Agenda and papers - Plymouth Hospitals NHS Trust

Plymouth Hospitals NHS Trust 

Trust Board Meeting on Friday 30 April 2010 

Board Room, Derriford Health & Leisure Centre 

1.30pm Opportunity for Questions 

2.00 pm Trust Board Meeting 

Agenda 

Part 1 

Patient Story – Sarah Watson-Fisher 

1. Verbal Apologies John Bull 

2. Paper Minutes of meeting held on 26 March 2010 John Bull 

3. Verbal Matters arising John Bull 

4. Paper Review of actions John Bull 

Strategy and Policy 

5. Paper Security Management Helen O’Shea 

Performance and Reports 

6. Paper Care Quality Commission Registration Paul Cooper 

7. Paper Interventional Cardiology Patient Safety Review Dr Alex Mayor 

8. Paper Performance Report Paul Cooper/Helen O’Shea 

8.1 Paper Achieving Cancer Targets Helen O’Shea 

9. Paper Joint Report of the Chief Nurse and the 

Medical Director 

10. Paper Human Resources Report Paul Cooper 

11. Paper Chief Executive’s Report Paul Roberts 

Sarah Watson-Fisher/ 

Dr Alex Mayor 

Date of next meeting 

Friday 28 May 2010

Item 2 

Present: 


Minutes of the Trust Board meeting Part I 

held on 26 March 2010 in the 


1.30 pm Opportunity for Questions 

D 

Karen Grimshaw, Director of Nursing & Midwifery 

John Bull, Chairman 

Paul Cooper, Acting Director of Finance 

Ian Douglas, Non-Executive Director 

Helen O’Shea, Chief Operating Officer 

Lee Paschalides, Non-Executive Director 

David Pond, Non-Executive Director 

Paul Roberts, Chief Executive 

R 

Margaret Schwarz, Non-Executive Director 

In Attendance: Gill Hunt, Foundation Trust Board Secretary 

Brydie Willis, Communications Manager 

‘Governors’ In 

Attendance 

A 

Marina Taylor, Public ‘Governor’ – Plymouth Constituency 

Vera Mitchell, Public ‘Governor’ – Plymouth Constituency 

F 

A member of the public requested that the foundation stone of the former 

Devonport Hospital, now located close the main entrance to Derriford 

Hospital, be cleaned. The Chairman would inform the Director of Estates 

of this request. 

T 

The Chairman welcomed questions from the public. 

Mrs Mitchell asked how the role of the new Chief Nurse would be 

incorporated into the existing organisational structure. Mr Roberts 

explained the arrangements made after the departure of the former Chief 

Nurse, the roles of the current joint Directors of Nursing & Midwifery, and 

the role of the new Chief Nurse, Sarah Watson-Fisher, who would take up 

her position on 6 April 2010. Ms Grimshaw welcomed Ms Watson- 

Fisher’s appointment, which would bring an enhanced patient focus to the 

Board. 

A member of the public welcomed the improved presentation of the 

hospital but was concerned that light well cleaning, although ongoing, had 

yet to be completed. Mr Roberts stated that the Estates Department’s 

programme of work was extensive and was prioritised around safety and 

infection control issues. 

The same member of the public stated that he had suffered complications 

during a recent inpatient stay and queried the level of audit work on 

patient outcomes. Ms Grimshaw stated that his experience was not 

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unusual; sometimes treatments for one condition can make patients more 

susceptible to others and sometimes patients are found to have 

underlying conditions that were unknown to them. The Trust undertook 

much benchmarking and clinical audit work. The member of the public 

stated that he had received good care and had recovered. 

A member of the public described a recent, very positive, patient 

experience; she had been treated with respect by all those with whom she 

had come into contact. Following a post-operative infection, she was 

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keen to progress the production of suitable patient information. Mrs Hunt 

would liaise with her after the meeting. 

Mrs Taylor wished to thank the staff at the Royal Eye Infirmary for the 

excellent care she had received during two cataract procedures. 

R 

Mrs Mitchell stated that having read the Mid-Staffs report and recent 

article by Karen Grimshaw in the Trust’s in-house newsletter, Vital Signs, 

she appreciated that sickness absence was a complex problem. She 

congratulated Ms Grimshaw on articulating the issues so clearly. 

There were no further questions. 

A 

F 

T 

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Item 2 


Minutes of the Trust Board meeting Part 1 

held on 26 March 2010 in the 


Present: 

Apologies: 

John Bull, Chairman 

Peter Burroughs, Non-Executive Director 

Paul Cooper, Acting Director of Finance 

Ian Douglas, Non-Executive Director 

Karen Grimshaw, Director of Nursing & Midwifery 

D 

Barry Lucas, Patient Representative 

Helen O’Shea, Chief Operating Officer 

Lee Paschalides, Non-Executive Director 

David Pond, Non-Executive Director 


R 

Margaret Schwarz, Non-Executive Director 

Alex Mayor, Medical Director 

In Attendance: Gill Hunt, Foundation Trust Board Secretary 

A 

Brydie Willis, Communications Manager 

‘Governors’ In 

Attendance 

Vera Mitchell, Public ‘Governor’ – Plymouth Constituency 

Pam Redgwell, Public ‘Governor’ – Plymouth Constituency 

David Satterley, Public ‘Governor’ – Plymouth Constituency 

F 

27/10 Welcome and Apologies 

28/10 

The Chairman welcomed members of the public and noted apologies 

from Alex Mayor, Medical Director. 

T 

Minutes of the last meeting held on the 26 February 2010 

The minutes of the previous meeting were agreed as a true and 

accurate record, subject to the following amendment: 

Item 21/10 Joint Report of the Director of Nursing & Midwifery and 

the Medical Director (page 7, paragraph 2) 

In first sentence, delete ‘Operating’ and insert ‘Nursing’. 

29/10 Matters Arising 

There were no matters arising. 

30/10 Review of Actions 

The Board noted the action table. 

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Item 2 

31/10 Stroke Services Presentation 

Dr Steve Allder, Consultant Neurologist and Head of Clinical 

Systems Engineering, and Ian Wren, Clinical Programme Manager, 

gave a presentation on improvements to the stroke service in the 

Plymouth health community, largely achieved through the 

introduction of two new clinical pathways. At the conclusion of the 

presentation Professor Bull invited questions. 

D 

Mr Pond asked if learning from patient pathway redesign could be 

applied elsewhere. Dr Allder described the steps in the redesign 

process and emphasised the importance of staff empowerment in 

the process. Dr Allder went on to describe the systematic approach 

to predefining the scoping of patient flows. Future focus would be 

applied to reducing still further the length of stay. Stroke prevention 

R 

was important; the recent high profile national advertising campaign 

emphasising the importance of early stroke recognition had resulted 

in little or no evidence in a reduction in the incidence of strokes. 

Professor Bull thanked Dr Allder and Mr Wren for their presentation, 

and for their work in the care of stroke patients, which had 

A 

undoubtedly provided better outcomes for those concerned. 

32/10 Report on Independent Inquiry into care provided by Mid 

Staffordshire NHS Foundation Trust 

Mr Roberts introduced the assessment requested by the Trust’s 

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Medical Director, Dr Alex Mayor, of the Trust’s response to the key 

recommendations of the recent Francis report into care provided by 

the Mid Staffordshire NHS Foundation Trust. 

Mr Roberts stated that PHNT was not in a similar position to Mid- 

Staffordshire; mortality rates were low and patient satisfaction levels 

T 

were good. However, complacency was not an option and the Trust 

could always learn. Having reviewed this initial corporate 

assessment performed by the Clinical Governance team, he and Dr 

Mayor had discussed the review with senior medical staff. Together 

they would hold similar discussions with nursing leadership and with 

other professional groups. Dr Mayor would identify small groups of 

clinicians and other health professionals to review the 

recommendations in more detail. The clinical directorates would be 

requested to undertake similar reviews of performance, thus giving 

vertical and horizontal assessments across the Trust. The findings 

would be combined and brought back to the Board when complete. 

Mr Roberts stated that it was important for the Trust to consider how 

to incorporate the patient’s perspective. A fundamental problem at 

Mid-Staffs had been their failure to listen to the patients’ voice and 

PHNT must consider how this can be used more directly to review 

the report’s recommendations. 

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Item 2 

The Board noted the report. 

33/10 Performance Report 

Financial Performance 

Mr Cooper reported a year to date surplus of £1.251m and confirmed 

that the Trust was on track to deliver the required £2m surplus at the 

end of the current financial year. Mr Roberts expressed his thanks 

to staff for their commitment and hard work in helping to achieve this 

result. 

