Trust Board papers July 2012 - Barking Havering and Redbridge ...

TRUST BOARD MEETINGWednesday, 4 July 2012 at 1.00 pmBoard Room, Trust HeadquartersQueen’s HospitalA G E N D A1. Apologies for Absence2. Minutes of the meeting held on 2 May 2012 (Attachment A)3. Matters Arising and Actions4. GOVERNANCE:4.1 Care Quality Commission (SB) (Attachment B)5. QUALITY AND PATIENT STANDARDS5.1 Quality & Patient Standards Performance Report – (Attachment C)May 2012 (NM/DCW/RMcA)5.2 Emergency Care/RESET Programme Update (CG) (Attachment D)5.3 Maternity Services Update (DCW/CG) (Attachment E)5.4 Learning Disability Progress Report (DCW) (Attachment F)6. FINANCE, WORKFORCE AND ACTIVITY6.1 Milestone Tracker/Composite Plan (NM) (Attachment G)6.2 Finance Report – Month 2 (May) 2012/13 (DIW) (Attachment H)6.3 Workforce Key Performance Indicators (RMcA) (Attachment I)6.4 Transformation Board Update (DH) (Attachment J)7. INFORMATIONMatters for Noting:7.1 Interim Chair and Chief Executive’s Report (Attachment K)7.2 Declaration of Members’ Interests 2012/13 (Attachment L)7.3 Infection Control annual report (DCW) (Attachment M)7.4 Minutes of the Quality & Safety Committee meeting held on (Attachment N)the 17 April 20127.5 Minutes of the Charitable Funds Committee meeting held on (Attachment O)the 27 March 20128. Any Other BusinessDate of Next Meeting: The next public meeting will be held on Wednesday,5 September 2012 at 1.00 p.m. in the Board Room, Trust Headquarters, Queen’s Hospital9. Questions from the Public10. Exclusion of the Public and Press In accordance with the Public Bodies Admission toMeetings Act), to resolve to exclude members of the public and press from the remainderof the meeting.Trust Board Agenda – 4 July 2012 1

1BARKING, HAVERING AND REDBRIDGE UNIVERSITYHOSPITALS NHS TRUSTMinutes of the Part I Trust Board Meeting held on the 2 May 2012in the Board Room, Trust Headquarters, Queen’s HospitalPresent: Mr George Wood Interim ChairmanMrs Averil Dongworth Chief ExecutiveMr Stephen Burgess Medical DirectorDr Maureen Dalziel Non-Executive Director (Designate)Mrs Cathy Geddes Chief Operating OfficerMr William Langley Non-Executive DirectorMrs Ruth McAllDirector of Human Resources & ODMr Keith Mahoney Non-Executive DirectorMr Neill MoloneyDirector of Planning & PerformanceDr Robert RoyceDirector of StrategyProf Anthony Warrens Non-Executive DirectorMs Deborah Wheeler Director of NursingMr Phil WilsonNon-Executive Director, NELCMr David WraggDirector of FinanceMs Caroline Wright Non-Executive DirectorIn Attendance: Mr Nick Hulme Project Lead for Integrated ServicesMs Imogen Shillito Director of CommunicationsMrs Sue WilliamsExecutive Assistant/Trust Board SecretaryMr Wood opened the meeting by welcoming Dr Maureen Dalziel as Non-Executive Director (Designate) forthe Trust. Mr Wood also welcomed members of the Public, including two prospective candidates forConsultant posts at the Trust.2012/001 APOLOGIES FOR ABSENCEMr Michael White, Non-Executive Director.2012/002 MINUTES OF THE PART I MEETING HELD ON 7 MARCH 2012The minutes of the Part I meeting held on the 7 March 2012 were noted as a true record and signed by theInterim Chairman.2012/003 MATTERS ARISINGAll actions from the previous meeting completed, or on the agenda for today’s meeting.2012/004 CARE QUALITY COMMISSION ACTION PLAN UPDATEMr Burgess presented the Programme Management Office CQC Trust-wide Action Plan Progress Reportand the updated CQC Trust-wide Action Plan for March. At present 39% of the 59 recommendations duefor completion by the end of March had been achieved and the majority of the others remained on courseto reach their conclusion within the next week or two. The PMO remained cautiously confident that theTrust would have 67 of its 81 recommendations green/blue by the end of April. This current position wouldbe presented to the Care Quality Commission and External Stakeholders at the Roundtable Event on the 8May. Mr Burgess confirmed that progress was good and he did not have to report any insurmountableblockages to the delivery of the Action Plan.The Trust Board noted the report.2012/005 BOARD ASSURANCE FRAMEWORK 2011/12 – QUARTER 4Mr Burgess pointed out to the Board that the Board Assurance Framework (BAF) was in a transitionalstage and its current format was not the final version. The Trust was working to improve it and would beholding further meetings in the next month to achieve this. Mr Burgess highlighted the detailed sectionsTrust Board Minutes Part I – 2 May 2012

2on Emergency Care, Infection Control and Complaints Management, which were additional to the previousBAF that was presented to the Board. He also highlighted the two sections on Governance and FinancialGovernance.Mr Wood raised the issue of the gaps in assurance in the Women & Children Services section and thecontinued overspending in Maternity due to overbooking of agency and bank staff. A review had beenundertaken in the early part of March regarding this continued reliance on bank and agency staff and it wasnoted that this was due to staff returning from maternity leave and then taking their annual leave. TheDirector of Nursing and the Chief Operating Officer were reviewing this and looking at what was requiredgoing forward. Mr Mahoney raised the number of Insufficient Workforce (20%) of the trends of risks on theRisk Register. Mr Burgess informed the Board that the Trust was aware that there was a gap inConsultants and Middle Grade Doctors in A&E and this was reflected in this number. Mr Langley raisedthe issue that the Trust was rated ‘red’ on Partnership Working and was still awaiting Department of Healthtools. The Board discussed the benefit of putting something else in place for the time being and agreedthat this required Board input, although everyone was aware that there was tangible evidence thatrelationships with partners had vastly improved. It had been noted at a meeting earlier in the weekbetween Local Authorities, Commissioners, Community Services and the Trust that the dialogue was now‘we’, rather than in the singular. Although the Trust did not have the tools in place, the Board felt thatPartnership working could be moved to ‘amber’ in order to demonstrate the improvement in relationships,which would be noted in the Trust’s TFA by NHS London and the Department of Health.The Trust Board noted the changes to the BAF. The Board agreed that Partnership Working could bechanged to ‘amber’.2012/006 HEALTH4NEL UPDATEMr Royce, as the Trust’s Executive Lead for Health4NEL, presented an update to the Board from a briefingpaper prepared by Heather Mullin, Project Lead for Health4NEL. He confirmed that these briefing paperswere being presented to all Boards of organisations in the Sector. Mr Royce highlighted the KeyDeliverables section and the amount of work involved with the commencement of implementation, alongwith the challenging timeline for these changes to be made. He also highlighted that in order to managethe activity, 100 beds would need to be released at Queen’s Hospital. This figure needed to be confirmedwithin the bed modelling work that was currently being undertaken. The original IRP had set out a figure of164 beds.Mr Royce informed the Board that there was a whole range of enabling capital works required, particularlyat Queen’s and the Trust now had confirmation from NHS London that it would be required to produce anOutline Business Case (OBC) and not go straight to a Full Business Case (FBC). The Trust was thereforeworking on the basis of the OBC being completed by the 31 July. It was very important that the OBC andthe Long Term Financial Model (LTFM) were entirely intertwined and one informed the other. Once theOBC had been prepared and assuming sign-off by the Board and the Commissioners, it would then go toNHS London and if approved there the Trust, with its Commissioner, would move to the preparation of anFBC. The Board noted that the preparation of an OBC would impact on the timing of implementation. MrRoyce had a copy of the framework for the production of the Business Case and informed all Boardmembers that this was available from him if anyone wished to review it.Mr Royce reported that it was planned to have the Urgent Care Centres treating 50% of patients presentingat the Hospitals by June 2013. This target was a considerable way off on both sites (King George andQueen’s), but on a more positive note, in relation to the Midwifery Led Unit (MLU), Cornflower A wasclosed as planned at the end of April, enabling the estates work to commence, so the MLU scheme wasnow ‘up and running’. The Chief Executive informed the Board that as the Trust had closed Cornflower A,it had opened a contingency ward at King George Hospital. The Chief Operating Officer raised the pointthat there were no Urgent Care Centres in the Sector that took 50% of patients (could meet 50% if youincluded Paediatrics), but it was extremely difficult to get to 50% and this therefore needed to be factored inand reviewed. Mr Royce would feedback these concerns to the Health4NEL Project Team and wouldpropose that the Trust would like to see a realistic analysis being undertaken as things moved forward.Trust Board Minutes Part I – 2 May 2012

3Mr Royce informed the Board that there was a specific workstream to look at King George Hospital withinthe context of the whole health economy and it was recognised that this was a key deliverable that had tobe met. The LTFM would include King George and how other communities fitted into it. Mr Royce wouldupdate the Board on progress at the July Board meeting, but he emphasised that it was important thatgiven the fact that the Commissioner’s and NHS London would no longer be around in March next year,that there was a completely solid plan in place by October this year at the latest.The Trust Board confirmed their support of the action plan and noted those areas which would be led bythe Trust.Action: Rob Royce 4.7.122012/007 QUALITY & PATIENT STANDARDS PERFORMANCE REPORT – MARCH 2012Mr Moloney presented the Quality & Patient Standards Performance Report for March 2012. Mr Langleyraised the issue of the team of Social Workers from Havering Social Services and a Trust DischargePlanning Nurse piloting six day working for six weeks and that although two weekends of the six hadshowed improved discharge performance, the others were disappointing. Mrs Geddes did not know thedetail around the pilot, but she commented that although additional resources could be put in, the Trust didnot have enough Consultant presence at the moment to facilitate an increase in discharges. This was partof the work she was taking forward with McKinsey. It could be something very simple like an administratorwho worked all week, but did not work at the weekend. It was therefore about finding out how the wholesystem worked and ensuring that everyone was clear and understood changes being made and how theyinter-related with other organisations.The Board agreed that it was good news that the Trust was delivering consistently on a whole range of keyperformance indicators, including the 18 week target, Cancer and Elective Admissions. An area ofconcern was the lack of confidence in the Trust, its Doctors and nurses and midwives. This wasdisappointing, due to the number of people that had been recruited recently. The fact that there was nosense as to what mitigating action the Trust was planning to take to address this was also of concern. MsWheeler confirmed that these were responses on the ‘real time’ surveys and there had been a report to theQuality & Safety Committee regarding this. She informed the Board that the hand held devices on thewards had now been installed at King George. The Trust had seen more information coming through overthe last couple of months from these sources and this would assist in providing more robust data. Thisdata could be drilled down to ward/unit level and the Director of Nursing’s Department was talking to thenew Clinical Directors to see how they could use this information with their teams.The Trust had recently received the Patient Survey and the Inpatient Survey, both of which were not goodand the Chief Executive confirmed that she had spoken to the Senior Leaders in the Trust this week andgiven them the results. Mrs Dongworth confirmed that the Trust would be taking all the work on thisthrough the Transformation Board and tracking it to ensure improvement over time.The Chief Executive drew the Board’s attention to the Trust’s performance on MRSA. Ms Wheelerinformed the Board that the Trust had exceeded the trajectory for last year by two. The target for this yearhad been set at seven and the Trust had already reported one case during April. Ms Wheeler confirmedthat a root cause analysis on this case was being undertaken. The Trust had been under scrutiny, as thiswas the first reported case in London. The Chief Executive confirmed that the Trust was sighted that, eventhough the target was seven, it wanted to come in under this figure by the year end and Mrs Dongworthhad invited an External Assessor, who was a Microbiologist at another Trust, to look at the Trust’s InfectionControl processes and the incidents of Norovirus last year. The Trust had had ongoing ward closuresthrough April for Norovirus. The External Assessor would look to see if there was anything that the Trustshould do to tighten up its policies.The Trust Board noted the content of the report and supported the actions to bring the performance back inline with trajectory/target.Trust Board Minutes Part I – 2 May 2012

42012/008 EMERGENCY CARE REPORT ON MARCH 2012 PERFORMANCEThe Chief Executive advised the Board that along with the Chief Operating Officer, she had attended aTFA Escalation meeting at the Department of Health with David Flory on the 17 April and he had made itquite clear the Emergency Care Pathway/Access target was the Department’s biggest concern, along withthe Trust’s finances. With regard to the Emergency Care Target, it was made very clear that theDepartment was setting the Trust a realistic target of continuous improvement, rather than a percentage bya set deadline.The Chief Operating Officer presented an update on the work started through the RESET Programme(Jonathan Dimson and Nicola Yates from McKinsey were present for this agenda item). In terms ofperformance, the Trust achieved 81.15% for the week ending 22 April and improved to 86.47% for theweek ending 29 April (KGH achieved 95%) and was the best performance for the last five weeks. TheBoard was shown a video, taken by McKinsey, on the Emergency Care Pathway. This was a powerfulmessage in terms of how the Trust’s staff viewed the Pathway at the moment, as well as some commentsfrom patients on the care they had received. Mrs Geddes confirmed that next week the Trust would befocusing more on the workstream relating to pre 11.00 a.m. discharges, as these were currently indicatingvery low numbers during the week and non at the weekend. She also confirmed that there would be a lotof changes taking place around the pre 11.00 a.m. discharges and starting from next week the Trust wouldbe looking at ways of getting the weekend discharge process in train very quickly. This would involvereviewing Job Plans, in order to get Consultants to come in at the weekend. The Board agreed thatCaroline Moore, one of the Deputy Directors of Nursing, should be commended for all her hard work inrelation to the improvement in the bed management process. Ms Geddes confirmed that an additionalresource had been put into the RATing area to enhance that process.Multi-disciplinary ward rounds at 8.00 a.m. had commenced this week and in addition to everything elsegoing on, the Trust was reviewing the length of stay of all patients over 30 days. As these reduced, theTrust would start looking at reviewing those patients with lengths of stay of over 14 days.The Chief Operating Officer was pulling together a Business Case around the costs of the changes to theEmergency Care Pathway, as there would be a cost if the Trust was going to ask Consultants to come in atthe weekend. In addition to Consultants working at the weekend, the Medical Director raised the point thatsupport services needed to be in place at the weekend, in order for the hospital to work on a 7/7 basis.Mr Wood thanked McKinsey’s for their work to-date and commented that the Trust would want to seecontinual sustained improvement. The Trust was working towards sustainability, but was sitting on a highlyvolatile system at the moment, and was not under any illusion that everything was fixed, as it was not.Mr Burgess informed the Board that an Interview Panel had been set in June for Consultants and MiddleGrades for the A&E Department and indications were that the Trust had attracted a good field ofcandidates. The aim of the Trust was to fill substantive posts with good quality individuals who would servethe organisation well. The medical staff in A&E felt more confident that the Trust would be in a betterposition than before to appoint to some of these posts. Recognition to Derek Hicks, Clinical Director forEmergency Care, and his colleagues, was given by the Board that with everything going on they had givensome of their personal time to go out to headhunt people, so the Trust would be able to recruit. Last year,the Trust could not get anyone to even fill in an application for a post in A&E.The Trust Board noted the performance and noted the actions taken to improve performance.2012/009 MATERNITY SERVICE UPDATE – MARCH 2012Ms Wheeler distributed the Maternity Services Weekly Performance Report for the week commencing the16 April 2012, together with a revised copy of the Balanced Scorecard with performance up to the end ofMarch. Ms Wheeler confirmed that the Trust was meeting regularly with the Commissioner’s and they hadasked the Trust to reflect back on the performance reporting over the last six months and to put forward aproposal about a revised assurance process that would change the way discussions were framed with theTrust Board Minutes Part I – 2 May 2012

5Commissioner’s and would move on to a more sustainable process, rather than detailed aspects of theservice being continuously discussed at meetings.Ms Wheeler informed the Board that elective c-sections had been repatriated to the Trust from theHomerton since the beginning of April and two elective lists per week were running at King GeorgeHospital. Initial indications from women were that they were reporting very good patient experiences. Inrelation to the ‘capping’ of deliveries, the Trust had a meeting with the Commissioner next week to reviewthis.Mr Wood referred to the recruitment of 18 midwives and the continued use of 42 bank and agency staff.Ms Wheeler confirmed that this was partly around e-rostering and the impact of annual leave that hadaccrued for midwives on maternity leave, as referred to earlier under the BAF agenda item. Other staff hadalso held back on taking annual leave whilst the service was in crisis and had waited for new people tocome into post. Sickness rates had also impacted on the usage of bank and agency staff.The Trust Board noted the content of the report.2012/010 REVIEW OF COMPLANTS MANAGEMENTMs Wheeler presented the report from NHS London received mid March, following the review of complaintsmanagement, structures and processes undertaken in January this year. The action plan attached to thereport was a draft discussed at the Trust Executive Committee last week and Ms Wheeler was veryconscious that the new Clinical Directors had not been involved in the initial process, as the Divisions hadbeen in place at the time. Therefore at the Trust Executive Committee meeting Ms Wheeler had asked forcomments back by the end of this week, following which the action plan would be formally signed-off andthe Clinical Directors would take ownership going forward.Ms Wheeler reported that complaints were continuing to be received at the same level; over 100 inFebruary. The biggest volume coming in was around Emergency Care, particularly the EmergencyDepartment. Additional administration support had been put into the Emergency Care Directorate, but theissue now was freeing up clinician’s time to prepare meaningful responses. One of the Associate MedicalDirectors was providing support to the Clinical Director in this regard. Ms Wheeler also informed the Boardthat the Complaints Department was looking at other ways of helping, in order to ensure complaints wereresponded to properly and quickly. It was recognised that the whole complaints process had not beenworking well, but the interviews for the report had taken place at the end of December, beginning ofJanuary before more processes had been put in place. The quality assurance for the complaint lettersremained at Executive Director level, but all complaint responses were signed-off by the Clinical Directorsbefore being forwarded for final sign-off. Ms Wheeler confirmed that the Complaints Department hadreceived positive feedback from staff now that they were copied in to the complaint letters/responses.Mr Wood highlighted that some of the recommendations contained in the report had not been included inthe action plan. Ms Wheeler informed the Board that she was trying to establish the complaints team as aresource and response unit for the organisation, rather than the driver for what happened. This linked intothe Care Quality Commission work and the cultural change required for how people work. The currentsystem was not delivering what was required and there did not appear to be any actions included aboutwhat the Trust was going to do to address this.It was agreed that Ms Wheeler would report back at the July Trust Board meeting on where the Trust waswith all of the above work. The question of a dedicated meeting room for complaints was highlighted by MsWheeler, as most meeting rooms were within clinical areas and were not a good place to conductconfidential complaints meetings. This issue would be addressed quickly.The Trust Board noted the attached draft action plan and the verbal update given to reflect the discussionsand decisions from the Trust Executive Committee meeting.Action: Deborah Wheeler 4.7.12Trust Board Minutes Part I – 2 May 2012

62012/011 ISSUES FOR ESCALATION FROM QUALITY & SAFETY COMMITTEEMr Burgess drew to the Board’s attention the Quality & Safety Committee’s recommendation that the Boardgive consideration for patient’s being invited to attend the Public Trust Board meetings to present theirexperiences/stories. The Patient Stories paper had been prepared by Gary Etheridge, Deputy Director ofNursing. The Board discussed whether, with all the current workload, this was the right time to take thisforward, as it would create additional work at a time when people were already very busy and shouldperhaps be deferred for the time being.The Chief Operating Officer informed the Board that this was a practice that had been in place when shewas at Whipps Cross and it had been recognised as really powerful and should be a top priority for thisTrust. Mrs Geddes felt it was really important for the Trust Board to agree to this recommendation fromthe Quality & Safety Committee. It was proposed that Caroline Wright and Anthony Warrens, as Co-Chairsof the Quality & Safety Committee, should test it out at their meeting, work the recommendation throughand bring back a proposition to the Board.The Trust Board noted the paper presented to the Quality & Safety Committee, supported it in principle, butagreed to defer for 3-6 months to provide the opportunity for the Co-Chairs of the Quality & SafetyCommittee to review the recommendation and to put a proposition together for the Board.Action: Caroline Wright/Anthony Warrens 5.9.122012/012 TRIPARTITE FORMAL AGREEMENT MILESTONE TRACKERMr Moloney presented the Tripartite Formal Agreement (TFA) Milestone Tracker, which was the formaldocument being used by NHS London and the Department of Health to assess the Trust’s performancetowards becoming a Foundation Trust. The TFA set out the timeframe and the indicators that the Trustneeded to meet around actions from the previous financial year – delivery of CIP and control total,Financial Planning (2012/13 SLA and Productivity Programme), Care Quality Commission –implementation of recommendations, Service Performance and implementation of Health4NEL. Aspreviously mentioned, detailed discussions had been held with NHS London and the Department of Healthwhen the Chief Executive and Chief Operating Officer had met with David Flory recently to review the TFA.The Chief Executive informed the Board that Neill Moloney and Helen Brown, Director of Performance &Delivery at NHS North East London and the City (NELC), were looking at how they could take the format ofthe TFA to the next level and were also reviewing the milestones that needed to be achieved. This wouldresult in a new format for the TFA being used for the next Trust Board report.Mr Wood raised the issue of the Trust meeting the agreed Emergency Care trajectory and Mrs Geddesconfirmed that she had prepared a draft trajectory to get the Trust to 95% by the end of July, but this wouldbe firmed up once the letter awaited from David Flory, following the meeting on the 17 April, was received.Mrs Geddes would provide copies of the trajectory for all members of the Board at the July Trust Boardmeeting.The Trust Board noted the report.Action: Cathy Geddes 4.7.122012/013 BUSINESS PLAN 2012/13Mr Moloney presented the Business Plan for 2012/13. This plan sat on top of the Directorate andCorporate Departments Business Plans and pulled together all planning assumptions and key priorities for2012/13. It also included a detailed analysis of the workforce plans and the underlying financialassumptions. Mr Moloney reported that there was still a gap on the QIPP (CIP Programme) and thiswould be the focus of the next few weeks. Following a question from Mr Langley regarding interdependencieswith other organisations within the local economy, Mr Moloney informed the Board that theTrust was not currently fully engaged and there was a lot more work to be done. Part of this work wouldTrust Board Minutes Part I – 2 May 2012

7include Integrated Services within the Health4NEL implementation, which Mr Nick Hulme was leading on.Services currently in place needed to change considerably and the Trust would expect to see this occurringduring 2012. Mr Moloney also informed the Board that the Commissioning Strategic Plans were beingreviewed, as these were ambitious in terms of their attempts to reduce non-elective admissions andoutpatients. The Trust was due to receive these Plans shortly and would then have a better idea of thelevel of investment that would be put into the community. These Plans would also have a section on interdependencies.Mr Wood raised the point that he would like to see tracking of the WTE by Directorates, along with thepayroll budgets; the WTE figures were included in the Plan, but were at Divisional level, not Directoratelevel. To achieve the Trust’s QIPP, the organisation must see significant reductions in headcount. Most ofthis would come out by the elimination of bank and agency staff. Mr Wragg confirmed that the Plans, asthey stood, had WTE projected by month and had been built into the budgets by month, but the key bitmissing was the QIPP target of £23m. Mr Wragg was reporting that the Trust was up to £9.5m ‘green’rated schemes for the QIPP, a further £4m ‘amber’, but the substantial proportion of £10m not yet rag ratedwould be driven by workforce reductions, which was not currently built into the budgets. With the supportof the Commissioner’s, a team from Ernst & Young had been appointed to look at the robustness of theQIPP and to identify further schemes to close the gap. Ernst & Young had already started this work andwould be in the Trust for another five weeks. Regular updates on progress would be reported through tothe Trust Executive Committee, the Transformation Board, and also through to the Finance & ProgrammeManagement Committee. Mr Wragg informed the Board that the process was behind where the Trustwould want it to be, but the Executive Team was absolutely clear it had to deliver a 5.5% reduction onincome as its QIPP and the process was now in place to deliver this. This key piece of work beingundertaken by Ernst & Young regarding the QIPP gap would enable the Business Plan to be completedand ready for ratification by the Trust Board.Mr Wood registered his concerns around the fact that the Trust had recruited 250 new staff, but the bankand agency costs had not declined.Ms Wright questioned the fact that there did not appear to be anything in the Business Plan to address theTrust’s cultural problems. The Trust needed to set out the action that it would be taking to address this andthe Chief Executive confirmed that it had been agreed that the Transformation Board would be looking atthe work programmes to fill this gap and would come back to the Trust Board on the timelines and whenthe Trust expected the Plan to be populated. This would also be incorporated into next year’s BusinessPlan as well.The Trust Board noted the current version of the Business Plan for 2012/13.2012/014 INCOME AND EXPENDITURE BUDGETS 2012/13Mr Wragg reported that the position showed an income and expenditure budget deficit of £39.7m,excluding the impact of impairments and IFRS. The report set out the bridge reconciliation from the2011/12 outturn position, the proposed budget control totals at Directorate level, QIPP targets for 2012/13and the key assumptions and risks. Mr Wragg informed the Board that a good contract had been agreedwith the Commissioner’s and they were comfortable with the assumptions that had been built in to theposition and the way it had been spread across the Clinical Directorates. The Trust was expected todeliver the required QIPP cost reduction programme, as other Trusts were delivering around 5% to 7%within their plans. NHS London and the Commissioner’s were concerned at the level of the QIPP schemesthat were not rated ‘green’, although they recognised the plan was moving forward. The Trust had beenworking through this with the Commissioner’s, with the assistance of Ernst & Young, to deliver a morerobust QIPP position.Along with the work being carried forward, which had been referred to above, Mr Wragg and the ChiefOperating Officer had been interviewing external Consultants in order to appoint an Interim QIPPProgramme Director to support existing resources and to lead the QIPP Programme once Ernst & Younghad completed their current contract. This additional support would provide the Trust with its own team tocontinue the monitoring and management of the process. Ernst & Young expected to be able to validatetheir work in five weeks time and would be preparing an interim report for the Finance & ProgrammeTrust Board Minutes Part I – 2 May 2012

8Management Committee later this month and the Transformation Board in June. Mr Wragg reported thatErnst & Young was also assisting with the other key element, which was the Long Term Financial Model(LTFM) and the three to five year QIPP plan.Mr Langley raised the issue of the current position of the Project Management Office (PMO) staff who werecurrently monitoring Emergency Care, Maternity and delivery of the CQC Action Plan. Mr Wragg informedthe Board that the Trust was currently using an Interim Management Advisory Service in the PMO and thedecision on the future of this area, following any recommendations from Ernst & Young that the Trust wouldwant to build on, would be made by the new Director of Transformation, Dorothy Hosein, as she would bethe Executive Director Lead for the PMO in the future.The Trust had already made two new appointments to the Service Transformation team; a Clinical Lead forQIPP Programme and a Head of Service Transformation; two excellent appointments.The Trust Board agreed the proposed budgets for 2012/13.2012/015 FINANCE REPORT – MONTH 12 (MARCH) 2011/12Mr Wragg confirmed that the Trust had delivered the year end control total of £49.9m before £1.1mimpairment reversals. Against plan the adverse variance was £10m, the key variances being income£20.4m favourable, pay £21m adverse and non-pay £9.7m adverse. Mr Wragg confirmed the substantialnon delivery of the Cost Improvement Programme (QIPP), which was the major cause of the extent towhich the Trust had slipped from the original control total of £40m (£13.9m reported as implemented, whichleft a £14.4m shortfall against the £28.3m target).Mr Wragg reported to the Board that the Trust had met its statutory targets and had a £1.3m underspendon capital allocation to carry forward to next year. There had been a significant injection of cash at the endof the financial year and the Trust’s debtors had dropped drastically.The Trust Board noted the report.2012/016 ACCOUNTABILITY FRAMEWORK FOR FINANCIAL PERFORMANCE AND COSTCONTROL (ESCALATION POLICY)Mr Wragg informed the Board that he had taken comments from colleagues and had put together aframework for the management of the Clinical Directorates, with a clear escalation process to be usedthrough the performance management structure. He confirmed that the framework had been designed toexert financial control, rather than correct poor individual performance and would be rolled out with effectfrom the M1 performance review meetings. All concerned would be informed that there would be a changein policy in that people would now be held to account and this would be communicated to the organisation.Mr Wragg confirmed that meetings would be held with anyone who needed to talk through the framework,in order to fully understand it.The Trust Board noted the contents of the report and approved the framework.2012/017 WORKFORCE KEY PERFORMANCE INDICATORS – MARCH 2012Mrs McAll highlighted several areas from the report, including the recruitment of 209 new staff in post,although there still remained some areas, such as A&E, where recruitment remained a challenge. Asreported earlier in the meeting, the Trust had been very encouraged that it had some good Consultant andMiddle Grade Doctor applicants coming through for interview. Reported sickness absence rates haddecreased for the month of March by 1.40% on the February position, falling from 5.81% to 4.41%. Asreported at the last Trust Board meeting, the HR Department was doing a lot of work around sicknessreviews and were targeting Occupational Health referrals. For the month of March the Trust’s annualisedturnover decreased to 10.9% from 11.0% in February, which was 1.1% below the average of other largeAcute Trusts of a similar size. Mrs McAll reported that over the last four weeks the Trust had seen asignificant decrease in the usage of temporary staff.Trust Board Minutes Part I – 2 May 2012

9The HR Department proposed to commence new starter and exit questionnaires, focusing on A&E andMidwifery where there were currently a higher than average turnover of staff (current turnover in A&Enursing 18.9% and in Midwifery 16.6%) and this information would be built into future reports.Mr Wood felt the sickness absence rate was disappointing and the lack of ‘Not known’ in terms of thereporting for sickness absence was unacceptable. The Trust would reinforce across the organisation thatLine Managers needed to be informed of the reason for sickness absence and this must be reported on thesystem. Mr Langley felt it would be useful to have a trend analysis on this so the Board could see theinroads being made and also the effectiveness of actions, rather than just seeing high numbers. The workbeing undertaken by the HR Department on training Line Managers would help. With the e-rosteringsystem the Trust recorded very accurately its sickness absence rates, perhaps more than other Trusts, andalthough the Trust was running at 4 - 5%, it wanted to get below 4%. As well as the initiatives being run bythe HR Department, the Trust needed to set stretch targets for each Directorate and foster team workingthrough the OD strategy. The Trust needed to get Operational Managers to understand that theorganisation was struggling to achieve the £23m savings and they were losing an opportunity in this area tomake savings.Mrs McAll reported that this was the last report that would be based on the old Divisional structure and nextmonth’s would be set out in the new Directorate structure format.The Trust Board noted the report.2012/018 CARBON MANAGEMENT PLANMr Royce reported that the Trust had been working in collaboration with the Carbon Trust, an organisationcreated in 2001 by the UK Government to help organisations reduce their emissions. The reduction incarbon emissions had financial consequences for the Trust, as well as for the environment. The paperpresented to the Board set out the scale of the challenge and outlined the actions required. The Boardagreed that they were fully in agreement to drive this programme down through the organisation and wouldbe pro-active in pushing this agenda. Quite a few of the actions had a lengthy pay-back period and insome cases required significant capital investment. As the Chair of the Capital Planning Group, Mr Roycewould be looking to undertake some of these actions this year in the 2012/13 Capital Programme, in orderto move the Plan forward. There were Grants available, but a lot of the funding had to come from theTrust’s Capital Programme. Mr Royce reported that the Trust was expected to fund the Programmes toreduce its carbon emissions and if it did not, it would be taxed.Mr Mahoney stated that there were normally quite a few savings to be made from good housekeeping,which could be used to fund the capital required in the longer term. Mr Royce also pointed out that theTrust had two pieces of Estate which were in a different preparedness for the future, therefore theinvestment would be different for the two sites.The Trust Board noted the content of the paper, approved the Carbon Management Plan and endorsed theactions described in the Plan for implementation.2012/019 MATTERS FOR NOTING:INTERIM CHAIR AND CHIEF EXECUTIVE’S REPORTThe Trust Board noted the Interim Chair and Chief Executive’s Report.2012/020 MINUTES OF THE QUALITY & SAFETY COMMITTEE MEETING HELD ON THE14 FEBRUARY 2012The Trust Board noted the minutes of the Quality & Safety Committee meeting held on the 14 February2012.2012/021 MINUTES OF THE STRATEGIC PARTNERSHIP BOARD MEETING HELD ON THE22 NOVEMBER 2012The Trust Board noted the minutes of the Strategic Partnership Board meeting held on the 22 November2012.Trust Board Minutes Part I – 2 May 2012

102012/022 MINUTES OF THE CHARITABLE FUNDS COMMITTEE MEETINGS HELD ON THE1 AND 28 FEBRUARY 2012The Trust Board noted the minutes of the Charitable Funds Committee meetings held on the 1 and 28February 2012.2012/023 ANY OTHER BUSINESSNo further business.Meeting closed at 3.35 p.m.The next meeting of the Barking, Havering and Redbridge University Hospitals NHS Trust Board will takeplace on Wednesday, 4 July 2012 in the Board Room, Trust Headquarters, Queen’s Hospital.Trust Board Minutes Part I – 2 May 2012

TRUST BOARD MEETINGActions from Minutes of Part I meeting held on 2 May 2012in the Board Room, Trust Headquarters, Queen’s HospitalAgenda ItemActionDeadlineDateDateCompleted/Update/Agenda Item2011/108(PerformanceReport)2012/006(Health4NELUpdate)2012/011(Issues forEscalationfrom Quality &SafetyCommittee)2012/012(TripartiteFormalAgreementMilestoneTracker)Update on non-elective length ofstay at next Trust Board meeting.Provide an update on Health4NELat July Trust Board meeting.Review Patient Stories paper atQuality & Safety Committee andprepare proposition for TrustBoard members to review atSeptember Trust Board meeting.Provide copies of the EmergencyCare trajectory at the July TrustBoard meeting.NM 4.7.12 4.7.12(included in Quality &Patient StandardsPerformance Report)RR 4.7.12 Deferred toSeptemberCW/AW 5.9.12CG 4.7.12 4.7.12Interim Chair …………………Date …………………..Trust Board Meeting (Part I) 2 May 2012

TRUST BOARD MEETING2 May 2012Board Room, Trust Headquarters, Queen’s HospitalPoints and Questions raised by members of the Publicat the above Trust Board meetingQuestion:Mr Skillman mentioned that during theLINk site visit to the Sunrise Wards theyhad observed water jugs being filled,rather than half filled. This made itdifficult for older people to lift the jugs.Response/Action:It was confirmed that the Trust hadworked with Sodexo on this and hadsourced some half size jugs.Mr Skillman also highlighted that thewater jugs were filled about three timesa day and pointed out that when therewas Norovirus on the wards, by takingall the jugs away to refill at the sametime, jugs could get mixed up and therewas a possibility of cross infection.Ms Wheeler confirmed that all waterjugs were washed before refilling, butshe would follow this point up with allthe Wards.Regarding the Maternity Report, MrSkillman had attended the ClusterBoard meeting when maternitynumbers were discussed (a reductionof 2k in 2012/13). What were theTrust’s figures?Why had there been a divert from KGHto Queen’s, as the number of midwiveshad increased and the Trust was ableto handle the number of births safely?There was a lot of work to do this yearto plan appropriately when activitytransferred across the whole healtheconomy, including Newham andWhipps Cross and there was reducedactivity at KGH, but plans had not beenfinalised, so the Trust was unclear onthe effect.This was about flow and the ‘cap’ thatwas still in place. There were furtherdiscussions planned for next weekabout the removal of the ‘cap’.When the MLU is in place, whatescalation plans would be put in place?There would be two escalation plans inplace, one for the MLU and one for theLabour Ward, which would form part ofTrust Board Meeting (Part I) 2 May 2012

Question:Response/Action:the overall escalation plan for theMaternity Unit.Are the C-sections taking place at KGHa permanent arrangement?Yes, until such time as they can berepatriated back to Queen’s. This wasall part of the Trust’s bigger plan tobring the KGH maternity unit over toQueen’s.Trust Board Meeting (Part I) 2 May 2012

EXECUTIVE SUMMARYTITLE:Care Quality CommissionBOARD/GROUP/COMMITTEE:TRUST BOARD – Part I1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:Trustwide Action PlanSince the last report to the Trust Board in May, the CQCaction plan has been revised. It is now produced in twoparts. One part is the ‘Development Plan’ where actionsidentified by the CQC in their report that are still to becompleted and/or new actions that have been identified aspart of the review process to achieve improvement, areadded. This Plan also shows the longer-term actions suchas culture change, leadership and strategy in a separateworksheet for ease of reference and it has been amendedto show Clinical Director responsibilities.The second part is a ‘Maintenance Plan’ where completedactions are placed once the supporting evidence has beencollected. This was developed to facilitate the ongoingmonitoring of actions to ensure improvements aresustainable.From the 9 th July the Transformation Board will be takingover the current Project Management Officeresponsibilities, although the existing Project Board willcontinue in its current format.The monthly update on progress is attached forinformation.Trustwide Review – Progress ReportThe CQC progress report was received on the 20 th Juneand checked for factual accuracy. This report reflects theposition at the Trust almost one year on from the CQC’soriginal investigation visits. Where inaccuracies wereidentified in the draft report these were highlighted to theCQC who made changes to their report where theyaccepted the Trust’s comments. Their summary ofprogress below shows the CQC’s decision of the currentstatus against the 81 action points:Met 27Part met 48Not met 6The CQC found the direction of travel at the Trust to beencouraging but felt we still have some way to go beforewe are consistently delivering the standards of care thatlocal people are entitled to expect. Their report shows thatimprovements have been made, and continue to be made,but they still have concerns about the standard of A&Eservices and about the sustainability of some of theimprovements.The release of the progress report heralds the end of theCQC’s investigation into wider governance structures atthe Trust, but they will continue to carry out unannouncedinspections as part of their planned reviews or if theyreceive information raising concerns about our services.Warning NoticesIn the last briefing to the Trust Board information wasprovided about the return visits to the Trust’s maternitydepartments at Queen’s and KGH, A&E at Queen’s,Radiology and Beech Ward. Their compliance reportswere checked for factual accuracy and returned to theCQC.□ TEC ……………..….. □ STRATEGY……….….……□ FINANCE ……..……… □ AUDIT ………….………….□ QUALITY & SAFETY …………..………….....……….…□ WORKFORCE ………………………………………….…□ CHARITABLE FUNDS ………………………………...…X TRUST BOARD …………4.7.12…………….……….….□ REMUNERATION ………………………………….….....□ OTHER …………………………..……. (please specify)

The final reports on these visits have now been receivedand circulated to relevant staff requesting action plans tobe developed. It is anticipated that these will beincorporated into the Trust’s existing action plan to ensureall issues are monitored centrally.The deadline for the Trust’s response to the CQC is the 5 thJuly, with an internal deadline for receipt of the actionplans of the 3 rd July. In summary the CQC’s findings areas follows:Maternity @Queen’sMaternity @KGHA&ERadiologyOutcome 4: Care andwelfare of peopleOutcome 11: Safety,availability and suitabilityof equipmentOutcome 13: StaffingOutcome 11: Safety,availability and suitabilityof equipmentOutcome 13: StaffingOutcome 4: Care andwelfare of peopleOutcome 4: Care andwelfare of peopleOutcome 13: StaffingOutcome 16: Assessingand monitoring the qualityof service provisionOutcome 1: Respectingand involving peopleOutcome 13: StaffingModerateconcernMinorconcernsModerateconcernsCompliantCompliantMajorconcernCompliantCompliantMinorconcernBeech WardModerateconcernModerateconcernTermination of PregnancyThe report into the Special Review visit for Termination ofPregnancy was received and the Trust was found to becompliant. No further actions were required.2. DECISION REQUIRED: CATEGORY:The Trust Board is asked to note the above report and theprogress being made against the CQC requirements.3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:None known4. DELIVERABLES□ NATIONAL TARGET □ RMSX CQC REGISTRATION □ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Mr Stephen Burgess, MedicalDirectorDATE: 25 th June 2012Compliance with the Care Quality Commission’s ‘Essential Standards of Quality & Safety’5. KEY PERFORMANCE INDICATORSCompliance with the Care Quality Commission’s ‘Essential Standards of Quality & Safety’AGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

Programme Management OfficeCQC Trust-wide Action PlanMonthly Progress Reportto BHRUT BoardJune 2012Version: 20120626.1

1.0 Purpose of this ReportThis report has been produced for the benefit of the Barking, Havering and Redbridge University HospitalsNHS Trust (BHRUT) Board, and its Quality & Safety Committee. Its purpose is to provide transparency andreassurance that BHRUT is progressing necessary action, to meet the requirements of the recommendationsidentified in the CQC Investigation Report, published in October 2011.At the same time the report will highlight, and provide a point of escalation for, any identified risks associatedwith a failure to achieve any of the target dates set. Reports are submitted toward the end of each month; theprevious report having being issued on 31 st May 2012.2.0 Background to the Trust-wide Action Plan ProgrammePrior to 2010/11, BHRUT had a high number of ‘conditions’ placed on it requiring improvements in care.Whilst some of these were lifted during 2010/11, a number of warning notices were subsequently issued tothe Trust (in March, June and July 2011), on staffing levels and maternity care. These were responded to ina separate regulatory report.At the end of October 2011, the CQC published its full Investigation Report, containing a total of 75recommendations, with which BHRUT were required to comply; a further 6 recommendations were added inlate November 2011. These 81 recommendations are spread across a number of general categories –strategy, capacity, leadership – and some more specific outcomes, including those in relation to maternityservices.Upon receipt of the full Investigation Report, BHRUT constructed a Trust-wide Action Plan, detailing all 81recommendations, and began populating the plan with the necessary actions required to achievecompliance; along with an identification of officers and clinicians responsible for delivery, and the targetdeadline dates.3.0 Progress to dateInitial construction of the Action Plan was undertaken by the Trust’s Clinical Governance Team inconjunction with operational staff, and the Trust’s Programme Management Office (PMO) appointed asguardians of its progress in mid-November 2011.In December 2011, a Project Board was appointed, chaired by the Trust’s Medical Director, and Terms ofReference approved. This group meets fortnightly, and is responsible for ensuring that actions in the plan areimplemented in a timely and rigorous manner.The detail of key progress made in the previous reporting period was as follows:• Since the previous report, of the 24 items then reported as red, 4 have completed and turnedgreen/blue with no further items added since turning red at month end; leaving 20 items at ‘red’status.• The number of fully completed items (green or blue) has increased from 37 to 47, which means that,currently, 58% of the 81 recommendations are fully complete. Inspection of the whole plan willconfirm that a significant number of individual actions are now completed.• A comprehensive review of the plan was undertaken, in advance of the proposal to freeze theexisting plan and create a Development and a Maintenance plan.• Work with Parkhill has commenced on an audit, to seek independent assurance that the Trust’sgovernance of the plan, its delivery of service improvements and the evidence gathered, is capableof withstanding scrutiny.• The major work being done by McKinsey Consulting, who are managing the RESET programme,has now been cross-referenced to the existing plan and will also inform the new Development Planreferred to above.The details of key progress made in this reporting period are as follows:• Since the last report, of the 20 items then reported as red, 4 have completed and turned green/bluewith no further items added since turning red at month end; leaving 16 items at ‘red’ status (seeparagraph 5).4

• The number of fully completed items (green or blue) has increased from 47 to 51, which means that,currently, 63% of the 81 recommendations are fully complete. Inspection of the whole plan willconfirm that a significant number of individual actions are now completed (also referenced inparagraph 5 below).• The original CQC Trustwide Action Plan was ‘frozen’ at 31 st May 2012 and the new Developmentand Maintenance Plans created (see below).• Work with Parkhill has continued on the audit, to seek independent assurance that the Trust’sgovernance of the plan, its delivery of service improvements and the evidence gathered, is capableof withstanding scrutiny. Their draft report is awaited.• Some of the items within the Development Plan have been reviewed, enhanced and expanded, inorder to ensure that they are comprehensive, reflect the true extent of the work to be undertakenand, thus, enable more effective monitoring of progress. (An example being strategicrecommendation S2, which has increased from 1 action to 13, to encapsulate the full range of theHealth4Nel programme.)As indicated in the last monthly report, the original CQC Trustwide Plan was ‘frozen’ as at 31 st May 2012.The reasoning behind this was twofold:• Once improvements had been achieved, it was essential that they become embedded and are seenas ‘business as usual’. Therefore, sustainability needs to be monitored;• The longer the plan existed in its original form, the more likely it was to become less ‘current’; astime progresses, additional improvements will be identified. Therefore, it was seen as essential thatthis flexibility was captured.Consequently, the decision was taken to create a ‘Maintenance Plan’ - in order to satisfy the first of thosepoints – and, a Development Plan – to satisfy the second of those points.Those recommendations fully completed, and evidenced, would drop into the Maintenance Plan, where amonitoring programme would be developed. Currently the recommendations in the Maintenance Plannumber 11, shown as ‘blue’ on the dashboard below. In future iterations, this dashboard may well need toevolve to reflect the changing nature of these plans.Those recommendations that remained incomplete would continue to sit in the Development Plan untilcomplete, currently those number 70.The Development Plan would become a dynamic document, constantly being improved and enhanced toreflect ideas and the evolving nature of some of the projects. To that end, those projects that have a deadlinedate that has not yet been reached – currently numbering 14 – have been dropped into a separateworksheet within the Development Plan – named as a ‘longer-term development plan’.The timing of this major change to the formatting of the plans has also coincided with the issue of the CQC’supdate report. This report is discussed in a little more detail below but, significantly, it states that it “marks theend of the CQC’s investigation” and, therefore, the changes we have made would seem entirely appropriate.In addition to the dashboard evolving, it is also reasonable to note here that future reports may also need tochange, in the format of their content.

4.0 Performance against Key IndicatorsThis is a Headline Dashboard showing current status of progress against the 81 original recommendations.Red indicates non-compliance with, or at serious risk of not meeting, target completion date;Amber indicates progress on-course for compliance with target completion date;Green indicates outcome achieved;Blue was added in and indicates that evidence of compliance has been stored in the electronic database.Risk Status / Category Red Amber Green Blue1 High RiskStrategy 1 1Capacity 1Leadership 1 1 2 1Maternity 1 1 7 1General Outcomes 7 4 11 52 Medium RiskMaternity 1 4General Outcomes 4 4 10 33 Low RiskMaternity 1General Outcomes 2 2 5Totals (81) 16 14 40 11Note: Whilst compliance against a single recommendation may not have been fully met, some of the singleactions and tasks required for attaining that recommendation may have been completed. The BRAG ratingagainst the single recommendation will not show green until all actions pertaining to it have been completed;then blue when evidence has been filed in the Trust’s central database. At this point, the recommendationwill drop into the ‘Maintenance Plan’.5.0 Risk and Issue EscalationAs indicated in paragraph 3, and confirmed in the dashboard at paragraph 4, there are 16 recommendationsthat are at ‘red’ status in the current Development Plan, plus 14 amber-rated recommendations.5.1 The current position on each of those red-rated recommendations is as follows:Leadership• Recommendation L2 – Put a cultural change programme in place. (6 actions – 3 incomplete.) ProjectBoard members are currently reviewing this item, as it is thought that we may have delivered it, in termsof the original requirements in the plan. 3 of 6 actions are showing as incomplete but, that may berevised. However, embedding culture change is a much longer term piece of work and one that shouldremain in the Development Plan.Maternity• Recommendation M7 – transfer of babies to NICU. (2 actions – 1 incomplete.) Audit prompted by CQCAction Plan proved that this was a non-issue but, had resulted in a sub-action plan to reinforce. This hasall but been delivered.•6

• Recommendation M14 – record keeping/management. (3 actions – 1 incomplete.) It is now consideredthat this recommendation is probably complete. The literal application of the recommendation/actions inthe CQC plan have been delivered. Since 1/1/12, all new birth records are tracked and, once we reach1/9/12, this will mean that all are.Outcome 4• Recommendation G5 – empowerment to challenge. (4 actions – 2 incomplete.) This work has now beenrolled into the RESET programme: workstreams 1&2.• Recommendation G6 – staff following hospital policy. (4 actions – 1 incomplete.) In terms of the originalCQC recommendation, only 1 of 4 actions remain outstanding, relating to an anaesthetic leaflet; which isbeing designed by one of the clinical fellows.• Recommendation G10 – discharge and bed management (linked to RESET). (6 actions –2 incomplete.)Incomplete actions should hopefully be delivered by end of June.• Recommendation G11 - Produce and disseminate clear guidance on the Trust’s expectations for all staffon the prescribing and dispensing of TTA medication. (5 actions – 2 incomplete.) (linked to RESET work)All processes and procedures are in place but, the software does not currently permit effectivemonitoring of compliance. Discussions underway with Project Board members and a business case isbeing prepared to seek budget for the enhancement.Outcome 10• Recommendation G25 – Clear lines of sight in inpatient areas. (1 actions – 1 incomplete.) Furtherconsideration needs to be given as to how the Trust can meet CQC expectations. In the meantime,Divisional Nurse Directors are progressing it by working on delivery of the SNCT, and implementinghourly rounds.• Recommendation G26 – Develop appropriate facilities in day surgery. (2 actions – 2 incomplete.) Oneaction is progressing, but will necessitate some internal building work. The other action is dependentupon Health4NEL programme, yet to be finalised. Therefore, delivery is some months away and ourdeadline date may need revising once plans are finalised.Outcome 11• Recommendation G29 – develop sense of responsibility. (2 actions – 2 incomplete.) One action is linkedto L2 and subject to review and inclusion in the Development Plan; and one action needs to becompleted but, its progression is dependent upon a Clinical Governance Report to Trust Board on 4thJuly.Outcome 13• Recommendation G30 - accurate, clear, comprehensive workforce data. (2 actions – 2 incomplete.)Unfortunately, this item has slipped; it has been escalated to Director of HR and current anticipateddelivery is mid-July 2012.• Recommendation G31 – workforce strategy. (3 actions – 2 incomplete.) Remaining actions relate toWorkforce Strategy - included in HR Business Plan. It is understood that this was due to be discussed atTEC in June, but was pulled from agenda by CEO.• Recommendation G36 – skills escalation programme. (4 actions – 1 incomplete.) 1 of 4 actions remainincomplete. A&E workforce review completed. All staff grades /types reviewed. Further work needed onthe role of Doctor's assistant. Potential support from other organisations being worked through. Trainingprogramme for consultation being developed.Outcome 14• Recommendation G37 (Refresh whistle-blowing policy) – This item is in relation to the BHRUT Whistleblowingpolicy, (3 actions – 2 incomplete.) Ostensibly complete. Remaining actions requireWhistleblowing Policy to be ratified at Policy Ratification - deferred and on agenda for 25/6/12. On theunderstanding the policy will be ratified work has started to prepare a training course to deliver theoutstanding actions.• Recommendation G38 - develop and deliver training for staff to support the development of qualityservices. (3 actions – 1 incomplete.) Remaining action is almost complete. The issue is attendance atmandatory training: e-modules are coming on line but, performance management and escalation needsembedding.

Outcome 21• Recommendation G50 – records management. (7 actions – 2 incomplete.)2 of 7 actions incomplete. However, one of those involves the development of an e-learning module onrecord-keeping at induction. This is underway but, delivery is anticipated end of July.5.2 The current position on each of those amber-rated recommendations is as follows:Strategy• Recommendation S2 – Identify and implement plans to secure a long term solution to reduce overcapacity. (1 actions – 1 incomplete.) This recommendation has now been expanded to reflect the fullimpact of the Health4NEL proposals, in order that a more effective measure of progress can be taken.The result is that there are now 13 actions progressing.Capacity• Recommendation C1 – Improve the flow of patients. (4 actions – 3 incomplete.) Action is progressing;however, the deadline date may need reviewing, as 1 of the outstanding actions links strongly to S2above.Leadership• Recommendation L1 – Right leaders and managers in place. (3 actions – 1 incomplete.) It wasanticipated that the remaining action would be completed when the appointment to positions in the newstructure were completed in June. However, events of this month have now raised questions about thelikelihood of delivering as anticipated.Maternity• Recommendation M1 – Identify and implement immediate solutions to deliver safe maternity services. (3actions – 1 incomplete.) This, too, is linked to the Health4NEL programme and it is anticipated that therevised date for delivery of the outstanding action will be 1 November 2012.Outcome 4• Recommendation G4 – Develop the ED strategy. (4 actions – 2 incomplete.) Being progressed andJonah is due to be re-rolled with the support of ‘ward sponsors’.Outcome 10• Recommendation G20 – Review directional signage. (3 actions – 2 incomplete.) Progressing – phaseone due to be completed June ’12.• Recommendation G21 – Review paediatric emergency facilities. (2 actions – 1 incomplete.) This, too, islinked to the Health4NEL programme. This recommendation is now linked to the expanded version of S2and will provide more comprehensive detail of the programme. Revised delivery dates will becomeavailable once the preferred reconfiguration option is known.• Recommendation G22 – Finalise and implement plans to improve X-ray facilities. (3 actions – 2incomplete.) See G21 above.• Recommendation G23 – Appropriate waiting facilities available for patients and relatives in the urgentcare centre. (1 actions – 1 incomplete.) See G21 above.Outcome 13• Recommendation G32 – Carry out systematic skill mix and staffing needs analysis. (12 actions – 6incomplete.). Skills for Health completed their skill-mix review of A and E at the end of May and an actionplan for implementation of their recommendations, plus other recommendations concerning staffing, wasdue to be submitted to the Workforce Committee on 25 th June. Once it has been to that Committee it willgo to the Staff Joint Committee in July and discussions will then take place with staff in the Department.Outcome 16• Recommendation G40 – Ensure that adequate systems of governance are in place. (4 actions – 1incomplete.) Clinical Governance Report has been subject to revisions and aligning with new directoratebusiness plans. Due to be considered by TEC at June meeting and Trust Board in July '12.• Recommendation G42 – Carry out a comprehensive review of all corporate and clinical governancesystems. (3 actions – 2 incomplete.) Clinical Governance Report has been subject to revisions andaligning with new directorate business plans. Due to be considered by TEC at June meeting and TrustBoard in July '12.8

Outcome 21• Recommendation G51 – Develop integrated patient administrative and information systems. (1 actions –1 incomplete.) This is a long-term piece of work, with delivery not expected until way into 2013. TheDevelopment Plan has been enhanced to include milestones to enable progress to be more effectivelymonitored and identified.Outcome 6• Recommendation G52 – Engage with and develop effective working relations with external providers andpartners. (3 actions – 1 incomplete.) Stakeholder survey due to be progressed June 2012.It is interesting to note that the CQC Update Report, due to be published 27 th June 2012 reflects that only 6of the 81 recommendations are ‘not met’. Whilst subtle differences in the CQC’s measure of ‘not met’,compared to the Trust’s ‘red-rated’, will explain some of this, it may also be apparent that the Trust is beingvery reasonable in its self-assessment.Whilst most of these recommendations are progressing towards completion, the Project Board will need toclosely monitor the impact on L1; G31; G40 & G42, where changes at Executive Level may have an impact.What is true to say is that the Development Plan is being used to drive progress and implementation, and theMaintenance Plan will be used to measure sustainability.6.0 Activity during the next period – July 2012The Project Board for the CQC Trustwide Action Plan will, from now, report to the Trust’s TransformationBoard. At the same time, personnel changes within the Programme Management Office will mean that ahandover will be effected before 6 th July 2012.This is a crucial activity in the next period, in order to ensure that there is no loss of momentum and there isno impact on the quality of patient care.Alongside this, work will continue to move the red-rated items toward completion at the earliest possibleopportunity; enhance the Development Plan to ensure that it is comprehensive; gather evidence on thoseactions that are completed in order that they can be dropped into the Maintenance Plan; and to expand thatplan to ensure that there is an adequate and appropriate methodology to measure sustainability – using theCQC’s ‘Essential Standards of Quality & Safety’ as a minimum.The PMO will continue to report back to the Project Board, should any significant risks be identified. TheProject Board will continue to meet fortnightly to check and monitor progress, and any risks identified by thePMO.7.0 SummaryThis reporting period has marked a watershed in terms of the CQC Trustwide Action Plan.Firstly, our decision to freeze the original plan at 31 st May, and create a Development Plan and aMaintenance Plan, was undertaken to recognise the need to measure the embedding of improvements; andalso to facilitate the flexibility required to reflect the evolving and emerging nature of projects as theyprogress.Secondly, the CQC Progress Report indicates that it is acknowledged that the Trust is making progressagainst the original 81 recommendations. As such, the CQC have stated that the report ‘marks the endof…(its)…investigation’.Thirdly, the Transformation Board, along with new personnel within the Programme Management Office, willnow move forward the Trust’s delivery of both the Development and the Maintenance Plan.Consequently, it is felt that this report effectively marks the end of ‘phase one’, ahead of the migration into a‘phase two’.

