the end of June 2016, the trust reported a deficit of £8,154k, this was £1,132k worse than plan. There was a cost improvement programme in place, the trust was cumulatively £587k behind the programme at the end of June 2016. Activity The trust informed us that in 2014/15, they admitted 43,000 patients. They also saw 239,026 attendances in outpatients and 51,717 to the emergency department. Alcohol-specific hospital stays among those under 18s is 56.5%, worse than the average for England. The rate of alcohol related harm hospital stays, rate of self-harm hospital stays and the rate of smoking related deaths, is better than the average for England. The first quarter of 2016/17 the bed occupancy at the hospital was 95%. For 2015/16 the bed occupancy was 94%, this was worse than the national average (88.9%). It is generally accepted that bed occupancy over 85% is the level at which it can start to affect the quality of care provided to patients and the orderly running of a hospital.

of 171


Population served

The trust provides hospital and community care to a population of 186,000 in Herefordshire and a population of more than 40,000 in mid-Powys, Wales. Herefordshire had the fourth lowest overall population density in England at 85 people per square kilometre/220 per square mile. Deprivation The health of people in Herefordshire is varied compared with the England average. Out of 326 authorities, Herefordshire is ranked 193th most deprived authority in England. In the 2015 Indices of Multiple Deprivation, Hereford Unitary Authorities were ranked in the second quintile for deprivation. Deprivation is better than average, however, about 13% (4,000) of children lived in poverty. In year 6, 17% (264) of children are classed as obese which is worse than the England average. Life expectancy for both men and women is better than the England average. The rate of statutory homelessness is worse than the England average. Rates of violent crime, long term unemployment, drug misuse and early deaths from cancer are better than average. Population age The average age of the population is older than the national average and there is a continuing trend of an increasingly ageing population.

Summary of findings

Are services at this trust safe? Requires improvement

We rated the hospital as requires improvement for being safe. For specific information please refer to the report for Hereford Hospital. We found that three of the eight services required improvement. We rated five services as good for being safe.

There was a high staff vacancy rate which meant an increased use of agency and bank staff. The safer nurse staffing levels were planned in line with the national recommendations. The trust fill rate for registered nurses remained below 95%, however, for health care assistants was over 116%.

Mandatory and statutory training compliance was at 86%, this did not meet the trust target of 90%.

We were not provided with evidence to show if staff had completed basic life support training. Therefore, we could not be assured that staff had the right skills to care for patients.

Patients’ weight were not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of medicines.

The anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby.

Staff were aware of their responsibilities regarding safeguarding procedures. The incident management policy detailed the requirements of the Duty of Candour

regulation. Staff understood the importance of reporting incidents and had awareness of the duty of candour process. However just prior to the inspection the trust had identified that it was not following all the requirements of the regulation in that it was not confirming their discussions with patients in writing and had put actions in place to address this.

Staff understood their responsibility to report concerns, to record safety incidents and near misses. Staff received feedback on all incidents.

of 171


Ward and clinical areas were visibly clean and staff were observed following infection control procedures

There were systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.

Duty of Candour

From November 2014, NHS providers were required to comply with the Duty of Candour Regulation 20 of the Care Quality Commission (Registration) Regulations 2014. The Duty of Candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person.

The incident management policy dated January 2014 last updated December 2015 detailed the requirements of the Duty of Candour regulation.

All incidents which triggered a duty of candour were notified to the patient safety lead and overseen by the quality and safety group. A record of all disclosures were kept on the incident investigation file and included in the root cause analysis (RCA) file. The patient/relevant person was informed that an incident had occurred and it was being investigated. The week before the inspection the trust identified that it was not following all the requirements of the regulation in that it was not confirming their discussions with patients in writing and had put actions in place to address this.

Staff understood the importance of reporting incidents and had awareness of the duty of candour process. We saw there was no training attributed to duty of candour although the trust had developed a leaflet to support staff’s knowledge.

Safeguarding

The trust did not have an individual adult safeguarding policy. They contributed to the “Adult Safeguarding: Multi-agency policy and procedures for the protection of adults with care and support needs in the West Midlands’ to ensure consistency across the region in the way adults were safeguarded from abuse. All key partners of the Herefordshire safeguarding adult’s board had agreed that the regional policy for safeguarding adults should govern all safeguarding work with adults at risk in Herefordshire. However, we noted that the policy was a working draft policy issued on April 2015. We saw no evidence of a review of the policy.

For end of June 2016, across the trust there was 91% compliance with safeguarding adult training across all levels. However, the patient access team had achieved 64% which did not meet the trust target of 90%. The adult safeguarding lead confirmed they were monitoring and tracking the training across the trust. An additional band 5 nurse had been employed by the trust to work alongside the adult safeguarding lead to provide support with adult safeguarding referrals

The safeguarding leads were trained to safeguarding level 4 and delivered a range of training to all staff, which was a combination of e-learning, and face to face.

The safeguarding younger people training was 88% for level 1, 69% for level 2, 85% for level 3 and level 4 training was at 100%. Training sessions for level 2 continued to be on-going and the trust had sent out communication through the electronic data capture system to staff.

The trust did not meet intercollegiate guidance for safeguarding training in the emergency department, which states all doctors and qualified nurses should be trained to level 3. Only 71% of nursing staff and 63% of medical staff in the emergency department had completed level 3 safeguarding children training.

The 2014/15 safeguarding annual report showed there had been 472 safeguarding alerts raised by the trust. We requested the safeguarding annual report but was told by the trust

of 171


that the report would not be available until August 2016, so we did not have the total numbers of safeguarding alerts for 2015/16.

There were key themes identified through the analysis of safeguarding applications which included:

o Pressure ulcers. A tissue viability nurse had been to the wards identified with sacral and heel sores. An audit of patient chairs was carried out in February 2016 which resulted in the order of 100 replacement chairs.

o Documentation. All documentation was being reviewed to consider their functionality. For example; the wound care documentation was reviewed which resulted in the number of pages being condensed from 16 to eight to make it more efficient.

o At the time of our inspection, there were three domestic homicide deaths with the home office. There was no individual action for the trust but they had resulted in the patient passport “This is me” being implemented. The safeguarding lead confirmed that once the findings had been published this would be disseminated to staff.

A Safeguarding and Promoting Children’s Health and Welfare Policy. The procedures within the policy were used in conjunction with Herefordshire Safeguarding Children Board Inter-agency Child Protection Procedures for Safeguarding Children. However, the policy was dated May 2014 and we saw no evidence of a review of the policy to ensure it contained the most recent information.

The trust had an independent domestic violence advisor working three days a week who was based within the emergency department. They provided support and advice to domestic abuse staff/victims. This was a six month contract and was under review by a task and finish group.

The trust quality improvement plan had actions in place to improve safeguarding younger people across the trust. This included completion of audits, learning from audits and appointing a paediatric safeguarding lead. Progress made against the actions were reported to the trust board monthly.

We reviewed of a sample of patient files on the paediatric ward and found that safeguarding referrals had been made appropriately and in accordance with trust policy. Staff told us that their confidence had increased since the new safeguarding lead had been in post and that if they needed assurance they would speak with the lead. This had improved since the September 2015 inspection, when we identified that safeguarding referrals were not made consistently and in accordance with trust policy.

Incidents

Staff understood their responsibility to report concerns, to record safety incidents and near misses. Staff told us that they were familiar with the incident reporting process and that they received feedback when they reported incidents.

There had been no never events reported for the period March 2015 to February 2016. A never event is a serious incident that is wholly preventable, as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

From December 2015 to February 2016, the patient safety quarterly report identified 20 serious incidents. There was no identified themes but some of the categories included; falls, ward closures, delayed diagnosis and pressure ulcers. All acquired pressure ulcers within the trust were subject to a root cause analysis investigation. Following the investigation, these may be reported externally if it was found that there were omissions in care which resulted in the development of the pressure ulcer. Ward sisters and department managers had dashboards which showed their current week, current month, falls incidents which they could share with their staff.

A total of 6,338 incidents were reported to the National Reporting and Learning System

of 171


(NRLS) between December 2014 and November 2015. Of these incidents 78% were categorised as no harm and 17% as low harm incidents. The trust had a lower reporting rate (5 per 100 admissions) compared to the England average (8.8 per 100 admissions).

During our September 2015 inspection, we observed that the trust approach to incident management did not enable timely assessment of the risks relating to the health, safety and welfare of patients. On this inspection, we found that the trust had implemented a patient quality and safety group that oversaw all incidents. The patient quality and safety quarterly report for December 2015 to February 2016 outlined the review of all serious incidents during this period which included the resume of the facts, the action taken and whether the duty of candour regulations had been implemented.

Staff received feedback on all incidents through summarised lessons learnt via the “team brief” and the “safety bites.” Additional learning was also periodically added to “trust talk.” Line managers were encouraged to provide feedback on an individual and collective basis at their team meetings. The exception to this was in paediatrics, where most paediatric staff we spoke with were unsure whether shared learning took place and were unable to recall recent incidents which had occurred within the previous 12 months either within their unit or within other departments within the hospital.

A new process for monitoring the national safety alerts was introduced in September 2015. This was undertaken by the clinical effectiveness and audit department (CEAD). We saw the reviewed cases from September 2015 to April 2016 which included the actions taken by the alert leads. The review was to establish whether or not clinical audits were relevant/ required for the alert. The CEAD informed the health and safety officer/administrator the outcome of the review. Any clinical audit project required was undertaken and forwarded as appropriate. We saw a copy of the report which outlined the outcomes and the actions taken.

Staffing

The overall vacancy rate for June 2016 for the trust was 7.9%, which was worse than the trust target of 5%. This was highlight as a significant risk on the risk register.

Nursing and midwifery remained the highest staff group with vacancies at 72% of the total vacancies, 83% of which were band 5 nurses. Some wards had a greater than 50% vacancy rate which meant an increased use of agency and bank staff.

The trust remained under establishment with 211 whole time equivalent vacancies. This was a decrease from 241 the previous month.

We saw the starters and leaver’s statistics from February 2015 to June 2016. Overall, the trend showed there were more staff across the trust starting than leaving, thus reducing the vacancies. However, for nursing and midwifery staff there were generally more staff leaving than starting. For example, in June 2016 there were 10 starters and 12 leavers.

Staff turnover in June 2016 showed a decrease from 1.15% the previous month to 0.73%. The 12 month rolling figure had decreased from 14.1% to 13.9%. The trust target was 10%.

The trust was taking actions to actively recruit staff and had a recruitment and retention strategy which included; recruitment events across the country, enhanced recruitment advertising and golden hellos. An analysis of the results of exit interviews were to present at the September 2016 finance and performance committee as part of the wider issues of recruitment and retention. However, nurse trajectory figures showing the gap between budget and staff in post was not closing. The number of band 5 nurse vacancy posts had increased in June 2016 compared to the previous month.

The safer nurse staffing levels were agreed in line with the national recommendation of 1:8 (registered nurses :patient ratio). However, it was recognised that with the growing difficulties of recruitment into substantive registered nurses positions, the initiatives being taken to address this would challenge the 1:8 assumption. As a consequence the

of 171


determinants for appropriate safe staffing become more complex, and a revision of the acuity tool and its application in the decision making process for nurse staffing levels was planned. All senior staff we spoke with understood the recruitment and financial pressures associated to staffing but remained dedicated to ensuring staffing levels were adequate to keep patients safe.

The trust fill rate for registered nurses remained below 95% between January and June 2016 except for May (95.7%). There was a strategy to cover unfilled registered nurse shift with health care assistants where appropriate. The fill rate for health care assistants was better than the target for both day and night shifts (116% and 122% respectively) for June 2016.

Nursing agency and bank usage had risen in June 2016. Nurse agency spend had increased to 19.3%. This was the highest percentage since recording started in October 2015.

The sickness absence rate had improved from 5% in October 2015, to 4.2% in June 2016, with both divisions worse than the trust target of 3.5%. Long term sickness had decreased to 78 staff. All cases were being actively managed. Short term absence was 1.7% for June 2016. The main reason for sickness absence remained as ‘stress and anxiety’ with a total of 407 staff absent from working during June 2016. This was a decrease from March 2016 which was at 532.

The trust continued to experience issues recruiting to consultant posts, accounting for 13% of all vacancies. We saw the vacancy rate had increased from 10 in March 2016, to 28 in April 2016. The trust confirmed this was due to the submission of the business development plan. The trajectory up to January 2017 showed a requirement of 23 consultants. However, the workforce statistics provided by the Health and Social Care Information Centre (HSCIC) showed the consultant percentage was just above the England average at 40%. The proportion of middle career (at least three years as a foundation year 2 or a higher grade within their chosen speciality) was at 14%. This was higher than the England average of 9%. Specialist registrars were below the England average of 38% at 25% and junior medical staff (foundation year 1/2) was at 21% which was above the England average of 15%.

The performance indicator for mandatory and statutory training was at 86% in June 2016. This did not meet the trust target of 90%. The trust had RAG (red, amber, green) rated themselves as red. It was noted that compliance had improved since 2015/16 when the rate was 77%.

We were not provided with evidence to show when staff had completed basic life support training. Therefore, we could not be assured that staff had completed this training when required. The Resuscitation Council (UK) Quality standards for cardiopulmonary resuscitation practice and training (2013) states that all healthcare staff should undertake resuscitation training at regular intervals to maintain knowledge and skills.

Any concerns/incidents identified with agency staff would be linked with the agency by means of a proforma to discuss any issues. The agency nurse/locum would be requested to complete a reflective statement which would be reviewed. All agency and locum staff are included in the trust training. If there was an allegation made against a professional this would be reported to the local authority and discussed with the staff member.

Cleanliness, infection control and hygiene

Ward and clinical areas were visibly clean, with the appropriate green 'I am clean' stickers on clean equipment. Staff were observed cleaning equipment after use.

Personal protective equipment, such as gloves and aprons, were used appropriately and were available in sufficient quantities.

Instructions and advice on infection control was displayed in the ward entrances for patients and visitors providing information on how to prevent and reduce infection.

of 171


Hand hygiene gel was available outside the wards, in bays and side rooms. Hand-wash basins were also available in bays and side rooms. We observed staff washing their hands as necessary during our inspection.

There had been no reported cases of MRSA since March 2013. There had been six cases of Methicillin-sensitive Staphylococcus aureus (MSSA) (a type of

bacteria) reported during April 2015 and March 2016. The six cases were reported in October 2015 to November 2015 and in February 2016. The number of cases reported was worse than the England average for six of the 13 months. There had been one MSSA case reported between April and June 2016.

There was 17 Clostridium difficile cases reported between April 2015 and March 2016, with the highest number reported in July 2015 (five cases). This was against an upper limit of 18. There had been six cases of Clostridium difficile reported between April and June 2016, against an upper limit of 18 for 2016/17.

Systems and processes in maternity were not always reliable or appropriate to keep patients safe. The anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby, and injury to staff from moving and handling within a small space. The trust had implemented mitigating actions to reduce the risk. However, the environment did not meet patient demand and could impact on patient care.

Medicines

The trust had amended their approach to medicines management by becoming more patient focused with an outcomes approach (medicines optimisation). This was to ensure patients were getting the maximum benefit from their medicines. The medicines optimisation dashboard report for February 2016 showed that 57% of clinical staff had attended face to face medicines optimisation training in the preceding 12 months. The trust had set a target of 40% compliance.

The trust had a medicines optimisation key performance indicator dashboard. This dashboard provided an indication of the trust’s compliance with for example; the safe and timely dispensing of medicines, safe storage and handling of medicines, clinical review, missed does and the timely transfer of discharge information to GP’s. There were a number of actions undertaken to address poor performance. Examples included;

o Although the pharmacy uses a double check system when issuing medicines, it was found that the first check was not being met. This was due to the pharmacy’s reliance on a significant number of trainee/locum staff which increased the error rate in dispensing medicines. The trust anticipated that the number of locum staff would reduce during the first two quarters of 2016/17 resulting in better compliance.

o Discharge and outpatient turnaround times for dispensing of medicines did not meet the trust standards resulting in patients not receiving their medicines in a timely manner and resulting in a poor patient experience. The divisions were investigating other models of utilising trained administrative staff to complete electronic discharge summaries to release junior medical staffs’ time and ensure discharge medicines was available in a timelier manner.

During the September 2015 inspection, medicine incidents were not always reported. The patient safety quarterly report for the period December 2015 to February 2016 showed that the rate of reporting medicine incidents through the NRLS was at 13%. This was seen by the trust to be a positive sign of good reporting which they attributed to the medicines safety officer’s heightening the awareness of recording issues.

The majority of medicine incidents were administration or prescription of medicines. Wye ward, Frome acute assessment unit (AAU) and the emergency department were the areas with most reported administration medicine errors during December 2015 to February 2016. AAU reported the most prescription errors. All medicine errors were

of 171


reviewed and fed back to the medicines safety committee. Learning from incidents was cascaded to staff in a monthly MedsTalk newsletter.

The administration of insulin and the management of inpatients with diabetes had been recognised through the incident reporting system as an area of concern. Both the medicines safety officer and the diabetes specialist nurses had provided training and support to the wards. This was confirmed by the diabetes specialist nurses spoken with who said they had raised awareness of hypoglycaemia to staff through the implementation of diabetes boxes to support staff with their knowledge. The records showed that 36% of staff had not completed their “Safe use of insulin eLearning” or had not declared they were exempt from completing this training.

We saw that insulin training as of April 2016 was behind schedule and showed an overall figure of 66% which was lower than the trust target of 90%.

Patients’ weight were not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of the medicine.

There was no policy available for parents to administer medicines to their children. The administration of medicines by a parent was an identified concern during the September 2015 inspection. The quality improvement plan identified that an audit of parent administration was undertaken in February 2016 which showed 70% compliance regarding the administration of medicines by parents. A further audit was planned for the end of August 2016.

60% of inpatient medicine charts were being reviewed by pharmacists due to the vacancy rate of pharmacists and pharmacy technicians. 16% of the pharmacy department’s qualified workforce were locums.

The quality committee’s medicine optimisation dashboard report dated February 2016 showed that the safe handling and storage of general medicines was at 63% which did not meet the standard target of 100%. We saw this was identified on the trust’s medicines optimisation risk register together with the actions to manage the identified risk. The register was last reviewed in April 2016.

The medicines optimisation dashboard report for February 2016 showed that 75% of electronic discharge summaries were not arriving with GPs within 24 hours of patient discharge and 9% of inpatients were discharged without an electronic discharge summary. This did not meet the target of 90% and 100% respectively.

Antibiotic stewardship compliance was achieved by ensuring patient’s medicine charts were accurately recorded when an antibiotic was prescribed. The overall compliance was 70%. Poor compliance was mainly due to not recording the duration of treatment and why an antibiotic was indicated. Ongoing support by pharmacists was in place at ward level.

Are services at this trust effective? Requires improvement

We rated the hospital as requires improvement for being effective. For specific information please refer to the report for Hereford Hospital. We found that four of the eight services required improvement. We rated three services as good for being effective. Outpatients and diagnostic imaging was inspected but not rated for effective.

The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated more patients were dying than would be expected. This had been reported to the trust board and an action plan was in place to understand and improve results.

Monitoring by the Care Quality Commission had identified four areas where medical care was considered a statistical outlier when compared with other hospitals.

The caesarean section rate was significantly higher (worse) than the national average and

of 171


the deteriorating rate was not recorded on the risk register. Care was delivered in line with legislation, standards and evidence-based guidance.

However, some trust guidelines needed updating. The service had a series of care bundles in place, based on the appropriate guidance for

the assessment and treatment of a series of medical conditions. However, there was no hip fracture pathway within the hospital although we were told that this was being drafted.

The trust had processes in place to monitor some patient outcomes and report findings through national and local audits and to the trust board. Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.

All necessary staff were involved with the assessing, planning and implementation of patient care

Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Staff and teams worked well together to deliver effective care and treatment. Overall 78% of staff had received an appraisal in the preceding 12 months. This was an

increase from the period 2015/16 which was 59%. However, this did not meet the trust target of 90%.

Evidence based care and treatment

Staff provided care to patients based on national guidance, such as the National Institute for Health and Care Excellence (NICE) and the Royal College guidelines. Staff were aware of recent changes in guidance and we saw evidence of discussion based on these guidelines in patient’s health care records. Staff had access to guidance, policies and procedures via the trust intranet.

The service had a series of care bundles in place, based on the appropriate NICE guidance for the assessment and treatment of a series of medical conditions including; community acquired pneumonia, dementia care, chronic obstructive pulmonary disease, hyperglycaemia (high blood sugar), gastro-intestinal bleeding, sepsis and acute kidney injury. Wards had posters on display to provide staff guidance on these care bundles.

The hospital followed the trust policy for management of sepsis (blood infection) and a sepsis bundle care pathway could be implemented if sepsis was suspected. The care pathway for suspected sepsis would usually be commenced in the emergency department. Wards did not have “sepsis boxes” available but did have access to appropriate antibiotics when required to facilitate immediate antibiotic treatment for those patients with suspected sepsis.

There was no hip fracture pathway within the hospital although we were told that this was being drafted. Patients who suffer a fractured hip have a high mortality and morbidity rate and often need long term care post fracture. A hip fracture pathway ensures that care is coordinated and is evidence based to reduce length of stay and mortality and morbidity.

The quality improvement meeting minutes identified guidelines and documentation which needed review and updating. We observed that guidelines were mostly in date. However, several were at least one year beyond their review date, for example the trust major incident plan was dated October 2013 with a review date of October 2014. This had not been reviewed since the identification at our September 2015 inspection.

Local audits monitored adherence to policies and procedures such as, National Early Warning Score (NEWS) and the Five Steps to Safer Surgery.

Patient outcomes

The trust had processes in place to monitor some patient outcomes and report findings

of 171


through national and local audits and to the trust board. The trust board used information gathered to benchmark practices against similar organisations.

The Hospital Standardised Mortality Ratio (HSMR) is an indicator of trust-wide mortality that measures whether the number of in-hospital deaths is higher or lower than would be expected. The trust’s HSMR for the 12 month period May 2015 to April 2016 was higher than expected, with a value of 113.

The Summary Hospital-level Mortality Indicator (SHMI) is a nationally agreed trust-wide mortality indicator that measures whether the number of deaths both in hospital and within thirty days of discharge is higher or lower than would be expected. In June 2016, the trust reported a 12-month rolling figure of 115, worse than expected (100). However, this had slightly improved since March 2015, where the trust reported a 12-month rolling figure of 117.

The trust had implemented a series of actions to address these concerns and a mortality governance improvement plan had been implemented by the medical director. A consultant lead for safety to support this plan commenced in April 2016. All deaths were reviewed weekly. Either deep dives or root cause analysis (RCA) were conducted where concerns were raised. A communication plan from reviews had been implemented for all lessons learnt.

Monitoring by the Care Quality Commission had identified areas where medical care was considered a statistical outlier when compared with other hospitals. The outlying areas for the trust were chronic obstructive pulmonary disease (a collective name for lung disease such as chronic bronchitis); sepsis; acute kidney injury (AKI); urinary tract infection; and fractured neck of femur. Actions were monitored through the hospital reducing mortality group. Improvements had been made with the exception of fractured neck of femur, where there were concerns regarding identification and management of end of life care and recruitment of orthogeriatricians.

The caesarean section rate was 42.5% in April 2016 and 39.2% in May 2016 in comparison with the national average of 26.5%. This was worse than the caesarean section rate in the two previous years. The deteriorating caesarean section rate was not recorded on the risk register.

Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.

The Sentinel Stroke National Audit Programme (SSNAP) is the single source of stroke data in England, Wales and Northern Ireland. In the March 2016 the trust was rated as band D (A being the best and E the worst). We saw actions taken in response to the audit.

Multidisciplinary working

All necessary staff were involved with the assessing, planning and implementation of patient care.

We observed the multidisciplinary team meetings on all wards visited and found they included all relevant nursing, medical and allied health professional staff. Meeting were well structured and inclusive of all disciplines. All staff were observed contributing to the meetings and the teams were open to ideas and suggestions from individuals.

Overall responsibility for the patient remained with the named consultant who was responsible for the care and treatment. Wards reported consultant lead ward rounds were held daily.

Patients were referred to specialist consultants if their condition changed and we saw evidence of effective referrals within patient notes.

Play therapists were available on the ward, Monday to Friday and every other Saturday. Play therapists provided communication between medical and nursing staff, and patients and their parents to ensure the child’s needs were catered for during procedures. Play

of 171


therapists also provided additional support in distraction for younger children whilst undergoing procedures.

Access to psychiatric services was available Monday to Friday from the Child and Adolescent Mental Health Service (CAMHS). This service was unavailable at weekends. Therefore if a child with mental health needs presented over the weekend, they were admitted and waited until Monday morning for a comprehensive assessment. The trust were working closely with the CAMHS to improve provisions and provide a weekend service for patients admitted to the ward. Agency nurses were employed to care for patients with mental health needs as required; patients were not admitted to the ward from the emergency department until one to one care was in place.

Consent, Mental Capacity Act & Deprivation of Liberty safeguards

Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

The MCA training was 56% against a target set by the trust of 80% with the aim to achieve 90% by July 2016.

The DoLS training had achieved 63% compliance. The action log from the safeguarding working group meeting of March 2016 identified the aim to achieve 90% by July 2016.

The trust had previously recognised there was no DoLS or MCA lead for the trust. This had been rectified with the appointment of a MCA/DoLS lead that was due to commence in September 2016 for a two year fixed term.

The trust did not have any DoLS champions. The safeguarding lead confirmed this had been recognised by the trust and this was a work in progress.

The audit regarding the completion of mental capacity forms was identified on the quality improvement plan as an area which required improvement. The safeguarding lead confirmed they were continuing to monitor the completion of documents monthly which had improved. The improvement was also identified in the safeguarding quality group meeting minutes for March 2016. A further audit was planned to be completed by the trust auditors in November 2016. We found no concerns with the completion of mental capacity forms.

The hospital as of July 2016 had 31 patients listed with a DoLS in place. The trust had received 237 applications since April 2016. The safeguarding team and the local authority had a daily morning meeting to discuss all safeguarding applications and any outstanding issues which meant the trust team had up to date knowledge regarding all patients within the hospital that either had a DoLS in place or were waiting for an assessment.

Staff confirmed capacity assessments had taken place and described actions taken as a result. We saw written evidence in patients’ notes which outlined the outcomes of capacity assessments, and details of best interest actions staff should take to maintain the patient’s safety.

We looked at 33 completed DNACPR forms across all ward areas, all were completed accurately, in line with trust policy and the MCA. This was a significant improvement since the September 2015 inspection, when we saw 21 cases where decisions had been made about a patient’s capacity, which were not line with trust policy or the MCA.

Staff we spoke with had a good understanding of gaining consent from children applying the Gillick competency assessment where appropriate.

Competent staff

Staff generally had appropriate qualifications, skills, knowledge and experience for their roles and the trust had processes in place to identify development needs.

The number of staff who had received an appraisal in the preceding 12 months was 78% in June 2016. This was an increase from the period 2015/16 which was 59%. However, this

of 171


did not meet the trust target of 90%. The number of medical staff that had received an appraisal in the preceding 12 months

was 98.2% in June 2016. This met the trust target of 90%.

Are services at this trust caring? Good

We rated caring as good for all eight core services. For specific information please refer to the report for Hereford Hospital. Staff were observed being polite and respectful during all contacts with patients and relatives. Staff protected patients’ privacy and dignity. Patients felt involved in planning their care, in making choices and informed decisions about their care and treatment. Staff understood the impact that a patients care, treatment or condition had on their wellbeing and on those close to them emotionally. Compassionate care

Staff respected patients, their individual preferences, habits, culture, faith and background. Staff were observed being polite and respectful during all contacts with patients and

relatives. This included when patients and relatives attended each ward, during telephone calls and in public areas.

Privacy and confidentiality were promoted through closing doors and screens when discussing patients or completing tasks. .

Patients told us staff were caring, with compassionate attitudes and they were well looked after.

The percentage of friends and family that would recommend the trust as a place to receive treatment were in-line with England averages for the period March 15 to March 16.

The trust scored about the same as other trusts in the 2014 CQC In-patient survey for all but one question which were scored as amongst the worst performing trusts (Were you involved as much as you wanted to be in decisions about your care and treatment?). Trust scores in 2014 were marginally worse for most questions in comparison to 2013.

Trust scores in the Patient Led Assessment of the Care Environment were mostly in-line with England averages in both 2014 and 2015. Although performance in regard to privacy, dignity and wellbeing showed a downward trend.

The trust scored in the top 20% compared to all trusts for nine of the 34 questions in the Cancer Patient Survey (2013/14). Trust scores were in the bottom 20% for five questions and in the middle 20% for the 20 remaining questions. Trust scores worsened in 2013/14 compared to 2012/13 for 17 and improved for 16 of the 33 questions for which data were available.