D 

Operational Performance 

Ms O’Shea stated that performance for February had been very 

good. 94.2% of patients treated on an admitted care pathway had 

been treated within 18 weeks of referral; performance for nonadmitted 

patients was 97.8%, both rates were above national 

R 

targets. 73.7% of patients treated on an admitted care pathway 

were treated within 13 weeks of referral. 19 patients had waited over 

six weeks for a diagnostic test in February, the majority relating to 

one test. There had been some difficulties with staff training and 

equipment but these issues were being resolved. The Trust’s 

A 

performance against the four hour A&E standard was 98.2%, placing 

it in the top five performers in the NHS South West area. 

Infection control performance was outstanding and the Trust 

continued to work towards screening all elective admissions. There 

had been no hospital acquired MRSA infections identified since 

F 

October 2009. 

Mr Burroughs noted that the Trust’s Hospital Standardised Mortality 

Rates were among the best in the country. Mr Cooper stated that 

the Trust had requested Dr Foster to undertake some further work 

around paediatric outliers and the result would be reported in the 

T 

Performance Report. 

There remained room for improvement in performance against the 

proportion of patients having their operation cancelled within 24 

hours of surgery and this remained an area of significant focus. 

31.2% of patients were not appropriately re-scheduled during 

February, mainly due to the high number of re-bookings in January 

but an improvement in performance was expected. Slight 

improvements were required to three areas in order to consolidate 

performance against national cancer standards, although Ms O’Shea 

emphasised that only one or two patients were affected. 

The Board noted the Performance Report. 

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Item 2 

34/10 Clostridium difficile Mortality 

Dr Peter Jenks, Director of Infection Prevention and Control, and 

Claire Haill, Lead Nurse for Infection Control, attended for this item. 

They were accompanied by Consultant Gastroenterologists Dr 

Stephen Lewis and Dr Andrew Latchford. 

Dr Jenks reported that NHS South West had recently undertaken an 

audit of deaths from Clostridium difficile in 2008. PHNT was found to 

D 

have performed significantly better than any other hospital in the 

south west, with a mortality of 2.1/100,00, compared to a mean 

mortality across the south west of 12.1/100,000. Dr Jenks stated 

that the reasons for the success had been threefold; the ability to 

successfully limit very virulent and dangerous strains; a vigorous 

management of the process for all patients with Clostridium difficile 

R 

and the involvement of gastroenterology colleagues to facilitate 

timely and expert review. 

On behalf of the Board, Professor Bull congratulated Dr Jenks and 

his team and invited questions. Mr Roberts queried the difficulties in 

sustaining such excellent performance. Dr Jenks acknowledged that 

A 

it was labour intensive but was aided by becoming ingrained in 

clinical practice. Consideration was being given nationally to the 

ability to drive performance to zero and whilst Dr Jenks felt this may 

be feasible for MRSA bacteraemias, he believed it was unlikely for 

Clostridium difficile. Mr Roberts stated that viral gastroenterology 

rates had been high across the peninsula generally but not at PHNT 

F 

and he queried any difference in the management process. Dr 

Jenks agreed that Norovirus had been less severe locally; the 

Infection Control and Operations teams worked closely together and 

speed of intervention was vital. Ms Schwarz asked if single rooms 

would effect a significant reduction in infection rates. Dr Jenks 

stated that whilst the Trust had to work with the fabric of the building, 

T 

it was recognised that single rooms would probably make an 

improvement to infection control. However, there were other 

reasons associated with patient care which meant that single rooms 

were not always the preferred option. 

On behalf of the Board, Professor Bull acknowledged the 

tremendous work of Dr Jenks and his team. The Board were 

committed to reducing infection rates and he gave his sincere thanks 

to all staff involved in this significant achievement. 


35/10 Theatre Efficiencies Programme update 

Ms O’Shea updated the Board on progress to the Theatre 

Efficiencies Programme. There were three main projects within the 

programme: 

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Item 2 

• cancelled operations 

• theatre Cost Improvement Plans (CIPs) 

• the Productive Theatre 

Improvement to performance against the cancelled operations target 

was on trajectory. 

Theatre CIPs concerned the removal of barriers between specialties, 

the identification 

D 

of fallow theatre sessions and the more efficient 

utilisation of theatres. Phase 1 would involve changes to staff job 

plans and theatre allocations, with two theatres worth of sessions 

due to cease from 5 April 2010. In phase 2 the process to release 

theatre sessions, led by an Associate Medical Director in conjunction 

with other clinical teams and operational management, would 

commence, with 

R 

sessions reallocated into other theatres and 

confirmation of the two theatres to be closed by early May. The third 

part of the project concerned increased productivity and efficiency in 

theatre usage. The key areas for review were identified in Ms 

O’Shea’s report. 

The third project, 

A 

the Productive Theatre, was similar to the 

successful Productive Ward project and would focus on the patient 

experience, improved stock control and the centralisation of 

processes. 

Ms Paschalides queried the scale of theatre under-utilisation as the 

Board had been previously 

F 

briefed that this was in the region of up to 

50%. Ms O’Shea agreed it could be as high as this under certain 

circumstances. Professor Bull noted the Programme’s significant 

contribution to Trust CIPs and Ms O’Shea stated that a corporate 

overview was necessary as it was difficult for some specialities to 

achieve what was required. 

T 

Mr Lucas stated that the Trust was not currently achieving the rebooking 

target and asked how the closure of two theatres would 

contribute to this. Ms O’Shea acknowledged that the Trust’s 

performance required improvement and stated that re-booking 

performance had not been adversely affected by any lack of theatre 

space but could be improved through better scheduling and use of 

theatre sessions. Mr Lucas asked what guarantees Ms O’Shea 

could give that patients cancelled and re-booked would not be 

cancelled for a second time. Ms O’Shea stated that this could not be 

guaranteed, which was why this problem must be eliminated. Mr 

Lucas requested, and Mr Cooper agreed, that repeat cancellations 

were included in the Performance Report. Mr Cooper assured Mr 

Lucas that theatre teams were aware of previously cancelled 

patients and only under extreme circumstances would they cancel 

again. 


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Item 2 

36/10 Pandemic Influenza and Vaccination Programme update 

The Board noted that a formal review of the Trust’s pandemic plans 

had been undertaken and that the resulting action plan would be 

reviewed by the Performance Board in April 2010. The Trust’s 

Emergency Planning Officer, Miriam Smith, would incorporate 

findings into other major planning issues. 

The Board noted that Plymouth was not one of the H1N1 ‘hot spots’ 

D 

nationwide and that the data collected would be used by the 

Department of Health for future pandemic planning. 


37/10 Joint Report of the Director of Nursing and Midwifery and the 

R 

Medical Director 

MAPs 

The Board welcomed the update on the MAPs electronic rostering 

system and the benefits it would bring. Roll out beyond the nursing 

staff group would be overseen by HR and the system would become 

web-based to facilitate remote access. 

A 

Safeguarding Adults in Emergency Department 

The Board noted the ongoing work in this regard. Ms Grimshaw 

stated that the case management approach of vulnerable adults had 

resulted in reduced attendance and improved management of care 

F 

plans. 

National Audit of Dementia Care 

The Board noted the National Audit and noted that the Trust was 

developing a care pathway in line with the National Dementia 

Strategy. 

T 

Lapco and Bowel Cancer 

The Board noted the good success of the world’s largest centrally 

funded, structured surgical training programme for consultants. 


38/10 Human Resources Report 

Mr Cooper highlighted the report’s three major themes: 

• improving sickness absence 

• appraisal process 

• staff induction review 

The Board welcomed the focus on these important issues. However, 

there was concern that the review of the staff appraisal process had 

concluded that this could not be streamlined. It was agreed that a 

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Item 2 

further consultation would take place using feedback from staff who 

were required to undertake multiple appraisals in order to identify the 

improvements the Board required. 


39/10 Chief Executive’s Report 

Mr Roberts welcomed the ‘governors’ present and wished to record 

D 

his appreciation to all ‘governors’ for their continued commitment 

during the period prior to the recommencement of a Foundation 

Trust application process. 

Mr Roberts was pleased to confirm that the new Finance Director, Mr 

Joe Teape, would take up his position on 4 May 2010. 

R 

The Independent Reconfiguration Panel (IRP) had visited the Trust 

on 22 March in response to the referral by Cornwall Overview and 

Scrutiny Panel regarding Upper GI services. The IRP had received 

a joint presentation from PHNT, the Royal Cornwall Hospital and the 

Royal Devon & Exeter NHSFT, which had demonstrated joint 

A 

working to develop this service. Mr Roberts wished to thank the 

clinicians involved, particularly Marilyn Bolter, Oncology Nurse 

Specialist. The IRP’s report was expected in June 2010. 

A well-attended senior staff event, held on 9 March, had been jointly 

presented with NHS Plymouth. 

F 


Finally, Mr Roberts wished to record his appreciation of the hard 

work of the Communications Team. 

