1 TRUST BOARD MEETING Wednesday, 6 March 2013 at 1.00 pm ...

TRUST BOARD MEETINGWednesday, 6 March 2013 at 1.00 pmBoard Room, Trust HeadquartersQueen’s HospitalA G E N D A1. Apologies for Absence2. Minutes of the meeting held on 9 January 2013 (Attachment A)3. Matters Arising and Actions4. GOVERNANCE:4.1 Care Quality Commission Reports (Maternity Services (Attachments B)and Emergency Department at Queen’s Hospital (DK)4.2 Emergency Care Risk Summit 7 February 2013 - Letter from (Attachment C)Medical Director, NHS London5. QUALITY AND PATIENT STANDARDS5.1 4-Hour Access Improvement Plan (DH) (Attachment D)5.2 Care Quality Commission Accident & Emergency Department (Attachment E)Survey 2012 (DH)5.3 Maternity Services Update, including sign off of King George (Attachment F)Hospital Maternity Services move to Queen’s Hospital (DH)5.4 Quality & Patient Standards Performance Report – (Attachment G)January 2013 (NM/Executive Directors)5.5 Staff Survey 2012 (DH) (Attachment H)6. FINANCE, WORKFORCE AND ACTIVITY6.1 Single Operating Model – December 2012 (NM) (Attachment I)6.2 Finance Report – Month 10 (January) 2012/13 (DG) (Attachment J)6.3 Workforce Key Performance Indicators – January 2013 (DH) (Attachment K)6.4 Barking, Havering & Redbridge University Hospitals NHS (Attachment L)Trust Revised Standing Orders (DK)7. COMMITTEE ESCALATION REPORTS7.1 Escalation Report from Quality & Safety Committee (CW) (Attachment M)7.2 Escalation Report from Trust Executive Committee (AD) (Attachment N)8. INFORMATIONMatters for Noting:8.1 Chairman’s Report (Attachment O)8.2 Chief Executive’s Report (Attachment P)8.3 Minutes of the Quality & Safety Committee meeting held on (Attachment Q)22nd January 20139. Any Other BusinessDate of Next Meeting: The next public meeting will be held on Wednesday,1 May 2013 at 1.00 p.m. in the Board Room, Trust Headquarters, Queen’s Hospital10. Questions from the PublicTrust Board Agenda – 6 March 2013 1

11. Exclusion of the Public and Press In accordance with the Public Bodies Admission to MeetingsAct), to resolve to exclude members of the public and press from the remainder of the meeting.Trust Board Agenda – 6 March 2013 2

EXECUTIVE SUMMARYTITLE:Care Quality Commission Reports (Maternity Services andEmergency Department) at Queens Hospital.BOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:Following the CQC unannounced visit to both the MaternityDepartment ( visits on 5 th and 6 th December 2012) and theEmergency Department (visits on 28 th and 289 th Novemberand the 5th December 2012).Maternity DepartmentThe trust was found to be compliant with 3 outcomes: careand Welfare of People who use services; safety availabilityand suitability of equipment; and staffing. Overall the CQCfelt that there had been improvements in our maternityservices and overall women were in receipt of goodservices.Emergency DepartmentThe Trust was found to be non- compliant with the 3outcomes reviewed: Care and Welfare of People who useServices; Safety; and Records. This culminated in a RiskSummit on the 7 th February to discuss the Trust actionplan to improve the Emergency Care Pathway. A furtheraction plan has been developed which is currently beingmonitored by NHSL, the NCB, CQC and ClinicalCommissioners.X TEC …………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….X QUALITY & SAFETY …………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:The attached reports outline the detail of the CQC findings.□ NATIONAL TARGET□ X CQC REGISTRATION□ CNST□ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Dorothy HoseinDATE:3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:The Attached Reports are for information.4. DELIVERABLES

5. KEY PERFORMANCE INDICATORSFailure to meet national target on emergency treatment and care within 4hours.AGREED AT __Trust Board MeetingORREFERRED TO: __________________________DATE: ____2013_DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

Inspection ReportWe are the regulator: Our job is to check whether hospitals, care homes and careservices are meeting essential standards.Queen's HospitalRom Valley Way, Romford, RM7 0AG Tel: 01708435000Date of Inspections: 06 December 201205 December 2012Date of Publication: January2013We inspected the following standards to check that action had been taken to meetthem. This is what we found:Care and welfare of people who use servicesSafety, availability and suitability of equipmentStaffingMet this standardMet this standardMet this standard| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 1

Details about this locationRegistered ProviderOverview of theserviceType of serviceRegulated activitiesBarking, Havering and Redbridge University Hospitals NHSTrustQueen's Hospitalis part of Barking, Havering and RedbridgeUniversity Hospitals NHS Trust which is located in Romfordand provides maternity services for women, includingwomen who have high risk pregnancies.Acute services with overnight bedsDiagnostic and screening proceduresFamily planningMaternity and midwifery servicesSurgical proceduresTermination of pregnanciesTreatment of disease, disorder or injury| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 2

ContentsWhen you read this report, you may find it useful to read the sections towards the backcalled 'About CQC inspections' and 'How we define our judgements'.Summary of this inspection:PageWhy we carried out this inspection 4How we carried out this inspection 4What people told us and what we found 4More information about the provider 5Our judgements for each standard inspected:Care and welfare of people who use services 6Safety, availability and suitability of equipment 8Staffing 9About CQC Inspections 11How we define our judgements 12Glossary of terms we use in this report 14Contact us 16| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 3

Summary of this inspectionWhy we carried out this inspectionWe carried out this inspection to check whether Queen's Hospital had taken action to meetthe following essential standards:• Care and welfare of people who use services• Safety, availability and suitability of equipment• StaffingThis was an unannounced inspection.How we carried out this inspectionWe looked at the personal care or treatment records of people who use the service,carried out a visit on 5 December 2012 and 6 December 2012, observed how people werebeing cared for and checked how people were cared for at each stage of their treatmentand care. We talked with people who use the service, talked with carers and / or familymembers and talked with staff.What people told us and what we foundSince our last inspection the maternity services at Queen's Hospital has made a range ofimprovements and the care of women has improved. Women we spoke with wereunanimous in saying that the care they had received was of a high standard. One womansaid "they have been really helpful, I think it's fine", and another commented "I wanted awater birth which I got, the midwife was spot on, when she needed a break another onecovered so I was never on my own".Women are seen more quickly in the triage area when they arrive at the hospital and morequickly when they need to be seen by an obstetrician. They are performing lesscaesareans sections than most other hospitals in London, but need to improve the time forcarrying out emergency caesarean sections.As part of our inspection we looked in a number of treatment rooms in the antenatal andlabour wards to check that equipment was available, and that maintenance records hadbeen kept up to date. Our inspection covered, cardiotocography monitors (CTGs - whichare used by staff to monitor the condition of the baby before it is born), infusion pumps,adult resuscitation equipment and infant resuscitaries. We found that the maternityservices had all the equipment it needs and that it is properly maintained.There was sufficient experienced midwifery and medical staff to ensure women receivedcare that met their needs. All women in labour had a midwife with them all of the time.You can see our judgements on the front page of this report.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 4

More information about the providerPlease see our website www.cqc.org.uk for more information, including our most recentjudgements against the essential standards. You can contact us using the telephonenumber on the back of the report if you have additional questions.There is a glossary at the back of this report which has definitions for words and phraseswe use in the report.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 5