Feedback from the CQCs children and young people’s survey 2014 was largely similar to other trusts with privacy and dignity reported as better than other trusts and communication about care and treatment reported as worse than other trusts.

Understanding and involvement of patients and those close to them

Patients told us they felt involved in planning their care, in making choices and informed decisions about their care and treatment.

Discussions regarding treatments and plans with patients and family members were documented in patient records. This included discussions relating to resuscitation and ceilings of treatment.

Staff took time to explain to patients and those close to them the effects or progress of their

of 171


condition, communicating with patients in a way that would help them understood their care and treatment and condition.

Emotional support

The chaplaincy department represented a number of Christian denominations. The team were trained to offer pastoral and spiritual care to patients, their families and staff. An emergency mobile phone was carried by a member of the team which all wards and departments had access to. A prayer room for those belonging to other faiths was located in the chapel and contact details of the leaders of these faiths were kept in the chaplain’s office.

Staff understood the impact that a patients care, treatment or condition had on their wellbeing and on those close to them emotionally.

The supportive palliative care team told us emotional, psychological and bereavement support and advice for families was an important component of the service. People we spoke with told us the supportive palliative care team had provided them with emotional support.

Patients had access to clinical nurse specialist, for example, breast care nurses and stoma care nurses. This meant that patients received specialist support when coming to terms with any adaptions in their everyday lives.

Are services at this trust responsive? Inadequate

We rated the hospital as inadequate for being responsive. For specific information please refer to the report for Hereford Hospital. We found surgery and outpatient and diagnostic services were inadequate for being responsive. We found that four of the eight services required improvement. We rated two services as good for being responsive.

Patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses and/or treatment. This remained a challenged since the September 2015 inspection. However, the trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.

The trust did not consistently meet all cancer targets for referral to treatment times, including the gynaecology cancer pathway.

Overall referral to treatment indicators within 18 weeks for admitted surgery patients was worse than the England average

The percentage of patients that had cancelled operations was worse than the England average. 22 operations cancelled were due to the lack of an intensive care unit bed. Cancelled operations were not always rearranged within 28 days as per NHS England standard.

The emergency department consistently failed to meet standards in terms of the amount of time patients spent in the department and waited for treatment.

Bed occupancy was consistently worse than the national average. Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on

the intensive care unit each month. The trust did not have an electronic system in place to identify patients living with dementia

or that had a learning disability. Staff adapted care and treatment to meet patient’s individual needs. We saw examples of services planning and delivery care to meet the needs of patients.

of 171


Systems and processes were in place to provide advice to patients and relatives on how to make a complaint. Face to face meetings with a complainant were seen as the way forward in effective complaint management. Learning from complaints was shared with staff.

Service planning and delivery to meet the needs of local people

The trust aimed to ensure that services were planned and delivered to meet the needs of local people. However, we saw that transfers of care was occasionally delayed due to waiting for further NHS non-acute care (46%). The waiting for packages in the patients’ own home was at 20%. The trust score was significantly higher than the England average for both factors.

The service was working collaboratively with external agencies to improve services provided by the trust. This included working with the clinical commissioners to identify the needs for the local community and planning of clinical pathways to meet demands. This was particularly noticeable within stroke services with the development of the early discharge team and discharge lounge.

The trusts quality improvement plan included service planning for patients with long term conditions, such as diabetes. The service aimed to improve the working relationships with GPs, the introduction of health promotion and wellbeing care plans, and staff training in every contact count. Making every contact count is a system used by the NHS to utilise day-to-day interactions with patients to support them in making positive changes to their physical and mental health and wellbeing.

Meeting people's individual needs

The trust did not have an electronic flagging system for patients with a learning disability. This meant that the trust was unaware of the number of patients with a learning disability admitted the hospital. The trust informed us that all patients with a diagnosis of learning disability were encouraged to have a “patient passport” outlining their preferences. This did not meet the National Institute for Care and Health Excellence (NICE) guidance “Challenging behaviour and learning disabilities: prevention and intervention for people with learning disabilities whose behaviour challenges” (May 2015); and the guidance set out in the Improving Health and Lives: Learning Disability Observatory in conjunction with the Department of Health which outlined key actions that all NHS trust and health services needed to consider, which included to ensure that patients with a learning disability are easily identified in records systems.

The trust linked with the learning disability nurses in the community if they were notified of an admission of a patient with a learning disability. More complex cases were included in the multidisciplinary meeting to plan their admission.

Elective patients with a learning difficulty had a pre-operative assessment in an environment that was most appropriate for the patient, to enable staff to adapt to their individual needs and to avoid any undue distress.

Staff knew how to access interpreting services. The trust had Polish interpreters who also managed the whole of the interpreting requests. The trust used the local diversity team to provide face to face interpreting for appointments where complex clinical information was being discussed. The trust also used telephone interpreting and Deaf Direct when required.

Hearing loop facilities were available throughout the hospital.

Dementia

The dementia lead reported that the trust had trained 30 individuals as dementia champions at the time of inspection, and were planning to increase numbers of dementia-trained staff across all areas as staffing levels permitted.

of 171


The dementia team had a dedicated email address, which was available on the intranet, which enabled staff to access them directly and seek support or advice regarding patients.

The trust did not have an electronic system in place to identify patients living with dementia. Although we were told this was being implemented in spring 2017. Patients living with dementia were identified on the ward and patient name boards by the use of a forget-me-not flower symbol. Permission was sought from relatives prior to completing this. The use of the symbol-enabled staff to identify patients who had a dementia diagnosis and ensured additional care and support were available.

All patients living with dementia were assessed using the standard trust documentation and the “9 things about me” checklist. This was completed in conjunction with the patient’s carer and/or next of kin to enable staff to gain insight and provide quality person-centred care.

Patients were assessed following the guidance of the safeguarding policies. This included a mental capacity assessment and if appropriate a Deprivation of Liberty Safeguard (DoLS) referral.

Person centred-care was planned post assessment. A suitable location on the ward environment was identified, when required, which provided increased visibility to mitigate the risk of absconding and/or falls. Additional staffing were provided as required based on the needs of the patients.

Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and twiddle mittens provided as patient activities.

The trust informed us they had admitted 1,980 patients living with dementia in 2015/16 and had 74 inpatients living with dementia at any one time. This was however, based on a snapshot of admission to the inpatients’ services.

Access and flow

Bed occupancy rates for the trust were higher than the England average for five of the six quarters between quarter two (2014/15) and quarter three (2015/16). The first quarter of 2016/17 the bed occupancy at the hospital was 95%. For 2015/16 the bed occupancy was 94%, this was worse than the national average (88.9%). It is generally accepted that bed occupancy over 85% is the level at which it can start to affect the quality of care provided to patients and the orderly running of a hospital.

The emergency department was not meeting standards in terms of the amount of time patients spent in the department and waited for treatment. In every month from April 2015 to March 2016, the trust scored worse than the 95% Department of Health target for patients being seen within four hours of arriving in emergency department. Percentages at the hospital ranged from a low of 84% in March 2016 to a high of 91% in June 2015, and averaged 89% for the whole period.

The amount of patients waiting four to twelve hours from the decision to admit until being admitted was consistently worse than the England average, with no patients waiting over 12 hours for admission between April 2015 and April 2016, with the exception of February 2016. This meant that patients could not access services in a timely way.

Patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses and/or treatment. There were long waiting lists for the majority of specialities including gastroenterology, dermatology, neurology and ear, nose and throat. This remained a challenged since the September 2015 inspection. However, the trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety

of 171


and welfare of patients on the waiting list. The trust did not consistently meet all cancer targets for referral to treatment times. Whilst the trust had reviewed 42,000 open patient pathways they still had approximately

28,000 open pathways to review. This meant there was a risk that the trust did not have full oversight of the risk to patients on open pathways.

Between June 2015 and May 2016, the overall referral to treatment indicators within 18 weeks for admitted surgery patients was worse than the England average (80%), with 61% of referred patients treated within 18 weeks of referral. For general surgery, 49% (373) of patients were not treated within 18 weeks; in ENT, 53% (332) of patients were not treated within 18 weeks. Of the patients requiring ophthalmology surgery, 72% (1353) of patients were not treated within 18 weeks. For trauma and orthopaedic surgery, 50% (1030) of patients were not treated within 18 weeks.

The percentage of patients that had cancelled operations was worse than the England average of 5%, at 28%. On average 20% of patients’ cancelled operations were not then treated within 28 days as per NHS England standard.

There had been 22 cancellations of on the day of surgery for the 12 month period ending March 2016, due to lack of the intensive care unit beds in 2015/16. This was significantly worse than the previous year, when six patients had their surgery cancelled on the day. The surgical division were aware of this and were trying to forward plan operations better to prevent on the day cancellations.

Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on the intensive care unit each month. There were 27 instances of mixed sex occupancy reported on the unit from January to June 2016.

The admission, access, appointments, transfers and discharges (AAATD) incidents showed 100 patients were affected for April 2016 in comparison to 60 patients reported in April 2015. The main three AAATD categories were:

o Delay in transfer to a ward with the majority of patients waiting in recovery to return to a ward.

o Unexpected readmission/re-attendance. This was mainly for babies less than 10 days old for weight loss or mothers readmitted to the maternity ward for raised blood pressure or possible infection.

o Failure in the referral process. Although no particular areas or themes were identified these included incorrect referrals from outside organisations and patients being brought up to the wards from the emergency department without notification.

The average length of stay at trust level was better than the England average for elective care but worse than the England average for non-elective admissions.

Learning from complaints and concerns

The complaints policy was appropriate and within date. Although it needed amending to reflect the change to divisions within the trust.

Systems and processes were in place to provide advice to patients and relatives on how to make a complaint. Information and leaflets about the complaints process were displayed across the trust. Complaints could be raised in a variety of ways; in person, verbally, in writing and electronically.

From April 2015 to March 2016, the trust received 260 formal complaints. The number of complaints received by the trust varied from month to month but had increased from April 2015 to March 2016, from 13 to 25. Surgery received the highest percentage of complaints (30%) followed by medicine (29%) and the emergency department (18%). Most complaints received were in relation to clinical treatment (23%), quality and safety of care (12%) and values and behaviour of staff (11%).

For 2015/16, 59% of all complaints received were upheld or partially upheld with 28% of complaints not upheld. 8% of complaints were still ongoing whilst 4% were withdrawn.

of 171


The patient experience team were responsible for managing complaints and overseen by the head of quality and safety. Complaints were discussed directly with the director of nursing and actions taken if necessary.

On receipt of a complaint, it was logged and an email was sent to the relevant divisional governance lead. The complaint was then allocated to the divisional lead (nurse or medic) for investigation. If the complaint spanned across divisions, the division with the significant element of the complaint lead the investigation. The patient experience team maintained a tracker of all complaints received.

An acknowledgement letter was sent to the complainant within three working days. Where the complainant provided a contact phone number the complainant would be contacted via telephone. This was to ensure they had clear understanding of the exact elements of the complaint, the type of response required and how they would like the complaint taken forward. The complainant would be offered a face to face meeting with the investigating officer, relevant members of staff (if appropriate) and the patient experience manager or a member of their team. Face to face meetings with a complainant were seen as the way forward in effective complaint management. Face to face meetings were noted in the complaints that we reviewed and the patient experience manager felt it had reduced the number of complaints that needed to be reopened following the sending of the complaint response.

Response letters were written by the divisional lead and sent to the chief executive officer (CEO) for final sign off. We were told that complaint responses were challenged by the CEO where appropriate. All response letters invited the complainant to contact the trust if they are unhappy with the response and contact details of the Parliamentary Health Service Ombudsmen were also provided.

All complaints that were upheld, or had elements upheld had an action plan written. The action plan was incorporated into the divisional improvement plan. The patient experience team did a random one out of 10 check to ensure actions were completed. If shared learning was identified the learning was included in the CEO monthly brief or if learning was urgent a memo was sent to all staff. In order to provide assurance of learning members of the patient experience team and the divisional governance lead attend the divisional unit monthly governance meetings.

The trust quality committee received a quarterly patient experience report which provided complaint information.

The complaints process was under review in order to make it more efficient and effective. The trust were rolling out datix web to ensure all aspects of complaints were recorded and staff investigating the complaint will have access to all upload information. The training was being delivered at the time of our inspection and should enhance complaints management if embedded in practice.

The patient experience team were located by the reception area in the main hospital entrance. Staff directed patients to the team who supported and advised patients, their families and/or carers with any questions, compliments or concerns. The patient experience team were available Monday to Friday, 8.30am to 4.30pm. Messages could also be left via e-mail or on the 24 hour telephone answer machine service.

Are services at this trust well-led? Requires improvement

We rated the hospital as requires improvement for being well-led. For specific information please refer to the report for Hereford Hospital. We found that four of the eight services required improvement. We rated four services as good for being well-led.

The trust had governance oversight of incident reporting and management. The board

of 171


assurance framework and corporate risk register identified most of the keys risks. The trust implemented a new organisatioanl structure in June 2016 we were unable to

assess the sustainability and effectiveness of the restructure as this had not yet been embedded into the trust.

The trust had a vison, their mission and their values. However, these were not fully embedded or understood by staff.

Although the leadership within the organisation were aware of the legal requirements the objectives aligned with Equality and Diversity Standards 2 there was no equality and diversity strategy to reflect these.

Following the trust being placed into special measures in October 2014, a comprehensive quality improvement plan was developed, which included a number of projects and actions. We saw that the action plans were reviewed regularly, with monitoring of compliance against targets and details of completed actions.

There was a sense of pride amongst staff towards working in the hospital and they felt respected and valued.

We were assured that appropriate steps had been taken to manage the ‘Fit and Proper persons’ legislation implementation.

The executive team did regular walkabouts within the hospital and most staff felt the executive team were visible.

The executive team could demonstrate good understanding of the risks, issues and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.

Vision and strategy

The trust had implemented a new mission, vision and values which included; o Vision “To improve the health and well-being of the people we serve in

Herefordshire and the surrounding areas”. o Mission “To provide a quality of care we would want for ourselves, our families, and

friends”. Which means: “Right care, right place, right time…every time”. o Values · Compassion · Accountability · Respect · Excellence

There was a mix of staff that were aware or unaware of the trust vision, mission and values.

The main commissioners and providers in Herefordshire had formulated a healthcare strategy for the next five years through its “One Herefordshire Programme.” The main expected benefits of this programme were:

o A step change in the way communities behaved when managing illness and reduced demand for services.

o Care to be localised, where possible, and centralised where necessary. o Services to work together and based on the patient’s needs. o Improved quality, efficiency and effectiveness of service. o A more sustainable health and care systems that could meet the demands of its

population. The trust had implemented a transformation programme alongside the commissioners and

providers by redesigning acute and community services following a review and development of a clinical strategy for the trust. Examples of the main themes were to:

o Optimise services for the older population. o Create new roles to replace traditional nursing and medical roles. o Increase capacity and availability of diagnostics across seven days. o Integrate records with other providers.

The clinical strategy and transformation programme relied on the development of a partnership with another provider in order to deliver services collaboratively. This was being taken forward across the Herefordshire and Worcestershire footprint.

The service reported that at the time of inspection there was no divisional strategy in place

of 171


for medicine. However, there was a strategy for delivering care to surgical patients. The trust had a comprehensive quality improvement plan, which included a number of

projects and actions. These were divided into projects such as risk management, information governance, reducing harm, estates, stroke services and clinical effectiveness. Each project was then further divided into themes and action plans. We saw that the action plans were reviewed regularly, with monitoring of compliance against targets and details of completed actions. For example, the risk management project included the production of a risk register that reflected the trusts risks accurately, and the completion of patient risk assessments. Both actions were in progress with a new risk register in place, and training plans in place for e learning for staff.

Governance, risk management and quality measurement

A trust restructure was implemented in June 2016, just prior to the inspection, with three service units reduced to two divisions, medical and surgical. Some areas the restructure hoped to address were to:

o Develop clinically led services to ensure the triumvirate of medical, nurses and senior management are represented from board to ward.

o To have clear lines of clinical and corporate governance through the structure. o Improve the clinical and operations’ responsiveness to variation in demand. o Strengthen the relationship between board, executive and those responsible for

service provision. We were unable to assess the sustainability and effectiveness of the restructure as this

had not been embedded into the trust. However, staff across the services felt the reconfiguration was positive and provided more support with key identifiable processes of whom to contact should any issues or concerns arise.

There was good governance between the executive board and the safeguarding team. Staff were able to explain how issues would be disseminated downwards from the various teams.

Both the board assurance framework (BAF) and the corporate risk register were reviewed monthly but the trust board. The majority of the organisation’s key risks were represented there was some reference to the risks and how they should be managed.

In March 2016 the trust commissioned the Good Governance Institue (GGI) to review the governance within the trust and make recommendations for improvement. The areas asked to be looked at were: strategy, capability and culture, quality governance process and structures and measurements. The report by the GGI highlighted recommendations some of which included;

o Trust risks should be managed through the risk register process. o Create closer collaborative relationships with and between the board and clinicians

as well as with middle managers for example, joint clinical governance meetings. o Provide development to staff around the use of data and to consider providing

training to staff on how data should be collected, analysed and presented. The trust had identified the need for a risk management e-learning training package to be

developed and imbedded within the trust. This was incorporated into the quality improvement plan and we saw that discussions with the head of education and development had commenced. However, the quality improvement plan identified the trust was behind with its target in relation to the draft of the risk management/risk assessment training.

The trust had created a “star chamber” group to review the evidence reports submitted to the quality improvement plan. This was to check and challenge the evidence each project lead presented, to ensure it met the desired objective.

The executive team members told us that there were regular challenges within board meetings from board members and non-executive directors. We saw in the minutes of the

of 171


meetings frequent questions and queries by non-executive directors. We reviewed the operational risks which could impact upon the strategic objectives of the

trust to improve the quality and safety of care to patients, their carer’s and families. Most of the risks had no variances between the review in March and May 2016. However, the risk to women and babies due to the lack of a second obstetric theatre; the risk to patients due to potential delay in patient care by obstetrics and gynaecology registrar between 8.30pm and 8.30am; and the risk to security of women and children within women’s and children’s services due to lack of a robust security systems had deteriorated. We saw the trust had recognised a new risk within elective care in relation to patient safety due to lack of critical care level two and three capacity to meet emergency requirements.

The trust had improved its oversight of incident reporting and management with the implementation of the quality and safety group which was overseen by the medical director. The group reviewed all incidents and completed root cause analysis. We saw the minutes were cascaded to the staff teams to identify any learning.

The quality and safety group conducted safety visits to wards. We reviewed the action plans and observed that although the actions plans had a due date there was no evidence of the outcomes of the actions and/or if the actions had been completed. For example, one of the actions stated the ward sisters should ensure documentation was fully completed with feedback to all staff highlighting the importance of fully completed documentation, such as the correct recording of fluids, incomplete discharge planning and falls care plans.

The trust had a comprehensive major incident policy and staff were able to tell us where this was located on the trust website. However, it was noted that the trust wide major incident policy was due for review in 2014 and had not been updated since it was published in 2013. According to the intranet, the trust was in the process of updating this policy.

Leadership of the trust

The majority of the executive team had been stable for 18 months. The exceptions to this was the director of nursing (DoN), where an interim was in post at the time of our inspection and a substantive DoN was due to start in August 2016; and the workforce director who was interim with interviews for a substantive post holder scheduled. The team were passionate about improvements within the organisation.

The trust was placed into special measures in October 2014 and remained in special measures following our September 2015 inspection. Following enforcement action by the Care Quality Commission a quality improvement plan had been developed. We were assured there had been effective oversight of this with outcomes and projections monitored weekly. Staff at ward level were aware of the programme and their responsibilities for delivery as necessary.

The trust had been in receipt of support from an improvement director allocated by NHS Improvement.

Most staff said the chief executive officer (CEO) was visible and had opened up lines of communication. Staff said they felt the CEO listened to them and supported them in their roles.

The chief operations officer (COO) and the medical director (MD) conducted a walkabout every Friday afternoon whilst the director of nursing (DoN) and their deputy regularly walked around the emergency department. Staff said they felt supported by the executive team and gave them the opportunity to discuss any issues and get their feedback. However, some staff said they were “fed up” with interim posts within the executive team and felt this did not lead to a “stable” environment.

Most staff that we spoke with reported to us that they saw their immediate line manager regularly.

Overall, we were assured that there was good corporate understanding of the risks, issues

of 171


and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.

Culture within the trust

Results for the 2015 NHS Staff Survey showed 13 positive and seven negative findings. The remainder of findings were within expectation between 2014 and 2015 results significantly improved for three questions and showed no significant change for 18 of the 21 comparable questions. The 2015 response rate and overall engagement scores improved in comparison with 2014 scores.

The trust performed within expectation for 14 questions in the General Medical Council National Training Scheme Survey. The trust scored worse than expected for Induction.

There was a sense of pride amongst staff towards working in the hospital and they felt respected and valued.

Staff described a supportive and encouraging working environment and one in which openness and honesty was encouraged.

Fit and Proper Persons

The Fit and Proper Person Test (FPPT) is established by Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014, which requires that directors of NHS providers are fit and proper to carry out their role. The trust had a fit and proper persons test policy dated August 2015 which covered the requirements of the regulation.

We looked at the files of all the executive directors and supplementary information. These demonstrated that FPPT was part of the recruitment process and involved a combination of self-declaration and checks. The checks made included a disclosure and barring check, financial checks and references. The non-executive directors had been appointed by either the Appointments Commission or NHS Improvement.

Equalities and Diversity

The training records showed an inconsistency in the completion of the equality and diversity training. For example, the trust management team showed a compliance level of 45% and the elective care service unit which included nursing and midwifery medical staffing at 67%. This did not meet the trust target of 90%.

The leadership within the organisation were aware of the legal requirements the objectives aligned with Equality and Diversity Standards 2 (EDS2) but did not have an equality and diversity strategy to reflect these.

The equality and diversity lead had tested out the board’s understanding and feeling around EDS2. The equality lead told us that the trust plan was to mirror the objectives of EDS2 to the trust strategy objectives and develop the strategy through a workforce stream. However, the vision was not robust and no completion date or milestones had been set.

Staff attending the black and ethnic minority focus group were unaware of any work around equality and diversity in the trust.

There was no evidence provided regarding completion of a workforce race equality standard indicators.

There was no evidence in complaints, grievances or employment tribunals to suggest there were any issues that the trust were aware of concerning equality and diversity.

An equality and diversity policy was in place which made reference to the bullying and harassment policy; both policies were within date. Staff did not express concerns about bullying or harassment to the CQC team during our inspection.

of 171


Public engagement

The trust and staff recognised the importance of the views of patients and the public. Using surveys, comment cards and questionnaires to gather information to enable improvement.

The trust had established a young people’s ambassador group. This was run by a group of patients who had used the service or continued to use the service. The group met regularly and were consulted on changes and developments, for example they had been instrumental in the development of the ‘Saturday club’ which was well established and had been running for over one year. The Saturday club had been set up to provide a comprehensive pre-assessment service for children and young people being admitted for surgery. The ambassadors also told us about their involvement in improving the paediatric emergency department environment and their plans to improve other aspects of care and support on the paediatric ward. The ambassadors felt listened to by hospital staff and were pleased with action taken in response to the issues raised. The ambassadors had an agenda and list of issues they planned to raise with the trust; next on the list was improving food for patients. The ambassadors were currently involved with making a film about transition which would be used nationally across the NHS and this was taking priority; the ambassadors told us they would soon be working their way through agenda items to further improve the service.


There was trust stakeholder group that provided feedback on trust business plans and patient care improvement plans. The group had representation from patients, carers, staff and commissioners.

Staff engagement

Results for the 2015 NHS Staff Survey showed 13 positive and seven negative findings. The remainder were within expectation.

The trust performed within expectation for 14 questions in the General medical Council National Training Scheme Survey. The trust scored worse than expected for induction.

Staff were encouraged to complete a “Celebrate the good work you do”. We looked at five forms which were completed by three wards, ED and the clinical assessment unit. Staff were asked a number of questions which included “what are you proud of” and “what are your top three risks”. There was a current theme regarding the risks which included; staffing levels which also included staff morale, bed availability and effective discharge.

Innovation, improvement and sustainability

There was a continued focus on the trust mortality which showed a small improvement since the September 2015 inspection. The safety and quality committee met weekly to review all morality cases within the trust.

The trust had identified several business plans for the year 2016/17 which included an additional 16 bedded Gilwern ward, the procurement of a second CT scanner and an additional ophthalmology unit. We saw all of these had either been implemented or were due to be completed within the next few months. This meant the trust had reviewed its objectives and strategies for the best interest of patients.

Recruitment was a significant challenge for the trust and there were a number of actions being taken to address this including recruitment of oversea nursing staff. However, the trust felt they were disadvantaged by their geographical location and were considering what other actions could be taken to provide a sustainable recruitment and workforce solution.

of 171


The trust had a financial deficit in 2015/16 of £20,455m against a revenue of £178,045m. at the time of the inspection they had yet to agree a financial control target for 2016/17

There was recognition that the organisation given its size and location needed to work differently to provide a sustainable model for delivery of sustainable services to its population. There was work on going to link with partner organisations which was actively progressed by the executive team.

Through the quality improvement plan the trust and stakeholders were able to review the trust’s performance against key issues identified in the inspection report of September 2015. This plan had gone through a number of variations, the most recent being key in understanding the progress the trust was making. However, with the relatively new approach to this and a new organisational structure, we were unable to assess the future projection based on present trends.

of 171


Our ratings for this Hereford Hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent & emergency services

Requires improvement Good

Good Requires improvement

Good


Medical care Good Requires improvement


Good


Surgery Good Requires improvement

Good Inadequate Requires improvement


Critical care Good Good Good Requires

improvement Good

Good

Maternity & Gynaecology






Children & young people


Good Good Requires improvement


End of life care Good Good Good Good Good

Good

Outpatients &Diagnostic Imaging


Inspected but not rated1

Good Inadequate Requires improvement


Overall Requires

improvement Requires

improvement Good Inadequate Requires

improvement Requires improvement

Safe Effective Caring Responsive Well-led Overall

Overall trust Requires

improvement Requires

improvement Good Inadequate Requires

improvement Requires improvement

Notes:

1. We are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging services.

Overview of ratings

of 171


Outstanding practice

Services for children and young people were supported by two play workers (one was on maternity leave at the time of inspection). The play workers regularly made arrangements for long term patients to have days out to different places, including soft play areas or bowling. An activity was arranged most months and the play workers sourced the activities from local businesses who donated their good and/ or services. This meant that patients with long term conditions could meet peers who also regularly visited the hospital. Patients found this valuable and liked the opportunity to meet patients who had shared experiences.

There was a children’s and young people’s ambassador group which was made up of patients who used or had used the service. We spoke with some members of the ambassador group who told us that they were involved in the service redesign when developments took place and improving the service for other patients.

The respiratory consultant lead for non invasive ventilation had developed a pathway bundle, which was used for all patients requiring ventilator support. The pathway development was based on a five-year audit of all patients using the service and the identification that increased hospital admissions increased patient mortality. The information gathered directed the service to provide an increased level of care within the patient’s own home. Patients were provided with pre-set ventilators and were monitored remotely. Information was downloaded daily and information and advice feedback to patients by the medical team. This allowed treatments to be altered according to clinical needs. The development had achieved first prize in the trust quality improvement project 2016.


Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and twiddle mittens provided as patient activities. The unit provided regular activities for patients, which included monthly tea parties and games.

Areas for improvement Action the hospital MUST take to improve

The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the emergency department.

The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment.

The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps.

The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine.

The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously.

of 171


The trust must ensure all medicines are stored in accordance with trust polices and national guidance, particularly in outpatients.

The trust must ensure that all patients receive effective management of pain and there are enough medicines on wards to do this.

The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.

The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.

The trust must ensure staff receive appraisals which meet the trust target. The trust must ensure that patients are able to access surgery, gynaecology and outpatient

services in a timely way for initial assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets.

The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the waiting list.

The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded accurately.

The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children and young people’s services.

The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy.

The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

Please refer to the location report for details of areas where the trust SHOULD make improvements.

This section is primarily information for the provider

Requirement notices Action we have told the provider to take The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activity Regulation Treatment of disease, disorder or injury Diagnostic and screening procedures

Regulation 12 (2)(a)(b)(c)(g) HSCA 2008 (Regulated Activities) Regulations 2014 Safe care and treatment

1. Care and treatment must be provided in

a safe way for service users — a. Assessing the risks to the health

and safety of service users of receiving the care or treatment.

b. Doing all that is reasonably practical to mitigate any such risks

of 171


c. Ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.

g. The proper and safe management of medicines.