As such, we can report the following summary of the current position:• 16 red recommendations;• 14 amber recommendations;• 40 green recommendations.The number of evidenced items in the maintenance plan is:• 11 blue recommendations.Progress TableRecs due Complete %March 56 42 75April 66 50 76May 67 51 76Total 81 51 6310

CQC’s InvestigationIntroductionThe report is an update on progress against the 81 recommendations which weremade as a result of the CQC’s investigation.CQC’s view is that BHRUT has made satisfactory progress against most of therecommendations made in it’s investigation.A number of significant recommendations remain part met and a small numberunmet, in many cases because the impact of changes in policy have not yetdelivered better outcomes in practice.The report marks the end of the CQC’s investigation. Quality of care at the Trust willnow be monitored through regular unannounced inspections.The Trust Wide Action PlanA number of actions were developed in order to deliver the 81 recommendations.The total number of actions developed were 256.The range of actions within the recommendations varied between as few as 1 and asmany as 12.Each recommendation is ‘RAG’ rated:Blue – All actions achieved and evidence logged.Green – All actions achieved. Not all evidenced.Amber – Actions progressingRed – Actions not progressing or exceeded time deadline.At the end of May the action plan was changed to consist of a Maintenance Plan anda Development Plan.The Maintenance Plan contains those recommendations which are RAG rated blue(actions complete and evidenced). As of the 22 nd June, 11 recommendations havebeen placed in the Maintenance Plan.The Development Plan has been subdivided into a Short Term Plan(recommendations due to be delivered) and a Long Term Development Plan.Currently 9 recommendations sit within the longer term plan. These are all rated asamber.Of the remaining 61 recommendations, 16 are currently red rated.CQC Assessment of PlanThe CQC assessed progress against the 81 recommendations as either met, partmet or not met. 27 were rated as met (33%), 48 as part met (59%) and 6 as unmet(8%).1

ReconcilliationAgainst the Maintenance Plan, the CQC agreed that 8 of the 11 recommendationswere met. 3 were assessed as part met, 1 because success needed to bedemonstrated over time.Against the longer term plan, all 9 recommendations were rated as part met, thusagreeing with the project board’s assessment.6 are related to Health4NEL proposals including facilities redesign. 6 are related tothe RESET project and workstreams within and 6 are related to long term impactwhich will need assessment in the future before the recommendations can be fullymet.In comparing the project board’s assessment against CQC assessment, there isagreement in 54 of the 81 recommendations. In 20 recommendations the Trust hasassessed progress rather more favourably. This is due in part to the assessmentbeing at different times, recommendations moving to RESET and Health4NEL andthe need for longer term assessment before recommendations can be met.Stephen Burgess,Medical Director, BHRUT.June 20122

Update on investigation reportBarking, Havering andRedbridge UniversityHospitals NHS TrustQueen’s HospitalKing George HospitalJune 2012

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportContentsPage1.1 The Trust 31.2 Regulatory background 31.3 CQC’s investigation 42.1 Executive Summary 52.2 Leadership, strategy and capacity 62.3 Maternity 72.4 Emergency Care 82.5 Complaints 83.1 Compliance activity at the Trust 93.2 Queen’s Hospital, Romford, and King George Hospital, Ilford(maternity services) 103.3 Queen’s Hospital, Romford (accident and emergency services) 113.4 The RESET programme at the Trust 113.5 Queen’s Hospital, Romford (radiology services) 133.6 King George Hospital, Ilford: Beech Ward(specialist stroke rehabilitation) 134 CQC’s recommendations –monitoring of progress against the CQC action plan 152

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report1.1 The TrustBarking, Havering and Redbridge University Hospitals NHS Trust (the Trust)serves a population of around 700,000 in outer north east London. It operatesacross two main sites; Queen’s Hospital in Romford, which opened in 2006, andKing George Hospital at Ilford, which opened in 1993.The Trust provides services to people across three local authority areas, Havering,Redbridge, and Barking and Dagenham, and general and emergency services tothe population of west Essex with some specialist services to all of Essex. Thethree areas have different demographic backgrounds. Havering has a populationof around 232,000 and low levels of deprivation, Redbridge has around264,000 people and average levels of deprivation, and Barking and Dagenhamhas around 172,000 people and high levels of deprivation.Queen’s Hospital at Romford is in the Havering local authority area, and is themain hospital for people from that area, while King George Hospital is in Ilford,and mainly serves people in Redbridge and Barking and Dagenham.1.2 Regulatory backgroundThe Trust had a history of poor performance under the previous regulatoryframework, prior to CQC registration in April 2010. It has long-standing andescalating debts. There have been numerous changes at executive level.At the time of registration with CQC, the Trust had a high number of ‘conditions’placed on it to mandate improvements in care. A series of inspections in2010/11 resulted in some of these conditions being lifted, but also resulted inCQC issuing warning notices (in March, June and July 2011) on staffing levelsand maternity care.CQC saw some signs of improvement, but its judgement was that continuing totackle poor care on a case-by-case basis was not going to address deep-seatedproblems at the Trust. As a result, the Commission took the decision to launch afull investigation into the quality of care at Queen’s Hospital and King GeorgeHospital.The investigation was designed to assess the systems and procedures the Trusthad in place to ensure people were protected against the risk of inappropriatecare and treatment. The CQC team focused on three care pathways – maternity,elective vascular surgery, and emergency care, and examined the Trust’s governanceand management systems. More details are available in the full investigationreport (available on CQC’s website www.cqc.org.uk), which was published inOctober 2011 and updated with further sections in November 2011.3

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report1.3 CQC’s investigationThis report is an update on progress against 81 recommendations which weremade as a result of CQC’s investigation.A CQC investigation allows the regulator to make recommendations outside itsscope – for example, to draw attention to service configuration andcommissioning issues. These issues can have a direct or indirect impact on theprovider’s ability to deliver care that meets CQC’s essential standards of qualityand safety. Responsibility for implementing these recommendations sits with theprovider and, where appropriate, with commissioners.The full set of recommendations addressed a range of outcome areas coveredby CQC’s essential standards: respecting and involving people, care and welfare,safeguarding, cleanliness and infection control, management of medicines,equipment, staffing, supporting workers, assessing and monitoring the qualityof service, records, cooperating with other providers, and complaints.A Trust-wide action plan was introduced in response to the recommendations.A project board was appointed by the Trust in December 2011, chaired by theTrust’s medical director, to ensure that the action plan was implemented and thatprogress against this was reviewed fortnightly.The final section of this report assesses progress against each of the 81recommendations. This assessment is partly based on the Trust and NHSLondon’s views, but CQC’s inspection findings have also been considered.Some of the Trust’s views on progress have been modified where inspectionevidence suggests otherwise.Progress against these recommendations is not equivalent to compliance withCQC’s essential standards. Where the recommendations have an impact on careoutcomes that fall under CQC’s core regulatory remit, compliance has beenchecked via inspection. As a result, this report includes a summary of recentunannounced inspections at the Trust. Full reports for these inspections can befound on CQC’s website.Several themes are highly significant in light of what CQC’s investigation found– particularly issues around leadership and governance, maternity, accident andemergency care, and complaints handling. As a result, a brief section on each ofthese has been included in this report in summary.4

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report2.1 Executive SummaryCQC’s view is that Barking, Havering and Redbridge University Hospitals NHSTrust has made satisfactory progress against most of the recommendations madein its investigation.The investigation has stimulated a clear improvement in the safety and quality ofcare in maternity and radiology services at the Trust. Governance and leadershipstructures have been overhauled as a result of CQC’s recommendations. Work isunderway to develop and embed a culture of patient-centred care that runs fromthe Board right through to the front line.Action has been taken in the majority of areas highlighted in CQC’s investigation,although a number of significant recommendations remain part-met and a smallnumber unmet – in many cases, because the impact of changes in policy havenot yet delivered better outcomes in practice.Maternity has been the greatest focus for the Trust and commissioners, reflectingthe level of concern identified by CQC. Recent evidence suggests this hasresulted in a marked reduction in the risk of poor maternity care at Queen’sHospital. This view is supported by CQC’s unannounced inspections, interviewswith staff and service users, and information from other stakeholders. CQC madeclear that it was prepared to restrict services – one of its strongest enforcementpowers – if maternity did not improve and the Trust’s response, supported byNHS London, has started to deliver results.These improvements need to be seen in context. The direction of travel at theTrust is right, but the quality of care on offer is still unacceptable in some areas– particularly in accident and emergency at Queen’s Hospital, where too manypeople are at risk of receiving poor care. More needs to be done in medicinesmanagement, in staffing across the Trust, and in making sure that the Queen’sHospital site is more patient-friendly. Complaints have increased (almostcertainly because of the attention created by CQC’s investigation) and the Trustis struggling to cope with the volume.Whether the improvements seen so far can be sustained is a big question andthe Trust’s leadership is aware of this, as are those involved in making decisionsabout future configurations of services. For example, the positive changes inmaternity have come about in part as a result of extensive support fromcommissioners. This kind of joint effort is tough to sustain, particularly whenaccident and emergency and maternity – two services facing huge demand atthe Trust – need ongoing support and attention.This report marks the end of CQC’s investigation. Quality of care at the Trust willnow be monitored through regular unannounced inspections. There are broaderdebates underway about the configuration of services in this part of London.If changes are made to services at this Trust, CQC’s role will be to assess whetheressential standards of quality and safety are met, however they are delivered.5

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report2.2 Leadership, strategy and capacityCQC’s view is that there has been considerable progress at executive level in theTrust in terms of taking ownership of the problems found during and sinceregistration in April 2010. It is early days, and the effort invested will take timeto have a lasting impact on frontline care, but the direction of travel ispromising. Given the Trust’s history of poor performance and failure to takeresponsibility for its problems over many years, some of the most significantprogress to date has been through the Trust acknowledging its challenges andopening itself to partnership working to create a climate that will promoteimprovement.NHS London is supporting the development of a number of clinical fellows atthe Trust as part of a clinical leadership and engagement programme. A newmanagement structure based around clinical directors and associate directors hasbeen introduced to bring in clearer lines of accountability and responsibility forthe quality of care. A major programme of internal engagement is underway totry to build a stronger sense of shared purpose between management and staffto deliver better care.The Chief Executive and members of the Board and Executive Team have beenopen and honest about the Trust’s problems and have demonstrated clearownership when seeking to tackle the challenges that lie ahead. The seniormanagement tier has been reshaped with a strong focus on drivingaccountability, transparency and responsibility for quality into the structure.The Trust recently announced that five members of the senior management teamwould be leaving or changing role. This has been explained as a move to supportthe clinical leaders and the change process, but the impact of this is not yetknown. Once these posts are filled and a stable Executive Team is in place, thenext challenge will be to ensure that the drive for improvement is embeddedacross the Trust. Given the amount of poor care seen in the CQC investigationthat was attributable to management and culture, this is critical to the Trust’sfuture success.The Trust’s interim Chair and Board are offering stronger challenge to theExecutive and the interim Chair has explicitly said that care quality is theirpriority; the new governance structures should enable the Board to carry outtheir scrutiny roles more effectively, and as a result take on more accountabilityfor quality within the Trust.6

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report2.3 MaternityThe pressures on maternity services are such that the Trust has not been able torespond to CQC’s regulatory challenge alone. Demand is huge and there was nosign of this reducing without active intervention. A combination of volume andthe capacity of staff to deal with complex cases are behind many of theproblems CQC and other bodies have seen (e.g. the Royal College ofObstetricians and Gynaecologists’ report for NHS London at the Trust late lastyear).Late in 2011, CQC made clear that it was considering a legal restriction on thenumber of births at Queen’s Hospital. This led to an escalation in theimprovement work underway and saw the Trust receive extensive support fromcommissioners.NHS London’s response has involved drawing on expertise and insight fromacross London, and looking at the challenges faced at the Trust in the context ofdemand and service provision the entire north-east London area. This hasreflected the analysis of the ‘Health for North East London’ programme and hasresulted in an ambitious plan to reduce demand on maternity at the Trustequivalent to some 2,000 births a year by the end of 2012/13, compared topre-investigation levels.The North East London and City cluster has taken on formal responsibility forimplementation of this maternity plan, which will see decisions taken across thecluster to improve access to safe maternity care. This has already seen plansimplemented (spring 2012) to move around 20 bookings a week from the Trustto Barts Healthcare, taking advantage of capacity elsewhere in the cluster(particularly Newham Hospital). These bookings will translate into births fromNovember.NHS North East London’s proposed response to the challenges faced inmaternity is wide-ranging, innovative and proportionate. The proof of the planwill be in its delivery. Success will mean primary care playing its part; GPs andcommunity midwives have a critical role in ensuring that mothers-to-beunderstand the context in which birth options are presented to them.Within the Trust, recruitment and retention of a suitable body of skilled andexperienced midwives continues to be a challenge. The Trust currently hasamong the best ratios of staff to mothers in London, but this has only comeabout after six months of intense support from external partners. Holding on tomidwife recruits in the London employment market is an ongoing challenge (andis not unique to this Trust). The NHS North East London plan to reduce demandis likely to be the only sustainable answer.CQC will continue to assess the quality and safety of maternity services at thisTrust, and in maternity units in other trusts taking part in this plan, throughout2012/13.7

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report2.4 Emergency CareEmergency care remains the area of greatest concern to CQC. Demand onservices is enormous and our original investigation and inspections since havefound this service is consistently failing to meet essential standards.A combination of demand, problems with staffing, challenges in streamingpatients properly, and blockages elsewhere in the hospital mean the emergencydepartment at Queen’s in particular is struggling to deliver acceptable care.Patients often face significant delays in admission, treatment and discharge.The lack of available beds across the hospital causes a backlog that has animpact on people arriving in A&E. The hospital continues to struggle to recruitmiddle grade doctors and there is reliance on doctors from locum agencies.This reduces the level of senior medical cover in the department, meaning it canbe difficult to find people qualified to make decisions about treatment, whichleads to delays in people being given access to the right care.This level of concern about emergency care is corroborated by a range ofexternal sources, ranging from information from patients and other stakeholders,through to performance data and other regulatory sources. A major programmeof work is underway at the Trust, supported by external partners, to try toaddress this. More detail on this programme - and on our recent inspectionfindings - is in section 3.2.5 ComplaintsThe Trust has seen a dramatic increase in complaints in recent months, from atypical level of around 40 a month to around 120 a month in early 2012. Staffattitude and communication are a key theme of many of these.Trust response speeds have increased and complaints are now all signed off byan executive director. Patient feedback kiosks are going up across the Trust,and discussions have taken place about introducing an integrated electronicpatient record. The approach to complaints handling looks to be much better,with far greater involvement of senior management and better processes in placeto ensure lessons are learned from mistakes, but the increase in volume meansthe improved process needs to keep pace with a surge in demand.CQC has seen a rise in information received about this Trust since theinvestigation was launched. Anecdotal accounts from stakeholders, includinglocal MP’s offices, indicate that they too have seen an increase in the volume ofcorrespondence about the Trust. Some of these complaints pre-date CQC’sinvestigation, although many are more recent. It is hard to know whether thisincrease is a result of more poor care, or a result of greater awareness about theTrust’s challenges and therefore more willingness on the part of patients andtheir families to raise concerns.8

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportThis remains an area where the Trust’s performance must improve. The Trust is ina challenging position given the volume of complaints it is now dealing with, butpatients and other stakeholders have made clear they expect to see betterperformance in this area despite the increased demand.3.1 Compliance activity at the TrustCQC has carried out a significant amount of inspection activity in parallel withthe investigation. The Trust was registered with CQC in April 2010 with eightconditions on its registration, setting out improvements that had to be madeagainst eight essential standards. This was among the highest levels of concernidentified during registration.During the course of 2010/11 most of these registration conditions were lifted,but ongoing compliance monitoring raised further concerns – particularly inmaternity and in accident and emergency at the Queen’s Hospital site in Romford.Warning notices were served on the Trust in March 2011 regarding staffing andcare in maternity, in June 2011 regarding patient care in A&E, and in July 2011regarding staffing levels. These compliance concerns triggered the investigationreferred to above. In parallel to the investigation, unannounced inspections tookplace in September and October 2011 to assess compliance with these warningnotices. Given the level of concern about maternity, weekly visits took place overeight weeks during October and November. Evidence from these visits – whichincluded an independent midwife – was incorporated into compliance reportspublished in early 2012.In these reports, CQC continued to have major concerns about care and welfarein A&E and in maternity and moderate concerns about staffing in maternity.Throughout the period since the investigation, CQC has received regularinformation from people who use services at the Trust, from local MPs, fromLINks, and from other sources including staff at the Trust. Information fromthese has been factored into compliance activity where appropriate.CQC took part in a risk summit about the Trust on 6 February with NHS London,the cluster, and the Department to discuss the ongoing challenges faced bythe Trust.Information received during this period and CQC’s assessment of risk led tofurther inspection activity in 2012, specifically:• An unannounced inspection of maternity services at Queen’s Hospital from19 to 21 March• An unannounced inspection of A&E services at Queen’s Hospital on 28 March• An unannounced inspection of radiology services at Queen’s Hospital on28 March, with a follow up on 4 April9

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report• An unannounced visit to stroke rehabilitation services at King George Hospitalon Saturday 17 March, in response to patient concerns raised with CQCWe received information after the maternity inspection alleging that staff andequipment had been moved between sites to try to influence our judgement.As a result, we went to both the Queen’s and King George hospital sites for asimultaneous unannounced inspection on the night of 4 April to confirm thatevidence gathered during our initial inspection was robust (see below).These compliance reports have been published alongside this update and can befound on CQC’s website.3.2 Queen’s Hospital, Romford, and King GeorgeHospital, Ilford (maternity services)We carried out an unannounced inspection of maternity services at Queen’sHospital on 19 March. This covered a three-day period and CQC had supportfrom a maternity expert from the Nursing and Midwifery Council. We looked atthree of CQC’s essential standards: ‘care and welfare of people who use services’(outcome 4), ‘equipment standards’ (outcome 11), and ‘staffing’ (outcome 13).The changes that have been introduced in maternity are detailed elsewhere inthis report. All new mothers we spoke to gave largely positive feedback abouttheir stay, including the support received from midwives and the pain reliefavailable. Staff told us care had improved as a result of several factors –a significant increase in anaesthetist cover, achieving 100% in one to one carein established labour, increased paediatric care on the postnatal ward to improvedischarge, some improvements in triage times, the moving of the antenatal wardto next to the labour ward, and a reduction in births that had helped theservice’s ability to deal with demand. The sustainability of these improvementswill be assessed over time.Equipment raised some concerns at Queen’s; while staff were not aware of itbeing moved between sites, and there was a general view that there was enoughequipment, it was not always easy to find. The Trust has improved policies forchecks on equipment, but we found evidence that these were not alwayscarried out.The Trust vacancy rate for midwives has reduced from 17% to around 11%.Recruitment and retention is a constant challenge and the Trust is now targetingUK midwives after a significant number hired from overseas left. The Trustcurrently has more midwives in place than is indicated as a result of a ‘birth rateplus’ assessment. Midwives generally felt that staffing was much better, althoughthey expressed concern about sustainability and the skills mix when so manymidwives were newly qualified or new to the Trust. Midwifery care assistants(MCAs) had more significant concerns about shortages, which were supportedby daily records. Staff told inspectors that they generally felt supported bymanagement and that morale was better.10

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportAfter our first inspection we received concerns from a member of staff suggestingstaff and equipment had been moved between hospital sites to mislead inspectors.We returned to the Trust, again unannounced, on the evening of 4 April to speakto members of staff on both day and night shifts at the Queen’s Hospital andKing George sites. We found no evidence to substantiate the concerns at eitherhospital other than those already covered above, although we did receiveconfirmation that members of staff were sometimes moved when another sitewas short-staffed. No member of staff thought this had put patients at risk.3.3 Queen’s Hospital, Romford (accident andemergency services)CQC carried out an unannounced inspection of accident and emergency atQueen’s Hospital on 28 March 2012. We looked at one of CQC’s essentialstandards: ‘care and welfare of people who use services’ (outcome 4).Major concerns were identified in this service during our last inspection.The Trust has made several changes as a result of these, but the departmentcontinues to fail in meeting quality indicators and patients remain at too higha risk of receiving poor care.These issues were being picked up by the Trust – the introduction of a rapidassessment and treatment process was welcomed by nursing and ambulancestaff, a recruitment strategy is in place to address the high number of vacancies,and the deanery is increasing the number of specialist registrars from two to fivefrom August 2012 – but progress has been challenged by the level of demand.Staff told inspectors that they felt there was a ‘whole hospital’ approach toimprove discharges and hospital-wide support for A&E. They did, however, alsosay that the key problem is too many people ‘coming through the doors’ andquestioned whether more could be done externally to reduce demand.CQC’s level of concern about this area of care has remained high since the Trustwas registered. The RESET programme (see 3.4) represents a watershedopportunity to introduce sustainable improvement to manage demand in A&E byaddressing performance challenges throughout the hospital. CQC will be seekingfurther assurance that it is having an impact in the near future.3.4 The RESET programme at the TrustThe Trust, with external support funded by NHS North East London, has put inplace an intensive improvement programme for emergency care. The ‘RESET’(Rapid End-to-end Sustainable Emergency Transformation) programme’s aim isto deliver rapid and sustainable improvements in the emergency care pathway.The full patient pathway is in scope, with a priority on the urgent care centre,emergency department, medical and elderly wards. This programme wasunderway when CQC carried out its latest unannounced inspection.11

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportRESET has identified that performance in the emergency care pathway is worsethan 2011, as evidenced by failure to reach the four-hour A&E target. Queen’shospital is the focus of the programme because they have two-thirds ofattendances (113,000 at Queen’s, 78,000 at King George), but almost four outof every five breaches.The RESET programme identified many challenges that CQC has picked upthrough its compliance work – high use of locums and agency staff, ineffectivebed management, and poor discharge – but has gone into a far more detaileddiagnosis of underlying issues.This analysis includes highlighting inconsistent triage, poor use of the urgentcare centre, a lack of accountability and effectiveness in bed management,discharges taking place late in the day (peaking at 4pm) rather than at 11am asneeded; and long lengths of stay, largely driven by factors within the Trust’scontrol. Length of stay across the Trust is variable (around 48% of patientsexceed the expected date, for internal and external reasons) and long-staypatients are a challenge in elderly care and general medicines. All these createsignificant strains across the care pathway.Staff have contributed to the RESET programme and it is clear that many feelunder a great deal of pressure, whether from too much work, high patient-tonurseratios, through to only hearing negatives in the media and the constantairing of the Trust’s problems in public. RESET aims to both improve performanceand (through this, in part) build a better working environment for staff.A broad programme of work is underway through RESET with emergencydepartment performance and flow, continuity of care and discharge rates in themedical assessment unit, and discharge, best practice care for complex patients,and effective care for elderly patients being prioritised. Initial results madeavailable to CQC indicate an improvement in A&E waiting times and week-onweekfalls in the number of breaches, although these results must be sustainedto demonstrate that this has taken root.The number of discharges per day has increased since the introduction of aboard round in the medical assessment unit. Planning for the following day’sdischarges is now taking place at 3pm the day before with a senior nurse leadand doctor in attendance. Consultant support has been increased to tackle issueswith care of the elderly and length of stay; more ward rounds have beenintroduced and lengths of stay are being reduced to more effective levels. Moreclinical nurse specialists have been introduced to improve the specialist responseto cases coming from the medical assessment unit and emergency department.Plans are in place to try to ensure that these improvements are sustained andbuilt upon. Selected initiatives are due to be rolled out to King George. CQC willseek assurance that RESET is having an impact via unannounced inspections atsome point in the months to come.12

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report3.5 Queen’s Hospital, Romford (radiology services)CQC’s original investigation identified serious concerns with radiology servicesand these unannounced inspections, which took place on 28 March and on 4April, were designed to assess whether improvements had taken root. The CQCteam included radiology experts, who also helped review our report. We checkedthree of CQC’s essential standards: ‘care and welfare of people who use services’(outcome four), ‘staffing’ (outcome 13) and ‘assessing and monitoring thequality of service provision’ (outcome 16).Details of the Trust’s work to improve clinical management, audit and staffingare included later in this report. We were presented with evidence that showed aweekend rota to reduce the backlog from A&E; a new ‘hot reporting’ rota hassped up the process and weekly checks on turnaround times for x-rays andscans. Turnaround times have significantly improved and people referred for CTscans from A&E have exceeded national targets. Compliance with a NationalPatient Safety Agency (NPSA) alert from 2007 has improved.A new role of clinical director for radiology has been created and radiologybecame a department in its own right on 1 April. Radiology leads withresponsibility for care pathways have been introduced. Trust documentationverified that vacancies in radiology are now minimal and new posts have beencreated through extra activity and better financial management. Staff have beengiven support to develop their reporting skills and a quality and safety audit fornewly-qualified radiographers has been introduced. Anaesthetic support hasincreased.A new Trust audit form and process has been introduced, but planned audits hadnot always been carried out and the clinical director and general manager forradiology indicated not enough audit had taken place.3.6 King George Hospital, Ilford: Beech Ward(specialist stroke rehabilitation)We carried out an unannounced visit of Beech Ward on 17 March as a result ofconcerning information about privacy and dignity, use of call bells, and staffbehaviour that we had received from current and former patients. We checkedtwo of CQC’s essential standards; ‘Respecting and involving people who useservices’ (outcome one) and ‘Staffing’ (outcome 13).The inspection took place on a Saturday afternoon and evening. We talked topatients and relatives about the care they had received and to staff about issueson the ward. Patients and relatives had mixed views; while some were positiveabout the care they had received, others told us that staff were sometimesabrupt and a bit rough, and that patients had to wait a long time to havecontinence pads changed or to be taken to the toilet.13

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportStaff told our inspectors that they were stretched because of shortfalls instaffing and that this had affected their ability to deliver good care. We foundevidence that shifts were not staffed in accordance with rotas, and that not allstaff had attended stroke training (particularly a problem on night duty).Management and staff were aware of and seeking to tackle these concerns.CQC has set a deadline for the Trust to address these and will be following up tocheck whether enforcement action is necessary.14

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4 CQC’s recommendations –monitoring of progress against the CQC action planThe following pages set out the recommendations made in CQC’s investigationreport and include an assessment by CQC of whether these appear to be met,part met or not met. This assessment is based on the Trust’s reporting ofprogress to NHS London against its ‘CQC Action Plan’, and where appropriate isinformed by CQC’s compliance activity. In some cases, the Trust may have takenmeasures to improve procedure but CQC has not yet seen a marked improvementin care quality. This will be followed up through our core regulatory work.Please note that this assessment (met, part met, or not met) is not equivalent toa statement of compliance or non-compliance with CQC’s ‘essential standards’– the regulations and illustrative outcomes published in the CQC ‘Guidanceabout compliance’. For the latest view of compliance, please refer to CQC’sinspection reports.Progress againstrecommendations:summaryPage Area Met Part met Not met16 Strategy and capacity 0 3 017 Maternity 9 6 121 Leadership 1 4 023 Respecting and involving 2 1 024 Care and welfare - Emergency 0 2 125 Radiology 1 2 026 Discharge 0 3 027 Surgery 2 0 028 Cooperation 1 2 029 Safeguarding 3 0 030 Cleanliness 1 2 031 Medication 0 2 032 Premises 1 5 134 Equipment 2 0 135 Staffing 2 5 138 Supporting staff 1 1 039 Quality monitoring 1 5 041 Complaints 0 3 143 Records 0 2 0Total 27 48 615

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.1 Strategy and capacity1. The Trust, in conjunction with NHS London, should seekappropriate external expertise to support a programme oforganisational change and service improvement.Part metThe Trust has introduced 10 clinical fellows and four midwifery clinicalfellows as part of a clinical leadership and engagement programme,supported by NHS London. Commissioners are offering support at executivelevel in the development of the Trust’s programme management board tocoordinate the transformation programme. Health for NEL, Skills for Health,and the RESET programme in A&E are evidence of the Trust’s willingness toengage external support.2. The Trust, in conjunction with its commissioners andother partners, should identify and implement plans tosecure a long term solution to reduce over capacity atQueen’s Hospital.Part metThe Health for NEL proposals and estates reconfiguration plan for the Trustshould see demand reduce significantly over the next two years to addresscapacity issues. This includes seeing demand on maternity fall by 15-20%(between 1,500 and 2,000 births a year) by April 2013 through effectiveuse of alternative maternity resources in North East London. Successdepends on partnership working and ongoing commissioner engagement,including the role of primary care in making sure that people are aware ofthe treatment choices open to them.3. Improve the flow of patients not only in the emergencydepartment, but across the whole hospital to ensure thatprocesses that do not add value are removed and patientsare seen and treated in a timely fashion.Part metA range of work is underway to address this – bed mapping, revised lengthof stay, reviews of decisions to admit, care pathways in place for emergencyand gynaecology care. The RESET programme in A&E is designed to ensurestronger visibility and accountability of care pathways throughout thehospital, from admission to discharge. Progress in this will be carefullymonitored both within the Trust (including at Executive and Board level) andby external partners.16

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.2 Maternity4. In conjunction with its commissioners and otherpartners, identify and implement immediate solutions todeliver safe maternity services at the trust, especially atQueen’s Hospital, while developing plans to secure along-term solution.Part metWork with NHS London in the short-term and in the longer term via Healthfor NEL, has so far and should address the highest risks to safety formothers. Improved audit and reporting on c-sections is in place. An audit of1:1 care in established labour saw the Trust achieve 100%. CQC’s inspectionshave confirmed that improvements have been made and are so far beingsustained.5. Ensure that it configures its maternity services wardsand departments appropriately to improve the quality ofantenatal and postnatal care at Queen’s Hospital.MetAntenatal and postnatal wards have been moved to ensure a better patientflow. Incidents and complaints about the design of the ward are being actedupon.6. Ensure that there are suitable numbers of midwives toprovide one-to-one care for all women during establishedlabour.MetAudit so far has indicated 100% success; the target for the year is to achievean average of 98% across 2012.7. Ensure that learning from incidents in maternityservices takes place to reduce the risk to women of unsafecare.Met‘Lessons learned’ sessions are now part of mandatory training days andnear-miss meetings. A newsletter is in place to disseminate learning. Moresupervisors of midwives have been recruited and this material feeds intotheir meetings.17

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report8. Take appropriate steps to ensure that all women canreceive adequate pain relief when they need it.MetThis is audited weekly by the cluster; cover has been extended from 8am to8pm, with out of hours cover needing to be increased. CQC’s inspectionshave identified a clear improvement in this area.9. Further improve the maternity triage process with theintroduction of regular monitoring and learning to ensurethat services improve for all mothers.Part metNew pathway implemented with monitoring in place; performance reportedweekly to NHS London; triage working group in place. Performance levelsneed to improve.10. Take appropriate action to ensure that babies are nottransferred to the neonatal care unit unnecessarily.Not metPolicy and guidelines in place but being reviewed; Trust audit has recentlytaken place. Performance outputs not meeting required levels.11. Ensure it uses all staff and systems effectively toimprove the discharge process.MetIncrease in qualified midwives allows better discharge; improved process andaudit in place with regular reporting.12. Undertake a skill mix review in its maternity services,for example Birth Rate Plus.MetBirth Rate Plus review undertaken in addition to Trust’s own review ofskills mix.18

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report13. Continue with its recruitment plans in maternityservices to ensure that it has suitable numbers of qualifiedstaff across all service delivery departments.Part metRecruitment is on target to deliver a 1:29 ratio, with higher numbers ofsubstantive staff in post. CQC inspections have identified some concernsaround midwifery care assistant staffing levels. Trust has faced challenges inrecruitment and retention, although these are not particular to this Trustalone.14. Review the clarity of its reporting processes withregard to cardiotocography (CTG) training in maternityservices.MetAll new doctors receive CTG training on appointment; attendance figures areaudited on a monthly basis as part of the maternity dashboard.15. Increase the level of training on the interpretation ofCTGs, so that all staff have undertaken this.Part metAll midwives were due to have completed training by end of March 2012,although the maternity dashboard showed 84% complete. Regular audits ofattendance are in place.16. Increase the number of supervisors of midwives as amatter of priority, to improve the quality of supervisionand reduce the burden on those currently in post.MetAdditional supervisors of midwives have been recruited and are in place;ongoing review and recruitment should deliver a 1:16 ratio by September2012.17. Improve the quality of record keeping and recordsmanagement in maternity services.Part metTraining for staff and a maternity records tracker and audit process are inplace, but some problems with implementation and targets not being met todate. More that 50% of staff have now been trained in appropriategovernance.19

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report18. Assure itself that it has the right managers andleaders in maternity services to deliver high quality safeservices for women.MetDirector of midwifery joined the Trust in March 2012, review of previousallegations of abusive / rude behaviour completed, new allegationsproactively investigated. ‘Role play’ training in place to ensure staff listen toand act professionally with women in labour, and their birth partners at alltimes. Senior maternity managers, midwives, clinical directors andconsultants aim to act as role models to drive home message on zerotolerance of abuse and rudeness from staff at any level in the Trust.19. Ensure that maternity audit processes are integratedwith the rest of the Trust.Part metWhile a clinical audit plan is in place and infection control is being audited,an audit midwife has only recently been recruited. The full set of policy andprocess measures are in place but performance is not meeting expectedlevels as of the time of writing.20

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.3 Leadership20. Ensure its board assures itself that it has the rightleaders and managers in place to develop the trust andimprove the quality of services.Part metThe Trust Board has completed its review of the Executive Team, leadingto appointments of chief operating officer and director of transformation.A new management structure is in place based around clinical directorates,led by clinical directors and associate directors. Recent information indicatesthat there are several changes being made to senior management at theTrust and the impact of this will need to be assessed. Significant staffengagement process is underway to consult on wider implementation ofnew structure.21. Put a cultural change programme in place across theorganisation. The programme of change needs to engageall staff so that the trust can clearly articulate what theexpectations are of individual staff, what a highperforming organisation feels like to work in and be clearof the penalties for staff they should not behaveappropriately.Part metBuilding blocks are in place – ‘Big Conversation’ underway with staffengagement group set up and several staff engagement meetings held.Executive team now dedicate one day a month to take on a front line role inorder to increase understanding of care challenges and improve managementvisibility and accessibility. Conflict resolution training is being delivered formanagers; BHRUT Code being reviewed with significant staff input,including seeking clear examples of acceptable and unacceptable practice.Consultants are carrying out an analysis of team working and practice inwomen’s services.22. Develop a culture of whole systems working across alldivisions to reduce ‘silo’ working and the combative natureof bed management.Part metWeekly operations meeting, with directorate managers, is now in place;multidisciplinary working being pursued as part of RESET project. New bedmanagement structures is in place, with all divisions and specialitiesattending; Matrons working together to ensure effective discharge process.21

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report23. Develop a programme of support for managers so thatstaff with the capability can be freed to undertake theirmanagerial roles effectively.MetStaff engagement process is underway; appraisal rates for managers haveimproved and monthly performance reviews now being introduced.24. Explore how to improve its communications bothinternally and externally so that perceptions of poorcommunication can be reduced.Part metInternally, significant staff engagement is underway; externally, meetingshave taken place with LINks and Improving Patient Experience Group(IPEG); stakeholder briefings being disseminated; stakeholder event withcommissioners, CQC, LINks, IPEG and local authorities took place in May.Some feedback to CQC suggests there are further improvements that couldbe made, particularly in terms of engagement with MPs.22

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.4 Respecting and involving people (outcome 1)25. Ensure that it acts on the outcomes of its own andnational patient surveys and demonstrate thatimprovements to the quality of the patient experienceacross the trust are made.MetAnnual report on findings is to be produced to coincide with national survey;Board now receiving quarterly reports to update on learning. Six-monthlyreports for Hospital Life and the Link on improvements achieved as a resultof real-time surveys. Feedback from NHS Choices and Patient Opinion is tobe acted on bi-monthly from February 2012.26. Enhance its existing systems for involving patients inthe development of services to ensure that the patient’svoice is an integral part of every division, ward anddepartment engagement strategy.MetRevised patient experience strategy in place, with divisions to develop andimplement six-monthly patient engagement forums. Links with IPEG willprovide two-way information channels. Real time survey is being rolled outacross wards through 2012; the first report from this went to the Qualityand Safety Committee in February 2012.27. Make sure that proactive and mandatory training andeducation regarding dignity, respect and tolerance isdelivered to all staff.Part metDignity and respect benchmarking has been done; compliance reports onnon-attendance are being reviewed and a mandatory training programme isbeing developed. A leaflet for new staff about the Trust’s expectations ofbehaviour has been drafted and is due to be reviewed with the staffengagement group before roll out. The BHRUT Code is being reviewed andwill be issued to all new starters with contract. Quality of Care audits ofdignity and respect have been carried out in December and March so far andwill continue in order to audit feedback from the real time patient survey.Bank managers to ensure that competence of all temporary clinical staff inthis respect is monitored; if concerns are raised about temporary staff theyshould either not be booked again or only done so with documentedsupervision.23

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.5 Care and welfare of people who use services(outcome 4)Emergency department28. Develop its strategy and work for improving flow ofemergency/urgent patients. This strategy needs to havethe engagement of all clinicians and managers as a keycomponent.Part metThe ‘Discharge JONAH’ tool is being implemented to focus on discharge andlength of stay. Daily meetings, weekly performance reviews, and the RESETproject mean there is frequent and in-depth scrutiny; this will be met whenoutputs match the aspirations in a sustainable way.29. Develop a culture where everyone feels empowered tochallenge episodes of variable or poor practice, includingregular monitoring of practice and feedback and learningopportunities for staff.Not metThe appraisal process for emergency department staff has been reviewed; allstaff in this area have personal development plans. Hourly vital signs checksare underway and monthly spot audits are being carried out to ensure stafffeel empowered to challenge poor performance. Patient satisfaction surveysare in place and staff are reminded of the importance of challenging poorpractice as a standing item on A&E team meetings. Audit results do not yetsupport the processes that have been put in place.30. Ensure that all staff, both permanent and temporary,follow hospital policy and procedures.Part metAs noted, the appraisal process for emergency department staff has beenreviewed; spot audits of elective surgical consent have indicated some issueswith consistency; not all emergency patients receive all the information theyneed about procedures; and a new information leaflet on anaesthesia risks isbeing developed. Performance indicators are still negative.24

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportRadiology31. Develop its planning and bed management processesto ensure all patients are cared for in appropriate facilities.Part metMatrons and ward sisters are monitoring this but the Trust has not yetestablished how best to measure success in this area. The X-Ray departmenthas introduced appropriate checklists for ensuring patients are properlyprepared.32. Put in place clear protocols for the management ofinterventional radiology patients with audit andimprovement cycles to ensure standards are attained andmaintained.Part metAudit processes are in place and are monitored at interventional radiologymeetings and at the Divisional Board. SOPs are in place and are beingimplemented for each procedure in interventional radiology. CQC’scompliance activity supports the Trust’s assessment of significant progress inthis area, although more audit activity needs to be delivered for this to beconsidered fully met.33. Ensure that it fully implements the 2007 NPSA alertregarding radiology imaging results being communicatedand acted on as a matter of urgency.MetA distinct operational and clinical policy is in place, supported by cyclicalaudits; a longer-term measure will be a reduction in incidents by March2013.25

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportDischarge34. Develop its discharge and bed management teamsand processes to ensure that they are interlinked and thatpatient flow is managed effectively from the point of entryto the point of discharge.Part metA single discharge policy is now in place with clear roles and responsibilitiesestablished and six discharge specialists employed to help with complexdischarges. The RESET project is playing a crucial role in ensuring thatdischarge is managed across all relevant pathways and wards. The DischargeJONAH project and accompanying audits are in place. Daily meetings withmatrons and senior nursing staff review the bed position and delays. Theunderpinning processes and policies are in place here, but CQC’s inspectionsand other performance measures make clear that delivery needs to improveto match the Trust’s aspirations.35. Ensure that clear guidance outlining the expectationsof all staff is produced and enforced so that theprescribing and dispensing of ‘to take away’ medication ismanaged effectively and patient discharges are notdelayed. The trust needs to ensure that it monitorsadherence with policy, guidance and audit and takes anyappropriate action to support staff to deliver a highquality service.Part metThe Trust has suitably robust guidance and policies, which is reaffirmed atinduction. Pharmacy is meeting dispensing targets, but better monitoringand audit needs to be introduced to ensure that treatment is appropriateand supported by suitable information. This has also been linked into theRESET project. The Trust’s Visible Leadership programme has included afocus on this area of care, with reports to the Nursing and Midwifery Boardand Quality and Safety Committee.36. Review and rationalise the discharge and bedmanagement information systems to ensure that the mosteffective and accurate system is fully utilised.Part metThe Discharge JONAH tool has been rolled out as per above; this is linked inwith the RESET project. As mentioned, the underpinning measures are inplace but performance is yet to meet expectations.26

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation reportSurgery37. Develop its day case surgery service to ensure thatappropriate patient flow is maintained including effectivepre operative assessment.MetAdmission times are being staggered to reflect the theatre list and restrictthe pre-surgery wait to four hours where possible; admission letters nowrefer to appropriate time of arrival and likely delays. Revised audit processesare in place to monitor progress.38. Improve standards of care for obstetric patients whoundergo minor surgical procedures.MetImproved patient satisfaction and flow is being monitored; some electivepatients do risk missing treatment due to over-extension of theatre lists, butthis process is under close scrutiny and review to make sure the risk of this isminimised and patients – where affected – are informed. Emergencyprocedures are prioritised to minimise waiting times and avoid harmfuldelays.27

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.6 Cooperation with other providers (outcome 6)39. Continue to engage, and develop effective workingrelations, with external providers and partners.Part metRegular stakeholder briefings have been introduced and the Trust has set upa regular programme of meetings at patient representative groups, OSCs,and briefing to media. CQC recently attended a stakeholder meeting at theTrust and feedback from local authority partners and the Improving PatientExperience Group was that communications with stakeholders hadsignificantly improved.40. Work with partners to ensure adequate provision ofspecialist rehabilitation services.MetDischarge partnership boards are held on a bi-weekly basis to discusscomplex discharges and the relationship between all relevant organisations.Access initiative meetings are held with Barking and Dagenham, Redbridgeand Havering. All site managers across acute and community services use asingle electronic bed system, which is helping discharges. A community bedreview is underway in line with the Health for NEL programme.41. Work with social care partners to develop robustworking practices to ensure appropriate admission anddischarge practices.Part metA programme director is working at the Trust with funding from the Clusterto liaise between the acute Trust and borough and community services. Thispost will currently run until October 2012. There is now a central point forescalation and consideration is being given to allocating a budge to theprogramme director to allow them to make spot purchases to resolvecomplex discharge problems. Work is underway to streamline processesacross all boroughs to access community services. Gaps in acute Trustresources are being identified to improve discharge to community services;early data indicates reduced length of stay.28

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.7 Safeguarding people from abuse (outcome 7)42. Complete the recruitment of senior staff intosafeguarding roles.MetStaff have been appointed to fill the relevant posts for safeguarding adultsand safeguarding children.43. Ensure that all staff are able to access and receive theappropriate level of safeguarding adults and safeguardingchildren training.MetA safeguarding training strategy is in place with data on staff trainedcollected and reviewed centrally.44. Continue to develop its joint working practice withexternal partners.MetThe director and deputy director of nursing now attend a range of externalsafeguarding meetings; external stakeholders sit on the Trust’s ownsafeguarding meetings, chaired by the Director of Nursing. Named nursesnow sit on external sub-committees as necessary.29

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.8 Cleanliness and infection control (outcome 8)45. Ensure that all equipment and disposable productsare stored appropriately.Part metWard managers have completed risk assessments of equipment managementand storage facilities. A new Trust environment / equipment disposal policyis in place. Weekly walkabouts with facilities and estates have beenimplemented and an action log is in place.46. Ensure that all public toilets are kept clean especiallyin areas of high usage.MetA site review of all public toilets has taken place and cleaning schedules havebeen reviewed in terms of frequency and content to ensure compliance withthe National Standards of Cleanliness 2007 / PEAT standard. A rapidresponse team is in place for ad-hoc cleaning. Audits are in place, spotchecks by senior executives have been introduced, and patient and publicfeedback is monitored.47. Ensure that staff are not posing an increased risk topatients from cross infection. The trust should take anynecessary steps to ensure that staff can store personalproperty as necessary.Part metThe staff uniform and dress code policy is being reviewed to ensurestandards are understood and remedial actions are available. An infectioncontrol annual plan is in place and is reported against to Infection ControlCommittee every other month.30

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.9 Management of medicines (outcome 9)48. Reinforce its policy on medication prescribing,dispensing and administration, ensuring that all staff areaware of their roles and responsibilities.Part metA briefing for clinical staff explaining the importance of this policy andsetting out accountabilities for prescribing and administration has beenprepared; this is due to be rolled out shortly. A Policy Ratification Group hasbeen set up to ensure policies are corporately signed off, published on theintranet, with summaries added to the Link to raise awareness of changesand expectations around compliance. Trends and issues relating toprescribing and medicines are reported in the Link, with a bimonthlyprescribing newsletter in place to ensure a strong focus on medicines safety.An ongoing audit programme has looked at omitted drugs in the MAU,pharmacist errors, and is looking at a range of other relevant issues.49. Ensure that the results of learning from medicationerrors are widely publicised across all services in theorganisation.Part metSafe Medicines Practice Group in place and produces a summary of incidentthemes and serious incidents to be used in directorate meetings. Pharmacistsand wards receive monthly reports on medicines and prescribing. Errortrends are fed back to relevant directorates and are published on theintranet.31

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.10 Safety and suitability of premises (outcome 10)50. Review the directional signage at Queen’s Hospital.The trust should ensure that it seeks the input of patients,relatives, visitors and staff, to ensure that any new signagemeets the needs of its populations.Part metWorking group involving patients, non-execs and staff set up in December2011 to set signage standards; main signage reviewed with specialist inputand new signs commissioned to arrive in June 2012. Leaflet and map underreview to ensure signage is in context of better overall patient information.51. Review the emergency department paediatricfacilities at Queen’s Hospital in line with the standardsoutlined in Services for children in EmergencyDepartment’s document and then develop an appropriatestrategy involving both the emergency and paediatricdepartments.Part metPaediatric waiting areas reviewed and funding agreed to improveobservation of sick children; project group set up to implement Health forNEL redesign of paediatric services.52. Finalise and implement plans to improve x-rayfacilities and ensure that patients waiting for x-rays in theemergency department are appropriately cared for.Part metReview of x-ray services including department layout linked to Health forNEL programme; project group set up with dedicated project managementsupport. Current process of caring for patients in waiting area addressed viaa short-term solution using a mobile x-ray device to limit patient waitingtimes.53. Ensure that appropriate waiting facilities are availablefor patients and relatives in the urgent care centre.Part metAs above, these waiting facilities are being reviewed as part of the Health forNEL programme.32

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report54. Explore options and take action to improve access tonatural light and ventilation in all clinical areas thatcurrently do not have windows at Queen’s Hospital.MetNatural light bulb pilot is underway to address areas where natural light isnot accessible. All patient-access areas where neither natural light norventilation is available are being identified. All reviews of capitalimprovement now include consideration of the environment in which care isdelivered, and any opportunity to provide access to natural light andventilation will be taken.55. Review and take any necessary action in all inpatientareas to ensure that there are clear lines of sight so thatpatients can be observed at all times.Not metThe ‘hourly staffing of wards’ element of the Safer Nursing Care Tool andother tools are being used to try to ensure there is suitable observation ofpatients, although concerns about staffing levels suggest there is room forimprovement.56. Develop appropriate facilities to ensure the day casesurgical patients are cared for in appropriate environmentsat Queen’s Hospital.Part metThe use of overnight recovery has been reviewed and works are underway toimprove facilities subject to funding. There is a plan in place to develop a23-hour facility in the day surgery unit and allow space in Recovery to beused as a ‘day of surgery’ admissions area, but these are pending theoutcomes of the bed-modelling work stream.33

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.11 Safety, availability and suitability of equipment(outcome 11)57. Review the availability of medical devices in clinicalareas to ensure that appropriate levels of equipment areavailable for the acuity of patients that it receives atQueen’s Hospital. Further revalidation of the review needsto take place following any changes to service provision.MetA matron-led audit of equipment took place in November 2011. This showedareas where equipment was above the current register and highlighted someshortfalls. The latter have been picked up via business cases (expenditure of£240k was approved for immediate procurement in March 2012) and shortfallsare routinely considered at the Medical Devices Committee. A manual equipmentloan process is in place to keep track of equipment (an electronic system wasconsidered but was too expensive). This is supported by a colour-coding systemwhich was introduced via a successful pilot. The existence of four separate contractsfor therapy equipment (Trust and three local authorities) means accessibilityissues will remain until contract renegotiations can take place. There are nobarriers to clinical areas obtaining stationery at any time it is needed. The MedicalDevices Policy has been reviewed, signed off and published; a new escalationprocess is in place to address faulty equipment, including matrons / managersaddressing governance issues with staff where reporting has not taken place.58. Ensure that systems are in place in all clinical areas sothat sufficient disposable equipment is available.MetA medical devices audit has been completed and business planning forequipment for 2012-13 reflected its findings. A process for monitoring,ordering and administering disposable equipment is well-established and subjectto audit; this is supported by the colour-coding and loan equipment protocol.59. Develop as part of its cultural change programmepeople’s sense of responsibility to take positive action toensure that clinical areas are suitably equipped to providesafe patient care.Not metThis will be audited by monitoring complaints on availability of equipmentand regular equipment audits; a business case may be considered for adedicated medical devices coordinator / trainer if the need is firmlyidentified. CQC’s inspections suggest this remains a serious issue that needsto be addressed.34

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.12 Staffing (outcome 13)60. Continue to review its human resource informationsystems and ensure that accurate data is available for theentire organisation, so that a clear and comprehensiveunderstanding of vacancies can be established.Not metThe Trust has introduced a phased programme to consolidate establishmentdata against the electronic staff record, including cleansing the record ofposts that are no longer in use, and with finance support. There have beenchallenges in aligning the HR ledger data with the electronic record. Furtherwork is needed and there is, as yet, no formal process in place or agreed formanaging establishment control. The move to electronic staff change /termination forms has been difficult to implement, and there has been adelay in getting fully accurate reporting on vacancies and establishment.61. Continue to review its workforce strategy to ensurethat it meets the needs of the organisation and reflectsthe reality of service delivery.Part metA review of the Workforce Strategy has been completed and is now beingtested via the staff engagement group.62. Undertake systematic skill mix and staffing needsanalysis to ensure that they have the right staff with theright skills at the right locations and that trust is receivingvalue for money.Part metSkills for Health are supporting the Trust in this, funded via NHS LondonFinancial Support. Pilot work in the Emergency and Maternity Departmentsis underway. Future phases are heavily dependent on the success of the pilotanalysis and capacity to roll its findings out across the Trust and this will onlybe able to be assessed in the longer term. CQC compliance activity continuesto suggest that the Trust faces challenges in terms of building a sustainableworkforce with the right skills mix.35

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report63. Continue to recruit appropriate permanent staff toensure that it reduces its reliance on agency and locumstaff improving the quality of care, and have in placeeffective retention strategies.Part metAn accelerated recruitment project and reduced use of agency staff havebeen put in place, with recruitment needs assessed on a monthly basis. Exitinterviews are now in place as part of KPIs and are reviewed by Directors.The Trust has introduced suitable procedures here, but CQC complianceactivity has identified ongoing challenges around locum use, particularlyin A&E.64. Develop and improve the human resources supportfor the divisions so that managers can take effectiveaction against staff where there are performance concerns.MetMediation training has been delivered to support managers; performancemanagement policies and processes are in place for 2012-13 to supportmanagers in taking early action against poor performance. Revised policieshave been approved by staff and HR performance is reviewed at directoratelevel on a monthly basis.65. Explore and develop strategies for delivering serviceswith different staff groups so that reliance on difficult torecruit staff groups is reduced.MetJob descriptions are being reviewed to ensure they reflect the need forflexibility; provisions for this within current contracts are being reviewed. Aflexible working policy has been agreed with the staff and take up is beingmonitored as part of recruitment KPIs.36

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report66. Support a skills escalation programme in theemergency department that seeks to develop nurses whohave already successfully completed an emergency nursepractitioner or advanced clinical practitioner course andreduce reliance on them undertaking traditional nursingduties due to shortages of staff.Part metA review of the A&E workforce has been completed and the unit has beenbenchmarked against other comparable trusts. A review of the skills mix,current roles, and supporting roles has been undertaken and budgetsreviewed in light of this. Current staff are taking part in an ongoing trainingprogramme to ensure staff update and refresh their skills. CQC’s complianceactivity has identified ongoing staffing challenges in A&E and the longertermimpact of this review work will need to be assessed at some point inthe future.67. Ensure that its whistleblowing systems and processesallow staff a route to raise concerns early so that quickaction can be taken and staff feel empowered to raiseconcerns.Part metThe Trust’s whistleblowing policy has been revised and communicated tostaff through Team Brief, the Link and the intranet. Staff feedback on theeffectiveness of the policy is now part of the staff engagement strategy andnew starters will be audited after six months to see if they are aware of it.Delivery of this recommendation is contingent on cultural changeembedding itself across the Trust (although it should be noted that CQC hasusually found staff open and willing to talk frankly about challenges duringinspections, whether in confidence or openly).37

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.13 Supporting workers (outcome 14)68. Continue to develop and deliver training for staff tosupport the development of quality services, seekingalternative solutions where staff have difficulty accessingtraining due to staffing constraints.Part metAn annual training needs analysis is carried out and new mandatory andstatutory training programmes are in place. Staff education is supported byspecialist trainers and compliance is reported to the Trust’s Education Board.Recording of training attendance has been improved and should be reportedto line managers. Better reporting and benchmarking is needed to considerthis met.69. Ensure that appropriate supervision is provided tomedical staff and that more junior medical are not leftwithout appropriate support, especially at weekends andat night.MetThe Trust’s supervision policy has been reviewed by a working party (part ofthe Post-Graduate Medical Education Committee) to include KPIs andintroduce accountability to this area. Benchmarking and audit will ensurethis is sustainable.38

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.14 Assessing and monitoring the quality of service(outcome 16)70. Ensure that it has adequate systems of governance topromote high quality care for patients and to deal withconcerns about performance in an effective and timelymanner.Part metClinical and committee structures have been reviewed and a new ClinicalGovernance Structure has recently been considered by the Trust’s Board.Expanded central data collection for the Quality and Safety Committee hasbeen proposed. A central monitoring and evidence database has beenintroduced for Serious Incidents, with Trust-wide audits being introducedand KPIs introduced for reporting and completion of investigations. Aweb-based incident reporting system is being introduced across the Trustafter a pilot in maternity.71. Develop a system of governance that offers itaccurate and real time information that translates into aneffective assurance process.Met72. Carry out a comprehensive review of all corporate andclinical governance systems across the organisation toensure that effective and streamlined systems andreporting structures are in place to provide robustassurance to the board.Part metClinical and committee structures have been reviewed and a new ClinicalGovernance Structure has recently been considered by the Trust’s Board.A complete review of Trust corporate committees has been completed andwas recently put to the Trust Board. A complete review of maternity clinicalgovernance was completed by October 2011 to ensure full integration withthe Trust’s main governance structures. The review also led to Divisionalmanagers taking on responsibility for alerting clinical governance teams toall external quality and safety recommendations (reinforced throughstringent audit and reporting), with regular reporting between HR andClinical Governance to ensure joint management of patient safety issues.39

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report73. Ensure that it has systems in place that allow effectivesharing and learning across the whole organisation.Part metExisting guidance on learning from serious incidents has been reviewed andKPIs for implementation have been introduced. A bi-monthly ‘LessonsLearned’ group meets to generate shared learning. This includes using thecontent of Ombudsman action plans to ensure learning points areappropriately extracted and shared. A rolling programme of articles in theLink is supporting learning. Directorate Boards now review Serious Incidentreports and action plans to ensure timely implementation. Clinical Directorsare sent details of each relevant Serious Incident and these are agenda itemsfor directorate clinical governance meetings until they are responded to in asuitable way. This recommendation will only be fully met when success canbe demonstrated over time. CQC and other stakeholders not only expect tosee evidence that Serious Incidents are being dealt with internally, but alsoto see commissioners and other external organisations being informed whenrelevant.74. Ensure that the incident reporting system for thewhole trust is operating effectively and all staff arelearning from incidents rather than simply reportingincidents.Part metAs noted above, a web-based incident reporting system is being introducedacross the Trust after a pilot in maternity. If the proposed clinical governancestructure is introduced as planned, directorate boards will take onresponsibility for regular reviews of learning from incidents. Learning fromincidents is now integrated into the ward staff meeting structure, and betterstructures have been introduced to ensure learning is shared between staffacross divisions. Again, this will need to be demonstrated over time.75. Ensure that it has appropriate levels of staff in placeto allow its governance systems to function effectively andthat these staff are embedding appropriate systems inclinical services.Part metFollowing the review of governance, suitable staff have been identified toensure its recommendations are properly implemented. As above, proof ofsuccess will be seen through delivery.40

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.15 Complaints (outcome 17)76. Continue to develop and improve its complaintshandling systems to ensure that complaints are respondedto fully and in a timely manner.Part metA review of outstanding Ombudsman complaints has taken place; adedicated manager has been appointed to follow up compliance with actionplans or to report non-compliance to the Director of Nursing. Complaintnumbers and trends are reported to the Quality and Safety Committee. PALSprocesses have been reviewed to try to address patient concerns at an earlierstage. CQC is aware that the Trust has seen a significant increase incomplaint numbers since the investigation was published last year; as aresult, while the underpinning systems have been improved, they arestruggling to cope with an unprecedented surge in numbers.77. Develop and support staff to ensure that opentransparent investigations take place, that complainantsare involved as necessary and that culturally complaintsare seen as opportunities to learn and improve the qualityof care.Part metNHS London has supported the Trust to undertake a root cause analysistraining campaign for senior management to ensure the importance of timelyinvestigation of complaints is fully understood. A report of trends andthemes aggregated across the Trust is reported every other month, includingidentification of trends and hotspots.78. Ensure that any staff identified in a complaint areinvolved in resolving the complaint and the resultinglearning, but where there is a complaint about anindividual there is appropriate separation of theinvestigation from the individual.Not metA revised policy has been drafted and is awaiting senior managementapproval; it is currently available to staff but will only be considered on itsway to being met when it is implemented and progress audited.41

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report79. Develop its reporting mechanisms to ensure that theboard are fully informed of all complaints, that detailedtrend analysis takes place and that the board can assureitself that learning is taking place, and repetition ofthemes is reduced.Part metThe Trust Executive Committee and Board now receive a monthly complaintsanalysis; reporting is discussed at the bimonthly Quality and SafetyCommittee. The Patient Experience report to the Quality and SafetyCommittee includes a full analysis by directorate and highlights key issues.Reporting began in April 201242

Barking, Havering and Redbridge University Hospitals NHS Trust - Update on investigation report4.16 Records (outcome 21)80. Improve its systems for records management toensure that notes can be retrieved effectively andexpediently, and reduce the risks associated with multiplesets of temporary notes and poor data handling.Part metThe Trust’s Medical Records Committee has been re-established with newTerms of Reference; training levels for healthcare professionals are discussedat this Committee on a regular basis. Weekend transport for transfer of noteshas been reintroduced and a nursing documentation booklet has beenpiloted across several wards and will be fully implemented by the autumn.81. Develop integrated patient administration andinformation systems to ensure that, where ever a patientis being treated within the trust, their full healthcarehistory can be accessed by all staff.Part metA procurement process is underway to introduce an effective system toenable access to patient histories. Funding challenges have slowedintroducing of a full electronic patient record.43

EXECUTIVE SUMMARYTITLE:BOARD/GROUP/COMMITTEE:Quality and Patient Standards PerformanceReport – May 2012Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:The Quality and Patient Standards Performance Reportprovides an analysis of performance against trust-wideand national targets for the following domains:• Patient Safety and Quality• Performance• Workforce• Productivity• FinanceThe following areas where year to date (YTD)performance is of concern are discussed within the report:□ PEQ……….…...……. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ CLINICAL GOVERNANCE …………..………….....……□ CHARITABLE FUNDS ………………………………...… TRUST BOARD – June 2012□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)• % of SI’s reported within 48 hours -• MRSA Bacteraemias• Clostridium Difficile• MRSA Screening – Emergency• % Complaints Responded to Within 30 days.• Pressure Ulcers• Elective and Non-elective Re-admissions

2. DECISION REQUIRED: CATEGORY:The Trust Board is asked to note the content of the reportand support the actions to bring the performance back inline with trajectory/target. NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY□ ASSURANCE FRAMEWORK CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR: Claire Burns, Head of Planning, Commissioningand InformationPRESENTER: Neill Moloney, Director of DeliveryDATE: June 20123. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:Not applicable.4. DELIVERABLESThe delivery of the Trust wide objectives.5. KEY PERFORMANCE INDICATORSPlease see attached Trust Performance Dashboard.AGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

Performance ReportMay 2012Performance Indicators - Exception Report1. IntroductionThe performance report has been revised for 2012/13. The dashboard now covers the followingareas• Patient Safety and Quality• Performance• Workforce• Productivity• FinanceThere are a number of new indicators included for 2012/13. This report provides the Board with anoverview of mitigating actions to be taken by Business Units to improve performance to ensureperformance meets the target, ld. Finance and Human Resources performance are subject toseparate reports to the Trust Board. Where either the staff appraisal or basic life support trainingdoes not achieve the performance target a commentary has been included in the exception report.2. Patient Safety and Quality% of SI’s reported within 48 hours - This is a new indicator for 2012/13. The target has been set inline with the CQUIN which has a quarterly trajectory.There was an improvement in the % of SI’sreported within 48 hours during Mayachieving a performance of 29% over twomonths. The SI CQUIN goals have beenissued to Clinical Directors who have beenrequested to ensure all services understandthe importance of urgent SI reporting.Clinical Governance is closely monitoringcompliance and raises with services and theappropriate Clinical Director any nonconformanceMRSA BacteraemiasThere was 1 case of MRSA bacteraemia during May. The cause was thought to be urinary tractinfection associated with urinary catheterisation. A root cause analysis meeting has been held andsome failings in compliance with catheterisation policy have been identified. There were also somefailings in medicines management – antibiotics not given in a timely manner – and issues regardingurological management were raised. An action plan has been prepared and a response is due by theend of June. The project to introduce Aseptic Non-Touch Technique (ANTT) across the trust isprogressing well and implementation will commence in July. This project will address many of theissues associated with previous causes of MRSA bacteraemia such as infection associated withwounds and intravascular lines.Clostridium DifficileThere were 7 cases of infection during May, 4 at Queens and 3 at King George, one of which was acase of relapsing infection, not a new case, but is reportable according to the criteria. All cases havebeen reviewed and there is no obvious connection between them. Individual review of the patientscare by ward staff showed between 95 and 100% compliance with policy – a considerablePage 1 of 10

improvement on previous findings. Therefore the reason for the increase remains obscure. Additionalhigh level cleaning of A&E and admissions wards has been carried out as the potential for spread ofinfection among newly admitted patients may be higher than on other wardsMRSA Screening – Elective The 2012/13 target forMRSA screening has been agreed at 85% forelective screening The current performance for thescreening of elective admissions MRSA screeninghas remained static at 78% but with non-electivescreening increasing from 69% in April to 74% inMay. The completion of waiting list clinical coding isaffecting elective performance. If coding is nottimely or complete the number of excluded recordsis lower than could be. This issue has beendiscussed with the Clinical Coding Department whoare working on increasing coding of the waiting list.MRSA Screening – Emergency The 2012/13 targetsfor MRSA screening has been agreed at 95% for nonelectivescreening. The majority of the emergencypatients enter via the CAU where the screening isdone however, where we have direct access to thewards the matrons are aware of the MRSA PTL andthis has been flagged to the ward staff. The responseto this will be reviewed at the weekly medical matronsmeeting and an action plan will be required to becompleted for those areas that are not achieving.% Complaints Responded to Within 30 days. This measure will be changed to % Complaintsresponded to within the agreed timeframe, in line with the national standard. As of 18.6.12, 28 opencomplaints were more than 3 months old. Two remain from 2011, and are expected to be dealt withby the time of the Board meeting, when a further update will be available. Overall, this is a 50%reduction on the number open at the beginning of January, and a 75% reduction on the number openfor more than three months. Weekly performance meetings remain in place with the directorates tosustain the performance going forwards and clear the remaining backlog of older complaints.Pressure Ulcers There were 2 grade 4 pressure ulcers reported in May, although both of these wereidentified as a result of patient complaints and related to care given some time previously; one fromFebruary 2012 and the second one from May 2011. There have been no new hospital acquiredgrade 4 pressure ulcers in April or May, and it is now over 110 days since the last instance within theTrust. This is a significant improvement on the position last year. Grade 3 pressure ulcers havecontinued to be reported at a consistent rate for the last 3 months, although there has been a slightreduction in those numbers over the last year. The Trust-wide action plan for reducing pressureulcers continues to be implemented, with patients being risk assessed on admission and then at leastweekly. Referrals to the tissue viability have team have significantly increased as a result of the workto highlight the need for early intervention. The team are now facing a challenge to ensure that everyreferral is seen within 24 hours.Page 2 of 10Elective and Non-elective Re-admissions

not yet been set. However the performance is currently not improving. With elective readmissionsrising from 2.97% in April to 3.4% in May and non-elective admissions rising from 12.75% to 13.9%in the same periodThe RESET work streams do not directly address readmission rates but with the focus on earlier andsafer discharge some improvement is to be expected over the coming weeks.There is also a programme of work being led by Alison Browne and Caroline Moore to try to integratemore closely the Community Discharge and Support teams with BHRUT Discharge team to supportmore effective and sustainable discharge.The Integrated Case Management work is being continued by ONEL in partnership with the Trust.The Trust is also working on a project inconjunction with NELFT to implement aCommunity Treatment team to‘gatekeep’ admissions andreadmissions for the frail elderly. Thiswork is in the early stages of discussionbut there is strong commitment by bothproviders to implement this team.Patient Experience the first measurefor this indicator is to achieve 50% of discharged patients completing a survey. To ensure the futuresuccess of real time patient surveys, this initiative needs to be owned and driven forward by theBusiness Units. To this end the following actions have been instigated :• Active encouragement by Matrons to ensure that all ward areas achieve a minimum of50% of discharged patients undertaking a real time survey.• Survey results to be discussed at Business Unit meetings• Real time patient survey results to be incorporated into Business Unit reporting• All areas which have hand held devices will be able to access their real time surveysonline via a unique link and passcodeThe questionnaires used in the Real Time Surveys are being reconfigured and will include thequestion “How likely is it that you would recommend this service to friends and family”? Thequestionnaires together with 10 additional kiosks will be implemented across the Trust by late June2012Same Sex Breaches There were 21 single sex breaches for the month of May 2012.These occurredwithin the High Dependency Unit (17), and Intensive Therapy Unit (3) at Queen’s Hospital. At KingGeorge Hospital, a single sex breach occurred in the High Dependency Unit (1). This is animprovement from the April when there were 30 single sex breaches. Following a discussion withinthe service it has been agreed that a modified root cause analysis will be undertaken for all breachesof this standard. The outcome will be circulated for discussion and learning across the organisation.All of the breaches occurred due to delays in the transfer out of patients who had been ‘steppeddown’ to general care. This was due to constraints on the availability of suitable beds for step downPage 3 of 10

Page 4 of 10due to patient flow delays across theorganisation. The Rapid End to EndSustainable Emergency Transformation(RESET) programme is expected to resolvethe issue of the delay in transferring ‘steppeddown’ patients from CCU, ITU and HDU tothe general wards at Queens.