T 

40/19 Signing and Sealing of Documents 


41/10 Any other Business 

Karen Grimshaw 

Professor Bull stated that the Board had formally recorded its thanks 

to Karen Grimshaw, who would be stepping down from the Board 

following the appointment of Sarah Watson-Fisher as Chief Nurse. 

This was Karen’s last public Board meeting and he repeated his 

appreciation of her contribution, made earlier during the Board’s 

private session. 

There was no further business and the meeting concluded at 

4.00 pm. 

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Item 2 

42/10 Date of next meeting 

Friday 30 April 2010 

Signed ------------------------------------------------------------------------ 

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Dated ------------------------------------------------------------------------ 

R 

A 

F 

T 

10

Updated: prior to April Board Item 4 

Outstanding Actions 


Action List for Trust Board Part 1 

Date 

Ref/ 

Page 

Action Lead Action 

Complete/ 

Comments 

No actions arising from the March 

2010 Trust Board. 

Completed Actions 

18.12.09 131/09, 

page 4 

Performance Report – with regard to 

stroke length of stay, the Board 

requested that Steve Allder, Head of 

Clinical Systems Engineering, and Ian 

Wren, Clinical Programme Manager, 

should be invited to the Board to give 

an update on the patient pathway and 

the issue for the community. 

AM 

Completed. 

26.02.10 17/10, 

page 5 

Independent Inquiry into care provided 

by Mid Staffordshire NHS Foundation 

Trust – a report on the 

recommendations would come to the 

next meeting. 

PDR 

Completed. 

26.02.10 22/10, 

page 8 

Human Resources Report – the HR 

Team had been asked to look at 

sickness absence and a report would 

come to the Board. 

PC 

Completed. 

Completed actions will be shown for one month only. 1

Item 5 


Trust Board Summary Report 

Date of Board Meeting: 30 April 2010 

Name of Report: 

Authors: 

Approved by: 

Presented by: 

Security Management 

Deputy Chief Operating Officer 

Chief Operating Officer 


Purpose of the Report: 

To inform the Trust Board of the minimum requirements of a Care Quality 

Commission (CQC) compliant security management structure. 

Action Required: 

Agree Board level responsibilities for security management. 

Recommendations: 

Agree recommendations. 

Relationship with the Assurance Framework (Risks, Controls and 

Assurance, Annual Health Check): 

Objective: 

S2 Provide safe hospital buildings and facilities for staff patients and public 

H1 Promote better health and well-being amongst patients and public 

W1 Plan and recruit workforce required to ensure safety quality and efficiency 

to support the Trust Vision and aims 

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Risk: 

S2 Increased risk of harm to patients and staff; CQC conditional registration. 

H1 Poor security processes and potential harm leads to a poor reputation to 

both patients and staff. 

W1 Patients and staff are at risk through lack of qualified LSMS 

Controls: 

S2, H1 minimum standards are documented in guidance, care quality 

assessed measure leading to registration to deliver services. Nominated 

Executive Security Director in place. 

W1 Plan and personnel in place. 

Assurance: 

S2, H1 Security reported to the Board at regular intervals. Risks recorded on 

Datix and escalated dependent on severity. Nominated Non-Executive 

director in place. 

W1 Training register. 

Summary of Financial & Legal Implications: 

Scored element on the CQC registration requirements. 

Equality & Diversity and Public and Patient Involvement Implications 

Public and patients are represented on the security steering group and staff 

and patients views regularly sought through patient and staff surveys. 

2

Item 5 


Report to: Trust Board - 30 April 2010 

Report of: 

Subject: 


Security Management 

Status: 

For information and approval 

_____________________________________________________________ 

1. Introduction 

This paper informs the Trust Board of the minimum requirements to have a Care 

Quality Commission (CQC) compliant security management structure. It also 

makes recommendations on future Board level responsibilities for security 

management. 

2. Background 

The NHS Security Management Service (SMS) is part of the Counter Fraud and 

Security Management Service (CFSMS), a division of the NHS Business Service 

Authority (a Special Health Authority). On behalf of the Secretary of State for 

Health, SMS has overall responsibility for all policy matters related to the 

management of security in the NHS. The SMS determines and dictates the 

policies, legal framework, and minimum operational standards necessary to 

provide a secure environment within NHS organisations. 

The SMS launched its strategy document “A Professional Approach to Managing 

Security in the NHS” in December 2003. Two national legal frameworks were 

introduced, in 2003 and 2004, subsequently amended in 2006. 

As of the 1 st April 2010 the Trust is required to have an accredited LSMS, a 

nominated Security Management Director (SMD) who is a voting member of the 

Board, and an identified Non-Executive responsible for security. The Trust’s 

compliance with SMS directives will be formally monitored by the NHSLA and the 

CQC, failure to comply will result in a red rating. 

3. Local Security Management Specialist 

The main responsibility of the Local Security Management Specialist (LSMS) is to 

lead on the strategic management of security in the Trust and oversee the 

delivery of an environment that is safe and secure. 

The Trust has had a nominated (but not accredited) LSMS in place since 2003. 

The Trust has nominated a fully accredited LSMS who is currently going through 

the pre-checks and will subsequently attend training. The LSMS will be 

accountable to the Security Management Director but will functionally report to 

the Deputy Chief Operating Officer/Director of Site Services. 

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4. Security Management Director 

It is the responsibility of the nominated Security Management Director (SMD) to 

ensure that adequate security management provision is made within the Trust. 

The SMD is required to be a voting member of the Trust Board with executive 

responsibility for all security matters at Board level. The SMD also has overall 

responsibility for the nomination, appointment and direction of the LSMS. 

The nominated Executive Director for security was previously the Deputy Chief 

Executive. With the changed executive responsibilities it is proposed that this 

executive responsibility now passes to the Chief Operating Officer. 

5. The role of the nominated Non Executive Director 

The role of the nominated Non-Executive Director is to support, and where 

appropriate, challenge the SMD on issues relating to security management at 

Board level. 

With the changes to Non-Executive personnel the Trust Board are required to reaffirm 

the Non-Executive Director for security. 

6. Recommendations 

The Trust Board are asked to agree the following: 

Endorse Peter Burroughs as the Non Executive Director for Security. 

Endorse the Chief Operating Officer as the Trust’s Security Management 

Director (SMD), with devolved day to day responsibility for security to the 

Deputy Chief Operating Officer 

Authorise the SMD to appoint an accredited LSMS, accountable to the SMD 

but reporting to the Deputy Chief Operating Officer 

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Authors: 

Approved by: 

Presented by: 

CQC Registration Update 

Acting Head of Governance 

Acting Director of Finance 



To provide an update on the Trust’s registration with the CQC under the 

Health and Social Care Act 2008. 


None 


None 

Trust Objective and relationship with the Assurance Framework: 

Objective: 

Covers all objectives on the Assurance Framework 

Risk: 

Covers all risks on the Assurance Framework 

Controls: 

Covers all controls on the Assurance Framework 

Assurance: 

N/A. 

Financial & Legal Implications: 

None. 


None. 

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Report to: Trust Board – 30 April 2010 

Report of: 

Approved by: 

Presented by: 

Subject: 

Status: 




Care Quality Commission Registration Update 

For noting 

1. The Care Quality Commission registered the Trust under the Health 

and Social Care Act 2008 without conditions on the 1 April 2010. 

This registration came into immediate effect and allows the Trust to 

undertake the following registered activities: 

‣ Accommodation for persons who require nursing or personal 

care 

‣ Accommodation for persons who require treatment for 

substance misuse 

‣ Treatment of disease, disorder or injury 

‣ Assessment or medical treatment for persons detained under 

the Mental Health Act 

‣ Surgical procedures 

‣ Diagnostic and screening procedures 

‣ Management of supply of blood and blood derived products 

‣ Transport services, triage and medical advice provided remotely 

‣ Maternity and midwifery services 

‣ Termination of pregnancies 

‣ Services in slimming clinics 

‣ Family planning 

2. Under the new regulatory system the Trust could be subject to 

inspection by the Care Quality Commission at any time in the next two 

years at any of the locations that provide the above services. These 

inspections will be based on the sixteen essential standards of quality 

and safety as set out in the CQC’s guidance on compliance. Regular 

updates on the compliance status of these standards will be provided 

to the Trust Board. 

Conclusion 

3. The Board are asked to note this report. 

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Authors: 

Approved by: 

Presented by: 


Interventional Cardiology Patient Safety Review. 

Mr Ian Wren 

Dr Alex Mayor 

Dr Alex Mayor 

To inform the Board of the process and current 

status of the review. 


For Information 


Nil Specific 



Objective: 

Ensure Patient Safety by thorough Investigation of Incidents. 

Risk: 

Patients may seek compensation where harm can be proved. 

Controls: 

Clinical Governance Processes now in place which comply with 

recommendations contained in the report. 

Assurance: Full compliance with Clinical Governance Framework. 