The level of safeguarding children’s training that staff in certain roles received was not compliant with intercollegiate document ‘Safeguarding Children and Young People: Roles and competencies for Health Care Staff (March 2014) in the emergency department. There were not enough staff trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment. There was not enough sharps bins available for safe and prompt disposal of used sharps. There was not always proper and safe management of medicines because patients’ weight was not always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine. It was not always clear on medicine records, the route a patient had received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously. Medicines were not always stored are stored in accordance with trust polices and national guidance, particularly in outpatients.

Regulated activity Regulation Treatment of disease, disorder or injury Diagnostic and screening procedures

Regulation 17 (1) (2) (b) HSCA 2008 (Regulated Activities) Regulations 2014 Good Governance

1. Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.

2. Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to—

b. assess, monitor and mitigate the risks relating to the health, safety and welfare

of 171


of service users and others who may be at risk which arise from the carrying on of the regulated activity

The regulation was not being met because risks were not always identified and all mitigating actions taken in all areas of the hospital. Effective systems and processes were not in place to improve the quality of services provided, including the quality of the experience of service users in receiving these services. Patients were unable to access surgery, gynaecology and outpatient services in a timely way for initial assessments, diagnoses and/or treatment. Access to services did not consistently meet trust or national targets, and were significantly worse. Times taken to assess and triage patients within the emergency department were not always recorded accurately. Incidents were not always reported or investigated in a timely way, particularly in children and young people’s services. Not all risks were identified on the risk register. Policies were not always up to date or evidence based, particularly in services for children and young people but not exclusively.

Regulated activity Regulation Treatment of disease, disorder or injury Diagnostic and screening procedures >

Regulation 18 (2) (a) HSCA 2008 (Regulated Activities) Regulations 2014 Staffing

2. Persons employed by the service provider in the provision of a regulated activity must— a. receive such appropriate support,

training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform

The regulation was not being met because not all staff were compliant with mandatory training, supervision and appraisals as required by the

of 171


trust’s policies.

of 171

Wye Valley Trust Board

Report to: Trust Board Agenda item: 9


Title of Report: Quality Improvement Programme Update


Position Statement & Approval

Report Approval Route: Director of Nursing

Lead Executive Director: Director of Nursing

Author: Service Transformation Lead

Appendices: 1. WVT Improvement Programme portfolio

2. Star Chamber timetable

3. CQC Should Do/Must Do review

4. Response to CQC re: Regulatory actions


To provide the Trust Board with an update on the development and delivery of the Quality Improvement Programme (QIP);

To inform the Trust Board of: o The must do and should do requirements of the CQC Inspection report o The Star Chamber timetable for QIP reviews o The actions identified, and the response to the CQC in relation to regulation requirements as

outlined in the CQC report

2. Recommendations

Trust Board members are asked to note the work related to the QIP and the CQC Inspection report and approve the Section 29a Action Plan.


This report provides assurance regarding:

The continuous improvement of the QIP, following the approach previously agreed by the Trust Board;

The CQC Inspection report must do/should do requirements being validated against the QIP

The governance and review timetable of QIP projects for December and January


4.1 Programme Delivery

4.1.1 QIP

As discussed at the October Board meeting, attached at Appendix 1, is an updated schedule of all of the WVT improvement programmes. It is important to highlight that this has been updated to include the reporting and

of 171

lines of accountability of all the projects (including projects outside of QIP e.g. FRP) that are being managed through the WVT Programme Management Office (PMO). Currently the portfolio has 59 projects within it, which are grouped into 17 themes. The portfolio has also been reviewed following the publication of the final CQC Inspection report to ensure that projects are aligned to the CQC findings and recommendations.

4.1.2 Programme assurance

There has been some loss of traction in the programme governance during the period of finalisation and publication of the report. Over the course of September and October, Star Chambers have reviewed the following QIP projects:

To ensure that the programme regains traction, 1‐1 sessions with project leads have been put in place to ensure that projects are up to date, responsive to the CQC findings and reflect the improvement priorities of the Trust.

A new timetable for Star Chamber reviews has been published (Appendix 2).

It is expected, with advanced publication of the star chamber timetable and the additional support to project managers that the rigour of project performance management improves to the levels leading up to the inspection in July.

4.2 CQC Inspection Report

Following the multi‐stakeholder Quality Summit held on the 2nd of November the final report of the Hereford County Hospital inspection was published on the 3rd of November.

The full report can be accessed on the CQC website:

www.cqc.org.uk

Improvements have been seen across many of the CQC domains and on the basis of the Inspection findings, Wye Valley Trust have been rated as “requires improvement” overall, with all core services rated ‘good’ for caring. Critical care and end of life care core services were rated ‘good’ overall.

However, the responsive domain for surgery, outpatient and diagnostic imaging services remained rated ‘inadequate’, resulting in the responsive domain being ‘inadequate’ overall.

Project Lead(s)

Workforce (all projects) Andrea Jones

Information Governance Pippa Whitfield

Patient safety for long waiters Claire Carlsen

Safeguarding Young People Hazel French

Dementia Fiona Blackwell

Health and Wellbeing CQUINs Andrea Jones, Stella Watkins, Julie Davis

Tissue Viability Michaela Powell, Lucy Woodhouse

Estates Christian Homersley

Outpatients Helen Byard

Patient/carer involvement Steph Cholmondeley

Appraisals Sarah Price

Mandatory Training Sarah Price

Adult Safeguarding Cath Holberry

of 171

The CQC have recognised the significant improvements that have been made across the organisation and have recommended that Wye Valley Trust is taken out of special measures. Confirmation that WVT have been taken out of special measures was received from NHSI on 16th November 2016.

The improvements in the ratings are illustrated in the following tables

(September 2015 and July 2016 Inspections)

Safe Effective Caring Responsive Well‐led Overall Safe Effective Caring Responsive Well‐led Overall

Urgent and emergency

servicesInadequate

Requires

ImprovementGood

Requires

Improvement

Requires

Improvement

Requires

Improvement

Requires

ImprovementGood Good

Requires

ImprovementGood

Requires

Improvement

Medical care InadequateRequires

ImprovementGood

Requires

Improvement

Requires

Improvement

Requires

ImprovementGood

Requires

ImprovementGood

Requires

ImprovementGood

Requires

Improvement

SurgeryRequires

Improvement

Requires

ImprovementGood Inadequate

Requires

Improvement

Requires

ImprovementGood

Requires


Requires

Improvement

Requires

Improvement

Critical CareRequires


Requires

Improvement

Requires

Improvement

Requires

ImprovementGood Good Good

Requires


Maternity and

GynaecologyInadequate

Requires


Requires

Improvement

Requires

Improvement

Requires

Improvement

Requires

ImprovementGood

Requires

Improvement

Requires

Improvement

Requires

Improvement

Services for children and

young peopleInadequate

Requires

ImprovementGood

Requires

Improvement

Requires

Improvement

Requires

ImprovementGood

Requires


Requires

Improvement

Requires

Improvement

End of life careRequires

Improvement

Requires

ImprovementGood

Requires

Improvement

Requires

Improvement

Requires

ImprovementGood Good Good Good Good Good

Outpatients and diagnostic

imagingInadequate Not rated Good Inadequate Inadequate Inadequate

Requires

ImprovementNot rated Good Inadequate

Requires

ImprovementInadequate

Overall N/A N/A N/A N/A N/A InadequateRequires

Improvement

Requires


Requires

Improvement

Requires

Improvement

Overall Trust InadequateRequires


Requires

ImprovementInadequate

Requires

Improvement

Requires

ImprovementGood

Requires

Improvement

Requires

Improvement

Requires

Improvement

Inspection September 2015 Inspection July 2016

As described previously, the Inspection Report has been reviewed to ensure that the CQC findings and recommendations are incorporated into the QIP. A review of the “must do” and “should do” recommendations has also been undertaken and is summarised at appendix 3.

As part of the inspection process and publication of the final report, Wye Valley Trust are required to respond to the CQC on actions we are planning to take in relation to any regulation breaches which are summarised at the end of the CQC inspection report. The response to this is due to be sent to the CQC by the 2nd of December. The Board is asked to note the response as attached at appendix 4.

of 171



and families High


Moderate


Low


High


High


High


Low


Board Assurance Framework references 544: Quality Governance 411: Reputation

of 171

Wye Valley Trust Improvement Portfolio Last Updated:

15/11/2016

NB ‐ Projects, where required,

encompass all WVT sites and settings

Governing Bodies:

Safety & Quality Committee

Finance and Performance Committee

Workforce Development Committee

Senior Sponsor Theme Project Project Lead

PID Owner

Accountable Body

Clinical Governance Jane Palin Safety & Quality Committee

Risk Management Lucy Simcock Safety & Quality Committee

Medicines Optimisation Tony McConkey Safety & Quality Committee

Cleanliness Safety & Quality Committee

PLACE Safety & Quality Committee

Security

Safety & Quality Committee

Patient Carer Engagement and Involvement Helen Byard/Steph Cholmondeley Safety & Quality Committee

End of life care Sally Johnson/Helen Donegan Safety & Quality Committee

Dementia and delirium Fiona Blackwell Safety & Quality Committee

Learning Disabilities Helen Byard Safety & Quality Committee

Tissue viability Michaela Powell/Lucy Woodhouse Safety & Quality CommitteeAdult safeguarding Cath Holberry Safety & Quality Committee

Safeguarding younger people Hazel French Safety & Quality Committee

Emergency Department Sarah Parry Safety & Quality Committee

7 day working Vanessa Lewis Safety & Quality Committee

Bed Reconfiguration Phil Ryan Safety & Quality Committee

Stroke pathway Sarah Parry Safety & Quality Committee

Sepsis (Inc. CQUIN) Ruth Johnson Safety & Quality Committee

AKI TBC Safety & Quality Committee

Fractured of Neck of Femur Cath Davies Safety & Quality Committee

Information Governance Pippa Whitfield F&P Committee (FRP)

Outpatients Kim Smith Safety & Quality Committee

Patient Safety for Long Waiters Claire Carlsen Safety & Quality Committee

Retention Andrea Jones F&P Committee (FRP)

Resourcing Andrea Jones F&P Committee (FRP)

Safer Staffing Andrea Jones F&P Committee (FRP)

Leadership Neville Bonner Workforce Development Committee

Development Neville Bonner Workforce Development Committee

Rota Management Andrea Jones F&P Committee (FRP)

Appraisals Sarah Price Workforce Development Committee

Mandatory Training Sarah Price Workforce Development Committee

Agency Andrea Jones F&P Committee (FRP)

Performance Andrea Jones F&P Committee (FRP)

Health and Wellbeing (Inc. CQUIN) Andrea Jones F&P Committee (FRP)

Governance Andrea Jones Safety & Quality Committee

Values & Engagement Neville Bonner Safety & Quality Committee

IPC Practice & standards Alison Johnson/Sarah Hardy Safety & Quality Committee

Training project leads in project management

and improvement methodologies

Ali Bolton Safety & Quality Committee

Training staff in improvement methodologies Ali Bolton Safety & Quality Committee

Health & Wellbeing, Healthy food for NHS staff,

visitors & patients

Stella Watkins Quality Committee /F&P Committee (FRP)

Antibiotic Consumption/Empiric Review Stella Watkins Quality Committee /F&P Committee (FRP)

MCA/DoLS Stella Watkins Quality Committee /F&P Committee (FRP)

Admission patients to Community Hospitals Stella Watkins Quality Committee /F&P Committee (FRP)

Planned Care Stella Watkins Quality Committee /F&P Committee (FRP)

Management of Frequent Attenders Stella Watkins Quality Committee /F&P Committee (FRP)

Establishment Review Cath Davies F&P Committee (FRP)

Rostering Carolyn Trew F&P Committee (FRP)

Temporary Staffing Office Karen Miller F&P Committee (FRP)

Procurement Sarah Pahal F&P Committee (FRP)

Quick Wins Fiona Blackwell F&P Committee (FRP)

Recruitment Phasing Andrea Jones F&P Committee (FRP)

Specialing Cath Davies/Fiona Blackwell F&P Committee (FRP)Education Sarah Price/Kevin Rogers F&P Committee (FRP)

Surgical Division Vanessa Lewis F&P Committee (FRP)

Medical Division Andy Parker F&P Committee (FRP)

Corporate Schemes Leads identified at project level F&P Committee (FRP)

Promoting normal birth and reducing C‐section

rate

Helen Price Safety & Quality Committee

Improving clinical environment Helen Price Safety & Quality Committee

Improving access Helen Price Safety & Quality Committee

Director of Nursing

Nurse Agency Reduction

Director of Finance and

Information

Financial Recovery Plan

Director of Nursing

Improving Women's Health Services

Medical Director

Medical Director

Chief Operating Officer

Director of Nursing


Medical Director

Director of Finance and

Information


Director of HR

Director of HR

Director of HR

Director of Nursing

Associate Director of

Strategy & Planning

Director of Nursing

Medical Director

CQUIN schemes

Urgent Care Flow

Clinical Effectiveness

Information Governance and Records

Management

Elective Pathways

Workforce Transformation (Productivity)

Workforce Transformation (Performance)

Workforce Transformation (Culture)

IPC

Improving Capability

Improving Quality Governance

Estates

Patient Experience

Safeguarding Vulnerable People

Christian Homersley

Reducing Harm

Page 1 of 1 of 171

Quality Improvement Program STAR CHAMBER TIMETABLE

Dec‐16

Date Time Projects Project Lead

6th 15:30 Emergency Department Sarah Parry

Room 51 16:00 Stroke Pathway Sarah Parry

16:30 IPC Practice and standards Alison Johnson and Sarah Hardy

13th 15:30 Values & Engagement Neville Bonner

Room 49 16:00 Leadership Neville Bonner

16:30 Development Neville Bonner

20th 15:30 Risk Management Lucy Simcock

Room 50 16:00 Medicines Optimisation Tony McConkey

16:30 Learning Disabilities Helen Byard

27th 15:30 No meeting

16:00

16:30

Jan‐17

Date Time Projects Project Lead

3rd 15:30 Promoting normal birth and reducing C‐section

rate

Helen Price

Room 50 16:00 Improving clinical environment Helen Price

16:30 Improving access Helen Price

10th 15:30 Cleanliness Christian Homersley

15:40 PLACE Christian Homersley

Room 49 16:10 Security Christian Homersley

16:30 Clinical Governance Jane Palin

17th 15:30 Andrea Jones, Stella Watkins, Julie Davies

Room 50 16:00

16:30

24th 15:30 Patient Safety for Long waiters Claire Carlsen

Room 49 16:00 Dementia and Delerium Fiona Blackwell

16:30 Tissue Viability Michaela Powell, Lucy Woodhouse

31st 15:30 Andrea Jones

Room 49 16:00

16:30

Health and Wellbeing CQUINs

Workforce projects

of 171

Requirement QIP Project Other workstream/department specific

Mandatory Training

Safeguarding Younger People

Emergency Department

The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient

receive timely safe care and treatment.

Must Do Stroke Pathway

The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps. Must Do IPC practice and Standards

The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing

of the medicine.

Must Do Medicines Optimisation

The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a

patient has been given the paracetamol orally or intravenously


The trust must ensure all medicines are stored in accordance with trust polices and national guidance, particularly in

outpatients.


The trust must ensure that all patients receive effective management of pain and there are enough medicines on wards to do

this


The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role Must Do Mandatory Training

The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems Must Do Workforce Transformation projects

The trust must ensure staff receive appraisals which meet the trust target Must Do AppraisalsPatient safety for long waiters

Outpatients

The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the

waiting list

Must Do Patient safety for long waiters

The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded

accurately

Must Do Emergency Department

The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children

and young people’s services

Must Do Clinical Governance

The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy Must Do Clinical Governance

The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken Must Do Risk Management

The trust should ensure all vacancies are recruited to Should Do Workforce Transformation projectsThe trust should continue to complete mortality reviews with the aim of reducing the overall Summary Hospital‐level Mortality

Indicator for the service

Should Do Clinical Governance

The trust should ensure patient records are stored appropriately to protect confidential data Should Do Information GovernanceThe trust should ensure all patient records are fully completed, including stroke pathway documentation and communication

detailing interactions and treatments provided within the care plan evaluation sheets

Should Do Clinical Governance

Stroke PathwayThe trust should ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national

performance standards for emergency departments

Should Do Emergency Department

The trust should ensure delays in ambulance handover times are reduced to meet the national targets Should Do Emergency DepartmentThe trust should ensure initial patient treatment times are reduced to meet the national target for 95% of patients attending the

emergency department to be admitted, discharged or transferred within four hours


Ensure that each service has a local vision and strategy which is disseminated and understood by all staff so that it is embedded

within the service

Should Do Values and Engagement

Emergency Department

Cleanliness

IPC Practice and Standards

The trust should ensure that systems are in place to provide adequate nutrition and hydration to patients in the emergency

department and clinical assessment unit


The trust should ensure treatment bays in the emergency department resuscitation area protect patients’ privacy and dignity Should Do Emergency Department

The trust should review staff safety and provision of an alarm call system in the rapid assessment area Should Do Emergency DepartmentThe trust should review its arrangements for transporting patients home if they need to travel on a stretcher, with emphasis on

improving patient flow.

Should Do Operational BAU

The trust should ensure that electronic discharge letters are completed in a timely manner to prevent delays in the preparation

of patient’s medication to take home and delays in patient discharge

Should Do Medicines Optimisation

The trust should ensure where possible, patients are placed in the most appropriate clinical area Should Do Operational BAUThe trust should consider implementing a checklist for transferring patients between wards, to ensure transfer is appropriate

and maintains patient safety

Should Do Clinical Governance Operational BAU

The trust should consider implementing a risk assessment for the admission of medical patients to outlying wards, to ensure

admission is appropriate and maintains patient safety

Should Do Clinical Governance Operational BAU

The trust should ensure unnecessary patient moves are minimised at night Should Do Operational BAU

The trust should continue to work with local stakeholders to improve the discharge pathway and facilitate timely patient

discharge


The trust should ensure mixed sex breaches are prevented Should Do Operational BAU

The trust should consider employing a lead nurse for learning disabilities to support patients Should Do Learning Disabilities

Governance

Values and Engagement

The trust should ensure that patents privacy and dignity is protected at all times, in particular during handover on Leadon ward Should Do Operational BAU

The trust should ensure that there are action plans as a result of audits, to promote improvements Should Do Clinical Governance

The trust should ensure that cancelled operations are prevented; and if cancelling an operation is essential, patients are then

treated within 28 days as per NHS England standard

Should Do Patient safety for long waiters

The trust should ensure staff are aware of the trust mission, vision, and strategic objectives. Should Do Values and Engagement

The trust should consider a follow‐up clinic for patients discharged home after an intensive care unit admission, as

recommended in National Institute for Health and Care Excellence guidance

Should Do Critical Care

The trust should ensure that flow is maintained throughout the hospital to ensure there is capacity to admit patients that

required critical care services and discharge patient in a timely manner


The trust should ensure there are systems and processes in place to keep patients safe, particularly in maternity services where,

the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose

Should Do Improving clinical environment

(Womens Health)

The trust should ensure there is clear oversight of outcomes and activity in maternity services Should Do Improving Access

(Womens Health)

The trust should ensure measures are in place to reduce the caesarean section rate Should Do Promoting normal birth and reducing C‐

Section rate

(Womens Health)

The trust should ensure that meeting minutes clearly record recommendations and lessons learnt from incidents Should Do Clinical Governance

The trust should ensure that appropriate transition arrangements for children are clearly defined Should Do

The trust should ensure there is an acuity tool to be used to determine patient dependency levels and staffing requirements in

paediatrics

Should Do Establishment Review

The trust should ensure that there is oversight of the service arrangements for the mortuary team to ensure that staff training

and supervision is in place


The trust should ensure that effective information on the percentage of patients who were discharged to their preferred place

within 24 hours is collected


The trust should ensure that corridors where patients wait for their consultation and treatment in the Victoria Eye Unit do not

pose a risk to patients with visual difficulties

Should Do Outpatients

The trust should ensure there is signage on the doors to indicate if a compressed gas is stored in the room, in line with the

Department of Health guidance (Medical gases. Health Technical Memorandum 02‐01: Medical gas pipeline systems. Part B:

Operational management, 2006)

Should Do Estates and facilities BAU

The trust should ensure that complaints are responded to within the trust target of 25 days. Should Do Patient/Carer engagement and

Involvement

The trust should minimise the percentage of outpatient clinics cancelled Should Do Outpatients

The trust should ensure all equipment has safety and service checks in accordance with policy and manufacturer’ instructions

and that the identified frequency is adhered to, particularly in outpatients, the emergency department and the intensive care

unit

Should Do Estates and facilities BAU

The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the

emergency department.

Must Do

The trust should ensure that systems and processes are in place to ensure cleanliness of equipment within the emergency

department

Should Do

The trust should ensure that all staff are aware of the trust structure and who their managers are Should Do

Must DoThe trust must ensure that patients are able to access surgery, gynaecology and outpatient services in a timely way for initial

assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets

of 171

1

Report on actions you plan to take Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action.

Account number RLQ

Our reference SPL1-2477839808

Location ID RLQ01

Location name Hereford Hospital

of 171

2

Regulated activity(ies)

Regulation

Treatment of disease, disorder or injury Diagnostic and screening procedures

Regulation 12 (2)(a)(b)(c)(g) HSCA 2008 (Regulated Activities) Regulations 2014 Safe care and treatment 1. Care and treatment must be provided in a safe way for service users — a. Assessing the risks to the health and safety of service users of receiving the care or treatment. b. Doing all that is reasonably practical to mitigate any such risks c. Ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely. g. The proper and safe management of medicines.

How the regulation was not being met: The level of safeguarding children’s training that staff in certain roles received was not compliant with intercollegiate document ‘Safeguarding Children and Young People: Roles and competencies for Health Care Staff (March 2014) in the emergency department. There were not enough staff trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment. There were not enough sharps bins available for safe and prompt disposal of used sharps. There was not always proper and safe management of medicines because patients’ weight was not always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine. It was not always clear on medicine records, the route a patient had received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously. Medicines were not always stored are stored in accordance with trust polices and national guidance, particularly in outpatients.

Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve Improvement work will continue to be progressed through dedicated projects within the QIP.

The schedule of QIP Themes and Projects is attached.

Additionally:

Safeguarding – The trust recognises that all clinical staff within the Emergency Department (ED) require level 3 training. This competence requirement is set as such for each individual.

of 171

3

The QIP6A will be amended to include specific actions, and targets for ED staff. This will include a baseline review of training compliance for ED and meeting with service leads to agree training trajectory for ED (December 2016). An ED specific training compliance report will be produced on a monthly basis and will be reviewed in QIP and the ED governance meetings (December 2016).

Doppler Assessments – A training needs analysis will be completed by the end of December 2016 and training programmes devised and rolled out by the Education & Development Centre in conjunction with service leads.

Sharps bins - The infection prevention team are regularly visiting all areas of the trust as part of the team’s daily practice and they will continue to be vigilant to ensure that availability is maintained.

Sharps bin audits will continue to be undertaken and the availability of sharps bins and sharps management will be part of the annual infection prevention audits.

Exposure incidents via occupational health department will be reported to IPC if there are any issues with availability of sharps bins. Sharps management also comprises part of mandatory training.

Medicines management – The Medicines Code will be reviewed to ensure that weight of the patient should be recorded on the inpatient chart (November 2016). Review and agree guidance for patients who are not able to be weighed or if prescription does not include weight for weight dependent drugs (December 2016). Update Medicines Code and implement (Mid-January 2017). Audit of compliance (31/03/2017).

Route of administration – policy to be reviewed, updated and approved by Medical Director and Director of Nursing (December 2016). Approval by Medicines Committee (mid-January). Audit 31/03/2017.

Storage – review of storage of medicines in OPD (November 2016). Risk assessment to be completed for lockable trolley solution. Audit of compliance as part of the annual audit programme for storage with monthly report to Quality & Safety Committee.

Who is responsible for the action? Department Lead/Project Lead

How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? The improvements will be monitored through:

Divisional Quality and Safety meetings Divisional Boards Performance Meetings QIP Star Chamber Quality and Safety Committee

Evidence of improvements will be submitted via star chamber to demonstrate delivery of improvements e.g. compliance data/audit results

Who is responsible? Quality and Safety Team/PMO

What resources (if any) are needed to implement the change(s) and are these resources available? No additional resources identified as being required

Date actions will be completed: March 31st 2017

of 171

4

How will people who use the service(s) be affected by you not meeting this regulation until this date? Safeguarding – impact is considered to be minimal as review and training implementation will commence from December. Safeguarding processes will continue to be supported and monitored through our Safeguarding Team.

Doppler assessments – Systems are in place regarding to provide alternative investigations which can be undertaken to ensure patients receive a timely service.

Sharps management – being addressed through IPC departmental visits and H&S checks.

Medicines – has been raised at safety summit and highlighted through discussion at divisional and directorate meetings.


Regulation


Regulation 17 (1) (2) (b) HSCA 2008 (Regulated Activities) Regulations 2014 Good Governance 1. Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. 2. Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to— b. assess, monitor and mitigate the risks relating to the health, safety and welfare

of service users and others who may be at risk which arise from the carrying on of the regulated activity

How the regulation was not being met: The regulation was not being met because risks were not always identified and all mitigating actions taken in all areas of the hospital. Effective systems and processes were not in place to improve the quality of services provided, including the quality of the experience of service users in receiving these services. Patients were unable to access surgery, gynaecology and outpatient services in a timely way for initial assessments, diagnoses and/or treatment. Access to services did not consistently meet trust or national targets, and were significantly worse. Times taken to assess and triage patients within the emergency department were not always recorded accurately.

of 171

5

Incidents were not always reported or investigated in a timely way, particularly in children and young people’s services. Not all risks were identified on the risk register. Policies were not always up to date or evidence based, particularly in services for children and young people but not exclusively.



Additionally:

ED Triage – A review of the process for triage data entry has been completed. Staff to be briefed regarding requirements for entering information (particularly triage times) accurately and contemporaneously. Symphony (ED information system) audit will be undertaken on a monthly basis to review compliance.

Risk - A review of the Risk Management Strategy & Assurance Framework is planned and will include a Trust wide training needs analysis for the identification, management and assessment of risks alongside triangulating of hard and soft intelligence. This will occur in conjunction with the roll out of a web based risk management system which will support better analysis of our risk profile and monitoring of sustainable actions & improvements.

Directorate, divisional and corporate reports are currently under review in terms of content, collective analysis and organisational learning with sustained improvements.

Risk management systems and processes in the divisions will be supported by the Quality & Safety Team who have recently restructured and recruited to senior posts to support the risk management, quality, safety and improvement agenda. The structure aims to provide much closer working links through a divisional relationship manager. The Quality & Safety Team structure includes a new senior manager position for risk management & patient safety, with a supporting team and a new senior manager position for quality surveillance and supporting team to horizon scan as part of a proactive risk assessment process.

Embedding new governance process in the new divisional structures will see risk monitoring and escalation occurring at speciality, directorate, divisional and corporate level with alignment to the performance framework, up to Trust Board subcommittee level and Trust Board.

Incidents - A review of training needs at induction and through mandatory training mechanisms will be undertaken and relevant training programmes will be implemented with a focus in this area. A revised system was implemented from September 2016 (post CQC inspection) for all incidents graded moderate and above to undergo a rapid review (72 hours) to detect any harm caused and to determine the level of investigation required. Scrutiny regarding investigation processes for serious incidents occurs at the Executive led Serious Incident Panel.

of 171

6

Additionally the new Quality & Safety Structure (Detailed above) will develop closer relationship roles to support the Divisions with the incident reporting, management, investigation and organisational learning processes. Development of directorate, divisional and corporate reports will aim to detect any areas of potential under reporting and compliance with investigation timeframes.

Policies - A review to provide a position statement for policies & procedures and associated governance arrangements is underway. A risk based approach will be used to progress reviewing & updating of policies & procedures. Use of supporting electronic systems to support the management will also be scoped.

Who is responsible for the action? Assistant Director – Quality Governance





What resources (if any) are needed to implement the change(s) and are these resources available? The new Quality & Safety Team structure is fully funded with full establishment expected by February 2017.

Upgrades to the risk management system are funded and will be part of a roll out programme.

Date actions will be completed: Risk management 1) New risk management strategy &

framework approval by March 2017. 2) New Quality & Safety Team fully

established by February 2017. 3) Web based risk management system

pilot evaluation January 2017. Roll out by September 2017.

Incident reporting 1) New Quality & Safety Team fully

established by February 2017. 2) Training needs analysis &

programme delivery commence March 2017.

of 171

7

3) Development of new directorate, divisional and corporate report templates (Including incident reporting and management data) by March 2017.

Policy Management 1) Position statement December 2016

Full implementation of revised systems post review September 2017.

How will people who use the service(s) be affected by you not meeting this regulation until this date? Interim measures are in place therefore no adverse impact is expected.