Our judgements for each standard inspectedCare and welfare of people who use servicesMet this standardPeople should get safe and appropriate care that meets their needs and supportstheir rightsOur judgementThe provider was meeting this standard.People experienced care, treatment and support that met their needs and protected theirrights.Reasons for our judgementThe maternity services at Queen's Hospital have made a range of improvements since ourlast inspection. We spoke to five women on the two postnatal wards and they wereunanimous in saying that the care they had received was of a high standard. One womansaid "they have been really helpful, I think it's fine" and another commented "I wanted awater birth which I got, the midwife was spot on, when she needed a break another onecovered so I was never on my own".The Trust itself uses a 'Maternity Patient Experience Survey' form which is given to eachmother before they leave. We examined a random selection of 146 of these forms andalso the management information the Trust collates from them. We found from the surveyfor November 2012 that 96% of women would recommend the maternity ward to friends orfamily if they needed similar care or treatment. Ninety five percent of women felt involvedin the decisions made about their care during labour and birth and 88% of women saidthey had the pain relief they wanted during labour.Six of the seven care records we reviewed had a clear birth plan setting out the women'spreferences about the type of birth and pain relief she wanted. They also showed thatwomen had received care in line with their wishes. In one case a woman who hadpreviously had a caesarean section was supported to have her second child naturally.Overall, we found care plans to be well documented with clear and appropriate notesmade on the records.During the last 12 months, there had been a change in the management of the service.Staff told us they found the new management supportive and clear about theirexpectations about the standard of care women should receive. They also told us they feltstaff had adopted a more caring approach to women.When asked about what happened when things went wrong, staff said that they werereported and in serious cases an investigation would be undertaken. The Trust had adetailed process for investigating and learning from Serious Incidents that occur.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 6

The maternity services at Queen's Hospital sets two key targets around triage; the first isthat all women in triage should be seen within 30 minutes 90% of the time. In the summerof 2011 our inspection noted that the Trust's performance for June, July and August was62%, 83% and 83% respectively. For the same months in 2012 this had improved to 88%,94% and 89% respectively. The latest figure for October 2012 showed performance at89%. From speaking to staff we found that women needing immediate assessment areidentified by the midwife looking after the seven triage beds. One midwife said "it worksvery well; we see them as soon as they arrive and if we need a doctor we can always getone very quickly". A mother we spoke to said, "I was seen straight away when I got here, Ididn't have to wait at all".The second target set by the trust is that 90% of women needing an obstetric assessmentwill receive one within one hour. Since our last inspection the Trust's performance hasimproved and the latest figure for October 2012 showed performance at 98%.The maternity services at Queen's hospital set targets around emergency caesareansections and grades them one, two and three; grade one must be performed within 30minutes, grade 2 within 60 minutes and grade 3 within 75 minutes. Information shows thatperformance around grade 1 has been inconsistent for the last six months ranging from54% to 90%. When we spoke to management about performance in this area they saidthat junior doctors were not always recording the time correctly making the figuresunreliable. To deal with this the Clinical Director was auditing the figures himself; he hadfound that the correct figure for October should have been 82%. The Trust might wish toensure that all doctors are clear on how to record the different categories of caesareansections in patient notes.With regards to caesarean sections overall, Queen's has a rate of around 25% whichcompares with a London average of 29%.Overall the maternity services at Queen's Hospital has improved its performance for mostindicators and women were positive about the care they had received. The staff we spoketo said that care had improved both in terms of midwifery and medical outcomes. Onemidwife said "we work well with the doctors, it's much more of a team than it used to be, ifyou need a doctor then there is always one available".| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 7

Safety, availability and suitability of equipmentMet this standardPeople should be safe from harm from unsafe or unsuitable equipmentOur judgementThe provider was meeting this standard.People were protected from unsafe or unsuitable equipment.Reasons for our judgementAs part of our inspection we looked in a number of treatment rooms in the antenatal andlabour wards to check that equipment was present, and that maintenance records hadbeen kept up to date. Our inspection covered, CTGs, infusion pumps, adult resuscitationequipment and infant resuscitaires.During our last inspection in April 2012 we found that equipment was not alwaysaccessible and was not always checked in line with the Trust and national guidance. Inparticular, there was evidence that CTGs had not always been checked and their variousattachments where not always easily available.We found that all appropriate equipment was available. We noted that all the equipmentwas accompanied by maintenance records which showed equipment had been checked atleast daily in compliance with the joint statement by the Royal College of Anaesthetists,Royal College of Physicians, Intensive Care Society and Resuscitation Council UK statesin chapter 9 which states, "Responsibility for checking resuscitation equipment rests withthe department where the equipment is held and checking should be audited regularly.The frequency of checking will depend on local circumstances but should ideally be daily".Midwifery care assistants (MCAs) told us that they have enough time to check equipmentand that all equipment is checked at least daily.Midwives and medical staff told us that equipment was always available and none of themwere aware of any incidents where equipment was missing or not working properly.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 8

StaffingMet this standardThere should be enough members of staff to keep people safe and meet theirhealth and welfare needsOur judgementThe provider was meeting this standard.There were enough qualified, skilled and experienced staff to meet people's needs.Reasons for our judgementOn our previous inspection in April 2012 we found that maternity services at Queen'shospital were not meeting this essential standard. This was because women using thematernity services did not consistently have their health and welfare needs met bysufficient numbers of appropriately skilled staff. There were concerns over the skill mix andexperience and training of midwives which was impacting on their ability to perform theirrequired duties and hence exposing women to potential risks. Some midwives were unableto perform skills which form a routine part of their role as a midwife such as cannulation(inserting a tube) and suturing.Overall the Maternity Unit at Queen's has a current complement of 321 midwives. Thisallows them to maintain a midwife to woman ratio of 1:29, which compares with a Londontarget of 1:30. The Trust's data shows that it has been able to maintain a 1:1 ratio ofmidwife to woman in the labour ward 100% of the time. A mother we spoke to said " therewere always plenty of people around, I was never left on my own when I was having thebaby". We examined a sample of 'Daily Staff Lists' for the Labour ward which records thedetails of staff on duty throughout the day. We found that the maternity management wereproactive in managing the workforce and when needed, they moved staff between wardsto match demand.We spoke to staff who said that generally they have enough staff. One of the midwivessaid," there are busy times when things are stretched but the management do plan aheadand bank and agency staff are brought in when needed". Another midwife said "wenormally have all our numbers on our shift".During our inspection we found that the vacancy rate for midwives had reduced from anaverage of 17% in 2011 to an average of 10% for the six months up to October 2012. Wediscussed the maternity recruitment strategy with management. The Trust is nowdeveloping a 'grow your own' approach where trainee midwives are encouraged to remainat Queen's. Most recently this approach has proved successful with every one of the lastgroup of 12 trainees deciding to stay on at Queen's Hospital.With regards to the skill mix of experienced to newly qualified midwives with less than 12months experience. We examined the staffing records for the High Dependency Unit(HDU) and the Labour ward. In the HDU over a seven day period in November we foundthat no staff had less than 12 months experience. On the labour ward for the same periodwe found that for each shift of about 15 midwives the highest number with less than 12| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 9

months experience on any individual shift was three, although the average was aroundtwo. Newly qualified midwives we spoke to told us that they had a great deal of supportfrom their more experienced colleagues.Previous inspections had raised concerns that not enough midwives were trained in,cannulation, suturing, and CTG monitoring. We spoke to midwives about this and they alltold us there had been an increase in training in these areas. Records showed that 86% ofstaff had received recent CTG training (an increase from 65% in January 2012); 64% aretrained in cannulation (an increase from 47% in January 2012); 90% are trained in suturing(an increase from 74% in January 2012).With regards to medical staff, the maternity unit has an establishment of 20 Obstetric andGynaecology consultants, who provide 98 hours of cover on labour ward. The maternitydepartment has submitted a business case to increase this to 168 hours of cover byemploying an additional four consultants.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 10

About CQC inspectionsWe are the regulator of health and social care in England.All providers of regulated health and social care services have a legal responsibility tomake sure they are meeting essential standards of quality and safety. These are thestandards everyone should be able to expect when they receive care.The essential standards are described in the Health and Social Care Act 2008 (RegulatedActivities) Regulations 2010 and the Care Quality Commission (Registration) Regulations2009. We regulate against these standards, which we sometimes describe as "governmentstandards".We carry out unannounced inspections of all care homes, acute hospitals and domiciliarycare services in England at least once a year to judge whether or not the essentialstandards are being met. We carry out inspections of dentists and other services at leastonce every two years. All of our inspections are unannounced unless there is a goodreason to let the provider know we are coming.There are 16 essential standards that relate most directly to the quality and safety of careand these are grouped into five key areas. When we inspect we could check all or part ofany of the 16 standards at any time depending on the individual circumstances of theservice. Because of this we often check different standards at different times but wealways inspect at least one standard from each of the five key areas every year. We maycheck fewer key areas in the case of dentists and some other services.When we inspect, we always visit and we do things like observe how people are cared for,and we talk to people who use the service, to their carers and to staff. We also reviewinformation we have gathered about the provider, check the service's records and checkwhether the right systems and processes are in place.We focus on whether or not the provider is meeting the standards and we are guided bywhether people are experiencing the outcomes they should be able to expect when thestandards are being met. By outcomes we mean the impact care has on the health, safetyand welfare of people who use the service, and the experience they have whilst receivingit.Our inspectors judge if any action is required by the provider of the service to improve thestandard of care being provided. Where providers are non-compliant with the regulations,we take enforcement action against them. If we require a service to take action, or if wetake enforcement action, we re-inspect it before its next routine inspection was due. Thiscould mean we re-inspect a service several times in one year. We also might decide to reinspecta service if new concerns emerge about it before the next routine inspection.In between inspections we continually monitor information we have about providers. Theinformation comes from the public, the provider, other organisations, and from careworkers.You can tell us about your experience of this provider on our website.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 11