3. PerformanceCancer Targets Although compliance with the CWT targets was achieved for the full yearending 31st March 2012, the 62-day performance fell in February and March 2012; this noncompliantperformance has continued into the new financial year. The main issue affectingthe 2 week wait target is that of capacity; there has been lost capacity due to sickness indermatology. There have also been an increased number of patients who are unavailablefor their appointment dates. In the main, the breaches have been caused by admin delays,followed by patient choice, then capacity issues. This reflects the fact that escalation hasnot been taking place as it should. The escalation policy has been re-circulated and thefocus of the weekly PTL meetings is to now identify any delayed escalation, with plans beingput in place to avoid the breach.The table below shows the breaches in April broken down to into the main reasons:PatientChoice Medical Capacity AdminComplexPathway TRUS/MRITotal 4.5 3 3.5 6 2 1.5 20.5Percentage 22% 15% 17% 29% 10% 7%In order to reduce the numbers of breaches, and bring the 2 week wait, BOS and 62-dayscreening performance back to target the following actions have been put into place:• Review format of Weekly Friday PTL meeting to focus on all targets (e.g. 2ww) anddiscuss service improvement as well as reviewing individual patients and escalatingdelays that haven’t been actioned;• Escalation policy has been updated and re-circulated;• Lead Clinician for Cancer to attend the MDT Meetings with the Lead Nurse for Cancer toensure further engagement from the Lead Clinicians;• The H&N MDT has met on a weekly basis for the past few weeks to review theirpathway. These meetings continue.• MDT structure has been reviewed to provide support for the MDT Coordinators duringtimes of leave or sickness.Emergency Department (ED)The Trust maximum wait target is measured on all attendances atA&E and UCC facilities on both Trust sites. The performance against this standard is shown belowand has improved in May in line with the agreed trajectory. Local specialty referral Key PerformanceIndicators (KPIs) are now in place as a measure of the Trust’s own internal professional standards.Measuring against these KPIs has now commenced and although performance is currently poorthere are a number of initiatives withinED and across specialties to addressthis going forward. These include:• extended rapidassessment and treatmentwithin ED to all patients• dedicated specialtyresponse to the ED insome areas• receiving rooms• assessment unitsPage 5 of 10

• improved escalation processesThe number of ambulance black breaches has significantly improved in May which is as adirect result of the extended rapid assessment and treatment within ED and the revised bedmanagement system whereby there is a bed manager responsible for managing both the‘front’ and ‘back’ door admissions. These improvements are being managed through theMcKinsey RESET programme, details of which are included under the Emergency CareRESET update.Page 6 of 10

4. WorkforceBasic Life Support Training (BLS) The latest resuscitation training compliance report, coveringthe period 1 st June 2011 – 31 st May 2012 reports Trust compliance at 77.86% an increase of1.57% on the previous report. Compliance reporting continues which identifies staff, at all levels,who still require resuscitation training. Attendance at Adult In-Hospital Life Support trainingsessions is improving but there are still a relatively large number of unfilled places, or nonattendanceon a number of courses as demonstrated by the low increase in overall compliance. Inorder to improve compliance rates the resuscitation service has offered targeted training to severalstaff groups where service demands makes releasing staff to attend advertised training sessionsdifficult. These session have been scheduled over the next few weeks and months,Page 7 of 10

5. ProductivityLength of Stay (LoS) There has been deterioration in LoS across the board with theexception of Elective (including 0 days). This was due to Bank Holiday leading to areduction in discharges Some of this may be due to the opening of Japonica ward at KGHfor the complex discharges which has introduced an additional step in these patientspathway which inherently increases their LoSThere is a new stream of work which focuses on weekend discharges – the additional support put infor the recent Bank Holiday weekends has proven to expedite discharge - a dedicated dischargeteam will be established in the short term while a proposal for Consultant 7 day working for medicalspecialties is worked through. A full update of the RESET work streams addressing LoS is givenunder the Emergency Care report.Delayed Transfers of Care has increased by 1% which will be a contributory factor in the observedincrease in length of stay. On reviewing the Jonah data, the number of patients in delay has increaseas well as the LoS for these patients..Work is now focusing on this with theward sisters and matrons to ensurethat while we have Japonica openevery effort is made to expedite timelydischarge.Performance for May was 4.99%against April’s performance of 3.9%which is very disappointing given theeffort that has been made to reduce thewait for community beds.The main cause for DTOC related tothe Health Needs Assessment process,Page 8 of 10

with most of the delays occurring on Japonica ward at KGH.The reasons for delays and their mitigation are:• Awaiting completion of the Health needs assessment by hospital staff – patientshave been transferred to Japonica with incomplete HNA or inadequate HNA whichhave to be repeated. This is lengthy process and the ward staff do not know thepatients. Additional complex discharge team resource has been assigned to clearthe backlog.• The moves to Japonica at KGH were undertaken to create capacity on the Queenssite to improve A&E performance, but this has had an adverse effect on DTOCperformance. RESET project work stream informed.• Delays caused by waiting for Occupational Therapy reports as part of theassessment process due to service capacity issues. Escalated as part of RESETproject• A delay in medical reviews of care after a section 5 has been issued. Escalated aspart of RESET project• Waiting ratification for nursing care funding – there were some delays this month.This has been escalated to the PCTA significant reduction (average was 20 and by the end May was 6) in the number of DTOC delaysrelated to waiting for non-acute beds resulted from the following actions which were undertakenduring May:• A single management structure for all community beds across NEL is now in place• A review of the referral and admission criteria into rehabilitation beds and serviceshas been undertaken• A single referral and assessment process for rehabilitation is now in place• A regular review of all in patients is undertaken to identify patients for early dischargeresulting in an increase in capacity, with a reduction in LOS, across all sites forcommunity beds• A reduction in the number of days patients wait for a community bed and a reductionin the number of patients waiting.• A reporting template has been agreed with NELFT so that Commissioners maymanage DTOC performance.Stroke rehabilitation processes have been harmonised to ensure that patients have all theirrehabilitation in one site and this has resulted in a significant drop in patients waiting for strokerehabilitation.% Patients Discharged Between 6 am and 11am -This is a new target this year. General Managersand Service Managers are actively supporting ward board rounds each morning to enable them to bemore proactive in managing operational issues which prevent a patient’s timely discharge.Page 9 of 10Outpatient First to Follow-up Ratio TheYTD first to follow up ratio has shown a

small improvement but remains below the performance target rate of 2.13 at 2.27. All outpatientclinic profiles have been reviewed across all specialties and changes have been applied to theclinics. As many of the specialties have clinics that are already fully booked and in some casesoverbooked, the re-profiling exercise is not expected to result in an improvement to the FFU ratiountil mid year. It was agreed, via the outpatient work stream, that the unregulated practice ofchanging slots within the clinic profile, especially changing new slots to follow ups slots, is to cease.The current list of staff across the Trust able to change slots has been reviewed as it was felt misuseof this functionality was taking place and affecting the Trust’s FFU ratio performance.DNA Rate 1 st Appointment The DNA rate for firstappointments has made progress and reached thetarget rate of 9.70%, but it is fairly static on previousmonth’s figures. The texting pilot in four specialitiesgynaecology, rheumatology, urology and T&O hasbeen completed. Except for T&O all specialities inthe pilot have shown improvement in DNA rates withmost the favourable impact seen in gynaecology.Funding has been agreed for a Trust wide textingreminder service and will be phased in over the next6 months.DNA rate for follow up appointments The DNA rate for follow up appointments has reached theperformance target of 10.30% at 9.92%. Inorder to further reduce the level of DNA'sthe Trust is looking to move to full partialbooking of follow up attendances. This is asignificant initiative and marks a transition toa more pro-active management ofOutpatients and promises significant gainsin efficiency and patient satisfaction. Apaper detailing the investment required toimplement full partial booking has beenproduced for the Director of Strategy fordiscussion by the Trust Executive.Page 10 of 10

April May Target red Trend April May Target red Trend April May Target Red TrendSHMI ‐ quarterly Sept 11 93.9293.92 95.00 = % untreated waiting less than 18 weeks 93.0% 93.7 92% 87% ↑ LOS (Elective) 3.12 3.0 3.1 3.48 ↓% emergency admitted patients review bysenior clinician within 12 hours 95% 96% RTT admitted in 18 weeks 90.7% 90.1 90% 85% ↓ LOS (Non‐Elective) 5.29 5.43 4.454 5.05 ↑% emergency admitted patients review byconsultant within 12 hours 95% 96% RTT non‐admitted in 18 weeks 98.7% 99.5 95% 90% ↑ LOS (Elective‐ excluding 0 LOS) 3.48 3.52 3.5 3.92 ↑Maternal Death Rate per 100000 ( rolling 1245 April 38 46 Aprilm) 32.09 31.09 May39 May ↑ RTT not delivered in all specialties 10 13 0 >20 ↓ LOS (Non‐ Elective‐excluding 0 LOS) 6.58 6.83 5.8 6.53 ↑% Day case rate ‐ All 87.74% 88.57% 80% 75% ↑Serious Untoward IncidentsCancerDTOC 3.90% 4.99% 3.50% 5.00% ↓Number 61 14 18 19 ↑ 2 Wk. % seen all urgent refs & ref for breast** 91.5% 95.70% 93% 88% ↓ admissions on day of surgery 79.1 86.42 85% 80% ↑% reported within 48Hours ‐ quarterly 29%30% ( Q1) 29% ↑ 2 Wk. GP RefTo 1st OP for susp cancer** 91.2% 96% 93% 88% ↓ % patients discharged between 6 am and 11 am 9.95% 9.96% 50% ↓MRSA BacteraemiaC Diff InfectionPatient Safety and QualityReducing hospital mortalityInfection Control21301 April 00May4 April 5MayPerformanceReferral to Treatment2 Wk GP Ref To 1st OP for breast symptoms** 94.5% 93.80% 93% 88% ↓31 Day 2nd Or Subs Treatment ‐ Surgery** 100.0% 100% 94% 89% =2 April 1May = 31 Day 2nd Or Subs Treatment ‐ Drug 100.0% 95.70% 98% 93%=Enhanced Recovery% patients with an ERP code entered onto the nationaldatabase 95% 95%5 April6 May ↓ 31 Day DTT for all cancers** 100.0% 98% 96% 91% ↑ % planned colorectal having GDFT 80% 80%MRSA Elective Screening 78% 78% 85% 77% = 62 Day RTT From Cancer Screening** 66.7% 90% 85% ↓ % emergency abdominal patients having GDFT 80% 80%MRSA Emergency Screening 69% 74% 85% 77% ↑ 62 Days ‐ treated from referral 80.7% 86% 80% ↓62 Day RTT From Hosp Specialist** 100.0% 85% 80% ↑OutpatientsComplaints62 Days Urgent RTT of all cancers** 80.4% 85% 80% ↑ FFU Ratio 2.61 2.27 2.16 2.2 ↑% complaints responded to in line with60% April 70% 54% Aprilagreement with patients 43% May63% May n/a 31 Day Subs Treatment ‐ Radiotherapy** 98.4% 94% 89% ↓ DNA First 10.45% 9.67% 9.37% 10.41% ↑number of complaints not yet responded toover 3 months old 10 28 25 in May 27 in May ↓ DNA Follow‐Up 10.52% 9.92% 9.33% 10.37% ↑A&E number extra clinics run in month 16 25 ↓79.50% AprilDementiaFour‐Hour Maximum Wait In A&E 83.90% 89.49% 95% 87.49% May% patients aged over 75% having a mental testscore 42%25% (Q1) 24%Percentage of patients referred to speciality team

RapidEnd-to-endSustainableEmergencyTransformationTrust Board update27 th June 2012

Headlines on progress▪ Overall Trust cluster performance continues to improve– Overall 4 hour breaches have been trending on a positive trajectory. Last week (18 th June – 25 thJune) the Trust achieved performance of 93.6%, the highest since October 2011. During the week of4 th June –10 th June the Trust achieved 91.9% against a trajectory of 88.3% and the previous week(29 th May – 3 rd June) 91.3% against a trajectory of 88.3%– Performance during the week of 11th June – 17th was poor (85.9%) with admissions and breachesincreasing significantly▪ Jubilee weekend performance demonstrated that the Trust can plan and execute. However it hasalso highlighted that planning needs to extend to the days following bank holiday weekends– Breaches spiked in the week after jubilee weekend and at the beginning of the following week– Preparation ensured high level of discharges before the jubilee weekend. However subsequentlydischarges were low and the number of complex patients in the hospital increased– Insufficient staffing in ED after the Jubilee weekend led to lack of senior decision making and tobreaches. RATing and senior ED leadership on site from Tues onward helped breach recovery▪ Initiatives are owned by trust teams, with routine monitoring and feedback– RATing has been extended to UCC and will be extended to KGH in August– Productivity improvements and workplace organisation is being implemented in UCC and majors– MAU continues to achieve consistent improved performance in 8am-5pm discharges and transfers– Pre-11 initiatives now owned by ward sponsors, providing daily feedback on ward performance– Weekend discharges now routinely monitored– Consultant and ward performance feedback dialogues now routine, with desire for more information

Performance – Trust Cluster Type 1,2,3 1% Patients treated in 4 hours, Target 95%April2012May2012May June June June28 th –3 rd 4 th –10 th 11 th –17 th 18 th –24 thWeek 5 Week 1 Week 2 Week 3QH 77.49% 85.71% 90.42% 88.74% 79.87% 93.38%KGH 92.92% 94.75% 92.51% 96.32% 94.57% 93.77%Trust 83.90% 89.49% 91.30% 91.94% 85.94% 93.55%1 This includes UCC KGH in KGH Cluster from 04/04/11 and UCC QH in QH Cluster 04/04/11 to 31/07/11; walk-in centres not includedSource: Performance Data team, B2 report 27/06/20122

A&E 4hr target performanceA&E 4hr target achievement (Whole Trust) 11009590858075706560555005.0319.0302.041 Type 1, 2, 3 breaches includedSource: BHRU Trust B2 Report; 1st Mar 2012 – 26 th June 2012Our performanceNational targetOur target16.04 30.04 14.05 28.05 11.06 25.06

A&E Black BreachesA&E Black Breaches (Whole Trust) 11816Number of black breaches151816Our performance14131210864287654321 12121133005Mar19Mar02Apr16Apr30Apr14May28May4June11June20June1 Black breaches from both sites are includedSource: Ambulance SUI list Master; 1st Mar 2012 – 5 th June 2012

Last week Queen’s saw its best overall breach performancesince October 2011….May AverageattendanceW/day: 427W/end: 326483447418399393375357AttendancesConversion rate,percent28 34 31 30 32 31 36May Averages:Discharge w/day: 146Admission w/day: 140Admission w/end: 116Discharge w/end: 104164155156150142136131 133130129121117113DischargesAdmissions713341122882444BreachesMon18/06Tue19/06Wed20/06Thu21/06Fri22/06Sat23/06Sun24/06Source: B2 data, all divisions5

…versus the week following Jubilee weekend whenperformance was poorAverage433attendance385W/day: 427 343 346351W/end: 326465416397329375411467465AttendancesConvention rate,percent35 30 30 34 33 30 35 40 36 32 36 30 29181AverageDischarge w/day: 146Admission w/day: 140Admission w/end: 116Discharge w/end: 1041511261041037912910311592139123146157158159119118 12071149146147111146135DischargesAdmissions115118138124129Breaches454050513441120Fri1/6Sat2/6Sun3/6Mon4/6Tue5/6Wed6/6Thu7/6Fri8/6Sat9/6Sun10/6Mon11/6Tue12/6Wed13/66

ED and MAU update• Achievements• Had an average of 17 breaches/day at the Queen’s site, the lowest since mid-April start of initiatives• MAU achieved consistent average throughput of 36 patients between 8 am-5 pm• Conducted an early diagnosis of KGH emergency pathway in ED and MAU• Started formulating a new bed management escalation plan• Ten week ED transformation plan agreed• Challenges• One Black breaches last week, ED is approaching this through the change oflayout in Ambulances RATing• We had a challenging KGH performance, with main reasons being quality ofsenior leadership, availability of beds and flow processes at different interface• Performance in both sites’ ED remain dependent on the quality of ED leadershipavailable• Priorities• Embed RATing through design and production of guidelines and training videos• Start improvement initiatives including RATing, 8 a.m Board round and Acutemedicine evening consultant cover• Coach new UCC lead to implement UCC flow initiatives agreedCoach Majors lead to implement Majors’ flow initiatives agreed

50454035302520151050The total number of discharges has increased since theintroduction of the MAU board roundPre-11, total and average weekly discharges from MAU unit, number of patients1715 16 1510 107 75 4 3 4 422 2 20 1 2Mon23/04Mon30/04All discharged (transferred to ward or home) from 8am-5pm11am: discharged by 11am, Cat B494748Weekly average for 5pm 4646454041383435 35 36 363230 3130312927 27 2822222223 23 23 23222220 20181616Tue08/059 9 9 9 986 6 6 7 7 7 65 5 564 4 5 4421Mon14/05Mon21/05Mon28/05Wed06/06Mon11/067565 4 522Mon18/063Mon25/06Source: Daily collection of data, Initiative started 23 rd April 2012 – 9 th May 2012; * Estimate

Breaches has been reduced by an average of 30/day sincestart of RATing500QH’s daily attendances and type 1 breaches in major/UCC,number of patientsAttendancesBreaches in main EDBreaches in UCCAverage400426421425 425425413414420412403405409 405 401389391 398 403401386393 389380 383384370374379 382380375362370360365366355 356358 358 3553633423493493443343293002001000RATing trial startedMon-Fri 9am-5pmWalk-in and Ambulance majors107108 109 11689 91 85 90 83 8880 81 8564616252424837Mon16/4Mon23/4Mon30/4Tue08/054636Mon14/05309122Mon28/051017564 64484538281911Mon21/0542Wed06/06111127 1279Mon11/069076522532208 3Mon18/06Mon25/06Source: validated internal ED data and Trust B2 report * Type 1 attendances for adults

No RATing is taking place at KGH, however reduction ofbreaches is evident300KGH’s daily attendances and type 1 breaches in major/UCC,number of patientsAttendancesBreaches in main EDBreaches in UCC255270200231211207 206196186 187180160234 232 232222 223226224226217221217 216211214209 20920620920320620120201202196199186 19019318818317717723022220718110003735 341819 16 17 141Mon16/4Mon23/4463438 3626 2328156 7 101227 5 8482Mon30/4Tue08/05Mon14/05Mon21/05Source: validated internal ED data and Trust B2 report * Type one attendances2234044Mon28/05201057Wed06/0664727Mon11/06114194 7Mon18/0664193 6Mon25/06

Medicine and care of the elderly update• Achievements• Ward sponsor reports and meetings under way• Increased total number of discharges, exceeding the number of admissions andcreating capacity on the wards for weekends• Held key 1 to 1 meetings for reducing the number of long-stay patients• Weekly performance feedback ongoing – increased attendance as part ofgovernance meeting• Challenges• Weekend discharges low and resulted in high number of breeches on Monday• Pre-11am reporting not systematic, still relying on manual processes• Simple observations reveal wards not embedding all practices• No agreement on how to achieve consistent consultant input into the wards• Priorities• Challenge established ways of working on wards• Establish rotation for ward sponsor observations so that they can work onembedding the components to pre-11am discharges• Kick-off long stay patient workstream and agree workplans

Last week we admitted 8 fewer patients thanwe discharged in medicine……Queens non-elective medical admissions and discharges,Number of patientsMedical admissionsMedical dischargesTotalNet80-4 -16 -8 -4 +9 -1 +14-860516759625640373522820Mon-18Tues-19Wed-20Thurs-21Fri-22Sat-23Sun-24360Source: Discharges by week by ward, Trust status summary admissions

.. versus the preceding week (11 th –17 th June) whenwe admitted 49 more patients than we dischargedQueens non-elective medical admissions and discharges,Number of patientsMedical admissionsMedical dischargesTotalNet800 -5 16 12 -1 7 2049605757505652404138620Mon-11Tues-12Wed-13Thurs-14Fri-15Sat-1624Sun-17337Source: BHRUT bed management team and information department

EXECUTIVE SUMMARYTITLE:Maternity Update – May 2012BOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) andDATE:The purpose of this report is to provide the TrustBoard with an update on the monthly performancefor maternity services.The key areas to note are:• In May the Trust went over the cap on sixoccasions however the units remainedclinically safe. Two women were divertedin the month.• Average of 78% of women were seen by amidwife in triage within 15 minutes and91% within 30 minutes.• 99% of women in May were seen by adoctor in the OAU.• Data capture in OAU out of hours hasfound to be calculated incorrectly this isbeing rectified.• 100% women received pethidine within 15minutes of the request and 91% womenreceived an epidural with 30 mins of therequest.• 2 SIs were reported in May.• 75% of the grade1 LSCS were performedwithin 30 mins from decision, at Queen’sand 100% at KGH. The Clinical Director isundertaking an audit of the records toascertain if the records have been gradedappropriately• The cap on the number of births has beenremoved from BHRUT with effect fromJune 2012.• The escalation process continues in linewith other maternity units and inconjunction with the PAN Londonescalation policy.• Weekly reporting to NELC has nowceased.• Monthly reporting will continue.• A draft BHRUT assurance framework hasbeen developed and under discussion withNELC.□ PBE ……………..….. □STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT……………………□ QUALITY & STRATEGY…………..………….....……□ CHARITABLE FUNDS………………………………...…□ TRUST BOARD……………………………….………….□ REMUNERATION………………………………….…...□ OTHER …………………………..…….(please specify)2. DECISION REQUIRED: CATEGORY:The Board are asked to note the content of the □ NATIONAL TARGET □ RMS

eport.□ CQC REGISTRATION □ HEALTH &SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROMCOMMISSIONERS□ CORPORATE OBJECTIVE……………………………....□ OTHER …………………….. (pleasespecify)AUTHOR/PRESENTER: W MatthewsPresenter: D WheelerDATE: 27 th June 20123. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:N/A4. DELIVERABLESMaternity Improvement plan.5. KEY PERFORMANCE INDICATORS91% of women seen within 30 minutes of arrival within Triage99% of women seen within an hour of referral to an obstetrician within the obstetric assessmentunit.100% of women received pethidine within standard.AGREED AT ______________________MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

Maternity Services Monthly Performance ReportTrust NameBarking, Havering & Redbridge University HospitalsNHS TrustReporting monthThis report covers the period:1 st May to 31 st May 2012Completed byMr Dele OlorunsholaClinical Director of Obstetrics, Gynaecology andSexual HealthReviewed byDeborah WheelerDirector of NursingNeill MoloneyDirector of Planning & PerformanceContact DetailsBarking, Havering & Redbridge University HospitalsNHS Trust1st Floor Green ZoneMaternity Services, Queens HospitalRom Valley Way, Romford, RM7 0AGTel: 01708 435 000 x 3894A monthly report will be provided to; monitor the progress made against the maternity servicesimprovement plan, provide assurance that the safety and quality of maternity services areimproving within BHRUT. It will summarise the themes and actions that have arisen from theweekly analysis of activity within the unit.Monthly maternity report May 2012 v1.1. DOPage 1 of 9Compiled by C Frisby 13.06.20121

1. IntroductionThe purpose of this report is to summarise the progress made In May 2012 against the maternityservice improvement plan and the KPIs agreed with the commissioning team within ONEL.2. Total Number of Births at BHRUT for May 2012KGHQueensElectiveLSCSEmergencyLSCSOtherTotalEmergencyLSCSElectiveLSCSOtherTotal5 7 154 166 112 45 464 6213. Weekly Activity (excluding elective LSCS)Weekly Delivery Activity KGH/QHTotal Deliveries18016014012010080604020005/09/201112/09/201119/09/201126/09/201103/10/201110/10/201117/10/201124/10/201131/10/201107/11/201114/11/201121/11/201128/11/201105/12/201112/12/201119/12/201126/12/201102/01/201209/01/201216/01/201223/01/201230/01/201206/02/201213/02/201220/02/201227/02/201205/03/201212/03/201219/03/201226/03/201202/04/201209/04/201216/04/201223/04/201230/04/201207/05/201214/05/201221/05/201228/05/2012Queens Deliveries(optimum 140)KGH DeliveriesWeek ending (optimum 49) DateOptimum Queens4. EscalationsAs part of the capacity management plan the escalation process has been reviewed. The status goesto ‘red’ when there are 15 deliveries or equivalent of labouring women at Queen’s and 5 at KGH.Site Red Amber Green EscalationsQH 17 31 31 2KGH 16 0 31 1Monthly maternity report May 2012 v1.1. DOPage 2 of 9Compiled by C Frisby 13.06.20122

4.1 CappingThe capping is currently set to 20 births for Queen’s Hospital and 7 births for King George Hospital(optimum delivery rate) 27 in total. This is an accrued total which is calculated from 6pm of day one to5:59pm of day two. These figures are calculated excluding elective caesarean sections.In May 2012 the Trust went over the cap on 6 occasions in total.DateNo of BirthstotalNo. abovecap01/05/2012 to 02/05/2012 29 203/05/2012 to 04/05/2012 29 204/05/2012 to 05/05/2012 28 111/05/2012 to 12/05/2012 28 122/05/2012 to 23/05/2012 28 128/05/2012 to 29/05/2012 29 2The maternity unit remained clinically safe on these six occasions4.2 DivertsThere were two diverts in May, one to Homerton Hospital and one to Basildon.5.0 TriageThe agreed standard is that 98% of women will be seen by a midwife within 15 minutes of arrival attriage. In May, overall 76% of women were seen within 15 minutes of arrival and 91% were seenwithin 30 minutes.Triage - % of Patients Seen within 15 Minutes of Arrival110100908070605040302010001/03/201206/03/201211/03/201216/03/201221/03/201226/03/201231/03/201205/04/201210/04/201215/04/201220/04/2012Number of Patients25/04/201230/04/201205/05/201210/05/201215/05/201220/05/201225/05/201230/05/2012Day% of patients Seen within 15 minutesMonthly maternity report May 2012 v1.1. DOPage 3 of 9Compiled by C Frisby 13.06.20123

Triage WaitingtimesNumber ofWomen% of TotalwomenUp to 15 minutes 888 76%15-30 minutes 169 15%31-60 minutes 85 7%61 minutes + 21 2%6.0 OAU ActivityIt has been agreed that 98% of women should be seen by an obstetrician, where this is deemedclinically appropriate, within 1 hour of their arrival to the Obstetric Assessment Unit (OAU) in hours.The Trust average for May 2012 was 99%.% of Patients seen within 1 hour on OAU by an Obstetrician110100908070605040302010001/03/201206/03/201211/03/201216/03/201221/03/201226/03/201231/03/2012% of patients seen05/04/201210/04/201215/04/201220/04/201225/04/201230/04/201205/05/201210/05/201215/05/201220/05/201225/05/201230/05/2012% of Patients seen within 1HourDateMonthly maternity report May 2012 v1.1. DOPage 4 of 9Compiled by C Frisby 13.06.20124

7.0 Out of Hours OAU98% of patients attending the Out of Hours OAU should be seen by an Obstetrician, where itis deemed clinically appropriate, within one hour of their arrival to this unit.The Out of Hours OAU is currently under review by Clinical Fellows and department leadsowing to consistently higher waiting times than it’s counterparts. This OAU is governed by thesame standard as the main OAU, however, the data collection for this area reflects a twentyfourhour period rather than 8pm to 8am when the main OAU is closed. Until the data isrefreshed a % is not available. Several changes are being piloted in this area to achieveshorter waiting times for clients. Changes have already taken place in OAU in hours whichhas improved waiting times. Once the planning phase is complete for out of hours OAU, themost appropriate pathway will be implemented.% of Patients seen within 1 Hour of Referral12010080604020001/03/201208/03/201215/03/201222/03/201229/03/201205/04/201212/04/201219/04/201226/04/201203/05/201210/05/201217/05/201224/05/201231/05/2012% of Patients seen within 1Hour of Referral Target8.0 Analgesia AuditSome additional information is at the base of this report, titled ‘Additional Information’ andcontains some references to analgesia administrations.On a weekly basis, as part of visible leadership, an audit is undertaken to monitor theamount of time women are waiting for their analgesia. The agreed standard is:• If a woman requests pethidine she should receive this within 15 minutes of the request.The Trust achieved 100% against this standard in May 2012 of those cases audited.• If a woman requests an epidural she should receive this within 30 minutes of therequest. The Trust achieved 91% against this standard for May 2012 of those casesaudited.Monthly maternity report May 2012 v1.1. DOPage 5 of 9Compiled by C Frisby 13.06.20125

9. Serious Untoward Incidents ReportedSUI’s are reported on a weekly basis, in retrospect, therefore the information below issummarised weekly but may include overlapping information from post and priormonth.ReportNo of Date of Details ofWeek Commencing Incidents Incident Incident7 th May 014 th May 021 st May 028 th May 2 06/05/2012 Unexpectedadmission to theneonatal intensivecare unit – infant>37 completedweeks gestationthat have a suddenor unexpectedcollapse followingdelivery.28 th May 16/05/2012 Unexpectedadmission to theneonatal intensivecare unit – infant>37 completedweeks gestationthat have a suddenor unexpectedcollapse followingdelivery.Site ofIncidentKing GeorgeHospitalKing GeorgeHospitalMonthly maternity report May 2012 v1.1. DOPage 6 of 9Compiled by C Frisby 13.06.20126

Caesarean Deliveries including Elective ActivitySome additional information is at the base of this report, titled ‘Additional Information’and contains some references to anaesthetics.When a decision is made to perform an emergency LSCS, the timing for this is dictated by theacuity of each case which is graded from 1-4.Grade 1Caesarean section is considered as urgent and has an immediate threat to the life of the womanand foetus. To be performed within 30 minutes.At Queen’s hospital 79% of the audited grade 1 C/S were performed within 30 minutes.At KGH, the average based on the notes audited was 100%.Grade 2Caesarean section is considered urgent with maternal or foetal compromise which is notimmediately life threatening. To be performed within 60 minutesAt Queen’s hospital of 78% the audited grade 2 emergency C/S were performed within 60 minutes.At KGH the average was for the notes audited 100%Grade 3 & 4Caesarean section is an emergency with no maternal or foetal compromise, but requires earlydelivery. To be performed at a time to suit the mother and the department.At Queen’s hospital, 100% of the audited grade 3/4 emergency C/S were performed within time.At KGH hospital 100% of the audited grade 3/4 emergency C/S were performed within time.Top 3 reasons for delays for all grades of LSCS like the previous month were:1. Clinicians required elsewhere due to busy Labour Ward and theatres2. Theatre capacity3. Delayed consent (by mother)Monthly maternity report May 2012 v1.1. DOPage 7 of 9Compiled by C Frisby 13.06.20127

Quarterly workforce report for May 2012RecruitmentCurrently there are 16 midwives in the recruitment process that are due to qualify in Septemberthat have been offered posts at BHRUT.6 midwives commenced employment in May and are currently on their induction programme2 nurses have been appointed and remain within the recruitment process.With have further interviews in June for the remaining MCA vacanciesWe interviewed for a Midwifery Placement Facilitator and successfully appointed, however shedeclined to take the post. This post was re-advertised and has already been shortlistedNew starters in May6 midwivesAdvertsWe are going out to advert for an 8a patient satisfaction/ lead midwife in BereavementThere is 2.74WTE vacancy in band 7; we are currently waiting for the review of the JD with theA4C panelLeavers9 midwives left the trust, some of which have returned to their own country and others who havegone to work in a surrounding low risk unit. Discussions took place with these midwives regardingBHRUT co-located birthing centre opening in the autumn however the midwives could not beretainedHow are we maintaining the 1:29 midwife to birth ratioWithin the wards the staffing is done on a monthly basis and temporary staff are booked for thevacant shifts. Every day this is reviewed and amended.% of bank and agencyThe % of bank and agency currently used within the month of May is:Midwife• 28.47 WTE = 8.9 % bank- this is an increase of 1%, due the increased number of midwivesthat left the trust in May.• 7.14 WTE = 2% agency- this is a reduction of 0.9 % on last monthNurses• 0.78WTE = 2% agency• 2.8 WTE = 10% bankMaternity Support Workers• 16.89 WTE = 22% bankMonthly maternity report May 2012 v1.1. DOPage 8 of 9Compiled by C Frisby 13.06.20128

Medical recruitmentWe have 2 Consultant vacancies, one left in June and one in March and we have 2 full timelocums covering these posts.Balanced ScorecardThe balanced scorecard for May 2012 is attached as Appendix 1. Please note that the scorecard isunder review and not all information was available at the time of submission of this report.Additional InformationDr R Pilling, has as part of his Clinical Fellow duties, has undertaken an audit into the impact of asecond anaesthetist being available out of hours. His conclusions are below.Conclusions from audit undertaken to ascertain the impact of a second anaesthetist beingavailable out of hours: Clearly extremely busy maternity unit Unpredictable nature of obstetric shifts 40% of shifts well above the average number of anaesthetic interventions required. Increased opening of 2nd theatre since the increased anaesthetic presence Several occasions of a few minutes overlap time Are the indications for a 2nd theatre becoming more relaxed? Or…are we now more compliant with target times for emergency LSCS? Sharing of the workload has definately eased the pressure on the labour ward anaesthetist What evidence do we have of an improvement in patient care?Conclusions from audit in relation to epidural waiting times…. Clear benefit from 2nd anaesthetist Improved epidural waiting times More time available to take an active role on maternity HDU Improved working conditions for duty anaesthetistRecommendations from same audit… Definate need for 2nd anaesthetist on labour ward Needs a separate audit of the indications for the use of 2 theatres Better epidural data(should improve with the imminent introduction of computerised data collection) Reaudit to ensure maintainance of high standardsMonthly maternity report May 2012 v1.1. DOPage 9 of 9Compiled by C Frisby 13.06.20129

EXECUTIVE SUMMARYTITLE:BOARD/GROUP/COMMITTEE:Learning Disability Progress Report Trust Board - 4 th July 20121. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) &DATEThe report provides the Trust Board□ PBE ……………..…..with an update on the delivery of theLD agenda, particularly in relation to: □ STRATEGY……….….…….• Health for All (2008)• Six Lives report (2010)• Death by Indifference (2007)• Learning disabilities StandardAssessment Framework (2012)(SAF)The report also contains an LD actionplan for 2012/13, which has beendiscussed and approved at the Trust’sLD, Safeguarding Adults and Quality &Safety Committees.Actions identified in plan have been setin line with national guidance and localidentified need.As part of the Learning Disabilities week(18 th - 22 nd June 2012), the Trust signedup to the Mencap Charter.□ FINANCE ……..………□ AUDIT ……………………□ QUALITY & STRATEGY …………..……□ CHARITABLE FUNDS ……………………...…□ TRUST BOARD…………………….………….□ REMUNERATION……………………………...□ OTHER:BHRUT Safeguarding Adults CommitteeBHRUT Learning Disabilities CommitteeBHRUT Quality & Safety Committee - 12 thJune 20122. DECISION REQUIRED: CATEGORY:For information and noting.□ NATIONAL TARGET□ CNST* CQC REGISTRATION (Outcome 7)□ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE……………………………....□ OTHER …………………….. (please specify)AUTHOR:Gary Etheridge, Deputy Director of NursingPRESENTER:Deborah Wheeler, Director of NursingDATE: July 20121

3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:N/A4. DELIVERABLESEnsure that the standards set within the LD Self Assessment Framework are achieved.Maintain the multidisciplinary collaboration within the local economy.Ensure that the relevant recommendations set in both Healths for All and Six Lives areimplemented within the organisation.5. KEY PERFORMANCE INDICATORSCQC Outcome 4 - Care and welfare of people using the serviceCQC Outcome 6 - Co-operate with other providesCQC Outcome 7 - Safeguarding people from abuseAGREED AT ___________MEETINGORREFERRED TO: _________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

LEARNING DISABILITIES PROGRESS REPORT - JULY 20121. IntroductionEquality in accessing healthcare is the central principle in the delivery of care within the NHS. The‘Death by Indifference’ (2007) report from Mencap highlighted significant evidence that equality forpatients with a learning disability who use NHS services was sadly lacking and identified patientstories of six deaths whilst in NHS care. In response to this report Sir Jonathan Michael wascommissioned to review the care delivered to these six patients. Following on from this inquiry, tenrecommendations were identified and published in the report ‘Healthcare for All’ (2008).The Ombudsmen Report ‘Six Lives’ (2009) supported the recommendations from Healthcare forAll. All of the recommendations were accepted by Government and were set out in Valuing PeopleNow: Delivery Plan in January 2009.The publication of the Death by Indifference report prompted a number of families to contactMencap, and they continued to do so in the weeks, months and years that followed. It is thesecases - a total of 74 to date that form the basis of the article published in the Guardian on 3 rdJanuary 2012.A further report was produced by Mencap (2012), ‘Death by Indifference: 74 deaths and counting.A progress report 5 years on’, which considers the steps that have been taken, the progress madeas a consequence and what they believe still remains to be done for LD patients. The report paysparticular attention to deaths that have been reported to Mencap between 2009 and 2011. Thesecases illustrate Mencap’s serious ongoing concerns that not enough progress has yet been madein addressing the health inequalities experienced by people with a learning disability.Joint working between the local learning disability population, community learning disability teamsand the Trust’s safeguarding team is constantly improving, with strong links now being formedacross all groups’ services and departments in the community and within BHRUT.2. Local ActionThe Trust has made significant progress in implementing a range of local measures to ensure thatpeople with a learning disability receive services/care that takes account of their healthcare needsand are proactive in helping them access the healthcare they need.A detailed learning disabilities action plan is regularly updated and presented at the Trust’sSafeguarding Adults and Learning Disabilities Committees.LD actions achieved to date are identified in Appendix I.There are still areas that require additional development during 2012/13 and these are contained inAppendix II.3. Mencap Charter LaunchAs part of the learning disabilities week (18 th June to 22 nd June 2012) stands were set up in themain entrances of King George’s and Queens Hospitals to showcase the current work that hasbeen progressed within the Trust to improve access to people with a learning disability, and toraise awareness of their needs when they come into hospital.3

Key stakeholders, including service users from the charity “People First” as well as staff from thelocal community learning disability teams of Havering, Barking & Dagenham, Waltham Forrest andRedbridge, supported by BHRUT, were involved in hosting the stands.To emphasise the commitment to real partnership working the Trust signed up to the MencapCharter at a launch event on the 22 nd June 2012.The nine key charter pledges that the Trust has signed up to are outlined below:4. RecommendationsMembers of the Trust Board are asked to note the content of this report.Gary EtheridgeDeputy Director of NursingJuly 20124

Appendix IHEALTHCARE FOR ALL - INITIATIVES ACHIEVEDRECOMMENDATIONRecommendation 1Those with responsibility for the provision and regulation of undergraduateand postgraduate clinical training must ensure that curricula includemandatory training in Learning disabilities. It should be competence-basedand involve people with learning disabilities and their carers in providingtraining.Recommendation 2All healthcare organisations should ensure they collect the data andinformation necessary to allow people with a learning disability to beidentified by the health service and their pathways of care tracked.Recommendation 3Family and other carers should be involved as a matter of course aspartners in provision of treatment and care, unless good reason is given,and Trust Boards should ensure that reasonable adjustments are made toenable them to do this effectively. This will include the provision ofinformation, but may also involve practical support and service coordination.ACHIEVEMENTS• As part of the 90 minute Trust’s statutory and mandatory safeguarding adults training a 30minute session on the care and management of patients with learning disabilities is included.• People with learning disabilities and their carers contribute to teaching on Trust wide in-housestudy days, which has given staff the tools to understand the complexity of the patient’sneeds.• Each ward/department has a safeguarding adult’s link nurse.• The Trust’s PAS system contains a learning disability code. This enables patients with a LD tobe flagged. This information is shared internally/externally.• The Trust’s LD sub-group has LD representation, to advice on the needs of people with LD.This includes peer reviewing any information to ensure that it meets the needs of the patientwith learning disabilities.• Trust Internet site contains patient information leaflets designed for and giving appropriateinformation for people with LD.• There is a signposting reception area to allow patients and their relatives to seek advice onwhere a department or ward is at the Queen’s site entrance. A member of staff in thereception will walk with the patient to ensure that they get to their destination within thehospital setting.5

RECOMMENDATIONRecommendation 4Primary Care Trusts should identify and assess the needs of people withLearning disabilities and their carers as part of their Joint Strategic NeedsAssessment. They should consult with the Local Strategic Partnership, theLearning Disability Partnership Boards and relevant voluntary user-ledLearning Disability organisations and use the information to inform thedevelopment of Local Area Agreements.Recommendation 5To raise awareness in the health service of the risk of premature avoidabledeath, and to promote sustainable good practice in local assessment,management and evaluation of services, the Department of Health shouldestablish a learning disabilities Public Health Observatory.Recommendation 6The Department of Health should immediately amend Core Standards forBetter Health, to include an explicit reference to the requirement to make‘reasonable adjustments’ to the provision and delivery of services forvulnerable groups, in accordance with the disability equality legislation. Theframework that is planned to replace these core standards in 2010 shouldalso include a specific reference to this requirement.Recommendation 7Inspectors and regulators of the health service should develop and extendtheir monitoring of the standard of general health services provided forpeople with Learning disabilities, in both the hospital sector and in thecommunity where primary care providers are located. The aim is to supportappropriate, reasonable adjustments to general health services for adultsand children with learning disabilities and their families to ensurecompliance with and enforcement of all aspects of the DisabilityDiscrimination Act.• N/A for acute Trust.• N/A for acute Trust.ACHIEVEMENTS• The Trust participated and completed the Learning Disability Standard AssessmentFramework (SAF) in 2011.• The Trust is compliant with relevant recommendations in Outcome 4, 6 & 7.• There are commissioning representatives on the LD Committee. Completed SAF is sharedwith NHS London who analyses and identifies gaps in service provision in relation to LDpatients receiving care within the Trust.6

RECOMMENDATIONRecommendation 8The Department of Health should direct Primary Care Trusts (PCTs) tosecure general health services that make ‘reasonable adjustments’ forpeople with Learning disabilities through a Directed Enhanced Service. Inparticular, the Department should direct PCTs to commission enhancedprimary care services which include regular health checks provided by GPpractices and improve data, communication and cross boundary partnershipworking. This should include liaison staff who work with primary careservices to improve the overall quality of health care for people with learningdisabilities across the spectrum of care.Recommendation 9Section 242 of the National Health Service Act 2006 requires NHS bodies toinvolve and consult patients and the public in the planning and developmentof services, and in decision affecting the operation of services. All TrustBoards should ensure that the views and interests of people with learningdisabilities and their carers are included.Recommendation 10All Trust Boards should demonstrate in routine public reports that they haveeffective systems in place to deliver effective, ‘reasonably adjusted’ healthservices for those people who happen to have a Learning Disability. This‘adjustment’ should include arrangements to provide advocacy for all thosewho need it and arrangements to secure effective representation on PALSfrom all client groups including people with learning disabilities.• N/A for acute care.ACHIEVEMENTS• There is LD representation at the LD Sub-Committee. All workstreams in relation to the LDagenda are discussed at this group. Further discussion will take place at the Trust’s LDCommittee.• Safeguarding issues/actions are included in a bi-monthly safeguarding adult’s progress report.• PALS have a LD lead for the team who is made aware of all PALS issues relating to LDpatients. This information is also submitted to the Deputy Director of Nursing.• Information relating to PALS issues is submitted to the Safeguarding Lead for inclusion in herbi-monthly report.7

Appendix IICARE OF PATIENTS WITH A LEARNING DISABILITYACTION PLAN - 2012/13RECOMMENDATION LEAD TIMESCALE ACTIONS PROGRESS EVIDENCE RAG1.Creation of Learning Disability(LD) champions to ensure thatthe workforce are givenappropriate support and trainingto equip them to deliver the LDagenda.2.Special arrangements to be putin place to ensure reasonableadjustments are included in thejourney of a patient with LD.3.The development / review of atransition protocol for patientswith LD from children servicesto either adult services or anyother specialist service.NamedNurseNamedNurseNamedNurse &MatronsNamedNurseNamedNursesNamedNurseApril 2012April 2012March 2013March 2013September2012December2012LD champions to be agreed and roleprofile to be developed.Develop and implement LD championtraining as part of the Safeguarding Linkworker programme. Learning disabilityleads in the community to participate in thetraining day.Clinical leads to review all current patientpathways and bundles to ensure thatreasonable adjustments have beenconsidered for LD patients and patientsat risk including timings of appointments,facilities and suitable support.Equality impact assessment to becompleted when implementing andreviewing these pathways and carebundles.Protocols to be reviewed to see whethera stand alone eclectic policy would beappropriate.Protocol to be signed off by appropriateCommittee as per the Trusts policy onpolicies and protocols.Existing safeguarding adultchampions in place. Role to beextended to incorporate LD.Training day held on the 26 thApril 2012.Agenda8

RECOMMENDATION LEAD TIMESCALE ACTIONS PROGRESS EVIDENCE RAG4.Ensure carer engagement ismaintained and that supportarrangements are shared andavailable at all times.5.PALS and complaints servicesmakes reasonable adjustmentsto ensure that patients andcarers with LD have a voice areand are aware of the servicesavailable.NamedNurseNamedNurseDeputyDirector ofNursingPALS &ComplaintsMgrsNamedNurseDeputyDirector ofNursingPALSManagerDeputyDirector ofNursingPALSManagerDeputyDirector ofNursingPALS MgrMay 2012& Nov 2012July 2012August 2012Bi-monthlyOctober 2012Bi-monthlyMay 2012LD patient surveys to be conducted twiceyearly.LD representation to be included on LDsub-committee.May 2012 Survey currently beingundertaken. Results will beavailable early June 2012.A LD sub-committee has LDrepresentation, to advice on theneeds of people with Learningdisabilities. This includes peerreviewing any information toensure that it meets the needs ofthe patient with LD.Complaints & PALS information to bemade available in easy read versions. .Bi-monthly reports to be produced oncomplaints & PALS issues raised inrelation to adults at risk.PALS to be advised of all in-patientadmissions of patients with LD and tomake pro-active contact with patient andfamily to introduce service.PALS information relating to LD patientexperience will be reported inSafeguarding Adult Committee reports.PALS staff to provide signposting to LSpatients and family members toadvocacy and support organisations.Bi-monthly reports presented atthe Quality & Safety Committee.In place.MinutesMinutesReports9

RECOMMENDATION LEAD TIMESCALE ACTIONS PROGRESS EVIDENCE RAG6.The Trust should align itscomplaints procedures withother partner agencies.7.Whilst the patient is under thecare of the Trust the needs ofthe patient with learningdisabilities are assessedcorrectly in order to reduce therisk of diagnostic oversight.(CQC Outcome 4).8.Trust needs to be assured that itis compliant with the coreaspects of the LD SAF.9.The Trust must be assured that20% of the workforce aretrained in the care andmanagement of patientsdiagnosed with Autism. (LDSAF requirement).DeputyDirector ofNursingAssistantDirector ofNursing &NamedNurseNamedNurse &externalpartnersNamedNurse &externalpartnersNamedNurseNamedNurseDeputyDirector ofNursingNamedNurseDeputyDirector ofNursingNamedJuly 2012Meeting to be arranged to identify if thisprocess is in place and next steps.August 2012 Development and review of nursingdocumentation to take into account LDneeds. LD sub-committee members to beinvolved in process.October 2012March 2013June 2012September2012September2012March 2013Trust health record for a patient with LDto be devised.Training to be coordinated to ensure staffknow the process of acquiring acompleted health passport or completethe Trust LD learning passport oncedevised.Complete Annual LD Self AssessmentFramework.Following SAF assessment, identifiedgaps to be included in LD action plan.Outcome of the review of the LD SAF tobe shared with the LD Committee andQuality & Safety Committee.Trust to liaise with the borough educationteams to ascertain local economyapproach to achieving this target.March 2013 Investigate other forms of training i.e. e-learning as a way of achieving targetaudience.Trust health record for a patientwith LD currently is currentlybeing devised with theassistance of the external LDlead nurses.Trust currently waiting for SAFdocument.10

RECOMMENDATION LEAD TIMESCALE ACTIONS PROGRESS EVIDENCE RAG10.Review and raise awarenesswithin the Trust of the risk ofpremature death and promotesustained good practice in theassessment, decision makingand implementation of care forLD patients who are at risk oflife threatening conditions andend of life provision (Death byIndifference 2007).11.Implementation of the MencapCharter.12.Review safeguarding adult’sintranet/internet site.NurseDeputyDirector ofNursingNamedNurseMarch 2013Compliance to be reported quarterly atLD Committee.Named Dr July 2012 Review DNR and End of Life Policy.Named July 2012NurseNamedNurseDeputyDirector ofNursingNamedNurseEnsure that staff are aware of the MentalCapacity Act 2005 and Deprivation ofLiberties process in relation to the LDpatient.July 2012 Review the Trusts Mental Capacity,Restraint and Deprivation of Libertiesprotocol to ensure the LD patient’s needsare covered within them.July 2012Implementation of Charter within agreedtimeframe.June 2012 Safeguarding site to be reviewed.Designated site for LD to be established.Gary EtheridgeDeputy Director of NursingProduced in May 2012Reviewed in June 201211

EXECUTIVE SUMMARYTITLE:Maternity Update – May 2012BOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) andDATE:The purpose of this report is to provide the TrustBoard with an update on the monthly performancefor maternity services.The key areas to note are:• In May the Trust went over the cap on sixoccasions however the units remainedclinically safe. Two women were divertedin the month.• Average of 78% of women were seen by amidwife in triage within 15 minutes and91% within 30 minutes.• 99% of women in May were seen by adoctor in the OAU.• Data capture in OAU out of hours hasfound to be calculated incorrectly this isbeing rectified.• 100% women received pethidine within 15minutes of the request and 91% womenreceived an epidural with 30 mins of therequest.• 2 SIs were reported in May.• 75% of the grade1 LSCS were performedwithin 30 mins from decision, at Queen’sand 100% at KGH. The Clinical Director isundertaking an audit of the records toascertain if the records have been gradedappropriately• The cap on the number of births has beenremoved from BHRUT with effect fromJune 2012.• The escalation process continues in linewith other maternity units and inconjunction with the PAN Londonescalation policy.• Weekly reporting to NELC has nowceased.• Monthly reporting will continue.• A draft BHRUT assurance framework hasbeen developed and under discussion withNELC.□ PBE ……………..….. □STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT……………………□ QUALITY & STRATEGY…………..………….....……□ CHARITABLE FUNDS………………………………...…□ TRUST BOARD……………………………….………….□ REMUNERATION………………………………….…...□ OTHER …………………………..…….(please specify)2. DECISION REQUIRED: CATEGORY:The Board are asked to note the content of the □ NATIONAL TARGET □ RMS

eport.□ CQC REGISTRATION □ HEALTH &SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROMCOMMISSIONERS□ CORPORATE OBJECTIVE……………………………....□ OTHER …………………….. (pleasespecify)AUTHOR/PRESENTER: W MatthewsPresenter: D WheelerDATE: 27 th June 20123. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:N/A4. DELIVERABLESMaternity Improvement plan.5. KEY PERFORMANCE INDICATORS91% of women seen within 30 minutes of arrival within Triage99% of women seen within an hour of referral to an obstetrician within the obstetric assessmentunit.100% of women received pethidine within standard.AGREED AT ______________________MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

Maternity Services Monthly Performance ReportTrust NameBarking, Havering & Redbridge University HospitalsNHS TrustReporting monthThis report covers the period:1 st May to 31 st May 2012Completed byMr Dele OlorunsholaClinical Director of Obstetrics, Gynaecology andSexual HealthReviewed byDeborah WheelerDirector of NursingNeill MoloneyDirector of Planning & PerformanceContact DetailsBarking, Havering & Redbridge University HospitalsNHS Trust1st Floor Green ZoneMaternity Services, Queens HospitalRom Valley Way, Romford, RM7 0AGTel: 01708 435 000 x 3894A monthly report will be provided to; monitor the progress made against the maternity servicesimprovement plan, provide assurance that the safety and quality of maternity services areimproving within BHRUT. It will summarise the themes and actions that have arisen from theweekly analysis of activity within the unit.Monthly maternity report May 2012 v1.1. DOPage 1 of 9Compiled by C Frisby 13.06.20121

1. IntroductionThe purpose of this report is to summarise the progress made In May 2012 against the maternityservice improvement plan and the KPIs agreed with the commissioning team within ONEL.2. Total Number of Births at BHRUT for May 2012KGHQueensElectiveLSCSEmergencyLSCSOtherTotalEmergencyLSCSElectiveLSCSOtherTotal5 7 154 166 112 45 464 6213. Weekly Activity (excluding elective LSCS)Weekly Delivery Activity KGH/QHTotal Deliveries18016014012010080604020005/09/201112/09/201119/09/201126/09/201103/10/201110/10/201117/10/201124/10/201131/10/201107/11/201114/11/201121/11/201128/11/201105/12/201112/12/201119/12/201126/12/201102/01/201209/01/201216/01/201223/01/201230/01/201206/02/201213/02/201220/02/201227/02/201205/03/201212/03/201219/03/201226/03/201202/04/201209/04/201216/04/201223/04/201230/04/201207/05/201214/05/201221/05/201228/05/2012Queens Deliveries(optimum 140)KGH DeliveriesWeek ending (optimum 49) DateOptimum Queens4. EscalationsAs part of the capacity management plan the escalation process has been reviewed. The status goesto ‘red’ when there are 15 deliveries or equivalent of labouring women at Queen’s and 5 at KGH.Site Red Amber Green EscalationsQH 17 31 31 2KGH 16 0 31 1Monthly maternity report May 2012 v1.1. DOPage 2 of 9Compiled by C Frisby 13.06.20122

4.1 CappingThe capping is currently set to 20 births for Queen’s Hospital and 7 births for King George Hospital(optimum delivery rate) 27 in total. This is an accrued total which is calculated from 6pm of day one to5:59pm of day two. These figures are calculated excluding elective caesarean sections.In May 2012 the Trust went over the cap on 6 occasions in total.DateNo of BirthstotalNo. abovecap01/05/2012 to 02/05/2012 29 203/05/2012 to 04/05/2012 29 204/05/2012 to 05/05/2012 28 111/05/2012 to 12/05/2012 28 122/05/2012 to 23/05/2012 28 128/05/2012 to 29/05/2012 29 2The maternity unit remained clinically safe on these six occasions4.2 DivertsThere were two diverts in May, one to Homerton Hospital and one to Basildon.5.0 TriageThe agreed standard is that 98% of women will be seen by a midwife within 15 minutes of arrival attriage. In May, overall 76% of women were seen within 15 minutes of arrival and 91% were seenwithin 30 minutes.Triage - % of Patients Seen within 15 Minutes of Arrival110100908070605040302010001/03/201206/03/201211/03/201216/03/201221/03/201226/03/201231/03/201205/04/201210/04/201215/04/201220/04/2012Number of Patients25/04/201230/04/201205/05/201210/05/201215/05/201220/05/201225/05/201230/05/2012Day% of patients Seen within 15 minutesMonthly maternity report May 2012 v1.1. DOPage 3 of 9Compiled by C Frisby 13.06.20123

Triage WaitingtimesNumber ofWomen% of TotalwomenUp to 15 minutes 888 76%15-30 minutes 169 15%31-60 minutes 85 7%61 minutes + 21 2%6.0 OAU ActivityIt has been agreed that 98% of women should be seen by an obstetrician, where this is deemedclinically appropriate, within 1 hour of their arrival to the Obstetric Assessment Unit (OAU) in hours.The Trust average for May 2012 was 99%.% of Patients seen within 1 hour on OAU by an Obstetrician110100908070605040302010001/03/201206/03/201211/03/201216/03/201221/03/201226/03/201231/03/2012% of patients seen05/04/201210/04/201215/04/201220/04/201225/04/201230/04/201205/05/201210/05/201215/05/201220/05/201225/05/201230/05/2012% of Patients seen within 1HourDateMonthly maternity report May 2012 v1.1. DOPage 4 of 9Compiled by C Frisby 13.06.20124

7.0 Out of Hours OAU98% of patients attending the Out of Hours OAU should be seen by an Obstetrician, where itis deemed clinically appropriate, within one hour of their arrival to this unit.The Out of Hours OAU is currently under review by Clinical Fellows and department leadsowing to consistently higher waiting times than it’s counterparts. This OAU is governed by thesame standard as the main OAU, however, the data collection for this area reflects a twentyfourhour period rather than 8pm to 8am when the main OAU is closed. Until the data isrefreshed a % is not available. Several changes are being piloted in this area to achieveshorter waiting times for clients. Changes have already taken place in OAU in hours whichhas improved waiting times. Once the planning phase is complete for out of hours OAU, themost appropriate pathway will be implemented.% of Patients seen within 1 Hour of Referral12010080604020001/03/201208/03/201215/03/201222/03/201229/03/201205/04/201212/04/201219/04/201226/04/201203/05/201210/05/201217/05/201224/05/201231/05/2012% of Patients seen within 1Hour of Referral Target8.0 Analgesia AuditSome additional information is at the base of this report, titled ‘Additional Information’ andcontains some references to analgesia administrations.On a weekly basis, as part of visible leadership, an audit is undertaken to monitor theamount of time women are waiting for their analgesia. The agreed standard is:• If a woman requests pethidine she should receive this within 15 minutes of the request.The Trust achieved 100% against this standard in May 2012 of those cases audited.• If a woman requests an epidural she should receive this within 30 minutes of therequest. The Trust achieved 91% against this standard for May 2012 of those casesaudited.Monthly maternity report May 2012 v1.1. DOPage 5 of 9Compiled by C Frisby 13.06.20125