Regulation


Regulation 18 (2) (a) HSCA 2008 (Regulated Activities) Regulations 2014 Staffing 2. Persons employed by the service provider in the provision of a regulated activity must— a. receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform

How the regulation was not being met: The regulation was not being met because not all staff were compliant with mandatory training, supervision and appraisals as required by the trust’s policies



Additionally:

ESR systems have been updated and WVT has signed up to the Core Skills framework for the West Midlands. This enables transfer of training records as employees transfer across organisations to ensure that training records are up to date and where training has been completed that this is reflected in the employee record and Trust training performance data.

of 171

8

The WVT training matrix has also been reviewed to ensure that training requirements reflect staff member’s positions and responsibilities.

A dedicated data compliance manager has been identified within the training department and weekly training team improvement meetings have been put in place to monitor performance and address issues related to records and delivery of training.

Who is responsible for the action? Head of Training & Education





What resources (if any) are needed to implement the change(s) and are these resources available? No additional resources identified as being required

Date actions will be completed: March 2017

How will people who use the service(s) be affected by you not meeting this regulation until this date? Improvements have started to be implemented and therefore no adverse impact is expected.

Completed by: (please print name(s) in full)

Jane Palin

Rob Cunningham

Position(s): Assistant Director – Quality Governance

Service Transformation Lead

Date: 23.11.2016

of 171

TRUST BOARD MEETING Report to: Trust Board Meeting ‘in public’ Agenda item: 10 Date of Meeting: 1st December 2016 Title of Report: Board Assurance Framework Status of report: (Approval, position statement, information, discussion)

For discussion

Report Approval Route: Trust Board Lead Executive Director: Managing Director Author: Company Secretary Appendices: 1. BAF

2. Corporate Risk Register excerpt 1. Purpose of the report

1.1 The purpose of the report is to provide Board Members with the opportunity to review and discuss the

‘extreme’ risks to the achievement of the Trusts Strategic Objectives as set out within the Board Assurance Framework (BAF) and to review the Corporate Risks rated 15 and above which are not on the BAF and which are managed operationally.

2. Recommendations

2.1 For Board Members to discuss and note the risks to the achievement of the Strategic Objectives as set out

in the attached Board Assurance Framework.

2.2 For Board Members to approve the removal of Risk Ref 544 (Risk to health, safety and welfare of service users due to ineffective Quality Governance systems and processes) from the Board Assurance Framework but for it to remain on the Corporate Risk Register.

2.3 For Board Members to approve the removal of Risk Ref 411 (Risk to the Trust’s credibility and reputation

due to remaining in Special Measures) from the Board Assurance Framework and for the risk to be closed due to it reaching its target rating.

2.4 For Board Members to note the Corporate Risks.


3.1 High levels of assurance can be given that there is a robust process in place for the monitoring and review

of the Board Assurance Framework which reflects the extreme risks to the achievement of the Trusts Strategic Objectives.


4.1 Attached at the appendix is the Board Assurance Framework which shows the ‘extreme’ risks to the achievement of the Trust’s Strategic Objectives. It has a ‘risk on page’ to provide the Board Members with the information required to undertake a ‘check and challenge’ of the controls, assurances and actions in place to manage or mitigate the ‘extreme’ risks. All new actions and changes to the Board Assurance

of 171

Framework have been highlighted in red.

4.2 If the Board approves the recommendations set out above there will be seven ‘extreme’ risks to the achievement of the Strategic Objectives, four of which are rated at 20.

• (417)Risk to recruitment of new staff and retaining current staff – (20) • (375)Risk of non-achievement of the 18 week pathway within General Surgery, Urology, Trauma

and Orthopaedics and ENT for admitted – (20) • (399)Risk of continued failure of the Urgent Care Pathway – (20) • (386)Risk to the financial sustainability of Wye Valley NHS Trust – (20) • (411) Risk to the Trust’s credibility and reputation due to remaining in Special Measures – (20)

recommendation to close as risk no longer exists • (544)Risk to health, safety and welfare of service users due to ineffective quality governance

systems and processes – (16) recommendation to reduce to 12 and monitor through the Corporate Risk

• (400)Risk of the Trust failing to achieve the NHS Constitutional targets – (16) • 302) Risk that the published high mortality indices are an alert of possible poor quality of care

and therefore potentially avoidable deaths – (15) • (412) Risk of critical failure in Hutted Ward environment – (15)

4.3 Each of the risks have been discussed with the Executive Director Lead to ensure that they accurately

reflect the risk, impact/consequence, controls, assurance and actions. The actions are followed up every month with the Executive Director Lead to ensure that the actions in place are undertaken in order to manage / mitigate the risk. Board Members are encouraged to raise any questions they have on the attached with the Executive Lead for that risk.

4.4 All risks on the Corporate Risk Register have been discussed at the Executive Risk Committee.



and families High


Moderate


Low


High


High


High


Low


6.1 Within the attached appendices.

of 171

Appendix 1

BOARD ASSURANCE FRAMEWORK 2016/17

1 | P a g e

November 2016

Strategic Objective 1 ‐ Improve the quality and safety of care to our patients, their carer’s and families (Risk Appetite to achieve objective– High)

Strategic Risk (1) Date added: 11.12.2015

Risk Owner & Committee

Key Controls Lines of defence

Assurance on controls

Lines of defence

Current Risk Rating C x L (after controls)

Target Rating/date C x L

1

2 3 1 2 3

(Ref: 544) There is a risk to health, safety & welfare of service users due to ineffective quality governance systems & processes. Context The Trust was placed in special measures as an outcome of the CQC visit performed in June 2014. Subsequent follow up CQC re‐inspection visit was performed in September 2015 & warning notice issued in November 2015. The final report was received from CQC on 14

th January with an overall rating of ‘inadequate’ and the Trust

remaining in Special Measures. A CQC Inspection was undertaken in July 2016. The report published in October 2016 provided a rating of Requires Improvement and resulted in the Trust also been lifted out of Special Measures. Cause / Source / Event Due to identified weaknesses in WVT quality governance systems & processes highlighted in the Warning Notice received from the CQC in November 2015 and the final CQC report published on 20th January 2016 there is a risk that service users may receive substandard care during their treatment by WVT. Impact / Consequence This could lead to; 1. Poor patient experience 2. Increased complaints 3. Patient harm 4. Possible litigation 5. Negative financial impact 6. Patients electing to go elsewhere thus affecting the Trusts income base. 7. Trust reputational damage

Medical

Director

Quality

Committee &

Audit

Committee

1. Quality Committee meets monthly ‐ to review & discuss quality & safety matters. This includes issues relating to quality of service provision (2)

2. Internal Audit programme ‐ checks that systems & processes are working as expected to safeguard quality (3)

3. Clinical Audit ‐ Report to the Quality committee on a quarterly basis (2)

4. Incident, complaints & claims reporting system in place ‐ managed by Q&S team (2)

5. Staff training programmes in place including mandatory training undertaken by all WVT staff (1)

1. Training registers showing mandatory training compliance levels (2) 2. Trust Quality Committee meeting minutes (2) 3. Internal Audit reports (3) 4. Incident, complaints & claims monitored & reported on (2) 5. GGI Report and action plan discussed at Trust Board (2) 6. Integrated quality and safety report introduced and presented to Quality Committee 23.6.2016 (2)

4x3=12

4x2=8

of 171

Appendix 1


2 | P a g e

November 2016

6. Service Unit Performance meetings & Service Unit Governance meetings ‐ conducted monthly where all SU governance matters are discussed & escalated where required (1)

7. Statutory and mandatory training is part of specialty doctor appraisals.(2)

8. Quality and Safety Manager in post and working full time (1)

9. Interim Associate Director of Governance in post from 5.5.2016 (1)

10. Terms of Reference for Divisions and directorate Quality & Safety Groups agreed 14.6.2016 (1)

11. Associate Director of Quality Governance in post from 31.10.2016 (1)

of 171

Appendix 1


3 | P a g e

November 2016

Gaps in control Gaps in Assurance

1. Currently limited culture surrounding holding staff to account for their actions / inaction.

Actions By whom By when Update

1. Perform a review of incident, complaints & claims reporting process & contents of reports sent to the Quality Committee with a view to improving triangulation between the three areas.

Medical Director

End Feb March May July 2016 December 2016

This action will now form part of action 5 see below therefore dates aligned – integrated quality and safety report presented to Quality Committee 23.6.2016. Further work required on triangulation of data but this links to development of the ‘cube’ – no further update currently.

2. Strategic Plan for Quality Governance to be developed. Interim Associate Director of Governance

End July 2016End Aug 2016 End Nov 2016 End Sept 2017

New Action ‐ The newly appointed Interim Associate Director of Governance will be developing a Strategic Plan for the delivery of Quality Governance this approach was agreed at the Trust Board on 7th April 2016. Date for completion of the Strategic Plan end of July 2016 – action continuing but due to involvement in operational matters action completion date extended to end of August 2016. Quality and Safety Road Map in place and being delivered due to be completed end of November – action complete Quality Strategy to be developed.

4. Review of Quality and Safety Team to be undertaken to ensure delivery of objectives and clear lines of accountability are in place

Interim Associate Director of Governance

End July End October 2016

Review CompleteProcess of implementation underway Management of Change process ongoing Band 8a posts out to advertisement. – Action complete posts appointed to and Management of Change process complete

of 171

Appendix 1


4 | P a g e

November 2016




Assurance on controls Lines of defence


Target Rating/date C x L

1 2 3 1 2 3

(Ref: 302) There is a risk that the published high mortality indices are an alert of possible poor quality of care and therefore of potentially avoidable deaths Context The published Mortality Indices; Summary Hospital level Mortality Index (SHMI) and Hospital Standardised Mortality Ratio (HSMR) have shown that Wye Valley is statistically higher than expected. Cause / Source / Event There is a risk that the published high mortality indices are an indication of poor quality care being provided by Wye Valley Trust to its patients. Additionally, delayed transfers of care and prolonged stays in community hospitals are adversely affecting SHMI. Multiple Finished Consultant Episodes (FCE’s) per patient spell are preventing accurate allocation of primary diagnosis. This is due to the way in which consultant episodes are managed on PAS. Impact / Consequence This could lead to; 1. Potentially avoidable deaths occurring at Wye Valley Trust resulting from poor or inadequate care. 2. Nationally published figures causing adverse publicity and reputational damage to the Trust 3. Difficulty in recruitment of staff (links to risk 417) 4. Increased costs filling gaps with temporary / bank & agency staff 5. Increased scrutiny from the NHSI, NHS England and the CCG

Medical

Director

Quality

Committee

1. Weekly review of all in hospital deaths led by Medical Director(1)

2. Escalation process for cases where lapses in care identified (1)

3. Implementation of Care Bundles (2)

4. Governance Mortality structure redesigned and implemented(2)

5. Sepsis Screening Tool designed and implemented (1)

6. Action plans in place where mortality higher than expected (1)

7. Review of unexpected cardio‐respiratory arrests(1)

8. Coders involved in mortality reviews (1)

9. Case note review of chronic obstructive pulmonary disease (COPD), acute

1. Mortality Indicators reported to Leadership Team, Quality Committee and Board, compared with National data (3)

2. Weekly Mortality Case Note Review Group(2)

3. Regular audit of use of Care Bundles (1)

4. External review undertaken by UHB ‐ October 2015 (3)

5. Standardised Hospital Mortality Indicator (SHMI) is 120 116 115 115 year ended June September December June 2016 (compared to 121 year ended June 2015) ‐ NEGATIVE ASSURANCE (3) HSMR is 111 as of August 2016 this has reduced from 118 as of August 2015 (3)

6. Improvement in HSMR in outlier groups referred to above.(3)

7. Monthly report of mortality indicators to Quality Committee from Hospital Reducing

5x3=15 5x1=5

of 171

Appendix 1


5 | P a g e

November 2016

kidney injury (AKI)and fracture neck of femur (#NOF) outlier alert (2)

10. Fluid management pack from 31.1.2016 (1)

11. Consultant Lead for Patient Safety appointed and in post from 1.4.2016 (2)

12. Review of all unexpected admissions from inpatient areas to critical care 30.9.2016 (1)

Mortality Group (2) 19.11.2015

8. UTI action plans signed off by CQC (3)

9. Audit of compliance with fluid management pack


of 171

Appendix 1


6 | P a g e

November 2016


1. Review of coding practice Medical Director End Nov 2015 End Mar 2016 End Aug Nov 2016 End Sept Nov 2016 End Dec 2016

Support being received from UHB to draft and implement new coding policy. UHB came to the Trust week commencing 12th October and have reviewed the new coding policy. Action complete. Formal audit to now be undertaken. This action will now form part of the work programme with our new buddy Trust. Medical Director to have discussion with South Warwickshire Foundation Trust during week commencing 25.4.2016. Dr Sarah Whiteman, Medical Director Midlands & East is putting the Trust in touch with a coding expert, as applies to mortality, to undertake a deep dive review. Contact details for coding expert as applies to mortality received however funding of expert needs to be agreed. – still to be agreed Consultant lead for patient safety leading project within division of medicine to address multiple FCEs. COO working with system wide stakeholders to address delayed transfers of care.

2. Reducing expected mortality in Sepsis, Acute Kidney Injury (AKI) and Fracture of the Neck of Femur (# NOF) now part of the Quality Improvement Programme and will be monitored through that process

Medical Director July 2017 Sepsis, AKI and UTI have now been closed by CQC due to improved performance and a robust action plan been delivered action complete. However, # Neck of the Femur still requires sign off by CQC.

of 171

Appendix 1


7 | P a g e

November 2016

Strategic Objective 2 ‐ Improve the responsiveness of our services for the benefit of our patients and their families (Risk Appetite to achieve objective – Moderate)





Lines of defence


Target Rating/date C x L 1 2 3 1 2 3

(Ref: 375) Risk of non‐achievement of the 18 week pathway across multiple areas within admitted and non‐admitted pathways. Context There is a high risk to 18 week Referral To Treatment (RTT) reporting, planning and delivery due to changes in the Trusts PAS data recording and reporting. In addition to this there is also not enough core staff capacity to deliver the backlog. Impact This could lead to; 1. Failure to meet constitutional targets for RTT 2 Increased potential harm to patients 3. Possible fines for the Trust 4. Reputational damage to the Trust 5. Increased complaints 6. Increased external scrutiny

Chief

Operating

Officer

Finance &

Performance

Committee

1. Improved weekly Patient Tracking Lists (PTL) for admitted patients in place from October 2015 (1) For non‐admitted patients from mid Dec (1) 2. Weekly scheduling meeting to profile the admitted waiting lists & prioritises according to chronological demand & patient urgency. In place from November 2015(1) 3. Weekly scheduling meeting to profile the demand for outpatient appointments & prioritising capacity available to do additional activity (ACAPS) to assist with the back log. In place from November 2015(1) 4. Weekly specialty and corporate PTL meetings with Head of Patient

1. Recovery trajectory action plans provide audit trail (from Oct 2015)(3) 2. Weekly scheduling meeting outputs ‐ logs & minutes (1) 3. Weekly external reporting on RTT position provided to NHSI from WVT Information department(3) 4. Monthly Monitoring of Cancelled Operations to Finance and Performance Committee and Trust Board(1) 5.Monthly divisional performance Meeting (1) 6. Joint Planned Care Programme

5 x 4 =20

5x2=10

of 171

Appendix 1


8 | P a g e

November 2016

Access and Deputy Chief Operating Officer Sept 2016 (1) 5. RTT Steering Group and other work streams established on the back of IST Action Plan. Meets monthly from April Sept 2016(1) 6. RTT recovery plan in place which includes using third party providers .(2) 7. Weekly Exploration of capacity available through third party providers. (1) 8. SOP in place from 2014 for Escalation of cancellations & impact of urgent flow on Elective capacity(1) 9. Twice daily Theatre huddle occurs Mon to Fri led by the lead nurse for surgery (1) 10. Harm reviews of long waiting patients happening weekly and reported to Quality Committee monthly (2) 1.1.2016 11. Data Quality Improvement managed through corporate PTL from 31.12.2015 12. Programme of education and training

Board meets monthly (3) 7. Remedial Action Plans (RAPs) provided weekly for Divisions for each specialty (1) 8. Validation Team audit of outpatient list over 52 weeks (1) 9. Open pathway validation work completed (1) 10. RTT Deep dive conducted by Chief Operating Officer to agreed recovery actions.

of 171

Appendix 1


9 | P a g e

November 2016

of 160 staff on principles of RTT complete 31.12.2015 (1) 13. Access Policy and action cards in place 1.4.2016 (1) 14. Patient Access Team in place 25.4.2016 (1) 15. New Divisional Structure in place clearly identifying appropriate lines of accountability for delivery of improvement plans 31.06.2016 (2) 16. Trajectory action plans in place and being monitored on a weekly basis at speciality level.(2) 17. Waiting list review of all patients waiting over 18. weeks for admitted and non‐admitted (1) 30.9.2016 19. Recovery trajectory action plans in place (2)


1. Poor data quality processes currently exist within WVT (Nov 2015). This results in high volume revalidation. 2. SOP for Escalation of cancellations & impact of urgent flow on Elective capacity is effective Monday to Friday but is not working for weekend.

of 171

Appendix 1


10 | P a g e

November 2016


1. The ongoing recovery plan for RTT needs to be agreed for 17/18 ‐18/19 Chief Operating Officer

End Dec 2016

A recovery model for each specialty is being developedA recover model for demand and capacity is also being developed to balance capacity and demand and reduce backlog to acceptable levels.

2. Return to reporting work schedule underway. Chief Operating Officer

End Dec 2016

Report mid‐January 2017 on December 2016 data. NHSI have been informed

3. Delivery of the RTT Standard is a key area within the Organisational Sustainability Plan (10 point plan) also includes above actions

Managing Director and Chief Operating Officer

TBC New action

of 171

Appendix 1


11 | P a g e

November 2016





Lines of defence



(Ref: 399) Risk of continued failure of the Urgent Care PathwayContext The Trust is unable to maintain the Urgent Care pathway & continues to breach 4 hour waits. This also impacts on Elective Care & on occasions results in sub optimal service provision to patients, breaches in 18 week RTT & 2 week waits & exacerbated the Trust's poor financial position. Cause / Source / Event There is a risk that the Trust will fail to maintain the Urgent Care pathway during the year 16‐17 due to demand for services potentially being greater than the capacity to supply. Impact / Consequence If the Urgent Care pathway & 4 hour wait are not met, this could lead to; 1) Reduced ability to provide Elective Care services 2) Cancelled procedures / appointments 3) Loss of service provision related income 4) Sub‐optimal service provision at certain times 5) Breaches in 18 week RTT, 2 week waits and 52 week waits 6) Worsen the Trust's financial position 7) Deteriorating Trust reputation 8) Increased scrutiny from the NHSI, NHS England and the CCG

Chief Operating

Officer

Finance &

Performance

Committee

1. Standardised approach to management of acute emergency admissions (1) 2. Clinical Assessment Unit (CAU) in place(2) 3. Emergency Physician of The Day (EPOD) implemented and provided by acute physicians Monday to Friday and general medical consultants at weekends from 8am – 8 pm (1) 4. Frailty Pathway & Frailty Assessment Unit (FAU) in place (2) 5. A & E Streaming in place(1) 6. Site management team & ward trackers in place (1) 7. Recovery trajectory in place ‐ control for reputational damage(2) 8. Increased weekend discharges through implementation of ward discharge team

1. National Standards (3) 2. Improvements against key performance indicators in Urgent Care (2) 3. Monitoring through KPI Dashboard (2) 4. Triage Time reports (1) 5. Re‐admission rates reported (2) 6. Recovery trajectory in place with action plan for achieving trajectory targets(2) 7. GAU performance monitored weekly (2) 8. ECIST review and additional review undertaken(3) 9. Ambulance handover times monitored by Chief Operating Officer (1)

4 x 5 =20

4x2=8

of 171

Appendix 1


12 | P a g e

November 2016

including additional registrars (1) 9. ED Manager in place (1) 10. Discharge team extended to 7 day working (1) 11. Escalation policy in place 30.9.15 (1) 12. Patient Flow Manager commenced 23.11.15 (1) 13. Integrated Care Co‐ordination Centre commenced 4.12.2015 (1) 14. Capacity Management Process commenced 30.11.2015 (1) 15. New Acute Medical Model 18.1.2016 (1) 16. Extension to Emergency Department creating additional capacity 28.02.2016 (2) 17. 3 additional Advanced Nurse Practitioners in post (1) 18. New A & E Delivery Board Chaired by the CEO in place (3) 19. System wide single action plan for A

10. Delayed Transfers of Care monitored by Finance & Performance Committee (2) from 01.02.2016 11. Length of Stay monitored by Chief Operating Officer (1) 12. Tracking of bed occupancy through Chief Operating Officer (1) 13. ECIST style review on length of stay over 7 days (3) 14. Urgent Care Pathway risk reviewed at Finance & Performance Committee 23.2.2016 (2)

of 171

Appendix 1


13 | P a g e

November 2016

& E, Cancer, RTT and Stroke (3) 20. Acute medical model delivered 30.9.2016 (2) 21 Medical Bed reconfiguration 31.10.2016 (1)


1. Ability to manage / balance capacity & demand over weekend. 2. Insufficient capacity to maintain flow at peak times of activity.

None identified


1. Recruitment of additional medical and extended role of nursing staff in A&E Department.

Service Unit Manager Urgent Care

End MarchMay Aug Dec 2016

Continue to seek to recruit additional medical and nursing staff in the A & E Department. This action will continue in the future so date extended from end November 2015 – End March 2016. Action still continuing therefore date extended of End of May 2016 – Business case in development and will be presented to September Trust Management Board and Executive Directors. 2 additional acute physicians to commence in September 2016. These two people have now started and 4 physicians’ assistant’s posts are out to advert – these have been interviewed and are commencing week beginning 12.9.2016. Three posts have been recruited to and a forth post is being re‐advertised.

2. One Herefordshire Urgent Care Work stream Plan Chief Executive End Oct Dec 2016

Proposing changes to the way in which Urgent Care Pathways work within the County – action ongoing with development of Memorandum of Understanding and forming of a shadow alliance and development of Sustainability Transformation Programme submission. To be signed end of October 2016. The timetable has slipped with final submission to still be signed off. One Herefordshire Plan forms part of the Organisational Sustainability Plan (10 point plan).

3. Green / Red Days (taking out non‐value added days) Chief Operating Officer

End Dec 2016

New action – pilot to commence before Christmas on 1 medical ward, 1 surgical ward and a community hospital.

of 171

Appendix 1


14 | P a g e

November 2016







(Ref: 400) Risk of the Trust failing to achieve the NHS Constitutional targets Context During 15/16WVT has failed to achieve the NHS Constitutional targets due to service demand exceeding supply which resulted in the non‐achievement of targets in three areas; Cancer, A&E and RTT. Cause / Source / Event There is a risk that the Trust will fail to achieve the NHS Constitutional targets in 16/17 due to our capacity & system response to increasing levels of demand. Impact / Consequence This could lead to; 1 Increased clinical risk to patients & potentially increase exposure to harm 2) Significant negative financial impact in the form of fines from the commissioners for missing targets 3) The impact of failing to deliver the A & E Constitutional target has caused the cancellation of elective procedures which could worsen the Trust's financial position 4) Increased scrutiny and performance management of individuals from the NHSI, NHS England and the CCG 5) Further measures imposed by external bodies 6) Further improvement notices being issued 7) Further improvement plan development & implementation being required 8) Deteriorating Trust reputation 9) Negatively affect staff morale 10) Poor performance in 4 hour target could negatively influence CQC’s view of the organisation

Chief Operating

Officer

Finance &

Performance

Committee

1. Monitoring of Recovery Plans & action progress on each of the 4 standards via the F&P Committee & the Trust Board (2) and Quality and Oversight Review Group (QORG) (3) 2. Constant monitoring and implementation of actions to improve position of NHS Constitutional targets reported to Trust Board, Quality Committee, Performance and Quality monthly meetings and Service Unit Governance Meetings (3) 3. Assertive management of cancer PTL (1) 4. Weekly delivery meeting with Chief Operating Officer (1)

1. Evidence provided through F&P Committee & Trust Board Reports (3) negative assurance 2. Monitor against recovery trajectory for each of the 4 3 standards (although currently not always met ‐ as of May 2015) (2) 3. Urgent Care Plan stress tested by ECIST with no further recommendations being made (3) 4. Contractual activity performance managed against target (2) 5. Delayed transfers of care of medically fit monitored through Finance & Performance Committee – negative assurance (2) 6. IST stress test of 62 day cancer recovery plan (3) 7. IST validation recommendations

4 x 4 = 16

4x2=8

of 171

Appendix 1


15 | P a g e

November 2016

5. Specialty level delivery plans on RTT – monitored weekly (1) 6. Escalation Policy and action cards from 30.9.2015 (1) 7. Patient Flow Manager commenced 23.11.15 (1) 8. Activity reflected in delivery plans by week (1) 9. New acute Medical Model in place with 2 new acute physicians in post from Jan 2016 & 2 more appointed during June 2016(1) 10. GAU open providing additional bed capacity from December 2015 (2) 11. Second CT Scanner from December 2015 (2) 12. Implementation of mobile theatre (2) 13. Remedial action plans in place for all constitutional targets (3) 14. New Divisional Structure in place clearly identifying

implemented (3)8. Risk Presented to Finance and Performance Committee on 28th June 2016 for review (2) 9. Community Collaboration Audit of all Emergency Department attendances to understand whether avoidable attendances / admissions happening (3)

of 171

Appendix 1


16 | P a g e

November 2016

appropriate lines of accountability for delivery of improvement plans 31.06.2016 (2) 15. New A & E Delivery Board in place chaired by CEO (3)


1. Don’t have capacity in all

specialties to deliver activity and

achieve plans.

1. None achievement of National Standards by the Trust on a consistent basis. 2. Recovery Trajectories were not met last month with exception of A & E (3) 3. Delayed transfers of care not getting better (2)


1. Please see other actions on BAF relating to risk ref 375 RTT and risk ref 399 Urgent Care Pathway

2. Cancer Pathway Chief Operating Officer

End Dec 2016

High level plan being developed with Clinical Cancer Lead to develop Cancer Strategy for 17/18 and beyond including a work plan for improvement. This will be discussed at the Cancer Board and Quality Committee. A & E Standard and RTT Standard on Organisational Sustainability Plan (10 point plan).

of 171

Appendix 1


17 | P a g e

November 2016

Strategic Objective 3‐ Provide more productive and better value care that improves the sustainability of our services (Risk Appetite to achieve objective – Low)





Lines of defence



(Ref: 386) Risk to the financial sustainability of Wye Valley NHS Trust Context The Trusts financial plan for 16/17 is showing a £ 31.5m deficit but current forecast is £37m (including fines). Cause / Source / Event The Trust Development Authority originally offered the Trust a control total of £15m. This control total was rejected by the Trust Board. A new control total was set at £20m and would have received £4m of support from NHSI reducing deficit to £16m which has also been rejected by the Trust Board. Impact / Consequence This could lead to; ‐ Negative impact on future sustainability of the Trust & possible future FT status Lack of investment in service development ‐ Difficulty in achieving constitutional targets ‐Potential impact upon quality and safety of patient care.

Director of

Finance &

Information

Finance &

Performance

Committee

1. Cost Improvement Programme (2) 2. Continuous review of pay and non‐pay expenditure(1) 3. Vacancy control process (1) 4. Fortnightly agency control meeting (1) 5. Additional sources of income included in financial plan (2) 6. 2016/17 financial plan approved by Trust Board 5.5.2016 (2) 7. Strengthened governance structure with Financial Recovery Plan Board now in place supported by Star Chamber process23.8.2016 (2) 8. Board approved Financial Recovery Plan Director in post from 3.10.2016 (3)

1. Reports to Executive (1) 2. Integrated Programme Group (1) 3. Monthly monitoring of financial position at Trust Board (2) 4. Monthly reporting to the NHSI (3). 5. Finance & Performance Committee(2) 6. Deep dive review by NHSI on financial controls (3) 7. Weekly CIP meeting in place from 1

st June 2016 (1) 8. RSM Report presented to F & P Committee 23.8.2016 (3) 9. SSG Report presented to Finance and Performance Committee (3)

5x4=20 5x2=10

of 171

Appendix 1


18 | P a g e

November 2016

10. Internal audit report on financial management presented to Audit Committee 14.9.2016


1. Lack of clarity on organisation future


1. Discussions with the NHSI regarding corrective actions and potential funding ‐ Director of Finance & Information

Ongoing Ongoing discussions taking place into 16/17. Further conversations have taken place and Regional Director of Finance written to on 17.10.2016.

2. Production of LTFM (5 year plan) Senior Finance Team

End March June Sept Dec 2016

The LTFM has been revised for the 16/17 financial plan. Further updates will be required of the LTFM – An update was completed for the end of June 2016 but a further update will be completed in September and presented to the Finance and Performance Committee and Trust Board. This will be completed as part of the planning process.