How we define our judgementsThe following pages show our findings and regulatory judgement for each essentialstandard or part of the standard that we inspected. Our judgements are based on theongoing review and analysis of the information gathered by CQC about this provider andthe evidence collected during this inspection.We reach one of the following judgements for each essential standard inspected.Met this standardThis means that the standard was being met in that theprovider was compliant with the regulation. If we find thatstandards were met, we take no regulatory action but wemay make comments that may be useful to the provider andto the public about minor improvements that could be made.Action neededThis means that the standard was not being met in that theprovider was non-compliant with the regulation.We may have set a compliance action requiring the providerto produce a report setting out how and by when changeswill be made to make sure they comply with the standard.We monitor the implementation of action plans in thesereports and, if necessary, take further action.We may have identified a breach of a regulation which ismore serious, and we will make sure action is taken. We willreport on this when it is complete.Enforcementaction takenIf the breach of the regulation was more serious, or therehave been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures inthe Health and Social Care Act 2008 and relevantregulations. These enforcement powers include issuing awarning notice; restricting or suspending the services aprovider can offer, or the number of people it can care for;issuing fines and formal cautions; in extreme cases,cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are setout in law and mean that we can take swift, targeted actionwhere services are failing people.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 12

How we define our judgements (continued)Where we find non-compliance with a regulation (or part of a regulation), we state whichpart of the regulation has been breached. We make a judgement about the level of impacton people who use the service (and others, if appropriate to the regulation) from thebreach. This could be a minor, moderate or major impact.Minor impact – people who use the service experienced poor care that had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was notsignificant and the matter could be managed or resolved quickly.Moderate impact – people who use the service experienced poor care that had asignificant effect on their health, safety or welfare or there was a risk of this happening.The matter may need to be resolved quickly.Major impact – people who use the service experienced poor care that had a seriouscurrent or long term impact on their health, safety and welfare, or there was a risk of thishappening. The matter needs to be resolved quicklyWe decide the most appropriate action to take to ensure that the necessary changes aremade. We always follow up to check whether action has been taken to meet thestandards.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 13

Glossary of terms we use in this reportEssential standardThe essential standards of quality and safety are described in our Guidance aboutcompliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and theCare Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social careservices have a right to expect. A full list of the standards can be found within theGuidance about compliance. The 16 essential standards are:Respecting and involving people who use services - Outcome 1 (Regulation 17)Consent to care and treatment - Outcome 2 (Regulation 18)Care and welfare of people who use services - Outcome 4 (Regulation 9)Meeting Nutritional Needs - Outcome 5 (Regulation 14)Cooperating with other providers - Outcome 6 (Regulation 24)Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)Cleanliness and infection control - Outcome 8 (Regulation 12)Management of medicines - Outcome 9 (Regulation 13)Safety and suitability of premises - Outcome 10 (Regulation 15)Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)Requirements relating to workers - Outcome 12 (Regulation 21)Staffing - Outcome 13 (Regulation 22)Supporting Staff - Outcome 14 (Regulation 23)Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)Complaints - Outcome 17 (Regulation 19)Records - Outcome 21 (Regulation 20)Regulated activityThese are prescribed activities related to care and treatment that require registration withCQC. These are set out in legislation, and reflect the services provided.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 14

Glossary of terms we use in this report (continued)(Registered) ProviderThere are several legal terms relating to the providers of services. These includeregistered person, service provider and registered manager. The term 'provider' meansanyone with a legal responsibility for ensuring that the requirements of the law are carriedout. On our website we often refer to providers as a 'service'.RegulationsWe regulate against the Health and Social Care Act 2008 (Regulated Activities)Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.Responsive inspectionThis is carried out at any time in relation to identified concerns.Routine inspectionThis is planned and could occur at any time. We sometimes describe this as a scheduledinspection.Themed inspectionThis is targeted to look at specific standards, sectors or types of care.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 15

Contact usPhone: 03000 616161Email:enquiries@cqc.org.ukWrite to usat:Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PAWebsite:www.cqc.org.ukCopyright Copyright © (2011) Care Quality Commission (CQC). This publication maybe reproduced in whole or in part, free of charge, in any format or medium providedthat it is not used for commercial gain. This consent is subject to the material beingreproduced accurately and on proviso that it is not used in a derogatory manner ormisleading context. The material should be acknowledged as CQC copyright, with thetitle and date of publication of the document specified.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 16

Inspection ReportWe are the regulator: Our job is to check whether hospitals, care homes and careservices are meeting essential standards.Queen's HospitalRom Valley Way, Romford, RM7 0AG Tel: 01708435000Date of Inspections: 05 December 201229 November 201228 November 2012Date of Publication: January2013We inspected the following standards to check that action had been taken to meetthem. This is what we found:Care and welfare of people who use servicesStaffingRecordsAction neededAction neededAction needed| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 1

Details about this locationRegistered ProviderOverview of theserviceType of serviceRegulated activitiesBarking, Havering and Redbridge University Hospitals NHSTrustQueen's Hospital is part of Barking, Havering and RedbridgeUniversity Hospitals NHS Trust. It offers acute services forall major specialities to a large and diverse population andincludes an accident and emergency department. The Trustruns a joint cancer centre with another London hospital, andis a regional neuroscience centre. We visited the accidentand emergency department.Acute services with overnight bedsDiagnostic and screening proceduresFamily planningMaternity and midwifery servicesSurgical proceduresTermination of pregnanciesTreatment of disease, disorder or injury| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 2

ContentsWhen you read this report, you may find it useful to read the sections towards the backcalled 'About CQC inspections' and 'How we define our judgements'.Summary of this inspection:PageWhy we carried out this inspection 4How we carried out this inspection 4What people told us and what we found 4What we have told the provider to do 5More information about the provider 5Our judgements for each standard inspected:Care and welfare of people who use services 6Staffing 9Records 10Information primarily for the provider:Action we have told the provider to take 11About CQC Inspections 12How we define our judgements 13Glossary of terms we use in this report 15Contact us 17| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 3

Summary of this inspectionWhy we carried out this inspectionWe carried out this inspection to check whether Queen's Hospital had taken action to meetthe following essential standards:• Care and welfare of people who use services• Staffing• RecordsThis was an unannounced inspection.How we carried out this inspectionWe looked at the personal care or treatment records of people who use the service,carried out a visit on 28 November 2012, 29 November 2012 and 5 December 2012,observed how people were being cared for and checked how people were cared for ateach stage of their treatment and care. We talked with people who use the service, talkedwith carers and / or family members and talked with staff.What people told us and what we foundThe accident and emergency department (known as the Emergency Department) has notmet most of the national quality indicators as a result of extensive delays in the care ofpatients. Five percent of patients who need to be admitted to the hospital are waiting formore than 11 hours in the department. The Trust should be aiming to transfer 95% ofpatients who are being admitted to wards within four hours of their arrival.This has led to poor care for patients in the 'Majors' area where seriously ill patients arecared for. The 'Majors' environment is unsuitable for patients to be nursed in for longperiods of time for a variety of reasons such as, lack of privacy/dignity, no washingfacilities, no storage space for personal belongings and no bedside tables. There is alimited range of food and drink available.We found that many patients, who were there for a long period of time, including overnight,were nursed on trolleys when they should have been moved onto a bed. Thisincreases the risk of them developing pressure damage, dehydration, and an increase infalls.There are not enough consultant or junior doctors to provide medical care for the numberof people who attend Queen's ED. In the 'Majors' area there are not enough nurses toprovide adequate care for patients.The Emergency Department Medical Unit (EDMU) had the names, dates of birth anddiagnosis of patients on 'white boards' which were visible to both the public and otherpatients.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 4