9. Serious Untoward Incidents ReportedSUI’s are reported on a weekly basis, in retrospect, therefore the information below issummarised weekly but may include overlapping information from post and priormonth.ReportNo of Date of Details ofWeek Commencing Incidents Incident Incident7 th May 014 th May 021 st May 028 th May 2 06/05/2012 Unexpectedadmission to theneonatal intensivecare unit – infant>37 completedweeks gestationthat have a suddenor unexpectedcollapse followingdelivery.28 th May 16/05/2012 Unexpectedadmission to theneonatal intensivecare unit – infant>37 completedweeks gestationthat have a suddenor unexpectedcollapse followingdelivery.Site ofIncidentKing GeorgeHospitalKing GeorgeHospitalMonthly maternity report May 2012 v1.1. DOPage 6 of 9Compiled by C Frisby 13.06.20126

Caesarean Deliveries including Elective ActivitySome additional information is at the base of this report, titled ‘Additional Information’and contains some references to anaesthetics.When a decision is made to perform an emergency LSCS, the timing for this is dictated by theacuity of each case which is graded from 1-4.Grade 1Caesarean section is considered as urgent and has an immediate threat to the life of the womanand foetus. To be performed within 30 minutes.At Queen’s hospital 79% of the audited grade 1 C/S were performed within 30 minutes.At KGH, the average based on the notes audited was 100%.Grade 2Caesarean section is considered urgent with maternal or foetal compromise which is notimmediately life threatening. To be performed within 60 minutesAt Queen’s hospital of 78% the audited grade 2 emergency C/S were performed within 60 minutes.At KGH the average was for the notes audited 100%Grade 3 & 4Caesarean section is an emergency with no maternal or foetal compromise, but requires earlydelivery. To be performed at a time to suit the mother and the department.At Queen’s hospital, 100% of the audited grade 3/4 emergency C/S were performed within time.At KGH hospital 100% of the audited grade 3/4 emergency C/S were performed within time.Top 3 reasons for delays for all grades of LSCS like the previous month were:1. Clinicians required elsewhere due to busy Labour Ward and theatres2. Theatre capacity3. Delayed consent (by mother)Monthly maternity report May 2012 v1.1. DOPage 7 of 9Compiled by C Frisby 13.06.20127

Quarterly workforce report for May 2012RecruitmentCurrently there are 16 midwives in the recruitment process that are due to qualify in Septemberthat have been offered posts at BHRUT.6 midwives commenced employment in May and are currently on their induction programme2 nurses have been appointed and remain within the recruitment process.With have further interviews in June for the remaining MCA vacanciesWe interviewed for a Midwifery Placement Facilitator and successfully appointed, however shedeclined to take the post. This post was re-advertised and has already been shortlistedNew starters in May6 midwivesAdvertsWe are going out to advert for an 8a patient satisfaction/ lead midwife in BereavementThere is 2.74WTE vacancy in band 7; we are currently waiting for the review of the JD with theA4C panelLeavers9 midwives left the trust, some of which have returned to their own country and others who havegone to work in a surrounding low risk unit. Discussions took place with these midwives regardingBHRUT co-located birthing centre opening in the autumn however the midwives could not beretainedHow are we maintaining the 1:29 midwife to birth ratioWithin the wards the staffing is done on a monthly basis and temporary staff are booked for thevacant shifts. Every day this is reviewed and amended.% of bank and agencyThe % of bank and agency currently used within the month of May is:Midwife• 28.47 WTE = 8.9 % bank- this is an increase of 1%, due the increased number of midwivesthat left the trust in May.• 7.14 WTE = 2% agency- this is a reduction of 0.9 % on last monthNurses• 0.78WTE = 2% agency• 2.8 WTE = 10% bankMaternity Support Workers• 16.89 WTE = 22% bankMonthly maternity report May 2012 v1.1. DOPage 8 of 9Compiled by C Frisby 13.06.20128

Medical recruitmentWe have 2 Consultant vacancies, one left in June and one in March and we have 2 full timelocums covering these posts.Balanced ScorecardThe balanced scorecard for May 2012 is attached as Appendix 1. Please note that the scorecard isunder review and not all information was available at the time of submission of this report.Additional InformationDr R Pilling, has as part of his Clinical Fellow duties, has undertaken an audit into the impact of asecond anaesthetist being available out of hours. His conclusions are below.Conclusions from audit undertaken to ascertain the impact of a second anaesthetist beingavailable out of hours: Clearly extremely busy maternity unit Unpredictable nature of obstetric shifts 40% of shifts well above the average number of anaesthetic interventions required. Increased opening of 2nd theatre since the increased anaesthetic presence Several occasions of a few minutes overlap time Are the indications for a 2nd theatre becoming more relaxed? Or…are we now more compliant with target times for emergency LSCS? Sharing of the workload has definately eased the pressure on the labour ward anaesthetist What evidence do we have of an improvement in patient care?Conclusions from audit in relation to epidural waiting times…. Clear benefit from 2nd anaesthetist Improved epidural waiting times More time available to take an active role on maternity HDU Improved working conditions for duty anaesthetistRecommendations from same audit… Definate need for 2nd anaesthetist on labour ward Needs a separate audit of the indications for the use of 2 theatres Better epidural data(should improve with the imminent introduction of computerised data collection) Reaudit to ensure maintainance of high standardsMonthly maternity report May 2012 v1.1. DOPage 9 of 9Compiled by C Frisby 13.06.20129

EXECUTIVE SUMMARYTITLE:Milestone Tracker/Composite PlanBOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:Attached is the monthly progress report forperformance against the requirements included in theMilestone Tracker. There are a number of process andoutcome requirements included in the milestonetracker under the following headings:• Corporate Governance and Assurance• Service Quality and Performance• Finance, Productivity and ReconfigurationEach criterion is RAG rated Green, Amber/Green,Amber/Red or Red. Included in the report is the TrustRAG rating.□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...… TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)Whilst there has been considerable progress againstthe requirements there are a number of areas whichhave been rated as RED or Amber/Red• Complaints• Emergency access standard• Cancer performance• CIP Plan and deliveryThis report only provides a summary of the document.The attachments, providing detailed progress andevidence of compliance, can be provided to TrustBoard members if requested.In addition to the May report the Trust has now agreeda revised Composite Plan with the cluster and NHSLondon. This is report is also attached.2. DECISION REQUIRED: CATEGORY:Report for noting. NATIONAL TARGET □ CNST CQC REGISTRATION □ HEALTH & SAFETY ASSURANCE FRAMEWORK CQUIN/TARGET FROM COMMISSIONERS CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Neill MoloneyDATE: 28 June 20123. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:The milestone tracker highlights the importance of delivering the £23m cost reduction within the QIPP programme.4. DELIVERABLES

There are a number of process and outcome requirements included in the milestone tracker under the followingheadings:• Corporate Governance and Assurance• Service Quality and Performance• Finance, Productivity and Reconfiguration•5. KEY PERFORMANCE INDICATORSIncluded in the milestone tracker report.AGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

BHRUT TFA: Corporate Governance and Assurance -FF0000 WORKING DRAFT (20 June 2012)Itemno.Activities and deliverablesBHRUT / NELC/JOINTdeliverableBHRUT accountable DirectorLeadNELC Director LeadComments:(1) Dependencies(2) RisksRAG rating Start date End date Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13Key# = transitional financial support and / or consultancy support provided to BHR to support delivery1 leadership, Board Development and WorkforceLeadership and Board developmentStrengthen Board leadership and governanceNote: Averil Dongworth, Alwen Williams and NHS London to discuss and agree approach andmilestonesBHRUT Averil Dongworth Alwen Williams‐ OD PlanOD Plan at leadership levels (Board level, senior management team and Senior Clinicians) withagreed deliverables / milestonesBHRUT Dorothy Hosein Helen BullersApr‐1201‐Dec‐12‐ Workforce Reduction PlanWorkforce reduction and transition plan (ahead of Workforce Strategy)BHRUT HRD Helen BullersDependency with CIPdeliveryMay‐12Jul‐12‐ Workforce StrategyBoard approved workforce strategy and education and training plan from 2012/13 to 2015/16. Thisneeds to have been reviewed with NELC and NHSL (link to LTFM & CIP)BHRUT HRD Helen BullersDependency withclincial strategy IBP /LTFMMay‐1201‐Dec‐12‐ National Workforce Assurance ToolBHRUT participates in National Workforce Assurance Tool and use data outputsMay‐12 OngoingBHRUT HRD Helen Bullers‐ Equality and Diversity PlanBoard approved Equality and Diversity plan BHRUT HRD Helen Bullers May‐12 31‐Jul‐12‐ Board reportingWorkforce report to be provided to all Board meetings to include Workforce metrics, key risks andmitigating actions to support Board assurance.BHRUT HRD Helen BullersApr‐12 Ongoing2 Clinical governance and risk managementBHRUT clinical improvement planHigh‐level approach to the development of an improvement strategy clearly definedBHRUT MD Caroline Alexander01‐Aug‐12‐ Improvement Strategy is finalised following internal engagement and OD process.BHRUT MD Caroline AlexanderBuilds on learningfrom the developmentof scorecards31‐Oct‐12BHRT corporate and directorate quality and safety scorecard and improvement trajectories to beagreed with NELC Director of Quality, evidence of escalation to Board and regular review via CQRM.RAG ratings and improvement trajectories to be monitored for all 11 directoratesNote: metrics to be included and not limited to those in appendix 2BHRUT MD Caroline AlexanderApr‐12‐ 1st iteration of scorecards BHRUT MD Caroline Alexander May‐12 01‐Jul‐12‐ Scorecards finalised BHRUT MD Caroline Alexander 01‐Jul 01‐Oct‐12

BHRUT TFA: Service Quality and Performance - FF0000WORKING DRAFT (20 June 2012)Itemno.Activities and deliverablesBHRUT / NELC/JOINTdeliverableBHRUT accountable DirectorLeadNELC Director LeadComments:(1) Dependencies(2) RisksRAG rating Start date End date Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13Key# = transitional financial support and / or consultancy support provided to BHR to support delivery1 Emergency CareBHRUT Cathy Geddes Helen Brown OngoingMonth on month improvement against emergency access standards‐ Trajectory for improvement to 95% to be agreed. Evidence of plans in place to sustain BHRUT Cathy Geddes Helen Brown Jun‐12improvement.‐ Clear assessment of risk and mitigations of performance deteriorating BHRUT Cathy Geddes Helen Brown Jun‐122 MaternityEliminate 60 minute plus ambulance handovers monitored via the hospital alert system(HAS)Month on month improvement to eliminate all mixed sex accommodation breaches on asustainable basis.BHRUT Cathy Geddes Helen Brown Dependency ondelivery of LOS andDTOCsBHRUT Cathy Geddes Helen Brown Links to emergencycare standardsimprovementOngoingOngoingEscalation and divertion approach to conform with policy agreed with all providers BHRUT Cathy Geddes Caroline Alexander Jun‐12 OngoingReduction of 2,100 births being delivered across all sites including a reduction in bookingsin September 2012 and deliveries by 2013/14NELC Cathy Geddes Helen Brown May‐12 Ongoing3 Planned CareNote: Quality and Safety metrics to be monitored through directorate scorecard andimprovement process. Exception reporting through CQRMContinue to sustain the aggregated position against the admitted, non‐admitted andincomplete RTT pathways. Maximum target timeframe for diagnostic is 6 weeksBHRUT Cathy Geddes Helen Brown OngoingCancer – continue to meet cancer targets in line with national and contractual reportingstandardsContinue to maintain or improve against all existing standards as outlined in NHSPerformance FrameworkBHRUT Cathy Geddes Helen Brown OngoingBHRUT Cathy Geddes Helen Brown OngoingAssurance meetingsKey BHRUT assurance meetings (tbc)External assurance Meetings

BHRUT TFA: Finance, Productivity, Reconfiguration -FF0000 WORKING DRAFT (20 June 2012)Itemno.Activities and deliverablesBHRUT / NELC/ JOINTdeliverableBHRUT accountable DirectorLeadNELC Director LeadComments:(1) Dependencies(2) RisksRAG rating Start date End date Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13Key# = transitional financial support and / or consultancy support provided to BHR to support delivery1 FinanceFinancial performance 2012/13: Delivery of CIP & Control TotalFinancial return surplus/deficit at month end is in‐line with or better than the trajectory in the annual BHRUT FD Stuart Saw Trust month 1 reporting only formallyplan (YTD and forecast outturn).available in month 2Apr‐12 OngoingGovernance and monitoring arrangementsBoard to agree, approve and sign‐off directorate budgets with the delegated budget holder. BHRUT FD Stuart Saw Dependent on CIP review Apr‐12 15‐Jun‐12An internal policy covering financial failure and escalation is produced. This is endorsed by the Boardand agreed with NHS London.BHRUT FD Stuart Saw Approved by BHRUT Board in May and finalrevisions to be made following NHS LondonfeedbackBudget holders are held accountable for adverse performance; they produce monthly variance analysisBHRUT FD Stuart Saw Apr‐12 Ongoingreports which clearly sets out favourable and adverse variances from budget (YTD and FOT), thecausality of those variances and mitigating actions being taken. The reports are evidenced andpresented to, reviewed and challenged by the Board; recovery plans agreed with budget holders whereapplicable.Apr‐12Jun‐122 Productivity‐ CIP Plan & delivery# BHRUT to develop a robust CIP plan for 2012/13. min 80% green rated and min 80% recurrent.Note: definition of RAG ratings to be agreedBHRUT FD Stuart Saw 1.05.2012 29.05.2012# Interim review of CIPs to be completed by external consultants and mitigating actions identified. NELC BHRUT FD Stuart Saw 18.05.2012to review and sign‐off refreshed plans.# Delivery of CIP Plan. Financial return CIP at month end is in‐line with or better than the annual plantrajectory (YTD and forecast outturn).BHRUT FD Stuart Saw Apr‐12 Ongoing‐ Commissioner QIPP Delivery‐Clearly quantify acute activity reduction embedded into BHRUT contract & associated QIPP schemes. NELC Conor Burke / Helen Brown May‐12 Jun‐12Ensure green rated Commissioner delivery plans in place with trajectories for delivery: i) unplannedcare 2) planned care‐ track and report delivery against trajectory as outlined in delivery plans 1) unplanned care 2) planned NELC Conor Burke / Helen Brown May‐12 ongoingcareClear delivery mechanism in place between CCGs and BHRT to support delivery NELC Conor Burke / Helen Brown Jul‐12‐ LOS improvement & deliveryAgree annual plan for delivery of LOS improvement/ bed reduction (BHR internal opportunity) BHRUT Cathy Geddes Helen Brown Dependency on LTFM and H4NEL Jun‐12including monthly phasing plan‐ Deliver to phased programme of LOS improvement/ bed reduction BHRUT Cathy Geddes Helen Brown 1.06.2012 OngoingIdentify baseline and agree a delivery plan and improvement trajectory with NELFT and other partners NELCHeather Mullins / Helento support reduction in DTOC health delays (external factors).Brown‐ Ongoing delivery of reduction in DTOC health delays NELC Heather Mullins / HelenBrownDependency on LTFM and H4NEL15.06.2012 OngoingJun‐12Develop plan for reduction in first to follow‐up ratios BHRUT Cathy Geddes Will Huxter / Helen Brown Dependency on LTFM and H4NEL 29.06.2012‐ Deliver plan for reduction in first to follow‐up ratios BHRUT Cathy Geddes Will Huxter / Helen Brown Dependency on LTFM and H4NEL 29.06.2012 Ongoing3 Reconfiguration‐ Clinical Strategy and LTFM# Development of LTFM Model: base case / gap analysis BHRUT FD Stuart Saw LTFM dependent on Health4NEL andJun‐12 15.06.2012reconfiguration strategy# Detailed plan outlining schedule of events supporting delivery of LTFM and clearly describing process BHRUT 29/06/2012and deliverables (including clincial service review)# LTFM and Clinical Service Review: scenarios for viablity, timeline to deliver, estimate of transitional BHRUT FD Stuart Saw LTFM dependent on Health4NEL andJul‐12 21/09/2012support required, multi‐year productivity programmereconfiguration strategy# Ensure jointly agreed Transitional Financial Plan NELC / BHRUT tbc 3.09.2012‐ Recofiguration planningRefresh Health4 NEL demand and capacity model ‐ jointly agreed BHR and Commissioner position BHRUT Nick Hulme Geoff Sanford Dependency with LTFM and LOSimprovement planOutline Business Case to BHRUT Trust Board BHRUT Nick Hulme Geoff Sanford see Appendix for current draft plan to bereviewed by Nick Hulme / Rob Royce06/07/201201/08/2012Outline Business Case to NHS L CIC BHRUT 27/09/2012Clinical Strategy, LTFM and Reconfiguration 'checkpoint'Review alignment of outputs from clincial Strategy / LTFM work with H4N OBC and whether any BHRUT / NELC / NHS L 10/10/2012revisions to the approach are required. Review readiness to initate PFI negotiations and capital funding‐ System‐wide strategic vision for out of hospital services including future of King George'sDevelop 'integrated care' business case including options for reconfiguration of out of hospital services NELC / CCGs Heather Mullin / Helen Brown Jul‐12 Oct‐12(including future vision for KGH), with clear linkages to BHRUT clinical strategy / LTFM and update CCGCSPs. Outputs to feed into Clinical Strategy and reconfiguration checkpoint in mid October.OBC / PCBC for proposed changes 31/10/2012Assurance meetingsKey BHRUT assurance meetingsBHRUT Financial Recovery Programme Board (monthly) BHRUT Averil Dongworth Apr‐12 OngoingExternal assurance MeetingsFinance and LTFM Steering Group JOINT BHRUT & NELC FD Stuart Saw TBC‐ Appointment of steering group JOINT BHRUT & NELC FD Stuart Saw 11.05.2012 18.05.2012Reconfiguration Programme Exec JOINT BHRUT & NELC Nick Hulme Helen Brown / David ButcherCommissioner QIPP delivery NELC Nick Hulme Will Huxter

BHRUT TFA Appendix 1: Reconfiguration planning - subject to review by Nick Hulme FF0000- WORKING DRAFT (20 June 2012)Reconfiguration planning ‐ First draft completed by Rob Royce and David Butcher subject to review by Nick HulmeItem no. Activities and deliverables BHRUT / NELC/ BHRUTJOINTdeliverableaccountableDirector LeadNELC Director Lead Comments:(1) Dependencies(2) RisksRAGratingStart date End date Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13Relocate KGH A&EPhase 1: Develop FBC for Estate changes that support Consolidation A&E and obstetric delvieries onto Queens HospitaTo be reviewed by NickHulme by 8 June 2012.Timeframes and activitiesare subject to his review# Submit design brief for to HealthPlannersBHRUT Rob Royce David Butcher 26.04.2012[Complete?]# Confirm service map and productivityassumptionsBHRUT Rob Royce David Butcher 27.04.2012[Complete?]# Submit detailed plan to Catalyst for TVE BHRUT Rob Royce David Butcher 25.05.2012production# Agree architect's plan BHRUT Rob Royce David Butcher 31.05.2012# Produce TVEs BHRUT Rob Royce David Butcher 20.07.2012# Confirm capital cost estimates and nonfinanceBHRUT Rob Royce David Butcher 20.07.2012sections# Complete options appraisal BHRUT Rob Royce David Butcher 20.07.2012# Produce forecast revenue assumptions BHRUT Rob Royce David Butcher 31.07.2012and Queen's main case# Confirm Queen's main case approval BHRUT Rob Royce David Butcher 31.08.2012Confirm plans for SCBU expansion /include within Queens capital businesscaseBHRUT Rob Royce David ButcherPhase 2: Deliver estates changesTo be reviewed by NickHulme by 8 June 2012.Timeframes and activitiesare subject to his reviewUndertake development of co‐locatedMLUUndertake SCBU expansionDevelop Sexual Health scheme design 30.06.2012Undertake Sexual Health capital workand relocationUndertake UCC and GP OOH works andrelocationUndertake work for Paeditrician A & EexpansionUndertake work for Radiology A&EexpansionUndertake works for Majors/ MinorsAssesment Unit re‐designIncorporate other agree capital works(e.g. Cath Lab, Resus and CC expansion)31.10.201231.01.201331/05.201331/05.201330.09.201330.09.2013Phase 3: Decision makingTo be reviewed by NickHulme by 8 June 2012.Timeframes and activitiesare subject to his reviewAgree System Readiness Indicators NELC 30.09.2012obstetricsAgree System Readiness Indicators NELCemergency care pathwayConfirmation of Queen's readiness NELC / BHRUT 31.10.2013provided by BHRUT and CCG Boards andconsoidation of obstetricsConfirmation of Queen's readinessprovided by BHRUT and CCG Boards andconsolidation of a&e / acute elementsof emergency care pathway ontoQueen's Hospital siteNELC / BHRUT

BHRUT TFA Appendix 2: Metrics and improvement trajectories to be agreed and monitored during the CQRM programme (Metrics to be included and not limited to those listed below) FF0000- WORKING DRAFT (20 June 2012)Metrics and improvement trajectories to be agreed and monitored during the CQRM programme ‐ Metrics to be included and not limited to those listed below14 June 2012: Quality KPIs /trajectories agreed with the trust (as below) with exception of NICU awaiting confirmation from Director of Midwifery. Rag rate: AMBERNote: update provided by Eirlys Evans 14 June 2012Activities and deliverables‐ Compliance with patient experience CQUIN targetFollowing review of plan in July meet agreed milestones for improvement‐ Complaints metrics being monitored:(1) Backlog of complaints resolved by September(2) Evidence of consistent reporting to board on complaints:· Numbers· Response rates· Themes and trend analysis· Actions/learning(3) Month on month reduction in the number of serious complaintsBHRUT / NELC/JOINT deliverableBHRUT accountable DirectorLeadBHRUT ND Caroline AlexanderBHRUT ND Caroline AlexanderNELC Director Lead Progress update RAGTrajectories have now been agreed:No overdue complaints more than 3 months oldby September 2012. 80% within 30 days *(Review to aim for 25 days.)Trajectory for responses within agreedtimescales:April complaints target 60%May complaints target 70%June complaints target 80%Then minimum 80% sustained monthlyAmberRED‐ Serious incidents being monitored, investigated and improvement in staff knowledge/awareness. Compliance with:(1) agreed CQUIN (timeliness of reporting and quality or reports) target(2) Backlog completed by end of July‐ Never events no repeated themes based on last year’s cases. Never events reported to NELCthrough SI reporting‐ HCAI rates monitored and reported daily to NELC. Participation in HCAI peer review.Completion of NELC site visits.Key metrics to be monitored:(1) MRSA and Cdiff ‐ meet agreed annual targets/trajectory(2) Bed closures – reduced in relation to last year’s monthly rates(3) Annual infection control plan meets expected milestones and embeds the learning from theHCAI peer review processBHRUT MD Caroline AlexanderBHRUT MD Caroline AlexanderBHRUT DN Caroline AlexanderFurther assurance requested on status ofmaternity SI backlogNo Never Events reported.Trust are above trajectory for MRSA objective.Currently 2 cases (1 in April & 1 in May) againstannual objective of 7 cases.C.diff current position is 15 against an annualobjective of 59.Ward closures and bed days lost are morethan in the same period 2011 i.e. 9 wardsclosed ,195 bed days lost April 2012 comparedto 0 in 2011May 3 wards closed 116 bed days lost anincrease of 32 bed days lost for same periodlast year ( 84).Red/AmberGreenRED‐ Hospital acquired pressure monitored and reported to NELC. Key metrics to be monitored:(1) Month on month reduction in grade 3 and 4 pressure ulcers(2) Reporting on safety thermometer CQUIN achieved(3) Actions agreed at June CQRM following review of trends and root causes are fullyimplemented according to the agreed milestones‐ Falls monitored and reported to NELC. Key metrics to be monitored include:(1) Month on month reduction in falls resulting in harm(2) Actions agreed at June CQRM following review of trends and root causes are fullyimplemented according to the agreed milestones(3) Reporting on safety thermometer CQUIN achieved‐ Falls resulting in fractures achieve reduction‐ Safeguarding children and adults. Key metrics to be monitored:(1) Training requirements met for safeguarding children at levels 1, 2 and 3 and an upwardtrajectory in safeguarding adults training(2) Implementation of annual safeguarding plan according to key milestones(3) Consistent attendance at LSCBs and SABs by senior leaderBHRUT DN Caroline AlexanderBHRUT DN Caroline AlexanderBHRUT DN Caroline AlexanderBHRUT DN Caroline AlexanderTrajectory AgreedZero grade 4s by end of Sept30% reduction of grade 3s by September andperformance maintainedCurrent position since April 2012:2 grade 4 and 8 grade 3 .Current position:April 2 severe harm. 1 deathMay 1 severe harm.More Detail on action plan required.Implementing Safety Themometer (CQUIN) formonitoring fallsOFSTED CQC report will be issued on 22 June2012 (to be updated following this beingissued)REDREDAmberAmber

BHRUT TFA -FF0000FINAL WORKING DRAFT (18 May 2012)BHRUT: TFADate of draft: 18 May 2012TFA focus areaAuthors and reviewersStage of draftSign‐off stage(1) Finance, Productivity, Reconfiguration Section Reviewer Role and organisation Input receivedMilestone planFinance Stuart Saw NELC 11.05.2012Will Huxter NELC 11.05.2012Dave Wragg FD BHRUT 11.05.2012Neil Moloney Director of Planning and Performance (BHRUT) 11.05.2012Productivity Heather Mullins NELC 02.05.2012Nick Hulme BHRUT 18.05.2012Cathy Geddes Chief Operating Officer (BHRUT) 18.05.2012Reconfiguration Geof Sanford NELC 15.05.2012(2) Service quality and performanceMilestone planQualityCaroline Alexander 17.05.2012Eirlys Evans Deputy Director of Nursing (NELC) 14.05.2012Christina McKenzie External contractor (NELC) 14.05.2012Helen Bullers Director of HR (NELC) 15.05.2012Deborah Wheeler Director of Nursing (BHRUT) 17.05.2012(3) Corporate Governance and AssuranceMilestone planCorporateGovernance andAssuranceHelen Brown Director of Performance and Delivery (NELC) 17.05.2012Caroline Alexander Director of Nursing and Quality (NELC) 17.05.2012Alwen Williams CEO (NELC) 17.05.2012Averil Dongworth CEO (BHRUT) 17.05.2012

EXECUTIVE SUMMARYTITLE:BOARD/GROUP/COMMITTEE:Finance Report – Month Two (May) 2012/131. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) andDATE:• Year to date deficit of (£10.9m) (excludingimpairments & IFRS), an adverse variance of£2.4m against profiled budget• Deficit in Month Two of (£3.2m) (excludingimpairments & IFRS), an adverse variance of(£1.7m) against profiled budget for the Month.• The adverse variance to date is mainly related toa QIPP/Cost Reduction shortfall of (£1.6m) –partly related to unidentified schemes of (£0.6m).• In addition there is a shortfall against incometargets of £0.8m. This includes £0.4m on centralPCT contract income, although it is anticipatedthat this shortfall will be recovered in futureMonths.• The risk assessment at Month Two of the QIPP/Cost reduction programme is £12.0m at Red,£2.4m Amber, £3.1m Green and £5.6m blue (i.e.implemented). The PMO team, with support fromErnst & Young are planning to report by the end ofthe week ending 22 nd June on the revisedprogramme for delivery of the full £23.1m target. Afurther update will be provided at the meeting.• There are also some emerging overspendings onpay described in the report, notably in theEmergency Care/Acute Medicine/NeurosciencesDirectorates, which require further action.□ S&SIB ………………□ EPB…...…………..□ FINANCE ……………□ AUDIT ….……..….□ CLINICAL GOVERNANCE …………..…......□ CHARITABLE FUNDS ……………………….TRUST BOARD ………………………………□ REMUNERATION ……………………………□ OTHER ………………………(please specify)CATEGORY:□ NATIONAL TARGET □ CNST□ STANDARDS FOR BETTER HEALTH□ ASSURANCE FRAMEWORK□ TARGET FROM COMMISSIONERS CORPORATE OBJECTIVE To monitor theTrust’s progress in achieving its financialturnaround, achieving control targets and meetingits statutory financial duties going forward.□ OTHER …………………….. (please specify)AUTHOR/PRESENTER:Alan Davies, Deputy Director of Finance / DavidWragg, Director of FinanceDATE:2. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:Set out under key issues3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION:N/A4. DELIVERABLES:N/A5. EVIDENCE :N/A6. RECOMMENDATION/ACTION REQUIRED:AGREED AT ______________________MEETING, ORREFERRED TO: ______________________DATE: ____________________________DATE: ____________________________REVIEW DATE _________________________(if applicable)1

1. EXECUTIVE SUMMARYMonthly I&E Run rate comparison.Monthly Net I&E PositionKey month 2 variances:2.00.0-2.0-4.0M01AprM02MayM03JunM04JulyM05AugM06SepM07OctM08NovM09DecM10JanM11FebM12Mar• Surgical Services (£587k adverse). Within this the majoradverse variances are: (£580k) unidentified QIPP/costreduction, mostly in Anaesthetics (£249k) which also has nonpayoverspending of (£67k – 5%, against an increase inTheatre activity of 9% against 11/12 average). There is also anoverspending on pay of (£96k), primarily a remnant of the backdatedsessions paid in M1 (as reported in M1).-6.0m£-8.0-10.0-12.0Trust I&E Summary2012/13 - Net I&E Deficit (-)/ Surplus2012/13 - Plan2011/12 - Net I&E Deficit (-)/ SurplusPrior 2 Yrs Average - Net I&E Deficit (-)/ Surplus*Febuary & March have been adjusted to show the underlying run rate position.2012/13 In Month (£'000) 2012/13 Year to date (£'000)Actual £'000 Var £'000 Var % Actual £'000 Var £'000 Var %2011/12 YTDActual £'000(36,771) (508) -1.36% Income inc. Divisional (67,790) (803) -1.17% (64,736) (412,888)Expenditure24,951 (391) -1.59% - Pay 49,233 (305) -0.62% 47,625 290,89911,374 (63) -0.56% - Non-pay 22,287 113 0.50% 22,768 133,687(749) -100.00% - QIPP/Cost Reduction (1,428) (14,536)44 100.00% - Reserves (17) 1,193(446) (1,668) -78.89% EBITDA 3,730 (2,439) -189.03% 5,657 11,698ITDA1,186 22 1.79% - Depreciation 2,373 43 1.79% 2,319 14,494355 0.00% - Capital Dividends 711 0.00% 647 4,2632,093 (15) -0.70% - Net Interest 4,084 7 0.16% 3,425 23,8223,189 (1,661) -108.70% Net position 10,896 (2,389) -28.09% 12,048 54,277(2,005) Impairments (2,005) (2,005)1,184 (1,661) -348.06% Net position 8,891 (2,389) -36.75% 12,048 52,2722AnnualBudget £'000• Emergency Care, Acute Medicine & Neurosciences (£395kadverse), with overspending of £438k in May related to;slippage in ward closure programme (£110k); Emergency Carepay overspending in month of (£153k) related to RESETprogramme and additional staffing levels; and overspending inNeurosciences pay of (£102k) related to CIP slippage andincreased Stroke Therapy staffing costs (linked to increasedactivity)• Diagnostics & Specialist Medicine (£605k adverse), including(£170k) unidentified QIPP/cost reduction. In addition: Pathologynon-pay overspending of (£136k) relating to reagents/chemicalson new MES contract; Radiology (£129k) on pay, relating toagency/locum cover for Radiologist vacancies and (£106k) onnon-pay, related to High Cost Devices, which will be offset bybilling to PCTs.• Women, Children & Support Services (£194k overspent), withan overspending of (£160k) in Month, related to SupportServices pay (£50k in month – Healthcare Records and MedicalSecretaries) , Womens pay (£75k in month – increased agencyMidwives), and Womens non-pay (£71k – increase in HIV drugexpenditure)• Corporate Directorates overall were £80k favourable YTD.Reserves show a negative variance of £541k, which primarilyrepresents the unidentified Central CIP target.

Trust I&E summary by division:2012/13 In Month 2012/13 In Month 2012/13 Year to date (£'000) 2011/122012/13Actual£'000 Var £'000 Var %Adj ActualWTEVarianceWTE Actual £'000 Var £'000 Var %Adj AverageActual WTEAverageActual £'000AnnualBudget £'000(34,338) (366) -1.05% Central Income (62,969) (449) -0.71% (32,119) (381,504)Surgical Services Division3,553 (95) -2.74% 599.58 8.94 Anaesthetics 7,181 (425) -6.29% 613.40 3,507 39,8751,444 (73) -5.30% 250.70 8.35 Specialist Surgery 2,801 (36) -1.29% 250.26 1,340 16,4301,621 (101) -6.63% 369.59 -4.57 Surgery 3,155 (127) -4.18% 384.78 1,624 18,2856,619 (268) -4.22% 1,219.87 12.72 Total 13,138 (587) -4.68% 1,248.44 6,472 74,590Emergency Care, Gen Med & Neurosciences3,773 (153) -4.22% 950.41 -21.54 Medicine 7,413 (208) -2.89% 1,033.10 3,829 41,6092,942 (216) -7.93% 582.67 8.37 Emergency Care 5,588 (154) -2.83% 583.37 2,573 32,1131,208 (69) -6.02% 232.30 3.35 Neurosciences 2,304 (33) -1.44% 230.86 1,136 13,5237,923 (438) -5.85% 1,765.38 -9.82 Total 15,305 (395) -2.65% 1,847.33 7,538 87,245Women's, Children & Support Services1,170 28 2.33% 243.33 13.11 Children 2,340 12 0.50% 263.71 1,188 14,050905 (50) -5.85% 385.69 -16.30 Support Services 1,819 (94) -5.43% 382.87 887 10,0773,012 (138) -4.81% 659.38 -0.84 Women 5,940 (112) -1.93% 678.97 3,124 35,4905,086 (160) -3.25% 1,288.40 -4.03 Total 10,099 (194) -1.96% 1,325.55 5,200 59,617Diagnostics & Specialist Medicine1,720 32 1.84% 285.98 0.90 Pathology 3,752 (240) -6.85% 284.06 1,777 20,5101,629 (88) -5.69% 290.43 -6.75 Radiology 3,320 (239) -7.74% 287.38 1,543 17,7203,712 (304) -8.92% 598.31 -6.36 Specialist Medicine 6,955 (126) -1.85% 605.48 3,441 39,8027,061 (359) -5.36% 1,174.72 -12.21 Total 14,027 (605) -4.51% 1,176.92 6,762 78,0317,230 93 1.27% 750.91 26.94 Corporate 14,317 80 0.55% 728.52 6,777 84,551(419) (1,499) -78.15% 6,199.28 13.60 - Sub-total Divisions 3,916 (2,151) -121.89% 6,326.76 630 2,530(27) 178 117.92% Central adjustment including provisio (187) 255 372.96% 134 410(346) Reserves (541) (4,576)1,186 22 1.79% Depreciation 2,373 43 1.79% 1,169 14,4942,448 (15) -0.63% PDC & Net Interest 4,794 5 0.11% 2,209 28,0753,189 (1,661) -108.70% Total 10,896 (2,389) -28.09% 6,326.76 3,512 40,933(2,005) Impairments (2,005) (2,005)1,184 (1,661) -348.06% Net position 8,891 (2,389) -36.75% 6,326.76 3,512 38,9283

2. CLINICAL INCOMEKey points:• Income for Month 2 has been forecasted using first cut activityfor the Month. Activity for A&E was taken at Day 30 and activityfor Inpatients, Out Patients and Daycases were taken at Day 29,and then extrapolated to a full month. This has ensured thatactivity is more accurate and gives greater assurance aroundIncome for the current month.• There was an under- performance of £0.2m in month, with a yearto date under-performance to £0.4m. At month 2, the Trustforecasts a breakeven position for the year. The expectation isthat the Trust will achieve the contracted activity by the year end,for each individual contract.• The over-performance for Acute Medicine is mainly as a result ofNon- elective activity. Some of this over-performance will beoffset by the transitional income from ONEL.Business UnitPerformanceIn Month Year to date ForecastActual Var Actual Var Actual Var(7,247) 325 Acute Medicine (14,226) 645 (82,308) 645(1,878) (1) Anaesthetics (3,529) (197) (22,180) (197)(2,029) 8 Children (3,877) (128) (23,928) (128)(2,463) 84 Emergency Care (4,800) 47 (28,569) 47(2,343) (113) Neurosciences (4,592) (217) (28,706) (217)(765) (62) Pathology (1,530) (123) (9,795) (123)(991) 74 Radiology (1,983) 148 (11,154) 148(2,369) (78) Specialist Medicine (4,729) (15) (28,552) (15)(3,595) 60 Specialist Surgery (6,892) 172 (40,729) 172(3,605) (112) Surgery (7,130) (9) (43,025) (9)(4,340) (2) Women (8,478) 51 (50,783) 51(636) (377) Corp (1,201) (824) (11,776) (374)(32,261) (194) Total (62,969) (449) (381,504) 0• Outpatients is over performing by £403k YTD, this is an area ofconcern as if the over-performance continues on the sametrajectory, the Trust runs the risk of not meeting the PCT plans,which exposes the Trust to risk of non-payment of overperformanceincome because of the Cap and Collar contract. Todate, the Trust has not received the Commissioning StrategyPlans from the PCTs, thus it is unclear when activity reductionsare likely to occur.• Contract Variations: The Trust is currently negotiating for extraincome for Best Practice Tariff, Breast Screening andCommissioners’ failure to move births to other providers• The activity table below compares current year YTD activity withthe same period last year. A&E activity has grown by 8% yearon year. This is mainly as a result of the UCC; the Trustacquired the UCC in month 4 last year.• There is a growth of 7% in Day cases year on year as a result ofthe achievement of the 18weeks targets, coupled with the Trustundertaking work that went to the ISTC last year.• Non Elective activity appears to have declined by 2%, this isbeing reviewed to confirm whether the reduction is as a result ofthe PCT QIPP plans being achieved.• Month 1 actual income came in at £30.7m; £2.1m more than wasforecasted, as such, the YTD position reflects the actual activityat Month 1 and the current month forecast.4

Income by PODIn Month Year to date ForecastActual Var Actual Var Actual Var(1,749) 37 A and E (3,450) 26 (20,571) 26(71) (4) Ambulatory Care (157) 6 (908) 6(192) 5 Breast Screening (384) 10 (2,252) 10(217) 0 Challenge Trust Board (433) 0 (2,600) 0(378) 0 CQUIN (756) 0 (4,536) 0(2,256) 18 Critical Care (4,353) (123) (26,731) (123)(2,828) (10) Daycases (5,393) 105 (32,091) 105(904) 31 Devices & Drugs (1,807) 61 (10,538) 61(1,186) (68) Direct Access (2,371) (137) (14,912) (137)(1,957) (125) Elective (3,839) (41) (23,428) (41)(355) 0 HIV Contract (711) 0 (4,264) 0(33) (12) ISTC Contract (62) (28) (512) (28)(11,419) 548 Non Elective (22,135) 392 (130,849) 392(2,598) (64) OP First Attendances (5,122) 162 (30,168) 162(2,684) (117) OP Follow Ups (5,449) 229 (31,804) 229(471) (0) OP Procedures (890) 13 (5,323) 13(1,552) 79 Other (3,104) 158 (17,836) 158(263) (18) Patient Transport Services (525) (36) (3,330) (36)(323) 1 Radiotherapy (645) 2 (3,862) 2496 0 Readmissions 992 0 5,953 0(470) 1 Regular Day Attenders (907) (32) (5,601) (32)(238) (1) Road Traffic Accidents (409) (68) (2,796) (68)0 (358) Support 0 (717) (4,033) (267)(614) (136) XBD (1,058) (432) (8,513) (432)(32,261) (194) Total (62,969) (449) (381,504) 0ActivityPOD Group 2011-12 2012-13 Var%ChangeAandE 31,117 36,809 5,692 8%Ambulatory Care 529 578 49 4%Breast Screening 3,692 3,878 186 2%Critical Care 4,379 4,290 (89) -1%Daycases 6,291 7,248 957 7%Direct Access 759,868 769,176 9,308 1%Elective 1,159 1,271 112 5%Non Elective 12,787 12,348 (439) -2%OP First Attendances 27,134 29,990 2,856 5%OP Follow Ups 63,589 68,307 4,718 4%OP Procedures 5,106 5,497 391 4%Other 13,642 13,146 (496) -2%Radiotherapy 3,040 3,308 268 4%Regular Day Attenders 2,171 2,166 (5) 0%XBD 7,043 3,269 (3,774) -37%Total 941,547 961,281 19,734 1%5

2. PAY EXPENDITUREPay & Headcount Position2011/12M12ActualWTE2011/12M12Actual£0002011/12 FYAv WTE2011/12FY Av£'000• The above WTE has been restated for M01 due to changes in the process of reporting agency and the capturing of the WTE.• M2 headcount (FTE), shows a further reduction, of 24 FTE from the M1 position.• Average pay costs were up in M2 compared to M1, partly due to enhanced payments for the April bank holidays, paid in May (impacting onpermanent and bank staffing).2012/13M1ActualWTE2012/13M1Actual£0002012/13M2ActualWTE2012/13M2Actual£000Mov'tfrompriormonthWTEMov'tfrompriormonth£'000M2 12/13v 11/12Av WTEM2 12/13v 11/12Av £'000Sum m ary LevelS taff TypeMedical StaffPerm anent 835 6,080 814 5,919 836 5,941 822 5,984 ‐ 15 43 7 65Bank 50 570 48 562 59 683 54 574 ‐ 5 (109) 6 12Agency 72 1,026 67 889 70 680 79 961 10 281 12 72Medical S taff Total 958 7,676 930 7,369 966 7,304 955 7,519 ‐ 10 215 26 150Scientific, Therap & TechnicalPerm anent 877 3,191 868 3,162 877 3,191 879 3,230 ‐ 1 0 ‐ 8 29Bank 21 87 25 60 19 73 18 72 ‐ 2 (15) ‐ 6 12Agency 41 287 30 200 34 176 41 251 ‐ 7 (111) ‐ 8 (24)Scientific, Therap & Technical Total 940 3,566 923 3,422 930 3,440 937 3,553 ‐ 10 (125) ‐ 22 18Nursing & Midwifery - Qual.Perm anent 1919 6,883 1909 6,846 1919 6,980 1920 7,231 0 251 11 385Bank 258 818 225 702 200 682 195 630 ‐ 5 (52) ‐ 30 (72)Agency 50 319 70 433 48 330 40 261 ‐ 8 (69) ‐ 30 (172)Nursing & Midwifery - Qual. Total 2227 8,021 2203 7,980 2166 7,993 2154 8,122 ‐ 12 129 ‐ 49 142Nursing & Midwifery - Unqual.Perm anent 691 1,420 669 1,374 679 1,434 662 1,507 ‐ 16 73 ‐ 6 133Bank 159 349 177 332 130 304 127 282 ‐ 3 (22) ‐ 50 (50)Nursing & Midwifery - Unqual. Total 850 1,769 846 1,706 809 1,737 789 1,789 ‐ 19 52 ‐ 57 83Ancillary StaffPerm anent 288 771 282 753 285 694 288 817 3 123 6 64Agency 0 3 0 3 0 1 - 0 (1) 0 (3)Ancillary S taff Total 288 773 282 756 285 695 288 817 3 122 6 61Managem ent & Adm in StaffPerm anent 987 2,767 1063 2,826 1002 2,887 1000 2,854 ‐ 2 (33) ‐ 63 28Bank 74 143 82 157 61 131 67 143 6 12 ‐ 15 (14)Agency 4 183 2 108 5 95 9 153 4 58 7 45Managem ent & Adm in Staff Total 1065 3,094 1146 3,092 1067 3,112 1076 3,150 8 38 ‐ 71 58N et D eficit / (Surplus) 6327 24,899 6330 24,325 6223 24,282 6199 24,950 ‐ 24 668 ‐ 130 625Total Perm anent 5597 21,112 5605 20,879 5598 21,127 5570 21,623 ‐ 29 496 ‐ 35 744Bank 562 1,969 556 1,814 469 1,873 461 1,701 ‐ 8 (172) ‐ 95 (113)Agency 167 1,818 168 1,632 156 1,282 169 1,626 13 344 0 (6)Total 6327 24,899 6330 24,325 6223 24,282 6199 24,950 ‐ 24 668 ‐ 130 6256

Monthly pay trend comparison:M£26.025.024.023.022.021.020.0Expenditure by pay groupMonthly Pay ExpenditureApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual Budget Prior Yr Actual*March has been adjusted to show the underlying run rate position.2012/13 In Month 2012/13 In Month 2012/13 Year to date 2011/12Actual£'000 Var £'000 Var % Paid WTEAdj ActualWTEAdjVarianceWTE Actual £'000 Var £'000 Var %Adj AverageActual WTEAverage£'0007,519 (58) -0.78% 972.86 933.67 39.19 Medical 14,824 (116) -0.79% 957.51 7,6768,122 (58) -0.72% 2,157.60 2,142.78 14.82 Nursing - Qualified 16,115 66 0.41% 2,226.74 8,0211,789 (206) -13.01% 731.69 789.45 -57.76 Nursing - Unqualified 3,526 (404) -12.95% 849.88 1,7693,553 (71) -2.05% 939.61 921.30 18.31 ST&T 6,993 (43) -0.62% 939.82 3,5663,150 13 0.42% 1,083.62 1,073.25 10.37 Management & Admin 6,262 118 1.84% 1,064.91 3,094818 (11) -1.32% 327.00 287.86 39.14 Ancillary 1,513 74 4.68% 287.90 77324,951 (391) -1.59% 6,212.38 6,148.31 64.07 Total 49,233 (305) -0.62% 6,326.76 24,899(743) -100.00% 0.50 0.00 0.50 Divisional Unallocated CIP (1,320) -100.00%50 100.00% 0.00 0.00 0.00 Reserves (11) -100.00%24,951 (1,085) -4.55% 6,212.88 6,148.31 64.57 Total 49,233 (1,636) -3.44% 6,326.76 24,899Key points:• Adjusted Actual WTE uses contracted for permanent staff and confirmedbooked hours on the IHB system for bank & agency in the month.• Pay costs in M02 show a reduction of £0.6m from the previous month and areabove the monthly average for 2011/12. The profiled pay budget (net of CIPtarget) for M02 is £24.6m. Actual pay was (£0.4m) over spent against this.Mostly on nursing and largely due to the 2 bank holidays that would have hitthis payroll for permanent and bank staff. There are a number of over spendsthat are mitigated by under spends elsewhere the key ones are describedbelow.• Pay over spent by £305k, driven by in month overspending of £391k. Mainpressures from:Emergency Care, Neurosciences & Acute Medicine division (£353k) advin month / (£283k) adv YTD month),A&E staffing - (£153k) M02 and (£41k) YTD. Mostly medical staff of which(£30k) is retrospective bookings and (£80k) is associated with vacancycover and the Reset project (plan to be submitted). (£30k) in month is arealignment from Medicine;Neurosciences - (£102k) M02 / (£54k) YTD mostly associated withadditional stroke activity;Medicine - (£98k) M02 / (£193k) YTD mostly from CIP ward closureslippage, additional Endoscopy Sessions to cover the growth in activityfrom bowel cancer screening extension and booking to e-rostering ratiosthat are being reviewed.Women, Children & Support ServicesMidwifery has a (£100k) a month over spend due to the operational ratiomethodology being used for bookings (paper being taken to TEC). Aprilbirths were significantly under budgeted plan.Support Services have A&C pressures (£24k) a month relating to -recruitment, prior year non recurrent CIP pressures and activity. Capacity,demand and recovery plan being developed.Diagnostics & Specialist MedicineRadiology is overspending bv (£65k) a month due to the continued use ofhigh cost temporary staffing for cover and vacancies.Surgical ServicesIn month break even is largely due to 2 months funding of additionaldedicated obstetrics cover which requires a long term signed off model ofcare and a recruitment/operational change plan. Anaesthetics continues toover spend on medical staff and there are small over spends withinUrology and General Surgery (medical and nursing staff) and Theatres(nursing).7

4. NON-PAY EXPENDITUREExpenditure by Non Pay category:2012/13 In Month 2012/13 Year to dateActual £'000 Var £'000 Var % Actual £'000 Var £'000 Var %2011/12Average£'0002,663 (141) -5.57% Drugs 5,025 35 0.69% 2,4672,845 (158) -5.88% Clinical supplies & services 5,707 (365) -6.83% 2,7401,402 61 4.15% General supplies & services 2,956 14 0.48% 1,5021,617 (125) -8.39% Premises & fixed plant 2,800 203 6.77% 1,5181,079 88 7.54% Other - PFI 2,284 33 1.42% 1,1471,026 (25) -2.55% Other - CNST 2,001 1 0.05% 900741 237 24.25% Other 1,515 191 11.21% 1,10911,374 (63) -0.56% Total 22,287 113 0.50% 11,382Non-pay expenditure by Business Unit:2012/13 In Month 2011/12 2012/13 Year to date (£'000)Monthly ActualActual £'000 Var £'000 Var %Average £'000 £'000 Var £'000 Var %Surgical Services Division985 (22) -2.33% Anaesthetics 1,009 1,961 (67) -3.55%244 (13) -5.49% Specialist Surgery 211 427 29 6.35%191 (12) -6.71% Surgery 168 337 15 4.33%1,420 (47) -3.44% Total 1,388 2,725 (23) -0.85%Emergency Care, Gen Med & Neurosciences675 (48) -7.62% Medicine 631 1,202 32 2.62%249 2 0.79% Emergency Care 258 492 14 2.76%239 (18) -8.13% Neurosciences 215 411 27 6.13%1,163 (64) -5.80% Total 1,103 2,105 73 3.36%Women's, Children & Support Services115 (42) -57.90% Children 106 210 (46) -27.84%39 (6) -18.29% Support Services 35 67 (2) -3.58%583 (71) -13.81% Women 553 1,102 (28) -2.58%736 (119) -19.23% Total 693 1,379 (76) -5.81%Diagnostics & Specialist Medicine626 71 10.14% Pathology 674 1,530 (136) -9.77%295 (21) -7.79% Radiology 285 654 (106) -19.32%1,931 (136) -7.55% Specialist Medicine 1,765 3,478 113 3.15%2,853 (86) -3.12% Total 2,724 5,661 (129) -2.33%Trend overview:M£12.011.511.010.510.09.59.08.58.0Non-pay expenditureApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2012/13 Actual2012/13 Budget2011/12 Prior Yr Actual2010/11 Prior Yr Actual*Feb and Mar have been adjusted to show the underlying run rate.Key points:• Non pay overall is down against last years average. However most categories of spendare higher with the exception of other non pay which is due to a reduction in ExternalConsultancy and Legal & Professional related fees.• Pathology (£0.1m) and Radiology (£0.1m) are the main areas of concern as these are13% and 14% up on last year’s average. Pathology is mostly re-agents and bloodproducts, some of which is suspected to be around Olympic stock preparation.Radiology is due to supplies and appliances mostly on the interventional side. Howeverreviews are under way for both by M03. Anaesthetics is also (£0.1m) over YTD largelyfrom doing additional Theatre cases.• Drugs has over spent in month bringing the YTD position on plan. Within the YTDposition though High Cost Drugs in specialist areas are causing pressures particularlyoncology £0.1m YTD and circa £0.5m FYE.• Clinical Supplies & Appliances over spent by (£0.4m) is the main category of overspendas discussed above by specialty analysis.6,172 (316) -5.40% - Sub-total 5,908 11,870 (154) -1.32%5,114 228 4.27% Corporate 5,252 10,395 163 1.54%88 25 21.92% Central I&E inc. Reserves 222 22 104 82.92%11,374 (63) -0.56% Net position 11,382 22,287 113 0.50%8

Trust Wide Perfomance Summary at 31st May 2012, And Forecast Overview to 31st March 20135. CIP and QIPP Programme Summary1. Annual Savings Forecast (part year and full year effect).Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Total PYE 2013/14 FYE£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Target 898 1,567 1,621 1,803 1,864 2,066 2,179 2,179 2,194 2,273 2,283 2,227 23,155IN MONTH Implemented ‐ 'Blue' 350 550 440 444 449 467 477 477 477 477 476 477 5,563 5,625Variance from Trust target -548 -1,016 -1,180 -1,359 -1,415 -1,599 -1,702 -1,702 -1,717 -1,796 -1,807 -1,750 -17,592Cumulative Target 898 2,464 4,085 5,888 7,752 9,819 11,998 14,177 16,371 18,645 20,928 23,155 23,155 This is the original CIP targetBLUE Schemes Actual / forecast Savings 350 900 1,341 1,785 2,234 2,701 3,179 3,655 4,132 4,610 5,086 5,563 5,563 5,625GREEN Schemes Actual / forecast Savings 0 0 85 359 590 910 1,276 1,638 2,000 2,365 2,735 3,111 3,111 2,677 This forecast includes only green schemesAMBER Schemes Actual / forecast Savings 0 0 15 120 255 508 828 1,149 1,470 1,791 2,111 2,437 2,437 3,367 This forecast includes only amber schemesRED Schemes Actual / forecast Savings 0 0 5 291 582 1,924 3,498 5,072 6,649 8,304 9,855 12,043 12,043 7,591 This forecast includes only red schemesBEST CASE Forecast Cumulative Target 898 2,464 4,085 5,888 7,752 9,819 11,998 14,177 16,371 18,645 20,928 23,155 23,155(includes all schemes) Actual / forecast Savings 350 900 1,446 2,556 3,661 6,044 8,781 11,515 14,252 17,069 19,788 23,155 23,155 19,260Variance from Trust target -548 -1,564 -2,639 -3,332 -4,091 -3,775 -3,217 -2,662 -2,120 -1,576 -1,140 0 0LIKELY CASE Forecast Cumulative Target 898 2,464 4,085 5,888 7,752 9,819 11,998 14,177 16,371 18,645 20,928 23,155 23,155(includes Blue, Green Actual / forecast Savings 350 900 1,441 2,265 3,079 4,120 5,283 6,443 7,603 8,765 9,933 11,111 11,111 11,669and Amber Schemes Variance from Trust target -548 -1,564 -2,644 -3,623 -4,673 -5,699 -6,715 -7,734 -8,769 -9,880 -10,995 -12,043 -12,043WORST CASE Forecast Cumulative Target 898 2,464 4,085 5,888 7,752 9,819 11,998 14,177 16,371 18,645 20,928 23,155 23,155(includes Blue and Actual / forecast Savings 350 900 1,426 2,145 2,825 3,612 4,455 5,294 6,133 6,974 7,821 8,674 8,674 8,302Green Schemes Variance from Trust target -548 -1,564 -2,659 -3,743 -4,928 -6,207 -7,543 -8,884 -10,239 -11,670 -13,106 -14,480 -14,480£'00025,00020,00015,00010,0005,000-Definitions8982,4649004,085Trust target: The efficiency required to meet the CIP plan.1,4461,3411,441Savings plan: Original savings potential (local estimate of savingsto allow performance management of project)Savings actual / forecast: In month / cumulative actual savingsand forecast savings for future periods.PYE: Part Year Effect: Benefit of saving in current financial year.FYE: Full Year Effect: Benefit of saving running for full 12 months.Forecast CIP Savings vs Trust Target Profile £0005,8882,5562,2652,1451,7857,7523,6613,0792,825 2,2349,8196,0443,6122,701Bed Review to be determined4,120Worst Green ForecastLikely Amber ForecastBest Red ForecastCIP TargetCumulative ImplementedUnlikely to deliver11,998Unlikely to deliverUnlikely to deliver8,7815,2834,4553,179Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarRisk Ratings for Projects14,17711,5155,2946,4433,65516,37114,2526,1337,6034,132BLUEScheme implemented and savings removed from budgets.GREENInitiative is delivering on plan and to the full value.AMBERInitiative is off trajectory or there are risks to delivery butassured that recovery/mitigation plans are adequate.May also be used if scheme has been actioned but it isachieving less than 90% of the cash value.REDInitiative is off trajectory and/or a significant risk to deliveryand not sufficiently assured that recovery/mitigation plansin place. There is a 50% or greater risk of non delivery.18,64517,0696,9748,7654,61020,92819,7887,82123,1559,9335,08623,15511,1118,6745,563Unidentified52%Unidentified63%Best CaseUnidentified0%Identified100%Likely CaseWorst CaseIdentified37%Identified48%This forecast includes all green, amber & red schemesThis forecast includes all green & amber schemesThis forecast includes only green schemesCIP Monthly Headlines May• Overall unfavourable variance to budget YTD was £1,564k, of which£582k relates to unallocated CIP which is phased evenly in 1/12ths.The Trust has taken into account the findings of the external reviewand is developing the CIP Delivery Plrogramme to identify furthersavings to meet the target.Scheme Narrative - Business Unit Overview• Acute Medicine - £105k achieved as per plan, £130k unfavourabledue to unachieved planned ward closures (£97k) and £33k fromadditional endoscopy costs and temporary staff costs not confirmed asCIP.• Emergency Care - £17k achieved as per plan, £86k shortfall due tobudget phasing of unidentified CIP• Neurosciences - £3k achieved, £94k variance due to £70k in tempmedical staff reduction not achieved and phasing of unidentified target.• Bed and Site - £0 achieved, £25k variance due to unidentified CIPtarget• Anaesthetics - £39k achieved, of which £22k from Amber B ward.£267k unidentified CIP target unachieved• Surgery - £35k achieved, of which £22k from closing Amber B ward.£80k unachieved from unidentified CIP allocation.• Specialist Surgery - £88k achieved from apportioned savings fromthe closure of Amber B, against a target of £134k. Includes £80kunidentified target and £33k not recognised relating to best practisetariffs.• Women - £205k achieved, of which £133k due to reduction onMidwifery temporary staff usage and £42k from HIV Home Care drugssavings. £30k shortfall due to unidentified CIP.• Children - £102k achieved, of which £83k from reduction intemporary staff usage. £24k shortfall due to unidentified CIP target.• Support Services - £0k achieved, £41k shortfall from unidentifed CIPtarget• Pathology - £41k achieved, £10k shortfall arising from delays inrevised consultant PA's and £40k unidentied CIP target.• Radiology - £25k achieved as per plan• Specialist Medicine - £38k achieved, of which £17k from Outpatientprescribing. £102k shortfall arising from failure to recognised savingsfrom manpower planning review (£67k), medicines management (£20k)and oncology drugs £(17)k .• Corporate - £203k achieved from actions identified in the plan, butshortfall of £96k arising due to not freezing recruitment - £37k,procurement plans - £15k , R&D cost savings of £13k and unidentifiedtarget of £5k.• Central - no planned schemes due for delivery for May12, but £127kunachieved as a result of unidetified CIP target phasing.9

Trust Wide Perfomance Summary at 31st May 2012, And Forecast Overview to 31st March 20131. Annual Workforce Savings Forecast (part year and full year effect).Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Total PYE 2013/14 FYE£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Target 53.0 81.0 96.8 107.8 108.8 126.1 171.1 170.1 170.1 169.1 169.1 170.1 170.1IN MONTH Implemented ‐ 'Blue' 46.5 42.1 51.1 49.4 48.4 56.4 59.4 59.4 59.4 59.4 59.4 60.4 60.4 60.4Variance from Trust target -6.5 -38.8 -45.7 -58.4 -60.4 -69.7 -111.7 -110.7 -110.7 -109.7 -109.7 -109.7 -109.7Target 53.0 81.0 96.8 107.8 108.8 126.1 171.1 170.1 170.1 169.1 169.1 170.1 170.1 This is the original CIP targetBLUE Schemes Actual / forecast Savings 46.5 42.1 51.1 49.4 48.4 56.4 59.4 59.4 59.4 59.4 59.4 60.4 60.4 60.4GREEN Schemes Actual / forecast Savings 0.1 7.6 14.6 21.4 17.4 13.4 17.4 16.4 16.4 11.4 11.4 11.4 11.4 11.4 This forecast includes only green schemesAMBER Schemes Actual / forecast Savings 0.0 26.4 25.2 21.7 21.7 31.7 31.7 31.7 31.7 31.7 31.7 31.7 31.7 31.7 This forecast includes only amber schemesRED Schemes Actual / forecast Savings 0.0 0.0 1.1 14.7 26.2 35.4 67.5 67.5 67.5 71.5 71.5 71.5 71.5 71.5 This forecast includes only red schemesBEST CASE Forecast Cumulative Target 53.0 81.0 96.8 107.8 108.8 126.1 171.1 170.1 170.1 169.1 169.1 170.1 170.1(includes all schemes) Actual / forecast Savings 46.6 76.2 92.0 107.2 113.7 137.0 176.0 175.0 175.0 174.0 174.0 175.0 175.0 175.0Variance from Trust target -6.4 -4.8 -4.8 -0.6 4.9 10.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9LIKELY CASE Forecast Cumulative Target 53.0 81.0 96.8 107.8 108.8 126.1 171.1 170.1 170.1 169.1 169.1 170.1 170.1(includes Blue, Green Actual / forecast Savings 46.6 76.2 90.9 92.6 87.6 101.6 108.6 107.6 107.6 102.6 102.6 103.6 103.6 103.6and Amber Schemes Variance from Trust target -6.4 -4.8 -5.9 -15.3 -21.3 -24.5 -62.6 -62.6 -62.6 -66.6 -66.6 -66.6 -66.6WORST CASE Forecast Cumulative Target 53.0 81.0 96.8 107.8 108.8 126.1 171.1 170.1 170.1 169.1 169.1 170.1 170.1(includes Blue and Actual / forecast Savings 46.6 49.7 65.7 70.8 65.8 69.8 76.8 75.8 75.8 70.8 70.8 71.8 71.8 71.8Green Schemes Variance from Trust target -6.4 -31.2 -31.1 -37.0 -43.0 -56.3 -94.3 -94.3 -94.3 -98.3 -98.3 -98.3 -98.3WTE250.0150.050.0-50.0Definitions76.292.0Trust target: The efficiency required to meet the CIP plan.Savings plan: Original savings potential (local estimate of savingsto allow performance management of project)Savings actual / forecast: In month / cumulative actual savingsand forecast savings for future periods.PYE: Part Year Effect: Benefit of saving in current financial year.FYE: Full Year Effect: Benefit of saving running for full 12 months.Forecast CIP Staff Reductions vs Trust Target107.290.9 92.670.8113.765.851.1 49.4 48.487.6137.069.8101.6Worst Green ForecastLikely Amber ForecastBest Red ForecastCIP TargetCumulative Implemented176.0 175.0 175.0 174.0 174.0 175.0Bed Review to be determinedUnlikely to deliverUnlikely to deliver76.8 75.8 75.8Unlikely to deliverRisk Ratings for Projects108.6 107.6 107.6BLUEScheme implemented and savings removed from budgets.GREENInitiative is delivering on plan and to the full value.AMBERInitiative is off trajectory or there are risks to delivery butassured that recovery/mitigation plans are adequate.May also be used if scheme has been actioned but it isachieving less than 90% of the cash value.REDInitiative is off trajectory and/or a significant risk to deliveryand not sufficiently assured that recovery/mitigation plansin place. There is a 50% or greater risk of non delivery.102.6 102.6 103.670.8 70.8 71.856.4 59.4 59.4 59.4 59.4 59.4 60.4Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar10Unidentified89%Unidentified94%Unidentified95%Best CaseIdentified11%Likely Case Identified6%Worst Case Identified5%This forecast includes all green, amber & red schemesThis forecast includes all green, amber & red schemesThis forecast includes only green schemesCIP Monthly Headlines May• Overall unfavourable variance to budget increased to 38.8 primarilyas a result of the planned ward closure not occuring, with the schemenow being removed.• Ongoing temporary staff cost reductions in the month were inprimarily as a result of the premium reduction of recruitment activity,rather than actual consumption reduction beyond the reductions seen inApril• Unidentified CIP requires a corresponding WTE reduction wherepotential workforce reductions will be required. The outcome of thecurrent external review will need to be detailed at a workforce level.Scheme Narrative - Business Unit Overview• Acute Medicine - 9.6 planned WTE reductions achieved.• Emergency Care - No planned reductions in the month.• Neurosciences - Although planned temporary staff cost reductionswere targeted from temp to perm price premium, these reductions arenot being achieved.• Bed and Site - No planned reductions in the month.• Anaesthetics - 7.4WTE planned, 4.4WTE achieved. Shortfallcontinues to be due to inability to remove additional lists resulting inadditional session costs.• Specialist Surgery - No planned reductions in the month.• Surgery - 0.6 planned WTE reductions achieved.• Women - 30.5WTE planned - 31.5WTE reported achieved - nochange from April• Children - Planned temporary staff cost reductions arising from tempto perm price premium reduction. No planned overall WTE reductionsin the month.• Support Services - No planned reductions in the month.• Pathology - 0.6 planned WTE reductions from changes to PA's notachieved• Radiology - No net headcount reduction. Financial Savings fromrecruitment displacing temporary staff.• Specialist Medicine - 5WTE included in plan as part of workforcereview not achieved up to end of May.• Corporate - 0.5WTE reduction in Estates implemented• Central - no planned schemes due for delivery from May 12.