3. Responding to the NHSIs control total. Director of Finance & Information

End March 2016 End April 20167

The Trust Board agreed at its meeting on 4th February that it would be rejecting the control total set by the NHS Improvement (NHSI). The NHSI have been informed of the Trust’s decision. Awaiting further discussions with the NHSI therefore extension of date of end of April 2016. NHSI have still not confirmed / agreed deficit position but the Trust was offered a second control total of £20m which was also rejected. NHSI are anticipating that the Trust deliver a £28.5m deficit. A draft Financial Recovery Plan has been developed and presented to Finance and Performance Committee on 23rd August 2016. This

of 171

Appendix 1


19 | P a g e

November 2016

requires final approval by the Trust Board after input from budget leads. A weekly Financial Recovery Board has been introduced with a proposal to hold ‘star chamber’ sessions in order to hold budget managers to account. No longer relevant for 16/17 but now in discussion with NHSI regarding 17/18 – see action 5 below

4. NHS Improvement doing another ‘deep dive’ review due to the increase in the deficit

position for 16/17

Director of Finance & Information

End April2016

Deep dive review complete and awaiting feedback from NHS Improvement. Still no feedback received. A formal response has been requested from NHSI on 18.10.2016

5. Discussion taking place with NHSI, the Chief Executive Officer and Finance Director to

improve outturn forecast and underlying position.

Chief Executive & Director of Finance and Information

End Dec 2016

New action

6. Financial benchmark exercise to be undertaken with SWFT Chief Executive & Director of Finance and Information

Part of Organisational Sustainability Plan (10 point plan).

of 171

Appendix 1


20 | P a g e

November 2016

Strategic Objective 4 ‐ Develop a highly skilled, motivated, healthy and engaged workforce (Risk Appetite to achieve objective – High)





Lines of Current Risk Rating C x L (after controls)


(Ref: 417) Risk to recruitment of new staff and retaining

current staff

Context WVT has increasingly experienced difficulty in recruiting & retaining nursing and medical staff for a number of reasons including but not limited to the rural nature of the county, the imposition of special measures on the Trust & the financial difficulties the Trust faces. This has been evidenced by candidates withdrawing from interviews & job offers, reduced applications to advertised vacancies, attrition of existing staff all of which have occurred at greater than expected average rates. Cause / Source / Event There is a risk to the retention of current medical and nursing staff & the successful recruitment of new medical and nursing staff as a result of the Trust being placed in special measures & the increased workloads & pressures on existing staff to cover the staff shortfalls. Impact / Consequence : This could lead to; 1) Further existing staff leaving the Trust 2) Further new candidates withdrawing from interviews / job offers 3) A reduction in applications received in response to job adverts 4) Difficulty in vacancies being substantively recruited to 5) Reduced capacity for service provision / patient care 6) Cancelled procedures / appointments 7) Loss of service provision related income

Director of

Human

Resources

Finance &

Performance

Committee

Strategic

Workforce

Committee

1. HR.19 Salary on Appointment and Reckonable Service Policy (1)

2. Generic recruitment for HCA's & registered nurses (1)

3. Recruitment and Selection Policy (1)

4. Workforce & Performance Group (1)

5. Recruitment Team KPIs in place (1)

6. HCA workforce in place to replace agency use (1)

7. Recruitment and Retention Strategy – short term solutions

8. E rostering rotas in place

9. Nurse Agency Recovery Plan Project (NARP) in place (2)

10. NHSI Returns/action plan for agency reduction. (3)

1. NationalStandards on staffing ratios are reviewed against WVT data (3) 2. Safer staffing levels toolkit is checked against WVT status. A monthly report is provided to the Board (3) 6. Staff survey results (2) 7. Agency Staffing internal audit report presented to Audit Committee 14.9.2016 – partial assurance

4x5=20

4x1=4

of 171

Appendix 1


21 | P a g e

November 2016

8) Breaches in national targets, 4hr wait, 18weeks, 2WW etc.9) Deteriorating Trust reputation 10) Increased costs filling gaps with temporary / bank & agency staff 11) Reduced morale of incumbent staff due to increased work pressures & demands whilst running with less than full complement of staff


1. Limited data available from reports from exit interviews 2. Managers responsiveness to progressing applications, shortlisting, recruiting etc. needs work as some times progress is too slow & applicants can be lost as a result. 3. Medical workforce plan 4. Continued use of nursing non‐framework agencies and cap on use. 5. Recruitment KPIs in place but not yet reporting on them. This forms part of the Quality Improvement Plan 6. Lack of realistic trajectory of actual numbers being recruited to.

Inability to achieve staffing

ratios and increase in number of

HCAs leaving


1. Restructure HR Directorate to ensure that it is fit for purpose in terms of policy and practice to address any risk. This will include:

(a) Co locating the Bank Officer (b) Co locating the Recruitment Function (c) Introducing HR Business Partner Model (operation HR support to divisions)(d) Reviewing Occupational Health Function (e) Reviewing Workforce information systems and parameters (f) Reviewing partnership arrangements (g) Extend remit of Learning and Development Function to address OD

challenges (h) The PGMC function being added to the portfolio of the Human Resources

Director to gain a better understanding of the post graduate and junior doctor arrangements at the Trust.

Director of Human Resources and Organisational Development

End March 2017

New action

of 171

Appendix 1


22 | P a g e

November 2016

2. Review of Bank and Agency usage (a) Review rates of both Bank and Apple Agency (b) Review agency framework arrangements (c) Investigate and instigate non‐price cap agency usage (d) Standardise bank processes (e) Resource bank appropriately to enable proactivity (f) Rationalise invoicing process


End Jan 2017

New action

3. Recruit to achieve a 5% vacancy gap (a) Identify vacancies and contributory factors (b) Ensure recruitment KPIs are measured and reported (c) Consider wider allocation or relocation policy (d) Explore the introduction of short and long term recruitment and retention

premiums (e) Develop a trajectory for improvement underpinned by an updated

recruitment and retention strategy and action plan.


End March 2018

New action

4. Governance (a) Introduce Strategic Workforce Committee which will routinely report into

Trust Management Board (b) Introduce Sub Committees of the Strategic Workforce Committee to

address problematic staffing groups such as Nursing & Midwifery and Medical & Dental and also specific workforce risks such as agency spend in line with NHSI requirements.

(c) Ensure that JLNC and JNCC are fully engaged in this agenda.


End March 2017

New action

of 171

Appendix 1


23 | P a g e

November 2016





Lines of defence



(Ref: 411) Risk to the Trust's credibility and reputation due to remaining in Special Measures Context The Trust was placed in special measures as an outcome of the CQC visit performed in June 2014. Subsequent follow up CQC re‐inspection visit was performed in September 2015 & warning notice issued in November 2015. The final report was received from CQC on 14th January with an overall rating of ‘inadequate’ and the Trust remaining in Special Measures. Cause / Source / Event Following the September 2015 CQC re‐inspection the Trust did not make the required improvements to get out of special measures or improve its overall rating of ‘inadequate Impact / Consequence This could lead to; 1. Trust reputational damage 2. Adversely impact upon staff recruitment. 3. Adversely impact on staff retention. 4. Patients electing to go elsewhere thus affecting the Trusts income base. 5. Impact upon staff morale leading to poor performance and engagement in improvement plan. 6. Trust Special Administrator could be appointed

Chief

Executive

Quality

Committee &

Audit

Committee

1. Trust wide communications channels to reach all staff have been established & actively used pre, throughout & beyond the inspection period including a proactive media management programme to deal with radio / television interviews etc.(1) 2. South Warwickshire NHS Foundation Trust appointed as new ‘buddy’. (3) 3. New Improvement Director in place – appointed by NHSI (3) 4. Monthly monitoring in place with CQC to test progress against the Tactical action plan (3) 5. Quality Improvement Plan in place and approved by Trust Board each scheme led by an Executive Director (3) 6. Robust project management arrangements in place with PIDs developed for each scheme which are reported to the Star Chamber and to the Integrated Programme Board (3) 7. South Warwickshire NHS Foundation Trust work programme in place(1)

1. pre inspection briefings with all staff prior to inspection (1)

2. Rehearsal Inspection organised and implemented

3. Verbal feedback from CQC Inspection stated that the Trust had made demonstrable improvement (3)

4. Must dos in Quality Improvement Plan implemented.

4x2=8

4x2=8

of 171

Appendix 1


24 | P a g e

November 2016

8. Inspection Preparation Lead appointed and undertaking role fully 18.4.2016(2) 9. Patient Safety Walk rounds (1) 10. Additional Communications support in place (1) 11. Revised QIP in place taking into account actions required from latest CQC Inspection draft report 6.10.2016 (2)


To be identified To be identified


1. Implement the ‘must dos’ from the quality improvement plan but the plan goes beyond the next inspection.

Chief Executive End June 2016 End March 2017 End Oct

Quality Improvement Plan being presented to Trust Board on 4th February 2016 – complete with further reporting from February onward to the Quality Committee and Trust Board ongoing and on target. These are reviewed through the CQC improvement meeting every week and cross referenced to the Quality Improvement Plan. All the ‘must dos’ from the plan are completed but other actions are still being identified. These will be monitored through two weekly meetings to discuss the QIP progress. Quality Improvement Plan being reframed to take into account new schemes/projects which need to be included e.g. learning disabilities / patient flow. Clarity to be reached as to what gets reported to Quality Committee, Finance and Performance Committee and Trust Board in the future. To be presented to September cycle of meetings starting with Quality Committee on 29th September. – Complete

2. Communication plan to be developed in readiness of publication of the latest CQC report.

Chief Executive End of October

Plan in place and ready to be rolled out once results are published on 31st October 2016 ‐ Complete

of 171

Appendix 1


25 | P a g e

November 2016

Strategic Objective 5‐ Develop first class facilities and technology to support the care we provide (Risk Appetite to achieve objective – High)







(Ref: 412) Risk of Critical Failure in Hutted Ward Environment Context The hutted wards were designed & built in 1943 with an intended life span of 10 ‐ 15 years. They are now 72 years old & are continuing to be used for patient care. However, they are long past their intended useable life span & are no longer adequate. A recent failure of the fabric of one area resulted in the temporary partial loss of beds on Monnow Ward. This resulted in an increased number of complaints, the cancellation of elective surgery & the uncertainty around a total loss of surgical capacity on Monnow & the increased workloads & pressures on existing staff to cover the staff shortfalls. Cause / Source / Event There is a risk of harm to staff and patients & the continued ability to provide inpatient care due to the age and condition of the hutted wards. Impact / Consequence This could lead to; 1) Reduced bed capacity for service provision / patient care 2) Patient harm 3) Patient claims ‐ Financial 4) Staff harm 5) Staff claims ‐ Financial & workforce 6) Cancellation of elective surgery 7) Loss of service provision related income 8) Breaches in national targets, 4hr wait, 18weeks, 2WW etc. 9) Increased costs if further building failures occur 10) Increased numbers complaints 11) Deteriorating Trust reputation

Chief Operating

Officer

Finance &

Performance

Committee

1. Estates Governance Processes (2)

2. Capital Programme(2)

3. Estates Strategy (2) 4. SOC was agreed by

Trust Board in January 2015(2)

5. Outline Business Case agreed at Finance and Performance Committee in October and submitted to NHSI(3)

6. SOC re‐approved by Trust Board in December and submitted to the NHSI (3)

1. Incident Reports(2)2. Surveyors Reports (1) 3. Estates Key

Performance Indicators (KPI's)(3)

4. NHSI carried out site review and agreed with the Trust’s Estate Strategy (3)

5. Risk discussed at Finance and Performance Committee 26.1.2016(2)

5x3=15 5x2=10


No alternative decant space

None Identified.

of 171

Appendix 1


26 | P a g e

November 2016


1. Business Case for Estates Strategy phase I and II being merged Head of Estates End MarchApril June Oct 2016 March 2017

Outline Business Case for Phase II being developed for approval in October to the Finance and Performance Committee and the Trust Board and submitted to the NHSI – complete. Full Business Case has slipped due to national prioritisation of capital and waiting outcome from NHSI therefore timescales for completion have been moved to the end of April 2016. NHSI presenting the SOC to their regional investment committee on 24.3.2016. This will be presented to June Trust Board. As the Trust is now not expecting any significant capital the current request from NHSI has been to combine phase I & II of the Estates Strategy but this is also dependent upon the agreement of a Clinical Strategy. SOC being presented to Trust Board in October 2016 to secure funding for 17/18 and which reduces overall investment to below £50m and focuses upon the removal and replacement of hutted wards in phases 2 & 3. Consideration being given to revising the options appraisal and then taking through the governance structure for consideration. This will first be considered at the Estates Strategy Group then, Trust Management Board, Finance and Performance Committee and finally Trust Board. Approach to develop new SOC approved at the Strategic Priorities Workshop

Strategic Objective 6 ‐ Transform health and wellbeing through working with our partners (Risk Appetite to achieve objective – High)

There are currently no ‘Extreme’ strategic risks to the achievement of this strategic objective.

Strategic Objective 7 – Play our role as an important asset to the people of Herefordshire and the surrounding areas (Risk Appetite to achieve objective – Low)

There are currently no ‘Extreme’ strategic risks to the achievement of this strategic objective.

of 171

Strategic Objective 1 - Improve the quality and safety of care to our patients, their carer’s and families

Extreme Operational Risks which may impact upon Strategic Objective 1 Risk Feb 2016

Risk Rating May 2016

Risk Rating Aug 2016

Risk Rating Nov 2016

Risk Rating Movement in quarter

Division

(449) Lack of clinical care level 2 HDU capacity to meet planned surgical requirements. 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 4 x 3 = 12 Surgical Division

(394) Risk of harm to patients due to capacity issues within the retinal injection treatment service.

4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 Surgical Division

(513) Risk to patient safety due to lack of junior medical paediatric staff

4 x 4 = 16 4 x 4 = 16 4 x 2 = 8

Closed 09.11.2016

after Division review

Surgical Division

(542) Risk of patient harm due to failing functionality of Oncology Patient Management Audit System (OPAS)

5 x 3 = 15 5 x 3 = 15 5 x 3 = 15 4 x 3 = 12 Medical Division

(471) Risk of breaches in statutory fire regulations

5 x 3 =15 5 x 3 =15 5 x 3 =15

Closed 8.8.2016


Surgical Division

(390) Risk of harm to patients due to the unsuitable utilisation of the A & E back corridor.


(341) Risk of safety to patients due to being inappropriately placed on Day Case Unit and theatre recovery


(352) Lack of continence service for paediatric patients 3 x 5 = 15 3 x 5 = 15 3 x 5 = 15 3 x 5 = 15 Surgical Division

(90) Risk of unsafe clinical service due to inability to identify locums to cover medical staffing vacancies in Emergency Department

3 x 5 =15 3 x 5 =15 3 x 5 =15 3 x 5 = 15 Medical Division

(448) Risk of patient harm due to the increased number of ‘outlier’ patients on surgical wards


(553) Risk to patient safety due to an over reliance on Consultant Locums in Acute Medicine


(510) Risk to women and babies due to the lack of a second obstetric theatre 5 x 2 = 10 5 x 4 = 20 5 x 3 = 15 5 x 3 = 15 Surgical Division

(578) Risk to patient safety due to lack of clinical supervision structures within community hospitals

Added March 2016

4 x 4 = 16 4 x 4 = 16 3 x 4 = 12 Surgical Division

of 171

(451) Risk of harm to patients due to a lack of orthogeriatrician to carry out timely review of patients with fractured neck of femur

Added March 2016


(441) Risk to patients due to potential delay in patient care by obstetrics and gynaecology registrar between 8.30 p.m. and 8.30 a.m.


(529) Risk to security of women and children within women’s and children’s services due to lack of a robust security system


(607) Risk of harm to patients due to lack of critical care level 2 and 3 HDU capacity to meet the Trust’s emergency requirements

New risk

added July 2016

4 x 4 = 16

Closed 26.07.2016


Medical Division

(621) Risk of patient harm due to the excessive dispensing of Discharge medication Out of Hours by an on call pharmacist

New risk added

October 2016

4 x 4 = 16 Surgical Division

(602) Prolonged admission on Children's Ward for Looked After Children and Young People on Paediatric Ward

New risk added July

2016 4 x 4 = 16 Surgical Division

Strategic Objective 2 - Improve the responsiveness of our services for the benefit of our patients and their families






Division

(552) Risk to patient safety as a result of excessive caseload within acute medicine 4 x 5 = 20 4 x 5 = 20 4 x 4 = 16 4 x 4 = 16 Medical Division

(533) Risk to patients due to the high level of delayed discharges from Critical Care 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 Surgical Division

(393) Risk of a breach of statutory legislation due to length of waiting times within the paediatric occupational therapy service


of 171

Strategic Objective 3 - Provide more productive and better value care that improves the sustainability of our services






Division

(580) Risk to patient safety due to lack of critical care level 2 & 3 capacity to meet emergency requirements

Added March 2016


(609) Risk of reduced service delivery due to Hill Rom mattresses on Delivery Suite decommissioned due to decontamination

New risk

added July 2016

3 x 5 = 15

Closed 07.08.2016


Surgical Division

Strategic Objective 4 - Develop a highly skilled, motivated, healthy and engaged workforce






Division

(543) Due to multiple competing priorities there is a risk that Ward Sisters will be unable to complete all the tasks requested within the required timescales


(590) There is a risk to patient safety and care due to poor anaesthetic staffing levels during out of hours.

New risk added June 2016

5 x 3 = 15 5 x 3 = 15 Surgical Division

(614) Medical workforce shortage within surgical division New risk added September 2016


(629) Need for additional two Paediatric Consultants New risk added November 2016


(590) Safe provision of Emergency Anaesthetic services New risk added


of 171

November 2016

Strategic Objective 5 - Develop first class facilities and technology to support the care we provide





Risk Rating Division

(587) Risk of patient harm due to the lack of a second obstetric theatre New risk

added May 2016

5 x 3 = 15 5 x 3 = 15 Surgical Division

Strategic Objective 6 - Transform health and wellbeing through working with our partners

Extreme Operational Risks which may impact upon Strategic Objective 6 Risk Feb 2016 Risk

Rating May 2016 Risk

Rating Aug 2016 Risk

Rating Nov 2016 Risk

Rating Division

There are currently no extreme operational risks which may impact upon Strategic Objective 6 Strategic Objective 7 - Play our role as an important asset to the people of Herefordshire and the surrounding areas

Extreme Operational Risks which may impact upon Strategic Objective 7 Risk Feb 2016 Risk

Rating May 2016 Risk

Rating Aug 2016 Risk

Rating Nov 2016 Risk

Rating Division

There are currently no extreme operational risks which may impact upon Strategic Objective 7

of 171

Wye Valley NHS Trust

Trust Board Meeting

Report to: Trust Board Meeting Agenda item: 11a


Title of Report: Key Performance Indicator (KPI) Performance October 2016/17


Information

Report Approval Route: F&PC and a summary to Board

Lead Executive Director: Howard Oddy, Director of Finance and InformationAuthor: Stephen Powell, Associate Director of Finance

Appendices: KPI schedule (PDF & Excel format)

Purpose of the report

To inform the Board of the performance of the Trust against a range of indicators, including operational performance against NHS Constitution targets, as at the end of October 2016 (month 7).

Recommendations

For the Board to consider performance against a range of Key Performance Indicators (KPIs) and to note the actions that are being taken to address areas of non‐compliance (which are documented in the subsequent detailed performance reports).

Executive Director Assurance and Managing Director opinion

The DoF has reviewed the performance information and is assured of the accuracy of the position being presented. Managing Director opinion Referrals have increased by 4% for the year to date, and out patients activity and elective activity are all significantly underperforming against plan. Performance against admitted 18 weeks standard (all that is currently available due to data quality issues) is deteriorating. I am not yet assured that activity plans will meet target levels by year end or that the agreed RTT trajectory will be met. Urgent care access remains below the standard for A&E performance the performance report does not provide assurance that plans are in place to improve performance. There is an improving picture for 2 week wait cancer performance (other than breast symptomatic) and whilst 62 days performance is poor there is a need to understand the impact the ’38 day rule’ implementation will have on performance relating to tertiary referrals.

of 171


In the absence of a quality report I have little information to provide assurance in relation to the indicatorspresented in the effectiveness, caring and safe domains. Mortality rates are concerning. Infection prevention performance appears to be in control with an improving level of serious infections for patients. I am unclear why incident reporting is rated as red and how the target level was derived. Further detail is required on the level of harm from incidents, but a high level of reporting is to be encouraged. In the well led domain a plan against priorities to address the deteriorating performance in almost all areas is being developed by the HR director. For the Finance domain the picture is clearly challenging with deteriorating income and expenditure positions, under performance against the financial recovery plan and a possibly optimistic view on activity levels recovering by the end of the year. The Director of Finance has recommended that the Trust changes its forecast for the year and the Board is required to provide assurance that a new protocol has been followed including agreeing a recovery plan.

Summary of Key Issues for discussion

1. Key Performance Issues

A number of key national targets were not met in October. These were:‐

1.1 Responsiveness Domain – A&E 4 Hour Wait, Ambulance Handovers, RTT (Admitted), 4 of the 7

Cancer Access Targets (September data reported a month in arrears);

1.2 Caring Domain – Same sex accommodation breaches, A&E Friends and Family Test (Score and

Response rate targets);

1.3 Safe Domain – VTE Risk Assessment and WHO Checklist Compliance;

1.4 Finance Domain – none of the elements were met, other than non‐pay actuals versus plan.

2. Summary position

The KPI domains are allocated to Executive Directors. The main issues are highlighted below and

additional information is provided in the following detailed reports on performance, workforce and

finance.

2.1 Responsive Domain

Overall NHS constitution performance is summarised in the table below. October performance

showed a small deterioration from that reported last month. All access standards falling below the

expected level are subject to performance recovery plans with NHSI. The Trust is also being fined by

Herefordshire CCG for those services whose access is below the NHSC standard.

of 171


2.2 Effective Domain

Reducing C sections forms part of the QIPP programme and the workstream is due to report on

progress in January 2017.

2.3 Caring Domain

Same sex accommodation breaches remain problematic at times when capacity is an issue within

the Trust. The SOP and mixed sex accommodation policy has been reviewed and the operational

teams continue to focus on keeping breaches to an absolute minimum.

The A&E FFT response rate and recommendation has been a particular focus in recent months.

Benchmarking highlighted that the Trust is just below the national average and attention is being

given to how to improve this. The significant deterioration this month was due to the monitor

being vandalised within the Emergency Department.

2.4 Safe Domain

The never event in August 2016 has now undergone investigation and the report signed off for release at the Trust SI panel. The full report will be shared with the family concerned at a face to face meeting in the near future. Although the number of CDif cases appears high, the target relates to lapses in care being less than

18 by the year end. Of the total numbers of cases reported year to date, and following a full Post

Infection Review (PIR), only 5 lapses in care have been identified. The findings of the PIR,

recommendations and learning have been shared.

Of the 12 Serious incidents reported in month, 10 were in the division of medicine, one in surgery and one corporate. Of the 10 in the medical division, 3 were old pressure ulcers and one was

of 171


reported by pharmacy and was not a WVT initiated incident. Full duty of candour compliance has been observed in those so far reviewed. The single SI in the division of surgery was a reaction to cement rather than an omission of care. Overall reporting of incidents continues to rise with a corresponding reduction in harm. An MSSA case relating to a patient on ITU has been reported and is currently under investigation. The Trust continues to benchmark highly in performance regarding MRSA bacteraemia. VTE protocol compliance has been identified as poor in some surgical departments. The Safety and Quality committee have requested submission of a VTE report from the surgical division.

2.5 Well Led Domain

There has been deterioration across all key performance indicators within the well led domain, with

the exception of Consultant appraisal rates.

Work is underway to re‐focus the work of the whole HR Directorate team to ensure these areas

have been prioritised i.e. (i) support to managers to deal with both short term and long term

sickness absence, (ii) supporting managers to undertake appraisals and address high levels of

turnover within their teams, (iii) the development of a robust plan to move to relaunch the in‐

house bank and reduce reliance on Apple and other external agencies, and (iv) the development of

robust workforce plans for key staff groups such as nursing and midwifery and also the medical

workforce that addresses new roles, different ways of working and most importantly, the need to

recruit to key vacancies.

2.6 Finance Domain

Financial performance continued to be challenging and, in month, actual performance was worse

than the deficit plan. Consequently, all KPIs were red rated with the exception of non‐pay

expenditure. Income was lower than plan because the Trust did not deliver the planned level of

activity (though an element of this related to lower than planned levels of private sector work,

which is also the reason why non‐pay expenditure was underspent). Pay was overspent primarily

due to the continuing levels of agency doctors and nurses. These issues are covered in more detail

in the finance report.

Please state which Corporate Objective your report relates to:

of 171



and families

High

2. Improve the responsiveness of our services for the benefit of our

patients and their families.