You can see our judgements on the front page of this report.What we have told the provider to doWe have asked the provider to send us a report by 09 February 2013, setting out theaction they will take to meet the standards. We will check to make sure that this action istaken.Where we have identified a breach of a regulation during inspection which is more serious,we will make sure action is taken. We will report on this when it is complete.Where providers are not meeting essential standards, we have a range of enforcementpowers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, ourdecision is open to challenge by the provider through a variety of internal and externalappeal processes. We will publish a further report on any action we take.More information about the providerPlease see our website www.cqc.org.uk for more information, including our most recentjudgements against the essential standards. You can contact us using the telephonenumber on the back of the report if you have additional questions.There is a glossary at the back of this report which has definitions for words and phraseswe use in the report.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 5

Our judgements for each standard inspectedCare and welfare of people who use servicesAction neededPeople should get safe and appropriate care that meets their needs and supportstheir rightsOur judgementThe provider was not meeting this standard.People did not experience care, treatment and support that met their needs and protectedtheir rights.We have judged that this has a major impact on people who use the service. This is beingfollowed up and we will report on any action when it is complete.Reasons for our judgementWe visited the emergency department (ED) at Queen's Hospital because we had identifiedmajor concerns about the care and welfare of patients during a previous visit in March2012. We carried out this inspection to ensure they had made improvements, in relation toconcerns identified about meeting waiting times and delays experienced by patients inreceiving care and the quality of the care they received.The ED monitors its performance times for dealing with all patients. For both patients whoare subsequently admitted and those who are not it aims to treat 95 % of them within fourhours. For those patients who do not require admission, since September 2012 the EDhas been meeting this target. However, for those patients who need to be admitted the EDis not meeting the target and 5% of patients were in the ED for more than 11 hours beforeadmission.The emergency department is subject to high levels of demand; it was originally built todeal with up to 90,000 patients, it now sees around 132,000 patients per year. Althoughother ED departments in London see more patients, in the financial year 2011/2012Queen's Hospital had 2,686 'Blue Light' (very serious) ambulance cases which was morethan any other hospital in London.The department consists of a separate paediatrics, resuscitation, rapid assessment andtreatment (RAT), Majors, Emergency Medicine Decisions Unit (EDMU), where ED patientscan be accommodated for up to 24 hours to assess their condition, and minor injuries areawhich is co-located with the urgent care area.We reviewed information provided by the London Ambulance Service (LAS) for the periodMay to November 2012 relating to Queen's Hospital. The report showed that Queen's EDwas responsible for most of the ambulance diverts (when an ED has to close and non- lifethreatening admissions and ambulances are diverted to other hospitals) in the North EastLondon region. For this six month period ambulances were diverted to other hospitals on| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 6

16 occasions.The LAS also records "black breaches" (those cases where it has taken over 60 minutesfrom the time the ambulance arrives at a hospital, until both the clinical handover and thepatient handover has taken place). For the three month period from January to March2012 there were 231 recorded "black breaches" at Queen's Hospital. This has recentlyimproved and for September to November 2012 52 "black breaches" were recorded,although the Trust believes this figure should be lower and is currently in the process ofreconciling them.Ambulance patients who are unwell and may need admission are assessed and directedthrough to the 'Majors' area; this area consists of 25 bays, 23 used for beds with two baysbeing used as a seating area with six seats; it also includes the five RAT cubicles.Once the hospital has made a Decision to Admit (DTA), a patient they should be moved assoon as possible from the ED to the main hospital wards or to the Medical AssessmentUnit. On our first day of the inspection at 11am there were 22 patients in the 'Majors' area.For five of these it was noted that a DTA had been made and six patients had been in theED since midnight. One of the patients had been in the ED since 5pm the previousevening. Patients told us the only drinks they had been offered was that morning with theirbreakfast which was toast. One of the female patients we spoke to said she was verythirsty and we could see that her mouth was dry, there was no information on her patientrecords indicating that she her been given a drink since her arrival 11 hours previously.On the second day of our inspection, at 1030am, there were 30 patients in the 'Majors'area. Eighteen of them had been in the ED for more than six hours and ten had been inthe ED since before midnight. We examined the patient's records and found that for elevenof them a DTA had been made and they were waiting for a bed in the medical admissionsunit or main wards in the hospital. Of the 10 patients who had been in since midnight, fourwere still on a hospital trolley instead of a hospital bed. We spoke to four of the tenpatients who had been there since before midnight, we found that they had been givendrinks when needed. We noted that their dignity was not always being respected forexample curtains were not drawn when needed and in one case an elderly person'sunderpants had been left hanging on the bottom of their bed.On the third day of our inspection we visited at 4pm and found there were 27 patients inthe 'Majors' area. Eleven of them had been at the hospital for more than four hours andnine had been there for more than six hours. The longest time a patient had been therewas 14 hours and 43 minutes. Staff told us that nine of the patients were waiting to seemedical specialists from other parts of the hospital. All of the patients were lying on ahospital trolley. Patients told us that they had been offered water throughout their stay andsandwiches at lunchtime.Over the three days of our inspection we spoke to a number of staff in 'Majors', they toldus that the area is not designed to provide ward type care, there is no meal provision otherthan soup and sandwiches and no ward furniture, such as lockers and bedside tables, isprovided. Staff told us that we had visited at a particularly busy time but that it was oftenvery busy and what we had found on our inspection was typical for the ED. They told usthat the problem was the hospital wards were not making beds available so they couldtransfer patients. In addition staff said that there were excessive delays in specialistdoctors from other parts of the hospital attending the ED to see patients. We examinedpatient's medical notes and confirmed this to be the case; we found two examples wherepatients had been waiting for more than seven hours to be seen by a specialist doctor.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 7

| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 8

StaffingAction neededThere should be enough members of staff to keep people safe and meet theirhealth and welfare needsOur judgementThe provider was not meeting this standard.There were not enough qualified, skilled and experienced staff to meet people's needs.We have judged that this has a major impact on people who use the service. This is beingfollowed up and we will report on any action when it is complete.Reasons for our judgementWe reviewed the number of nurses in the 'Majors' department, which was very busyduring the three days that we were inspecting. Staff also told us that the department wasusually very busy. We examined the staff rotas and observed the actual number of nurseson duty. We found that there were always four nurses on duty in the 'Majors' area which,for the number of patients they had to look after, meant their ratio ranged from oneregistered nurse to 5.5 patients to one registered nurse for 7.5 patients. We were informedthat the baseline ratio for 'Majors' was a ratio of one registered nurse to six patients atnight and one registered nurse to five patients in the day.We spoke to some of the nurses in the 'Majors' who told us, " we can cope with thenumbers if things are quiet, but when things get busy there are not enough nurses here".With regards to medical staff, the Trust has 16 Consultants in the General ED to coverboth Queen's and King Georges Hospitals. They provide an on-site presence from 8am to10pm Monday to Friday and 6 hours (as a minimum) on Saturdays and Sundays, at eachsite. In addition there are two Paediatric Consultants. It currently has 11.6 permanentconsultants in post and provides the rest of the cover by employing locum staff. The RoyalCollege of Emergency Medicine would recommend that for the number of patients seen atthe ED at Queen's Hospital it should have 16 consultants to provide cover 16 hours a day,seven days a week. The ED has a number of consultants working between 9am and 5pmbut after 5pm there is often only one consultant available until 10pm. Staff told us thatconsultants do not finish their shift at 10pm until they are happy it is 'safe' to do so. After10pm there is a consultant available on call. The ED at Queen's is under resourced forconsultants.Additionally consultants need to be supported by a multidisciplinary workforce that reflectsthe case mix and complexity of the workload. There are 29 doctor middle grade posts, ofwhich only 14 are filled. These doctors work a rolling shift pattern covering both KingGeorge and Queen's Hospitals. The rest of the vacancies are filled by locums. The ED atQueen's is under resourced for middle grade doctors.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 9

