Trust Board papers November 2012 - Barking Havering and ...

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1. Introduction Under the Local Authority Social Services and NHS Complaints (England) Regulations 2009, all NHS bodies are required to prepare an annual report on complaints received. The report should include the number and subject matter of all complaints received during the year, the number upheld, the number known to have been referred to the Parliamentary and Health Service Ombudsman (PHSO) and any actions taken to improve services as a result of complaints. This report provides a summary of complaints received by Barking, Havering & Redbridge University Hospitals NHS Trust (BHRUT) in relation to its own services during the period 1 st April 2011 - 31 st March 2012. 2. Overview of the Complaints Service 2.1 Barking Havering & Redbridge University Hospital NHS Trust (BHRUT) complaints service is accessible to all patients who have used the services provided by the Trust. Specifically these services are delivered on the two main hospital sites - King George Hospital (KGH) and Queen’s Hospital, but also include any outreach services provided. Every effort is made to ensure that complainants are able to access the service in a way which meets their needs. The service operates Monday to Friday, 9am - 5pm. The Complaints Team can be contacted in the following ways: Telephone - there is a dedicated complaints telephone number which is supported by an answer phone facility at busy times and outside of core working hours. Email - there is one dedicated complaints email address where enquirers can send their complaint. Letter - enquirers can write to the Complaints Team at either of the two main hospital sites. The complaints process in the Trust is for all formal complaints to be received, logged and acknowledged by the core Complaints Team. They are then sent to the Directorates who are responsible for liaising with the complainant, agreeing the complaint plan, agreeing appropriate response times, undertaking a full investigation and providing a draft response. The core Complaints Team then resume responsibility for the complaint, checking the investigation and response before it is reviewed and signed by the Accountable Officer. During 2011 - 2012, the core Complaints Team was resourced by: 1 WTE Band 7 Complaint Manager 1 WTE Band 6 Complaint Manager 2.92 WTE Band 4 Complaints Administrators The service is also supported by four Band 3 Directorate Complaint Co-ordinators and adhoc Directorate administrative support as needed. During 2011 - 2012, the budget for complaints was £305,131. 3
3. Complaints Activity 3.1 Total Complaints Received During the year, the Trust received 1096 formal complaints. There was a significant rise in the number of complaints received this year compared with the previous year of 671. During the year, the Trust was the subject of a Care Quality Commission (CQC) investigation which highlighted a number of areas of concern across the Trust, and the increase in the number of complaints received reflects this. The chart below shows the total activity received on a monthly basis: 140 120 100 80 60 40 20 0 April May June July August September October November December January February March Each complaint is assigned to the relevant Directorate it is regarding and the chart below demonstrates the percentage of total complaints received for each Directorate. 21% 10% 2% 33% C.D.T Corporate Non Clinical Medical Surgical Women And Children 34% 4
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TRUST BOARD MEETING Wednesday, 7 No
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2 Following Mr White’s concerns r
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4 forecast in terms of community be
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6 The Trust Board noted the Plan fo
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8 The Co-Chair of the Improving Pat
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TRUST BOARD MEETING Actions from Mi
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Agenda Item Action Deadline Date Da
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Question: Mr Skillman was pleased t
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CQC Trust-wide Action Plan Review a
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1.0 PURPOSE 1.1 Background This rep
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• Review the Senior Responsible O
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APPENDIX 1 ‐ CQC ACTION PLAN - EX
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RECORDS records management to ensur
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CQC Update Report 2012 Theme CQC Re
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CQC Update Report 2012 ASSESSING &
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CQC Update Report 2012 ASSESSING &
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CQC Update Report 2012 pathways thr
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CQC Update Report 2012 identified i
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CQC Update Report 2012 outlining th
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CQC Update Report 2012 improvements
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CQC Update Report 2012 aware of the
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CQC Update Report 2012 are now supe
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CQC Update Report 2012 autumn. RECO
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CQC Update Report 2012 of the pilot
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EXECUTIVE SUMMARY TITLE: Informatio
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INFORMATION GOVERNANCE STRATEGY 201
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Information is a vital asset in ter
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starters as well as being mandatory
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The standards are split into the ar