Financial implications as a result of possible compensation claims. NHSLA 

aware. 


Helpline was set up to allow concerned patients to contact the Trust. 

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Report to: The Trust Board – 30 April 2010 

Report of: 

Prepared by: 

Subject: 

Dr A Mayor (Medical Director) 

Mr Ian Wren (Strategic Care Programme Manager) 

Interventional Cardiology Patient Safety Review. 

Status: 

Discussion and information 

________ 

Introduction 

This report is aimed at updating the Board as to the current position regarding 

the review into the interventional practice of Dr J Motwani. 

Summary 

Plymouth Hospitals NHS Trust has undertaken a detailed patient safety 

review to look at a number of heart patients who have undergone 

interventional cardiology procedures at Derriford Hospital between 2001 and 

2007. 

The Trust commissioned independent interventional cardiologists from outside 

of the organisation to review the clinical records and specialist investigations, 

of 597 patients who underwent stenting procedures of coronary arteries, by 

Consultant Cardiologist, Dr Joe Motwani. 

The review was commissioned by the Trust in response to concerns raised 

internally, to determine whether the care received was of a safe and high 

standard. The review has shown that the majority of patients received safe 

and appropriate treatment. However, the reviewers state that 18 of these 

patients received inappropriate treatment as described within the report. 

Three patients were identified as having received inadequate heparin 

treatment, a clot-preventing drug. The reviewers felt that a further 28 patients 

needed their cases reviewing because of ongoing concerns. 

Of the 49 patients of whom concerns were expressed, the reviewers judged 

that four patients died as a result of complications arising from the procedure 

and a further two died as a result of complications arising from inadequate 

heparin administration. It is important to note that these patients had complex 

clinical conditions and it is not clear whether these patients would have 

survived alterative treatments. 

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Item 7 

The independent reviewers also reported that they found the care and 

treatment being provided by the Trust to be of a very high standard and their 

concerns were over the practice of one individual Consultant Cardiologist, 

who is not currently working at the Trust. The care provided by other members 

at the South West Cardiothoracic Centre is of a high standard and is not in 

question. 

Current Status and Actions to Date 

Plymouth Hospitals NHS Trust has, during March 2010, been contacting 

patients or their families where concerns were raised within the independent 

review. Discussions were aimed at informing them about the review and what 

had been identified in their individual case. In addition, discussions also 

included any concerns expressed by patients or their families, and to ensure 

they are receiving appropriate ongoing care. All of the patients or their 

relatives contacted have also been offered the opportunity to meet with a 

senior consultant from the Trust, and many have taken up this offer. 

A helpline was also established on 1 April 2010 and which remained in 

operation during the bank holiday weekend, to enable worried patients or their 

relatives to make contact with the hospital. The help line has now been 

diverted to the Cardiology Department for an unspecified period of time so 

that contact with the Trust is still possible should patients have concerns. 

Dr Motwani remains excluded from the organisation, and the General Medical 

Council (GMC) are holding a separate investigation into Dr Motwani’s medical 

practice which commences in June 2010. 

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Item 8 





Authors: 

Approved by: 

Prepared by: 

Performance Report 

Acting Director of Finance/Chief Operating Officer 




To present the Trust’s performance against the Trust’s objectives as recorded 

in the Assurance Framework. 


For review 


None 


Objective: 

All objectives in the Assurance Framework 

Risk: 

All risks in the Assurance Framework 

Controls: 

All controls in the Assurance Framework 

Assurance: 

Provides outcome assurance against objectives. 


None. 


None. 

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Item 8 



Report of: 

Approved by: 

Prepared by: 

Subject: 

Status: 




Performance Report 

For Review and Discussion 

Introduction 

1. This paper summarises performance across the full range of NHS 

Performance Standards for the year ended 31 March 2010. 

Finance 

2. At the end of March 2010, the Trust reported a surplus before 

impairments of £2.015m. The Trust has therefore met its control total 

target agreed with NHS Southwest for 2009/10. 

Actual at Mth 

12 

£000 

TOTAL INCOME (380,133) 

EXPENDITURE 

Pay 233,265 

Non-pay 117,674 

TOTAL EXPENDITURE 350,939 

NET (SURPLUS)BEFORE DEPRECIATION AND INTEREST (29,195) 

TOTAL DEPRECIATION AND INTEREST 25,037 

(SURPLUS)/DEFICIT (4,158) 

NON RECURRENT ADJUSTMENTS 

Annual leave adjustment (857) 

Agreed income reduction from PCT 3,000 

NET (SURPLUS)/DEFICIT CONTROL TOTAL (2,015) 

Modern Equivalent Asset Value Impairment 2,275 

NET (SURPLUS)/DEFICIT 260 

1

Item 8 

2. The final District Valuer’s report received on 31 March 2010 valued the 

Trust’s impairments under the new Modern Equivalent Asset Value 

regime to be £2,275k compared to the £2,000k forecast. As agreed 

with NHS Southwest, the impairment value will be reported below the 

control total line and therefore does not affect the achievement of our 

year end target. 

3. The outturn balance sheet for 2009/10 is currently being finalised and 

will be reported to the Board in May as part of the year end financial 

reporting process. 

4. The cashbook balances at the end of March totalled £4.5m, with 

cleared bank balances of £4.6m, ensuring that the External Financial 

Limit was achieved. Performance against the Public Sector Payment 

Policy target has fallen – the cumulative result to the end of March was 

85% of non-NHS creditors paid on time, against a target of 95%. Whilst 

payment time for some creditors has increased, this has been 

managed sensitively to the size and nature of the supplier. 

5. During 2009/10 the Trust spent £22.0m against at Capital Resource 

Limit of £22.7m, an under spend of £0.7m. This is mainly due to the “nil 

valuation” of the George Park and Ride scheme by the District Valuer. 

During the year this scheme was capitalised to the value of £645k. We 

continue to discuss this position with the District Valuer and will update 

the Board as soon as possible. 

Infection Control 

6. MRSA 

There have been only 15 post 48 hour MRSA bacteraemia identified 

during 2009/10; significantly (37.5%) better than the 24 case trajectory 

set for this Trust. There were 29 cases identified in the previous year, 

so the incidence has fallen by close to 50% during the year. 

The Department of Health have adopted a three month rolling average 

as the key measurement for MRSA bacteraemia. On that measure the 

Trust is running at an average of less than 1.33 per month, better than 

target. 

7. Clostridium Difficile 

There have been 77 cases of Clostridium Difficile infection during the 

year, again far (41.6%) fewer than the 132 case trajectory set for the 

Trust. There were 160 cases identified in the previous year, so the 

incidence has fallen by over 50% during the year. 

2

Item 8 

Hospital Standardised Mortality Rates 

8. The Hospital Standardised Mortality Rate (HSMR) is a statistical 

calculation that measures the overall rate of deaths within a hospital, 

compared with a national benchmark. Each hospital’s HSMR should be 

compared with ‘100’, representing the expected level given the types of 

cases treated. A hospital with a rate below 100 had fewer deaths than 

would be expected, conversely a rate above 100 will have had more 

deaths than would be expected. 

Access 

The HSMR for Plymouth Hospitals NHS Trust is 73.6 for the period 

April 2009 to February 2010; a mortality rate almost 26% lower (better) 

than expected. 

9 Referral to Treatment 

During March 94.2% of patients treated on an admitted care pathway 

were treated within 18 weeks of referral, significantly better than the 

national target of 90%. The performance for non-admitted pathways at 

97.6% was also above the national target of 95%. 

Target rates were achieved, in all but one specialty. In that specialty, 

Neurosurgery, an improvement plan is established, on track and will 

deliver sustained performance from April onwards. Delivering across 

all specialties from this point forward, the Trust compares extremely 

favourably with others, both in the South West and nationally. 

Although not a national requirement the Trust continues to work 

towards the 13 week referral to treatment standard with over 70% of 

Trust patients being seen within 13 weeks on the admitted pathway 

and over 90% of patients being seen within 13 weeks on the nonadmitted 

pathway. 

10. Accident and Emergency 4 Hour Standard 

Performance against the Accident and Emergency 4 hour wait standard 

improved significantly during 2009/10, ending the year above national 

standards both from a Trust position, 98.03%, and also following the 

inclusion of community based Minor Injury Unit at 98.7%. This level of 

performance makes the Trust one of five type one Accident and 

Emergency facilities in the South West to have achieved the standard 

as a stand alone organisation. 

11. Reperfusion Waiting Times 

The Trust has moved to the primary percutaneous coronary 

intervention (pPCI) as its preferred first treatment for patients suffering 

heart attack, although in certain circumstances thrombolysis may still 

be administered when clinical judgement deems this appropriate. 

There were no patients thrombolysed in March and the full year 

3

Item 8 

performance remained at 70%, above the national standard of 68%. 