Workstream Summary 2012-13 - May 2012(all figures in £'000)Annual Statement In Month Statement Ytd StatementWTE ReductionsDataDivision CIP Scheme Scheme Expenditure Type12/13 Target12-13 12-13 In Mth In Mth In Mth Ytd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTEGreen Amber RedF-cast Variance Target Delivery VarianceAcute Medicine Divisional CIP Endoscopy 4th Room Pay 138 - 96 - 96 (42) 13 - (13) 13 - (13) - - -FYE Angelica Pay 390 390 - - 390 - 33 33 - 65 65 - 8.6 8.6 -Perfusion Scans Pay 40 40 - - 40 - 3 3 - 7 7 - - - -Staff Secondment Opportunity Pay 81 81 - - 81 - 7 7 - 14 14 - 1.0 1.0 -Overseas Nursing Recruitment Non-Pay 120 120 - - 120 - 10 10 - 20 20 - - - -Temporary staff reduction Pay 120 110 - - 110 (10) 10 - (10) 20 - (20) - - -Income Opportunities Cardiology Direct Access Non-Pay - - - - - - - - - - - - - - -Length of stay / Ward closures LOS to national mean 95% (Discharge Co-Or) Pay 264 - - - - (264) 24 - (24) 24 - (24) - - -LOS to national mean 95% (5/7 Day Wrk) Pay 583 - - - - (583) 53 - (53) 53 - (53) - - -LOS to national mean 95% (CofE Physician) Pay 189 - - - - (189) - - - - - - - - -LOS to national mean 95% (Card) Pay 90 - - - - (90) - - - - - - - - -LOS to national mean 95% (Resp) Pay 224 - - - - (224) 20 - (20) 20 - (20) - - -LOS to national mean 95% (Amb) Pay 90 - - - - (90) - - - - - - - - -LOS to national mean 95% (EDS) Pay 30 - - - - (30) - - - - - - - - -LOS to national mean 95% (DTOC) Pay 206 - - - - (206) - - - - - - - - -LOS to national mean 95% (Ward 1 + Surge) Pay - - 207 207 207 - - - - - - - -LOS to national mean 95% (Ward 2 + Surge) Pay - - 415 415 415 - - - - - - - -To be identified Total Divisional Target Pay - - - 1,106 1,106 1,106 - - - - - - - -Acute Medicine Total 2,565 741 96 1,728 2,565 1 172 53 (120) 235 105 (130) 9.6 9.6 -Neurosciences Divisional CIP Neurosciences Temp Staff Reduction Pay 420 - 100 - 100 (320) 35 - (35) 70 - (70) - - -Head of Neuropsychology regrade Pay 20 20 - - 20 - 2 2 - 3 3 - - - -Develop Spinal Elective Service West essex Ext Income - - - 48 48 48 - - - - - - - - -Neurosciences permanent recruitment Pay 100 - - - - (100) - - - - - - - - -To be identified Total Divisional Target Pay 146 - - 518 518 372 12 - (12) 24 - (24) - -Neurosciences Total 686 20 100 566 686 - 49 2 (47) 98 3 (94) - - -Emergency Care Divisional CIP Advanced Nurse Practiitioner Pay 80 - 56 - 56 (24) - - - - - - - - -PELC VAT Pay 100 100 - - 100 - 8 8 - 17 17 - - - -Temp Medical Staff Reduction -A&E Pay 105 105 - - 105 - - - - - - - - - -ED Skills for Health Review Pay 250 - - - - (250) - - - - - - - - -To be identified Total Divisional Target Pay 515 - - 789 789 274 43 - (43) 86 - (86) - -Emergency Care Total 1,050 205 56 789 1,050 - 51 8 (43) 102 17 (86) - - -Bed and Site To be identified Total Divisional Target Pay 152 - - 152 152 - 13 - (13) 25 - (25) - -Bed and Site Total 152 - - 152 152 - 13 - (13) 25 - (25) - -11

Workstream Summary 2012-13 - May 2012(all figures in £'000)Division CIP Scheme Scheme Expenditure TypeData12/13 TargetAnnual Statement In Month Statement Ytd StatementGreen Amber Red12-13F-cast12-13VarianceIn MthTargetIn MthDeliveryIn MthVarianceWTE ReductionsYtd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTEAnaesthetics Divisional CIP Invest in Gambro Dialysis Devices for ITU Non-Pay 44 32 - - 32 (12) 4 - (4) 4 - (4) - - -Procurement moving from Supply Chain to BMIfor consumablesNon-Pay 67 67 - - 67 - - - - - - - - - -Procurement reduction in Prothesis spend Non-Pay 67 67 - - 67 - - - - - - - - - -Sevoflurane Reduction Non-Pay 26 30 - - 30 3 2 2 0 4 5 1 - - -Key Recruitment Recruitment into Vacant ITU nursing posts Pay 40 - 40 - 40 - - - - - - - - - -Length of stay / Ward closures Closure Amber B Pay 241 - - 241 241 - 22 22 - 22 22 - -Medical staffing productivity Match Theatres plan to Outturn Pay 42 42 - - 42 - 3 3 - 7 7 - 1.0 1.0 -Reduction of Study Leave for AnaestheticDoctorsPay - - - - - - - - - - - - -Reduction of Study Leave within Theatres forNursing StaffPay 14 14 - - 14 - 1 1 - 2 2 - 1.9 1.9 -Recruitment - Temp to Perm Pay - - - - - - - - - - - - - - -Senior Nurse staffing Reduction of Study Leave in ITU Pay 3 - - 3 3 - - - - - - 0.1 0.1Theatre productivityRecruitment of Locum Doctor into DR Jonesposition on 10 PasPay 23 23 - - 23 - - - - - - - - - -Recruitment of Specialty Doctors Pay 20 20 - - 20 - - - - - - - - - -Remove weekend Initiative list and use vacanttheatre list due to A/L (Bhargava)Pay 19 19 - - 19 - 2 2 - 3 3 - 1.4 1.4 -Remove weekend Initiative list and use vacanttheatre list due to A/L (Ojo)Pay 16 - - - - (16) - - - - - - 1.4 - (1.4)Remove weekend Initiative list and use vacanttheatre list due to A/L (Pittathankal)Pay 16 - - - - (16) - - - - - - 0.4 - (0.4)Run HCA Lists wintin current schedule and staffPayon duty- - - - - - - - - - - - 1.0 - (1.0)Recruitment - Temp to Perm Pay - - - - - - - - - - - - - - -Ward productivity Reduction of Study Leave in ITU Pay 3 - - - - (3) 0 - (0) 1 - (1) 0.1 (0.1)To be identified Total Divisional Target (blank) 1,638 - - 1,439 1,439 (199) 133 - (133) 267 - (267) - -Anaesthetics Total 2,035 556 40 1,439 2,035 0 146 31 (116) 288 39 (249) 7.2 4.4 (2.8)SurgeryDivisional CIPRepatriate Lower GI physiology tests fromBARTSExt Income 26 - - 12 12 (15) - - - - - - - - -Income Opportunities Best Practice Tariff Ext Income 200 - - - - (200) 17 - (17) 33 - (33) - - -Length of stay / Ward closures Closure Amber B Pay 241 - - 241 241 - 22 22 - 22 22 - -Management Structure Management Restructure Pay 83 - - 83 83 - - - - - - - -Surgical Management Restructure Pay 83 - - - - (83) - - - - - - - -Medical staffing productivity Urology Consultant Saving (CZI) Pay 79 79 - - 79 - 7 7 - 13 13 - 0.6 0.6 -Junior Doctor Banding Pay - - - - - - - - - - - - -KGH Specialty Doctor On Call Rota - 13 to 10PA'sPay 41 41 - - 41 - - - - - - - - - -Outpatient productivity Breast One Stop Clinics Pay - - - - - - - - - - - - - - -Surgical Hot Clinics Pay - - - - - - - - - - - - - - -Best Practice Tariff Breast Best Practice Tariff Breast (blank) - - - - - - - - - - - - - - -To be identified Total Divisional Target (blank) 562 - - 536 536 (26) 40 - (40) 80 - (80) - -Surgery Total 991 443 - 548 991 (0) 63 28 (35) 126 35 (91) 0.6 0.6 -Specialist Surgery Divisional CIP Max Fax Bipolar (blank) - - - - - - - - - - - - - - -Length of stay / Ward closures Closure Amber B Pay 802 321 - - 321 (481) 67 22 (45) 134 88 (46) - - -Procurement - other Siemens Audiology Contract Pay 49 - - 49 49 - - - - - - - -ISTC Activity Retention ISTC Activity Retention Ext Income - - - - - - - - - - - - - - -To be identified Total Divisional Target (blank) 106 - - 538 538 432 9 - (9) 18 - (18) - -Specialist Surgery Total 908 370 - 538 908 (0) 76 22 (54) 151 88 (64) - - -12

Workstream Summary 2012-13 - May 2012(all figures in £'000)Division CIP Scheme Scheme Expenditure TypeData12/13 TargetAnnual Statement In Month Statement Ytd StatementGreen Amber Red12-13F-cast12-13VarianceIn MthTargetIn MthDeliveryIn MthVarianceWTE ReductionsYtd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTEWomenDivisional CIPBest Practice Tariff - Gynae OPD procedures(MA10z and MA21Z)Pay - - - - - - - - - - - - (1.0) - 1.0Ext Income 200 - - - - (200) - - - - - - - - -Unidentified Non-Pay - - 50 50 50 - - - - - -ISH increase in income including due toOlympics Net of all costPay - - - - - - - - - - - - - - -Ext Income - - - - - - - - - - - - - - -Renegotiated contract with BLT Non-Pay 25 25 - - 25 - 2 2 - 4 4 - - - -Terminated psycho sexual contract) Non-Pay 50 50 - - 50 - 4 4 - 8 8 - - - -ISH stopped using Drs lab Non-Pay 10 10 - - 10 - 1 1 - 2 2 - - - -Gynae OPD Productivity Non-Pay - - - - - - - - - - - - - - -Gynae Theatre Productivity Non-Pay 30 - 30 - 30 - - - - - - - - - -Midwifery temp staff removal due to recruitmentPayand rota managemnet -17.8 less staff900 800 - 100 900 - 67 67 - 133 133 - 31.5 31.5 -Maternity Consumables Non-Pay 50 - - 50 50 - - - - - - - - - -IT savings in ISH Non-Pay 10 10 - - 10 - 1 1 - 2 2 - - - -ISH Workforce reconfiguration Non-Pay 160 160 - - 160 - 1 1 - 14 14 - - - -HIV - Home Care drugs savings Non-Pay 250 250 - - 250 - 21 42 21 42 42 0 - - -Drugs Savings Non-Pay 25 - 25 - 25 - - - - - - - - - -To be identified Total Divisional Target (blank) 169 - - 319 319 150 21 - (21) 30 - (30) - -Women Total 1,879 1,305 55 519 1,879 - 118 117 (1) 235 205 (30) 30.5 31.5 1.0Children Divisional CIP Best Practice Tariff - Paediatric Diabetes Ext Income - - - - - - - - - - - - - - -Cardiology visiting consultants from GOS Non-Pay - - - - - - - - - - - - - - -PAU Pay - - - - - - - - - - - - - - -Paeds nursing recruitment - temp staffingremovalPay 500 500 - - 500 - 42 83 42 83 83 0 - - -Paediatric Drugs Non-Pay 25 25 - - 25 - - - - - - - - - -Paediatric Consumables Non-Pay 10 10 - - 10 - - - - - - - - - -Remove External Consultancy Non-Pay 110 - - 110 110 18 18 18 18 - -To be identified Total Divisional Target (blank) 170 - - 60 60 (110) 8 - (8) 24 - (24) - -Children Total 705 645 - 60 705 0 49 102 53 107 102 (5) - - -Support Services Divisional CIP Outpatient productivity Pay 200 - - 200 200 - - - - - - - - - -Outpatients - Efficiency Savings Non-Pay - - - - - - - - - - - - - - -Medical Secretaries Pay 80 - - 80 80 - - - - - - - - - -Medical Records Pay - - - - - - - - - - - - - - -To be identified Total Divisional Target Pay 247 - - 247 247 - 21 - (21) 41 - (41) - - -Support Services Total 527 - - 527 527 - 21 - (21) 41 - (41) - - -13

Workstream Summary 2012-13 - May 2012(all figures in £'000)Division CIP Scheme Scheme Expenditure TypeData12/13 TargetAnnual Statement In Month Statement Ytd StatementGreen Amber Red12-13F-cast12-13VarianceIn MthTargetIn MthDeliveryIn MthVarianceWTE ReductionsYtd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTESpecialist Medicine Divisional CIPPharmacy Production Unit - MaximiseContributionExt Income 60 - - - - (60) - - - - - - - -Ext Income 60 - - 60 60 - - - - - -Additional Income Radiotherapy Chemotherapy (blank) - - - - - - - - - - - - - - -Therapies In House Non-Pay 30 - - - - (30) 3 - (3) 5 - (5) - -Non-Pay 28 - - 28 28 3 3 3 3 - -Pharmacy Efficiencies - Medicines management Non-Pay 390 - - 135 135 (255) 10 - (10) 20 - (20) - - -Non-Pay 245 - - 245 245 10 10 10 10 - -Junior Doctor Banding Pay 27 - - - - (27) 2 - (2) 5 - (5) - -Pay 27 - - 27 27 2 2 5 5 - -Bone marrow pathway Ext Income 24 - - - - (24) - - - - - - - -Ext Income - 24 - 24 24 - - - - - -Non Pay Drug Saving (Onc Pharm) Non-Pay 100 - - - - (100) 8 - (8) 17 - (17) - -Non-Pay - - - - - - - - - - -Review MDT and CRO structure to increasesupport and reduce costsExt Income 25 - - - - (25) 2 - (2) 4 - (4) - -Ext Income 25 - - 25 25 2 2 4 4 - -Manpower Planning review Pay 700 - - 650 650 (50) 33 - (33) 67 - (67) 5.0 - (5.0)Outpatient Prescribing Non-Pay 100 - - - - (100) 8 - (8) 17 - (17) - -Non-Pay 100 - - 100 100 8 8 17 17 - -Pharmacy Robot Pay 48 - - - - (48) - - - - - - - -Pay 48 - - 48 48 - - - - - -Wastage Saving Non-Pay 54 - - - - (54) - - - - - - - -Non-Pay 54 - - 54 54 - - - - - -Rapid Arc - Ext Income 100 - 100 - 100 - - - - - - - - - -Therapies Reduction in Premium Cost Pay 160 80 80 - 160 - - - - - - - - - -Agency Bank Reduction - Through on call review Pay 158 - 79 - 79 (79) - - - - - - - - -Pay 79 - - 79 79 - - - - - -To be identified Total Divisional Target (blank) 35 - - 198 198 163 3 - (3) 6 - (6) - -Specialist Medicine Total 2,011 745 283 983 2,011 - 70 25 (45) 139 38 (102) 5.0 - (5.0)14

Workstream Summary 2012-13 - May 2012(all figures in £'000)Division CIP Scheme Scheme Expenditure TypeData12/13 TargetAnnual Statement In Month Statement Ytd StatementGreen Amber Red12-13F-cast12-13VarianceIn MthTargetIn MthDeliveryIn MthVarianceWTE ReductionsYtd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTERadiologyDivisional CIPCo-ordination of MRI scanning - ClaustrophobicNon-Paypatients10 10 - - 10 - 1 1 - 2 2 - - - -Demand Management - Through Cross ChargingNon-Payetc Pathology42 - - - - (42) - - - - - - - -Demand Management - Through Cross ChargingNon-Payetc Radiology550 - 200 350 550 - - - - - - - - - -Electronic Request to GPs - Saving on A&C Pay 16 - 16 - 16 - - - - - - - - - -Employment of Additional Radiographers -Reduce outsourcingPay 54 25 - 35 60 6 2 2 (0) 4 4 (0) - - -Employment to full establishment forRadiologistsPay 96 96 - - 96 - 8 8 - 16 16 - - - -Recruitment of CT & MRI Staff Pay 26 - - - - (26) - - - - - - - -Pay 26 - - 26 26 - - - - - -Sign off of remuneration rate towards activitybasedPay - - - - - - - - - - - - - - -Total Implementation of Voice Recognition Non-Pay 16 16 - - 16 - 1 1 - 3 3 - - - -Recruitment Drive for Sonographers Pay 100 100 - - 100 - - - - - - - - - -To be identified Total Divisional Target (blank) - - - 36 36 36 - - - - - - - -Radiology Total 910 273 216 421 910 - 12 12 - 25 25 - - - -PathologyDivisional CIPDemand Management - Through Cross ChargingNon-Payetc Pathology98 - 42 98 140 42 - - - - - - - - -Pathology Investment Programme Pay 90 50 40 - 90 - - - - - - - - - -MRSA Screening Pay 75 75 - - 75 - 6 6 - 13 13 - - - -Blood Products Ext Income 50 - - - - (50) 4 - (4) 8 - (8) - -Ext Income 50 - - 50 50 4 4 8 8 - -Pathology Investment Programme - MicroAutomationPay 287 - 150 137 287 - - - - - - - - - -Pathology Investment Programme - OrderCommsPay 45 45 - - 45 - - - - - - - - - -Pathology Investment Programme - OtherWorkforce PlanningPay 38 38 - - 38 - - - - - - - - - -Consultant PAs Pay 60 - - - - (60) 5 - (5) 10 - (10) 0.6 (0.6)Pay 55 - - 55 55 5 5 5 5 - -Bring Vitamin D in house Non-Pay 40 - - - - (40) 3 - (3) 7 - (7) - -Non-Pay 40 - - 40 40 3 3 7 7 - -M.E.S. - Full year effect in 11/12 Non-Pay 50 - - - - (50) 4 - (4) 8 - (8) - -Non-Pay 50 - - 50 50 4 4 8 8 - -To be identified Total Divisional Target (blank) 240 - - 203 203 (37) 20 - (20) 40 - (40) - -Pathology Total 1,073 403 232 438 1,073 - 43 23 (20) 86 41 (45) 0.6 - (0.6)15

Workstream Summary 2012-13 - May 2012(all figures in £'000)Division CIP Scheme Scheme Expenditure TypeData12/13 TargetAnnual Statement In Month Statement Ytd StatementGreen Amber Red12-13F-cast12-13VarianceIn MthTargetIn MthDeliveryIn MthVarianceWTE ReductionsYtd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTECorporate Divisional CIP Investment in KGH Bleeps (stbc) Non-Pay 24 - - 24 24 2 2 2 2 - -24 - - - - (24) 2 - (2) 4 - (4) - -McKesson Contract Change Non-Pay 90 45 45 - 90 - - - - - - - - - -Pagers - reduced operating costs Non-Pay 15 - - 15 15 1 1 1 1 - -30 - - - - (30) 3 - (3) 5 - (5) - -Procurement Non-Pay 89 - - - - (89) 7 - (7) 15 - (15) - - -Reduced McKesson Payroll Cost - weekly tomonthly payrollNon-Pay 72 - 72 - 72 - - - - - - - - - -Review of Payphones at KGH Non-Pay 3 - - 3 3 0 0 0 0 - -6 - - - - (6) 1 - (1) 1 - (1) - -Rollover NEPT Contract Non-Pay 60 38 - - 38 (22) 5 6 1 10 6 (4) - - -Consolidation of PCT Transport SLA's Non-Pay 66 - 60 - 60 (6) - - - - - - - - -Reduction to Outturn on Fixtures and Fittings(non-capital)Non-Pay 72 36 - - 36 (36) 6 3 (3) 12 3 (9) - - -Reduce Non-Capital Minor Works Non-Pay 30 30 - - 30 - 3 3 - 5 5 - - - -Activity Reduction - NEPT Usage Non-Pay - - - - - - - - - - -Bad Debt Charge Reduction - 20121/3 Non-Pay 129 - - - - (129) - - - - - - - -- - - - - - - - - - -Reduced External Consultancy Fees Pay 99 (5) - - (5) (104) 8 (5) (13) 17 (5) (22) - - -Removal of Seconded Staff Pay - - - - - - - - - - - - 1.0 - (1.0)HR - Staff Efficiencies Non-Pay 25 - - 25 25 - - - - - - - - - -E-Rostering - Consolidated Med Staff RotaPlanning SavingsPay 140 - 140 - 140 - - - - - - - - - -R&D Enhanced Income/Cost Efficiency Non-Pay 76 - - - - (76) 6 - (6) 13 - (13) - - -London/Quadrant Room Rduction FYE Non-Pay 39 39 - - 39 - 3 3 - 7 7 - - - -ISTC 3rd Party Income Share Non-Pay 20 20 - - 20 - 2 2 - 3 3 - - - -RO Water Testing Contract FYE Non-Pay 120 120 - - 120 - 10 10 - 20 20 - - - -Goodmayes Rental Non-Pay 86 86 - - 86 - 7 7 - 14 14 - - - -Car Park Expansion - 50 Spaces KGH Ext Income 46 46 - - 46 - 4 4 - 8 8 - - - -Waste Contract Review of Service Spec KGH Non-Pay 40 40 - - 40 - 3 3 - 7 7 - - - -Clinical Engineering Post Reduction - 8d0.5WTEPay 58 58 - - 58 - 5 5 - 10 10 - 0.5 0.5 -Food/Meal Spc Change Trustwide FYE Non-Pay 243 243 - - 243 - 20 20 - 41 41 - - - -DOV12 KGH FM Element Non-Pay 50 25 - - 25 (25) 4 - (4) 8 4 (4) - - -Laundry Lease Non-Pay 170 170 - - 170 - 14 14 - 28 28 - - - -Clincal Engineering SLA Non-Pay 8 8 - - 8 - 1 1 - 1 1 - - - -Medical Gases Non-Pay - - - - - - - - - - - - - - -SBS Contract & Debt Mgt Resource Non-Pay 118 108 - - 108 (10) 10 59 49 20 59 39 - - -Pay (67) (67) - - (67) 0 (6) (11) (6) (11) (11) - (2.0) - 2.0Freeze recruitment for first 3months of the yearfor 2wte band 8a Snr MgrsPay 36 36 - - 36 - 21 - (21) 21 - (21) - - -Freeze recruitment for first 3months of the year Pay 29 29 - - 29 - 16 - (16) 16 - (16) - - -Staff member on long term sickness. Will not beback to work for the last six months of the year. Pay 16 16 - - 16 - 7 - (7) 7 - (7) - - -Give up budget as CIPMember of staff retiring. Do not replace 5 monthsPayCIP24 24 - - 24 - 8 - (8) 8 - (8) - - -remove the DBA Pay 33 33 - - 33 - 7 - (7) 7 - (7) 1.0 - (1.0)Medical staffing productivity Recruitment - Temp to Perm Pay - - - - - - - - - - - - - - -Theatre productivity Recruitment - Temp to Perm Pay - - - - - - - - - - - - - - -To be identified Total Divisional Target (blank) 29 - - 544 544 515 2 - (2) 5 - (5) - -Corporate Total 2,106 1,219 317 569 2,105 (1) 179 128 (52) 300 203 (96) 0.5 0.5 -16

Workstream Summary 2012-13 - May 2012(all figures in £'000)Division CIP Scheme Scheme Expenditure TypeData12/13 TargetAnnual Statement In Month Statement Ytd StatementGreen Amber Red12-13F-cast12-13VarianceIn MthTargetIn MthDeliveryIn MthVarianceWTE ReductionsYtd Target Ytd Delivery Ytd Variance WTE Target WTE YTD Var WTECentral Divisional CIP Stafflow Pay 506 506 - - 506 - 46 - (46) 46 - (46) - - -Jnr Doctors Rotas Pay 150 150 - - 150 - 14 - (14) 14 - (14) - - -Vacancy Restriction to review up to 100WTErelative to 12/13 budgetsPay - - - - - - - - - - - - - - -CNS Pay - - - - - - - - - - - - - - -SNR Nursing Pay 100 - - 100 100 - 9 - (9) 9 - (9) - - -Pharmacy - 5% Staff Pay 125 - - 125 125 - 11 - (11) 11 - (11) - - -Radiology Pay - - - - - - - - - - - - - - -ARMD Non-Pay 150 - - 150 150 - 14 - (14) 14 - (14) - - -Drugs Non-Pay - - - - - - - - - - - - - - -Management & Admin Pay 250 - - 250 250 - 23 - (23) 23 - (23) - - -Capital Driven Efficiences Non-Pay - - - - - - - - - - - - - - -PMO Driven Efficiences Non-Pay - - - - - - - - - - - - - - -Direct Access Non-Pay - - - - - - - - - - - - - - -Income Opportunities Capital project mgt Non-Pay 500 500 - - 500 - 45 - (45) 45 - (45) - - -Outpatient productivity OP Nursing Pay - - - - - - - - - - - - - - -OP Diagnostics Pay - - - - - - - - - - - - - - -Procurement - other Consumables Non-Pay 292 292 - - 292 - 27 - (27) 27 - (27) - - -Ward Consumables Non-Pay 225 - 225 - 225 - 20 - (20) 20 - (20) - - -Vat on Energy Non-Pay 230 - 230 - 230 - 21 - (21) 21 - (21) - - -Project / External Consultancy Non-Pay 188 - 188 - 188 - 17 - (17) 17 - (17) - - -Bed Contract - KGH (Cap'n) Non-Pay 50 50 - - 50 - 5 - (5) 5 - (5) - - -HCA Non-Pay - - - - - - - - - - - - - - -VAT on IT Managed Service Non-Pay 150 - 150 - 150 - 14 - (14) 14 - (14) - - -A&E A&E KGH @ night Non-Pay 750 - - 750 750 - 68 - (68) 68 - (68) - - -Staff Absence IHB Bookings Sickness cover Pay - - - - - - - - - - - - - - -IHB Bookings Additional Sessions Pay - - - - - - - - - - - - - - -IHB Bookings Additional Resource Pay - - - - - - - - - - - - - - -Procurement automation Procurement Automation Non-Pay 500 250 250 - 500 - 45 - (45) 45 - (45) - - -To be identified Total Divisional Target (blank) 1,392 - - 1,392 1,392 - 127 - (127) 127 - (127) - -Central Total 5,557 1,748 1,043 2,767 5,557 - 505 - (505) 505 - (505) - - -Grand Total 23,155 8,674 2,437 12,043 23,155 0 1,567 550 (1,016) 2,464 900 (1,564) 54.0 46.6 (7.4)17

Workstream Summary 2012-13 - April 2012(all figures in £'000)Data12/13 TargetAnnual StatementIn Month StatementDivision CIP Scheme SchemeMandated12-13 12-13 In Mth In MthExpenditure Type Project ManagerY/NGreen Amber RedF-cast Variance Target DeliveryCorporate Divisional CIP Investment in KGH Bleeps (stbc) Y Non-Pay S Adams 24 22 - - 22 (2) 2 - (2)McKesson Contract Change N Non-Pay G Perry 90 45 45 - 90 - - - -Pagers - reduced operating costs Y Non-Pay S Adams 30 - 28 - 28 (3) 3 - (3)Reduced McKesson Payroll Cost - weekly tomonthly payrollN Non-Pay L Malyon 72 - 72 - 72 - - - -Review of Payphones at KGH N Non-Pay S Adams 6 - 6 - 6 (1) 1 - (1)Rollover NEPT Contract N Non-Pay L Kruse 75 75 - - 75 - - - -Consolidation of PCT Transport SLA's N Non-Pay L Kruse 60 - 60 - 60 - 5 - (5)Reduction to Outturn on Fixtures andFittings (non-capital)N Non-Pay J Doyle 72 66 - - 66 (6) 6 - (6)Reduce Non-Capital Minor Works N Non-Pay J Doyle 30 30 - - 30 - 3 3 -Activity Reduction - NEPT Usage N Non-Pay L Kruse 45 - - 45 45 - - - -Bad Debt Charge Reduction - 20121/3 N Non-Pay D Wragg 150 - 150 - 150 - - - -Reduced External Consultancy Fees N Pay N Moloney 99 61 - - 61 (38) 8 5 (3)Removal of Seconded Staff N Pay D Wragg - - - - - - - - -HR - Staff Efficiencies N Non-Pay R McAll 25 - - 25 25 - - - -E-Rostering - Consolidated Med Staff RotaPlanning SavingsN Pay G Perry 140 - 140 - 140 - - - -R&D Enhanced Income/Cost Efficiency N Non-Pay J Alcolada 76 - - - - (76) 6 - (6)London/Quadrant Room Rduction FYE N Non-Pay J Doyle 39 39 - - 39 - 3 3 -ISTC 3rd Party Income Share N Non-Pay J Doyle 20 20 - - 20 - 2 2 -RO Water Testing Contract FYE N Non-Pay J Doyle 120 120 - - 120 - 10 10 -Goodmayes Rental N Non-Pay J Doyle 86 86 - - 86 - 7 7 -Car Park Expansion - 50 Spaces KGH N Ext Income J Doyle 46 46 - - 46 - 4 4 -Waste Contract Review of Service SpecN Non-Pay J Doyle 40 40 - - 40 - 3 3 -KGHClinical Engineering Post Reduction - 8dN Pay J Doyle 58 58 - - 58 - 5 5 -0.5WTEFood/Meal Spc Change Trustwide FYE N Non-Pay J Doyle 243 243 - - 243 - 20 20 -DOV12 KGH FM Element N Non-Pay J Doyle 50 50 - - 50 - 4 4 -Laundry Lease N Non-Pay J Doyle 170 170 - - 170 - 14 14 -Clincal Engineering SLA N Non-Pay J Doyle 8 8 - - 8 - 1 1 -Medical Gases N Non-Pay J Doyle - - - - - - - - -SBS Contract & Debt Mgt Resource Y Non-Pay A De Swarte 100 92 - - 92 (8) 8 - (8)Pay A De Swarte (60) (55) - - (55) 5 (5) - 5Medical staffing productivity Recruitment - Temp to Perm Y Pay (blank) - - - - - - - - -Theatre productivity Recruitment - Temp to Perm Y Pay (blank) - - - - - - - - -To be identified Total Divisional Target (blank) (blank) (blank) 54 - - 182 182 128 5 - (5)Corporate Total 1,968 1,216 500 252 1,968 (0) 114 81 (33)In MthVariance18

Workstream Summary 2012-13 - April 2012(all figures in £'000)Data12/13 TargetAnnual StatementIn Month StatementDivision CIP Scheme SchemeMandated12-13 12-13 In Mth In MthExpenditure Type Project ManagerY/NGreen Amber RedF-cast Variance Target DeliveryCentral Divisional CIP Stafflow N Pay (blank) 506 506 - - 506 - - - -Jnr Doctors Rotas N Pay (blank) 150 150 - - 150 - - - -Vacancy Restriction to review up to 100WTErelative to 12/13 budgetsN Pay (blank) - - - - - - - - -CNS N Pay (blank) - - - - - - - - -SNR Nursing N Pay (blank) 100 - - 100 100 - - - -Pharmacy - 5% Staff N Pay (blank) 125 - - 125 125 - - - -Radiology N Pay (blank) - - - - - - - - -ARMD N Non-Pay (blank) 150 - - 150 150 - - - -Drugs N Non-Pay (blank) - - - - - - - - -Management & Admin N Pay (blank) 250 - - 250 250 - - - -Capital Driven Efficiences N Non-Pay (blank) - - - - - - - - -PMO Driven Efficiences N Non-Pay (blank) - - - - - - - - -Direct Access N Non-Pay (blank) - - - - - - - - -Income Opportunities Capital project mgt N Non-Pay (blank) 500 500 - - 500 - - - -Outpatient productivity OP Nursing N Pay (blank) - - - - - - - - -OP Diagnostics N Pay (blank) - - - - - - - - -Procurement - other Consumables N Non-Pay (blank) 292 292 - - 292 - - - -Ward Consumables N Non-Pay (blank) 225 - 225 - 225 - - - -Vat on Energy N Non-Pay (blank) 230 - 230 - 230 - - - -Project / External Consultancy N Non-Pay (blank) 188 - 188 - 188 - - - -Bed Contract - KGH (Cap'n) N Non-Pay (blank) 50 50 - - 50 - - - -HCA N Non-Pay (blank) - - - - - - - - -VAT on IT Managed Service N Non-Pay (blank) 150 - 150 - 150 - - - -A&E A&E KGH @ night N Non-Pay (blank) 750 - - 750 750 - - - -Staff Absence IHB Bookings Sickness cover N Pay (blank) - - - - - - - - -IHB Bookings Additional Sessions N Pay (blank) - - - - - - - - -IHB Bookings Additional Resource N Pay (blank) - - - - - - - - -Procurement automation Procurement Automation N Non-Pay (blank) 500 250 250 - 500 - - - -To be identified Total Divisional Target (blank) (blank) (blank) 1,604 - - 1,604 1,604 - 134 - (134)Central Total 5,769 1,748 1,043 2,979 5,769 - 134 - (134)In MthVarianceGrand Total 23,145 8,693 4,231 10,221 23,145 0 1,027 355 (672)19

6. Business Unit SummariesBelow are the summaries for each of the Clinical Business Units. They show the Direct Central Income position and their local Income and Expenditureposition, giving an overall Net Deficit (+) / Surplus (‐) position. All Income is shown as a credit (‐) and all variances are expressed as Adverse (‐) or Favourable(+). This is not an SLR report as none of the central income has been apportioned out to the activities that are supporting it, rather it represents where theincome is coded to. They do show the movement in the relation ship between coded income and expenditure between current year to date and prior yearaverage for expenditure and actual reported income.Anaesthetics.Description 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthAnaesthetics(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Critical Care 2,144 2,121 (18,634) (2,679) (29) 2,485 2,194 (3,264) (3,042) (222) 19,583Daycases 275 324 (1,865) (270) 41 409 388 (334) (330) (4) 2,023Devices & Drugs - - (6) 0 - - (18) (44) 26 107Elective 5 - (24) (4) 6 - (5) (3) (2) 28Non Elective - - (7) 0OP First Attendances 515 311 (470) (57) (37) 442 432 (84) (85) 1 506OP Follow Ups 272 120 (142) (11) (15) 206 295 (21) (25) 3 130OP Procedures 0 - (0)Direct Central ActivityIncome3,211 2,876 (21,148) (3,017) (45) 3,549 3,309 (3,726) (3,529) (197) 22,377Divisional/Local income (1,112) (169) (16) (174) (161) (13) (1,041)Pay- Permanent 529.29 29,272 4,377 502 602.28 538.17 5,176 4,529 647 31,056- Bank 42.88 772 589 (461) - 49.02 10 664 (653) 63- Agency 16.70 165 200 (172) 6.24 12.39 98 188 (90) 154Pay Total 588.87 30,209 5,166 (132) 608.52 599.58 5,285 5,381 (96) 31,273Non Pay 10,559 2,018 (258) 1,894 1,961 (67) 11,332CIP / Turnaround Target 0 (249) - (249) (1,690)Net Divisional I&E 39,656 7,015 (406) 6,756 7,181 (425) 39,875Net Deficit 18,508 3,998 (450) 3,030 3,653 (622) 62,25220

Specialist SurgeryDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthSpecialist Surgery(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Daycases 1,402 1,127 (9,984) (1,136) (268) 1,540 1,505 (1,673) (1,669) (4) 10,119Devices & Drugs - - (344) (39) 39 - - (89) (71) (17) 532Elective 274 226 (6,048) (851) (169) 249 241 (965) (959) (6) 5,835Non Elective 560 455 (7,796) (1,250) (208) 486 539 (1,188) (1,328) 140 7,129OP First Attendances 6,694 5,863 (6,122) (879) (111) 6,203 7,118 (905) (953) 48 5,474OP Follow Ups 10,985 11,825 (6,397) (1,013) 72 10,843 12,862 (936) (997) 60 5,662OP Procedures 1,726 1,748 (1,691) (289) (1) 1,710 1,787 (280) (292) 12 1,693Other 2,632 2,692 (3,528) (271) 0 2,454 2,256 (600) (553) (47) 3,602Regular Day Attenders 1 2 (3) (1) 1XBD 340 239 (486) (65) (28) 314 226 (85) (71) (14) 512Direct Central ActivityIncome24,615 24,179 (42,399) (5,796) (672) 23,799 26,534 (6,721) (6,892) 172 40,558Divisional/Local income (943) (151) (6) (158) (142) (16) (945)Pay- Permanent 220.90 14,251 2,090 285 258.90 230.36 2,530 2,248 282 15,227- Bank 11.26 359 205 (145) - 16.74 - 210 (210) -- Agency 7.05 62 114 (104) 0.15 3.60 1 57 (56) 7Pay Total - 239.21 14,672 2,409 36 259.05 250.70 2,531 2,516 15 15,234Non Pay - 2,698 419 31 456 427 29 2,728CIP / Turnaround Target 0 (64) - (64) (587)Net Divisional I&E 16,427 2,677 61 2,766 2,801 (36) 16,430Net Deficit (25,972) (3,118) (612) (3,955) (4,091) 136 56,98721

SurgeryDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthSurgery(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WT E) WTE)£000 £000 £000 £000Daycases 1,880 1,750 (6,981) (1,062) (109) 1,758 1,916 (985) (1,059) 74 5,960Devices & Drugs - - 631 (23) 23 - - (60) (73) 12 361Elective 611 572 (9,726) (1,540) 12 626 610 (1,650) (1,596) (54) 9,982Non Elective 1,187 1,314 (16,569) (2,804) 263 1,290 1,118 (2,751) (2,522) (229) 16,504OP First Attendances 3,177 3,282 (4,287) (684) 12 3,201 3,649 (654) (682) 28 3,955OP Follow Ups 5,590 5,528 (3,974) (618) (30) 5,184 6,070 (571) (596) 25 3,456OP Procedures 387 285 (1,058) (92) (61) 476 550 (120) (122) 2 724Other - - (280) (25) 0 - - (181) (328) 147 1,087Regular Day Attenders 95 117 (132) (27) 6 94 84 (38) (37) (1) 227XBD 531 595 (842) (140) (0) 493 402 (129) (115) (14) 779Direct Central ActivityIncome13,458 13,443 (43,218) (7,013) 114 13,122 14,400 (7,140) (7,130) (9) 43,035Divisional/Local income (1,680) (294) 14 (292) (282) (10) (1,749)Pay- Permanent 331.99 18,805 2,825 309 364.02 333.00 3,046 2,810 236 18,259- Bank 46.10 (4,506) 310 (1,061) 1.00 33.67 11 261 (250) 162- Agency 5.96 - 71 (71) - 2.92 2 29 (27) 13Pay Total - 384.05 14,300 3,205 (822) 365.02 369.59 3,060 3,100 (41) 18,434Non Pay - 2,102 337 13 352 337 15 2,107CIP / Turnaround Target 0 (91) - (91) (506)Net Divisional I&E 14,721 3,249 (795) 3,029 3,155 (127) 18,285Net Deficit (28,497) (3,764) (681) (4,111) (3,975) (136) 61,320MedicineDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthMedicine(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Daycases 1,562 2,015 (8,734) (1,310) 290 2,130 2,319 (1,482) (1,549) 67 8,964Devices & Drugs - - (115) (1) 1 - - (180) (172) (8) 1,080Elective 92 96 (1,052) (183) 17 92 92 (185) (170) (15) 1,117Non Elective 3,510 4,250 (61,608) (9,955) 1,386 3,927 4,376 (8,840) (9,722) 882 53,038OP First Attendances 3,195 4,005 (5,264) (879) 112 3,521 3,515 (864) (863) (1) 5,228OP Follow Ups 7,330 7,842 (5,759) (920) 49 7,671 7,763 (863) (849) (14) 5,218OP Procedures 813 98 (664) (15) (112) 842 772 (146) (140) (5) 881Other 1,448 2,205 33 (317) (23) 2,065 1,940 (130) (123) (7) 781Regular Day Attenders 1 - (6) (0) 1 - () () () 2XBD 3,734 3,164 (6,268) (758) (196) 3,475 2,077 (892) (638) (254) 5,354Direct Central ActivityIncome21,684 23,674 (89,436) (14,338) 1,523 23,723 22,854 (13,581) (14,226) 645 81,663Divisional/Local income (5,579) (903) (27) (844) (817) (27) (5,001)Pay- Permanent 837.51 41,353 6,108 784 913.69 810.35 6,735 5,968 767 40,038- Bank 133.69 180 813 (783) 4.93 118.62 (10) 741 (751) (1,161)- Agency 23.19 611 379 (277) 10.25 20.14 110 319 (209) 525Pay Total - 994.39 42,145 7,300 (276) 928.87 949.11 6,835 7,028 (193) 39,402Non Pay - 7,117 1,262 (75) 1,234 1,202 32 7,328CIP / Turnaround Target 0 (20) - (20) (120)Net Divisional I&E 43,683 7,659 (378) 7,205 7,413 (208) 41,609Net Deficit (45,753) (6,679) 1,145 (6,376) (6,813) 437 123,27222

Emergency CareDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthEmergency care(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000AandE 27,887 30,738 (19,761) (3,102) 228 35,330 36,809 (3,424) (3,450) 26 20,545Ambulatory Care 333 484 (953) (145) 45 510 578 (150) (157) 6 902Daycases - - (1) 0Elective 7 4 (93) (4) (8) 12 - (21) (12) (9) 130Non Elective 964 1,338 (5,656) (970) 258 1,379 1,306 (1,070) (1,094) 23 6,421OP First Attendances 558 518 (258) (48) (4) 477 503 (57) (57) 346OP Follow Ups 49 48 (30) (5) (0) 38 56 (1) (2) 9Other - - (243) (28) 0 - - (28) (28) 169XBD 3 - (116) (1) 0 - () () ()Direct Central ActivityIncome29,801 33,130 (27,111) (4,303) 518 37,746 39,252 (4,753) (4,800) 47 28,522Divisional/Local income (769) (101) (27) (119) (104) (16) (688)Pay- Permanent 455.78 25,791 3,375 923 555.28 477.62 4,537 3,638 900 27,182- Bank 44.68 91 362 (346) 7.42 45.01 77 375 (298) 461- Agency 48.17 1,872 996 (684) 28.34 54.13 544 1,187 (643) 2,823Pay Total - 548.63 27,755 4,733 (107) 591.04 576.76 5,159 5,200 (41) 30,466Non Pay - 2,788 515 (50) 505 492 14 3,002CIP / Turnaround Target 0 (111) - (111) (667)Net Divisional I&E 29,774 5,147 (184) 5,434 5,588 (154) 32,113Net Deficit 2,663 844 334 681 788 (107) 60,635NeurosciencesDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthNeurosciences(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Daycases 42 61 (413) (57) 1 70 72 (73) (60) (12) 439Devices & Drugs - - (1,679) (338) 29 - - (298) (254) (44) 1,791Elective 147 168 (3,344) (643) 26 147 166 (679) (706) 27 4,110Non Elective 299 374 (9,822) (1,629) 66 388 373 (1,678) (1,575) (103) 10,067OP First Attendances 1,138 890 (1,794) (223) (90) 1,046 1,135 (322) (339) 17 1,950OP Follow Ups 1,549 1,611 (1,480) (199) (14) 1,643 1,895 (250) (263) 13 1,513OP Procedures 228 337 (292) (47) 14 365 292 (54) (49) (5) 326Other 899 1,333 (8,092) (1,459) 241 1,078 936 (1,301) (1,303) 2 7,804XBD 603 385 (794) (97) (68) 571 22 (153) (42) (111) 923Direct Central ActivityIncome4,905 5,158 (27,711) (4,692) 206 5,308 4,891 (4,809) (4,592) (217) 28,923Divisional/Local income (935) (123) (33) (90) (108) 19 (538)Pay- Permanent 201.45 11,252 1,685 191 229.42 198.77 1,967 1,757 210 11,804- Bank 31.32 66 199 (188) 4.74 29.05 28 179 (151) 167- Agency 4.75 - 81 (81) 1.49 4.48 (48) 65 (113) (386)Pay Total - 237.52 11,318 1,965 (78) 235.65 232.30 1,947 2,001 (54) 11,584Non Pay - 2,789 430 35 438 411 27 2,624CIP / Turnaround Target 0 (24) - (24) (146)Net Divisional I&E 13,171 2,271 (76) 2,272 2,304 (33) 13,523Net Deficit (14,539) (2,421) 130 (2,537) (2,288) (249) 42,44623

PathologyDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthPathology(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Direct Access 738,864 754,371 (10,274) (1,644) 3 783,818 749,546 (1,653) (1,530) (123) 9,918Direct Central ActivityIncome738,864 754,371 (10,274) (1,644) 3 783,818 749,546 (1,653) (1,530) (123) 9,918Divisional/Local income (1,162) (139) (55) (139) (125) (15) (835)Pay- Permanent 276.99 14,106 2,261 90 286.88 278.02 2,325 2,284 41 13,656- Bank 2.04 68 17 (5) - 4.07 - 24 (24) -- Agency 6.01 (404) 68 (136) - 3.89 (13) 38 (50) (75)Pay Total - 285.04 13,770 2,346 (51) 286.88 285.98 2,313 2,347 (34) 13,581Non Pay - 8,281 1,348 32 1,394 1,530 (136) 8,363CIP / Turnaround Target 0 (56) - (56) (598)Net Divisional I&E 20,888 3,555 (74) 3,511 3,752 (240) 20,510Net Deficit 10,614 1,911 (71) 1,858 2,222 (364) 30,428RadiologyDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthRadiology(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WT E) WTE)£000 £000 £000 £000Breast Screening 3,370 3,794 (2,221) (376) 42 3,774 3,878 (374) (384) 10 2,241Devices & Drugs (1,189) 0 - - (161) (302) 141 968Direct Access 14,049 14,297 (3,985) (637) 38 14,679 13,920 (650) (645) (5) 3,900OP First Attendances 397 33 (38) (5) (61) 36 45 (6) (6) 1 36OP Follow Ups 87 - (7)OP Procedures 12 - (3)Radiotherapy 3,263 3,190 (2,977) (530) (12) 3,169 3,308 (643) (645) 2 3,860Other (163) 0Direct Central ActivityIncome21,177 21,314 (10,571) (1,547) (4) 21,657 21,151 (1,834) (1,983) 148 11,005Divisional/Local income (395) (67) 1 (67) (62) (5) (400)Pay- Permanent 248.03 13,867 2,088 224 283.68 256.21 2,599 2,130 469 15,467- Bank 11.22 27 183 (178) - 20.36 - 242 (242) -- Agency 10.83 155 314 (289) - 13.86 - 356 (356) -Pay Total - 270.08 14,048 2,585 (243) 283.68 290.43 # 2,599 2,728 (129) 15,467Non Pay - 2,964 569 (75) 548 654 (106) 3,273CIP / Turnaround Target 0 1 - 1 (620)Net Divisional I&E 16,617 3,087 (317) 3,081 3,320 (239) 17,720Net Deficit 6,046 1,539 (321) 1,247 1,337 (90) 28,72524

Specialist MedicineDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthSpecialist Medicine(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Daycases 357 355 (1,713) (217) (7) 411 479 (254) (275) 20 1,539Devices & Drugs - - (511) (91) 21 - - (920) (867) (52) 5,519Direct Access 4,221 4,625 (1,234) (254) 22 5,942 5,710 (205) (196) (9) 1,231Elective 34 28 (290) (25) (26) 34 24 (59) (56) (2) 355Non Elective 129 171 (3,330) (509) 125 185 170 (536) (524) (12) 3,215OP First Attendances 3,200 2,564 (3,364) (476) (121) 2,803 3,007 (533) (538) 5 3,223OP Follow Ups 13,997 15,607 (7,471) (1,172) 63 14,413 16,170 (1,072) (1,120) 48 6,482OP Procedures 108 1,256 (753) (118) 101 1,382 1,417 (124) (129) 5 751Other - - (326) (115) (7) - - (132) (147) 15 792Regular Day Attenders 1,892 2,009 (4,956) (771) (5) 2,172 2,016 (875) (844) (31) 5,252XBD 176 506 (332) (123) 77 131 91 (35) (32) (3) 209Direct Central ActivityIncome24,114 27,120 (24,281) (3,872) 244 27,472 29,084 (4,744) (4,729) (15) 28,566Divisional/Local income (5,661) (1,137) 194 (1,182) (1,072) (110) (7,090)Pay- Permanent 546.32 27,092 4,101 414 591.95 558.98 4,534 4,196 338 27,254- Bank 17.50 5 118 (117) - 15.87 - 100 (100) -- Agency 22.18 (494) 270 (353) - 24.56 - 253 (253) -Pay Total - 586.00 26,602 4,489 (56) 591.95 599.41 4,534 4,549 (15) 27,254Non Pay - 19,280 3,530 (317) 3,591 3,478 113 21,598CIP / Turnaround Target 0 (114) - (114) (1,960)Net Divisional I&E 40,222 6,882 (179) 6,829 6,955 (126) 39,802Net Deficit 15,941 3,011 65 2,085 2,226 (141) 68,368ChildrenDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthChildren(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Critical Care 2,025 1,856 (7,502) (1,133) (133) 2,020 2,096 (1,212) (1,311) 99 7,271Daycases 38 83 (594) (69) 42 114 99 (87) (79) (9) 528Devices & Drugs (6) 0 - - (20) (25) 5 119Elective 8 17 (155) (30) 20 14 13 (25) (42) 18 148Non Elective 2,361 2,617 (11,841) (1,646) 245 2,837 2,329 (1,898) (1,605) (293) 11,389OP First Attendances 807 712 (1,250) (182) (20) 800 1,361 (216) (276) 60 1,305OP Follow Ups 1,465 1,158 (1,028) (168) (37) 1,120 1,286 (173) (186) 13 1,048Other - - 208 (129) (0) - - (210) (210) 1,260Regular Day Attenders 60 43 (17) (4) (28) 61 66 (25) (26) 152XBD 128 979 (713) (167) 125 435 360 (139) (119) (20) 835Direct Central ActivityIncome6,892 7,465 (22,897) (3,528) 214 7,402 7,610 (4,005) (3,877) (128) 24,056Divisional/Local income (1,136) (161) (28) (162) (154) (8) (973)Pay- Permanent 217.88 12,117 1,962 58 256.44 217.63 2,339 2,045 294 14,035- Bank 25.86 279 223 (176) - 21.78 16 173 (156) 98- Agency 9.74 (33) 141 (146) - 3.92 - 66 (66) -Pay Total - 253.48 12,363 2,325 (265) 256.44 243.33 2,355 2,284 71 14,132Non Pay - 1,029 211 (40) 164 210 (46) 950CIP / Turnaround Target 0 (5) - (5) (60)Net Divisional I&E 12,257 2,376 (333) 2,352 2,340 12 14,050Net Deficit (10,640) (1,152) (119) (1,653) (1,537) (116) 38,10625

Support ServicesDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthSupport Services(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Average Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE) £000 £000 £000 £000Direct Central ActivityIncome- - - 0 - 0 0.00 0.00 0Divisional/Local income (123) (22) 2 (25) (20) (5) (147)Pay- Permanent 346.44 10,832 1,596 209 369.39 368.14 1,727 1,699 28 10,361- Bank 31.44 (299) 117 (167) - 17.55 (0) 72 (72) -- Agency 3.31 - 14 (14) - - - 0 (0) -Pay Total - 381.19 10,532 1,727 28 369.39 385.69 1,727 1,771 (45) 10,361Non Pay - 399 69 (3) 65 67 (2) 391CIP / Turnaround Target 0 (42) - (42) (528)Net Divisional I&E 10,809 1,774 27 1,725 1,819 (94) 10,077Net Deficit 10,809 1,774 27 1,725 1,819 (94) 10,077WomenDescription 2011/12 2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13 2012/13YTDActualIn Month In monthWomen(Activity / AnnualBudget ActualYTD YTD AnnualYTD Budget Av e rage Budget Actual Varianc (Activity (Activity / YTD Budget Actual Variance BudgetActivity WTE) £000 £000 e £000 / WTE) WTE)£000 £000 £000 £000Daycases 582 516 (2,739) (457) (45) 542 470 (399) (372) (27) 2,414Devices & Drugs (36) 0Elective 130 126 (1,855) (297) (12) 130 125 (292) (295) 4 1,765HIV Contract - - (4,316) (719) 0 - - (711) (711) 4,264Non Elective 2,144 2,285 (24,887) (4,188) 305 2,143 2,137 (3,782) (3,765) (17) 22,692OP First Attendances 8,318 9,172 (8,463) (1,377) 132 8,886 9,223 (1,320) (1,322) 2 7,983OP Follow Ups 17,829 20,494 (9,691) (1,532) 187 18,035 21,911 (1,332) (1,411) 79 8,057OP Procedures 694 736 (876) (151) 10 721 678 (155) (158) 3 936Other 7,647 8,138 (2,917) (418) 24 7,574 8,014 (381) (403) 22 2,287XBD 149 112 (389) (47) (13) 134 90 (55) (41) (15) 333Direct Central ActivityIncome37,493 41,579 (56,168) (9,187) 587 38,165 42,649 (8,427) (8,478) 51 50,732Divisional/Local income (2,303) (387) 3 (380) (374) (6) (2,281)Pay- Permanent 604.54 30,201 4,699 335 655.54 591.40 5,047 4,657 390 30,911- Bank 59.95 (160) 410 (436) 2.50 59.52 117 403 (287) 990- Agency 31.44 10 421 (420) - 8.46 - 153 (153) -Pay Total 695.93 30,051 5,530 (521) 658.04 659.38 5,164 5,212 (49) 31,901Non Pay 5,956 1,106 (113) 1,074 1,102 (28) 6,444CIP / Turnaround Target 0 (30) - (30) (574)Net Divisional I&E 33,705 6,249 (631) 5,827 5,940 (112) 35,490Net Deficit (22,464) (2,938) (44) (2,600) (2,538) (61) 86,22126

7. BALANCE SHEETCurrent Previous Last(£m) Period Period Yr EndMay-12 Apr-12 Mar-12Non-current assets £390.4 £387.5 £389.1Current assetsInventories £5.8 £5.8 £7.0Trade and other receivables £37.3 £55.8 £29.5Cash and cash equivalents £26.6 £11.2 £2.8£69.6 £72.8 £39.3Current liabilitiesTrade and other payables (£79.6) (£79.8) (£48.2)PFI \ Borrowings (£6.3) (£6.3) (£5.5)Provisions (£1.9) (£2.1) (£1.8)Net current assets/(liabilities) (£18.2) (£15.4) (£16.2)Non-current liabilities:PFI \ Borrowings (£257.1) (£257.1) (£259.9)Trade and other payables (£4.9) (£4.9) (£4.9)Provisions (£5.8) (£5.6) (£5.0)Total assets employed £104.5 £104.5 £103.0Financed by taxpayers' equity:Public dividend capital £365.7 £365.7 £307.3Retained Earnings - P&L (£272.7) (£271.5) (£216.4)Retained Earnings - Donated Assets - - -Revaluation reserve £11.5 £10.3 £11.3Donated asset reserve £0.0 £0.0 £0.8Total taxpayers' equity £104.5 £104.5 £103.0• oCurrent Prior LastKPIs Period Period Yr EndMay-12 Apr-12 Mar-12Average Debtors days 18 21 21Debtors >90 days (£'000s) £451 £776 £592Debtors >180 days (£'000s) £1,023 £823 £1,536Debtors >365 days (£'000s) £2,104 £2,021 £2,825Total Bad Debt Provision (£'000s) £2,521 £2,431 £1,926>365 days provided (£'000s) £1,857 £1,755 £1,293Average creditor days 54 80 58Current ratio 74% 78% 71%Better payment practice code performance:- Non-NHS- Volume - paid on time 3,127 1,659 2,773- Volume - % paid on time 66.19% 82.66% 27.96%- Value - paid on time (£'000s) £7,167.00 £16,910.00 £5,150- Value - % paid on time 75.70% 98.34% 35.85%- NHS- Volume - paid on time 65 7 316- Volume - % paid on time 34.95% 22.58% 34.39%- Value - paid on time (£'000s) £170 £116 £1,630- Value - % paid on time 22.13% 6.06% 30.52%Key points:• The overall balance sheet position shows an increase of £15m in cash and cash equivalentscompared with April 2012. This is from the reduction in debtors with PCT’s paying June’sSLA invoices in advance. The cash balance has been left in order to pay the PFI invoice inJuly.Key points:• Average creditor days decreased from 80 in April to 54in May. The reason for this is due to the PCT’s payingfurther invoices in advance to enable creditors to bepaid.27