RecordsAction neededPeople's personal records, including medical records, should be accurate andkept safe and confidentialOur judgementThe provider was not meeting this standard.Records are not being kept securelyWe have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.Reasons for our judgementThe ED has an Emergency Department Medical Unit (EDMU) where patients from the EDcan be accommodated for up to 24 hours to assess their condition. The unit consists oftwo wards with four bays in each. We looked at the unit in detail and found that it was fullwith eight patients. However, only one of them met the criteria for an EDMU patient, all theothers were overflow from the Medical Assessment Unit (MAU) which is a ward that is notpart of the ED and can accommodate up to 60 patients for stays for up to 48 hours beforepatients are either discharged or transferred to a main ward.When we visited the EMDU, we found that patients' notes were securely stored in alockable trolley. However, we found that patient's names, dates of birth and a summary oftheir diagnosis where written on large 'white boards' that were fully visible to the public andother patients. We identified this issue to senior staff on the first day of our visit but foundthe same situation when we returned on the second day.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 10

This section is primarily information for the providerAction we have told the provider to takeCompliance actionsThe table below shows the essential standards of quality and safety that were not beingmet. The provider must send CQC a report that says what action they are going to take tomeet these essential standards.Regulated activityTreatment ofdisease, disorder orinjuryRegulationRegulation 20 HSCA 2008 (Regulated Activities) Regulations2010RecordsHow the regulation was not being met:To be advisedThis report is requested under regulation 10(3) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2010.The provider's report should be sent to us by 09 February 2013.CQC should be informed when compliance actions are complete.We will check to make sure that action has been taken to meet the standards and willreport on our judgements.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 11

About CQC inspectionsWe are the regulator of health and social care in England.All providers of regulated health and social care services have a legal responsibility tomake sure they are meeting essential standards of quality and safety. These are thestandards everyone should be able to expect when they receive care.The essential standards are described in the Health and Social Care Act 2008 (RegulatedActivities) Regulations 2010 and the Care Quality Commission (Registration) Regulations2009. We regulate against these standards, which we sometimes describe as "governmentstandards".We carry out unannounced inspections of all care homes, acute hospitals and domiciliarycare services in England at least once a year to judge whether or not the essentialstandards are being met. We carry out inspections of dentists and other services at leastonce every two years. All of our inspections are unannounced unless there is a goodreason to let the provider know we are coming.There are 16 essential standards that relate most directly to the quality and safety of careand these are grouped into five key areas. When we inspect we could check all or part ofany of the 16 standards at any time depending on the individual circumstances of theservice. Because of this we often check different standards at different times but wealways inspect at least one standard from each of the five key areas every year. We maycheck fewer key areas in the case of dentists and some other services.When we inspect, we always visit and we do things like observe how people are cared for,and we talk to people who use the service, to their carers and to staff. We also reviewinformation we have gathered about the provider, check the service's records and checkwhether the right systems and processes are in place.We focus on whether or not the provider is meeting the standards and we are guided bywhether people are experiencing the outcomes they should be able to expect when thestandards are being met. By outcomes we mean the impact care has on the health, safetyand welfare of people who use the service, and the experience they have whilst receivingit.Our inspectors judge if any action is required by the provider of the service to improve thestandard of care being provided. Where providers are non-compliant with the regulations,we take enforcement action against them. If we require a service to take action, or if wetake enforcement action, we re-inspect it before its next routine inspection was due. Thiscould mean we re-inspect a service several times in one year. We also might decide to reinspecta service if new concerns emerge about it before the next routine inspection.In between inspections we continually monitor information we have about providers. Theinformation comes from the public, the provider, other organisations, and from careworkers.You can tell us about your experience of this provider on our website.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 12

How we define our judgementsThe following pages show our findings and regulatory judgement for each essentialstandard or part of the standard that we inspected. Our judgements are based on theongoing review and analysis of the information gathered by CQC about this provider andthe evidence collected during this inspection.We reach one of the following judgements for each essential standard inspected.Met this standardThis means that the standard was being met in that theprovider was compliant with the regulation. If we find thatstandards were met, we take no regulatory action but wemay make comments that may be useful to the provider andto the public about minor improvements that could be made.Action neededThis means that the standard was not being met in that theprovider was non-compliant with the regulation.We may have set a compliance action requiring the providerto produce a report setting out how and by when changeswill be made to make sure they comply with the standard.We monitor the implementation of action plans in thesereports and, if necessary, take further action.We may have identified a breach of a regulation which ismore serious, and we will make sure action is taken. We willreport on this when it is complete.Enforcementaction takenIf the breach of the regulation was more serious, or therehave been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures inthe Health and Social Care Act 2008 and relevantregulations. These enforcement powers include issuing awarning notice; restricting or suspending the services aprovider can offer, or the number of people it can care for;issuing fines and formal cautions; in extreme cases,cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are setout in law and mean that we can take swift, targeted actionwhere services are failing people.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 13

How we define our judgements (continued)Where we find non-compliance with a regulation (or part of a regulation), we state whichpart of the regulation has been breached. We make a judgement about the level of impacton people who use the service (and others, if appropriate to the regulation) from thebreach. This could be a minor, moderate or major impact.Minor impact – people who use the service experienced poor care that had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was notsignificant and the matter could be managed or resolved quickly.Moderate impact – people who use the service experienced poor care that had asignificant effect on their health, safety or welfare or there was a risk of this happening.The matter may need to be resolved quickly.Major impact – people who use the service experienced poor care that had a seriouscurrent or long term impact on their health, safety and welfare, or there was a risk of thishappening. The matter needs to be resolved quicklyWe decide the most appropriate action to take to ensure that the necessary changes aremade. We always follow up to check whether action has been taken to meet thestandards.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 14

Glossary of terms we use in this reportEssential standardThe essential standards of quality and safety are described in our Guidance aboutcompliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and theCare Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social careservices have a right to expect. A full list of the standards can be found within theGuidance about compliance. The 16 essential standards are:Respecting and involving people who use services - Outcome 1 (Regulation 17)Consent to care and treatment - Outcome 2 (Regulation 18)Care and welfare of people who use services - Outcome 4 (Regulation 9)Meeting Nutritional Needs - Outcome 5 (Regulation 14)Cooperating with other providers - Outcome 6 (Regulation 24)Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)Cleanliness and infection control - Outcome 8 (Regulation 12)Management of medicines - Outcome 9 (Regulation 13)Safety and suitability of premises - Outcome 10 (Regulation 15)Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)Requirements relating to workers - Outcome 12 (Regulation 21)Staffing - Outcome 13 (Regulation 22)Supporting Staff - Outcome 14 (Regulation 23)Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)Complaints - Outcome 17 (Regulation 19)Records - Outcome 21 (Regulation 20)Regulated activityThese are prescribed activities related to care and treatment that require registration withCQC. These are set out in legislation, and reflect the services provided.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 15

Glossary of terms we use in this report (continued)(Registered) ProviderThere are several legal terms relating to the providers of services. These includeregistered person, service provider and registered manager. The term 'provider' meansanyone with a legal responsibility for ensuring that the requirements of the law are carriedout. On our website we often refer to providers as a 'service'.RegulationsWe regulate against the Health and Social Care Act 2008 (Regulated Activities)Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.Responsive inspectionThis is carried out at any time in relation to identified concerns.Routine inspectionThis is planned and could occur at any time. We sometimes describe this as a scheduledinspection.Themed inspectionThis is targeted to look at specific standards, sectors or types of care.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 16

Contact usPhone: 03000 616161Email:enquiries@cqc.org.ukWrite to usat:Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PAWebsite:www.cqc.org.ukCopyright Copyright © (2011) Care Quality Commission (CQC). This publication maybe reproduced in whole or in part, free of charge, in any format or medium providedthat it is not used for commercial gain. This consent is subject to the material beingreproduced accurately and on proviso that it is not used in a derogatory manner ormisleading context. The material should be acknowledged as CQC copyright, with thetitle and date of publication of the document specified.| Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 17

EXECUTIVE SUMMARYTITLE:Emergency Care Risk Summit held 7 th February 2013BOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:The attached letter is feedback from the NHS LondonMedical Director and the Care Quality Commission onthe Emergency care pathway diagnostic andimprovement plan presented to the risk summit on the7 th February 2013.□ TEC …X………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …X………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:The board are asked to note the comments receivedfrom NHS London, The commissioning Board(London), The National Trust Development Authorityand the Care Quality Commission. Currently these arebeing addressed through the Emergency CarePathway improvement plan.□ NATIONAL TARGET □ CNST□ X CQC REGISTRATION □ HEALTH & SAFETY□X ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ X CORPORATE OBJECTIVE……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Dorothy HoseinDATE:3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:The Board are asked to note that the Emergency Care pathway plan addresses the further requirements that this letterhas asked for. The majority of the short term objectives are being financially supported by winter pressures monies.4. DELIVERABLESTo ensure we have a comprehensive approach to assuring the Trust Board that strategic risks are being mitigated.5. KEY PERFORMANCE INDICATORSNational targets e.g. emergency department access, reduction in health care acquired infections.Hospital wide performance metrics have been developed and work is on-going, to ensure they meet both theTrust needs and those of our commissioners.