Performance against the new pPCI standard was, at 67% slightly below 

the 75% target for the month but full year performance, at 85% is 

significantly better than the target level. 

12. Choose and Book Slot Availability 

The Trust’s performance against the rolling 4 week average has 

improved 9% in March, now just to 1% above the regional average. 

13. Existing Cancer Standards 

The performance against all existing cancer standards is above the 

required level for the year to 31 March 2010. 

14. Going Further on Cancer Standards 

Apart from 31 day wait for subsequent surgery and 2 week wait for 

symptomatic breast patients, the Trust has achieved all national going 

further on cancer targets. Within this position, the Trust achieved the 31 

day wait for second or subsequent treatment for radiotherapy 

treatments standard ahead of the January 2011 national timeframe. 

The 2 week wait for symptomatic breast patient’s performance has 

been affected by patient choice, with many patients choosing to wait 

longer than the specified two week period. This is being reviewed 

nationally, as this pattern is reflected across the service. Following this 

review there is the potential that target will be reduced to reflect the 

impact of patient choice. 

When reviewing year end performance the Board should note that the 

national data collection process for quarter 4 does not close until the 10 

May. This is to allow for review of tertiary referrals, patients referred 

who are subsequently diagnosed with cancer and those patients 

transferred from another provider into the Trust where the timing of the 

transfer makes meeting set standards impossible. The figures reported 

above and in the performance data book are therefore subject to small 

changes. 

15. Diagnostic Waiting Times 

The focus on the management of the diagnostic and treatment decision 

elements of the patient’s referral to treatment pathway continue. 23 

patients waited over 6 weeks for a diagnostic test in March. The overall 

diagnostic waiting list has decreased from 6,730 to 6,673 patients 

during March. 

16. Cancelled Operations 

The proportion of patients cancelled on the day or within 24 hours of 

surgery, represents 1.7% of elective admissions (84 patients) during 

the month. Across the full year, 2% of elective admission had their 

4

Item 8 

Conclusion 

operations cancelled on the day or within 24 hours of surgery, above 

the Care Quality Commission tolerance of 0.8%. The Trust has started 

to implement an improvement plan in this area and March performance 

is in line with the expected trajectory set by the Trust Board. 

The number of breaches of the 28 day standard for re-booking 

previously cancelled patients during the month has improved; there 

were 13 patients that failed to be rescheduled appropriately during 

March. The full year performance of 14.1% is the 5% tolerance allowed 

by the Care Quality Commission. The improvement actions mentioned 

above for cancelled operations will have a positive impact on this 

standard. 

17. This report describes significant achievements and improvements in 

performance across a range of standards during 2009/10. There are 

areas that require further attention, each with a rigorous action plan 

that is delivering to schedule. 

18. The Board is asked to note the content of this report. 

5

Performance Dashboard 

Mar-10 

Year to 

Annual Healthcheck Standards 

Standard 

Current 

Month 

Date (where 

applicable) 

18 week referral to treatment Admitted 90% 94.2% N/A 

Non-admitted 95% 97.6% N/A 

Incidence of Clostridium Difficile 132 3 77 

Incidence of MRSA 24 2 15 

Access to GUM See below^ 92% 90% 

Cancelled Operations 0.8% 1.6% 1.9% 

Those cancelled not admitted within 28 days 5% 15.5% 14.1% 

Time to reperfusion for patients who have had a heart attack 75% 67% 85% 

Total Time in A&E 98% 98.8% 98.7% 

Data quality on ethic group 85% 100% 100% 

All cancers: one month diagnosis to treatment 96% 96.7% 97.5% 

All cancers: two month urgent referral to treatment 85% 89.3% 85.0% 

All cancers: two week wait 93% 95.5% 94.6% 

62 day wait for first treatment from consultant screening service referral 90% 100.0% 92.9% 

31 day wait for second or subsequent treatment: anti cancer drug treatment 98% 100.0% 99.2% 

31 day wait for second or subsequent treatment: surgery 94% 96.6% 93.0% 

31 day wait for second or subsequent treatment: radiotherapy treatments* 94%^ 98.7% 94.3% 

Two week wait for symptomatic breast patients** 93%^ 96.4% 91.6% 

Delayed Transfers of Care See below^ 3.6% 3.3% 

Breast Feeding Initiation See below 70% 68% 

Smoking During Pregnancy See below 18% 18% 

Outpatients waiting longer than the 13 week standard 0.03% 0% 0% 

Inpatients waiting longer then the 26 week standard 0.03% 0% 0% 

Rapid Access Chest Pain Service 98% 100% 99.9% 

Patients waiting longer than three months for revascularisation 0 0 0 

Patients with stroke spend at least 90% of time on stroke unit*** 80%^ 55% 46% 

* This is a January 2011 target and therefore is included for completeness of 

all cancer standards 

** This is a January 2010 target. 

*** This is a 2010/11 target and is included for reference only 

^ The standards or thresholds for these areas have not been set nationally 

Achieving 

Under-achieving 

Failing

Item 8.1 





Authors: 

Approved by: 

Presented by: 

Achieving Cancer Targets 





To assure the Board that processes and systems are in place to meet the 

cancer standards during 2010/11. 


Challenge, request any further clarification. 


Note the report. 



Objectives 

Q1 To provide accessible elective services that respond to patients needs, 

ensuring short waiting times and avoiding unnecessary delays. 

Risks 

Q1 That processes and systems either are not implemented or do not result in 

achieving the waiting times. 

Controls 

Q1 Action plans in place with clear timescales and responsibilities. Included 

within the performance dashboard. 

Assurance 

Daily/weekly/monthly PTL monitoring, cancer peer reviews, PCT/SHA 

performance reports. 

1

Item 8.1 


Not linked to CQINN or financial penalties but important from a quality of 

service and patient experience perspective. Failure to treat within timescales 

could lead to complaints and/or possible litigation. 


Standardises practice for all who require cancer services. Patient involvement 

is largely via the cancer networks, plus internal local surveys. 

2

Item 8.1 


Report to: Trust Board - 30 April 2010 

Report of: 

Prepared by: 

Subject: 

Status: 



Achieving Cancer Targets 

For information 

1. Purpose 

This paper is to update the Trust Board on progress with the achievement of the new 

cancer standards that have been underachieving in some areas over the last few 

months. 

2. Background 

Nationally the cancer standards were revised to reflect improved pathways of care for 

patients, for example patients requiring a 2 week wait urgent referral for suspected 

cancer could reject an appointment within the two weeks and then be excluded from 

the breach returns. The target was previously 100% to be seen within two weeks now 

this is lowered to 93% but must include patient choice ‘breaches’. Additionally further 

standards were set – ‘going further on cancer waits’ - that included new groups of 

patients, E.G. those with secondary cancer diagnoses and inclusion of waits between 

different treatment types. 

The Trust has been monitored against these new standards throughout the year. 

3. 2009/10 Year End Performance Position 

Cancer Standards performance end of March 2010 

Standard Target End year position Comments Status 

2 week wait 93% 94.60% 

31 day 96% 97.50% 

62 day 85% 85.00% 

62 day screening 90% 92.90% 

31 day DTT to subsequent 

treatment - anti cancer drug 

98% 99.20% 


treatment - surgery 


treatment - radiotherapy Jan 2011 

2ww symptomatic breast started 

Jan 2010 

94% 93.% 

94% 94.4% 

94% 93% 

93% 91.6% 

March 

97.3%, met 

target for 

all months 

in Q 4. 

March 

96.4% 

1

Item 8.1 

The two standards that have not been achieved, from a total year perspective, are 

the 31 day from decision to treat to subsequent surgical treatment and the 2 week 

wait for all symptomatic breast referrals (which became a ‘live’ target from January 

2010). In both cases the performance has improved during the year and the Trust 

was achieving these targets in March 2010. 

Many Trusts have found the new breast referral target challenging due to patient 

choice issues affecting the level of performance that is actually attainable, this is the 

subject of national debate and may be revised in the future. 

4. Forecast Performance 

Although the achievement against the cancer standards has improved and the Trust 

delivered against all targets in March, there remains some fragility to this 

performance. The reasons for this fragility are numerous and are being addressed by 

each cancer tumour site, some of the reasons/actions are noted below: 

• Urology – access to the heamaturia clinic - cross cover for this clinic has now 

been agreed and priority cover by imaging is being sought. If all clinics operate 

there is not a capacity issue. 

• Administration issues – accuracy of the calculation of the breach date and its 

visibility to all staff within the process, and the role of the clerk in escalation 

should they not be able to book an appointment within the timescales required 

have been addressed. 

• Urology – single handed Consultant specialists - there remains an issue with a 

single consultant being appropriately qualified to undertake a specific 

procedure. Exceedingly close management of activity and scheduling are 

being applied to this issue, however it remains a risk to delivery. 