Moderate

3. Provide more productive and better value care that improves the

sustainability of our services

Low

4. Develop a highly skilled, motivated, healthy and engaged

workforce

High

5. Develop first class facilities and technology to support the care we

provide

High

6. Transform health and wellbeing through working with our

partners

High

7. Play our role as an important asset to the people of Herefordshire

and the surrounding areas

Low

Reference to the Risk Register or Board Assurance Framework

NHS Constitution performance is included on both the Risk Register and Board Assurance Framework.

of 171

StandardTarget

set

Current data

month

Month actual Trend

YTD (to mnth reported)

Trend (January 2014 to

date)

Referrals (2016/17 v 2015/16) L September 5.1% 4.1% A A A C

Total A&E Attendances (2016/17 v Plan) L October 0.9% 2.4% A A A C

Total Inpatient / Daycase Activity (2016/17 v Plan) L October -10.3% -4.1% R R A C

Total Outpatient Activity (2016/17 v Plan) L October -8.7% -7.6% R R A C

A&E 4 hour wait target 95% N October 86.9% 87.8% R R R C

12 hour trolley waits 0 L October 0 = 1 G G R C

Ambulance handover > 30 minutes 0 N October 206 1344 R R R C

Ambulance handover > 60 minutes 0 N October 15 117 R R R C

18 weeks referral to treatment time - admitted 90% N September 53.6% R R R M

% spending >90% of their stay on a stroke unit 80% N October 73%(draft)

81.2% A A G C

Delayed Transfers of Care (acute only; pts as % of occ beds) <3.5% N September 3.7% A A A M

Diagnostic waiters, 6 weeks and over - DM01 1% N October 0.0% = G G G M

Non-clinical ops (elective) cancelled on day 10 per month L October 27 136 R R R C

% Last minute non-clinical cancelled ops (elective) 0.80% N October 1.4% 1.1% A A A C

Breaches of the 28 day readmission guarantee 5% N October 44.4% 63.2% R R R C

Urgent operations cancelled more than once 0 N August 0 = 0 G G G C

2 week GP referral to 1st outpatient appointment 93% N September 92.0% 86.8% A G R C

31 day diagnosis to treatment 96% N September 97.5% 98.1% G G G C

31 day second or subsequent treatment (drug) 98% N September n/a = 98.0% G G G C

31 day second or subsequent treatment (surgery) 94% N September 100% = 95.0% G G G C

62 days urgent referral to treatment 85% N September 77.7% 81.0% R A R C

62 day referral to treatment from screening 90% N September 100% = 95.7% G G G C

Consultant upgrade (62 days decision to upgrade) - September 77.0% 84.1% G G G C

Urgent referrals for breast symptoms 93% N September 72.7% 54.9% R R R C

Standard Target set

Current data

month

Month actual

TrendYTD

(to mnth reported)


date)

Mortality - SHMI <100 N 116 R R R C

Mortality - HSMR <100 N 112.37 A A A C

Deaths in Low Risk Conditions <100 N April 2014 to March 2015 112 C

Emergency readmissions within 30 days of discharge L June 5.9% = 5.9% C

Caesarean section - Elective <9% L October 14.6% 13.8% R R R C

Caesarean section - Emergency <14% L October 13.2% 17.7% A A R C

Bed occupancy - G&A Wards (Acute Site) 90% L October 96.5% = 96% R R R C

Bed occupancy - Community Wards 90% L October 95.7% = 93.5% R R R C

Standard Target set

Current data

month

Month actual

TrendYTD

(to mnth reported)


date)

Number of Complaints received 15/16 Comparison L October 32 239 R A R C

Number of Compliments L October 232 2065 C

Inpatient Scores from Friends and Family Test 95% N October 95% A G G M

A&E Scores from Friends and Family Test 95% N October 83% R R R M

Community Hospital Scores from Friends and Family Test 95% L October 97% G G G M N

Maternity Scores from Friends and Family Test 95% L October 94% G G G M

Inpatients response rate from Friends and Family Test 30% C October 23.4% A G G M

A&E response rate from Friends and Family Test 25% C October 6.9% R R R M

Community Hospital response from Friends and Family Test 30% L October 82.6% G G G M

Maternity response rate from Friends and Family Test 30% L October 31.2% G G G M

Same Sex Accommodation Standard breaches 0 N October 8 51 R R R C

Type

Responsiveness Domain

Cancer Targets

Access

Cancelled Ops

Experience

Forecast

Yea

r en

dY

ear

end

Type

Nex

t m

onth

Nex

t m

onth

3 m

onth

s

April 2015 to March 2016

Effectiveness Domain

Caring Domain

Quality

Forecast

August 2015 to July 2016

3 m

onth

s

Wye Valley NHS TrustTrust Key Performance Indicators (KPIs) - 2016/17

Nex

t m

onth

Yea

r en

d

3 m

onth

s

Forecast

Type

Trend Target Type Forecast Type

Improvement on last month N National C Cumulative

Deterioration on last month C CQUIN M Monthly

= No change L Local

Page: 1 of 2 Information Services

of 171

StandardTarget

set

Current data

month

Month actual Trend



date)

Never Events 0 N October 0 = 0 G G G C

Number of >AD+1 MRSA Bacteraemia 0 N October 0 = 0 G G G C

Number of >AD+2 clostridium difficile cases 18 N October 0 12 A A A C

Number of E.Coli 0 L October 0 = 10 G G R C

Number of MSSA Bacteraemia 0 L October 0 = 2 G G R C

VTE Risk Assessment 95% N September 92.0% G G G M

Safety Thermometer - Harm Free 95% N October 97.0% G G G M

Number of incidents reported 7839 L October 685 4117 A A A C

Number of SIs reported 159 L October 10 88 G G G C

% compliance with WHO checklist 100% N Jun-Aug 99.5% = G G G M

StandardTarget

set

Current data

month

Month actual Trend



date)

Appraisal rate - consultant 90% L October 94.0% G G G C

Appraisal rate - all 90% L October 69% = R R A C

Mandatory Training 90% L October 84% = A A A C

Sickness rate 3.4% L October 5.1% R R A C

Staff Friends and Family Test N M

Staff Turnover 10% L October 1.5% 13.9% C

% of complaints responded to within 25 days 90% L October 44% R A A M

Number of complaints reopened 69 L October 2 25 A A G C

Number of complaints referred to Ombudsman 6 L October 0 2 G G G C

Standard Target set

Current data

month

Month actual (£k)

TrendYTD (April to March)

(£k)


date)

I&E surplus margin Breakeven / Surplus N October -£2,883 -£19,918 C

I&E surplus margin (actuals versus plan) Actual v Plan N October -£443 -£2,581 C

Total income (actual versus plan) Actual v Plan L October -£535 -£2,406 C

Pay expenditure (actual versus plan) Actual v Plan L October -£296 -£884 C

Non pay expenditure (actual versus plan) Actual v Plan L October £327 £274 C

CIP (actual versus plan) Actual v Plan L October -£241 = -£1,388 C

Yea

r en

d

Type

Forecast

Type

Forecast

Type

Finance Domain Nex

t m

onth

Forecast

Nex

t m

onth

3 m

onth

s

Yea

r en

d

Safety

Safe Domain

3 m

onth

s3

mon

ths

Well Led Domain

Value for Money

Workforce

Complaints Management

Yea

r en

d

Nex

t m

onth

Page: 2 of 2 Information Services

of 171

TRUST BOARD MEETING

Report to: Trust Board Meeting ‘in public’ Agenda item: 11b


Title of Report: Activity Performance Report to 31st October 2016 (M7)


Position statement / Information

Report Approval Route:

Lead Executive Director: Jon Barnes - Chief Operating Officer

Author: Jon Barnes

Appendices: None


To inform the Trust Board of October 2016* performance against key national standards. To highlight areas of non-compliance To identify actions taken or to be taken to manage risks and ensure delivery *Cancer & DTOC performance report is for September 2016

2. Recommendations

To receive and note the report on the Trust’s Operational Service performance To discuss the planned actions being taken to ensure the Trust performs at or above all service standards


The report provides assurance that where performance against constitutional standards is below the required level,

there is a real understanding of the issues driving that performance and a credible plan in place to address those

underlying causes of failure.

of 171


Activity Summary for October 2016: Acute:

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

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

Follow Up Outpatient Attendances

2016-17 actual plan

0

50

100

150

200

250

300

350

400

450

500


Elective

2016-17 actual plan

0

200

400

600

800

1000

1200

1400

1600

1800

2000


Daycase

2016-17 actual plan

0

1000

2000

3000

4000

5000

6000


Accident & Emergency

2016-17 actual plan

0

200

400

600

800

1000

1200

1400

1600

1800

2000


Emergency

2016-17 actual plan

0

1000

2000

3000

4000

5000

6000

7000

8000


New Outpatient Attendances

2016-17 actual plan

A&E Attendances continued to be on plan in the month with the average number of attendances per day decreasing to 145 during October from 152 in September. Daily attendances ranged from 120 to 172. Year to date attendances remain above plan by 746 (2.4%). Emergency Activity returned to the levels that we saw at the start of the year with 1748 attendances in October, having previously been 1815 in September, year to date activity remains 0.8% (97 actual) above plan. Day-case activity continued to show the highest level of this financial year. The revised profile plan is now in place and while activity remains down on plan in October (-367 actual) it matches last year in the same month (1488 actual). Year to date activity is now 9.3% (1019 actual) behind plan but this is expected to recover over the coming months with the new recovery plan for each Division. Elective Activity is currently 135 cases behind plan for the year (5.1%). October saw 46 cases more than last financial year however it was still 67 cases (15%) short of the plan for the month in this year’s projections. Outpatient Activity: remains down on plan for both new and follow ups in the month by 8.2% (547 actual) and 8.9% (1285 actual) respectively. For the financial year to date, new appointment activity is down on plan at -3.7% (-1627 actual) and follow up is down -9.2% (-9770) on plan.

of 171

Community:

MIU Activity decreased significantly with October (350 actual) reporting 80 less attendances than September (430 actual). This month is the first of this financial year that has seen a decrease against last year. Year to date attendances show a 12.1% (306 actual) increase over the same period in 2015/16. Bed Day Activity has increased to 2932 for October. This extends the year to date position up 5.4% (1009) compared to the corresponding period last year. Bed occupancy remained at 96% in October. Day Case Activity saw similar levels of activity to last month (October – 92, September - 93). Year to date activity 0.2% (1 actual) down when compared to last year. Contacts Activity continues to be above plan for the year to date, activity is 9.4% (13617 actual) greater than the same period during 2015/16. October was 8.4% higher than last year with 22963 actual cases. Outpatient Activity continues the previous outlook being down against the corresponding month last year and year to date. New activity is -12.6% (-1240 actual) against last year while follow up activity is 10.6% (-3277 actual) also down.

of 171

Key Performance exceptions and remedial actions: A&E, RTT & Diagnostics:

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

Trajectory 94.4% 92.2% 94.9% 86.5% 90.3% 91.4% 93.5% 93.9% 91.7% 93.5% 94.3% 95.3% 95.3% 95.2% 95.2%

Actual 87.9% 88.5% 84.3% 90.4% 90.2% 88.6% 89.0% 83.5% 85.3% 86.9%

Trajectory 67.1% 67.5% 70.8% 72.8% 75.5% 79.0% 83.0% 88.1%

Actual

Trajectory 0.1% 0.1% 0.1% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3%

Actual 0.04% 0.0% 0.0% 0.2% 0.0% 0.0% 0.3% 0.0% 0.0% 0.0%

2015/16 2016/17

A&E 95%

RTT - Incomplete Pathways 92%

Diagnostics <1%

A&E standard: October’s Trust-wide A&E performance was 86.9% against the national standard of 95%. The Trusts planned performance (as per recovery trajectory) for the month was 93.5% Performance against the A&E standard continues to be poor. Recent pressures on performance are due in part to

increased ‘front-door’ pressure and reduced patient flow as a result of a now chronic Delayed Transfer of Care (DTOC)

pressure.

The Trust is now finalising plans to pilot the ‘red/green day’ initiative from December 12th 2016 in order to help tackle, arguably the single biggest cause of delays in the emergency department, poor patient flow. RTT 18 week standards: Return to reporting: The Trust is now aiming to achieve a ‘return to reporting’ date in January 2017, reporting December’s ‘Incomplete’ RTT position. This reporting date will be subject to positive outcomes by external validation, IST review and Trust Board approval. The additional planned activity elements of the 2016/17 RTT revised recovery trajectory are now being delivered with additional activity occurring at both WVT and within the independent sector. Whilst activity to date in outpatient, new and follow-up, inpatient and day-case is all greater than last year it remains behind the Trust’s planned level of activity. A detailed review of plans has been undertaken and it is expected that those plans will be achieved for the remainder of the year. A weekly monitoring process has been established through a corporate weekly ‘PTL’ meeting chaired by the Deputy Chief Operating Officer. Diagnostics: The Trust achieved the Diagnostic standard of less than 1% of patients waiting over 6 weeks with performance at 0.0%; 0 patients breached the standard.

of 171

Cancer standards (September 2016):

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

Trajectory 95.1% 95.7% 95.4% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93%

Actual 96.1% 95.4% 87.8% 89.2% 83.3% 79.2% 87.6% 89.7% 92.0%

Trajectory 96.8% 97.1% 97.5% 72.6% 57.9% 82.2% 84.7% 84.6% 90.5% 90.3% 89.2% 84.8% 87.3% 95.0% 85.3%

Actual 86.9% 94.8% 84.6% 82.8% 21.8% 28.4% 70.3% 56.3% 72.7%

Trajectory 98% 98% 98% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96%

Actual 96.7% 96.2% 95.7% 98.5% 98.4% 96.3% 100.0% 97.8% 97.5%

Trajectory 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98%

Actual 85.7% 100% 100% 100% 90.0% 100% 87.5% 100% 100%

Trajectory 80.0% 83.3% 85.2% 83.0% 85.4% 85.7% 85.8% 85.4% 86.3% 86.4% 85.7% 85.4% 85.7% 85.8% 86.0%

Actual 82.6% 87.1% 79.8% 74.0% 81.3% 80.0% 86.0% 85.0% 77.7%

Breast 85% 100% 100% 100% 90.5% 90.0% 100.0% 100.0% 100.0% 77.8%

Gynaecology 85% 33.3% 0.0% 54.5% 75.0% 100.0% 20.0% 100.0% 60.0%

Haematological 85% 100% 100% 100.0% 100.0% 75.0% 66.7%

Head & Neck 85% 25.0% 0.0% 50.0% 0.0% 0.0% 0.0% 0.0%

Lower GI 85% 85.7% 60.0% 57.1% 23.1% 33.3% 88.9% 88.5% 83.3% 66.7%

Lung 85% 100% 100% 66.7% 100% 100.0% 100.0% 71.4% 50.0% 100.0%

Sarcoma 85% 100% 0.0%

Skin 85% 90.3% 97.4% 92.6% 100% 100.0% 100.0% 92.9% 91.2% 90.0%

Upper GI 85% 100% 100% 33.3% 100% 62.5% 81.3% 72.7% 87.5%

Urological 85% 66.7% 66.7% 82.4% 57.1% 70.6% 66.7% 58.8% 90.9% 75.0%

Other 85% 100% 100% 50% 100% 100.0%

Trajectory 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Actual 100% 50.0% 100% 75.0% 100% 100% 100% 100% 100%

Trajectory 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

Actual 65.0% 100% 78% 66.7% 100% 88% 100% 85.7% 76.9%

Trajectory n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Actual n/a 100% 0% 100% 0% n/a 100% n/a n/a

2015/16 2016/17

Two Week Waits (Breast Symptomatic) 93%

Cancer Two Week Waits 93%

Cancer 31 Days 96%

Cancer 31 Days Subsequent Treatments 98%

Cancer 62 Days 85%

Cancer 62 Days Screening 90%

Cancer 62 Days Upgrades 85%

Cancer 31 Days Rare cancers 85%

The Trust achieved the following ‘Cancer targets’:

Cancer ‘31 days’

Cancer ‘31 Days Subsequent Treatments’

Cancer 62 days screening

Cancer 62 days upgrades

The Trust failed the following ‘Cancer Targets’:

Cancer Two Week Waits with performance of 92.0% against as national standard of 93%

Two Weeks (Breast Symptomatic) with performance of 72.7% against a national target of 93%

Cancer ‘62 days’ with performance of 77.7% against a national target of 85%

Two Week Wait:

• The trust failed the 2 week wait standard but continued to see an improvement in the month and again being the best performing month this financial year.

• Capacity remains an issue in a small number of specialties and the Divisions continue to review weekly and add additional clinics where possible.

• The Trust continues to see an increase in 2 week wait referrals across all tumour sites with a rolling 52 week

growth of 9.8%

of 171

Breast Symptomatic:

• Capacity pressures within the Breast service remain but the Division continues to monitor the situation and additional clinics are being set up to clear the backlog and thereby improve performance.

Cancelled Operations and Stroke/TIA:

Threshold Mar** Apr May Jun Jul Aug Sep Oct YTD

Indicator 1 - last minute cancellations 0.8% 2.10% 0.98% 1.21% 0.71% 1.05% 1.54% 0.64% 1.43% 1.01%

Indicator 2 - breach 28 day rebooking 5% 30.6% 76.5% 38.1% 76.9% 84.2% 88.9% 150.0% 44.4% 79.9%

Stroke: patients spending min 90% of

time on stroke unit80% 74.3% 90.9% 79.5% 84.2% 75.5% 82.4% 82.9% 75.9% 80.7%

TIA: high-risk pts scanned & treated

within 24 hrs of 1st contact with HCP60% 13.8% 19.4% 19.5% 13.2% 43.8% 48.3% 42.9% 60.0% 32.6%

Cancelled

Operations

Stroke/TIA

Cancelled Operations: October had 27 on the day non clinical cancellations of surgery which was the same as August and therefore the joint highest amount in a month for the year. The Trust did not achieve the 0.8% threshold with performance of 1.43%, a sharp increase away from September’s 0.64%. The Trust remains below the standard year to date at 1.08%. The Trust continues to fail the 28 rebooking standard with 12 breaches in the month. Stroke/TIA: Performance against the Stroke ‘standard’ was not achieved for the month with 75.9% of patients spending 90% of their time on a Stroke ward (threshold is 80%). Performance against the TIA ‘standard’ was achieved for the month with 60.0% of ‘high-risk TIA patients being scanned and treated within 24 hours of referral (threshold is 60%) The appointment of a second locum consultant and the increase in urgent TIA clinic slots, as previously reported, has continued to have a positive impact on performance against this standard. Delayed Transfers of Care (DTOC) (September 2016) The number of bed days lost decreased in September (787) following the highest levels of the year in August (819). The current year remains above last year’s levels. September’s 787 lost bed days on average equates to 26 beds per day against a bed base of 320 (8%). A ‘Discharge Pathway’ work stream has commenced and has identified a series of work-streams to address concerns around the deteriorating DTOC position. The Programme will be overseen by the A&E Delivery Board. Progress reports will be provided to the Trusts Board in the coming months.

of 171




High


Moderate


Low


High


High


High


Low


Risk ref 375 – risk of non-achievement of 18 week pathway Risk ref 399 – risk of continued failure of urgent care pathway Risk ref 400 – risk of the Trust failing to achieve the NHS constitutional targets

of 171

TRUST BOARD MEETING

Report to: Trust Board Meeting ‘in public’ Agenda item: 11c Date of Meeting: 1st December 2016 Title of Report: Workforce Report – October 2016 Status of report: (Approval, position statement, information, discussion)

Discussion

Report Approval Route Finance & Performance Committee Lead Executive Director: Sue Smith, Director of HR & OD Author: Andrea Jones, Workforce Planning Manager Appendices:

1. Workforce Report

This report provides an analysis of workforce information and issues covering: • HR Key Performance Indicators (KPIs) 2. Recommendations

The Committee are invited to note the contents of the report and actions underway to improve performance efficiency and productivity.


There has been deterioration across all key performance indicators within the well led domain, with the exception of Consultant appraisal rates.

Work is underway to re-focus the work of the whole HR Directorate team to ensure these areas have been prioritised i.e. support to managers to deal with both short term and ong term sickness absence, supporting managers to undertake appraisals and address high levels of turnover within their teams, the development of a robust plan to move to relaunch the in-house bank and reduce reliance on Apple and other external agencies, and the development of robust workforce plans for key staff groups such as nursing and midwifery and also the medical workforce that addresses new roles, different ways of working and most importantly, the need to recruit to key vacancies.

The outcome of this work will feed into the update of the Board Assurance Framework risk 417 “Risk to recruitment of new staff and retaining present staff” and form the basis of the update for the Quality Improvement Plan and Financial Recovery Plan actions attributable to the HR Directorate.


Vacancies have increased this month from 244 wte to 260 wte. Nursing & Midwifery vacancies were down this month from 152 to 144 wte. Nurse Agency Spend as a % of the total nursing costs and has slightly increased from 15.9% to 17.47%

of 171

this month. Sickness Absence has increased this month from 4.47% to 5.08%. Substantive workforce numbers have decreased this month from 2628.34 to 2618.43 wte. Turnover in month shows an increase from 1.10% to 1.48%. The 12 month rolling figure has also increased from 13.74% to 13.9%.




High


Moderate


Low


High


High


High


Low

6. Reference to the Risk Register or Board Assurance Framework Board Assurance Framework risk 417 “Risk to recruitment of new staff and retaining present staff”

of 171

Workforce Report

1.1 KEY PERFORMANCE INDICATORS

Category Performance Indicator Target 2013/14 2014/15 2015/16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Trend

Budgeted Establishment 2812.13 2802.24 2828.64 2849.39 2858.45 2872.67 2876.97

Progress V's workforce Plan Total Staffing WTE

2736.24 2379 2474.89 2601.32 2600.67 2584.78 2603.42 2611.05 2602.88 2628.34 2618.43 Headcount Total Staffing 2947 3051 3174 3163 3143 3169 3171 3163 3188 3179 Vacancy %

% of WTE vacant to total workforce 5.00% 7.53% 7.78% 7.92% 8.36% 8.91% 8.51% 9.04%

Nurse Agency Spend %Nursing agency costs as % of total

nursing costs8.00% 15.10% 16.70% 19.30% 18.10% 15.20% 15.90% 17.47%

Sickness Absence (YTD) % of WTE lost to sickness

3.69% 4.20% 4.33% 4.51% 4.54% 4.61% 4.65% 4.72% 4.73% 4.70% 4.71% =Sickness Absence

(Mthly) % of WTE lost to sickness3.49% 4.38% 4.53% 4.21% 4.84% 4.56% 4.47% 5.08%

Turnover % (YTD exc. Jr Drs) % of Headcount 10% 12% 12% 14% 13.96% 14.10% 13.90% 14.46% 14.18% 13.74% 13.90%

Mandatory & Statutory Training

% of staff completed Mandatory training in last 12

months90% 81% 77% 79% 82% 86% 86% 84% 84.3% 84.4%

Staff Appraisal% of staff appraised in last 12

months 90% 76% 68% 59% 61% 66% 78% 77% 72% 69.0% 69.3% Consultant Appraisal

% of staff appraised in last 12 months 90% 89% 92% 96% 96.5% 98.2% 98.2% 96.5% 93.9% 91.5% 94.01%

WorkforceStaff In Post data only Key Indicators Scorecard

of 171

Summary of Workforce 1. Total Staffing

The Trust remains under establishment with 260 wte vacancies. This is an increase from last month (244). The 2nd chart is showing Starters and Leavers at the Trust. The overall trend shows starters (green line) are more than the leavers (red line) thus reducing the overall vacancies. This month there have been more starters than leavers. The chart also shows the Nursing & Midwifery Starters and Leavers (dashed lines) and this general shows there are more Leavers than Starters in this group. In October there were 7.13 wte (9) starters/12.65 wte (16) leavers in the N&M group, a net loss of 7 (5.52 wte).

of 171

2. Vacancies

The Trust’s in month vacancy rate is 9.04% up on last month’s rate of 8.51%. Nursing & Midwifery remains the highest staff group with vacancies at 55% of the total vacancies (down on last month). There have been increases in Additional Clinical Services, Admin. & Clerical and Scientific & Technical staff groups. Further analysis shows the Nursing & Midwifery vacancies broken down by Band, with 89% of vacancies being Band 5, a decrease from last month’s 94%.

of 171

3. Sickness Absence

The October Sickness absence rate increased to 5.08% (4.47% last month) with both Divisions above the Trust target. Long term sickness numbers have remained the same at 72 staff listed on ESR (72 last month).

Case numbers with close dates.

72 Total

Return to Work 17 ESR Issue Leaver/Retire 2 Final Review 2 Maternity leave Total Net LTS 51

All cases are being actively managed as per policy with 21 of the 72 having return to work dates or leave dates planned. The absence rate increased to 2.25% from 2.16% last month. Short term absence has increased this month to 2.83% from 2.31% last month. The main reason for sickness absence this month remains Stress & Anxiety. There was a total of 512 staff absent from work during October 2016, an increase from last month (448). October has seen an increase in five out of the eight staff groups for sickness absence. The highest group is Estates & Ancillary staff at 15.44% (note: this is a small group of staff), followed by Additional Clinical Services staff (HCA’s/support) at 8.29% (an increase on last month 6.66%).

of 171

4.Turnover

The 12 month turnover up to October 2016 has increased from 13.74% to 13.9%. The Medical Division had 22 leavers. Surgical had 20 leavers. (an increase on last month) The highest percentage staff group this month is Professional Scientific & Technical staff group at 18.59% (increase on last month– chart 2). This is followed by Healthcare Scientists at 16.03% (same as last month - chart 2), then Additional Clinical Services staff at 14.56% (an increase from last month – chart 1). The highest number of staff leaving this month was in the Nursing & Midwifery staff group with 16 (12.65 wte), of which 10 (8.29 wte) were Band 5 nurses. Then Additional Clinical Services group with 13 staff (10.51 wte).

of 171

5. Nurse Recruitment

(Note: Chart trajectories take into account possible starters, average leavers and possible retirements)

Data assumptions of proposed initiatives have been removed from the data as proposals were not approved. April and May 2017 sees an increase in Nursing numbers as staff on the overseas nurse training programme are due to qualify. Agency Usage Agency usage was up in October. Bank usage was also up. Nurse Agency % of spend was at 17.47% an increase on last month (15.9%). HCA Pool It has been agreed that the Trust will introduce a HCA Pool for Band 2 employees to fill vacant shifts in order to reduce agency usage.

of 171

Philippine Recruitment – timeline (included in the above charts)

Wte Arrive as

Band 3 In Country

Band 3Operational

Band 5In country

Bd 5July 0 0August 0 1 0September 1 0October 0 0November 0 1 0 1December 1 0January 2 0 1February 3 1March 9 2Total 16 2 in Country 3 2 5April'17 3May 9June 0

15 2 17

This chart is showing the Band 5 vacancy and trajectory against the actual Band 5 Staff in Post and Budget. Filipino Nurses We now have a further 12 nurses pass their IELTS and are due to arrive in Feb/Mar time. Facebook Recruitment have recently created a facebook page to promote vacancies. All posts will be uploaded to the page. Recruitment events will also be posted. Careers Fairs Recruitment & education have been attending local career fairs to promote NHS jobs and work experience.

of 171

Development Programmes Overseas Band 4 to Band 5 Programme

SummaryApril'17 May'17 July'17 Sept.'17

2 15 1 6

Band 4 to Band 5 by:

This is the overseas nurse programme for those already in this country that need to get their NMC registration. 2 are due to complete the programme and be operational by April, 13 in May and 7 by September 2017. Numbers are now being included in the Nurse trajectory figures.

Aug'16 Sept'16 April'175 1 1

Dec'171

Aug'16 Aug'17 Feb'18 Aug'18 Feb'19 Aug'192 1 2 4 2 3Completion

Return to PracticeCompletion

Non EU ConversionCompletion

Secondments

HCA – Band 4 Programme

June'1728

Aug'175

Higher Apprentice - HCA Band 4 ProgrammeCompletion

CompletionFoundation Degree

of 171

5.1 HCA Recruitment

During October the Trust recruited 6.91 wte HCA’s starters against 10.51 wte leavers. (2.00 wte were ward based starters and 5.16 wte were ward/Community Hospital based leavers). The chart shows a gradual decrease in numbers as some HCA’s will qualify as nurses and some will leave. HCA Pool It has been agreed that the Trust will introduce a HCA Pool for Band 2 employees to fill vacant shifts in order to reduce agency usage. Recruitment have made 6.00 offers to date to commence in December. The Trust will need to continue to recruit HCA’s to maintain the establishment numbers.

of 171

5.2 Medical Recruitment

The Trust is still experiencing recruitment issues to Consultant posts. The graphs show an increase in Medical staff, specifically Consultants from April 2016, this is due to submissions in the Business Planning process. During October there was an increase in Medical Agency usage to 6,745 hours, with the highest usage within Medicine, Anaesthetics and A&E. Junior Doctors The Trust has Jr Doctor vacancies and as anticipated from August 2016 this has become worse. 20.00 wte. There is a significant shortage of trainee posts across the West Midlands. A plan has been agreed to address and mitigate these shortages.

of 171

6. Education & Training and Appraisal

Divisions Overall % Compliance

229 Capital 85.86%229 Director Of Operations 81.35%229 Director of Nursing 86.49%229 Finance 90.97%229 Human Resources 93.88%229 Medical Directorate 87.50%229 Medical Division 83.90%229 Patient Access Team(Div) 75.19%229 Surgical Division 83.91%229 Trust Headquarters 85.19%229 Wye Valley NHS Trust 84.37%

Mandatory Training - Oct'16

Mandatory training for October 2016 is at 84.37%, slightly up on last month (84.32%). (Trust target of 90%). Training and Appraisal data is now supplied directly from ESR and will report on compliance %’s only and not attendances. Appraisal completion for October is at 69.34%, a slight increase from on last month (69.0%). The (Trust target is 90%). All managers are responsible for checking that their department’s records are correct.

Divisions Reviews Completed %

229 Capital 90.00%

229 Director Of Operations 92.00%

229 Director of Nursing 62.79%

229 Finance 81.25%

229 Human Resources 78.43%

229 Medical Directorate 71.43%

229 Medical Division 71.77%

229 Patient Access Team(Div) 50.00%

229 Surgical Division 65.57%

229 Trust Headquarters 63.64%

Grand Total 69.34%

Appraisal Data - Oct'16

of 171


TRUST BOARD MEETING

Report to: Trust Board Meeting ‘in public’ Agenda item: 11d


Title of Report: Financial Performance Report (Month 7, 2016/17)


Information

Report Approval Route: Full report to F&PC; summary report to Board

Lead Executive Director: Howard Oddy, Director of Finance and Information

Author: Howard Oddy, Director of Finance and Information

Appendices: None

Purpose of the report

To inform Board members of the financial position of the Trust at the end of October 2016 (month 7).

Recommendations

The Board is asked to note the financial position at the end of October 2016 and the actions being taken to bring the forecast back in line with the Board approved plan.

Executive Director Assurance

The DoF has reviewed the financial position and is assured of the accuracy of the financial position being presented.

Summary of Key Issues for discussion

The Income and Expenditure deficit at the end of October was £19,918k. The three drivers of the deterioration in month were activity falling below the revised RTT plan (excluding the sub-contract element which is financially neutral), the cost of medical and nursing agency staff (particularly nurse agency which increased again in month), and slippage against the Financial Recovery Plan (FRP). The current outturn forecast for the Trust has been increased to £33.9m, i.e. a further deterioration of £0.8m. Whilst this forecast position recognises significant slippage in the Financial Recovery Plan, it also assumes full delivery of the revised activity plan in the last 5 months of the year. When the £3.5m fines, levied by the CCG in relation to failure of constitutional targets are included, the forecast outturn increases to £37.4m deficit, compared to the £31.5m planned deficit. This position assumes no improvement from the current position in the delivery of the FRP. In recent correspondence from Jim Mackey, Chief Executive NHS Improvement, a new protocol was introduced for Trusts which want to change their financial forecast for the year. It has already been acknowledged by NHSI that it will be necessary for this Trust to change its forecast at the next allowable point (month 9) and this requires the protocol to have been followed. There needs to be discussion and a report to the Regional Managing Director and the Regional Director of Finance outlining the factors behind the position. It will also be necessary that the position has been discussed with the CCG, and it will be necessary to demonstrate that the Board is fully aware of the position and is signed up to a

of 171


recovery plan. Finally, it will be necessary for the Chair, the CEO, the FD and the Chair of the Audit Committee to sign an assurance statement to confirm that the Trust has adhered to the protocol. The Trust is thus working through these requirements prior to changing its forecast at month 9.