AGREED AT __Trust Board MeetingORREFERRED TO: __________________________DATE: ____DATE: ____________________________REVIEW DATE (if applicable) ___________________________2

By email:Averil DongworthChief ExecutiveBarking, Havering and Redbridge University Hospitals NHS TrustRom Valley WayRomfordEssexRM7 0AG13 February 2013Tel: 020 7932 3700Fax: 020 7932 3800Dear Averil,Emergency Care Risk Summit - 7 February 2013Thank you for hosting last week’s risk summit, held to consider the emerging plans ofthe Trust to address significant shortfalls in the care of patients on the emergency carepathway at Queen’s Hospital. These shortfalls had been highlighted during the CareQuality Commission’s (CQC’s) unannounced visits to the Hospital towards the end of2012. Having chaired the summit, I am writing to summarise the outcomes of it and toset out next steps.Members of the expert panel that considered the proposed action plans were:NHS London / NHSCommissioning Board(London) (NHSCB(L)) /NHS Trust DevelopmentAuthority (TDA)AdvisorsCQCDr Andy Mitchell, Medical Director, NHS London / NHSCB(L)Caroline Alexander, Chief Nurse, NHS London / NHSCB(L)Dr Henrietta Hughes, Medical Director & Responsible Officer,NHSCB(L) NC&NE London Area TeamPeter Coles, Interim Delivery Director, NHSCB(L) NC&NE LondonArea TeamAlastair Finney, Deputy Director of Strategy and ProviderDevelopment, NHS London, and Portfolio Director, TDALucie Butler, Head of Nursing Emergency & Trauma, BartsHealth NHS TrustDr Julian Redhead, Consultant in Adult Emergency Medicine,Imperial College Healthcare NHS TrustProfessor Derek Bell, Practising Consultant at Chelsea &Westminster Hospital NHS FT and Chair in Acute Medicine atImperial College Healthcare NHS TrustMatthew Trainer, Deputy Director of Operations (London)David Harris, Compliance InspectorMargaret McGlynn, Compliance ManagerWe welcomed the significant contribution made by you and your team to develop adeep understanding of the challenges faced by the Trust in delivering high qualityservices to emergency care patients and the steps that have been taken to begin todevelop a set of actions in response to those challenges. At the same time, we agreedthat a cohesive health economy-wide set of actions was the right approach. It was clearthat all organisations understood that they each had a responsibility to work together todeliver the changes necessary to improve patient care and emergency careLondon Strategic Health AuthorityInterim Chair: Professor Mike SpyerChief Executive: Ruth Carnall CBE

performance. In addition, there was clear leadership demonstrated by the clinical body,which both Caroline and I were pleased to note represented a positive change in yourorganisation’s determination and approach to transforming care.Matthew Trainer and CQC colleagues agreed with this view, commenting that theysensed an improved sense of ownership of the issues and increased level of clinicalengagement. Also, Matthew confirmed that the CQC would consider the Trust’sproposed actions when implementing the condition on the Trust’s registration that theCQC would be applying.The expert panel’s recommendations and observations were:Although the Trust and its partner organisations outlined an extensive proposed actionplan, we felt it contained too wide a range of initiatives - with too many that were littlemore than aspirations at this stage - to drive improvement successfully. We noted theambitious recovery trajectory that featured in the plan which, although agreed betweenthe Trust and the three CCGs, risked not being met without prioritising actions in moredetail. We therefore suggested that the Trust - working with North East London NHS FTand Barking and Dagenham, Havering and Redbridge CCGs - should develop a morefocussed plan highlighting short-, medium- and long-term objectives. In doing so, theTrust should revisit its proposed plan to set out more precisely priority actions, keydeliverables, milestones and key improvement criteria. The plan should have its heartthe agreed London-wide acute emergency clinical standards as a basis to developfurther the detailed proposals.The Trust should ensure that, in the short term, actions were taken to secure rapidimprovements in patient experience that could be sustained for the longer term. Thisneeded to be explicitly highlighted in the revised action plan.The Trust and its partner organisations should ensure that the funding that had beenmade available through the additional winter funding allocation is deployed in a way thatmaximises the short-term gain but also in a way that brings the benefit of sustained longtermimprovements.The Trust clearly experiences significant challenges in the recruitment and retention ofstaff in key clinical areas, across medical consultant and key nursing posts. Therefore,the Trust should consider developing flexible staffing roles to support patient care, ratherthan just focussing on recruitment to existing posts.Clinical colleagues in NHS London, the NHSCB(L) and TDA would continue to supportthe Trust by helping to nurture the relationship with UCL Partners and exploring thepotential for developing clinical rotas that spanned the Trust and Barts Health NHSTrust. In addition, Caroline offered to support the Trust to develop transformationalnursing roles across the emergency care pathway and helping to connect the Trust towider nursing networks that would support the recruitment challenges.In view of some constraints in the physical layout of Queen’s Hospital and the need thathas been identified to relocate sexual health services and renal services to facilitatedepartmental reconfiguration, the Trust should ensure that the plan for these moves areincluded in the action plan.Given the expert panel’s concern that little evidence of Board-level engagement andscrutiny of the plan was presented, the Trust should strengthen its plan so that there is

explicit reference to the governance and reporting framework in which the improvementprogramme would sit.Next stepsIt is vital that the work undertaken so far to engage with the wider local health economycontinues at pace to inform the development of the Trust’s action plan. I would expectyou to work with your local CCGs and other stakeholders, including the relevant localauthorities and the London Ambulance Service, to develop an action plan to be agreedthat sets out clearly the contribution from the various organisations across the widerhealth economy. This plan should identify the actions that are needed both to addressthe weaknesses identified by the CQC and to deliver the sustained improvement inemergency care as highlighted by the expert panel.The plan should be agreed and in place by 15 March. It would be helpful if you andyour team could present further progress in developing the plan, demonstrating that youare addressing the actions agreed at the risk summit and the recommendations listedabove, at the next monthly escalation meeting with the Trust, chaired by AlwenWilliams. I understand this meeting is scheduled for Friday 22 February. If necessary,further actions will be identified and agreed at that meeting to ensure agreement of theplan by 15 March. In addition, the TDA will require the performance metrics and planmilestones to be reflected in the Trust’s 2013/14 operating plan.Once the plan (with its performance metrics and milestones) is agreed, the TDA willhold the Trust to account for delivery against it, working alongside the NHSCB(L) toensure local CCGs’ contribution to delivering the plan is similarly secured.I trust you agree the risk summit on 7 February was valuable in helping the Trustdevelop its plan for transforming the quality of emergency services and patientexperience at Queen’s Hospital. I look forward to continuing working with you andcolleagues in addressing the challenges over the coming months.Yours sincerely,Dr AT MitchellMedical Directorcc:Conor BurkeMatthew TrainerMargaret McGlynnRuth CarnellAlwen WilliamsSimon WeldonKate SouthwellAlastair FinneyCaroline AlexanderPeter ColesVanessa Lodge