• Agreement to flex capacity as referral demand dictates for all tumour sites, 

including leave/cover arrangements. 

• 

• Skin – appointment of 2 locums has eased the pressure on this service, which 

is high volume in nature. 

The Trust continues to monitor every breach and assess the cause; there are still 

occasions when they are not for ‘acceptable reasons’ i.e. medical decision, patient 

choice or complex pathways. Each of these is then addressed through the 

performance meetings with the service concerned. 

Implementing the actions by tumour site and closely monitoring and challenging 

performance should result in the Trust achieving against all of the cancer standards 

during 2010/11. 

2

Item 8.1 

5. Conclusion 

The Trust has made good progress against the new cancer standards and the 

underachievement seen has been due to very small numbers of patients not 

completing their pathways in the prescribed timescales. Each tumour site has the 

responsibility to meet the new standards and has action plans to ensure this. The 

performance team are now monitoring and escalating issues prospectively and 

facilitating a trust wide overview of the position. This is more robust than previous 

cancer standard monitoring and increases confidence in the Trusts ability to achieve 

the targets in this financial year. 

6. Recommendations 

The Board is asked to note the contents of this report, request further detail or clarity 

if required to ensure assurance regarding the delivery of the cancer standards. 

3

Item 9 





Authors: 

Approved by: 

Joint Report of the Chief Nurse and the Medical 

Director 

Karen Grimshaw, Joint Director of Nursing and 

Midwifery 

Dr A. Mayor, Medical Director 

Sarah Watson-Fisher, Chief Nurse 


Presented by: 

Sarah Watson-Fisher, Chief Nurse 



To update the Board on clinical and patient initiatives. 


The Trust Board is asked to discuss and consider the report. 


None 


Various 


None 


None. 

1

Item 9 



Report of: 

Subject: 

Status: 

Chief Nurse and Medical Director 

Chief Nurse and Medical Director Report 

For formative discussion 

__________________________________________________________________________ 

Review of Nursing absence management at ward level 

As part of the work towards the national High Impact Actions, the Deputy Director of 

Nursing has worked with Matrons and Senior HR managers to review the 

management of absence at ward level within nursing teams. Thirty eight nursing 

managers were met with covering nine specialities within the Trust, Emergency 

Services, Oncology, Cardiothoracic, Neurosciences, Medical Specialities, Child 

Health, Ambulatory Care and Orthopaedics. 

Good practice identified from this review includes: 

‣ Use of staff information leaflet detailing the absence management policy 

and implications – given to staff on return to work interviews. 

‣ Informal return-to-work interviews with staff who have had time off for a 

domestic crisis. 

‣ Domestic crisis leave only authorised by Matron - this ensures consistency 

across the department. 

‣ Regular praise for staff re attendance - one manager sends a letter 

thanking their members of staff for improving their attendance. 

‣ High standards of record keeping for absence management. 

‣ Regular review of all nursing absence with HR. 

‣ High level of support from HR managers when dealing with complex 

issues of individual staff. 

Issues for which ward managers are often seeking support from HR, occupational 

health or senior managers include: 

• Timeliness of response from departments such as HR and Occupational 

health. 

• Phased return to work – often difficult to arrange in practice. 

• Payment of unsociable hours/enhanced rates to those staff off sick – 

managers identified that this has removed an incentive for getting staff back 

to work. 

• A need for a common approach to use of management discretion e.g. 

domestic crisis leave. 

• Standardised management file with standard documentation processes. 

1

Item 9 

This review has led to work by Matrons to agree common approaches to the 

management of absence and a standard approach to documentation. HR managers 

are now meeting regularly with Matron group to discuss absence management 

issues and any concerns with the implementation of absence policies. An action 

plan has been developed by the Deputy Director of Nursing, who is working with 

Matrons to improve the standards of absence management at ward and directorate 

level. 

Ward Nursing establishments 

High quality patient care requires appropriate teams to be in place to deliver the right 

care. The nursing establishments at ward level need regular review in order to 

maintain an appropriate nursing workforce to meet patient needs. With an ever 

changing patient population at ward level, the nursing workforce needs regular 

reviews to consider the numbers and skill mix of nursing staff to meet patients’ 

needs. 

In May of 2008 the Trust took part in the Audit Commission benchmarking exercise 

on Nursing establishments, receiving the results of this assessment in April 2009. 

Concurrent to this the Trust engaged the services of ‘Kudos Healthcare’ to 

undertake an establishment review, the final report of this work having been 

published in February 2009. Both methodologies compared the Trust nursing 

establishments for ward areas against other acute hospital trusts. 

Revised ward establishments were then agreed with each Directorate in 2009 – the 

establishments have a 21.5% absence factor built in (15% leave; 4% sickness; 1% 

study; 1.5% Mat leave). The Deputy Director of Nursing presented the current 

position on establishments to the Audit Committee earlier this month. 

On a day-to-day basis the management of nursing establishments is led by the 

Matrons. A ‘Duty Senior Nurse’ rota covers 24 hours a day, seven days a week, 

which complements the normal in-day directorate cover to monitor staffing levels 

and take appropriate measures to address identified gaps. This includes an admin 

support post that acts as the key link to NHSP. A record is kept daily on actual 

staffing levels against planned levels and this is kept up to date with actions taken. 

This daily management process has a clear escalation and control process to the 

senior nursing team for the verification of planned actions, and escalation when it is 

thought necessary to use Agency nursing solutions. This includes an out-of-hours 

escalation plan to the On-call Executive Director. 

The ability for nursing teams to ensure appropriate levels of patient care also 

depend on the patient population of each ward. With escalation beds open for many 

months on some wards, the nursing establishments have been stretched to meet the 

needs of the increase in number of patients. 

Another key influence on the appropriateness of nursing establishments is the level 

of patient need. With an increase in acuity of illness, patients often require highly 

skilled registered nurses at ward level; the increase in general dependency of many 

2

Item 9 

patients, in particular the frail elderly, requires an increase in availability of 

appropriately trained nursing staff to meet their ongoing clinical needs. 

The AUKUH Acuity and Dependency Tool has been developed to help NHS 

hospitals measure patient acuity and/or dependency to inform evidence-based 

decision making on staffing and workforce. This tool will be used initially within the 

Healthcare of Elderly speciality to assess the current nursing establishments, which 

were agreed last year without reference to patient acuity or dependency. A full rereview 

of all acute ward areas will then be planned, to consider national 

benchmarks, changes to patient pathways, the management of escalation beds, 

increased dependency of complex patients and the need for highly skilled and 

technical care at ward level. 

Management of long-term conditions – repeat hospital admissions 

As part of the improved communication and co-ordination of care and services for 

people with long-term conditions, the Repeat Attending Patient Analysis (RAPA) 

system is being implemented within the local health & social care community. This 

is an IT system which flags those patients with long term condition, mental health, 

learning disability or long term social care need and who have ongoing community 

services and/or a key worker. 

RAPA provides the means for improving the communication of patient needs 

between different teams and organisations – by alerting clinical teams to the fact that 

a patient is known to community services and has a key worker either health or 

social care worker. This will allow prompt discussion between the hospital and 

community teams regarding patient risks and needs, improve co-ordination of care 

management of these patients with long term conditions and promote earlier 

discharge from hospital, with reduced incidence of readmissions. 

The RAPA system will allow community staff and specialist nurses to ‘in-reach’ to 

the hospital in order to help facilitate assessment and plans for discharge. This will 

improve the general management of patients and enable improved risk management 

of specific needs such as mental health, safeguarding adults, end of life care. 

As an alert system, the RAPA will allow prompts of clinical teams to review plans for 

patients. It is not a predictive tool for admission risk but will be useful in identifying 

those patients who are admitted frequently, so that improved plans of care can be 

made to better support them to avoid hospital admission and better manage their 

long term condition. 

Carers’ Support 

The Trust recognises that many patients are supported by carers – the unpaid 

workforce who often undertake a long-term, sometimes thankless task of providing 

ongoing care and support to patients. As part of every patient assessment on 

admission, there is consideration of the need for ongoing care and the needs of 

carers in meeting patient these needs. On admission through urgent care services, 

it is common to find an exhausted relative who has struggled for some time to 

support an individual patient with their increasing needs for care and support. 

3

Item 9 

For this reason, many of the clinical care pathways being reviewed and developed 

include the need for clinical teams to involve and consider the needs of carers. The 

Emergency Department often identify carers who themselves have real clinical 

needs or need for support at home. 

As part of the work to involve and support carers, the Trust is working closely with 

Carers’ organisations to signpost individuals to various support, services and help. 

The HR department is involved in this work, to ensure that appropriate support and 

advice are available to the many staff who are also carers. 