Please state which Corporate Objective your report relates to:


1. Improve the quality and safety of care to our patients, their carers

and families

High

2. Improve the responsiveness of our services for the benefit of our

patients and their families.

Moderate

3. Provide more productive and better value care that improves the

sustainability of our services

Low

4. Develop a highly skilled, motivated, healthy and engaged

workforce

High

5. Develop first class facilities and technology to support the care we

provide

High

6. Transform health and wellbeing through working with our

partners

High

7. Play our role as an important asset to the people of Herefordshire

and the

surrounding areas

Low

Reference to the Risk Register or Board Assurance Framework

The financial position is currently on the BAF as an extreme risk.

of 171


I&E Performance against Budget Plan

Headline Income & Expenditure position:

The deficit increased in the month by £507k to a cumulative position of £19,918k. This resulted in a variance of £2,581k against the £31.5m deficit plan as shown in the table.

The drivers of this position were:

Contract income fell £446k further behind the new revised plan, resulting

in a cumulative shortfall of £1,992k.

Within these income values, £290k in-month and £1,006k year-to- date relate to the work sub-contracted to the private sector, which is largely cost neutral, i.e. there is an opposite underspend in cost.

The balance of £156k in month and £986k year-to-date are of most concern as this represents shortfall against the revised activity plan and also against a cost base which was increased through the investment in theatre 10 and the signficant workforce investment.

It was forecast that the Financial Recovery Plan (FRP) would have

delivered £368k by the end of October but an adverse variance occurred (£134k) which has further deteriorated the Trust position.

Nurse agency expenditure (also linked to the FRP) has increased to

£863k in month and is now returning to a trajectory towards £9.9m in the full year.

Medical agency reduced marginally in month but is showing the third

consecutive month of a step-increase and is currently trended to reach £5.7m by year end.

It is essential that, in respect of all these issues, urgent action is taken by the Divisions to ensure delivery of the current activity plan over the remainder of the year, efforts to reduce agency spend are intensifed and the delivery of the FRP trajectory is stepped up.

STATEMENT OF COMPREHENSIVE INCOME - To Month 7 - 31st October 2016 - 2016/17

ANNUAL CURRENT MOVEMENT

FINANCIAL ANNUAL IN

PLAN BUDGET CURRENT

As At PLAN BUDGET ACTUAL VARIANCE MONTH

31/03/2016

£000 £000 £000 £000 £000 £000

Contract & PbR Income 156,232 148,624 86,476 84,484 (1,992) (446)Excluded Drugs 14,679 8,563 8,732 169 (40)Non Contracted Activity (NCA's) 2,090 2,118 1,223 1,183 (40) 27Other Income for Patient Care 17,796 11,898 7,443 7,443 0 0Donations For Non Current Assets 1,100 1,100 642 204 (438) (63)Other Non Patient Income 4,233 5,146 3,297 3,191 (106) (14)

Total Operating Income 181,450 183,565 107,643 105,237 (2,406) (535)

Pay Expenditure 131,893 132,510 76,992 77,876 (884) (296)Non Pay Expenditure 69,839 57,246 33,350 32,927 423 291Excluded Drugs 14,038 8,170 8,319 (149) 36

Total Operating Expenditure 201,731 203,794 118,512 119,122 (610) 31

EBITDA (20,281) (20,228) (10,869) (13,885) (3,016) (504)

Depreciation 4,254 4,133 2,364 2,364 0 (0)Gain or loss on asset disposal 0 0 0 0 0 0Interest Receivable 31 25 18 18 (0) (1)Interest Payable on Loans 912 1,078 546 549 (3) (3)Interest Payable on PFI 5,296 5,296 3,089 3,089 (0) (0)Dividends on PDC 0 0 0 0 0 0

Operating Surplus/ (Deficit) (30,711) (30,711) (16,851) (19,869) (3,018) (507)

Technical Adjustments

Donated Assets - Additions 1,100 1,100 642 204 438

Donated Asset Depreciation (311) (311) (155) (155) 0

Donated Assets - Additions less Dep'n 789 789 486 49 438

Net impact of fixed asset revaluations and impairments

Adj. financial performance retained

Surplus/ (Deficit) (31,500) (31,500) (17,337) (19,918) (2,581)

YEAR TO DATE

of 171


Income and Expenditure run rate

The current outturn forecast of £37.4m, as at month 7, assumes full delivery of the revised activity plan in future months. In terms of the FRP, it assumes that the current forecast of £1.5m (of the required £3.4m plan) is delivered. The above would equate to a combined delivery of CIP and FRP of £4.6m. This outturn forecast results in the following variances by year end:

Income £1.8m Fines £3.5m Cost £0.6m

The above figures follow implementation of the revised activity plan, which removed £1m of activity income and £1m of cost from the plan. There is a new protocol for Trusts which want to change their financial forecast for the year and it has already been acknowledged by NHSI that it will be necessary for this Trust to change its forecast. This will need to be completed at the next allowable point (month 9) and this requires the protocol to have been followed. This includes discussion with the Regional Managing Director and the Regional Director of Finance outlining the factors behind the position.

INCOME & COST TRENDS AFTER APPLICATION OF FRP

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Current

Trajectory Outturn

Income

Contract & PbR Income 11,433 11,787 12,353 12,407 11,755 12,526 12,224 12,776 13,102 12,648 11,752 9,299 144,061 120

Excluded Drugs 1,525 1,300 1,271 1,235 1,130 1,076 1,195 1,286 1,161 1,151 1,127 1,222 14,679 0

Non Contracted Activity (NCA's) 170 167 52 203 187 197 207 185 185 188 180 196 2,118 0

Other Income for Patient Care 1,031 1,030 1,002 1,043 1,025 1,249 1,063 848 848 848 848 1,063 11,898 0

Income - (Donated Asset Depreciation) 92 92 92 92 (221) 29 29 29 29 29 29 29 350 0

Strategic change 457 611 438 448 402 378 457 374 368 369 369 370 5,040 0

0 0

Total Operating Income 14,708 14,987 15,207 15,427 14,278 15,454 15,175 15,498 15,693 15,234 14,306 12,178 178,146 120 178,266

Pay Directors & Sen. Managers =>Band 8 340 318 340 346 301 303 312 305 307 308 307 307 3,795 (20)

Medical & Dental 3,014 3,089 2,952 3,179 3,347 3,366 3,293 3,387 3,410 3,449 3,399 3,402 39,286 (55)

Nurses & Midwives 4,845 4,795 5,053 5,033 4,775 4,850 4,993 4,994 4,990 5,010 4,997 4,999 59,333 (802)

AHPs 813 850 864 838 883 858 877 881 877 881 880 877 10,379 (60)

Pharmacists 122 120 115 97 99 113 112 112 115 115 114 114 1,348 0

Professional, Technical, Scientific 505 480 515 482 498 488 473 509 507 506 508 507 5,979 0

Managers/Technical >Band 5 172 173 196 183 190 193 189 190 190 190 190 188 2,245 0

Clerical <=Band 5 1,044 1,024 1,044 1,046 1,071 1,072 1,070 1,085 1,086 1,087 1,087 1,089 12,804 (30)

Other Pay 0 11 6 5 6 4 4 5 4 4 4 4 57 0

Redundancy pay 0 127 0 0 0 0 0 0 0 0 0 0 127 0

0 0

10,854 10,988 11,084 11,209 11,170 11,247 11,323 11,469 11,487 11,549 11,486 11,487 135,354 (967) 134,387

Non Pay Drugs 312 275 307 336 327 330 346 312 312 312 312 312 3,790 0

Excluded Drugs 1,447 1,236 1,214 1,179 1,080 1,023 1,140 1,144 1,144 1,144 1,144 1,144 14,038 0

Med & Surg Supplies 974 946 1,067 1,069 1,126 927 927 1,013 1,013 1,013 1,013 1,010 12,100 (89)

Implants & Accessories 154 180 182 126 117 170 100 166 166 166 166 167 1,858 0

Other Clinical Supplies 240 205 196 138 211 291 200 211 211 211 211 211 2,537 0

Clinical Services contracts 681 582 671 633 677 906 806 808 808 798 798 798 8,966 0

PFI Contract 665 598 738 732 683 697 678 684 684 684 684 684 8,212 0

Transport & Travel 231 222 233 239 230 233 272 241 256 268 240 239 2,906 (2)

Establishment expenses 368 335 365 347 372 387 368 240 348 348 348 346 4,173 0

I.T. 99 83 109 182 166 200 139 139 139 143 139 139 1,675 0

Trust Overheads (inc. Insurance) 348 376 352 353 380 341 348 384 381 381 381 380 4,403 0

Other Non Pay 439 530 422 463 508 393 455 459 460 458 456 458 5,501 (87)

Hoople Services & Retained IT 71 74 76 74 74 74 74 74 74 74 74 74 882 0

0 0

6,029 5,642 5,929 5,870 5,949 5,973 5,852 5,875 5,996 6,000 5,966 5,962 71,043 (178) 70,866

16,884 16,630 17,013 17,079 17,119 17,220 17,176 17,344 17,483 17,549 17,452 17,449 206,397 (1,145) 205,253

EBITDA (2,176) (1,644) (1,806) (1,652) (2,840) (1,765) (2,001) (1,846) (1,790) (2,315) (3,145) (5,271) (28,251) 1,265 (26,986)

Depreciation 338 335 337 339 348 339 327 354 354 354 354 354 4,133

(Gain) or loss on asset disposal 0 0 0 0 0 0 0 0 0 0 0 0 0

Interest Received 6 2 2 3 1 1 3 3 3 3 3 2 30

Interest Payable Loans 67 70 67 67 97 73 109 78 78 78 78 78 941

Interest Payable PFI 441 441 441 441 441 441 441 441 441 441 441 441 5,296

Dividends Payable 0 0 0 0 0 0 0 0 0 0 0 0 0

0

840 845 843 845 885 852 874 871 871 871 871 872 10,340 0 10,340

Total Operating Surplus/(Deficit) (3,016) (2,488) (2,649) (2,496) (3,726) (2,618) (2,875) (2,717) (2,661) (3,186) (4,016) (6,143) (38,591) 1,265 (37,326)

Donated Assets 350 350

Donated Asset Depreciation (311) (311)

(38,630) (37,365)

Recovery

Plan (Inc in

Trajectory)

2016/17 - Full Delivery

Total Operating Expenditure

ForecastActual

of 171


Temporary Staffing and Additional Payments 1] Agency Ceiling Controls

The agency expenditure ceiling cap for the year is £9,760k set to the above profile. The graph shows the Trust continuing to operate substantially above this value and with an increasing divergence against the target profile. It is the overall increase driving the increasing divergence against a reducing target which is of most concern. There is, however, a programme of actions being implemented to improve the current position regarding nursing agency spend, and a similar programme is being developed in respect of medical agency costs.

of 171


Cost Improvement & Financial Recovery Plan The original CIP targeted the delivery of £5.4m and by August it had become apparent that in its present form, it was not likely to deliver more than the £3.1m (see table below). Over the last three months, a Financial Recovery Plan (FRP) has been developed. The current target for this, based on approved schemes, is £3.4m (although initially the organisation was asked to consider the possibility of delivering more radical schemes targeting £5.4m of recovery plan items including cost avoidance schemes to compensate for under delivery of activity and cost overspends).

The FRP is currently forecast to deliver £1.5m, which would result in a combined delivery of £3.1m from the CIP and £1.5m of FRP. This value is a financial issue for two reasons, 1] as a combined value, it is still £0.8m short of the original cost improvement plan and 2] it does not address the recovery required to compensate for activity below plan together with cost pressures. If the current FRP, valued at £3.4m of approved schemes was to deliver in full, together with the £3.1m of the original CIP, this would result in £6.5m i.e. £5.4m per original plan, plus £1.1m of ‘recovery’. The table to the left shows performance against the original CIP and the tables below the show current outturn forecast and progress to date against the FRP. It should be noted that nurse agency transferred in effect from the CIP into FRP and is reported below.

Div

isio

n

Category Stat

us

Ris

k

Tota

l p

lan

M1

- M

7 p

lan

M1

- M

7 A

ctu

al

Cu

rre

nt

Var

ian

ce

M8

M9

M1

0

M1

1

M1

2

Cu

rre

nt

traj

ect

ory

Var

ian

ce f

rom

pla

n

Mit

igat

ion

re

qu

ire

d

Fore

cast

Locally Managed Nurse Agency Reduction PP H 420 261 33 (228) 5 5 5 5 5 58 (362)

Drugs FD M 20 12 7 (5) 13 16 17 17 17 87 67

Income Margin on Service Devs FD H 317 159 77 (82) 11 11 17 14 16 146 (171)

Non Pay Efficiencies FD L 343 214 209 (5) 32 32 32 12 12 329 (14)

Pay Efficiencies FD L 230 146 88 (58) 14 14 14 14 14 158 (72)

WLI/ACAPs FD M 44 10 11 1 2 2 2 2 2 21 (23)

Vacancy Management FD L 22 22 22 0 0 0 0 0 0 22 0

Nurse Agency Reduction PP H 886 500 6 (494) 3 3 3 3 3 21 (865)

Community Savings FD M 50 29 40 11 6 6 6 6 6 70 20

Income Margin on Service Devs FD M 567 318 165 (153) 37 37 50 50 50 389 (178)

Non Pay Efficiencies FD L 23 10 2 (8) 0 11 11 11 11 46 23

Pay Efficiencies FD L 158 80 142 62 9 9 9 9 9 187 29

Vacancy Management FD L 100 17 100 83 0 0 0 0 0 100 0

Estate Cost Savings FD L 193 108 135 27 16 16 27 16 26 236 43

Estate Cost Savings PP M 72 26 2 (24) 6 6 9 9 9 41 (31)

Estate Cost Savings U H 107 62 0 (62) 11 11 14 14 14 64 (43)

Finance Renegotiation audit contract & cancellation of system licence FD L 58 35 35 0 5 5 5 5 5 60 2

3,610 2,009 1,074 (935) 170 184 221 187 199 2,035 (1,575) 1,575 3,610

Carter Review Non Pay O M 500 292 0 (292) 0 (500)

Corporate Vacancy Management FD L 200 109 109 0 18 18 18 18 18 200 (0)

WLI/ACAPs FD M 500 292 136 (156) 20 20 20 20 22 238 (262)

IM&T FD L 80 44 44 0 7 7 7 7 8 80 0

Procurement FD M 450 257 287 30 52 51 51 51 53 545 95

Procurement U H 151 77 0 (77) 0 0 (151)

Unidentified U H (78) (42) 0 42 0 0 78

1,803 1,029 576 (453) 97 96 96 96 101 1,063 (740) 740 1,803

5,413 3,038 1,650 (1,388) 267 280 317 283 300 3,098 (2,315) 2,315 5,413

Centrally Managed CIP Schemes

Corp 740 1,803

CIP Devolved and under the control of Service Unit Management

Surgical

1,575 3,610

Medical

Comm

of 171


The Trust has experienced significant difficulties in getting traction on the FRP and the current state of detailed plans broadly falls into two positions, as shown in the table below. £1.7m of the schemes have good plans and should now be focussed on implementation, whereas £1.2m of schemes have so far failed to gain traction and planning has not yet commenced.

The following table records current year-to-date performance and outturn forecast by category. The present position with the nurse agency reduction programme is one of the immediate priorities, as £1m of delivery from these schemes is still included in the FRP forecast and the Trust outturn.

Since October, some dedicated resource has been in place to support the FRP. This resource has initially sought to test the robustness of the FRP, to provide some support and progress chasing to elements of the plan which are at risk and to identify potential mitigations. A range of schemes are under development to mitigate, at least in part, the risks demonstrated in the forecast tabulated above. Once these schemes have a sufficiently robust project plan and financial target, they will be incorporated in to the existing FRP schedule. The schemes with the most likely impact on the current financial year (i.e. short term) relate to improved procurement, improved stock management and reduced waste. Medium term projects delivering improved efficiency of human and other resources will be developed – a transformational approach is required to be applied to service delivery to begin to improve the financial health of the organisation.

Cost CategoryPlan

Current State

ForecastVariance

YTD Variance @

M07

Productivity 575.9 46.7 (529.2) 0.0

Agency - Nursing 1,276.1 951.1 (325.0) (78.4)

Bed optimisation 300.0 - (300.0) 0.0

Agency - Medical 263.0 13.6 (249.4) (22.8)

Admin 173.0 - (173.0) (28.8)

Merge PGMC with EDC 60.0 - (60.0) 0.0

Further Cost Control 160.5 93.6 (66.8) (4.2)

Off Payroll Contractors 68.0 18.0 (50.0) 0.0

WLI's 77.9 40.0 (37.9) 0.0

Recruitment/Retention 32.5 - (32.5) 0.0

CQUIN 150.0 120.0 (30.0) 0.0

Procurement to £600k CIP 95.0 76.0 (19.0) (3.2)New income 17.0 - (17.0) (2.8)

Bed Fund 15.0 - (15.0) 0.0

Agency - AHP 66.0 62.8 (3.2) (0.5)

Vacancy/skills mix 38.0 77.0 39.0 6.5

3,367.9 1,498.8 (1,869.1) (134.3)

£k Red Amber Green ASSUMED

All Execs - - - - -

HO 364.8 100.0 95.0 169.8 -

JB 1,091.1 573.2 - 415.9 102.0

LF 1,276.1 - 259.2 1,016.9 -

RB 11.5 - - - 11.5

SG 400.9 333.9 - 50.0 17.0

SS 223.5 205.5 - - 18.0

Total 3,367.9 1,212.6 354.2 1,652.6 148.5

RAG Rated Plan Plan

Director

of 171


Revenue Cash-flow Position

Nov-16 Dec-16 Jan-17

£000's £000's £000's

Inflows

NHS Contract Income 14,366 14,150 14,941

Non-NHS Income 208 258 258

Revenue Support Loans 9,643 2,139 3,355

Other Income (31) (31) (31)

VAT Recovery 1,100 126 126

CCG Advance (1,500) (1,500) 3,000

Total Receipts 23,786 15,141 21,648

Outflows

Salaries (Monthly and Weekly) (5,638) (5,676) (5,641)

Tax, NI etc (2,451) (2,451) (2,451)

Superannuation (1,538) (1,538) (1,538)

PFI Unitary Charge (11) 0 (5,722)

Other Fixed Payments (585) (357) (357)

Total Fixed Commitments (10,222) (10,021) (15,708)

Cash available for payments run (13,064) (5,129) (5,945)

Total Payments (23,285) (15,151) (21,654)

Net Cash Inflow/(Outflow) 500 (9) (5)

Revenue Cash bal bfwd 971 1,471 1,462

Revenue Cash bal cfwd 1,471 1,462 1,457

The cash flow position has been updated to reflect Month 7 receipts and payments and future month’s cash flow assumptions have also been reviewed to reflect the revised annual plan. In addition, the forecast includes the receipt of an additional cash injection in November, with smaller amounts being received during the remainder of the year. The cash is utilised to reduce the value of accounts payable outstanding. The cash received in November also includes funding for £2.936m of emergency capital expenditure which has been provided through revenue rather than capital sources. The Trust continues to draw down borrowing on a monthly basis in order to meet its regular commitments. The borrowing plan reflects the planned deficit included in the Trust’s 2016/17 annual plan. Note that the cash balance identified at month end incorporates the requirement to maintain a balance of £1m plus an estimate regarding capital funding drawn down in advance of payment. Capital funding is drawn down to match the accrued capital expenditure profile and therefore the cash balance will reflect the time lag between expenditure accrued and actual payment.

of 171


Capital Position

Capital EPR

Loan

Revenue

uncommitted

term loan Charitable Total

Month 7 YTD

Actual

£K £K £K £K £K

General Schemes

Estates

Backlog Maintenance 300 300 52

CAU redesign costs inc Gases 40 40 0

Underwrite Monkmoor 5 5 0

Project Management 150 150 114

Ledbury Road - Kite Centre 0 0 0

Interim works to 2nd Obs Theatre anaesthetic room to make safer 50 50 0

Estates - Other 76 76 37

Sub Total - Estates 0 621 0 621 203

Clinical Equipment

Anaesthetic machines (Theatres) - 16 machines required 0 0 0

Endoscopy scopes [Replacement in next 12 months] 0 0 0

SIFT Capital 150 150 0

Medicines Storage System (Pharmacy) 95 95 0

Contingency 172 172 0

2 x replacement ultrasound machines for Womens Health 99 99 0

Replacement ultrasound machines for radiology 99 99 0

Equipment - Other 219 219 27

Sub Total - Equipment 0 834 0 834 27

ICT

Intranet & Collaboration 72 72 0

Minor Injuries Unit migration to Symphony 20 20 5

Patient Wi-Fi 60 60 0

Digital Dictation UPGRADE 19 19 4

Ascribe system UPGRADE 39 39 0

ICT - Other 6 6 2

Sub Total - ICT 0 216 0 216 11

Total General Schemes 0 1,671 0 1,671 241

Estates Strategy

Fees for revised SOC and phase 2 enabling OBC & FBC 320 320 60

Phase 2 Enabling works (Year 1) 0 0 0

Phase 3 fees for Business Case 0 0 0

Total Estates Strategy 0 320 0 320 60

EPR Year 2

EPR (Year 2) 6,163 6,163 2,577

Total EPR (Year 2) 6,163 0 0 6,163 2,577

Donated

Midwifery Led Unit 0 0 0

Misc donated equipment 181 181 59

Mobile retinal unit 169 169 61

Total Donated Assets 0 0 350 350 120

Total 6,163 1,991 350 8,504 2,998

Funding Source and Revised Budget

Year to date The Trust had spent £2,998k at month 7 against a revised budget of £8,504k. The £658k expenditure during the month of October included: • £601k on EPR • £12k on backlog maintenance • £22k on project management of estates schemes • £16k on fees for revising the estates strategy SOC Capital financing The Trust has now received financing to support the £1,991k general capital programme (incl. estates strategy fees of £320k). This was given by DoH as part of an uncommitted term revenue loan, rather than a capital loan, and therefore is not automatically reflected in the Trust’s Capital Resource Limit (CRL). However NHSI has actioned a limit adjustment to ensure the Trust has sufficient CRL cover. Review of capital plan Following the confirmation of financing, the capital plan for 2016/17 has been reviewed in terms of; a) What is achievable in the remaining 5 months of the year,

and, b) The prioritisation of schemes which have moved from an

amber RAG rating to red since the original prioritisation exercise undertaken in March.

of 171


Single Operating Framework – Finance Score

20% Capital service capacity

Degree to which the

provider's generated income

covers its financial obligations

4

20% Liquidity (days)

Days of operating costs held

in cash or cash-equivalent

forms including wholly

committed lines of credit

available for drawdown

4

Financial efficiency 20% I&E marginI&E surplus or deficit / total

revenue4

20% Distance from financial plan

Year-to-date actual I&E

surplus/deficit in comparison

to Year-to-date plan I&E

surplus/deficit

4

20% Agency Spend Distance from provider's cap 4

4

Trust

Rating YTDArea Weighting Metric Definition

Total Finance and Use of Resources Score

Financial

sustainability

Financial controls

The framework was published in September 2016 and incorporates five key themes relating to, quality of care, finance and use of resources, operational performance, strategic change and leadership capability. This table focusses on finance and performance and the measurements adopted in order to arrive at an overall score for the Trust in relation to finance and use of resources. Each metric is calculated using a formula from information taken from the Trust's monthly financial monitoring submission to NHSI. The scoring ranges from 1 (highest) to 4 (lowest) score and the overall rating is a weighted average of the individual scores. If a provider scores 4 on any specific measure, the overall use of resources score cannot exceed 3. The table includes details of the Trust's rating as at Month 7. The Trust's year to date rating is 4, thus reflecting the challenges faced in terms of financial sustainability and the in-year deficit incurred.

of 171

TRUST BOARD MEETING

Report to: Trust Board ‘in public’ Agenda item: 12


Title of Report: Acute Hospital Clinical Services Strategy – update on implementation


Information


Lead Executive Director: Susan Gilby, Medical Director

Author: Alan Dawson, Associate Director of Strategy and Planning

Appendices: Strategy summary on a page


To update the Board on how the Acute Clinical Services Strategy for the Trust is being implemented.

2. Recommendations

That the Board notes this update report.


This document updates the Board on how this key organisational strategy is being used to form implementation plans. The strategy was consulted on widely over a long period of time and has clearly influenced the high-level Sustainability and Transformation Plans (STP) for Herefordshire and Worcestershire, the One Herefordshire transformation programme and the Trust’s internal planning process.


Background The Acute Hospital Clinical Services Strategy was approved by the Board in 2016. The strategy describes how the Trust will deliver high quality care in response to patient and carer feedback and commissioner requirements. It was developed by our staff and our partners and reflects their priorities for clinical services. The strategy set out our priorities for transformation for the organisation between 2016 and 2021 and set out what we need to do differently to develop our services; this included the development of new roles and skills, new ways of working and adopting new technologies. Turning the Strategy into Plans Having developed the strategy, this is now being turned into plans across a number of fronts: At a regional level the strategy has been used to inform the STP for Herefordshire and Worcestershire in the key workstreams of Maternity, Urgent Care and Planned Care. In each case the Trust has used the strategy to highlight the need for local services and the crucial clinical co-dependencies within an acute trust. At a local level the strategy is being used to inform the next phase of the acute workstream of the One Herefordshire transformation programme. This next phase is currently being finalised but is expected to support the delivery of the ‘unplanned care strategy’ (Appendix 1), particularly the implementation of the acute medicine model, and the delivery of some elements of the ‘planned care strategy’, particularly the work to improve the

of 171

clinical sustainability of smaller services. Within WVT, the strategy has been key to the operational planning process for the coming two years. When asking the two divisions to prioritise their plans for 2017-19, developments that delivered the Acute Hospitals Clinical Services Strategy were identified as one of the areas for prioritisation. The planning process is still underway and the divisions have submitted their first draft plans which include key elements of the strategy, such as:

Improving stroke care by working across a three counties footprint

Creating a number of new roles that replace roles that would have traditionally been carried out by medical staff or nurses

Creating joint clinical roles with other providers to improve service resilience

Improving urgent care

Improving the acute medical flow through the Trust

Improving trauma care

Delivering more services over seven days

Replacing the hutted wards with an integrated surgical unit

Improving access to key medical and surgical specialities Through the planning process over the coming weeks, the need for these proposals will be balanced against their affordability before being finalised in the Trust’s Operational Plan. Turning Plans into Actions Once the Trust’s Operational Plan is agreed the strategy will be delivered through the divisional teams, supported by corporate department and the plan will be monitored through the Trust’s usual performance management process.

of 171




High


Moderate


Low


High


High


High


Low


The Acute Clinical Services Strategy seeks to address a number of the risks identified in the BAF such as mortality rates, the urgent care pathway and the recruitment and retention of staff.

of 171

Appendix 1 – Summary on a page

Overarching Acute Care Strategy Focus on core acute care services and the services they are dependent upon

Optimise services for the older population

Deliver through a strategic partnership with another Trust(s) Developing new roles to replace traditional nursing and medical roles

Ensure low volume procedures are safe and effective

Increase capacity and availability of diagnostics across seven days

Integrate records with other providers and improve access for patients

Transform the estate to support the new model of care

Unplanned Care Strategy Increase cohort of acute physicians to deliver a seven day service Increase number of consultants in core medical specialities to deliver seven day cover Reconfigure beds at the County Hospital to create designated geriatric beds, increased speciality beds and a surgical assessment unit Increase bed capacity at County Hospital and reduce community hospital bed numbers Grow older peoples services to incorporate support to community teams / hospitals Link unplanned care to physical and mental health teams and primary care

Planned Care Strategy Deliver key specialities from a community setting where possible Focus on day and short stay surgery as a default Deliver high quality inpatient surgery in high volume specialities Increase elective capacity in core specialities Deliver theatre and OP services across seven days Deliver more services across three session days where efficient and effective Create additional physical theatre capacity and increase their utilisation Provide lower volume/more specialised care through networks with other providers Become a centre of excellence for specific complex procedures where there is high demographic demand

of 171

TRUST BOARD MEETING Report to: Trust Board ‘in Public’ Agenda item: 13 Date of Meeting: 1st December 2016 Title of Report: Electronic Patient Record Programme Highlight Report Status of report: (Approval, position statement, information, discussion)

Information

Report Approval Route: Programme Director & Programme SRO Lead Executive Director: Director of Finance and Information Author: Programme Director Appendices: Inform Highlight Report in Full

1. Purpose of the report Provide a monthly update on the current status and plan progress for the INFORM programme (electronic patient record) highlighting progress & issues for the current period and expected activity for the next.

2. Recommendations

The Board is asked to note the recommendations


This report has been reviewed by Programme SRO (Howard Oddy) with the assistance of the Programme Director and it is accurate and reflective of the current state of the programme.