EXECUTIVE SUMMARYTITLE:Maternity Services Update, including sign off of KingGeorge Hospital Maternity Services move to Queen’sHospitalBOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:A Update on current status and progress pertaining tothe reconfiguration of Maternity Services from KingGeorge Hospital to Queens’ Hospital□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY: TO NOTETo Note progress and actions to date.□ NATIONAL TARGET X CNSTX CQC REGISTRATION HEALTH & SAFETYX ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERSX CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:Reduce overall cost base, improve safety and quality of service to women.AUTHOR/PRESENTER: Neil HARDY (Interim ADOW&C)DATE: 20 th February 20134. DELIVERABLESAction Plan to be fully implemented5. KEY PERFORMANCE INDICATORSMaternity ActivityAGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________Trust Board Update Maternity Reconfiguration 1Feb 2012

RECONFIGURATION OF MATERNITY SERVICES1. SummaryFollowing a meeting held on 6 th February 2013, the NHS London team chaired byDr Andy Mitchell, Medical Director agreed that NHS London would be writing to theSecretary of State for Health stating that:• NHS London were satisfied that the IRP recommendations had been met• The standards of care at Queen’s Hospital was no longer a cause forconcern• The overall health economy was ready to make this change on a sustainablebasis, in support of NEL demand for deliveries.In reaching these conclusions NHS London had considered the following evidence:• Verbal and written evidence from NELC and its provider organisations• NELC gateway review reports undertaken at BHRUT, Barts Health andHomerton• Advice from neonatal commissioning lead (NCB) that it is satisfied with thearrangements• A positive CQC report on Maternity Services at Queen’s Hospital followingan unannounced visit• Achievement of Level 1 NHS Litigation Authority Standards (CNST)• Feedback received by the London Deanery regarding improvements intraining arrangements and supervision for trainees.The Queen’s Birth Centre (QBC), opened on 8 th January 2013 has received muchpraise for the levels of care it provides to women. To date the target trajectory setby commissioners has been met with 30 deliveries in January and 32 in February todate.The QBC comprises 8 Delivery rooms and 6 Post-Natal beds Birthing Pools are wellused and this has meant few transfers of care to the main labour ward. It shouldalso be noted that there are high level of breast feeding initiation, which can bedirectly linked to the atmosphere, levels of care and environment experienced bywomen choosing the QBC for delivery.The Board is asked to note that the service is planning to close to births onTuesday 19 th March, with a final closure to deliveries at King George Hospitalon 20 th March 2013.The Board is asked to note that the provision of Antenatal clinics remainsunchanged. This is subject to the NELC Board decision on 7 th March.2

EXECUTIVE SUMMARYTITLE:BOARD/GROUP/COMMITTEE:Quality and Patient Standards PerformanceReport – January 2013Trust 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• FinanceA number of additional indicators have been includedfollowing a review of the Dashboard by the Patient Safetyand QualityCommitteeThe following areas where monthly performance is of concerndiscussed within the report• MRSA blood stream isolates (previously MRSA)• Clostridium difficile toxin-positive stools(previously Clostridium Difficile)• MRSA Screening – elective and emergency• Complaints• Dementia assessments• %Patients assessed as risk free• Number of falls resulting is serious harm• 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: Feb 20133. 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

1. IntroductionPerformance ReportJanuary 2013Performance Indicators - Exception ReportThis report provides the Board with an overview of mitigating actions identified by the BusinessUnits to improve performance such that it brings it back into line with target. Finance and HumanResources performance are subject to separate reports to the Trust Board.2. Patient Safety and QualityMRSA blood stream isolates (previously MRSA bacteraemia) - At the end of January 2013there has been 127 days since the last MRSA blood stream isolate.The following actions are being undertaken to reduce MRSA blood stream isolates:• An MRSA eradication protocol prescription sticker has been ordered and awaitingdelivery.• Pre-printed blood culture bags due for delivery 18th February 2013• Infection Prevention & Control pathway now embedded into Trust and will be audited inMarch 2013• ANTT will be reviewed regarding the trusts current status and progress and localownership.Clostridium difficile toxin-positive stools (previously clostridium difficile infection) - At theend of January 59 C. difficile positive patients had been reported, an increase of 5 on theprevious month.The following actions are being taken:• Hot spots to be targeted - Education commenced on these areas jointly with pharmacy.• C.difficile ward rounds continue with input from antibiotic pharmacist.Pathology willundertake an audit ofthe forms in Microbiology to ascertain whatinformation is missing and which areas thisaffects.MRSA Screening There is no improvement in MRSAemergency screening (82.1 %) or elective screening (85.1%)for January 2013. Screens that have inadequate or incorrectinformation do not get processed and there have also beenincidences of screensnot arriving at thelaboratory.Complaints – The Trust has a target of 80% of responses being sent within the agreedtimescale. During the reporting period the Trust has identified a blockage within the CoreComplaints Team which has impacted on Trust and Directorate response rates. During January2013, the Complaints Team have undertaken focussed work to ensure that complainants are keptupdated with response due dates and to ensure that all responses are quality checked andprocessed in a timely manner.Page 1 of 8

The Head of Complaints and PALS is now undertaking daily complaint review meetings to ensurethat all complaints are being progressed and it is expected that the reduction in responsepercentages in January 2013 will not be repeated.Dementia assessments – Achievement of metric 3 continues however metrics 1 and 2 havedeteriorated. Daily ward data is now available and sent to Matrons enabling wards that requirefurther support to be focussed on. However the resource to support this initiative is currentlylimited whilst the dementia clinical nurse specialist (CNS) posts are recruited to. Release of stafffrom the elderly care area to support staff in the interim has been limited as nursing shifts havenot been backfilled.% Patients Risk Free92.34%92.05% 92.04% 91.81%90.92%90.92%89.67% 89.76% 89.62% 89.40%% patients assessed as risk free - Monthlymonitoring continues across all wards anddepartments. The new Energising forExcellence group, where the learning is beingshared across the nursing team, hascommenced. Steady sustainable progress hasbeen made and continues. The performancetarget remains 95% and the service arefocusing on the individual ward areas that fallbelow this.Number of falls resulting in serious harm – Overall the trend for 2012 compared to 2011 hasshown a 10% decrease in the total number of falls reported. However, there has been a minimalincrease, of two incidents, in patient’s that have sustained severe harm as a result of the fall.Unfortunately, in January 2013 to date, six patients have fallen and sustained severe harm.During January the Serious Incident (SI) process for falls has been reviewed and a new SItemplate circulated, training given and currently in use following consultation with NHS London.Review of the Falls Pathway is planned by the Falls Prevention Group to make it simpler tocomplete and address concerns identified from SI reporting with regard to medication review andcompliance with completion of the documentation. The Falls Prevention Group aim to provide fallprevention strategies for ward staff i.e. is equipment within reach of the patient, is the patient’sfootwear suitable and the actions staff should take post fall.Re-admissions: elective

Re-admissions: non-elective

3. PerformanceReferral to treatment (RTT), delivery in all specialties – the Trust continues to deliver theoverall trust target on the RTT admitted pathway. Information has been shared withcommissioners and the National Trust Development Agency on how speciality level targets couldbe met. However the consequence of reducing the backlog in 18 weeks will be that the in monthadmitted patients performance will deteriorate.Cancer targets –• 62 Day RTT from Cancer Screening – the data is currently still being validated and our finalperformance will be known at the beginning of March. The reason for the under performanceis the small number of treatments; there are currently 13.5 treatments with 1.5 breaches. Thehalf breach was due to a patient requesting a referral to the Royal Marsden at the end of herpathway and the other patient was a breach due to a delay in obtaining her stereotactic biopsystains and results.• 62 Day RTT From Hosp Specialist – the data currently still being validated and our finalperformance will be known at the beginning of March. The poor performance this month is theresult of patient choice, the patient requesting a slow pathway for personal reasons• 31 Day Subs Treatment – Radiotherapy - the data is currently still being validated and ourfinal performance will be known at the beginning of March. The current underperformance isdue to the small number of treatments that have been uploaded so far. A small delay hasoccurred in the recording of these patients on the cancer system and additional support hasbeen organised to resolve this as a matter of urgency. As we have until the close of Q3 toupload the data the cancer management team are currently working to ensure the back log isentered as soon as possible.Four hour wait in A&E – The Trust failed to meet the 95% standard in January 2013 with aperformance of 83.57%. There has been a significant pressure on bed flow throughout January2013.Actions being taken to improve performance and monitored with the Chief Operating Officer are:• Opening of a new Surgical Assessment Unit from 4th February 2013• Opening of a new GP unit based on the Medical Assessment Unit form 11th February2013• Increased provision of rehabilitation beds in partnership with the GP commissioners.• Working with the GP commissioners reviewing the actions taken in the community fordemand management• Working with LAS with regard to the use of alternative pathways of care to preventinappropriate attendances at the Emergency Department (ED).• Implementation of competency based streaming, including GP streaming to ensure thepatients are signposted to the most appropriate organisation / area for their presentingcondition this includes redirection back to their own GP and or community supportorganisation including Walk-in-centres and pharmacies.% of patients referred to speciality team