8. CAPITAL AND CASHFLOWo2Summary Cashflow - Year to date£000'sOperating Deficit (4,300)Interest Paid (6,164)PDC Dividend Paid 0Interest received 10Impairments (1,786)Transfers -Net I&E deficit (cash impact) (12,240)Capital Programme SummaryMay-12TotalApproved 2012-13TotalProposed 2012-13TotalFunding2012-13YTDExpenditureInternally Funded AssetsMedical Equipment 1,282 2,130 3,412 829IT – Hardware 1,119 659 1,778 343IT – S o ftwa re 0 0 0 36Other Plant & Machinery 500 0 500 0E s ta te s 2,782 382 3,164 259sub-Total 5,683 3,171 8,854 1,467Depreciation and Amortisation 2,373Movements in working balances:Decrease in Inventories 53Increase in Trade and Other Receivables 207Increase in Trade and Other Payables 36,611Decrease in Provisions (11)- sub-total 26,993Capital expenditure (3,467)Revenue Rental Income 207Net cashflow before financing 23,733Capital Element of Finance Leases and PFI (1,488)Loans repaid -Public Dividend Capital Received -Externally Funded AssetsP a tho lo g y 4,194 900 5,094 208SAN 967 0 967 249MLU 2,576 0 2,576 51Access Funded Assets 117 0 117 11sub-Total 7,854 900 8,754 519Trust Variation Enquiries 0 2,966 2,966 161Total Trust - Funded 13,538 7,037 20,575 2,146Subject to External Approval & FundingCardiac Cath Lab 0 1,700 1,700 0CT Scanners 0 2,000 2,000 0A&E Reconfiguration 0 3,000 3,000 0Digital Mammography 0 1,548 1,548 0PAS Replacement 0 10,000 10,000 0sub-Total 0 18,248 18,248 0Total Capital Plan to Date 13,538 25,285 38,823 2,146Net Increase/(Decrease) in Cash and CashEquivalents22,246Opening cash balance 4,343Closing cash balance 26,589Cashflow - Key points:• The year to date cash deficit arising from the I&E position stands at £12,240k.• The closing cash balance has increased to £26,589 as the Trust is building upfunds to pay the next PFI instalment in July.• The increase in trade payables includes the £23m PCT advances, which wasreceived close to Month end, accounting for the high closing cash balances.Total Trust Submitted Plan 40,011Balance to Submitted Plan 1,188Assets to be Considered via Charitable FunDa Vinci Robot 0 2,400 2,400Capital - Key points:• Year to date capital expenditure is £2,146k• Subject to external funding is £25,285k which has yet to be finalised.The additional funding is required for the Trust reconfigurationFoundation Trust application.28

9. Financial Risk Rating (Using Dept of Health’s risk bandings between 1.0 and 3.0 where riskier organisations score closer to 1)The weighted financial risk score for May is 1.38, (April 1.55). Although creditor days has improved the score by 0.05, the score as a whole worsens inmonth because the operating deficit to date now exceeds 2% of planned income. April’s rating would have been artificially high.Overall movement in Risk Rating29

Appendix 7Financial indicators for acute & ambulance trusts : BHRUT May 12SCORINGCriteriaInitial PlanningMetricPlanned Outturn as a proportion ofTurnoverFormula for organisations with aplanned operating breakeven orsurplusSHA expected operating surplus orbreakeven -planned operating surplus or breakevenPlanned IncomeFormula for organisations with aplanned operating deficitx 100 x 100Planned operating deficitPlanned IncomeWeight (%)5 5Measure-9.4%3 2 1Planned operating breakeven or surplus that iseither equal to or at variance to SHAexpectations by no more than 3% of income.Any operating deficit less than 2% of income ORan operating surplus/breakeven that is atvariance to SHA expectations by more than 3%of planned income.Operating deficit more than or equal to 2% ofplanned incomeBHRUTBHRUT RawWeightedScore APR 12Score APR 1210.05Year to DateYTD Operating PerformanceFormula for organisations with a YTD Formula for organisations with a YTDactual operating breakeven or surplus actual operating deficitYTD planned operating breakeven/surplus/deficit - YTD actual operatingbreakeven or surplusForecast Incomex 100YTD operating deficitForecast Incomex 1002520-2.6%YTD operating breakeven or surplus that iseither equal to or at variance to plan by no morethan 3% of forecast income.Any operating deficit less than 2% of income ORan operating surplus/breakeven that is atvariance to plan by more than 3% of forecastincome.Operating deficit more than or equal to 2% offorecast income10.20YTD EBITDAYTD EBITDAActual YTD Incomex 1005-5.5%Year to date EBITDA equal to or greater than 5%of actual year to date incomeYear to date EBITDA equal to or greater than1% but less than 5% of year to date incomeYear to date EBITDA less than 1% of actual yearto date income.10.05Forecast OutturnForecastForecast Operating PerformanceEBITDAFormula for organisations with aforecast operating breakeven orsurplusPlanned operating breakeven/surplus/deficit - Forecast operatingbreakeven or surplusForecast Incomex100Forecast EBITDAForecast IncomeFormula to be used for organisationswith a forecast operating deficitForecast operating deficitForecast Incomex100x 10040205-9.9%-0.4%Forecast operating breakeven or surplus that iseither equal to or at variance to plan by no morethan 3% of forecast income.Forecast EBITDA equal to or greater than 5% offorecast income.Any operating deficit less than 2% of income ORan operating surplus/breakeven that is atvariance to plan by more than 3% of income.Forecast EBITDA equal to or greater than 1%but less than 5% of forecast income.Operating deficit more than or equal to 2% ofincomeForecast EBITDA less than 1% of forecastincome.110.200.05Rate ofChange inForecastSurplus orDeficit.(Current period forecast surplus/deficit) - (Prior period forecast surplus/deficit)Forecast Incomex 100150.0%Forecasting an operating deficit with aStill forecasting an operating surplus with amovement less than 2% of forecast income ORmovement equal to or less than 3% of forecastan operating surplus movement more than 3% ofincomeincome.Forecasting an operating deficit with amovement of greater than 2% of forecastincome.20.30Underlying FinancialPositionUnderlyingPosition %EBITDA Margin (%)Underlying Breakeven/Surplus/DeficitUnderlying IncomeUnderlying EBITDAUnderlying Incomex 100510x 100 5-12.7%3.1%Underlying breakeven or SurplusUnderlying EBITDA equal to or greater than 5%of underlying incomeAn underlying deficit that is less than 2% ofunderlying income.Underlying EBITDA equal to or greater than 5%but less than 1% of underlying incomeAn underlying deficit that is greater than 2% ofunderlying incomeUnderlying EBITDA less than 1% of underlyingincome110.050.05Processes & Balance Sheet EfficiencyBetter BetterPayment PaymentDebtor Days Current Ratio Practice PracticeCode Volume Code Value%%Value of ALL Bills paid within targetValue of ALL Bills paid within the yearVolume of ALL Bills paid within targetVolume of ALL Bills paid within the yearDebtors as at current periodForecast Incomex 100x 100Current AssetsCurrent Liabilities202.52.5561%54%0.7495% or more of the value of NHS and Non NHSbills are paid within 30days95% or more of the volume of NHS and NonNHS bills are paid within 30daysLess than 95% but more than or equal to 60% ofthe value of NHS and Non NHS bills are paidwithin 30daysLess than 95% but more than or equal to 60% ofthe volume of NHS and Non NHS bills are paidwithin 30daysLess than 60% of the value of NHS and NonNHS bills are paid within 30 daysLess than 60% of the volume of NHS and NonNHS bills are paid within 30 daysCurrent ratio is anything less than 1 and greaterCurrent Ratio is equal to or greater than 1. A current ratio of less than 0.5than or equal to 0.5Debtor days greater than 30 and less than orx365 518Debtor days less than or equal to 30 daysDebtor days greater than 60equal to 60 days2 0.051 0.032 0.103 0.1530

EXECUTIVE SUMMARYTITLE:Workforce Key Performance IndicatorsBOARD/GROUP/COMMITTEE:Trust Board & TEC1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) and DATE:• For the month of May 2012 the overall number ofFTE's in post across the Trust increased by31.13 FTE's on the April position and hasincreased by 185.40 FTE's across the 12 monthperiod.• The number of starters in month was 49.48FTE's compared to 45.04 FTE's in the previousmonth. Following a period of focussedrecruitment activity, a total of 617.99 FTE's havestarted in the Trust since June 11. Maydemonstrated another decrease in the number ofleavers with 32.33 fte leavers compared to 45.83in April.• Starters & leavers data analysis over the sameperiod differs from the staff in post growth for thesame 3 reasons as in previous reports.1. If new starters commence employment or leaveafter the payroll cut off date (midmonth) they will notbe entered or removed onto/off ESR until month end– therefore they will not appear on the staff in postreport generated from ESR until the following month.2. Staff who increase or decrease their hours willaffect the reported FTE’s in post but not the startersand leavers3. Timliness of managers completing and submittingthe appropriate forms to HR - for entering onto ESR.• In addition to the overall Trust Bank & Agencyspend increasing by £713,527 in month, dataalso shows that May 2012 produced the highesttemporary staffing spend over the 12 monthperiod . The bank and agency spend for Mayaccounts for 16.32% of the pay bill, an increaseof 3.12% on the April position.• The fact that temporary staff spend in Mayincreased significantly yet FTE usage decreasedis likely to be attributed to accrual of invoices atyear end.• Despite the significant increase in spend, overallTrust bookings of Bank & Agency remainedrelatively static on the April position with a 0.39FTE increase from the previous month. Thenumber of agency bookings increased by 7.37FTE's in month - bank bookings decreased by7.76 FTE's over the same period.1. Midwifery bank and agency FTE bookingsdecreased in May by 3.10 FTE's on the Aprilposition.√ TEC June 2012 □ EPB………..…….□ FINANCE …………… □ AUDIT ………..….□ CLINICAL GOVERNANCE …………..…...……□ CHARITABLE FUNDS ………………………...…√ TRUST BOARD July 2012□ REMUNERATION ………………………….…...□ OTHER ………………………. (please specify)CATEGORY:□ NATIONAL TARGET□ CNST□ STANDARDS FOR BETTER HEALTH□ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE …………………..……………………………………………………..□ OTHER …………………….. (please specify)AUTHOR/PRESENTER:Author – Linda Baker – Head of workforcePlanningPresenter – Ruth McAll – Director of WorkforceDATE: 22 June 20121

2. Registered Nursing temporary staff bookingsdecreased in May by 14.57 FTE's on theApril position.3. We have seen an increase this month to thetemporary staffing usage in the Medical &Dental staff group by 9.64 FTE whencompared to April 2012.4. Admin & Clerical have seen the biggestincrease in Bank and Agency usage thismonth, rising from 64.24 FTE in April to76.98 in May. An overall increase of 12.74FTE• Feedback from the Divisions & AssociateDirector IHB have identified that there continuesto be a high number of requests for specialistagency bookings• For the month of May, Trust annualised turnoverremained the same at 10.9% - this is 1.1% belowthe average of other large Acute Trusts.• The overall reported sickness absence rates forthe month of May has increased slightly by0.22% on the April position, rising from 4.29% to4.51% across the month.• The sickness absence rate has decreased by0.31% when compared to the same period lastyear.• HR have repeated the pan Londonbenchmarking exercise against other acuteLarge London Trusts this shows that thecombined average sickness absence rate for thisgroup is 3.59% - as such the graph has beenrevised to reflect this. Based upon this revisedinformation BHRUT's benchmarked positionshows us as currently sitting 0.92% above the3.59% average of all other large acute LondonTrusts. The Trust's target has been left at 3.6%• The estimated costs associated with sicknessabsence has increased this month, in line withoverall percentage. It is estimated that the costto the Trust for April was £645,566. This figurehas risen by an estimated £26,612 on the sameperiod last year.• When the number of FTE's lost due to sicknessabsence is analysed by reason for absence, thehighest loss is seen in 'Unknown causes - notspecified' with 52.39 fte lost• In order to further improve the accuracy ofsickness absence reporting and recording, HRhave incorporated ‘effective recording processes'in their ' Essential skills for managers ' trainingprogramme. The effects of this training on theactual reported data may take time to show ademonstrable change2. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:None3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION:N/A2

4. DELIVERABLES:Continuous measurement and monitoring of workforce performance against NHS and local agreedtargets5. EVIDENCE :ESR dataIView DataNHSIE data6. RECOMMENDATION/ACTION REQUIRED:No action for information onlyAGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE ___________________________(if applicable)3

TRUST - WORKFORCE KEY PERFORMANCE INDICATORS - MAY 2012Indicator Target May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 YTDStaff In Post 5192.63 5215.55 5223.68 5250.52 5263.48 5313.23 5363.19 5353.99 5355.45 5350.71 5366.64 5366.82 5397.95 182.40Starters *¹ 55.83 46.59 40.73 59.29 70.57 78.23 55.37 31.24 44.46 38.74 58.25 50.44 49.48 623.39Leavers *¹ 32.60 35.25 44.96 46.70 49.75 38.32 40.87 42.38 39.15 41.19 52.31 45.83 32.33 509.04Turnover (Annualised)*¹12.0% 11.0% 11.0% 11.65% 10.88% 10.69% 10.60% 10.70% 10.78% 10.82% 11.0% 10.9% 10.9% 10.9%Trust SicknessAbsence % for month4.5% 4.82 3.63 5.05 5.35 4.80 5.46 5.13 6.00 5.15 5.81 4.41 4.29 4.51Trust SicknessAbsence Rolling 12Month PeriodTrust Estimated Cost ofSickness Absence(Month)3.6% 4.38 4.30 4.38 4.46 4.49 4.63 4.31 4.77 4.76 4.87 4.92 4.99 4.97£672,178 £482,909 £668,946 £704,259 £618,998 £760,710 £707,395 £903,771 £756,866 £764,730 £594,960 £582,757 £645,566 £8,191,867Appraisals 80.0% 78.60% 72.40% 72.09% 76.72% 76.03% 76.42% 72.25% 73.74% 77.80% 79.3% 74.3% 77.9% 78.49%Resus 80.0% 80.26% 78.42% 77.38% 72.62% 69.04% 68.22% 68.26% 72.15% 75.69% 77.8% 78.6% 76.3% 77.86%Paybill Budget £22,735,275 £22,223,328 £22,030,665 £22,326,245 £21,393,649 £21,806,873 £22,000,988 £21,907,263 £22,422,582 £22,276,976 £25,028,069 £23,895,905 £23,701,154 £271,013,698Paybill £23,999,750 £24,005,808 £24,058,435 £24,665,197 £24,012,335 £24,085,519 £24,357,038 £24,267,150 £24,857,841 £24,430,745 £24,518,224 £24,282,126 £24,950,935 £292,491,353Bank/Agency Spend £3,437,137 £3,361,872 £3,662,378 £3,653,979 £3,259,189 £3,179,473 £3,176,222 £3,079,296 £3,527,427 £3,053,265 £3,584,109 £3,155,363 £3,868,890 £40,561,463% Paybill Budget spenton bank & Agency staff15.12% 15.13% 16.62% 16.37% 15.23% 14.58% 14.44% 14.06% 15.73% 13.71% 14.32% 13.20% 16.32% 14.97%Overtime Spend (£) £131,254 £93,063 £104,179 £112,130 £116,637 £67,772 £65,940 £58,911 £69,768 £70,658 £62,666 £53,941 £61,881 £937,546IHB FTE Bookings 663.81 637.33 677.85 688.47 646.05 663.25 661.31 600.15 667.76 672.17 714.77 587.37 586.98 7803.46IHB FTE Booked as a %of Substantive SIP12.78% 12.22% 12.98% 13.11% 12.27% 12.48% 12.33% 11.21% 12.47% 12.56% 13.32% 10.94% 10.87% 12.23%*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotationFinancial value in month of February 2012 for Bank/Agency spend has been adjusted by a £353,356 reduction relating to prior period accruals. This has come about from: an improved system between IHB and Finance creating a more accuratebase resulting in an downward adjustment of £182,354 for agency; a further reduction to the agency accrual due to writing off of old year agency accruals from the system of £51,186 as part of an aged analysis; and as a reduction for ageing to theBank Accrual of £119,816.1

Staff in PostStarters & LeaversFTE's5500.005400.005300.005200.005100.00FTE's90.0080.0070.0060.0050.0040.0030.0020.0010.000.005000.00May-11Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11Dec-11MonthJan-12Feb-12Mar-12Apr-12May-12May-11Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11Dec-11MonthJan-12Feb-12Mar-12Apr-12May-12Staff in PostStartersLeaversStaff in Post ( SIP )For the month of May 2012 the overall number of FTE's in post across the Trust increased by 31.13 FTE's on the April position and has increased by 185.40 FTE's across the 12month period.Starters & leaversThe number of starters in month was 49.48 FTE's compared to 45.04 FTE's in the previous month. Following a period of focussed recruitment activity, a total of 617.99 FTE's havestarted in the Trust since June 11. May demonstrated another decrease in the number of leavers with 32.33 fte leavers compared to 45.83 in April. Supported by the HR Advisors,Divisions have been tasked to actively promote Exit interviews so that 'reasons for leaving' can be truly understood. Findings of this piece of work will be reported within futurescorecards once the data has been analysed in a meaningful way.Starters & leavers data analysis over the same period differs from the staff in post growth for the same 3 reasons as in previous reports.1. If new starters commence employment or leave after the payroll cut off date (midmonth) they will not be entered or removed onto/off ESR until month end – therefore they will notappear on the staff in post report generated from ESR until the following month.2. Staff who increase or decrease their hours will affect the reported FTE’s in post but not the starters and leavers3.Timliness of managers completing and submitting the appropriate forms to HR - for entering onto ESR.Trust Overall Scorecard - May 2012 - Workforce Information Department

Temporary staff Use and Spend4500000Bank/Agency Spend ( Provided by Finance)800IHB Bookings - FTE3750000700Spend (£'s)3000000225000015000007500000May-11Jun-11Jul-11Bank/Agency SpendAug-11Sep-11Oct-11Nov-11Dec-11MonthJan-12Feb-12Mar-12Apr-12May-12FTE6005004003002001000Apr-11May-11Jun-11Jul-11Aug-11Sep-11Oct-11DateNov-11Dec-11Jan-12Feb-12Mar-12Apr-12May-12AgencyBankBank & Agency SpendIn addition to the overall Trust Bank & Agency spend increasing by £713,527 in month, data also shows that May 2012 produced the highest temporary staffing spend over the 12month period . The bank and agency spend for May accounts for 16.32% of the pay bill, an increase of 3.12% on the April position.. The fact that temporary staff spend in Mayincreased significantly yet FTE usage decreased is likely to be attributed to accrual of invoices at year end.Bank & Agency UsageDespite the significant increase in spend, overall Trust bookings of Bank & Agency remained relatively static on the April position with a 0.39 FTE increase from the previous month.The number of agency bookings increased by 7.37 FTE's in month - bank bookings decreased by 7.76 FTE's over the same period.Midwifery bank and agency FTE bookings decreased in May by 3.10 FTE's on the April position.Registered Nursing temporary staff bookings decreased in May by 14.57 FTE's on the April position.We have seen an increase this month to the temporary staffing usage in the Medical & Dental staff group by 9.64 FTE when compared to April 2012.Admin & Clerical have seen the biggest increase in Bank and Agency usage this month, rising from 64.24 FTE in April to 76.98 in May. An overall increase of 12.74 FTETrust Overall Scorecard - May 2012 - Workforce Information Department

TURNOVERActual Versus Target Annualised Turnover14.012.0Turnover %10.08.06.04.0TurnoverFor the month of May, Trust annualised turnover remained the same at 10.9% -this is 1.1% below the average of other large Acute Trusts.2.00.0May-11Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11Dec-11Jan-12Feb-12Mar-12Apr-12May-12Actual TurnoverTarget TurnoverMonthA&E Registered Nursing Turnover, recruitment and temporary staff use - Hotspot monitoringCombined A&E Qualified Nursing - Staff in Post v IHB Booking v Annualised TurnoverA&E detailed turnover and leavers update formonitoring purposes20025.00%The overall effects of the registered nurse band 5recruitment & over-recruitment strategy is demonstrated tothe right.17515020.00%N&M Qual(IHB)For the month of May the combined QH & KGH A&Eregistered nursing turnover rate fell from 20.63% to 19.51%.There were no registered nursing leavers across either sitein month. The graph to the right shows the number of FTE's,turnover and temporary staff usage for all registered nursingbands within both A&E's. The overall number of registerednursing FTE's in post increased by 4.36 FTE this month andwe have seen an decrease in temporary staff bookings by0.66 FTE's.FTE's12510075502515.00%10.00%5.00%Turnover %N&M Qual(SIP)N&M Qual(Turnover)00.00%May-11Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11MonthDec-11Jan-12Feb-12Mar-12Apr-12May-12Trust Overall Scorecard - May 2012 - Workforce Information Department

SICKNESS ABSENCEReal - Time Sickness AbsencePercentage (%)6.506.005.505.004.504.003.503.002.502.001.501.000.500.00May-11£1,000,000Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11MonthDec-11Jan-12Feb-12BHRUT Target Other Large Acute LondonTrust Estimated Cost of Sickness Absence (Month)Mar-12Apr-12May-12Sickness AbsenceReported sickness absence rates for the month of May has increased slightlyby 0.22% on the April position, rising from 4.29% to 4.51% across the month.The sickness absence rate has decreased by 0.31% when compared to thesame period last year. HR have repeated the pan London benchmarkingexercise against other acute Large London Trusts this shows that thecombined average sickness absence rate for this group is 3.59% - as suchthe graph has been revised to reflect this. Based upon this revisedinformation BHRUT's benchmarked position shows us as currently sitting0.92% above the 3.59% average of all other large acute London Trusts. TheTrust's target has been left at 3.6%£900,000Estimated costs of sickness absenceEstimated Cost (£'s)£800,000£700,000£600,000£500,000£400,000£300,000£200,000The estimated costs associated with sickness absence has increased thismonth, in line with overall percentage. It is estimated that the cost to theTrust for April was £645,566. This figure has risen by an estimated £26,612on the same period last year.£100,000£0May-11Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11Dec-11MonthJan-12Feb-12Mar-12Apr-12May-12Trust Overall Scorecard - May 2012 - Workforce Information Department

Sickness Absence - FTE LostReason for AbsenceS10 Anxiety/stress/depression/other psychiatric illnessesS11 Back ProblemsS12 Other musculoskeletal problemsS13 Cold, Cough, Flu - InfluenzaS14 AsthmaS15 Chest & respiratory problemsS16 Headache / migraineS17 Benign and malignant tumours, cancersS18 Blood disordersS19 Heart, cardiac & circulatory problemsS20 Burns, poisoning, frostbite, hypothermiaS21 Ear, nose, throat (ENT)S22 Dental and oral problemsS23 Eye problemsS24 Endocrine / glandular problemsS25 Gastrointestinal problemsS26 Genitourinary & gynaecological disordersS27 Infectious diseasesS28 Injury, fractureS30 Pregnancy related disordersS31 Skin disordersS98 Other known causes - not elsewhere classifiedS99 Unknown causes / Not specifiedReasons for Sickness Absence vFTE's lostWhen the number of FTE's lost due tosickness absence is analysed by reasonfor absence, the highest loss is seen in'Unknown causes - not specified' with52.39 fte lost. HR acknowledge thiscreates concern as it means that staffare not providing their absence reasonor it isn't being recorded by theirmanager/supervisor. In order to furtherimprove the accuracy of sicknessabsence reporting and recording, HRhave incorporated 'effective recordingprocesses' in their ' Essential skills formanagers ' training programme. Theeffects of this training on the actualreported data may take time to show ademonstrable change. Directoratesmust not only ensure that managersrecord absence correctly within theweekly absence returns but also thatreturns are submitted in a timely way.0 10 20 30 40 50 60FTE LostWORKFORCE DEVELOPMENTSTrust Overall Scorecard - May 2012 - Workforce Information Department

1. Skills for Health projectsSupported by CTB funding, earlier in the year the Trust commissioned Skills for Health (SfH) to assist us in addressing key actions identified within the CQC action plan relating to:- Improving workforce planning capacity and capability across the Trust- completion of a systematic skill mix review of identified clinical areasImproving workforce planning capacity and capability across the TrustThe Trust and SfH identified and agreed that Directorates and Business Units should receive introductory training sessions on workforce planning in order to support the businessplanning process ( bottom up approach) and improve capacity and capability at service level.The main purpose of these sessions is to increase awareness of and raise the profile of workforce planning across the Directorates, demonstrating how it supports the development ofbusiness plans and ultimately ensuring optimum patient care. The main focus of these sessions relates to supporting the required shift in behaviours as well as technical abilities toeffectively workforce plan and secure the Directorates engagement with the principles of workforce planning and getting participants to think about their role and ways of taking thelearning forward. . SfH's experience shows that these sessions are a good way of engaging a large number of people within organisations and starts the process of “doing thingsdifferently”.The first session took place on the 19th June with the next booked for 11th July - initial feedback has been very positive.Systematic skill mix reviewAs already highlighted BHRUT commissioned SfH to carry out a systematic Skill Mix Review - initially within A&E on the QH site, this piece of work was completed at end May and SfHhave provided a report of their findings and recommendations. The next phase is for the A&E department to take this piece of work forward through developing an action plan forimplementation. In the original SfH brief the skill mix review was to be preceded and informed by a Functional Mapping Exercise but this was removed from the brief to avoid overlap withthe new McKinsey project.Skill mix matters because it affects service delivery, performance and financial out-turn and a Skill Mix Review forms part an important part of any strategic workforce developmentprogramme. SfH's approach was to utilise service, workforce and finance information and data to determine how closely the current skill mix matches the Trust’s future skills requirement.Evidence was gained from interviews with staff and Directors, other information provided by the Trust, external reports, guidelines and comparative sources. information provided hasthen been analysed using Skills for Health’s expertise, tools & workforce analysis techniques in order to:- Assess the skill mix requirements in the Queens’ Hospital A&E Department.- Analyse how staff resources are used in the Department.- Review benchmarking data relevant to the project brief.- Triangulate the findings and make recommendations for the Trust to skill mix improvements in order to overcome problems identified in the delivery of A&Eservices.Key findings as to the workforce and skills mix challenges identified include:- Skills mix change is an imperative in the context within which the Trust is operating- New ways of working have been trialled but there is no consistent approach to the development and deployment of new roles- Rotas are not aligned with workload and staff lack information to improve performance- There are significant recruitment and retention difficulties for medical and other staff- Activity indicators highlight systemic local challenges that need to be addressed- Current staffing is expensive and over reliant on Band 5&6 nursing staff and on locum medical staff- Nursing staff hours are less closely aligned to A&E attendances than medical staff hours.WORKFORCE DEVELOPMENTS - continuedTrust Overall Scorecard - May 2012 - Workforce Information Department

Key opportunities identified for the Trust to improve quality and productivity through workforce change include:- Changing skill mix to achieve a more effective deployment of support staff and advanced practitioners the A&E Department- Ensuring that HCAs achieve competence in a more structured way.- Understanding and utilising skill sets more fully to improve productivity and ensure more effective planning for supply shortages in qualified nursing staff.- Using skill sets more effectively to increase role satisfaction and improve staff retention, thereby reducing staff turnover and temporary staff usage- Reviewing the alignment of staff rotas to workload.- Giving more systematic information to staff to enable them to take responsibility for improving performance.Main issues identified regarding current staffing and skill mix:- Skill mix. The staffing appears to be light on Bands 2, 3 and 4. This is particularly so in the sense that A&E at Queen’s is like a “ward”, and you expect to use HCAs heavily in wards.Also, light on advanced nurse practitioners, who could replace some of the vacant staff grade posts currently filled by locums who appear to be almospermanent (but at twice the cost, and with some quality issues).- Workforce planning issues. There are some serious recruitment difficulties for doctors and recruitment/retention issues for nurses. The supply of qualified nursesmay in fact get tighter by 2014/15 as the number of nurses in training has been cut by 25% in 2011/12. The Trust may face continuing difficulties in recruiting staff gradedoctors. However, the supply of local people capable of developing “assistant practitioner” HCA skills may be significant, and they will be much less likely to leave.- Cost. It may be more cost effective to deploy advanced nurse practitioners to replace some staff grade doctor posts, and to replace some qualified nurse posts withcompetent HCAs.Key recommendations for action for the Trust to consider are:1. To develop and implement a support staff & advanced practitioner strategy for A&E incorporating:• a clear competence framework for A&E roles supporting role clarity and progression opportunities from Band 3 onwards• a system for recognizing and rewarding the achievement of competence• accessible learning opportunities to facilitate staff development2. To design and implement a programme for the systematic introduction of new roles and skill mix change ensuring effective communication and governance arrangements are in place3. To put in place a process to ensure that A&E performance data is systematically made available to staff enabling teams and individuals to take personal responsibility for performance4. To arrange a process for dialogue with commissioners and GPs to develop an integrated strategy for reducing demand pressuresThe General Manager A&E is currently developing an action plan for implementation of the SfH recommendations in addition to other recommendations concerning staffing. Thefindings and resulting action plan are being presented to the Workforce Committee on 25th June 2012 followed by the Joint Staff Committee in July before discussions then take placewith staff in the Department.WORKFORCE DEVELOPMENTS - continuedTrust Overall Scorecard - May 2012 - Workforce Information Department

2. Essential Skills for Managers TrainingIn April 2012 the Education Department in conjunction with Human Resources launched the second Essential Skills for Mangers Programme. For 12/13 there are 2 separate Cohortsrunning each consisting of 10 days study - with attendance to all 10 being mandatory. The programme will cover the following components:Confident delegation Effective team leadership Effective communicationDealing with poor performance Recruitment and Selection of the right staff appraisal, development and trainingWork load planning, prioritisation & organisation Interpretation and application of HR Policy and ProceduresDIRECTORATE WORKFORCE KPI'sDIAGNOSTICS & SPECIAL MEDICINE DIRECTORATE -WORKFORCE KEY PERFORMANCE INDICATORS - MAY 2012Trust Overall Scorecard - May 2012 - Workforce Information Department

Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTDStaff In Post 1094.28 1104.66 1099.47Starters *¹ 9.43 12.66 22.09Leavers *¹ 6.12 4.46 10.58Turnover (Annualised) *¹ 12.0% 9.1% 8.6%Trust Sickness Absence %for month3.6% 4.29% 4.51%Directorate SicknessAbsence For Month3.6% 5.11% 5.03%Directorate SicknessAbsence Rolling 12 MonthPeriodDirectorate Estimated Costof Sickness Absence(Month) *²3.6%£151,450 £162,189 £313,639Appraisals Compliance 80.0% 71.95% 71.96%Resus Compliance 80.0% 77.57% 77.13%Paybill Budget£4,719,045 £4,655,044 £9,374,089Paybill £4,763,991 £4,859,576 £9,623,567Bank/Agency Spend £496,296 £189,999 £686,295% Paybill Budget spent onbank & Agency staff10.52% 4.08% 7.32%Overtime Spend (£) £15,913 £22,366 £38,279IHB FTE Bookings 77.34 75.64 152.98IHB FTE Booked as a % ofSubstantive SIP7.07% 6.85% 6.96%*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotationEMERGENCY, GEN. MEDICINE & NEUROSCIENCES DIRECTORATE -WORKFORCE KEY PERFORMANCE INDICATORS - MAY2012Indicator Trust Overall Scorecard Target - May 2012 Apr-12 - Workforce Information May-12DepartmentJun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTD

Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTDStaff In Post 1497.50 1488.89 1493.20Starters *¹ 24.47 16.48 40.95Leavers *¹ 16.71 5.00 21.71Turnover (Annualised)*¹12.0% 12.3% 12.4%Trust SicknessAbsence % for month3.6% 4.29% 4.51%Directorate SicknessAbsence For Month3.6% 3.71% 3.88%Directorate SicknessAbsence Rolling 12Month PeriodDirectorate EstimatedCost of SicknessAbsence (Month) *²3.6%£128,632 £143,589 £272,221Appraisals Compliance 80.0% 74.07% 75.21%Resus Compliance 80.0% 76.26% 78.64%Paybill Budget£6,897,802 £6,887,836 £13,785,638Paybill £6,945,598 £7,283,477 £14,229,075Bank/Agency Spend £1,351,514 £1,514,580 £2,866,094% Paybill Budget spenton bank & Agency staff19.59% 21.99% 20.79%Overtime Spend (£) £4,331 £6,229 £10,560IHB FTE Bookings 247.95 261.02 508.97IHB FTE Booked as a %of Substantive SIP16.56% 17.53% 17.04%*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotationSURGICAL DIRECTORATE - WORKFORCE KEY PERFORMANCE INDICATORS - MAY 2012Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTDTrust Overall Scorecard - May 2012 - Workforce Information Department

Staff In Post 1122.50 1151.10 1136.80Starters *¹ 7.00 3.60 10.60Leavers *¹ 10.67 7.43 18.10Turnover (Annualised)*¹12.0% 8.5% 8.9%Trust SicknessAbsence % for month3.6% 4.29% 4.51%Business Unit SicknessAbsence For Month3.6% 3.44% 3.90%Business Unit SicknessAbsence Rolling 12Month PeriodBusiness UnitEstimated Cost ofSickness Absence(Month) *²3.6%£99,908 £120,250 £220,158Appraisals Compliance 80.0% 85.65% 86.14%Resus Compliance 80.0% 76.42% 78.59%Paybill Budget£5,182,485 £5,288,767 £10,471,252Paybill £5,501,762 £5,495,357 £10,997,119Bank/Agency Spend £753,584 £655,882 £1,409,466% Paybill Budget spenton bank & Agency staff14.54% 12.40% 13.46%Overtime Spend (£) £25,315 £22,791 £48,106IHB FTE Bookings 137.79 112.35 250.14IHB FTE Booked as a %of Substantive SIP12.28% 9.76% 11.02%*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotationWOMEN, CHILDREN & SUPPORT SERVICES DIRECTORATE -WORKFORCE KEY PERFORMANCE INDICATORS - MAY 2012Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTDStaff In Post 1181.94 1180.51 1181.23Starters *¹ 3.40 11.00 14.40Trust Overall Scorecard - May 2012 - Workforce Information Department

Leavers *¹ 12.33 12.00 24.33Turnover (Annualised)*¹12.0% 11.4% 11.7%Trust SicknessAbsence % for month3.6% 4.29% 4.51%Directorate SicknessAbsence For Month3.6% 5.24% 5.57%Directorate SicknessAbsence Rolling 12Month Period3.6%Directorate EstimatedCost of SicknessAbsence (Month) *²£140,926 £149,545 £290,471Appraisals Compliance 80.0% 85.03% 86.20%Resus Compliance 80.0% 76.40% 77.79%Paybill Budget£4,559,907 £4,562,188 £9,122,095Paybill £4,627,315 £4,640,770 £9,268,085Bank/Agency Spend £444,148 £266,534 £710,682% Paybill Budget spenton bank & Agency staff9.74% 5.84% 7.79%Overtime Spend (£) £2,542 £3,422 £5,964IHB FTE Bookings 103.68 108.89 212.57IHB FTE Booked as a %of Substantive SIP8.77% 9.22% 9.00%*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotationTrust Overall Scorecard - May 2012 - Workforce Information Department

EXECUTIVE SUMMARYTITLE:Transformation Board UpdateBOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:Provide an update to the Trust Board.□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…√ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:For Information□ NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY√ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:AUTHOR/PRESENTER: Dorothy Hosein, Director ofTransformationDATE: June 2012There is currently a significant gap between the CIP programme and Trust required position. The TransformationProgramme is necessary to bridge that gap and ensure financial stability.Twelve Corporate Workstreams have been established which will support Trust’s cost improvement programme. Each ofthese Workstreams is led by a senior Executive and at the time of writing this report, targets are being confirmed. EachWorkstream will have a number of clinical indicators and quality measurements to ensure there is no adverse effect tothe quality of care that we provide to our patients. The above is described in more detail within the attached report.In addition, a rigorous structure of accountability and performance management is being introduced, together with closemonitoring of performance. The Programme will be supported by a Project Management Office, described in theattached report.4. DELIVERABLES1, End of June 2012 all short term measures in the attached report initiated.Emergency Pay controls all in place.2. First week of July 2012 all Workstreams together with targets established.3. End July 2012 Improvement in the Trust increment expenditure position by (tbc)Key Performance Indicators1. Status of Workstream2. Status of Cost improvement Programme3. Monitoring of clinical risks associated with plans.Agreed at Transformational Board Meeting.

5. KEY PERFORMANCE INDICATORSAGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

2012/13 Cost Improvement Strategy: High level approachTrust Board Update: 4 th July 2012Dorothy HoseinJan BergmanPaul McAuliffeProgramme Management Office

IntroductionThe Trust needs to identify and deliver a £23m costimprovement strategy in 2012/13 and there is a further£4m of recurrent cost pressures. The resulting totalfinancial challenge for 2012/13 is £27m. Thepurpose of this paper is to provide an overview of thedelivery strategy to the Finance Committee andconfirm support for implementation.The paper is broken down into the following foursections:1)Workstream targets2)Workstream scope and delivery timescales3)CIP governance framework4)Short term tactical controlsThe PMO have identified FYE saving opportunities ofup to £29m facilitated through twelve coreworkstreams (see table opposite and described inmore detail on pages 4-6). Each workstream has anaccountable officer to drive and ensure delivery, withadditional support from the newly established ProjectManagement Office (PMO).Work streamAccountable officer1. Medical staff costs Medical Director2. Nursing staff costs Nursing Director3. Allied Health Professional staff costs Nick Hulme - Project Director ofReconfiguration4. Admin & Clerical staff costs and T&C Dorothy Hosein - Director ofTransformation5. Beds Cathy Geddes - Chief Operating Officer6. Theatres Eileen Moore - Associate Director ofSurgery7. Outpatients Arshiya Khan - Associate Director ofWomen & Children & Support Services8. Diagnostics Elizabeth Lyons - Associate Director ofCDT9. Non pay/procurement Director of Finance10. Medicines management Portia Omo-Bare - Chief Pharmacist11. Estates and facilities Jackie Doyle - Head of Estates &Facilities12. Corporate costs Jan Bergman - Head of PMO2

Breakdown of suggested opportunity by workstreamNote: Top down analysis has identified some initial savingsopportunities, as more detailed analysis is completed within eachworkstream, there will be some redistribution of some parts of theworkforce targets(medical, nursing, AHP, A&C) into the crosscutting schemes (theatres, outpatients, diagnostics).Amber / Green schemes M2Current gap3

High level projection of the opportunities in 2012/13Workstreama. Opportunitiesidentified FYE - £mb. Opportunities identifiedPYE (estimated*) - £mc. Green / Amber schemes(M2 tracker) - £md. PYE + Green / Amberschemes (b+c) - £m1. Medical staff costs 7.67 1.85 1.06 2.902. Nursing staff costs 5.69 3.29 2.01 5.303. Allied Health Professionalstaff costs4. Admin & Clerical staffcosts and T&C1.42 0.71 0.41 1.121.39 0.59 0.38 0.965. Beds 4.30 1.08 0.80 1.886. Theatres 0.55 0.18 0.09 0.277. Outpatients 0.40 0.13 0.22 0.368. Diagnostics 0.00 1.03 1.039. Non pay/procurement 2.24 0.95 1.34 2.3010. Medicines management 1.19 0.40 0.63 1.0211. Estates and facilities 2.16 0.72 1.67 2.3912. Corporate costs 2.04 0.68 1.42 2.10Total 29.03 10.58 11.05 21.63CIP target 27.00Gap to CIP target -5.37Workforce impact: Delivering savings of £29m approximates to c450 WTE (based on average WTE cost); in practice a proportion of the savings will befrom changes to skill mix and reductions in agency usage. Therefore, further work is needed to be completed with accountable officers to understand the fullstaffing implications.*Some elements of the opportunities may already be accounted for in the Trust’s schemes in progress (column c). Further analysis is required on this area as workstreamsprogress.4

Workstream scope and required action (1)Workstream Scope Outcomes to deliver £10.6m PYE Savings tocommence*1. Medical staffcosts2. Nursing staffcosts3. Allied HealthProfessional staffcosts4. Admin & Clericalstaff costs and T&C►All medical pay savings throughreduction in staff, staff skill mix,rotas and reductions in bank /agency usage► All Nursing pay savings throughreduction in staff, staff skill mix ,rotas and reductions in bank /agency usageNB: Bed reduction strategies are notincluded in this workstream.►►►All AHP / scientific / technical paysavings through reduction in staff,staff skill mix , rotas andreductions in bank / agencyusageAll admin & clerical pay savingsthrough reduction in staff, staffskill mix , rotas and reductions inbank / agency usageTerms & conditions (all staffgroups)5. Beds ► Ward costs saved throughreducing LoS• Removal of bank/agency spend over budget.• Conversion of 75% agency usage to bank• 10% reduction in agency costs through reduced supplierlist and standardised rates for internal/external sessions.• Removal of bank/agency spend over budget.• Conversion of 75% agency usage to bank• 10% reduction in agency costs through reduced supplierlist and standardised rates.• Release of £1.95m pay costs from Jan 13 through skill mixreviews focussing on band 6+ and non ward roles.• Removal of all bank/agency over budget.• Conversion of 75% agency usage to bank• 10% reduction in agency costs through reduced supplierlist and standardised rates.• Release of £158k therapy, £266 Radiology, £282mpharmacy pay costs from Jan 13 through skill mix reviews.• Removal of all bank/agency over budget.• Conversion of 75% agency usage to bank• 10% reduction in agency costs through reduced supplierlist and standardised rates.• Release of £909k pay costs from Jan 13 through skill mixreviews.• Closure of 134 non elective beds from Jan 13 across bothsites.Jul 12Jul 12 (bank andagency)Jan 13 (skill mix)Jul 12 (bank andagency)Jan 13 (skill mix)Jul 12 (bank andagency)Jan 13 (skill mix)Jan 13*Enables consultation where required. However the Trust pay protection policy will need to be considered.5

Workstream scope and required action (2)Workstream Scope Outcomes to deliver £10.6m PYE Savings tocommence*6. Theatres ► Theatres costs saved throughincreasing the productivity of theatres► Theatre workforce efficiencies► Theatre non pay efficiencies7. Outpatients ► OP costs saved through increasing theproductivity of clinic usage► OP workforce efficiencies8. Diagnostics ► All Diagnostics costs (pay and nonpay) saved through increasingefficiency and decreasing demand.9. Nonpay/procurement10. Medicinesmanagement►►All costs saved through decreasing theusage and unit price of in scope nonpayspend (excludes theatres,diagnostics)All costs saved through decreasing theusage and unit price of medicines(includes outsourcing opportunities)• Reduction of 348 theatre lists per annum from Jan 13through achievement of 90% utilisation (auditcommission calculation)• Reduction in 1,375 OP clinics per annum from Dec 12through reduced DNA rates to 5% for new and followup patients.•N/A• £500k reduction in non pay spend through ‘red pen’exercise with Business Unit Managers. Further 5%reduction in remaining non pay spend (£1.7m)through tactical/strategic schemes from Dec 12.• 4% reduction in drug costs (£1.2m FYE ) from Dec12 through tactical and strategic schemes.Jan 13Dec 12N/ADec 12Dec 1211. Estates and► All Estates costs, PFI & non-PFIfacilities• 5% reduction in corporate costs (4.2m FYE) fromDec 12Dec 12.12. Corporate costs ► All Corporate costs excluding estates Dec 126

Programme GovernanceWorkstream & Divisional AccountabilityProgramme Governance StructureWorkstream 1Workstream 12Trust BoardTransformationBoardChair: CEO+ External partnersMonthlyQuality & SafetyCommitteeFinance CommitteeTrust ExecutiveCommitteeChair: CEOFormal ClinicalAgreementMonthlyProject Management Planning & ReportingID Task NameNov '10 Dec '10 Jan '11 Feb '11 Mar '101 08 15 22 29 06 13 20 27 03 10 17 24 31 07 14 21 28 0741 Develop Finance training material to train budget holders staProgramme SteeringGroupChair: Director ofTransformationDeputy: QIPPProgramme DirectorFortnightly42 Finance induction training43 Agree induction training content with Clare Stafford44 Present plan for training material to FMs meeting45 Talk to HR to get a place on induction agenda46 Develop training material47 First induction training session held48 Budget holder training49 Review current training and define improvement areas50 Agree training content with Clare Stafford51 Present plan for training material to FMs meeting52 Develop training material53 Specialist finance trainingWorkstreamsPMOClinical ReviewGroup54 Define specialist training content55 Agree training content with Clare Stafford56 Present plan for training material to FMs meeting57 Develop training materialChair: AccountableOfficerProject TeamPMO SupportWeeklyDelivery SupportUnitWeeklyClinical Review7

Additional short term tactical measures to close the£5.4m gapA number of short term measures are being planned andimplemented to decrease the current rate of expenditure acrossthe Trust. These include:1) Additional Pay controlsa) Increased authorisation levels for booking bank and agencystaff across all staff Groups.a) Nursing: Matron and General Manager approval nowrequired; Out of Hours authorisation by Site manager.Short notice sign off by Associate Directorsb) Medical: Associate Director sign off. Off frameworkrates for locums require COO approvalc) AHP: Associate Director sign offd) A&C : Can only be approved by COO.2) Red pen reviewDetailed analysis of General Ledger data (expenditure, budgets andtrends) to identify opportunities for rapid cost reduction with a robust, wellgoverned process which gives leaders in the Trust the opportunity to holdmanagement to account for delivery.b) Weekly Pay Controls group led by the Transformation Directorto monitor spend against budget. Budget holders challengedwhere spend £/ WTE is over funded levels.8

1REPORT TO:REPORT FROM:Trust BoardChief ExecutiveDATE: 23 June 2012SUBJECT:FOR:INTERIM CHAIR & CHIEF EXECUTIVE’S REPORTInformation______________________________________________________________1. INTRODUCTIONThis report contains a summary of:• Actions taken under emergency powers• Executive decisions• National Issues/News• Local Issues/News2. RECOMMENDATIONThe Board is asked to note this report.3. ACTIONS TAKEN UNDER EMERGENCY POWERSNo actions have been taken by the Interim Chairman or Chief Executiveacting under emergency powers.4. EXECUTIVE DECISIONSThe Trust Executive Committee has been meeting on a monthly basis andhave reviewed and inputted into several reports prior to their submissionto the Trust Board, such as the Care Quality Commission Report,Learning Disability Progress Report, Milestone Tracker/TFA and theTransformation Board update.Interim Chair & Chief Executive’s Report – July 2012

25.NATIONAL ISSUES/NEWSHealth Secretary sets objectives for NHS Commissioning BoardAuthority:Andrew Lansley has set out the Government’s strategic objectives for theNHS Commissioning Board Authority and the basis against which theAuthority will be held to account. The Department of Health will hold theAuthority to account for its performance against our strategic objectives,relating to: transferring power to local organisations, establishing thecommissioning landscape, developing specific commissioning andfinancial management capabilities, and developing excellent relationships.For more information go to: http://www.dh.gov.uk/health/2012/04/authorityobjectives/Sir Peter Carr confirmed as Chair of NHS Trust DevelopmentAuthority:Sir Peter, currently Vice Chair NHS North of England, will head up theNHS Trust Development Authority, the new organisation that will supportNHS Trusts to achieve foundation status, when it is established in June2012. The NTDA will be accountable for the performance managementof NHS Trusts, driving up quality and delivering value for money, whiledeveloping and supporting NHS organisations to achieve FoundationTrust status. Sir Peter Carr stepped down from his role with NHS Northof England and took up post as NTDA Chair from 1 June 2012.For further information go to: http://mediacentre.dh.gov.uk/2012/04/25/sirpeter-carr-confirmed-as-chair-of-nhs-trust-development-authority/New guidance to speed up access to the drugs patients need:Lord Howe has announced new guidance on the Cancer Drugs Fund,which will help speed up access to the drugs patients need. In mostcases, patients will be able to access drugs within a matter of days ofapplication to the Fund. The Department has worked with NHScolleagues to review the guidance issues in 2011, taking into accountpublic feedback from cancer charities.For further information to: http://mediacentre.dh.gov.uk/2012/04/23/newguidance-to-speed-up-access-to-the-drugs-patients-need/Clinical Commissioning Group Authorisation : Final Draft Guide:The Clinical Commissioning Group Authorisation : Final Draft Guide forapplicants has been published following formal ratification at the Boardmeeting of the NHS Commissioning Board Authority on 13 April 2012.This document is designed to help emerging Clinical CommissioningGroups (CCGs) develop clear plans to progress through the authorisationprocess and become authorised CCGs.Link: http://www.commissioningboard.nhs.uk/files/2012/04/ccg-auth-appguide.pdfInterim Chair & Chief Executive’s Report – July 2012

3Raising the bar on patient safety: the journey of ‘harm free’ care:On 17 May 2012, Maxine Power, QIPP Safe Care National WorkstreamLead, gave an overview of Safety Express, an initiative that aims to deliverhigher quality ‘harm free’ care at lower cost. It plans to do this byreducing the number of patients who experience harm from pressureulcers, falls, infections in patients with urinary catheters and blood clots.Link: http://bit.ly/Js4rLGSir Keith Pearson confirmed as Chair of Health Education England:Sir Keith Pearson has been confirmed as Chair of Health EducationEngland (HEE). Sir Keith, currently Chair of the NHS Confederation, willhead up Health Education England, the organisation that will providenational leadership to the new system of education and training inhealthcare, established in June 2012.For further information, go to: http://mediacentre.dh.gov.uk/2012/05/02/sirkeith-pearson-confirmed-as-chair-ofhealth-education-england/Situations vacant in the new NHS:Leadership, innovation and the ability to inspire confidence in others arejust some of the qualities sought by the Secretary of State for Health as heseeks to recruit high calibre candidates to the new NHS structure.Vacancies are currently advertised for two Chairs and three Non-Executive Directors of the Independent Reconfiguration Panel,Healthwatch England and the NHS Commissioning Board Authorityrespectively.For further information, go to: http://cno.dh.gov.uk/2012/05/01/situationsvacant-in-the-new-nhs/Guidance on new National CQUIN goals:Two new National Commissioning for Quality and Innovation (CQUIN)goals, on dementia and on the use of the NHS safety thermometer, havebeen introduced for use in 2012/13. This guidance is designed to assistCommissioners and Providers when including CQUINs in contracts.Link: http://www.dh.gov.uk/health/2012/05/guidance-on-new-nationalcquin-goals/Department teams up with doc2doc forum to gather views on longterm conditions:-The Department of Health is working with doc2doc, the BMJ Group’sonline community for health professionals, on its long term conditionsstrategy. This is a cross government strategy being drafted by theDepartment of Health.For further information, go to:http://www.dh.gov.uk/health/2012/05/doc2doc/Interim Chair & Chief Executive’s Report – July 2012

4How to maintain quality during the transition: preparing forhandover:To help organisations maintain quality during the transition, the NationalQuality Board has produced guidance for all sending and receiving bodieson how to prepare for handover during the transition. PCT and SHAClusters were asked to produce plans by the 23 and 30 June 2012respectively, setting out how they intend to produce and handover thenecessary quality information to their successor bodies.Link: http://www.dh.gov.uk/health/category/policy-areas/nhs/nqb/NHS companion document – Chronic Obstructive PulmonaryDisease and Asthma:Improving outcomes for people with respiratory disease is a key priority forthe NHS. To support the Outcomes Strategy for Chronic ObstructivePulmonary Disease and Asthma, published last July, a companiondocument has been published that sets out 46 key recommended actionsfor the NHS, to help deliver on the five domains in the NHS OutcomesFramework.Link: http://www.dh.gov.uk/health/2012/05/nhs-companion-copd/Making medical tests work for you: offering patients more choice:For the first time, patients will now have more choice about where, whenand how they receive some of the most common medical tests. Newproposals published during May outlined how patients will be able tochoose where they receive essential tests, including blood tests and heartscans. From April 2013, patients will be able to pick somewhere closer tohome, or near where they work, instead of having to accept the nearerlocation offered.For further information, go to:http://mediacentre.dh.gov.uk/2012/05/23/offering-patients-more-choice/NHS Commissioning Board Authority Update:The NHS Commissioning Board Authority (Board Authority) has publishedthe proposed configuration, member practices, indicative running costsallowances, and the complete list of authorisation waves, for 212proposed Clinical Commissioning Groups (CCGs). There are nowproposed CCGs covering the whole of England. The geographicalboundaries have been drawn for each of them for the first time. Thepractice information provides the planning assumptions about the memberpractices in each proposed CCG. The Board Authority has also publishedNational and Regional CCG maps.Links: www.commissioningboard.nhs.uk/2012/05/24/board-meet-21012/Interim Chair & Chief Executive’s Report – July 2012

5Friends and family test:An NHS ‘friends and family’ test to improve patient care and identify thebest performing hospitals in England has been announced by the PrimeMinister. From April 2013, patients will be asked a simple question;whether they would recommend hospital wards, accident and emergencyunits to a friend or relative based on their treatment.Link: http://www.dh.gov.uk/health/2012/05/friends-family/Transfer of patient safety function to the NHS Commissioning BoardSpecial Health Authority:On 1 June this year, the key functions and expertise for patient safetydeveloped by the National Patient Safety Agency (NPSA) transferred tothe NHS Commissioning Board Special Health Authority. This ensurespatient safety is at the heart of the NHS and builds on the learning andexpertise developed by the NPSA, driving patient safety improvement.Link: http://www.npsa.nhs.uk/corporate/news/transfer-of-patient-safetyfunction/World class procurement in the NHS – call for evidence and ideas:Sir Ian Carruthers, on behalf of the NHS Chief Executive, has issued a callfor evidence on how procurement in the NHS can be transformed todeliver the highest quality patient care, offer value for money, supportinnovation and stimulate growth in the UK. This is part of a widerengagement process that will report in December 2012.Link: www.dh.gov.uk/health/2012/05/procurement-review/NHS procurement guidance and the NHS standards of procurement:The guidance aims to start the journey to world class procurement byidentifying actions which require immediate attention and to layfoundations for a fuller and further reaching procurement strategy later inthe year, following a wider call for evidence, as mentioned above.Link: www.dh.gov.uk/health/category/qipp-procurement/PCT Estate – planning for property transfers:On 1 April 2013 PCTs and SHAs will be abolished. On, or beforeabolition, it is imperative that all PCT and SHA estates, and associatedassets rights and liabilities, are properly dealt with. It is proposed that alltransfers to successor bodies will take place at a single point on 31 March2013. The aim is to have all documentation prepared and signed off bythe 31 December 2012, with an effective date of 31 March 2013. Thedocuments describe the actions and timetable required to prepare forthese transfers.Link: http://www.dh.gov.uk/health-category/publications/letters-circulars/Interim Chair & Chief Executive’s Report – July 2012

6David Behan CBE appointed CQC Chief Executive:David Behan CBE, the Department’s Director General of Social Care,Local Government and Care Partnerships, has announced his departureto take up the role of Chief Executive at the Care Quality Commission(CQC).For further information, go to: http://www.dh.gov.uk/health/2012/06/davidbehan-cqc/NHS Chief Executive’s annual report published:The Department of Health has published ‘the year’, NHS Chief ExecutiveSir David Nicholson’s annual report for 2011/12, in which he reviews theachievements of the previous 12 months and considers the challenges tocome. This edition also includes ‘the quarter’, which provides thedefinitive account of how the NHS is performing at National level againstthe requirements and indicators set out in the NHS Operating Framework2011/12.For further information, go to: http://www.dh.gov.uk/health/2012/06/theyear-2011_12/NHS patient feedback challenge – expert panel announced:The NHS patient feedback challenge, created and managed by the NHSInstitute for Innovation and Improvement and funded by the Department ofHealth, is a one year programme to find and spread great approaches toimproving services, using patients’ feedback. It is an opportunity tomeasure how we are doing and share ways to improve the patientexperience across the NHS. The NHS patient feedback challenge isbacked by a £1m fund.For further information, go to:http://www.dh.gov.uk/health/2012/06/feedback-challenge-panel/Ambulance handover delays:This letter from David Flory focuses on the increased concern about theongoing problem of patient handovers from ambulances to hospitals.While this is not a widespread problem, the unacceptably long handovertimes in a number of places are sufficient to warrant focused attention.Link: http://www.dh.gov.uk/health/2012/06/patient-handover-delays/Accelerating the release of public sector land for development:This letter from David Flory updates the NHS on progress with theircontribution to the Government’s plans to build 100,000 new homes onpublic sector land. Further information on guidance and support availableto the NHS is included at the link below.Link: http://www.dh.gov.uk/health/2012/06/update-surplus-land/Interim Chair & Chief Executive’s Report – July 2012

7Delivering safe and sustainable Cost Improvement Programmes(CIPs) Conference:On 11 September 2012, David Bennett, Chair and acting Chief Executive,Monitor, in partnership with the Healthcare Financial ManagementAssociation (HFMA), will deliver a keynote speech. The Conference aimsto provide a high level forum for learning, discussion and debate betweenBoard members around the Board’s role in delivering safe and sustainableCost Improvement Programmes. Jim Easton, Director of ImprovementTransformation, NHS Commissioning Board Authority, will speak, as willothers. The Conference chair is Eric Morton, Interim Chief Executive,Morecambe Bay NHS Foundation Trust.Link: http://www.hfma.or.uk/events-and-conferences/national/cip.htmInterim Chair & Chief Executive’s Report – July 2012

EXECUTIVE SUMMARYTITLE:Declaration of Member’s Interests for 2012/13BOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:Each Executive Director and Non-ExecutiveDirector must declare annually any Membershipof Professional Associations and Charitablebodies, and whether they hold Directorship andShareholdings in Public and Private companies□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ CLINICAL GOVERNANCE …………..………….....……□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:The Board is asked to note this report.□ NATIONAL TARGET□ CQC REGISTRATION□ CNST□ HEALTH & SAFETY3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:NA□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS CORPORATE OBJECTIVE Compliance withstatutory obligation under the Code ofAccountability for NHS Boards.□ OTHER …………………….. (please specify)AUTHOR/PRESENTER:Sue Williams, Executive Assistant to CEO & ChairmanDATE: 25 June 20124. DELIVERABLESNA5. KEY PERFORMANCE INDICATORSNAAGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

DECLARATION OF INTERESTS 2012/13Interests DeclaredBoard MemberCharitable BodiesTrustee, Sight Action (Havering)National Development Lead, The Health Quality Improvement Partnership (HQIP)Vice President (to March 2013) President (March 2013/15), British Transplant SocietyChair of Council (2007 onwards), London School of Jewish StudiesGovernor (Secondary School 2009), Immanuel College, Bushey, HertsWilliam LangleyElaine Young (Wife - David Wragg)Prof Anthony WarrensProf Anthony WarrensProf Anthony WarrensStatutory BodiesMember, Advisory Committee for Safety in Blood, Tissues and Organs (2008 onwards)Member, UK (Transplant) Donation Ethics Committee (2009 onwards)Prof Anthony WarrensProf Anthony WarrensDirectorships:Private CompaniesDirector, Protopack (Food Packaging Design Company)Director, Tranquil Training (Inland Waterways RYA Training School)Executive Director, LUDO Management LtdKeith MahoneyKeith MahoneyWilliam LangleyJune 2012

Associate, Zenon ConsultingDirector, MD Heath Consultancy Ltd (2004)Company Secretary, MD Health Consultancy Ltd (2004)Dr Maureen DalzielDr Maureen DalzielIan Dalziel (Husband – Dr Maureen Dalziel)OtherConsultant, Private Practice at Hartswood Hospital, BrentwoodConsultant, Hunter HealthcareLeader (Member), London Borough of HaveringNon Executive Director, London Thames Gateway Urban Development CorporationChairman, East and South East London Transport PartnershipBoard Member, London Enterprise PartnershipBoard Member, LGA Improvement BoardBoard Member, Capital AmbitionBoard Member, NHS Supply Chain Customer BoardCompany Director, Caroline Wright Communications LtdDirector, British Education Supplies AssociationConsultant, Private Clinical Practice at Wellington, Garden and London Independent Hospitals (2009 onwards)Board Member, Intensive Care National Audit Research Centre (ICNARC) (1994)Board Member, British Pregnancy Advisory Service (BPAS) (2007)Mr Stephen BurgessDr Robert RoyceMichael WhiteMichael WhiteMichael WhiteMichael WhiteMichael WhiteMichael WhiteKeith MahoneyCaroline WrightCaroline WrightProf Anthony WarrensDr Maureen DalzielDr Maureen DalzielJune 2012