The Trust is hosting a Carers Coffee morning in May and will be involved in Carers 

Awareness week in June, promoting the needs and services for carers, in the main 

hospital foyer. These events will give carers a chance to seek advice, information 

and support from organisations and services. It will allow the Trust opportunity to 

find out from carers in general the issues they have when someone comes into 

hospital, whether on a planned or emergency basis, so that we can better involve 

carers in the plans of care for patients and ensure the appropriate support for carers 

is planned for their ongoing role of long-term caring. 

New Appointments 

Dr Imran Saif has recently been appointed as a Consultant Nephrologist at Plymouth 

Hospitals NHS Trust. We look forward to welcoming him to the Trust to further 

strengthen our Renal Services. He brings a wealth of experience from both the UK 

and abroad and will be a valuable asset to the organisation. 

Quality Accounts 

Further to the Trust Board paper presented in July 2009 on Quality Accounts, 

preparations are now well under way for the 2010 Quality Account which will 

address aspects of patient safety, patient experience and effectiveness of care and 

will be brought to the Trust Board in May 2010. This is particularly important as it 

focuses very much on the patient, and on patient and public experiences of the 

services that we offer. 

4

Item 10 


Trust Board – Summary Report 

Date of Board meeting: 30 April 2010 


Authors: 

Approved by: 

Presented by: 

Human Resources Report 

Acting Director of Human Resources 

Interim Director of Finance 


Purpose of the report: 

The purpose of the report is to update the Trust Board of any significant changes 

in legislation or in the wider NHS which will affect the workforce, and to interpret 

the workforce key performance indictors and to highlight any key issues and any 

actions required. 

Action required: 

The Board is asked to note the Human Resources Report. 


None 


Objective: W1, W2, W3 and W4 

Risk: Insufficient trained staff with the right attitude and skills to deliver the 

aims and objectives of the Trust 

Controls: Workforce Strategies and HR Directorate work programme 

Assurance: CQC Outcomes 12, 13, and 14; Staff Survey 

Summary of Financial and Legal Implications: 

Financial impact of sickness absence 

Equality & Diversity and Public & Patient Involvement Implications: 

The most recent Equality and Diversity statistics for the last quarter are available 

on the Trust’s website and included in the Performance Report. 

Other key issues with significant implications for the Trust: 

None 


1

Item 10 



Report of: 

Prepared by: 

Subject: 

Status: 


Acting Director of Human Resources 

Human Resources Report 

For Information 

________ 

EXECUTIVE SUMMARY 

The Trust Board are invited to note performance in respect of human resource 

and workforce indicators. 

Sickness absence has improved from 5.47% in January to 4.98% in February, 

with sickness absence averaged over the last 12 months at 4.78%. In 

comparison, benchmarking data from the NHS Information Centre database 

shows national average sickness absence rates for large acute Trusts to be 

4.57%. 

Staff turnover has fallen slightly to 10.44%, with workforce numbers marginally 

increasing by 1.12 WTE from 6,433 to 6,435. 

Demand for temporary nursing staff increased during March from 210.5 WTE to 

247.5 WTE. Demand for “other staff group” temporary staffing increased by 6 

WTE to 45.8 WTE. 

At the end of March 2010, 81% of staff have attended their Essential Skills update 

training in the past 12 months, taking into account long term sickness and 

maternity leave. Appraisal completion rates for non-medical staff have increased 

to 73.33% as at 31 March 2010. 

In order to support the achievement of the Trust’s objectives, urgent work is being 

undertaken by the HR Directorate to streamline and redesign a number of key HR 

processes. This work includes the redesign of the recruitment pathway to reduce 

the time to recruit, enhancing and streamlining the appraisal process to ensure 

appraisal is of a high quality and meaningful for staff and that identified 

development and training needs are supported and achieved, sickness absence 

management, and other employee relations processes. This work is described in 

more detail below. 

As at the end of March 2010, 1,820 staff have been immunised against seasonal 

flu, and 2,414 staff have been immunised against swine flu. 

2

Item 10 

WORKFORCE PRODUCTIVITY 

Sickness Absence 

Sickness absence has decreased from 5.47% in January, to 4.98% in February, 

with sickness absence averaged over the last 12 months at 4.78%. In 

comparison, the national NHS average sickness rate for large acute Trusts is 

currently 4.57% (source NHS national Information Centre). 

The Anaesthetics Theatres & Pain (8.52%), Critical Care Services (6.67%), 

Operations (6.10%), and Site Services (7.19%) directorates reported the highest 

sickness rates during February. Emergency Services, Gastroenterology, Medical 

Specialties, Pathology, and Surgery and Renal directorates, all reported a 

decrease of over 1%. 

Nursing and Midwifery, Additional Clinical Services, and Estates and Ancillary 

staff groups continue to experience the highest levels of sickness at 6.22%, 

7.68% and 7.50%, compared to 6.97%, 8.82%, and 5.80% respectively in the 

previous month. 

As reported in last month’s HR Report, the Nursing and HR Directorates are 

working together on a specific Staff Forum of nurses and midwives from across a 

range of directorates, using the Listening Into Action methodology, to explore the 

issues around nursing sickness absence, to help find ways of both preventing and 

tackling sickness absence more effectively. 

Turnover 

Turnover has decreased slightly during March to 10.44%, excluding doctors on 

rotations and staff on zero hours contracts. 

WORKFORCE PLANNING AND RECRUITMENT 

Workforce numbers increased marginally during March by 1.12 WTE from 6,433 

to 6,435 (Current Staff WTE = 5,445.03). There were 54 starters and 52 leavers 

during March. Most directorates experienced only minor changes in staff numbers 

during March with Clinical Professions directorate having the highest increase of 

8 (6.07 WTE). 

Temporary Staffing 

The demand for temporary nursing staff increased during March from to 210.5 

WTE in February, to 247.5 WTE. 

NHS Professionals achieved a fill rate of 78.70% (194.8 WTE), comprising 109.9 

WTE registered nurses and 137.6 WTE unregistered nurses. Agency fill 

accounted for 0.5 WTE. The demand for other staff groups (predominantly Admin 

& Clerical) increased by 6 WTE to 45.8 WTE, with NHS Professionals achieving a 

95% fill rate (43.5 WTE). The Trust is currently in discussion with senior NHSP 

3

Item 10 

representatives to identify ways of tackling and reducing late cancelled nursing 

shifts where this occurs. 

In relation to locum doctor requests during March, NHS Professionals filled 80 

(76%) of the 106 placement requests, 15 (14%) of requests were filled by external 

agencies, with the remainder filled by the Trust. 

WORKFORCE DEVELOPMENT 

Training 

At the end of March, 81% of staff have attended their Essential Skills update 

training in the past 12 months, taking into account long term sickness and 

maternity leave. 

Appraisal 

Appraisals have continued to be a high priority, with 73.33% of (non-medical) staff 

having received an appraisal as at the 31 March 2010. 

HR PROCESS REDESIGN 

In order to support the achievement of the Trust’s objectives urgent work is being 

undertaken by the HR Directorate to streamline and redesign a number of key HR 

processes. This work includes the redesign of the recruitment pathway, the 

appraisal process, sickness absence management, and other employee relations 

processes including the grievance, capability, and disciplinary processes. 

Recruitment 

The recruitment process is being reviewed by an experienced team comprising 

Service Improvement Team experts, senior HR staff, the Deputy Director of 

Nursing, operational managers, matrons and ward managers. This is a rapid, high 

impact process, to identify ways of reducing the overall time to recruit and making 

the process more effective and customer-focused. 

An early outcome has been the establishment of a new data management system 

to enable each stage of the recruitment process to be tracked and to increase 

visibility of recruitment activity at each stage of the process. This will enable 

changes made to the process to be accurately tracked to identify whether or not 

the changes made to the process as part of this review are making a positive 

impact. 

The substantive stage of the review, scheduled for the first week in May, will 

involve a multi-disciplinary review group examining and challenging each and 

every stage of the recruitment pathway that has been mapped. This will include 

reviewing the way interviews are planned and employment checks are 

undertaken, in order to take a completely fresh look at the process, and to identify 

the changes that can be quickly piloted and implemented to streamline the 

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process and reduce the overall time to recruit, whilst maintaining essential 

elements of the process. Changes to the process will be put in place and 

carefully tracked and piloted rapidly following the process review event scheduled 

to take place in the first week of May. 

Alongside this, the process surrounding the financial approval of vacancies will 

also be reviewed in conjunction with Finance, to ensure that the process meets 

the current and future needs of the organisation and supports an overall faster 

recruitment process. 

HR is also working with the Directorate of Nursing to agree suitable, bespoke 

recruitment events and solutions to meet the identified demand for ward-based 

vacancies. 

Appraisal 

The appraisal process has been reviewed and redesigned during the past two 

weeks, taking into account feedback from staff and users of the existing appraisal 

process, staff survey feedback, and examples of excellence in other Trusts that, 

based on their 2009 Staff Survey results, have highly effective appraisal systems 

and processes in place in terms of completion rates and, more importantly, in 

terms of the quality and perceived value to staff. 