4. Summary of Key Issues for discussion The programme remains on track for a 26th March go-live, although some difficulties have been experienced with the latest data migration test cycle and pressure is building from testing, data migration & data quality. The ‘go-Live’ release, version 12.0, is still on track for delivery to the Trust on 30th November 2016. IMS MAXIMS will be releasing the first of two updates that are required for go-live with the second update expected in mid-January. Training is expected to start mid-February. It is planned that invitations will be issued to staff before the end of the calendar year in order comply with the requirement of 6 weeks’ notice for clinical staff. It is recognised that, even with notice, this is likely to cause a level of disruption to normal operations. The overall programme status remains at amber, and there are recovery plans either in place or under development for all areas of risk.

of 171



and families High


Moderate


Low


High


High


High


Low


There are no risks on the Board Assurance Framework however the EPR Programme holds and manages its own risk register which is routinely reported into the Trust Management Board.

of 171

7. INFORM EPR Programme Status RAG Change on last period

Programme Overall: A A Programme Plan: G G

Programme Budget: G G Programme Director Summary: Overall the programme remains at amber for a second month, although there have been challenges with data migration testing and application testing planning. There have also been growing concerns regarding organisational readiness with many existing areas of the organisation being asked to cleanse data, develop new clinics etc. in preparedness for configuration of versions 12 and 12.1 of IMS MAXIMS when delivered in November and January respectively. These risks and concerns are being addressed through multiple means and channels and to-date have not affected the planned go-live for phase 1, which is set for 26th March 2016. Whilst confidence remains high with both the Trust and the supplier (IMS MAXIMS), the situation is being kept under constant review. Progress has continued well in this period, though not without some set-backs. Some of the functionality expected at the end of November from the supplier was moved without discussion to the second release in January and this was thus rejected by the programme. Consequently, it has now been agreed that the functionality will be delivered separately throughout December. This has not affected the overall delivery objectives for the programme but has put additional pressure on the reporting and interfacing work streams. There have also been some problems with one of the data migration testing cycles, but these were found to be due to a technical problem rather than one associated with the data or Trust activities and were subsequently rectified. The first tranches of new computer equipment have been ordered and will start to roll-out over the next few weeks. Also, significant upgrades to the wired and wireless networks commence in December that will address issues that have previously been identified.

8. Key Programme Achievements for reporting period up to 23th November 2016

• Data Migration cycle 4 (of 12) completed, later than planned but recovered after an initial technical problem.

• Phase II scope workshop was undertaken with IMS MAXIMS in attendance, to build on the work already undertaken and to build the requirements for the next phase of the programme that will add more clinical involvement and input into the system and move the Trust towards a paperless organisation.

• Initial order for desktops and specialist computing devices has been placed with that equipment identified as unsuitable for the EPR system being replaced first.

• Detailed go-live planning commenced; this is the day-by-day and hour-by-hour plan that helps us to manage the cut-over from our existing PAS and ORMIS systems to the new EPR next year.

9. Planned Key Activity next reporting period up to 23th December 2016 • The key release of IMS MAXIMS software that will be the backbone of the system that we go-live with next

year will be delivered at the end of November. This release will then be checked to ensure that it contains the functionality that we are expecting and then the configuration work that has already taken place on the existing version will be applied to version 12, followed by data migration testing and user acceptance testing. This is the major activity for the next period, though there are a number of other key activities also

of 171

expected for December: - • Some training is already underway for system champions, including basic computing skills. The next period

will also see the release of invitations to the staff throughout the organisation for the bulk of training in February and March next year.

• New equipment and network upgrade will commence to roll-out throughout the period. • Numerous communications and awareness sessions are being planned to build awareness of the

programme. • Organisational readiness will be receiving more focus through the next period with encouragement to

complete information requests and data cleansing activities.

10. Summary Timeline for EPR Phase 1 (v.26 plan)

of 171

11. Programme Workstream/Work Package Reports PLEASE NOTE * DENOTES AREAS WHERE PARTICULAR FOCUS IS REQUIRED TO MAINTAIN THE CURRENT STATUS

Workstream/Work package THIS LAST Narrative/Commentary

Programme Plan A G

• Overall the plan remains on track but is coming under a degree of pressure with vigilance required to ensure that critical path activities do not slip.

• Latest plan shows a Phase 1 go-live of 26th March 2017

• The amount of testing required remains a concern an additional resource is/has been identified to mitigate this.

Programme Team G* G*

• Extra effort is required to ensure that resourcing issues are identified and managed quickly and effectively.

• Additional resource brought in to support testing and training workstreams

• A long standing vacancy in the Theatres workstream has now been filled which will gives confidence that that particular workstream will catch-up quickly.

Data Migration G* A

• A Data cycle failure was resolved after a technical issues was identified by IMS MAXIMS and consequently, successfully re-run

• Over all, the data migration work stream is running 6 days behind plan but is expected to catch up over the next few weeks.

Reporting G G

• The development work by the information team is progressing well and is expected to complete on time.

• The news that we will not have to wait until version 12.1 is released in January to receive the CDS extract information is very welcome

• The programming support resource for reporting has been extended till the end of February to support the information team and provide assurance.

Infrastructure G G*

• The physical and wireless network upgrades have commenced and the work will be continuing throughout the trust for the next couple of months.

• Slow site connections have been identified and will be upgraded to ensure they do not impact on the performance of MAXIMS.

• Initial orders for new computers have been placed and their roll-out will commence in the next 2-3 weeks.

of 171

Integration/Interfacing G* G

• There are some concerns regarding the messaging composition and completeness being provided by IMS MAXIMS. However, overall this work stream is progressing well with targets and development being delivered on time.

Business Change A G*

• Resourcing levels for BC are under constant review and concerns around progress on the future process maps have led to an effort to identify additional resource for this workstream, overall the workstream is progressing well but is being monitored closely.

Communications G G*

• Multiple engagement and awareness opportunities are being undertaken throughout the Trust and will be expanded over the next few weeks.

Testing A G

• There is a significant amount of User Acceptance testing to be completed throughout December and January and additional resource has been allocated and is still being sought to ensure that this is done thoroughly and safely.

• A recovery plan is in place to ensure this is managed to plan.

Training G* G

• The amount and impact of training has not been underestimated with multiple channels for training being explored as well as the established classrooms.

• With the expected invitations to training planned to start being delivered in December, activity in this area is expected to increase quickly.

• Currently we are attempting to fill two vacancies in training.

System Configuration A A

• This workstream remains amber due to the existing knowledge of the amount of configuration that will need to be done for version 12 and 12.1 of the system.

• It will be hard to find additional resource to augment this area, should it be required, because of the requirement for existing knowledge of the configuration work already completed earlier in the year. Nevertheless options are being explored.

of 171

Organisational readiness A* N/A

In order to configure the system and make ready for final data migration and go-live, the Trust has been asked to undertake tasks ranging from designing new clinics, data cleansing, correspondence review through to general information about practices and processes. This effort has not been reported on before in this report and is included here now as it will have a bearing on the success of the programme.

• In some areas, the response to requests for information from the Trust has been excellent but in others it is clear that there are many competing priorities. As a programme, we are working directly with Trust management and senior management to address issues that are impeding programme work but more needs to be done.

of 171

Trust Board

Report to: Trust Board Agenda item: 14.


Title of Report: Draft Sustainability and Transformation Plan


Information


Lead Executive Director: Glen Burley, CEO

Author: Alison Roberts, STP Programme Manager (H&W)

Appendices: STP Summary


To share the latest draft of the Sustainability and Transformation Plan (STP) for Herefordshire and Worcestershire, outline the engagement process designed for the plan and next steps.

2. Recommendations

The Trust Board is asked to:

Note that the Herefordshire and Worcestershire STP was published on Tuesday 22 November 2016.

Note the document is intended for discussion and public engagement – it is not a final plan at this stage.

Note that formal approval of the final plan will be sought at the end of the public engagement and discussion process.


This version of the STP has been developed to the point that it can be used to engage our staff, patients and the public about the sort of changes that are required to local health and care services. For this reason, the document is still draft and there is still time to influence its direction. WVT have been involved with a number of the STP workstreams such as Maternity, Urgent Care, Planned Care, Workforce and Finance. The development of operational plans are also linked to the STP and the Trust is expected to develop plans that deliver the first two years of the five year STP.


Introduction On 22nd December 2015, NHS England issued the annual and long term planning guidance. As well as the requirements for a two year operational plan, this guidance called for the development of whole system (STP) covering a defined “planning footprint”. The planning footprint agreed for this area was Herefordshire and Worcestershire – a footprint covering a population of approximately 780,000 people. There are 44 footprints nationally, with the average sized footprint covering 1.3m people and the largest footprints covering 2.8m people.

of 171

Purpose of the STP The STP builds upon local transformation work already in progress through One Herefordshire, Well Connected and the Future of Acute Hospital Services in Worcestershire and other local transformation schemes. The purpose of the STP is to develop the opportunities for local bodies to work on a more sustainable planning footprint in order to address the Triple Aim Gaps:

Health and Well Being - The main focus being on achieving a radical upgrade in illness prevention to reduce the long term burden of ill health – both from a quality of life perspective for individuals and a financial perspective for the health and care system.

Care and Quality - The main focus being on securing changes to enable local provider trusts to exit from the CQC special measures regime and to reduce avoidable mortality through more effective health interventions in areas such as cancer, stroke, dementia, mental health and improved maternity services.

Finance and Efficiency - The main focus being on reducing unwarranted variation in the demand and use of services and securing provider efficiencies through implementing new approaches to care provision

Work undertaken to date There have been four main phases to the development work to date:

Phase 1 – Undertake an initial gap analysis to identify the biggest areas of concern across the triple aim areas – This phase of work was undertaken during March and April 2016.

Phase 2 – Define and understand the challenge arising from this gap analysis – This phase of work was undertaken during April, May and June 2016.

Phase 3 – Consolidate existing ideas and develop new ideas and themes to address the challenge – This phase was undertaken during July to October.

Phase 4 – National review and assurance to assess how well the local ideas and themes meet national priorities – This phase was undertaken during October and November.

Publication The STP for Herefordshire and Worcestershire was published on Tuesday 22nd November 2016. With two documents published – the full STP and a public summary version. These are available on the following websites, with a link from individual organisation’s websites within the STP footprint: http://www.yourconversationhw.nhs.uk Engagement The plan itself outlines in detail our proposed communication and engagement process. It is important to emphasise that this is not a final plan. It is a proposed plan for engagement and discussion. This period of engagement and discussion will take place between November 2016 and March 2017. At the Board meeting in April 2017 we will receive an updated plan that takes account of the discussions that have taken place. Equally it is important to note that the engagement process is not a formal consultation on the plan. This is because the plan sets out the challenges we face and some of the ideas and themes we have identified to address those challenges. It does not set out specific service changes. Any specific service changes will be developed through engagement with patients and the public and will be subject to the formal legislative consultation process as appropriate to the scale of the change. Next steps

of 171

The NHS planning process requires NHS organisations to produce annual operational plans. This year, the process requires that we set out a two year operating plan and that we use the STP as the basis for developing this plan. The normal NHS planning cycle calls on these plans to be produced during January to March, for sign off in April and implementation from the beginning of the next financial year. This year the process has been brought forward by three months and operational plans are expected to be finalised by 23rd December. We are therefore currently in the process of developing a single STP system operational plan across the four CCGs with providers developing individual operational plans reflecting the relevant parts of the STP delivery plans for 17/18 and 18/19.



and families High


Moderate


Low


High


High


High


Low


The STP addresses a number of risks on the risk register.

of 171

Health and care services in Herefordshire & Worcestershire are changing An update on a five year plan to provide safe, effective and sustainable care in our area

www.yourconversationhw.nhs.uk

Your Health & Wellbeing

#YourConversation

of 171

Across Herefordshire and Worcestershire, health and care organisations are committed to providing safe and effective services, but the way some services are run may need to change.

This is because we have a growing population with people living longer than ever, but as we age our health needs change. This leads to rising demands on services, and we want to make sure we can provide safe and effective services with the resources available.

We are also experiencing some practical issues in our area:• Recruiting and retaining staff is a challenge• Our health, local authority and other care

services are not always joined up, designed to meet people’s individual needs and do not always balance physical health with mental health and wellbeing

• We spend too much of our time and resources treating illnesses which can be prevented or supported in different ways

• On current projections, we won’t have enough funding to meet expected levels of demand

All of this means we have to make some really tough decisions about how we provide and access care, treatment and support in our local area. By working together as organisations and with our patients and communities we think we can do lots of things better, but we also have to be clear that we can’t carry on doing what we’ve always done, and some hard choices are required which may mean some things being delivered differently, or not at all, over the coming few years.

Why our health and care services need to change

of 171

#YourConversation This update provides some thoughts on how health and care service could change to help us continue providing safe, effective and sustainable care and support. We won’t make these tough choices without the views of patients and our wider communities and while there may be constraints on what is possible, there will be lots of opportunities to get involved in helping shape things moving forward. The information described in this update are some initial thoughts and concepts, they are not set in stone.

This is your health and wellbeing, and therefore #YourConversation so we want you to let us know what you think. Details of how you can do this are at the end of this document.

What you’ve told us is importantOver the last few years health and care organisations across Herefordshire and

Worcestershire have been out and about listening to feedback on services and the way care has been organised. This has helped inform some of the thoughts described in this document. We have heard that:• You want to receive more care at home or as

close to home as possible• You want us to provide more care, including

urgent care through GP practices• You want better communication between

teams/staff so you don’t have to repeat your story over and over again

• You want to access the right service, first time but often it is not clear how to do this

• You and your family want to be part of developing your care plan, and you want easy access to help and support

• You want to be empowered to self-care aspects of your conditions where this is appropriate

• You want improvements in the range of mental health services and support so you can access help before things get too serious

• Transport needs to be key consideration in any proposals to change how services are provided.

of 171

Our vision:Local people will live well in a supportive community with joined up care underpinned by specialist expertise and delivered in the best place by the most appropriate people.

In reality this will mean:• Organisations working better in partnership to

make services easier to navigate and access• We all need to do more to support healthy

living, or to self-care and manage aspects of our conditions ourselves

• Improving parity of esteem between mental and physical health, so both types of conditions are viewed equally

• Providing more care in the place where you live or closer to home, reducing avoidable hospital admissions

• Making our current out-of-hospital system more efficient and effective

• Improving access to urgent care• Ensuring our specialist services are safe and

sustainable

Safe, effective and sustainable

of 171

Prevention and self care

We know there are lots of serious and long-term health conditions such as diabetes, stroke and heart disease which in lots of cases can be prevented.

We also recognise that if we can encourage healthy living within children and young people then they are likely to take their healthy life choices into adult hood, which will help prevent the kinds of illness which are influenced by lifestyle. We also want to encourage children and young people to get active and healthier now so avoidable health issues, for example those triggered by obesity, can be prevented.

We want to view prevention and healthy living as everyone’s responsibility, and not just an issue for health and social care organisations. We want

to work better with housing providers, schools, colleges and local businesses, and we also need to empower local communities, voluntary sector organisations and other community groups to help put physical and mental wellbeing at the heart of our communities.

When someone does get ill we want to be better equipped to support them and their families with tools to stay independent and in control which lots of people tell us is important. We want patients to become equal partners with those caring for them; make more decisions about their own treatment plans; ensure timely advice and support; and to enable them to become increasingly confident to manage their own conditions supported by useful and usable technology. For example, the number of people living with dementia is increasing,


of 171

but early diagnosis and support can help people to live as well as possible. We want to support people who notice that their own or a loved one’s health is deteriorating, so that they can make timely decisions about the support they might need to live independently and safely and so that carers are supported and able to keep themselves well.

CarersCarers are key to providing safe and effective out of hospital care however they don’t always get the recognition and support they need to;a) help and support the person they care

for to safely manage their condition at home,

b) stay well themselves so they have the resilience to fulfil their caring role.

We need to work with carers to better understand the impact of any changes we make.


Patient story– KateKate was a real sports fan but an injury stopped her playing for a few months and she struggled to get back in to it. By the age of 40 Kate did little exercise herself. She was stressed at work, and because she was putting in long hours she had become over reliant on fast food. On a regular check-up at her GP, Kate was told she was quite overweight and that there was a risk of developing diabetes as well as other health conditions if things didn’t change. She was encouraged to change her lifestyle habits and was put in touch with a fitness coach who could recommend an exercise programme. She downloaded an app so she could access healthy food options, and was put in touch with primary care mental health teams which provided help to alleviate stress and

anxiety. The fitness programme helped her get back into shape and when things do start getting too much at work, she has some self-help tools to keep things manageable. She’s now thinking about re-joining her tennis club as well joining a local amateur running club to maintain her new found fitness.

of 171

Getting an appointment at my local GPIt can be really frustrating ringing for a routine GP appointment and being told you may have to wait two or three weeks. We also know that once you get one, the consultation with your GP is often restricted to just 10 minutes. This is because demand on GPs is increasing too, making it almost impossible to get same day appointments in some of our surgeries.

We think there are opportunities for local surgeries to pool their resources to more effectively share some of the demand. We also need to think, ‘if I need an appointment, does it really need to be with my preferred GP’?

There may be times and circumstances when that is appropriate, but in lots of cases people have illnesses or conditions which can be just as effectively dealt with by a nurse who works in the local surgery.

This could help people get appointments much sooner, get the help and treatment needed, reduce demand on GPs, and ensure when someone really needs to see the GP they have a better chance of getting an appointment quicker. If this works we also want to increase the consultation time for those who need it.

We also want to develop our local community teams with input from local GPs to help maintain someone’s health at home and reduce the risk of them being admitted to hospital unnecessarily.

Providing more care at home

Most admissions in people over 75 have bypassed GPs or out-of-

hours services. Older people are more likely to call an

ambulance, more likely to be conveyed to hospital,

and once there, more likely to be admitted.

of 171

Providing more care at home or out of hospitalWherever possible we should ensure that people do not get admitted to hospital unless they absolutely need to be there. Currently too many people are admitted to hospital for issues which could reasonably be treated at home or in the place where they live. We also know that once admitted to a hospital bed, sometimes people stay there longer than necessary. This can actually have a bad effect on someone’s health so we want to make sure they can leave hospital as soon as they are well enough.We have services which are equipped at providing

care at home and reducing the risk of hospital admission; for example we have teams which support children with complex conditions at home; we have community nursing and therapy teams who help manage long-term issues at home or in care homes, including dressing wounds and support with medication; and we also have social care teams which provide domiciliary care at home, such as supporting someone preparing meals, dressing and washing.

However these services don’t always work well together and the communication between the teams could be better. By working better in partnership we think there are real improvements to be made to the care we are able to give people at home.

Providing more care at home of 171


How could we do this?More than 70% of hospital bed days are occupied by emergency admissions, so we want to reduce the risk of emergency. We will do this by developing multi-skilled teams who will work around a person at home, helping reduce unnecessary admission to hospital.

The physical and mental health nurses, therapists and social care professionals will all be part of one team who will get to know the person and their medical history. There will be one contact point which can be used whenever additional help is required. There will still be health issues, but wherever possible these can be dealt with at home by the local team who will work on the principle that ‘your own bed is best’.

If someone does need to be taken to hospital, the team will know about it and will ensure they are able to leave and return home without delay. Delays in getting discharged from a hospital bed can be a real problem, often caused by challenges arranging social care or community support back home. But the local team will be able to sort this out much more quickly and easily, reducing the chance of any delay.

We could also support this by developing something called an ‘integrated frailty pathway’, which in simple terms is about ensuring those identified as being at greatest risk of being admitted to hospital have access to staff who can provide 24 hour care in their home. It is also about having real alternatives to hospital admission when someone needs more care than we can deliver at home.

GP Practice

Therapists

Social Workers

Nurses(Physical & Mental health)

of 171


Patient story – Margaret and Len After she turned 80, Margaret found her health deteriorating. She was diagnosed with diabetes and emphysema (COPD), as well as early stage dementia. She lives with her husband, Len, who is also in his 80s, and who has his own health issues.

Margaret’s GP said she needed to be supported by the local community nursing team. Angela, a member of the community team, is her care coordinator and following an initial visit, quickly arranged what support Margaret needs from the rest of the team. Margaret is visited a few times a week, once by a nurse, then a therapist and finally from a mental health professional to support her with her dementia. A social worker will also visit to help with any domiciliary care needs. As each of them are part of the

same team they each have up to date notes on Margaret’s condition and she gets familiar with all of them, building up a rapport and an understanding. There is a contact number which she or Len can use if there is a problem. They have only used it a couple of times but on each occasion someone from the team have been out to check on them, and have been able to provide additional support without them needing to go to hospital.

There are volunteers from a local carers charity who are also part of the team and they contact Len regularly to check he’s coping well too. They also give him support to maintain his own health.

of 171

We believe ‘there is no health without mental health’ and so through partnership with other public services, local business and communities we will support people to understand how to keep themselves well, and how to access support and guidance if they need it.

Sometimes people will need expert care and at the moment, particularly for children and young people, this might mean travelling to another part of the country. We want to be able to provide specialist care in our two counties so that people can stay connected to their families and friends whilst they recover.

Having a baby is often a joyful event but sometimes it can affect people’s mental as well as physical wellbeing. We are committed to ensuring that staff supporting women and their families through pregnancy childbirth have the skills to support women’s mental and physical health needs.

Living with complex mental health problems can also affect some people’s physical health. We will prioritise how we use our resources so to reduce the impact this has on people’s quality and length of life.

We want to support more people with mental health issues early to prevent issues escalating, and then at home or in the community when more care is needed. This is what people tell us is important.

When admission to a mental health ward is required this should be more recovery focused and designed to help people get back home quicker so they can regain control and independence over their lives.

Mental health and well-being


Patient story – AdamFollowing a family bereavement Adam had become increasingly isolated and had withdrawn from his social circle. He had even told a colleague at work that he couldn’t continue with things the way they were. He was persuaded to seek help and after the GP referred him to the local mental health team he was diagnosed with severe depression. He was in the care of the community mental health team who visited him regularly at home to check he was doing ok; Adam had a contact number he could use if he felt really unwell. Adam’s depression meant he had to give up work, but through the support of his mental health nurse he was put on a work placement programme which provides opportunities for those recovering from a mental health problem to get back into employment. He really benefitted from this and is now starting to apply for part-time work. Because he’s made

so much progress he’s been discharged from the community mental health team, but he has lots of self-help resources which he can refer too, and he also has contact details for primary care services which can help those with more common mental health illnesses.


Community Hospitals

These alleviate pressure on the acute hospital sites and traditionally provide short-term in-patient support for someone who can’t stay at home, but neither are they too poorly that they require the specialist expertise of an acute bed.

Community hospitals will play a key role in our local system, and we believe there is potential for some of them to do even more than they currently do.

This would mean even more services provided in the local community, closer to home. As we provide more responsive local support in people’s homes, we do think the use of community hospitals might change.

We will be working with stakeholders to understand how many beds we may need and how community hospitals could offer a broader range of services such as more outpatient or day case activities.

Safe and effective hospital care when you need it of 171

HA&E

Urgent Care

Sometimes we all need urgent care for an emergency or life threatening condition and we want to make sure that the right care is available across our two counties, 24 hours a day. This is about getting someone in this position the right care they need when they need it and in the most appropriate place without unnecessary delays.

But we also know that many people go to A&E when they could have been treated elsewhere. This overloads the services and leads to long waiting times and too many people waiting on trolleys in corridors.

To help understand the pressures in A&E we have been looking at A&E attendance, performance and staffing levels to ensure that people who really need it are getting the best service possible in the right place, from the right professionals who have the skills to meet people’s physical and mental health needs.

We also need to strengthen the range of 7-day services and support for both physical and mental health issues, to prevent people getting in crisis and requiring urgent care services. This links back to the improvements we want to make to our out of hospital services.

In Herefordshire we have already worked with the public and local clinicians to identify what outcomes are important to people, and how we can best meet their urgent care needs through local services. We have used this to look at what changes we might need to make and we will be consulting on this in the coming months.

Safe and effective hospital care when you need it of 171

Acute Hospitals

By preventing the risk of avoidable hospital admissions and by moving some activity into the community, this will help ensure that only those with an acute medical condition need to access an acute hospital, and when that is required they don’t have to stay any longer than required.

Given some of the challenges we have recruiting to certain specialist roles, we want to ensure they are sustainable so we aren’t spreading our resources too thinly which is a risk. We need to make sure we have the right staff equipped and skilled to provide the specialise care needed. This might mean having to travel further in some cases in order to get the safest and most effective care possible. Some services are already delivered in a specialist ‘centre’ which is safer and more clinically appropriate, for example: • Major trauma – if you are in a car accident

and suffer a head injury you are taken straight to a major trauma centre out of county

• Stroke – anyone who has a stroke in Worcestershire is treated at the Worcestershire Royal where a specialist stroke team is available to provide the highest level of care

• Heart attacks – if you have a heart attack because your arteries are clogged up you are likely to need a stent (a small tube) to re-open them. This is done in a specialist centre in Worcester where there are highly trained staff capable of carrying out this life saving procedure.

Safe and effective hospital care when you need it

Ten days in a hospital bed for someone over 75 leads to a 10% loss of aerobic capacity and

14% loss of muscle strength – equivalent

to 10 years of life

of 171

Using our land and buildings better:

We want to bring all our NHS and local government sites up to modern standards. We want to make better use of our out of hospital sites, which may mean selling some buildings to invest in other modern, local facilities.

We want to explore how we can work together to get more value from our land and buildings.

Using technology to modernise health:

Good information and advice helps people take control of their health. Shared information will help hospital clinicians, GP practices, local community teams, which include health and social care, to work together more effectively. Technology will help us to provide more rapid and reliable information for patients, and our clinicians will make sure technology is built into new services, with support provided for those who might need it.

A sustainable system of 171

Finances

We will receive more money over the next five years but on current projections it won’t be enough to meet the continual rise in demand. Even with the increase in funding, if we do nothing the gap between what we receive and what we would need to meet that demand will be around £230million.

We have thoroughly reviewed our finances, including making comparisons with national

figures, looking for opportunities to secure savings and ways to organise services more efficiently. We continue to look at the demands on services and our costs.

We think the types of changes described in this update will help us save money and ensure we have sustainable services long-term. We cannot continue overspending as it puts services at greater risk so while the quality of care will always be our priority, we will also have to make sure we are using our resources the best we can.

But with demand increasing

it’s expected that we’ll need an additional

£230m unlesswe act now

The amount we currently receive

£1.17 billion

2016

The amount we will receive

£1.37 billion

2021

A sustainable system of 171

In summary, we will...• Maximise efficiency and effectiveness

across clinical, service and support functions

• Put prevention at the heart of what we do, and create an environment where people stay healthy supported by resilient communities

• Improve our services which care for people at home or closer to home, supported by GPs working alongside community teams

• Ensure acute sites have the capacity to provide the care the staff are trained to provide

• Ensure our specialist services are safe and sustainable

• Involve and engage our communities before any significant changes to services.

of 171

Safe and effective hospital care when you need it

Urgent Care

Improving access to urgent or emergency care when you need it, in the right place first time.

This will ensure there is capacity for emergency/ life threatening care when it is required.

Your local GP surgery

Caring for you at home

More health and care services will be provided at home with one local team who know you and your medical history• More people cared for at home• Fewer admissions to a hospital bed• Getting you out of hospital as soon as you

are medically fit to leave

Hospital beds

Community HospitalsThe role of these might change and could provide more outpatient clinics which support the plan to deliver more services closer to home.

Acute hospitalsEnsuring that only those with acute conditions which require specialist care access acute hospitals.

Therapists Nurses(Physical &

Mental health)

Social Workers

Reducing duplication Better use of our buildings The right workforce Partnership working



We will ensure that prevention and self-care are at the heart of the health and care services we provide. We need to encourage healthier lifestyles, and empower people to take greater responsibility for their own health, so together we can help prevent issues and illnesses which are influenced by lifestyle.

We also want to support more people to self-care more of the day to day aspects of their conditions, and to only access the support of healthcare professionals for the complex bits.

When you are medically fit to return home you will, without delay.

A sustainable system

of 171

Produced by Herefordshire and Worcestershire Sustainability and Transformation Programme. November 2016

Your health and wellbeing in

Herefordshire and Worcestershire

#yourconversation

We want your views on the information in this update which provides some thoughts for how health and care services may changeoverthenextfiveyears.

There will be more details to follow and we won’t make any significant changes until we have carried out full engagement and consultation work with our patients, staff and

the wider community. You can join in the conversation online at:www.yourconversationhw.nhs.uk or by following the organisations on social media.We will be getting out and engaging our patients and local communities on this update over the next few months and we will be publicising events and engagement activity at www.yourconversationhw.nhs.uk

Your Health & Wellbeing

#YourConversation

of 171

trust board meeting the boardroom ... - wye valley nhs trust · trust board meeting the boardroom,...

Documents