Shareholdings:Private CompaniesJune 2012

EXECUTIVE SUMMARYTITLE:BOARD/GROUP/COMMITTEE:Infection Control annual report Trust Board 4 July 20121. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:Attached is the annual infection control reportfor 2011/12, which will be published on the Trustwebsite.The June Infection Control Committee alsoreviewed the plans for 2012/13. keydeliverables are:- implementation of the ANTT programme,due for launch in July- re-launch of a Trust-wide “clan yourhands” campaign- review of the management of norovirusoutbreaks, following the external reviewby Dr Hosein and the recent publicationof best practice guidance by the HPAfrom the Norovirus Working Partyx□ TEC…26.6.12….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …………..………….....……□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...x□ OTHER …Infection Control Committee 12.6.122. DECISION REQUIRED: CATEGORY:Ratification of the annual report. Agreement tosupport the highlighted initiatives for 2012/13x□ NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)PRESENTER: Deborah Wheeler, Director ofNursing/DIPCDATE: 26.6.123. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:4. DELIVERABLES5. KEY PERFORMANCE INDICATORSAGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

Director of Infection Prevention and ControlAnnual ReportApril 2011 – March 2012Authors:Sheila O’MahonyMatron Infection Prevention & ControlDr Lindsey BainInfection Control Doctor/Consultant MicrobiologistMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM1

CONTENTS1.0 EXECUTIVE SUMMARY 52.0 BACKGROUND INFECTION PREVENTION AND CONTROLARRANGEMENTS2.1 Infection Prevention and Control Team structure 72.2 Budget allocation for infection prevention and control staffing 72.3 Infection Control Committee 82.4 Infection Prevention and Control Annual Plan 82.5 Training/Education delivered by the Infection Prevention and Control Team 92.6 IPCT Training and Development 103.0 HEALTH CARE ASSOCIATED INFECTION RATES & OTHER IPCSURVEILLANCE3.1 Results of Mandatory HCAI Reporting 103.1.1 MRSA Bacteraemia 103.1.2 Clostridium difficile 123.1.3 GRE Bacteraemia 133.1.4 Orthopaedic Surgical Site Infections 133.2 Trends in Health Care Associated Infections Statistics 143.2.1 Urinary catheter associated bacteraemia (CAUTI) 143.3 Outbreaks and incidents 143.3.1 Outbreaks of Norovirus (or presumed Norovirus) infection leading toclosure of wards3.3.2 Other outbreaks/incidents of infectionQueen’s Hospital3.3.3 Neonatal Intensive Care Unit 153.3.4 Harvest B Ward outbreak of Mupirocin Resistant MRSA3.3.5 Neurosciences Unit Patient with Sporadic Creutzfeldt Jacob DiseaseKing George Hospital3.3.6 Ante Natal Chicken pox incident 163.3.7 ITU - Vancomycin resistant Enterococcus/ Klebsiella 164.0 HAND HYGIENE 165.0 DECONTAMINATION 175.1 Arrangements 175.1.1 Decontamination Committee Activities 176.0 CLEANING SERVICES 17Page71014151516Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM2

6.1 Management Arrangements Queen’s Hospital 176.1.1 Monitoring Arrangements 176.2 Management Arrangements KGH 186.2.1 Monitoring Arrangements 186.3 Patient Environment Action Team Audits (PEAT) Results 2011 187.0 AUDITS AND EXTERNAL PEER REVIEW 197.1 Audit Programme 197.2 Quality of care audits – improving the quality of nursing care using acontinuous audit cycle207.2.1 Process 207.2.2 Results 207.2.3 Health care associated Infections (HCAI’s) peer review 207.3 Report from Antimicrobial Pharmacists/Consultant Microbiologists 227.3.1 Background 227.3.2 Guideline development and implementation 227.3.3 Development of the Trust Antimicrobial Management Code.237.3.4 Implementation of the Trust Antimicrobial Management Code237.3.5. Formation of the Antimicrobial Stewardship Committee 237.3.6 Education and Training 247.3.7. Adult Pocket Antimicrobial Guide for Common Infections 247.3.8 Audits 248.0 ACTION PLAN FOR 2012/3013 258.1. Audits 258.2 Education and training 258.3 Guidelines 258.4 Paediatric Antimicrobial guidelines 258.5 Miscellaneous 259.0 CONCLUSIONS 2610.0 REFERENCES 26APPENDICESMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM3

Appendix 1 Clinical Governance reporting chart 27Appendix 2Infection Prevention & Control Team organisational chart…………………………………………………….Appendix 3 IPC Annual Trust Action Plan 2011-2012 29Appendix 4IPC Annual Trust Action Plan 2012-2013 including the annual plan foreducation and the annual plan of audit2834Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM4

1.0 EXECUTIVE SUMMARYThis report covers the period from April 1 st 2011 to March 31 st 2012 and informs the Board ofthe progress being made to reduce Health care associated infections HCAI and to agree theAnnual Plan for sustained reduction and improvements in infection control practices for2012/13. In December 2010 a revised code of practice was introduced for the preventionand control of health care associated infections (HCAI); The Health Act (2008), Code ofPractice on the Prevention and Control of Infections and Related Guidance. The code ofpractice is also referred to as the Hygiene Code and is regulated by the Care QualityCommission the Trust remains fully compliant with the Hygiene Code. The Hygiene Coderequires the Director of Infection Prevention and Control (DIPC) to produce an annual reporton the state of healthcare associated infections in the organisation.This report includes:‣ A description of the Infection Prevention and Control infrastructure‣ An update on the Trust's performance against key targets for infection prevention andcontrol‣ A summary of initiatives and activities‣ Detail of key successes and areas for future developmentThe final plan for year 2011-2012 is in Appendix 3. Actions outstanding are added into theannual plan for 2012-2013 which is in appendix 4.The Trust achieved the annual Clostridium difficile (C.diff) improvement objectives. Therewere 43 cases against a target of no more than 81. Last year there were 111 cases against atarget of no more than 128.The Trust unfortunately exceeded the annual target for MRSA bacteraemias which was 10cases against a target of 8. Last year there were 14 cases against a target of no more than11. However, on 2 occasions the Trust went over 100 days without a bacteraemia.As the Trust breached the annual objective of 8 cases of MRSA bacteraemia with 4 cases inNovember taking the year to date total to 9 the improvement team from NHS Londonundertook a peer review. The performance team at NHS London had set up project groupsacross London to review processes and systems in place to enhance the Government’saspiration that all NHS organisations adopt a zero tolerance approach to all avoidablehealthcare associated infections. The review was done in January 2012 at Queens Hospital.The review team concluded that BHRUT had most of the actions required to reduce HCAI inplace and a desire to create much stronger local accountability, assurance and governanceprocesses to sustain reductions in HCAI. They had nothing new to recommend in terms ofMRSA, and its control but, suggested the focus should continue to be on: antibioticstewardship; prompt diagnosis and isolation; competent clinical practice and cleaning andenvironmental hygiene. Recommendations have been added to the infection control annualplan.The Infection Prevention & Control Team (IPCT) had a busy year with yet again a particularlychallenging Norovirus season that resulted in BHRUT being an outlier in the region foroutbreaks of diarrhoea and vomiting. The ward based ward outbreak management trainingMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM5

that was delivered from August to December demonstrated continuing improvement in staffawareness and prompt reporting of potential outbreaks of infection.There were 42 ward closures resulting in 1,360 bed days lost and 30 wards had positivenorovirus results. During last years norovirus season there were 28 wards closed with 1,092bed days lost and only 7 wards confirmed norovirus positive. This was a significant increasein closures to last year’s norovirus season and posed challenges for all services involved toensure minimum disruption to planned and emergency activity. Reviews of the outbreaks didnot suggest any one reason why this was a particularly bad season. The IPCT willsummarise common themes that occurred during the outbreaks and ensure the pre norovirusseason training reflects the themes.As well as wards that were closed a further 48 wards reporting diarrhoea and vomiting wereinvestigated but NOT closed initially. From the 48 wards 40% were confirmed noroviruspositive. Five of the 48 wards were closed after 24 hours observation because more patientsdeveloped symptoms of D&V presenting like norovirus.From September 2011 the IPCT held monthly outbreak review meetings with ward staff,domestic services, and representatives from the Health Protection Agency (HPA) andPrimary Care Trusts. The meetings were based around the HPA‘s Top Ten Tips (TTT) fornorovirus management and proved useful in identifying any issues that occurred during theoutbreak for action. Common themes were delay in isolating patients with diarrhoea,inappropriate use of gloves and staff working whilst symptomatic. However the meetings alsohighlighted areas of good practice including prompt reporting of patients, excellent nursingcare of sick patients and high standards of cleaning.Other outbreaks/incidents of infection included:-The Neonatal Intensive Care Unit (NICU) QH had clusters of neonates with multi resistantorganisms.Harvest B ward at Queen’s Hospital had an outbreak of Mupirocin resistant MeticillinResistant Staphylococcus Aureus (MRSA)1 chicken pox incident in the Maternity unit at KGHITU –KGH Vancomycin resistant Enterococcus/ Klebsiella1 Patient identified with Sporadic Creutzfeldt Jakob Disease (CJD)Work continued to complete root cause analyses (RCA) of Meticillin Resistant StaphylococcalAureus bacteraemias. From April 2011 all Meticillin Sensitive Staphylococcus Aureus(MSSA) bacteraemias were also investigated using the RCA tools. In January 2012 the IPCTdevised a rapid review tool to review the MSSA’s because of the large number and amount oftime it took to complete the RCA’s. This, in addition to completion of other priority RCA’s wasputting pressure on the clinical areas which delayed the opportunity to ascertain the rootcause and the implementation of any actions required.The continuing compliance with Saving Lives formed the basis of the infection control annualplan. Further work is required to achieve robust information to monitor against but inconjunction with the quality of care programme, which was previously known as the visibleleadership programme, significant improvements have been made to clinical practice.Training in infection prevention & control included the very popular passport study days, linknurse programme, general staff induction, registered nurse and support workers induction. InMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM6

January 2012 consultant’s mandatory training commenced: On a monthly basis the IPCTdelivered hand hygiene session using the ‘glo germ’ kit.Audits undertaken include environmental, personal protective equipment audits and isolationaudits.The key risks during this period were exceeding the MRSA target. and managing theNorovirus outbreaks.2.0 BACKGROUND INCLUDING INFECTION PREVENTION & CONTROLARRANGEMENTSThe work of the infection prevention & control department supports the Trust in minimisingthe risk of healthcare acquired infection to patients in accordance with and taking intoaccount the duties of the Hygiene Code, NHS Litigation Authority (NHSLA) and the CareQuality Commission’s Core standards. The Trust is compliant with the Health and SocialCare Act 2010 Outcome 8: Improve cleanliness and infection control compliance levels whichis regulated by the Care Quality Commission2.1 Infection Prevention & Control Team structure (IPCT)Deborah Wheeler, Executive Director of Nursing is in her 3 rd year at the Trust and remainsthe Director of Infection Prevention & Control (DIPC). The DIPC is accountable to the ChiefExecutive and is responsible for the strategy, policy development, implementation andperformance relating to all aspects of infection prevention and control. Appendix 1 shows thereporting line for the team through to Trust board; Appendix 2 shows the team structure.The Infection Control Doctor (ICD) is Dr Lindsey Bain, who meets with the IPCT fortnightly toreview infection control issues and review any new guidance or policy changes. Dr Bain waspreviously allocated 4 professional activities (PA’s) for infection control per week. This wasnot achievable after one of the 4 microbiologists left the Trust in December 2011. As a resultof this Dr Bain now has only 2 PA’s for infection control distributed across the weekThe infection prevention & control team operate during normal working hours, and consist of:• 1 wte band 8b Matron• 2 wte band 7 senior infection prevention and control nurses (SIPCN’s)• 1 wte band 7 practice facilitator• 2 wte band 6 infection prevention & control nurses (IPCN’s)• 1.67 wte band 4 administrative support.One of the band 7 nurses was on maternity leave until March 2012 and had a phased returnto work. The team were able to recruit a band 2 Health Care Assistant from King Georgemedical assessment unit on a secondment basis for 4 months. This secondment ceases inJune 2012. The secondee was trained to undertake audits of hand hygiene, isolation andpersonal protective equipment. She also did ward to ward hand hygiene training and followedup practice after outbreaks of D&V. and was well received by clinical colleagues. Thissecondment proved to be an advantage for the IPCT as it enabled them to concentrate onother clinical duties and policy development.Matron Sheila O’Mahony and Dr Lindsey Bain are taking early retirement in July and Augustrespectively so the Trust is recruiting to these posts.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM7

2.2 Budget allocation for infection prevention and control staffingSUMMARYStaff Group Amount £Administrative support 46,773.00Nursing 312,316.00Total 359,089.00The IPCT does not have a dedicated budget for consumables or other overheads required todeliver infection prevention and control training to staff. Tools for teaching and managingoutbreaks have been sourced by BHRUT charity money and support from companyrepresentatives. The IPCT won the £200 first prize for the Annual Clinical Audit competitionby presenting an audit on improvements on implementation of the Clostridium difficile policyusing exception reports. The team used the prize money to purchase hand held monitors thatcan be used for audit purposes and verification that cleaning procedures are working. Theuse of the monitors will progress through 2012-2013The Infection prevention and control service delivery is supported by many other staff anddepartments, but specifically by consultant microbiologists, antibiotic pharmacists, facilitiesdept, occupational health team and clinical matrons. The core infection prevention & controlservice is advisory and educational whilst maintaining programmes of audit, surveillance andmanagement of outbreaks, both seasonal and unexpected.2.3 Infection Control CommitteeThe Trust Infection Control Committee (ICC) met bi monthly chaired by the Director ofNursing in her role as DIPC. The ICC agenda reflected the infection control annual plan andtherefore ensured compliance with the Saving Lives High Impact Actions Programme andcompliance with the Health Act. All MRSA and Clostridium.difficile RCAs are signed off bythe DIPC and are presented as a summary action plan at each Infection Control Committee(ICC). The MRSA RCAs this year were also signed off by the Chief Executive and MedicalDirector. Attendance at the ICC is variable but with the development of the newly appointedclinical business units there will be designated clinical leads for infection prevention & control.The proposal is that the leads attend the committee and participate in championing the highimpact interventions within their own units. They will also be involved in audit programmeslinking into the infection prevention annual plan. As the role is new it will be progressed anddeveloped through the year.Infection control policies were reviewed and updated as necessary including:-‣ The Control and Management of Panton Valentine Leukocidin (PVL) AssociatedStaphylococcus Infections Policy‣ The Management of Patients with suspected or confirmed Transmissible SpongiformEncephalopathy TSE/CJD‣ The Infection Prevention & Control policy‣ Isolation Policy‣ Varicella Vaccination for health care staff policy (Occupational Health)‣ Policy for the Control and Management of Norovirus Policy‣ Guidelines for taking blood culturesMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM8

The implementation of the Root Cause Analysis (RCA) policy proved useful to get theprocess embedded into clinical areas. The investigation tools for MRSA and Clostridiumdifficile were amended so they were easier to complete. Further review of the policy isscheduled for June 2012 to ensure the RCA process is consistent throughout the Trust.2.4 Infection Prevention and Control (IPCT) Annual PlanThe 2011-2012 annual plan focussed on achieving MRSA and Clostridium difficile targets,implementing the emergency MRSA screening, Saving Lives high impact interventions andcompliance with the Health & Social Care Act and requirements of the Care QualityCommission. The year end updated plan is attached at Appendix 3The annual plan for 2012-2013 is attached in Appendix 4. Implementation of the annual planis monitored by the Infection Control Committee and reported to the Quality & SafetyCommittee, which is a committee of the Trust Board (Appendix 1).2.5 Training/Education delivered by the IPCTThe IPCT maintained the monthly infection prevention & control passport study day for 8months of the year; 398 staff attended in this year. The February passport study day wascancelled due to organisational pressures. The infection prevention and control link nursesmet quarterly and held an annual study day in November 2011. The link nurse programmehas been successful in training them to undertake the passport assessments in their ownareas. This has been achieved in 10 areas to date. The aim is for all the link nurses to beable to assess staff but priority areas are where outbreaks or other infection prevention orcontrol incidents occur.The IPCT also contribute to the following training sessions:‣ General induction twice a month‣ RGN induction 2 weekly‣ Healthcare Assistant induction monthly‣ Junior doctor Induction twice a year‣ IV cannulation and venepuncture monthly‣ Trust mandatory training sessions weekly‣ Trust Midwifery mandatory training monthly‣ Neonatal & Paediatric mandatory including doctors monthly‣ Contracted services as required‣ Principles & Practices at London South Bank University twice a year totalling 30 hoursof teaching This has been upgraded to Masters degree level for this year‣ Ward based training as requested and after all outbreaks of infection‣ Student nurse passport. This year 1 st .2 nd and 3 rd students attended the half daysessions monthly‣ 6 sessions a year on standard infection control precautions are dedicated toprofessions allied to medicineMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM9

Comparasion of Attendance at Formal Infection Prevention & Control Education & Trainingpresented at the Trust between:April 2010 - March 2011 & April 2011 - March 2012120010008006004002002010/ 2012011/20120Mandatory Registered NursesInduction Registered NursesInfection Control Link NursesPassport Registered NursesMandatory MidwiferyPassport HCSWMandatory HCSWInduction HCSW2.6 IPCT training and developmentThe IPCT Matron attended the national Infection Prevention Society Annual Conference inSeptember 2011. From the conference the team have implemented a new stool assessmentchart that supports investigation during outbreaks of diarrhoea and vomiting. This hasenabled staff to properly assess patients with diarrhoea and implement appropriate isolation,treatment and management.The Infection Prevention & Control Practice Facilitator is in the last semester of the MA Edwhich finishes in September 20123.0 HCAI RATES AND OTHER IPC SURVEILLANCE3.1 Results of Mandatory HCAI Reporting3.1.1 MRSA BacteraemiaOccurrences of MRSA bacteraemia are displayed in the graph below.For 2011/12 the target given to the Trust applied only to ‘hospital acquired’ cases (diagnosedmore than 48 hours after admission). The target set was to reduce our rate to the median ofall trusts’ rates the previous year. This was not more than 8 cases. We ended the year with10 cases.Although we did not achieve the target set, we did see a 29% reduction in cases comparedwith 2010/11. This was the second successive year we saw a reduction of this magnitude,having reduced cases by 25% the previous year.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM10

During 2010/11 the process of root cause analysis of each case was devolved to thedivisions, who report outcomes and actions to the ICC. On review of the individual cases, 6were judged to have been potentially preventable: 1 post-operative infection, 3 venouscannula associated infections and 2 cases where the blood culture was potentiallycontaminated, although this is always difficult to prove. As previously seen, most infectionsoccur in medical patients, but the potentially preventable infections were mostly surgical.No. of cases14121086420MRSA Bacteraemias 2011/12diagnosed >48 hours since admissionApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMedCTDCummulative totalSurgW&CTargetThe graph below shows how BHRUT compares with other hospitals locally and nationally.For several years our improvement correlated with national figures, but then fell away. Oneobvious difference between BHRUT and other trusts is that we were late to implementscreening of emergency admissions. Screening of emergency patients according to DoHguidance commenced in December 2010 and has now been in place for 16 months. This ismonitored by monthly audit of wards. Across the Trust the compliance for the year was 75%.Recently a lot of work has gone into improving compliance and ensuring that the datagathered is as accurate as possible. National standards for compliance with emergencyadmissions have not been set, however preliminary results of the ‘National One Week’(NOW) prevalence audit of English trusts showed that the average compliance acrossEnglish trusts was only 61%. Further results from this study, which should show thecomparative prevalence of MRSA colonisation in BHR hospitals compared with the rest of thecountry, are expected in the coming summer.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM11

16.014.0Trust-apportioned MRSA bacteraemia rate, with Trust-apportionednational & regional rateTrustLondonEngland12.0rate per 10,000 bed days10.08.06.04.02.00.0Oct - DecJan -Apr - JunJul - SepOct - DecJan -Apr - JunJul - SepOct - DecJan -Apr - JunJul - SepOct - DecJan -Apr - JunJul - SepOct - DecJan -Apr - JunJul - SepOct - DecJan -Apr - JunJul - SepOct - DecJan -Apr - JunJul - SepOct - Dec2006 2007 2008 2009 2010 2011 2012Barking, Havering & Redbridge Hospitals NHS TrustMRSA screening of elective and day case patients has been in place since April 2009.Compliance this year across the trust was only 69%. The infection prevention team haveworked with the information and surgical management teams to improve this. Development ofa computer programme by the information team identifies expected admissions that have notbeen screened, thereby enabling pre-emptive action. We have also done further work toclarify which groups of patients do not need screening. This has been made clear to theclinical units who can now focus on the screening of the correct patient group.3.1.2 Clostridium difficileCases of this infection are shown in the graph below. The target applied only to those caseswhich occurred more than 3 days after admission.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM12

No. of new cases80706050403020100Clostridium difficile 2011/12diagnosed >72 hours after admissionApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMedCTDCummulative totalSurgW&CTargetAs can be seen, BHRUT was well within the target of not more than 81 cases, ending theyear with 44 cases. This was a considerable improvement on results in 2010/11 when wehad 111 cases. We consider this is due to continuing the process of immediate individualpatient review against a set of standards produced from our existing policy, which we startedin October 2010 and have continued since. A summary of results is produced for review ateach infection control committee. The most common failing continues to be immediateisolation of patients who develop diarrhoea.3.1.3 GRE BacteraemiaThese are enterococci which are resistant to glycopeptide antibiotics (vancomycin andteicoplanin).There were 12 cases this year, a considerable increase in cases compared with the previoustwo years. There was no obvious connection between any of the cases and it is clear thatdifferent species of are enterococci involved. The most likely explanation is increased use ofantibiotics such as levofloxacin (introduced to comply with guidance for treating pneumonia)and meropenem (required for treatment of multi-resistant organisms) may have encouragedthe selection of these organisms; however this needs to be confirmed by audit or systematicreview. This will be implemented in 2012. No actual date has been agreed for this to happenyet.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM13

GRE Bacteraemia at BHRUTOctober 2003 to March 2012No. of cases876543210Oct-Dec 04Apr-Jun 05Oct-Dec 05Apr-Jun 06Oct-Dec 06Apr-Jun 07Oct-Dec 07Apr-Jun 08Oct-Dec 08Apr-Jun 09Oct-Dec 09Apr-Jun 10Oct-Dec 10Apr-Jun 11Oct-Dec 11KGH OCH/HWH/QH Total3.1.4 Orthopaedic Surgical Site InfectionsThe surgical division are responsible for collection of the data and have been reporting therepair of fractured neck of femur for the 3 periods to date. The data is uploaded to the HealthProtection Agency for Surgical Site Surveillance (SSIS) web site by the Trauma Co-ordinator.There are still some operational difficulties in collecting the information, however, there hasbeen a recent improvement with data collection as the trauma Co Ordinator now also ringsElm and Erica Ward at KGH on a daily basis where the orthopaedic patients who have beenoperated on at Queen’s Hospital for fractured neck of femur have their rehabilitation ifrequired. The Community Orthopaedic Project in Essex (COPE) Team also report any woundinfections following discharge.Within this period there have been 6 surgical site infections of which 4 were during admissionand 2 after discharge that were identified by the COPE team. All these patients wereappropriately treated. In future the infection control lead for orthopaedics will report suchpatients and their management at the infection control committees.For the forthcoming year the surgical division have agreed to commence surveillance onpatients following elective hip or knee replacement. The start date has yet to be agreed.3.2 Trends in Health Care Associated Infection Statistics3.2.1 Urinary catheter associated bacteraemia (CAUTI )During 2010/11 we managed to achieve a 10% reduction in cases and the target for 2011/12was set at no more than 38 however the final figure for the year is 43. Whilst RCA processeshave not been initiated for this, the quality of care audits suggest that the introduction ofAseptic Non-touch Technique (ANTT) will address the asepsis on insertion of a urinarycatheter Further training will be given on the importance of continual aseptic managementduring the daily care of catheterised patients whilst maintaining a closed circuit As the rate ofcatheterisation reduces it is hoped that the CAUTI will also reduce.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM14

50Urinary Catheter Associated BacteraemiaApril 2011 - March 2012No. of cases403020100Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMed Clin Supp SurgW&C Target Cumm3.3 Outbreaks and incidents3.3.1 Outbreaks of Norovirus (or presumed Norovirus) infection leading to closure ofwardsThe total number of wards affected was more than in 2010/11 which puts BHRUT as anoutlier in the region. The ward staff did identify patients with sudden onset vomiting ordiarrhoea quickly which enabled the IPCT to implement outbreak management policy toensure tight control ensuring minimal transmission. Despite these measures Norovirus wasparticularly virulent. Prior to next years norovirus season the IPCT will summarise theoutbreak management review meetings and present the overall findings to the ICC anddebate as to whether any other measures should be in place.18BHRUHT Wards closed due to Diarrhoea includingNorovirus 2006 - March 20121614No. of wards closed121086420Nov-06Mar-07Jul-07Nov-07Mar-08Jul-08Nov-08Mar-09Jul-09Nov-09Mar-10Jul-10Nov-10Mar-11Jul-11Nov-11Mar-12Wards closed due presumed Norovirus KGHWards closed due presumed Norovirus Queen's3.3.2 Other outbreaks/incidents of infectionMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM15

Queen’s Hospital3.3.3 Neonatal Intensive Care UnitIn January and September the Neonatal Intensive Care Unit (NICU) had clusters of neonatescolonised with multi resistant organisms but no clinical .infection. These clusters wereinvestigated and led to further environmental investigation of the tap water in the unit. Thisinvolved sampling of water used for hand hygiene. Following inconclusive results of the watersamples it was agreed to put in place a programme whereby the unit taps were ‘flushed’through and removal of any lime scale, prior to re sampling. Flushing simply means lettingthe taps run freely for 10-20 minutes twice a week. This was performed by the estatesdepartment. To ensure safety of the neonates a decision was taken to bathe the babies insterile water. After further water testing the IPCT was assured the tap water was safe but theuse of sterile water for bathing continues for level 2 neonates in the Queen’s NICU in theshort term until the newly formed Water Safety Group** (explained below) agree aprogramme of regular testing to be dictated by the department of Health. The method ofcleaning taps to ensure no recontamination was also reviewed and found to be satisfactory.Subsequent to this outbreak an incident occurred regarding Pseudomonas aeruginosa in aHospital in Northern Ireland and whilst the review is outstanding guidance on management ofwater in critical care units has been updated and re issued. BHRUT is compliant with thisguidance and the IPCT, estates, domestic services and relevant clinical staff have formed a**Water Safety Group to progress future actions.3.3.4 Harvest B ward outbreak of Mupirocin resistant MRSASix patients from Harvest B ward were identified as being colonised with Mupirocin resistantMRSA between 13/04/2011 and 25/05/2011. The index case was identified on admission toBeech ward where MRSA screening was done. Although the first patient was identified inApril, no further cases were identified until a cluster of four patients in the week of 16/05/2011Actions were taken to minimise further spread including blitz cleaning, weekly MRSAscreening for 3 weeks and a 3 week long audit programme of standard infection controlprecautions. No further clusters of patients were identified as MRSA positive. There were noclinical infections associated with this episode.3.3.5 Neurosciences Unit- Patient with Sporadic Creutzfeldt Jakob Disease. (CJD)A patient was admitted to Neurosurgery with a diagnosis of Sporadic CJD. Followingoutbreak meetings including representatives from the Health Protection Agency and theirCJD section it was agreed that the patient had not had any procedures in BHRUT that poseda risk to other patients or staff.3.3.6 Ante Natal Chicken pox incidentA pregnant patient attended the ante natal clinic at KGH unaware she had chicken pox whichwas subsequently diagnosed by her GP the following day. As a significant exposure riskoccurred, a list of all patients and staff that were in direct contact with the infectious personwas compiled. Clinical advice about management of infected patients was obtained from theConsultant Microbiologist covering the relevant area. Staff were advised to contactOccupational Health if they did not know their immune status. 53 patients who were possiblecontacts were tested as soon as possible. Five of the 53 patients were found to be non-Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM16

immune. As a result of this incident a leaflet explaining Chicken Pox is being prepared for theante natal clinic to be given at the patient’s first visit.3.3.7 King George ITU - Vancomycin resistant Enterococcus/ KlebsiellaBetween 21/08/2011 and 29/08/2011 five patients in King George ITU became colonised withExtended Spectrum Beta Lactamase (ESBL) producing Klebsiella pneumoniae, two of whomsubsequently developed Vancomycin Resistant Enterococcus (VRE), and one patient wasidentified with VRE without a history of Klebsiella pneumoniae. A meeting was held toestablish any risks or contributing factors and links (medical /surgical l/geographical/prescribed antibiotics) between the affected patients and to determine any areas of deviationfrom best practice. It was found that the VRE was of different strains however 5 patients hadthe same Klebsiella strain. An action plan was put in place to ensure a safe environment andno further transmission occurred.4.0 HAND HYGIENEThe IPCT held hand hygiene awareness days in April and November 2011 and January2102. They had support from the Contract services Sodexo and the infection prevention &control Link nursesThe promotion of hand hygiene was achieved by a variety of ways including:-‣ Infection prevention & control Link nurses attending sessions at the Atriums of theboth hospitals and demonstrating the glo germ machine to members of the public andstaff‣ Infection prevention & control Link nurses going to individual wards with a member ofthe IPCT promoting hand hygiene with the glo germ machines‣ Screen saver on PC desktops to remind staff about hand hygieneThe IPCT purchased 2 new Ultraviolet hand hygiene training kits.5.0 DECONTAMINATION5.1 ArrangementsThe DIPC is the executive lead for decontamination. The Matron of IPCT investigates andescalates any operational issues. The Sterile Services Department (SSD) is fully accreditedand is overseen by a hard facilities contracts manager in BHRUT, who manages any noncompliances.5.1.1 Decontamination Committee ActivitiesDecontamination Trust wide audit was undertaken by an external consultant. Reports weresent to individual managers to progress any actions. These were followed up at the Medicaldevices/decontamination committee with an overall action plan that is monitored by thecommittee. The external auditor also visited the Sterile Service Department which ismanaged by the company Synergy. The audit findings were excellent other than a fewenvironmental issues which were dealt with at the time of the audit.6.0 CLEANING SERVICESMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM17

6.1 Management Arrangements Queens Hospital‣ Queens’s hospital is a 939 bed PFI hospital. The hospital building is operated by aprivate sector partner (Catalyst Healthcare Management) who manage theFacilities Management Company, Sodexo.‣ Sodexo are responsible for providing the cleaning, 24hrs a day with workschedules for each ward/department. Queens is cleaned to National Standards ofCleanliness 2007, this was introduced in October 2011, all work schedules havebeen updated to reflect the enhanced cleaning, as previously the hospital wascleaned to 2002 standards.‣ Regular operations meetings continue to be held monthly between the Trust,Sodexo and Catalyst; the format of these meetings is to discuss and resolve anyoperational issues during that period. Any issues that cannot be resolved at thismeeting are escalated to the PFI Board meeting which again is held monthly, andthe membership includes senior management from the Trust, Sodexo and Catalyst.‣ Catalyst issue a monthly report to the Trust to coincide with the PFI Board whichincorporates the Key Performance Indicators, along with the cleaning scoresachieved for the month.6.1.1 Monitoring Arrangements‣ Weekly walk around (environmental audit), which includes Soft and Hard FacilitiesManager for the Trust, Sodexo Domestic Manager, Sodexo Estates Manager &representation from Catalyst The Deputy Director of Nursing, and a member of theInfection Control Team now join the walk around.‣ The format for the walk around is to visit a specific area, and monitor the wholeenvironment.‣ Matrons’ audit Includes Soft Facilities Manager for the Trust, Sodexo Manager andTrust Matrons, including the IPCT Matron. The format for the audit is to visit aspecific area, with the relevant matron, and use the NSC audit tool (49 point audittool).‣ Cleaning Audits: Sodexo Domestic Supervisors undertake audits using the NSCaudit tool, inline with the recommended frequencies for audit.6.2 Management Arrangements KGHThe Trust awarded a Total Facilities Contract to Sodexo in August 2009 for a period of 5years. There is a Contracts Manager to monitor the service provision.‣ Monthly TFM operational meetings are held with Sodexo Management Team andthe Trust TFM Management team whereby any operational issues are dealt with..‣ The Domestic KPI report gives cleaning checklist scores for the month.‣ A TFM User Group meeting is also held monthly which comprises of DepartmentLeads for Sodexo, the Trust Contracts Managers, Infection Control and aMatron/s to discuss the day to day issues on the wards and departments and anychanges in procedures etc.‣ A quarterly review meeting is held between Senior Management of the Trust andSodexo where issues have been escalated from the Operational meetings.6.2.1 Monitoring ArrangementsMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM18

‣ Domestic Service - Monitoring of the domestic service provision is carried out usingthe National Standards of Cleanliness 49 point audit tool. The contractrequirement states that the cleaning of the hospital must be carried out to 2007standards and frequencies.‣ Monthly combined audits are carried out with Deputy Director of Nursing, InfectionControl and Soft Services Manager,‣ Matrons Audits are held bi-weekly and Infection Control and Nursing audit held biweekly.‣ The Soft Services Manager monitors Sodexo cleaning audits ward areas weekly.This year the Trust submitted total cleaning scores for the whole year. They are asfollows:-King George 96.6%- Queen’s Hospital 95.6%6.3 Patient Environment Actions Team Audits (PEAT) Results for 2012-2011-2010-2009Scores for 2012EnvironmentPrivacy & DignityFood ScoreSite NameScoreScoreKing George Hospital Good Excellent GoodQueen's Hospital Good Excellent GoodScores for 2011EnvironmentPrivacy & DignityFood ScoreSite NameScoreScoreKing George Hospital Good Excellent GoodQueen's Hospital Good Excellent GoodScores for 2010EnvironmentPrivacy &Food ScoreSite NameScoreDignity ScoreKing George Hospital Good Excellent GoodQueen's Hospital Good Good GoodScores for 2009EnvironmentPrivacy &Food ScoreSite NameScoreDignity ScoreKing George Hospital Good Acceptable AcceptableQueen's Hospital Good Excellent Good7.0 AUDIT AND EXTERNAL REVIEWS7.1 Audit ProgrammeThe IPCT undertake audits on an annual basis and as required due to an outbreak, incidentor untoward event.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM19

The audits and results are as follows:-AuditNo. of Wards/departmentsaudits2010-2011Results% Range2010-2011No. ofWards/departmentsauditedResults% Range.2011-20122011-2012Environment 62 86-100 74 88-100Isolation 63 93-100 61 93-100Personal ProtectiveEquipment (PPE)69-98-100 74 87-100Written feed back is given to all wards /departments following an audit session. However,those who achieved a score below 90% are re audited within two weeks of the original audit.If there is no improvement a meeting is arranged with the Ward manager and Matron and theoutcomes are emailed to the Deputy Directors of Nursing.7.2 Quality of care – improving the quality of nursing care using a continuousaudit cycle.7.2.1 ProcessOn the timetabled days each clinical area is assessed by a staff member and the datacollected and analysed on the day. A third of the patients in every relevant clinical area areaudited. This enables immediate feedback to be given to the nurse in charge who identifieswith the auditor areas of good practice and areas which need to be improved before the areais audited again. .7.2.2 ResultsThese are presented on a dashboard which is sent monthly to ward teams, matrons, clinicaldirectors and senior nursing team and is RAG rated. Areas score green with 100%compliance, amber if above 90%, red if 89% or below, and pink if below 60%.Hand hygiene Quarterly Trust percentagesJun-11 Aug-11 21.11.11 13.02.1267.50 76.93 69.67 66.51Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM20

IV cannula Quarterly Trust percentages05.05.11 18.07.11 31.10.11 30.01.1252.91 57.27 60.53 57.75Urinary Catheters Quarterly Trust percentages27.06.11 Sep-11 09.01.1278.84 83.23 80.24Action plans are written for areas that require assistance and this is monitored by thematrons, assistant director of nursing or Director of Nursing.7.2.3 Health Care Associated Infections (HCAI’s) Peer ReviewColleagues from NHS London undertook a review at BHRUT in January 2012 The purposewas to determine if the systems and processes in place were sufficiently robust and to beable to advise if there are additional actions the organisation could take. The team revieweda range of documentation provided by the IPCT The review team also observed theenvironment and practice by visiting a number of wards, and interviewed a range of staff.including the IPCT, Matrons, ward staff, cleaning staff and some medical staff. The full reporthas been shared with clinical staff, below are the key areas noted during the review.Key areas of action focus on the following risks:‣ Board to ward accountability‣ Staff having the necessary competence to assure consistent application of evidencebased practice when inserting lines and catheters and following agreed guidelines andprotocols consistently‣ Assuring prudent antimicrobial practices are in place‣ Governance and assurance processes being robust enough to inform the Board ofprogress and alert the Board to any further risks.Culture and Ownership‣ To enhance medical engagement:Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM21

‣ Set objectives for HCAI with each clinical director‣ Identify medical leads for infection prevention within each speciality‣ Agree four or five specific actions and outcomes that BHRUT seek from the lead e.g.‣ RCA involvement‣ Antimicrobial prescribing‣ Training and competence‣ Involvement of juniors in HCAI/antibiotic audits‣ Hand hygiene/BBE‣ Include objectives for HCAI in consultant job plans‣ Ensure this features in Consultant appraisalsRole of Infection Prevention & Control Team‣ The team work with “positive alerts.”‣ Explore ways to develop roles and seek ways to balance being reactive with aproactive approach that focuses on the strategic goals of the teamBoard Assurance‣ Build stronger relationships with specific directorates.‣ Review The Board how receives success a report of the on incumbent the Quality robust and “link Safety worker Performance role” can indicators. be measured Thisincludes a graph demonstrating compliance to agreed performance measures includingTraining HCAI’s and then has a section titled “Mitigating Actions”. Review this section to ensurethat the report articulates the risks to delivery and the actions required to minimise or‣ Reviewmitigateassessmentthese, in orderofthatcompetence,the Boardparticularlycan seek assurancefor clinicalonskillsthe effectivenesssuch as asepticof thesetechnique,controls.line insertion, and taking blood culture.‣ Build on existing work achieved on ensuring all staff inserting central lines are trainedRoot Cause Analysisand assessed.‣ Continue to undertake RCA’s and review by by the DIPC and Medical DirectorCleaning‣ ensureandTrustEnvironmenthave a slightly more robust process for tracking progress and ensuring therequired changes are made‣ Ensure BHRUT these RCA’s have are copies owned of by all the the Clinical 2007 cleaning Business specificationsUnits‣ Review who is responsible for cleaning specific items of equipmentClinical The Audits IPCT have set up training sessions for ward managers and Sodexo to understandroles and responsibilities and details of the 2007 cleaning standards‣ Test the effectiveness of the current methods of undertaking the audits required toAntimicrobial populate Stewardshipthe dashboard to be assured the controls are effective‣ As audits are weekly and staff generally know when they are taking place. Consider staff‣ Place auditing clear in areas responsibility they do not and normally expectation work in for or improvement getting other with staff the or volunteers senior leadership toteam undertake of the audits Clinical at different Business times. Units‣ Ensure this is underpinned with an effective governance and assurance process thatFunction articulates of Infection the risks Control to delivery Committee and the actions necessary to minimise or mitigate thoserisks.Review scope and assurance processes of ICC, including setting clear expectation‣ Undertake smaller audits more frequently until Trust is assured good practice isregarding attendance as there is an absence of medical staff (many sending apologies toembedded.the last two quarterly meetings).‣ ReviewUse formalcontentandofinformalthe meetingmethodsand review(such asto makejunioritdoctorsmore compelling,undertaking(suchaudits,as cliniciansand seniormedicalbringingstaffrelevantcheckingtopicscomplianceto discuss) butduringalsowardensuringrounds)it adequatelyConsultantfulfilsanditsseniorrole ofmedicalstaff providing need assurance. to regularly check and review antibiotic prescribing during their ward roundsPlansMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM22

Action plans are in place but to help in Trust’s desire to create greater local ownershipand clarity of outcome, review them in order to:‣ Clearly identify and separate the corporate actions from the Directorate ones.‣ Identify the outcomes BHRUT are seeking rather than just the processes (e.g. highcompliance to antimicrobial prescribing) and align the actions to delivering those.‣ Clearly identify the person(s) accountable for the action(s) and the timescales fordelivery.‣ Put in place an effective process for tracking progress and identifying anyslippage to timescales so that issues are escalated and addressed.7.3 Report from Antimicrobial Pharmacists/Consultant MicrobiologistsThis report details the activities that have been carried by pharmacy and microbiology indeveloping a robust antimicrobial stewardship programme throughout BHRUHT in2011/2012.7.3.1 BackgroundThe point-prevalence baseline audit carried out in October 2010 highlighted that improvingthe documentation of antimicrobial prescribing is essential to allow monitoring of adherenceto guidelines and the appropriateness of antimicrobial prescribing. Based on the results, anumber of recommendations were made which led to the implementation of the antimicrobialstewardship programme at BHRUHT in 2011/2012. The programme included the followingelements:7.3.2 Guideline development and implementationThe process of reviewing antimicrobial guidelines was reviewed which included theimportance of communicating and cascading information to all prescribers and educatingstaff about them.The following guidelines approved by the Drugs and Therapeutics Committee have beenwritten in conjunction with consultant microbiologists and with the involvement of theappropriate senior medical staff:• Gastro-Intestinal Infections– May 2011• Lower Respiratory Tract Infections- June 2011• Updated Gentamicin Guidelines- Oct 2011• Obstetrics and Gynaecology Antimicrobial Guidelines- Nov 11• Adult pocket antimicrobial guide for common acute infections. Dec 2011• Amikacin once daily dosing and monitoring guidelines- Jan 2012• Vancomycin dosing and monitoring guidelines -Jan 2012• Gentamicin Multiple Daily Dosing Guidelines for the Treatment of Endocarditis-Jan 2012• Treatment and prophylaxis of Influenzae- Jan 2012• Gentamicin guidelines for paediatrics – Jan 2012• Update of the Restricted Antimicrobial list- February 20127.3.3 Development of the Trust Antimicrobial Management CodeMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM23

This was written to avoid situations where patients are inappropriately exposed to longcourses of either intravenous or oral antibiotics and to allow monitoring of adherence toguidelines.The antimicrobial management code includes four antimicrobial prescribing indicators (APIs):‣ API- Indication of antimicrobial to be documented on drug chart and medicalnotes‣ AP2- Duration/stop date or review date documented on drug chart and medicalnotes‣ AP3- All IV antimicrobial therapy to be reviewed at 48 hours‣ AP4- Restricted antibiotics approved by microbiologists must be documentedon the drug chart7.3.4 Implementation of the Trust Antimicrobial Management CodeA multipronged awareness programme to implement the Antimicrobial Management codewas launched in April 2011 which comprised of:(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)The distribution of the code to all medical, nursing and pharmacy staff via email.Display of policy poster on wards;A series of announcements at clinical team meetingsInduction for medical staffAn article on the hospital’s staff information bulletinDesktop image of the code on all Trust computersRedesign of a new drug chart to include dedicated antimicrobial prescribingsection to prompt prescribers to document the indication and durationA sticker designed to be used by clinical pharmacist to notify prescribers if therewas non compliance to the code.7.3.5. Formation of the Antimicrobial Stewardship CommitteeAn assessment of the trust against a published national evidence-based Antimicrobial Selfassessment tool recommended by the DOH was carried out in 2010 As a result of theassessment the following specific actions were completed:• A formal Antimicrobial Stewardship Committee with representation frompharmacy, microbiology, senior nursing staff and consultant from otherspecialities which reports to the Drugs and Therapeutics and Infection ControlCommittees was established, the first meeting was held on 28 th2011.A written audit strategy on antimicrobials.• Written strategy for Antimicrobial Education and Training.7.3.6 Education and TrainingSeptemberThe antimicrobial pharmacists and the consultant microbiologists were actively involved inclinical education. A mandatory antimicrobial stewardship training competency package wasdeveloped and was delivered to all junior doctors via hard copy and a one hour face-to-facetraining session. We have focussed our efforts not just on policy change but also educatingall staff across all disciplines to improve antibiotic prescribing. We have delivered over 30sessions of teaching to medical staff, nurses and pharmacists. As part of the antimicrobialMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM24

education and training package at BHRH we have set up an antimicrobial accompanied wardvisits for junior pharmacists. The main aim of these visits will be to aid their antimicrobiallearning and build on their confidence of dealing with antimicrobials whilst on the wards.7.3.7. Adult Pocket Antimicrobial Guide for Common InfectionsThe first edition of adult pocket guide was launched in January 2012. The cards have beendistributed to all doctors and pharmacists7.3.8 AuditsThis financial year saw the 2 nd point prevalence study conducted at BHRH, providing afurther snapshot view of prescribing patterns within the trust. Consequently, this has allowedcomparisons to be drawn against last year’s audit conducted. (Table 1).Table 1 Point Prevalence Audit2010 2011No of charts seen 649 868No of antimicrobials prescribed 378 409Allergy Documented 99.5% 99.7%Nature of Allergy documented 21% 33%Indication documented in Drug Chart 7% 53.3%Indication documented in medical notes or 67% 84.1%drug chartDocumentation of duration/course length 32% 51%on drug chartFollowing regular teaching to doctors and the greater awareness that has been raised aroundthe documentation of course lengths, indication there has been significant improvement withthese indicators (table 1). These along with extra efforts by pharmacy staff to focusprescribers on the quality of antibiotic prescribing have been successful in improving the useof antibiotics and reducing unneccessary prescriptions.The point prevalence audit for 2011 was awarded a 2 nd prize in the annual clinical auditcompetition.A trust-wide gentamicin prescribing, administration and therapeutic monitoring was carriedout in August 2011 and was awarded the first prize for the Tony Fuller Award in patientsafety.A poster on quality improvement programme to improve antimicrobial stewardship andpatient safety at BHRH was presented at the Research and Development Annual conferencein November 2011Our work has shown that proactively developing an Antimicrobial stewardship programmehas improved documentation of antimicrobial prescribing as per the management code. It hasalso improved engagement of prescribers on antibiotic issues and raised the profile ofprudent antibiotic prescribing within the Trust. There has also been a decrease in Clostridiumdifficile cases within the Trust. The antibiotic stewardship programme will be continued ondeveloping guidelines with more emphasis on education and training and awareness andcompliance to guidelines will continued to be audited.8.0 ACTION PLAN FOR 2012/2013Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM25

The action plans identified in 2011/2012 report were all met. The plans for 2012/2013 are asfollows:8.1. Auditsa) 3 rd Point prevalence Auditb) Monthly audit of the management code in different specialist area and report to therelevant clinical directorate meetings- May 2012c) Trust-wide antibiotic prophylaxis audit in surgery April 2012d) Audit the appropriateness of use of antibiotics in respiratory infectionse) Audit the use of restricted antibiotics8.2. Education and traininga) Convert the current antimicrobial stewardship competency package to an E-Learningmoduleb) Continue Antimicrobial Stewardship training for doctors, nurses and pharmacists8.3 GuidelinesUpdate/review the following guidelines:a) Malariab) Infective Endocarditisc) Sexually Transmitted Diseased) Urinary Tract Infectionse) Clostridium difficilef) Neutropenic sepsisg) Antibiotic prophylaxis for surgeryh) Tuberculosisi) Eye and Dental Infectionsj) Osteomyelitis and septic arthritisk) Central Nervous infectionsl) Opportunistic infections associated with HIVI8.4) Paediatric Antimicrobial Guidelinesa) Set up a working group to develop the first edition of paediatric antimicrobial guidelinesb) The guidelines identified for paediatrics are:1) pneumonia (community acquired and hospital acquired), 2) UTI (Nice guideline) 3)Meningitis (NICE guideline) 4) Soft tissue infection 5) orbital cellulitis 6) Osteomyelitis7) Eczema herpeticum 8) peritonitis 9) suspected sepsis (< 3 months and >3 months),10) TB8.5 Miscellaneousa) Design and distribute penicillin allergy posters to all wardsb) Distribute pocket size antimicrobial guidelines to all new doctors in August 20129.0 CONCLUSIONSMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM26

It has been another challenging year for the Trust, which missed out on achieving the MRSAtarget but did achieve the Clostridium difficile target. The quality of care programme hasbeen successful in engaging clinical staff and raising the expectations and standards ininfection prevention and control practices. Overall it was a successful year except fornorovirus which as previously mentioned was present for a long period of time this year andhad a significant effect on the Trusts activity due to closed beds. A peer review of thenorovirus management at BHRUT by an external Microbiologist/ Director of InfectionPrevention & Control has been requested and took place in May 2012.The priorities for 2012-2013 are to reduce the number of MRSA bacteraemias and C.diffs, toprogress with the annual plan, ensuring a more robust process for root cause analysistraining and the implementation of the Aseptic No Touch Technique (ANTT) programme.10. 0 REFERENCESo Winning ways (DH 2003),o Towards Cleaner Hospitals and lower rates of infection (DH 2004)o A Matron’s Charter: an action plan for cleaner hospitals (DH 2004),o Revised guidance on contracting for cleaning (DH 2004),o Saving Lives: A delivery program to reduce healthcare associated infection (HCAI)including MRSA (DH 2005).o Going further faster: implementing the Saving Lives delivery program (DH 2006)o The Health and Social Care Act 2008 (2010 ) Code of Practice for the Prevention andControl of Health Care Associated Infections (DH 2006)o The National Specifications for Cleanliness in the NHS: a framework for setting andmeasuring performance outcomes. (NPSA 2007)o Essential steps to safe clean care (DH 2007)o Clean, safe care: reducing infections and saving lives (DH 2008)o Board to ward how to embed a culture of HCAI prevention in acute trusts (DH 2008)o Clostridium difficile infection: How to deal with the problem (HPA& DH 2009)**The front page picture was taken during a hand hygiene awareness day whenvisitors joined in with the ‘glo germ’ demonstration of hand hygiene.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM27

Appendix 1CLINICAL GOVERNANCE REPORTING – JUNE 2011TRUST BOARDQuality and Safety CommitteeAudit CommitteePatient Experience CommitteeStatutory Safety CommitteeSafeguarding Children CommitteeSafeguarding Adults CommitteeClinical Risk Management CommitteeEvidence Based Practice CommitteeDrugs and Therapeutic CommitteeInfection Control CommitteeClinical Audit CommitteeTerms of Reference – risk topicscovered:• Mortality• Patient experience• External Clinical Accreditations• CQC Registration• Clinical Effectiveness andoutcomes• Quality Account• Complaints• Incidents and Serious Incidents• Closed claims review• Key Trust Objectives• Risks to Reputation• Service Changes• Horizon scanningBAF & Risk RegisterCQC RegistrationResearch and DevelopmentNursing & Midwifery BoardMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM28

Appendix 2Infection Prevention & Control Staff ChartDeborah WheelerDirector of Infection Prevention & Control& Director of NursingLesley MarshAssociate Director of NursingDr Lindsey BainInfection Control DoctorSheila O’MahonyMatron, Infection Prevention & ControlKate MartinSenior Infection Control NurseCorinne Cameron-WatsonSenior Infection Control NursesMercia WilliamsIC Practice FacilitatorTracey MortonInfection Control NurseLynne SmithAdministrative Co-ordinatorLucy EllisInfection Control NurseSheree BlackAdministrative Co-ordinatorMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM29

Appendix 3Annual Trust Action Plan to Prevent and Reduce Health Care AcquiredInfections 2011-2012Updated March 2012 Sheila O'Mahony Matron IPCTKey:Appendix 3W = Not yet startedG = CompleteA = In progress, on trackR = Overdue*Leads are responsible for action and supported by the infection prevention & control team asrequiredAim Actions Required Lead ReviewDateRAGrating1. Reduction in Maintain compliancenumber of MRSA with Intravenous andBacteraemias and central venous carestaying within target bundlesof 8 bacteraemiasRCA investigation ofeach MRSAbacteraemiaAgreed target of 8bacteraemias for wholeyear 1.4.11 - 31.3.12Audit through qualityof care audits.Monitor eachbacteraemiaundertake RCA andreport to ICC.Improvementsidentified from RCAsto be taken forwardand monitored viaaction plansRCA investigationtool and policy is to beupdated and adaptedto ensure it is robustMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM30Progress at March 15 th 2012DIPC/IPCT/DND's RED Target to date is 10 which is 2above trajectoryICDDND to designateleadMarch31 st2012March31 st2012AMBERAMBER5 RCA’s have been signed off andaction plans presented to ICCDates set for sign of remainingRCA’s by 31 st March 2012RCA tool has been adapted andused successfully on 4/5 RCA’sUpdated policy remains

2. To monitorincidence and reducenumber of MeticillinSensitiveStaphylococcusAureusNo target has been setfor MSSA65 HCAI were reportedin 2010 -2011and 72CAI3. To monitor andreduce the number ofE.coli bacteraemiaand to be approvedat ICCAll RCA's to be signedoff by DIPC and CEOand added tosummary action planand presented to ICCMaintain compliancewith care bundlesAudit through qualityof care auditsSet local trust targetto reduce currentbacteraemia figureMonitor each infectionand complete RCAImprovementsidentified from RCAsto be takenforward andmonitored via actionplansSummary action planto be collated andpresentedat ICC and signed offby DIPC and CEOAll E coli bacteraemiato be manuallyrecorded on MESSHealth ProtectionAgency data baseand reported throughICCIPCTIPCT/MatronsDIPC/CEOInfection ControlDoctorMarch31 st2012March31st2012March31 st2012March31 st2012AMBERGREENoutstanding to be carried forwardto annual plan for 2012-20135 RCA’s awaiting sign off beforeMarch 31 st 2012Local targets to be set afterbenchmark data completed for2010-2011. NO targets set by DHfor 2012-2013MSSA RCA's beingundertaken since 1st April 20112 HAI - 2 CAI April 20112 HAI – 5 CAI May 20115 HAI – 7 CAI June 20118 HAI - 7 CAI July 20113 HAI – 7 CAI August 20113 HAI - 5 CAI September 20113 HAI – 6 CAI October 20113 HAI- 8 CAI November 20111 HAI - 6 CAI December 20112 HCAI 9 CAI January 20122 HCAI 8 CAI February 2012Total HA1 to end of February 2012= 31GREEN Reported from June 1 st 20117 HAI - 15 CAI June 201110 HAI - 42 CAI July 20115 HAI - 28 CAI August 20118 HAI - 29CAI September 201111 HAI – 25 CAI October 20116 HAI – 20 CAI November 201110 HAI – 31 CAI December 201111 HCAI 28 CAI January 2012Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM31

No target has been setfor E coli's - no dataavailable for 2010-2011as not collected byPathology4. Hand HygieneAll staff working inclinical areas to meet aminimum of 95%compliance againststandardSet local trust targetto reduce currentbacteraemia figureDeliver hand hygienetraining for all staff onan annual basis asper separate handhygiene training plan.Carry out ongoing 6weekly audits tomonitor compliance.Feedback and reporton compliance byward and specialityIPCTDND's/ Matrons /Infection ControlTeamMarch31st2012March31 st2012GREENGREEN9 HCAI 20 CAI February 2012Total HAI to date = 77Local targets to be set afterbenchmarkdata completed for 2010-2011.Training sessions rolled out trustwide.Monthly audits undertakenby senior nursing team as part ofVisible Leadership Initiative.Results of audits shared atexecutive and local level, andreported to ICC Performance asappropriate.Hand Hygiene awareness dayheld on January 24 th both sites5. Adherence to Saving Lives High Impact Interventions5.1 Central VenousLine Management HII1All CVC lines to beinserted and managedin accordance withSaving Lives CareBundle Guidance5.2 Care ofIntravenous Lines HII2All peripheral lines to beinserted and managedin accordance withCarry out weeklyaudits to monitorcompliance with allrelevant Saving LivesCare Bundles.Feedback findings toclinical care /wardteams. Report to ICCtwice annually as peragreed timetable.Report to ICC twiceannually as peragreed timetable to beagreed with DND's aspart of quality careDND's for allSaving Livesitems. ITU clinicallead Matrons,ward sistersDND'sMarch31 st2012March31 st2012AMBERAMBERCentral line policy updateoutstanding plan to be discussedwith infection control lead whennominated by clinical directorMore work required on insertion ofperipheral lines plan to bediscussed with infection controllead when nominated by clinicaldirectorMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM32

Saving Lives Care programmeBundle Guidance Ward managers andsenior consultants toaccount for noncompliancePerformancemanagement ofpersistently noncompliantstaff5.3 Prevention of Report to ICC twiceSurgical Siteannually as perInfections HII4agreed timetableAll surgical sites to becared for using aseptictechnique in accordancewith Saving Lives CareBundle GuidanceTrust to participate inthe Health ProtectionAgency's Surgical SiteInfection SurveillanceScheme(SISS) currentlyreporting fractured neckof femursAll ventilated andtracheostomy patients tobe managed inaccordance with theSaving Lives CareBundle GuidanceNeed more robustreporting withclinician’sengagement. Need toagree other modulesof SSISNo progress with thisHII - roll over to 2012-2013 planDND's GREEN Ward level audits continue to becarried out as part of Quality CareProgrammeSurgical DNDSurgical DNDITU Clinical Lead/Critical CareMatronsMarch31 st2012March31 st2012March31 st2012AMBERAMBERAMBERNo report/action to date Plan forfuture SSIS reporting to bediscussed with infection controllead when nominated by clinicaldirectorTo be carried forward to next yearsaction plan5.5 Urinary CatheterCare HII6 &Report to CQUINquarterly and at ICCICD/IPCTMarch GREEN April 2011 HAI =131 st May 2011 HAI =2Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM33

Agreed target of 38urinary catheterassociated bacteraemiafor whole year 1.4.11 -31.3.12meetings 2012 June 2011 HAI = 0July 2011 HAI = 4August 2011 HAI = 3September 2011 HAI = 2October 2011 HAI = 9November 2011 HAI = 6December 2011 HAI = 4January 2012 HAI = 3Total to February 2012= 345.6 Clostridiumdifficile ManagementHII7To meet annual target of81 cases of C.diffinfectionsPrescribing practice tomeet a minimum of 90%compliance with policy.Prevent C.diff spread byadherence to carebundle guidance at alltimesAgreed target of 81infections for wholeyear 1.4.11 - 31.3.12.Monitor eachinfection, complete anexception report andundertake RCA ifdeath occurred and isstated on part 1a ofdeath certificate andreport to ICC.Improvementsidentified from RCAsto be taken forwardand monitored viaaction plansCarry out ongoing 6monthly audits tomonitor compliancewith Policy. WardPharmacists to checkand challengeprescribing practiceDND's ICDMarch31 st2012GREENApril 2011 HAI = 6 .Two cases oneHarvest B underwent RCAMay 2011 HAI = 5June 2011 HAI = 3July 2011 HAI = 2August 2011 HAI = 5September 2011 HAI = 5October 2011 HAI = 5November 2011 = HAI =3December 2011= HAI 2January 2012 = 2February 2012 = 1Total to February = 39Await report date6. Screening (Saving Monitor Trust ICD/IPCT GREEN IPCT provide positive results toMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM34

Lives - A strategy forNHS Trusts: asummary of bestpractice)Screening Protocol toinclude all patientsEnsure positiveresults arecommunicated andacted uponwardsMonthly reports sent to divisionsfor action re complianceEnsure all patients arescreened for MRSA7. Death associatedwith HCAI'sTo monitor screeningrates with feedback torelevant areaAll patient deathsassociated withHCAI's should bechecked to ensurethat the HCAI isaccurately recordedas a cause of death orcontributor factorUndertake review ofjunior doctors trainingfor death certificationIPCTIPCT / MedicalDirectorMedical DirectorMarch31 st2012March31 st2012AMBERAMBERAMBERInformation departmentdeveloping data warehouseinformation reports will begenerated from this system whenup and running.Awaiting date of meeting.If dealt with by medical educationremove from annual plan8. Antibiotic actionplan 2011-2012 Seeseparate planAnti MicrobialManagement Codeapproved at ICC andimplemented May2011 to be auditedweek commencing25th July and resultsto Sept ICCManisha Madhani/ Dr Diane OshiruMarch31 st2012GREEN9. Environmental issues supporting hand hygiene and management of wards closeddue to outbreaks of infectionAudit completedReported at Nov ICCMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM35