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10a Reapproval of IG training progr
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343 Directorate Anaesthetic: Risk:
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Table of Contents TRUST PRINCIPAL O
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BHRUT STRATEGIC OBJECTIVES WITH EAC
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DIRECTORATES RISKS REVIEW 12 10 8 6
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RISKS DETAILS PRINCIPAL RISK What c
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PRINCIPAL RISK What could prevent t
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RISK DESCRIPTORS OBJECTIVE SAFE, HI
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BOARD ASSURANCE FRAMEWORK ELEMENTS
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EXECUTIVE SUMMARY TITLE: Risk Manag
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Contents Section Page 1 Introductio
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incorporate mitigation controls wit
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“Risk Register” “Risk Registe
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potential risks they may face in ac
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4.1.1 Quality and Safety Committee
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• Financial risks: risks associat
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Proactive risk assessment enables t
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Trust’s risk matrix and will popu
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Risk Grading Staff Group Evidence R
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4.8 RISK REGISTER The Risk Register
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5.1 Consultation and Communication
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The Trust recognises the importance
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Page 109 and 110: Checklist for the Review and Approv
Page 111 and 112: Equality Impact Assessment Tool To
Page 113 and 114: Plan for Dissemination of Procedura
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Page 117 and 118: Frequency How often might it/does i
Page 119 and 120: Appendix 3 Framework for Risk Manag
Page 121 and 122: Risk Register inventory they are ex
Page 123 and 124: 2. DECISION REQUIRED: CATEGORY: The
Page 125 and 126: • A review of data capture to ens
Page 127 and 128: Pilot Wards Division Discharges Per
Page 129 and 130: Workforce Appraisals - the actions
Page 131 and 132: Delayed transfers of care (DTOC) -
Page 133 and 134: EXECUTIVE SUMMARY TITLE: Emergency
Page 135 and 136: • Training competencies are being
Page 137 and 138: Appendix A: Trajectory for all type
Page 139 and 140: would welcome feedback from the Tru
Page 141 and 142: Maternity Services Monthly Performa
Page 143 and 144: 4. Capping The maternity service is
Page 145 and 146: 7. Obstetric Assessment Unit (OAU)
Page 147 and 148: 10. Serious Incidents Reported Inci
Page 149 and 150: 12. Maternity Dashboard The dashboa
Page 151 and 152: It should also be noted that the ta
Page 153 and 154: Priority Action Lead Monitoring Too
Page 155 and 156: Priority Action Lead Monitoring Too
Page 157: Contents Section No: Description Pa
Page 161 and 162: 3.5 Themes General care issues and
Page 163 and 164: Corporate Non Clinical Category Num
Page 165 and 166: order to resolve concerns. Particul
Page 167 and 168: The findings of the review were tha
Page 169 and 170: SELF-CERTIFICATION RETURNS Organisa
Page 171 and 172: 12 AA - Quality Improvement Strateg
Page 173 and 174: TFA Progress BHR University Hospita
Page 175 and 176: 25 TFA - Final IBP /; LTFM Dec-12 H
Page 177 and 178: Effectiveness GOVERNANCE RISK RATIN
Page 179 and 180: Safety 4b MRSA Enter Are you below
Page 181 and 182: FINANCIAL RISK RATING BHR Universit
Page 183 and 184: CONTRACTUAL DATA BHR University Hos
Page 185 and 186: 4 Single Sex Accommodation Breaches
Page 187 and 188: TITLE: EXECUTIVE SUMMARY BOARD/GROU
Page 189 and 190: causes/ Not specified' will be remo
Page 191 and 192: Staff In Post Starters & Leavers FT
Page 193 and 194: TURNOVER Actual Versus Target Annua
Page 195 and 196: FTE Lost due to Sickness Absence by
Page 197 and 198: The data on the previous page has b
Page 199 and 200: Indicator Target Apr-12 May-12 Jun-
Page 201 and 202: Starters *¹ 7.00 3.60 5.00 7.43 6.
Page 203 and 204: EXECUTIVE SUMMARY TITLE: COST IMPRO
Page 205 and 206: Month 6 CIP Performance Workstream
Page 207 and 208: Governance The Cost Improvement Pro
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1 REPORT TO: REPORT FROM: Trust Boa
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3 Preparations for winter planning
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5 Preparing the Payment by Results
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7 People with dementia to receive m
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9 Clinical Patient Management and H
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102/2012 Apologies Apologies were r
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Action Members were advised that ac
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Action 115/2012 Any Other Business
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EXECUTIVE SUMMARY TITLE: Finance Re
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1. EXECUTIVE SUMMARY Monthly I&E Ru
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Trust I&E summary by Division/Direc
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Income by POD In Month Year to date
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Devolved income Annual Budget Forec
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4. BALANCE SHEET Balance Sheet Curr
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6. Business Unit Summaries Attached
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Trust Board papers November 2012 - Barking Havering and ...

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