The proposal has a much reduced administrative requirement ensuring that staff 

have the necessary time to undertake a meaningful appraisal, and that training 

and development activity identified through the appraisal process as part of an 

individual's personal development plan, subsequently takes place. Appraiser 

training will focus on enhancing the value of appraisal rather than the process 

itself. 

The redesigned process will very shortly be piloted during May 2010, and refined 

as necessary, prior to wider implementation across the Trust to support the 

Trust’s objective of a meaningful and high quality annual appraisal for all staff. 

Sickness Absence, Grievance, Capability and Disciplinary Processes 

A number of other important HR processes, policies and procedures have been 

reviewed and re-designed where necessary, to ensure that they are fit for 

purpose, add value, and meet the future needs of the organisation, including new 

capability, grievance, and disciplinary procedures, and an updated sickness 

absence management process. 

A review of the Trust’s sickness absence management procedure has been 

completed, with the involvement of a range of experienced Trust managers and 

the trades unions. This provides greater clarity around the processes, 

expectations and responsibilities of managers and staff, and provides managers 

with additional tools for effectively managing sickness absence. The new 

procedure will be put in place during April 2010. 

The Trust’s overall 12 month average sickness absence rate has continued to 

reduce from 5.22% and 5.10% in 2007/8 and 2008/9 respectively, to the current 

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12 month average of 4.78%. A recent internal Audit review of the management of 

sickness absence management found that clear procedures and processes were 

in place and that, overall, staff and managers are aware of the correct procedures 

to follow with regard to the management of episodes of sickness absence. A 

further action identified in the report was to ensure that line managers comply 

with the agreed Trust processes. 

The Trust is committed to further reducing sickness absence rates, through 

effective attendance management, and also through implementation of the 

Department of Health, Health and Wellbeing Review recommendations (led by 

Steven Boorman) in terms of the sickness prevention and increased productivity 

agenda. This is supported by focused work being undertaken in areas of higher 

than average sickness levels, including joint working between the Nursing 

Directorate and HR on significantly reducing nursing staff group sickness 

absence. 

The Trust’s Grievance Procedure and Disciplinary Procedure are in the process 

of being reviewed, and it is anticipated that both will be implemented during June 

2010, following the necessary consultation with staff, managers and trades 

unions. 

OCCUPATIONAL HEALTH 

Swine and Seasonal Flu Vaccination Programme 

The Trust’s ongoing vaccination programme has continued to provide both 

seasonal and swine flu vaccines. As at the end of March 2010, 1820 staff have 

been immunised against seasonal flu, and 2414 have been immunised against 

swine flu. Swine and seasonal flu vaccines continue to be available from the OH 

department. 

RECOMMENDATION 

The Board is requested to note the content of this paper. 

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Item 11 





Authors: 

Approved by: 

Presented by: 

Chief Executive’s Report 





Update the Board on key issues not covered elsewhere on the agenda. 


None, for information only. 


None. 



Ensures the Board is briefed on key issues which may include issues of 

assurance. 


No direct financial or legal implications. 


Keeps the Board informed of items of great public interest and media 

coverage involving the Trust. Gives an opportunity in the public part of the 

meeting to draw the attention of the public and media to the achievements of 

the Trust. 

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Report of: 

Subject: 

Status: 

Chief Executive 

General Update 

For information and discussion 

________________________ 

1 Royal College of Obstetricians and Gynaecologists 

I am delighted to announce that Dr Tony Falconer, Consultant Obstetrician, 

has been elected as President of the Royal College of Obstetricians and 

Gynaecologists. Tony will take up his post in September. 

The strap line for the College is: “Setting standards to improve women’s 

health”. Over the last few years Tony has been a tireless campaigner and 

activist on global women’s health issues and in particular the health of women 

in Africa as Vice President of the College. For many more years he has been 

a leading light in championing health services for women in Plymouth and the 

wider South West. 

2 Organisational Announcement 

I am pleased to announce that following recent discussions with NHS 

Plymouth, Helen Allen has accepted a six month secondment to Plymouth 

Hospitals NHS Trust as Director of Workforce, a post which she will hold 

concurrently with her substantive position for NHS Plymouth. This role will 

support the strategic development of workforce across the whole system and 

is as a further example of collaborative working in Plymouth. 

3 Shadow Membership and Governor Activity 

The Trust’s ‘governors’ in waiting are currently mid-way through a further 

round of training sessions covering membership, finance at a Directorate level, 

the Trust’s environment and estate, our Care Quality Commission registration 

and how the current economic climate will affect the NHS. I would like to thank 

‘governors’ for their continued commitment to their role. 

In most instances, Governors of Foundation Trusts have no opportunity to 

shape, guide, or comment on their own trust’s Membership Strategy because 

it is written prior to them taking up their role. However, having had ‘governors’ 

in place for twelve months, PHT has the opportunity to draw on ‘governors’ 

knowledge and experience in order to update our Membership Strategy as 

part of a renewed FT application, although it is acknowledged their responses 

will, inevitably, be limited by their lack of a formal role. The FT Board 

Secretary has invited ‘governors’ to review and revise, where necessary, the 

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Item 11 

key themes of our Membership Strategy and ‘governors’ have provided 

welcome and valuable insight into its development. 

A feature on the Members’ Forum in the autumn edition of Members’ News 

encouraged new members to join. The survey enclosed with the newsletter 

provided valuable feedback on past Forum events which, as promised, has 

been used to shape the frequency, timings and content of future sessions. 

The next series of events begins on Tuesday 18 May 2010 with two of the 

most popular topics that members wanted to learn more about - nutrition and 

men’s health. Further details of Forum meetings can be obtained from the 

Foundation Trust office, 01752 439060. 

4 College of Medicine and Dentistry 

I am representing the NHS (with Angela Pedder) in the appointment process 

for a Dean for the College of Medicine and Dentistry. This is a very important 

post for the NHS and universities in Devon and Cornwall. I will keep the 

Board informed of progress. 

5 National Top Leaders Programme 

The Trust Executive Directors have been enrolled on the NHS Top Leaders 

Programme. It is aimed at the Directors of the most complex organisations in 

the NHS and at Directors who have the potential to lead such organisations. 

The opening session is on the 27 April. 

6 Communications report for March 2010 

Reputation Management 

Maintaining Mutually Beneficial Relationships with Key Stakeholders 

• The Director of Infection Prevention and Control attended the public 

session of the Plymouth Health and Wellbeing Overview and Scrutiny 

Panel in March to present the annual update on infection prevention and 

control. 

Reputation Management - Engaging Online 

• The website was visited over 23,000 times during March 2010 with over 

111,000 pages being viewed. Developments on the site include an inhouse 

production video tour of the maternity unit, publication of way finding 

information. The clinical services sections are currently being merged in 

order to provide clearer information to website visitors. 

• What is a visit? 

Visits represent the number of individual sessions initiated by all the 

visitors to our site whereas a visitor represents the number of unique users 

that visit the site on a daily basis. 

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Item 11 

Reputation Management - Media Engagement and Freedom of 

Information 

Media Enquiries 

Media Outputs 

(news releases, 

diary notes, 

statements) 

Media 

Outcomes 

(online, 

broadcast or 

traditional media 

articles) 

Freedom of 

Information 

Requests 

114 18 139 12 

Analysis of Media Outputs (Sept 09-Mar 10) 

160 

140 

120 

Number of Media Outputs 

100 

80 

60 

40 

Significantly Negative 

Marginally Negative 

Marginally Positive 

Significantly Positive 

20 

0 

September 

October 

November 

December 

January 

February 

March 

April 

May 

June 

July 

Month 

Items that attracted significantly positive coverage during March were: 

• Diet or my Husband Dies – BBC One (50 minute documentary featuring 

the work of the South West Transplant Centre) 

• New liver unit for Derriford – The Herald, BBC Radio Devon, Heart 

Plymouth 

• Team leading way in liver disease prevention effort – Western Morning 

News 

• Two glasses of wine a night almost killed me – The Herald 

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• Derriford has fewest deaths from superbug – The Herald and Heart 

Radio 

Items that attracted significantly negative coverage during March were: 

• Muriel Elliott Inquest – The Herald, BBC Spotlight, Western Morning 

News, ITV Westcountry Tonight, BBC News Online, BBC Radio Devon 

• Cancelled Operations – Heart Plymouth 

• NHS Facility had no permission –The Herald 

Throughout March, 12 letters were published in the local newspapers and 

online. Eight were significantly positive, praising the Trust’s staff and the work 

they do and four were significantly negative in content. 

Paul Roberts 

Chief Executive 

4

Agenda and papers - Plymouth Hospitals NHS Trust

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