Review all signageFloor signsTalking KonesExternal BannerInstallation of Saniposthand hygiene stations(both sites)Review ward postersrolling over from cleanyour hands campaignto the five moment’scampaign. Replaceold postersAssess current stateof floor signs andliaise with Sodexo toremove tatty stainedsigns. Reviewpossibility and costsof replacement ofsigns.Establish whichKones are stillfunctionalCheck condition ofexternal clean yourhands banner.Remove if tatty orsoiled beyondreasonable repair.Review costs ofreplacement if bannernot suitable.IPCTIPCTMarch31 st2012March31 st2012IPCT March31 st2012IPCTIPCT/TrustContract ManagerSoft FM Estates &FacilitiesMarch31 st2012January2012GREENGREENAMBERGREENAMBERWard entrance posters changed tofive momentsSome floor signage removedreview 20124 Kones in need of repair/replacement no action to dateIPCT to decide if cost effective tohave repairedRemains in good conditionCompany who provide sanipostceased trading remove from planMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM36

Appendix 4Key:W = Not yet startedG = CompleteA = In progress, on trackR = OverdueAnnual Trust Plan to Prevent and Reduce Health Care Acquired InfectionsApril 2012 - March 2013Updated 01/05/2012*Leads are responsible for action and supported by the infection prevention & control team as requiredAim Actions Required Lead Review Date RAG rating Progress at 1.5.121. Reduction in number of MRSABacteraemias and stay within targetof 7 bacteraemiasRCA investigation of each MRSAbacteraemiaMaintain compliance withIntravenous and central venouscare bundlesApproved business case for theintroduction of Biopatch dressingto be used post insertion ofperipheral, central lines to aid inthe reduction of bacteraemiasAudit through quality of careaudits – appendix oneMonitor each bacteraemiaundertake RCA and report to ICC.Report using SI STEIS process ifdeath occurred and is stated onpart 1a of death certificateDIPC/IPCT/ AllBusiness UnitClinical DirectorsDr OdejinmiAll Business UnitClinical DirectorsICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCREDAMBER1 MRSA bacteraemia12/04/2012Round table scheduled for2.5.12All RCA's to be signed off byDIPC and CEODIPC4 weeks postRCAMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM37

All RCA’s to be added tosummary action plan andpresented to ICCReduction in trends and demonstratelearning across the organisation followingcompletion of each RCA2. To monitor incidence and reducenumber of Meticillin SensitiveStaphylococcus AureusBusiness units to demonstrateimplementation of findingsthrough action plan at ICCQuality of care auditsdemonstrate a consistent upwardtrend across Trust in relation toinfection control.Maintain compliance with carebundlesAudit through quality of careaudits – appendix oneAll Business UnitClinical DirectorsIPCT/MatronsICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCMarch 31st2013REDCatheter audit results in April2012 = 77.4%AMBER 3 hospital apportioned – 1RCA analysis completed. 2being completedLocal targets to be set after benchmarkdata completed for 2012-2013.Set local trust target to reducecurrent bacteraemia figureMonitor each infection andcomplete simple RCA analysisImprovements identified fromRCAs to be taken forward andmonitored via action plans3. To monitor and reduce the numberof E.coli bacteraemiaLocal targets to be set after benchmarkdata completed for 2011-2012Summary action plan to becollated and presentedat ICC and signed off by DIPCAll E coli bacteraemia to bemanually recorded on MESSHealth Protection Agency database and reported through ICCSet local trust target to reducecurrent bacteraemia figureInfection ControlDoctorIPCTJanuary 2013March 31st2013AMBER12 hospital apportionedMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM38

4. Hand HygieneDeliver hand hygiene training for allclinical staff on an annual basis (seeappendix 2).Support hand hygiene complianceTraining sessions rolled out trustwide.Through train the trainerand link nurse programsIPCT to record attendees onESR and follow-up nonattendance by notifying linemanager for actionHand Hygiene awareness daysplanned for 2013 May 2012,October and February 2013IPCTTwice yearly toICC in Sept andMarchIPCT May 12October 12Feb 13AMBERAMBERImplement World HealthOrganisation (WHO) 5 MomentscampaignAll staff working in clinical areas to meeta minimum of 95% compliance againststandardReview poster placements andupdate where necessaryAudit hand hygiene quarterly aspart of the Quality of Careprogramme to monitorcomplianceADNQuarterly to ICCin July and JanAMBERFeedback and report oncompliance by ward andspeciality to ICC.5. Adherence to Saving Lives High Impact Interventions5.1 AsepsisDeliver ANTT for all clinical staffAll staff undertaking clinical procedures as per separate ANTT projectmust use Aseptic Non Touch Technique plan through train the trainer and(ANTT) to reduce risk of crossrecord training on ESRcontaminationIPCT/train thetrainerICC31/07/201202/10/201204/12/2012Feb 2013 TBCAMBERANTT project plan presentedto ICC on 2.5.12 andapproved. Roll out in August2012 following training inJuly.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM39

5.2 Central Venous Line ManagementHII1Policy on CVC insertion andmanagement to be writtenConsultant lead foranaesthetics1.7.12All CVC lines to be inserted andmanaged in accordance with SavingLives Care Bundle GuidanceImplementation of the approvedpolicyAgree tool to be used to audit theeffect of the policy5.3 Care of Intravenous Lines HII2All peripheral lines to be inserted andmanaged in accordance with SavingLives Care Bundle GuidanceStaff follow policy for insertion andmanagement of peripheral lines.The process of insertion andcare of peripheral lines is auditedquarterly using quality of careaudit toolFeedback and report oncompliance by ward andspeciality to ICC.PCT / MatronsADNICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCAMBER5.4 Prevention of Surgical SiteInfections HII4All surgical sites to be cared for usingANTT in accordance with Saving LivesCare Bundle Guidance.1. fractured neck of femurs –ongoing2. commence surveillance for postoperative surgical wounds in Q23. commence surveillance for postoperative caesarean wounds inQ34. commence surveillance for longbone surgery in Q4Results are discussed withinbusiness units and learning isshare across the TrustTrust to participate in the HealthProtection Agency's Surgical SiteInfection Surveillance Scheme(SISS) currently reportingfractured neck of femursImplement an additional siteeach quarter.Use Health Protection AgencySurgical Site Surveillance toolReport compliance and findingsat business unit meetings andICCIdentify actions required andreport on completion onceMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM40All ClinicalDirectors MatronsCD specialistsurgeryCD general surgeryCD womenSee attachedaudit plan12/06/201202/10/2012Feb 2013 TBCAMBER

5.5 Ventilation and TracheostomiesHII5All ventilated and tracheostomy patientsto be managed in accordance with theSaving Lives Care Bundle Guidance5.6 Urinary Catheter Care HII6Target for 2011 – 12 was 38 and 44occurred.This is now incorporated in the safetythermometer work whereby 95% ofpatients receive harm free care by Dec12 relating to pressure ulcers grade 3+4,falls, CA-UTI and VTE.implemented.Collect data in accordance withnational reporting guidance fromIntensive Care National AuditResearch centre (ICNARC)Present findings every quarter toICC with associated actionsrequired and progress againsttarget.Complete safety thermometerevery month for al patients in thetrust.Rapid review of all CAUTIbacteraemia within 1 week ofnotification to IPCT. Developaction plan and implement asrequired.Feedback findings to relevantstaff.Clinical Director -AnaestheticsQuarterly to ICC31/07/201204/12/2012Feb 2013 TBCICD/IPCT 01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCAMBERAMBERCurrent position in April 12 is87%Report to CQUIN quarterly andat ICC meetings5.7 Clostridium difficile ManagementHII7To meet annual target of 59 cases of C.difficile infections 1.4.12 - 31.3.13Complete quality of care urinarycatheter & continence auditsevery quarterComplete an exception reportwith ward manager followingeach case of C. difficile within 1working day of infection controlbeing notified to monitorcompliance with C.difficile policy.ICT provide immediate feedbackof results to ward followed byIPCT/wardmanagersICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCAMBER5 hospital apportionedMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM41

written report including actionsrequired (if any) sent to businessunits and DIPCReport compliance and findingsat business unit meetings andICCIdentify actions required andreport on completion onceimplemented.Wardmanagers/MatronsMatronsUndertake Root Cause Analysisif death occurred and is stated onpart 1a of death certificate or ifmore than 2 C.difficile infectionsin a month in one ward andreport to ICC.MatronsPrescribing practice to meet a minimumof 95% compliance with antibiotic policy.Improvements identified fromRCAs to be taken forward andmonitored via action plans andreported through ICCUndertake annual audit tomonitor compliance withantibiotic prescribing Policy.AntibioticPharmacistOct 2012 AMBERWard Pharmacists to check andchallenge prescribing practicewhen they review a drug chart.Report findings from the annualaudit to business units andinfection control committee toagree actions requiredShare learning regarding practicechanges requiredMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM42

6. Screening for MRSA (Saving Lives -A strategy for NHS Trusts: a summaryof best practice)Ensure 100% of inpatients are screenedfor MRSAAll patients who fit the criteria arescreened for MRSA within 24hours of admission.Monitor Trust Screening Protocolto include all patients using datawarehouse information.ICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCAMBERMonthly compliance reports aresent to the business units. Eachunit not achieving 100% need toreview and action appropriately.ICC review Trust compliance.Positive results arecommunicated by IPCT to therelevant clinical area within 1working day of notificationIPCT advise treatment plan andreview accordingly7. Implement recommendations fromHCAI Peer Review January 2012The recommendations were:• Board to ward accountability• Staff having the necessarycompetence to assure consistentapplication of evidence basedpractice when inserting lines andcatheters and following agreedguidelines and protocols consistently(see ANTT in section 5.1)• Assuring prudent antimicrobialIPCT monitor compliance ofpatients positive with MRSA andreport trends to ICCAll clinical business units tonominate a consultant lead forInfection Prevention & Control tochampion High ImpactInterventions and ensure ward toboard responsibility andaccountabilityClinical Directors to ensure IP&Cis included in PDP/AppraisalsIPC Consultant Leads andmatrons to take forward andClinical DirectorsClinical DirectorsIPC ConsultantLeads01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCAMBERAMD for has sent a letter toconsultants calling forchampions.Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM43

practices are in place (see section 8)• Governance and assuranceprocesses being robust enough toinform the Board of progress andalert the Board to any further risksreport progress to own businessunit and ICCChange working practices withinIPCT to promote proactiveworkingQuality of Care dashboardsubmitted monthly to BusinessunitsIPCTADN8. Antibiotic action plan 2012-2013 Adhere to antibiotic plan -summary in appendix 39. Isolating patients with health careassociated infection -NorovirusReduce the risk of transmission ofnorovirus during the anticipated seasonalsurge from September onwardsDeliver training sessions to keyclinical staff in non outbreakmonths in preparation foroutbreak management (seeattached education plan).IPCT attendance at morning bedmeetings to give situation reportPromote the safer clinical care ofan individual or group of patientswith norovirus by isolation or cohortcontrol.Hold monthly outbreak reviewmeetings with managers fromaffected wards, bed teams,domestic services, HPA. andcommissioners using the HPATop Ten Tips for norovirusmanagement and summary ofexception report findingsAudit outbreak control on wardre-opening using exceptionAntibioticpharmacistIPCTOctober 2012 AMBERICC01/05/201212/06/201231/07/201202/10/201204/12/2012Feb 2013 TBCAMBERMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM44

eports and feed back findings toward staff and summary to ICCAction recommendations fromexternal review to occur in May2012.10. Policies relating to Infectioncontrol are evidence based and valid.Policies are reviewed by IPCTevery quarter.Policies due for review this yearare:• Meningitis• Hand Hygiene• Tuberculosis staffscreening• C Difficile• RCA policyIPCT June 12Sept 12Dec 12Mar 13AMBERANTT, hand hygiene, TBstaff screening and C.diff aredue to be present at ICC inJune 12RCA policy away dayscheduled for 16.5.12New policies to be written• ANTTSheila O'Mahony Matron IPCTPlease note:Recommendations from the Tuberculosis Look back exercise will be added once the look back process is completed - anticipated completion date isJuly 2012.KEY:DIPC – Director of Infection Prevention & ControlICD- Infection Control DoctorIPCT – Infection prevention & Control TeamHAI – Health Care Acquired InfectionsCAI – Community Acquired InfectionsAND – assistant Director of NursingAMD – associate medical directorMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM45

Title:Infection Control Annual Programme of Audits incorporating Criterion 8 of the Health and Social Care Act & HighImpact Interventions (HII’s) for 2012– 2013Purpose: To improve Infection Prevention & Control practice and compliance at BHRUT targeting all clinical practitioners andsetting standards for those practitioners to teach non-clinical staffAim: To audit all clinical areas thereby ensuring compliance with Infection Prevention & Control practice.Objective: To achieve compliance rates of greater than 95% in all clinical areas.Plan Owner:Matron for the Infection Prevention & Control Team (IPCT)Project manager: Infection Prevention & Control FacilitatorMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM46

Infection Control Annual Programme of Audits incorporating Criterion 8 of the Health and Social Care Act & High Impact Interventions (HII’s) for2012/2013Topic Saving Lives Audit Timescale LeadpersonTo ensure all staff comply with proper hand hygiene practice to reduce the April 2012IPCTrisk of cross infection and to enable the Trust to adhere to a compliance Nov 2012rate of 95% and above.Hand Hygiene using the InfectionPrevention Society (IPS) ToolEnvironmental audit policy usingthe IPS toolPPE audit using the IPS toolIsolation audit using the IPS toolTo ensure standards of cleanliness and hygiene are complied with tomaintain a safe environment for patients/ staff/ visitors in prevention ofinfection.To ensure clinical practices are based on best practice and reflect infectioncontrol principles to reduce the risk of cross infection to patients’ whilstproviding appropriate protection to staff.To ensure compliance with the appropriate isolation precautions to promotesafer clinical care of an individual with an infectionMay 2012March 2013 and followingany outbreak of infectionJune 2012February 2013 andfollowing any outbreak ofinfectionJuly 2012March 2013 and followingany outbreak of infectionIPCTIPCTIPCTHII7 Reduce the risk fromClostridium difficileScreening for meticillin – resistantStaphylococcus Aureus (MRSA)colonisationAudit compliance with the ‘Control of Clostridium difficile Policy &procedures’ through the use of exception reports following every case ofC.diffTo ensure compliance with the MRSA policy on Screening of ElectiveAdmissions and EmergenciesFeedback given at time ofaudit to wardmanagers/matrons withaction identifiedTrust results feedback toevery ICCTrust results feedback toevery ICCIPCTIPCT/ICDGeneralManagersQuality of Care Programme infection Control AuditMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM47

Hand Hygiene (observationalTool)Continence including UrinarycathetersIntravenous CannulaePressure UlcersTo ensure all staff comply with proper hand hygiene practices and togive feedback on individual ward compliance ensuring rate the Trustto adhere to a compliance rate of 95% and above.To ensure staff comply with the policy on ‘Urethral Catheterisation inAdult Patients’To ensure all peripheral lines are inserted and managed inaccordance with the ANTT guidelines and ‘Policy for Reducing theRisk of Infections Associated with Intravascular Devices’To ensure the Skin bundle pathway are being followed and correctpressure grading and equipment are used.14 th May 201213 th August 201223 rd April 201223 rd July 201230 th April 201230 th July 20122 nd April 20122 nd July 2012ADN/Matrons/IPCTADN/Matrons/IPCTADN/Matrons/IPCTADN/Matrons/TVNDepartmental Infection Control AuditsAntimicrobial prescribing To ensure staff comply with the Trust Antibiotic policies Proposed for October 2012 antibioticpharmacistManagement of the antimicrobialprescribing codeTo ensure staff comply with the code Annual antibioticpharmacistHII1 Central Line care bundle To ensure all CVC lines are inserted and managed in accordancewith the ANTT guidelines and the Policy for Reducing the Risk ofInfections Associated With Intravascular Devices.September / October AnaestheticleadHII5 Care bundle from ventilatedpatients (or tracheotomy whereappropriate)HII4 Care bundle to preventsurgical site infections (SSIS)To ensure staff compliance with the NICE guidelines and theventilator care bundle.The aim of SSIS is to enhance the quality of patient care byencouraging hospitals to use data obtained from surveillance tocompare their rates of SSI over time and against a benchmark rate,and to use this information to review and guide clinical practice.Company AuditsSeptember 2012March 2013April - June12July - September12Oct - December 12Jan – March 13ITU MatronsOrthopaedictrauma CoordinatorCommodesTaking blood cultures (HII as bestpractice)HII2 Peripheral line as bestpractice(Product and usage)HII6 Urinary catheter audit(Products and usage)To ensure the commodes used are in a good state of repair and cleanand to make recommendations as required.March 2013Verna careCompanyTo review the correct product usage and make recommendations as Nov 2012Greiner /IPCTrequired.To ensure all peripheral lines are inserted and managed inOctober 2012B Braun/IPCTaccordance with the ANTT guidelines and ‘Policy for Reducing theRisk of Infections Associated With Intravascular Devices’To review the product usage and make commendations as needed. July 2012 Bard/ IPCTMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM48

Safe Handling and disposal ofsharpsHand Hygiene i.e. Spirigelplacement and usage AuditMattress AuditsPressure UlcersTo review the product usage, do spot training as required and tomake recommendations as needed.To ensure correct usage of the product and do spot training asneeded.To ensure that mattresses purchased are for the provision of safe andeffective patient careTo ensure the Skin bundle pathways are being followed and correctpressure grading and equipment are used.19 th & 20 th April 2012 Daniels/ IPCTMarch 2013Ecolab/IPCTNovember/December 2012 NurseConsultantTVN/Hill-Rom &Huntleigh21 st May 2012 NurseConsultantTVN/ Hill-Rom& HuntleighKEY:IPCT - Infection Prevention & Control TeamICD - Infection Control DoctorADN - Assistant Director of NursingTVN – Tissue Viability NurseMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM49

Title Annual Infection Prevention and Control Education Programme for 2012 -2013Purpose:To ensure the education plan incorporates the NHSLA Risk Management Standards, Criterion 8 of the Health andSocial Care Act & High Impact Interventions (HII’s) and that it is based on the principles of andragogics.Aim: To ensure all staff attend and are competent with infection prevention & control practices.Objective: To ensure all staff are able to correlate theory with practice enabling them to render safe patient carePlan Owner: Matron Infection Prevention & Control Team (IPCT)Project manager:Mercia Williams Infection Prevention & Control FacilitatorMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM50

Annual Infection Prevention and Control Education Programme for 2012-2013Course Name Objectives Content TargetaudienceInfectionPrevention &ControlPassportPrinciples andPractices ofInfectionControlLondon SouthBank• Through 9 all daysessions with a capacityof 450 places for 2012/13raise awareness withregard to prevention andcontrol of HAI• To discuss the causesspread and treatment ofHospital AssociatedInfection (HAI)• To discuss the basicinfection prevention andcontrol strategies to beimplemented in theclinical environment tominimise transmission ofinfection.• The Trust hascommissioned 12 placesfor BHRUT staff to givean overview of infectionprevention & controlpractices• Standard InfectionControl Precautions(SICP)• Specimen Collection• Decontamination ofequipment• Hand Hygiene• Safe Handling anddisposal of Sharps• Protocol for NSI• Infectious diseases e.g.TB• HAI’s• Clinical audit results• Introduction to Infectioncontrol• SICP• Food Safety• Specimen Collection• Care QualityMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM51AllHealthcareWorkersRGN’s andDegreepathway &MasterslevelstudentsAssessmentmethodFormalassessment:6 weeks postdate ofattending thestudy day.Tool used isInfectionControlPassportBookletAssignmentas per LSBUcurriculumStudy Dates Duration ProgressReport toICCSeptember2012 andMarch 201317 th April 12 Full Day25 attendees22 nd May 1221 st June 1220 th Sept 1225 th Oct 1222 nd Nov 12Bi-annuallywith anexpectationof 6attendeesper course7 hours

University(LSBU)MandatoryTraining forSpecialist staffSocial WorkersIntegratedTherapiesRadiologyPharmacySiemens(Medicalequipmentservice staff)• To update staff oncurrent developments inInfection Prevention &Control practicesspecific to their workingenvironmentcommission• Root Cause Analysis(RCA) & SeriousIncidences• Audits• Environmental Hygieneand Safety• Legislation• SICP• Statistical analysis ofcurrent HAI’s within thetrustand othermultidisciplinary staffAll SocialworkersAll Physio’s&OccupationalTherapistsAllRadiographerand RadiologiAll pre andpostregistrationPharmacystudentsFormal handhygieneassessment:Simulationusing the UVlightAnnually 2 hours (x 1session)2 hours (x 4sessions)1 hour (x 2sessions)1 hour asrequired1 hourInfectionPrevention &Control LinkPractitionersTrainingProgramme• To implement evidencebased practice which iscentral to clinicaleffectiveness• To improve quality ofcare• To improvecommunication with themulti-professional team(MPT).• Standard infectioncontrol precautions;• Specimen collection.• Decontamination ofward equipment.• Hand hygiene.• Safe handling anddisposal of sharps.• Protocols for needlestick injuries.AllEngineersInfectionPreventionand ControlLinkPractitionersFormalassessment;1. Train thetrainerprogramme2. WardbasedAudits3. Case14 th Feb201228 th May201217 th July201213 th Nov2012Full dayMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM52

• To bridge the gapbetween theory andpractice• To share effective andineffective strategies withthe MPT• To share knowledge andexpertise with themembers of the MPT• Infectious diseases i.e.TB.• Healthcare associatedinfections.• Clinical audits.• Link Practitionertraining• Train the trainerprojects i.e. passportassessments• Case presentationsstudypresentation4. AnnualconferencepresentationsOutbreakManagementPre and duringNorovirusseason• To update staff of theprinciples of outbreakmanagement• To discuss thelegislation and policiesrelating to outbreakmanagement.• To discuss theprinciples of outbreakmanagement includingthe lines ofcommunication to befollowed in the event ofan outbreak.• To discuss the timelines within which thedocument has to becompleted.• Discuss the documentsto be completedAll StaffQuestion andanswersessionAugustthrough toMarch½ hrsession oneach shiftGeneralInduction• To ensure all staff areaware of and able todemonstrate proper handhygiene technique andsafe handling anddisposal of sharpsincluding management of• Hand Hygiene theory &practiceMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM53AllHealthcareWorkersFormal handhygieneassessment:Simulationusing the UVlightMonthly asper Trustinductionprogramme.½ hour

needle stick injuries.RegisteredNursesInductionProgramme• To ensure adherence toinfection control practicerelating to IV therapy isadhered to.• Legislation• Micro-organismsresponsible for IVdevice relatedinfections• Causes of IV devicerelated infections• Prevent IV devicerelated infection• VIP scoring• Complicationsassociated with IVdevices• Hand hygieneRGN’sFormal handhygieneassessment:Simulationusing the UVlightMonthly asper trustinductionprogramme1 hourMandatoryTraining forRGN’s, HCWS,& ODP’s• To update staff oncurrent developments inInfection Prevention &Control practices• Legislation• SICP• Statistical analysis ofcurrent HAI’s within thetrustAllattendeesFormal handhygieneassessment:Simulationusing the UVlightTri-weekly asper trusteducationprogrammeMon &Fridays:50 minutesMandatoryTraining forSpecialistAreas;Midwives’ andMedical StaffNeonatal andPaediatricNurses• To update staff oncurrent developments inInfection Prevention &Control practices asapplied to Midwifery,Obstetrics and Gynae• Legislation• SICP• Statistical analysis ofcurrent HAI’s within thetrust as applied toMaternityMidwives,Gynaecologists, &ObstetriciansNeonatalNurses;NurseryNurses, &MaternityHand hygieneassessmentusing UV lightMonthly asper speciallyeducationprogrammeTuesdays1 hourTuesdays 1hourMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM54

MandatoryHand HygieneTraining forclinical andnon clinicalstaffConsultantsMandatoryHand HygieneTrainingCannulation &VenepunctureTrainingHealth CareSupportWorker’sInductionProgramme• To demonstrate anddiscuss proper handhygiene practice• To demonstrate anddiscuss proper handhygiene practiceTo ensure best infectioncontrol practice relating to IVtherapy is adhered to.To discuss the generalprinciples of Infectionprevention and control• Legislation• Indication for handwashing (5 moments)• The correct steps tofollow when washinghands• Areas frequentlymissed• Indications for handwashing (5 moments)• The correct steps tofollow when washinghands• Areas frequentlymissed• Legislation• Principles of infectionprevention relating toCannula insertion andcare• Audits• Hand hygiene• Legislation• Standard InfectionControl Precautions• Specimen Collection• Decontamination ofequipment• Hand Hygiene• Safe Handling anddisposal of Sharps• Protocol for NSI• Infectious diseases e.g.CareAssistants.All clinicaland nonclinical staffAllConsultantsRGN’sNewlyappointedHCSW’sFormal handhygieneassessment:Simulationusing the UVlightFormal handhygieneassessment:Simulationusing the UVlightFormalassessmentmodule as pertrusteducationdepartmentFormal handhygieneassessment:Simulationusing the UVlightWeekly asper trustmandatoryprogrammeBi-weekly asper trusteducationprogramme3 rd March 1227 th April 1215 th June 1213 th Aug 1228 th Aug 1212 th Oct 1210 th Dec 1230 th Dec 1214 th Dec 12Monthly asper trusteducationprogrammeWeds:½ hourMondays½ hour1 hour2 hoursMelisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM55

TBM Williams 1.5.12Melisande/ Annual reports /DIPC Annual Report 2011-2012 SMOM56

Approved at Quality & SafetyCommittee 12.06.12QUALITY & SAFETY COMMITTEEPart IMinutes of the meeting held on Tuesday 17 th April 2012 at 14.00 hrs in Board Rooms 1&2,Trust Headquarters, Queen’s Hospital, Romford.Present:Prof. Anthony Warrens, Non Executive Director (Joint Chair) (Chair)Averil Dongworth, Chief Executive (AD)Magda Smith, Associate Medical Director – Emergency Care, Medicine &Neurosciences (MS)Stephen Burgess, Medical Director (SB)Cathy Geddes, Chief Operating Officer (CG)Arshiya Khan, Associate Director – Women & Children and Support Services(AK)Portia Omo-Bare, Chief Pharmacist (POB)Pam Strange, Clinical Governance Director (PS)Imogen Shillito, Director of Communications (IS)Gary Etheridge, Deputy Director of Nursing (GE)Geraldine Soosay, Clinical Director – Pathology (GS)Michael White, Non Executive Director (MW)Elaine Clark, Patient Representative / Chair of IPEG (EC)Cris Robinson, Committee Coordinator (Minutes) (CR)Action32/2012 ApologiesApologies were noted for Caroline Wright, Non Executive Director; JohnAlcolado, Associate Medical Director – Academia; Alison Crombie, Director ofEducation; Ian Grant, Associate Medical Director – Diagnostics & SpecialistMedicine; Tan Vandal, Associate Medical Director – Surgery & Anaesthetics;Deborah Wheeler, Director of Nursing; Richard Howard, Associate MedicalDirector - Women’s & Children’s and Support Services; Jane Moore, ONEL.33/2012 Minutes of the Meeting held on 14 th February 2012 (Part I)The minutes were agreed as a true record of the discussions with the followingcaveats:• 15/2012 - The figures relating to the number of sickle cell patients tobe clarified as they appear very high.• 09/2012 – The wording in the last sentence to be changed to show thatHavering Chief Executive leads on safeguarding children acrossLondon, not Havering.IGCR1

34/2012 Matters ArisingCriticism of the late arrival of agenda papers was made by MW, with othermembers agreeing that it hindered a thorough review of the large number ofdocuments for discussion. AD advised this was also a problem with otherTrust committees which required a rigorous approach to ensuring papers weresubmitted on time to the committee administrators. It was agreed that in futurereports must be submitted no later than 1 week in advance of the meeting orthe papers would be produced without them. The Committee’s terms ofreference would be checked to ensure this was included.Action LogAll actions were reported to be either in hand or completed with the followingexceptions that require further follow up:04/2012 – The importance of narrative for the Quality Dashboard to beemphasised to the Clinical Directors.06/2012 – The roll out plans for increasing ward round Consultant cover todeliver improved senior medical review of patients was not an agenda itemand there was no one present to talk to the item. A written response includingan early unpopulated action plan was noted, but this was felt to be insufficientto satisfy the Committee and a detailed report should be presented to the nextmeeting; this to be requested from the Associate Medical Director.16/2012 – In the absence of the Director of Nursing it was unclear whether theproposed separate meeting to discuss Health Care Assistant development,planned to address the findings from the Havering Enter & View visit had takenplace. An update on this was requested for the next meeting.18/2012 – SB advised that this outstanding item remained unresolved as a fullconversation had not been held to discuss the contractual arrangementsbetween the Trust and the ISTC. AD explained that a meeting has beenrequested but this has not yet taken place.Rolling ProgrammeThe rolling programme was noted, and no items were added by members.However, an initial meeting has taken placed between AD, SB and PS toreview the future direction for the Quality & Safety Committee andconsideration is being given to using the Rolling Programme to capture thework of the Clinical Directors and other committees.STRATEGY35/2012 Divisional Quality DashboardSB advised that the report included two sections: one the quality dashboardand the other the East Midlands Observatory report which came with a healthwarning due to the majority of the data being somewhat out of date. Heexplained that the SHMI data in the Observatory report has been supersededwith the latest Trust position being 94.1. Furthermore the Trust was not anoutlier for pneumonia as shown by the Observatory but was in fact performingon average with other Trusts. PS assured CG that a full mortality report isbrought to every other Committee that provides clear mortality data based onDr Foster and the dashboard contained a summary only. However, SB didpoint out that some areas do appear to be outliers such as cancer deaths, andthese required further review.A debate then ensued as to the value of the Observatory data. MS felt that theObservatory format was very easy to scan and would like to see other datapresented in that way to the Committee. PS and SB were asked to considerhow the data could be usefully used and to bring a report to the next meeting.ActionAllCRSBCRDCWSBSB / PS2

The main quality dashboard was then discussed and it was stressed that itwould be important for the Clinical Directors to own the dashboard and toprovide the necessary data for their Directorate. This triggered a query by CGregarding the level of clinical governance support available to the Directoratesand it was explained that PS and MS are meeting with each Clinical Director toexplain what was required of them, but the intention was to move from acentral clinical governance structure to one that was embedded into therevised structure. In addition a Clinical Governance Handbook had beenprovided to each Clinical Director.There was a general level of concern that due to annual leave, some datawere missing from the dashboard and if read externally, this could lead othersto assume this was unavailable or not being adequately covered, which wasincorrect. It was agreed that SB would discuss outside the meeting, whatother arrangements can be put in place to ensure future access to PMO datawhen staff are on leave. AD felt strongly that operational managers need toensure the information required to populate the dashboard is available and CGoffered to take this back through the operational structure.Questions were raised about the breakdown between hospital acquired andcommunity acquired pressure damage cases shown in the dashboard and GEconfirmed that the figure shown was a combined figure but explained that inthe Energise for Excellence report appearing later on the agenda, thisbreakdown was shown.MW felt that the narrative relating to single sex breaches did not address thequery raised by the Committee in February for more information on the plansto address the problem. GE explained that he had visited Whipps Cross andother Trusts to review how they were managing the breaches occurring inITU/HDU and as a result costed plans have been drawn up for physicalchanges amounting to approximately £1m. However, he felt that no workshould be undertaken until the McKinsey emergency access work hadprogressed as improving the bed flow would result in greater ability to ‘stepdown’ ITU/HDU patients to general wards thus reducing the number ofbreaches. CG concurred feeling that more time should be allowed before adecision was made. SB added that the Health4NEL and re-jigging of criticalcare across London would also impact on the Trust’s single sex breaches. GEconfirmed in response to a query by AD, that to ensure full transparency thetopic was on the agenda for the next Improving Patient Experience Group.36/2012 Items for Escalation from Feeder CommitteesPS explained the key issues that were being escalated by the Quality & SafetyCommittee’s feeder committees. These were from the Clinical AuditCommittee where information on National audits has not been forthcomingfrom the clinical leads; this issue together with the tardiness in completing theaudit registration procedures has been raised with Clinical Leads.The Clinical Risk Committee raised the issues of poor record tracking by wardbased staff and the lack of a suitable system for maternity health records. Ofconcern was the extremely poor compliance by doctors to include their GMCnumbers on prescription charts. The final item for escalation was theperceived lack of accountability across the organisation. SB suggested thatthe previous requirement for presentations by the relevant areas would, ifreintroduced, go some way to dealing with this issue. It was proposed that thissuggestion would be considered further by MS, SB and PS.ActionSBCGMS / PS/ SB3

In relation to the GMC concern, SB advised that he has written out on 3separate occasions stressing the requirement to comply but this has not led tothe expected improvements. It was generally felt that taking a tough stance byrejecting the request for drugs if the GMC information was not provided mightbe a way of delivering a strong message to doctors, but the potential impact onpatient care was a major concern. EC felt that if patients understood thereason for delays this would be understood. POB agreed with EC butconsidered the GMC issue to be a separate one to the TTAs (drugs to takeaway). A solution to improving untracked patient notes and doctors complyingwith the GMC requirement would be sought by MS, PS and POB outside themeeting.37/2012 Corporate Accreditation Quarter 4 RegisterSB reported on the 3 visits that had taken place during the last quarter of2011/12, explaining that informal feedback from the HFEA visit was good andtheir report was expected.GS advised that both Haematology and Biochemistry had been reviewed andhad high levels of critical non-compliances. This appears to be because of arebasing of the criteria being applied to ‘critical’ and did not take account of theresource implications for ensuring compliance. Due to the rebasing, GSstressed that the Trust’s preparations will be reviewed very carefully before thenext inspection for Microbiology. At the present time Cellular Pathology is theonly area fully accredited. GS went on to explain that within pathology theyare reconsidering how quality is being managed and are looking at roles,responsibilities and support mechanisms with the intention of appointing aQuality Manager.Since the detailed action plans for Haematology and Biochemistry had notbeen provided to enable the Committee to review the intended actions to moveforward towards full compliance, GS was asked to send these to CR forcirculation.PATIENT SAFETY38/2012 Care Quality Commission Update & Action PlanThe latest iteration of the action plan, together with the March report to NHSLondon had been included with the agenda papers, and are also being sharedwith the Audit Committee, Trust Board and Trust Executive Committee.Progress against the 81 actions is being closely monitored by the ProjectBoard and PMO, with updates every 2 weeks to NHS London and theCommissioners. The Trust Board was being kept informed.SB advised that whilst progress was on course, there were a number of longerterm actions that will not achieve full compliance for some time but, at thecurrent time, only 6 of the outstanding ‘red’ items had 2 or more elementsrequiring completion with the potential to lead to delays and these were beingdiscussed with the Operational and Executive leads. All other actions arenearing completion with many of their under-pinning individual actionscompleted and evidence collected.The position with the Trust wide review and progress against the WarningNotices were also summarised within the executive summary to the report.There was some debate about the timing of positive outcomes on the CQCwebsite where there appeared to be a delay between what is being told to theTrust and what is actually being shown. SB suggested he discuss this with ADso that this could be raised informally with the CQC at a future meeting.ActionMS / PS/ POBGSSB4

39/2012 Maternity Implementation Plan UpdateAK explained that the plan had been agreed with NHS London and theCommissioners in September 2011 and capped daily deliveries at Queen’s at20 and 7 at King George; the initial plan was for this to continue until the 31 stMarch 2012. At a meeting last week the Trust was offered assurances and isawaiting confirmation that the capping of deliveries will stop from the 1 st Mayand the Trust will resume its activity. An internal review has shown that onaverage the Trust is currently delivering 17-19 births a day at Queens and 4-5at King George which with the average of 4-5 labour rooms empty each dayand good levels of staffing would ensure the Trust can maintain a safe service.However, to ensure there are no future problems there is now a clear definitionof excessive levels and a London-wide Escalation Policy is in place with clearStandard Operating Procedures to follow.The Chair, on behalf of the Committee, praised the significant progress thathas been made. AD advised the improvements have been recognised by boththe CQC and NHS London.AK went on to explain that the elective caesarean sections that had beendiverted in early October were now being performed by the Trust. Memberswere asked to note that the Essex Overview & Scrutiny Committee has askedthat the diverted Essex women are allowed back and the intention is to resumeelective caesarean sections for an average of 30-40 Essex women per week.40/2012 Vascular & Stroke Network Standards – 6 monthly updateSB presented this report explaining that the Trust’s Stroke Unit and HyperAcute Stroke Unit were accredited. The report details the pressures that arebeing experienced when non stroke emergency admissions are placed inthese units. The Stroke Network are aware of these pressures which arebeing experienced at other stroke units. Patients are currently being escalatedto the Network for repatriation to their local stroke unit as required.Since the centralisation of vascular services from both the Trust’s main sites toQueen’s Hospital in March 2011 evidence is available to demonstrate that theTrust has achieved 14 of the 22 standards in a short period, however evidenceagainst the remaining 8 required before approval as a complex vascular centrehave been deferred. The requirements to ensure each consultant to enterdata onto the National Vascular database and that a 24/7 interventionalradiology rota should be in place have now been demonstrated. Finalevidence was submitted to an external peer review on the 30 th March and theoutcome has yet to be communicated to the Trust although it is expected wewill be accredited as a Vascular Unit. SB advised there had been issues aboutvolume and numbers but case loads are being met, and the Trust feelsconfident it will do so in future.41/2012 Medicines Security Assurance ReportPOB asked for it to be noted that the Governance of Medicines Managementreport was still to be completed, and the paper circulated is Medicines SecurityAssurance Report. The need for this report arose following Freedom ofInformation requests about medicines security that led the Department ofHealth to ask for an audit by all Trusts to be completed by the 31 st March2012. The report is attached and although it has not yet been ratified by theDrugs & Therapeutic Committee, it was signed off by the Chief Executive toenable compliance by the deadline.The audit was based on retrospective information from Visible LeadershipAction5

audits carried out quarterly on the storage of medicines, the controlled drug 3-monthly audits and patient drugs 3-monthly audits. 25 different areas werereviewed and the findings showed compliance in 13 areas, with 12 areas thatwere non-compliant. POB cautioned that the criteria was set very high and a10% failure resulted in a finding of non-compliant. The key issues found werethat drugs in some areas were being left outside of the lockable cupboards;fridges were not locked and temperature recording was not consistently beingcarried out. The third area was that in some departments patients’ TTA drugswere found, which should have been returned to pharmacy to reduce the riskof them being given to another patient or being misused and to allowpharmacy, where appropriate, to return the drugs to the pharmacy stock.ActionAn action plan has been prepared and will be taken with the report to theDrugs & Therapeutic Committee. Further audits are planned and a jointpharmacy / nursing group has been asked to look at the issues. Newsletterswill be used to ensure the key messages from the review are shared.GE felt the report was excellent, and confirmed with POB that it was beingtaken to this week’s Nursing & Midwifery Board. GE offered his support.AW felt that most of the areas of non-compliance were relatively easy to dealwith.42/2012 Infection Control Annual PlanGE presented the draft infection control annual plan that has been reviewed bythe Infection Control Committee, explaining that relevant staff had beeninvolved in its development. The Committee was asked to comment on theplan by providing feedback to the Director of Nursing.SB reported that the Trust’s MRSA bacteraemia target for 2011/12 had been 8and the final number of actual cases had been 10. The target for 2012/13 hasbeen set at 7 and the Trust has already had 1 confirmed case. It is importantthat a rigorous root cause analysis be applied and the findings used toreinvigorate the infection control strategy. It was also felt that the Trust’sMRSA policy needed to be rigorously applied. IS stressed the need for sharedlearning from the root cause analysis and GE explained that the LearningLessons Group will have a regular item on their agenda. The groupmembership includes an Infection Control Nurse.43/2012 MRSA Screening PerformancePATIENT OUTCOMESAt the February meeting DCW had been asked to provide an update on thepoor MRSA screening data. The report confirmed that there has been anoverall improvement in compliance with screening elective admissions acrossall Divisions, but emergency screening was static. In addition, there has beenconfusion in some areas about the need to screen or not; particularly forgynaecology patients admitted for very short stays. Actions are in hand tomake improvements through the exclusion of those patients that do not needscreening.44/2012 AEU Expansion ReportMS provided a report on the acute elderly service which showed that followingthe launch of the Acute Elderly Unit in June 2010, Phase 1 had beencompleted with various actions being completed between opening andDecember 2011. Two of the Phase 2 actions have been completed with 36All

items at ‘amber’ and 2 at ‘red’ requiring completion in 2012.Further plans include increased specialist input to older persons at the ‘frontdoor’, consultant geriatrician input to all older persons admitted, improvedskills and knowledge in the care of patients with dementia, delirium anddepression, and consistent care across the whole week. There were noquestions on the report, which was felt to be both informative and helpful.45/2012 Emergency LSCS Performed within Graded TimeAK advised there were ongoing concerns relating to the timeframes foremergency caesarean sections. She explained the different timeframes forthe different grades. The high number of Grade 1 cases which are those withlife threatening consequences and which should be within 30 minutes havebeen discussed with Commissioners and bench marked against other Trusts.It would appear that our Consultant and medical staff are grading some casesincorrectly and this has been discussed at an internal meeting. AK stressedthat any changes to the way patients are graded requires very carefulassessment and review with appropriate training to avoid confusion and risk topatients.Discussions with Commissioners are also reviewing the target to ensure it ismore realistic, but AK advised that last year the Trust achieved 77% for Grade1 cases and this year the rate is 95.5%; this has been achieved throughimproved cover in the labour ward. Following a query by AW about themedian value and range, AK explained that the delays in Grade 1 cases beingachieved within 30 minutes was often only delayed by 1 or 2 minutes andwhere the delay was over 10 minutes, this was frequently because of clinicalreasons. AK agreed to provide AW with an estimate of the range.AD pointed out that there were lessons to be learnt, stressing that staff need tobe aware of what other Trusts are doing and bench-marking their ownperformance. SB felt the Trust was actually being bench-marked by NHSLondon against a wide range of parameters that other Trust’s are not beingmeasured against, and which are highlighting some areas for improvement. Itwas felt that SB should consider whether the positives of the bench-markingprocess could be used in a positive journal article.46/2012 Energise for ExcellenceGE presented the report prepared by the Assistant Director of Nursing. Thereport showed there were high numbers of pressure ulcers reported duringQuarter 3 and steps were being taken to carry out root cause analysis to clearthe backlog and ensure lessons are learnt.GE asked members to note there had been 3 deaths from falls during 2011and again, root cause analysis investigations were being conducted and thefindings would come to this Committee when they are signed off. POB felt thatreviews of patient falls should consider appropriate prescribing.Concerns were raised by AW that the pressure ulcer situation was gettingworse but SB advised that better reporting was partly responsible for theincrease and the Trust was getting better at recognising hospital andcommunity acquired pressure damage. He also explained that seriousincidents are now a CQUIN target and the Trust was meeting its trajectoryalthough it was important to continue looking closely at them. MS felt the rawdata showed that community acquired pressure damage accounts for a highproportion of the cases, and she advised there is a lot of work going on withthe community to develop a ‘no blame’ framework for the recording andmanagement of pressure damage. It was agreed the report needs additionalnarrative to explain the reasons for the high numbers and the actions beingActionAKSBGE7

taken. GE was asked to take this comment back to the author.SB commented that falls and catheter related incidents are included as part ofthe Milestone Tracker, and these were currently graded as ‘amber/red’ and sogave cause for concern.47/2012 Safeguarding Adults Update ReportPATIENT EXPERIENCEGE presented the Safeguarding Adults report, highlighting the key points thatthe safeguarding team is now fully established; safeguarding adults trainingneeds analysis and strategy have been produced, and the Trust’s draftSafeguarding Adults Policy has been developed. In addition the safeguardingadult link worker scheme has been reinvigorated. GE advised there had beena total of 82 safeguarding adult referrals to the safeguarding team between 1 stDecember and 18 th March.It was noted that from the 1 st April the national dementia CQUIN comes intoforce and the Trust’s Dementia Committee is looking at its existing dementiapathway to ensure it meets the CQUIN requirements.GE reported that a comprehensive plan is in place to deliver CQC Outcome 7targets and is on target to meet all of the deadlines, this is now ‘blue’ on theCQC action plan as the supporting evidence has been provided.Whilst providing an update to the Committee, GE advised that there will be aLearning Disability week commencing the 18 th June with a number of eventsplanned to launch the MenCap Charter with lots of stands to generateengagement.48/2012 National Outpatient SurveyThe report provided members with an update against the 2009-2011 resultswith the results appropriately RAG-rated. In essence, the results show nochange despite the plan put in place following the last survey to generateimprovements. It was felt important the a multi-disciplinary approach wasneeded to ensure ownership across the organisation with each ClinicalDirector mapping their own area’s performance.MS stressed the need for there to be a clear strategy for engaging with teamsin Outpatient Clinics with more innovative ways of recording patients’ views;suggesting a simple red ball/green ball being given to patients for them to putinto tubs at the end of their visit to record how they felt about the visit.GE agreed to contact the Committee responding to the survey to convey theCommittee’s views and would feedback to the next meeting.49/2012 National Inpatient SurveyThe Inpatient Survey was based on the views of patients discharged duringJuly 2011. A similar review of the Inpatient Survey to the one for theOutpatient survey shows there has been a deterioration since the 2009-11survey and this aligns to CQUIN questions being asked through the real timesurvey. The report will be made public on the 24 th April by the CQC so untilthat date, there should be no onward transmission of the report. Oncereleased the CQC will identify where the Trust sits in relation to other Trusts inthe country.The members again debated how the organisation can own the findings andturn them around with additional concerns raised about changing patientperceptions; citing mixed sex ward responses as an example of whereActionGE8

communications could be better used. It was suggested that Executives couldgive presentations at different forums to stress the importance of ensuringattitudes and beliefs are changed and patients remain the central focus ofperformance. The similarity between the themes from this report, theoutpatient report and the staff survey was stressed by IS. GE explained that abid has been made for 10 more feedback kiosks, new comment cards arebeing printed and big banners have been ordered to inform patients how theycan have their views heard.GE was asked to bring an action plan to the next meeting.50/2012 Update on Surgical ComplaintsA short briefing paper on responding to surgical complaints was presentedacknowledging the backlog and the poor response times. MS advised that theSurgical Division’s backlog had been considerable and had proved challenginghowever with a lot of effort all but 3 of the complaints up to the end ofDecember had been cleared. The team felt they were now on track to achievethe expected 80% by the end of March; the figures are yet to be finalised.MS explained that additional support was needed to manage the complaints inemergency care. However, because of the level of scrutiny of the complaintresponses the number of complainants returning unsatisfied has reduced.It was felt by AW that the additional efforts had produced positive results thatshould receive praise.51/2012 Implementing Patient StoriesGE told the Committee how in previous employments it had been standardpractice for patients to be invited to Trust Board meetings to tell their stories.The executive summary to the report listed how this could be achieved atBHRUT.POB felt this was a good initiative but questioned how front line staff wouldbecome involved. This was also a view held by MS who said that whilstaddressing Trust Board, it also needed to be cascaded to the rest of theorganisation through Directorate teams. EC explained how a film had beenmade of her own experiences and how this, and other similar patient videos,had proved highly effective tools; she was happy to offer her services if thisidea was taken forward. IS felt the idea was very good and advised that acouple of patients were currently being filmed but she cautioned the need toensure both good and bad experiences needed to be included in any Part ITrust Board. The importance of subsequent patient feedback was alsohighlighted by EC.52/2012 Equality ObjectivesIn the absence of AD, IS reported there is a new legal requirement on theTrust to have measurable indicators for equality and the three shown in thereport are those proposed by the Trust. Members were asked to providefeedback and the consensus was that they were reasonable.ActionGE53/2012 Any Other BusinessNo other business was proposed.54/2012 Summary of Issues for Escalation to Trust Board• The suggestion of patients attending Trust Board to tell their patient storyshould be escalated to the Trust Board.SB9

20/2012 Date of Next MeetingThe next meeting will be held at 14.00 hrs on the 12 th June 2012 in MeetingRooms 1&2ActionACTION LOG – PART I33/2012 MINUTES OF THE MEETING – 14.2.12The figures relating to the number of sickle cell patients to be clarified as theyappear very high. (15/2012)Wording in the last sentence of 09/2012 to be changed to show that HaveringChief Executive leads on safeguarding children across London, and not Havering.ResponsibilityIGCRQSC terms of reference to be checked in relation to the time for submission ofreports for meetings.34/2012 MATTERS ARISING / ACTION LOGAll reports to future meetings to be submitted no later than 1 week in advance ofmeeting.The importance of narrative for the Quality Dashboard to be emphasised toClinical Directors. (04/2012)A detailed report providing detail of the roll out plans for increasing ward roundConsultant cover to deliver improved senior medical review of patients is requiredfor the next meeting. This to be requested from the Associate Medical Director.(06/2012)Information to be provided at the next meeting on whether the proposed separatemeeting to discuss HCA development as a result of the Havering Enter & Viewvisit has taken place. (16/2012)The contractual arrangement between the Trust and ISTC remains an outstandingitem requiring feedback at the next meeting.35/2012 DIVISIONAL QUALITY DASHBOARDValue and use of the East Midlands Observatory data to be considered andreported to the next meeting.Action to be taken to ensure data is available even during PMO annual leave.Operational managers’ responsibilities to provide requested data / information ontime to be raised.36/2012 ITEMS FOR ESCALATION FROM FEEDER COMMITTEESThe reintroduction of presentations from feeder committees on areas of concern tobe discussed and fed back to the Committee.Explore options to improve untracked patient notes and ensure doctors complywith the Trust requirement to quote GMC number on prescription charts.37/2012 CORPORATE ACCREDITATION QUARTER 4 REGISTERThe Haematology and Biochemistry action plans to be sent to CR for onwardcirculation to members.CRAll membersSBCRDCWSBSB / PSSBCGMS / PS / SBMS / PS / POBGS10

38/2012 CARE QUALITY COMMISSION UPDATE AND ACTION PLANThe delay between CQC verbal reports on improvements and the changesbecoming evident on their website to be discussed with the Chief Executive andraised informally with the CQC.42/2012 INFECTION CONTROL ANNUAL PLANFeedback to be provided to the Director of Nursing on the draft Annual Plan.45/2012 EMERGENCY LSCS PERFORMED WITHIN GRADED TIMEAn estimate of the range used for this data to be provided to AW.Consideration to be given to producing a positive journal article about the benefitsof measuring and meeting the NHS London performance indicators.46/2012 ENERGISE FOR EXCELLENCEQSC comments on the report to be relayed to the Assistant Director of Nursing48/2012 NATIONAL OUTPATIENT SURVEYFeedback from the Quality & Safety Committee to be made to the OutpatientSurvey Response Committee with feedback to next QSC.49/2012 NATIONAL INPATIENT SURVEYAn action plan to address the Inpatient Survey findings to be brought to the nextmeeting.54/2012 SUMMARY OF ISSUES FOR ESCALATION TO TRUST BOARDThe suggestion of patients attending Trust Board to tell their patient story to beescalated to Trust Board.SBAll membersAKSBGEGEGESB11

Charitable Funds CommitteeMinutes from meeting held onMonday 27 th March 2012Attendees: Keith Mahoney KM Non- Executive Director, ChairmanDavid Wragg DIW Director of FinanceDeborah Wheeler DCW Director of NursingBill Langley WL Non-Executive DirectorJackie Doyle JD Divisional Manager-Estates, Facilities & CapitalLinda George LG Charitable Funds AccountantChris Stevens CS Head of Fundraising1 Charity Branding – Superfantastic PresentationRepresentatives from Superfantastic attended the meeting to present their suggestionson different types of branding, including logos, colour schemes and promotionalleaflets. The Committee was informed that the representatives would also show theseideas to some focus groups for their input and feedback2 ApologiesNone3. Minutes of the Previous Meeting & Matters ArisingThe minutes from the previous meeting held on 28th February 2012 were agreed as acorrect record.Investment presentationsThe Committee members were informed that the proposed Investment Managers’representatives attended the presentations on 22 nd March and it was agreed thatShroders would be our new Investment Managers.Application for the Complementary Therapy Co-ordinatorThe Committee approved an extension to support the Complementary Therapist for afurther year once the current period has ended in June.Application for Positive Patient IDThe Committee was informed that DIW had met with Campaign. DIW report that, froma personal perspective, there would be an upfront cost with a large administrationInterim Chairman: George WoodChief Executive: Averil Dongworth

urden and he was not in agreement with this being charitable. It was also agreed thatit seemed a big investment for what it was. This was not approved.Usage of KGH PharmacyDCW and JD were communicating about ambulance transport and also reported thatthe waiting room was cold and draughty. JD reported that the team inspected thewhole area including the patients’ waiting room and suggested that the Outpatientsarea could be placed where it would be warmer, with the ambulance booking in areabeing on the left hand side. The ambulance desk would be moved to where theinformation desk currently is and that this could then leave a place for aninformation/reception desk. This could also be where keys and bleeps were housedand could be the main expense. The Committee agreed that Claire McLaughlin shouldsubmit a bid for the work including the reception desk. DCW asked where the PALSoffice would go and was informed that this would remain where it was. CS re-iteratedon the commercial aspect of the siting of the PALS office, but it was agreed that thePALS office needed to be accessible. JD to draw up a cost.ACTION JDSenior Sisters’ MeetingCS updated the Committee on the Senior Sisters’ meeting. He reported that peoplewanted to meet up and that there were a number of wish lists. The attendees hadheard of the Charity but some were unaware if their wards or departments hadbenefited.Screens for the Multi Faith Room at QHThe Committee was updated on the investigations on the Multi Faith screen applicationand it was agreed that this application would be passed. ApprovedRequest for Toasters and MicrowavesIt was noted that microwaves could not have elements in. The pantrys were notclassed as enclosed rooms. CS informed the Committee that he was waiting to hearwhere the toasters and microwaves were needed at KGH and the idea needed to beconsistent with QH. JD reported that it would not be ideal to go down that route andthat smaller areas now have toasters and/or microwaves. The fire officer will bearranging local training and could discuss the need. CS will liaise with him aboutlocations and the correct detector heads. JD suggested the approval of microwaves insome relevant areas and to see how these go, but reminded the Committee of the highcosts due to the equipment being industrial and the need for fire-retardant casings.ACTION CS2

Verbal Request for Patient FaresLG informed the Committee that TfL would not give any concessions for bulk purchasesof Oyster Cards and the Committee discussed the possible costs involved. WLsuggested that we should support the costs for a couple of weeks and see theoutcome.ACTION LG/CSRefurbishment of DSU Patient Waiting AreaCS sought clarification from the DSU team that the request was just to improve thewaiting area. KM enquired if this needed doing and it was reported that there was noset time for some surgical procedures, so patients could be waiting for long periods andthe improvements would benefit those patients awaiting surgery. This was approved.4 Fundraising – Draft StrategyCS informed the Committee that 5 keys challenges had been added to the draftstrategy and that if these could be met there would be more chances of fundsincreasing. KM felt that the wording in section 1.1 needed to be replaced with theemphasis on the growing demand for Charitable Funds. WL suggested that part ofsection 1.2 should be moved to the ‘Objectives’ area and to incorporate the use of radioand commercial relationships within the opportunities at 1.3. WL also felt that otherareas of weakness could involve the website and communications as well as thepossible dilution of the charity as a result of KGH League of Friends being seen to be incompetition, although not directly. WL also felt that Communications should also beincluded within the objectives. It was agreed that CS could focus on Communicationsand seek promotional leaflets etc.ACTION CS/JD5 Statement of Financial Activities and Balance Sheet for the period:1 st February 2012 – 29 th February 2012The Committee received the updated SoFA and Balance Sheet for February 2012 andthe Committee noted the report..6 Income and Expenditure from 1 st February 2012 to 29 th February 2012The Committee was asked to note the report.5 7 Requests for ExpenditureComplementary TherapyCS said that the funding was now in place and the Committee agreed to support the3

post for a further additional six months. JD suggested that, after two years, if therewas positive feedback, the post should not continue to be paid by charities and thatthere should then be a business case in place and a budget available. WL requestingverification of the costs and CS explained the some volunteers offer to assist and somepatients return after treatment is completed for one more complementary treatment.This request was approved to cover funding until June 2013Additional Cots for Tropical LagoonJD informed the Committee that this equipment as well as mattresses were High Specand would be coming from her budget.TV for Discharge loungeJD explained the benefit to patients waiting to be collected after being released from thewards, who may have a considerable wait to be picked up by relatives or anambulance. There is a requirement for cabling to be put in place to facilitate a TV, butthis would make the patients’ waiting time more pleasurable. This request wasapprovedAfinion HbA1C analysersAn analyser is already being used at QH having been paid for by donations fromDiabetes UK. DCW asked to check with clinical engineers on the full cost. Marinod’Aliessio should be approached to ensure that there are no installation costs. WLasked if this was something that KGH League of friends would pay for. This requestwas not approved until further investigation.ACTION CS/KMBreast Lipo FillingWL and DCW asked if we received income from the procedure and DIW confirmed thatthe trust charges, but the additional funds are being requested to remove and replacethe fat tissue. JD informed the Committee that this was not full reconstruction andDCW asked why there was not a tariff. CS informed the Committee that a staffmember had raised just over £10k. JD suggested that Eileen Moore should beapproached for more information. This request was not approved until furtherinformation was receivedACTION CS/LGBreast Ultrasound RoomJD informed the Committee that the area was in poor condition and CS reported that hewas also awaiting the cost for a water cooler in the area. This request was approvedwith an additional cost authorised for the water cooler.4

Occupational Health and WellbeingWL asked how the equipment would promote the business, how long on average dopeople wait in the waiting area; what types of messages will they be displaying on thescreen and who/how would they be produced and how many people visit occupationalhealth? JD asked for clarification on the costs.ACTION CSAOBCS informed the Committee that Malcolm Buckley, a councillor from Basildon, wants toraise funds for a neuro stimulator and wants to get the Basildon Mayor involved. CSsent details to Mr Low, as the Trust is already using one, but not the updated version.WL asked whether this was a necessity or just for the sake of getting a new one. CSexplained that the newer version was faster to use This request was not approveduntil a full bid is received.ACTION CS/LG8. Children’s Wards Charitable AccountsCS reported on the Paediatric accounts and explained that the manager wanted all thefunds to go into one charitable account. KM agreed with the objectives, but said thatthis should not stop the play leaders from accessing funds for play items as there wasno budget for these otherwise. The Committee agreed that donations with specificrequests should be spent straight away and the holding accounts should be put into thechildren’s wards general purpose accounts but earmarked for the relevant expenditure.It was suggested that the paediatric directorate should have a fundraising workinggroup similar to that in Oncology.ACTION CS9. Lavender Garden UpdateThe Committee were notified that both George and Avril were unaware of the officialopening of the Lavender Garden. KM mentioned that he had emailed both George andAvril, but this was not entered in Sue William’s diary. CS informed the Committee thatall the invitations had been sent out. Communications recommended that staff shouldbe invited and an email sent to matrons to nominate one or two staff members. WLasked how many we would expect to cater for. CS reported the expected numberwhich included local MPs, councillors and community groups. He also informed theCommittee that Apex Conference Centre had raised funds and asked if they could filmthe event at no cost to the Charity, and that they would also like to do interviews.Bedrock would be providing the PA system, and marquees had also been organisedwith the decision to buy them as these would be cheaper than hiring. The Committeeagreed that a speaker could inform all the attendees on the difference that the Charitymakes. The Committee approved the use of retained gains proportionately to coverthe balance costs of the garden.5

10. Investment Report and TenderingKM, DW and WL attended the Investment Manager’s presentations along with PaulGreenshaw on 22 nd March, and it was agreed that the shares would be placed in thehands of Schroders. This was duly noted.ACTION DIW/LGLG reported to the Committee that the value in the portfolio as at 27 th March 2012 hadincreased by £162k and the report as at 27 th March was distributed.11. Any Other Business – The meeting came to a close at this point.Dates of Future Meetings for 2012Dates and Venues for the Remaining Meetings for 2012All meetings will take place at 2pm – 4pmTuesday 29 th May – BoardroomTuesday 26 th June – BoardroomTuesday 31 st July – BoardroomTuesday 25 th September – Sky Room on 4 th Floor (CS or LG to collect key from Education)Tuesday 30 th October – BoardroomTuesday 27 th November – Boardroom6