10.24% were seen by the specialty team following referral within 30 minutes at the QH site.Information regarding specialty delays will be provided to the specialties to enable them to reviewthe time periods in which they are non-compliant to further support the Clinical Directors toaddress these issues and ensure their action plans meet the hours where there is noncompliance. The opening of the SAU will further support General Surgery with their responsetimes to the ED.Number of ambulance black breaches – The number of black breaches has significantlyreduced compared to the same period last year. In January 2011 there were 49 black breachescompared with 10 in December 2013. The underlying cause of the black breaches was a lack ofcapacity in offloading the ambulances. All 10 black breaches occurred on the 28th January 2013.On the 28th January 2013 there were a total of 427 attendances to the ED with 135 ambulanceconveyances to QH ED, equating to 31.06% of total attendances being conveyed by ambulance.There were 2 peaks of 11 and 10 at ambulance arrivals per hour in the evening. Patients areconstantly monitored on an individual patient basis by a clinician to assess the patient’srequirements to be placed on a trolley, when they could potentially be placed onto a comfortablechair. Work is currently being undertaken to further increase direct ambulance conveyance to theUCC to further support ambulance handover times and ensure all patients are treated in theappropriate care setting for their presenting condition. However further improvement in bed flowneeds to be maintained in order to sustain flow from the RAT area to ensure that ambulanceassessment and handover can take place effectively and efficiently.Page 5 of 8

4. WorkforceAppraisals (rolling 12mnts) – Appraisal rates have increased steadily over the last quarter witha further increase of nearly 3% in December. The current appraisal compliance rate across theTrust is 73.88%. Performance across the directorates is generally improved with all business unitsseeing some increase, albeit small, contributing to the overall percentage increase. January 2013figures for the Clinical Directorates are:Diagnostic & Specialist medicine 78.35%Emergency & General Medicine 75.56%Surgical Services 78.35%Women, Children & Support Services 76.82%Corporate Directorate 41.65%Corporate areas have increased from 40.66% in December to 41.65% in January however,corporate still remain very much below target. There is no one area within the corporatedirectorate that can be identified as a specific outlier. There are many single post holders withinCorporate who, due to management restructures, are waiting on new objectives to be set and anappraisal done by their new line manager. On review of the corporate areas, there are planneddates in place for outstanding appraisalsAn appraisal lead has not yet been identified in each Directorate but will be in advance of theupdate and re-launch of the trust’s appraisal policy originally planned for February, although nowto be included in the organisational development strategy plan.All Corporate Leads will be sent a list of their staff with the reminder for appraisal to be completed.Basic life support training (BLS) - Resuscitation training compliance for the period stands at72.68%. This shows a slight increase in compliance of 0.57% from last month’s report. This hasincreased the projected overall compliance rate for the end of March 2013 to 76.67%, an increaseof 2.82% on last months report, based on bookings already made.Uptake on advertised resuscitation training sessions to date remains good. Non-attendance ratesare being monitored closely and absences continue to be escalated to the appropriate managers.Monthly compliance reports continue to be sent to the business units to highlight those staff thatstill need to book onto training, outlining actual and projected compliance ratesPage 6 of 8

5. ProductivityLength of stay (LoS)January LOS deteriorated for non elective patients reflected by poor patient flow and impact onED target. Lack of community rehabilitation beds was a problem post Christmas, this wasmanaged by our partners and additional beds opening.January saw eight patients discharged with a LOS of longer than 100 days, with one patienthaving a LOS over over one year. If this patient was removed from the caculation the LOS wouldbe 5.06. this compares to two patients with a length of stay over 100 days discharged inDecember and in November four patients.The revised model for medical management is being developed and focusing on enhanced 7 dayworking for the specialties and senior input in A&E. The plan will also enhance the care of elderlyliaison service and change one of the wards to a short stay ward elderly care ward. Detailedproject plans are currently being developed.In the short term additional winter capacity beds in the form of 14 additional side rooms have beenopened and winter funding allocated to enable the backfill of senior sisters to enable them tofocus on discharge planning and standards of care. Unfortunately few of these shifts are beingfilled. High sickness rates on the ward is also impacting on the discharge planning process.The community treatment team programme commenced on January 14th concentrating on fallsand COPD. In addition an enhanced consultant MAU rota commenced increasing the consultantpresence supporting the oncall team in A&E.% Patients discharges between 6am and 11am – The significant work, as part of the 4 houraccess plan, with all clinical staff aims to improve current performance and implement earlierward rounds to enable beds to be given to the emergency department earlier in the day.Page 7 of 8

Goal directed fluid therapy (GDFT) for emergency abdominal patients – A further improvedfigure this month is due to continuous communication and raised awareness throughout thedepartment to use the GDFT for all emergency abdominal patients. The Clinical Lead for theatreswill continue to contact all consultants and junior grade doctors who have not used the devicesduring their procedures when appropriate to challenge their practice.The use of GDFT has been raised at a recent Clinical Governance meeting and discussedextensively in medical meetings. The Enhanced Recovery Program (ERP) nurses have attendedtheatres during November to educate staff in the use of GDFT and improve general awareness ofthe ERP program.First to follow-up ratio (FFR) - This remains at the same level as December. The activity inJanuary for new patients increased by 18% in the month. The activity for follow-ups increased by30%. The spike in activity is to reflect additional activity to avoid potential breaches.Did not attend (DNA) rates for first and follow-up appointments – The Trust DNA rate for Firstattendances has shown a small improvement from 10.45% to 9.9%. Follow Up DNA rates are stillat previous levels against a target of 5%.Progress against current initiatives to improve DNA performance:• Review of text alerts set up for specific clinic codes are being validated by PAS andOutpatients Appointment Team. This will be completed in mid March. This will help toincrease the number of text messages sent to patients. Review completed last monthshowed that a number of clinic codes were missing from the specialty lists.• DNA policy review has been completed by all specialties.• Criteria for discharge and discharge protocols for specific surgical procedures are nowbeing discussed with CCG Chairs through the Planned Care Steering group. This willhelp to formalise discharge plans. Progress is monitored monthly by this groupPage 8 of 8

Nov Dec Jan Target red Nov Dec Jan Target red Nov Dec Jan Target RedSHMI Jan= September11-November 12 97.50 97.50 95.00 95.00 100.10 % untreated waiting less than 18 weeks 92.20% 92.10% 92.30% 92% 87% LOS (Elective) 2.87 3.12 3.00 3.10 3.48% emergency admitted patients review bysenior clinician within 12 hours ND nd nd 95% 94% RTT admitted in 18 weeks 91.60% 90.10% 90.10% 90% 85% LOS (Non-Elective) 5.15 4.98 5.46 4.45 5.05% emergency admitted patients review byconsultant within 12 hours ND nd nd 95% 94% RTT non-admitted in 18 weeks 99.10% 98.90% 98.80% 95% 90% LOS (Elective- excluding 0 LOS) 3.46 3.74 3.52 3.50 3.92Maternal Death Rate per 100000 ( rolling 12m) 0.00 0.00 0.00 TBA TBA RTT not delivered in all specialties 5 6 5 0 >20 LOS (Non- Elective-excluding 0 LOS) 6.37 5.97 6.67 5.8 6.53% Day case rate - All 88% 88% 89% 80% 75%Serious Untoward IncidentsCancerDTOC 3.24 2.34 2.24 3.50% 5.00%Number 8 14 17 18 19 2 Wk. % seen all urgent refs & ref for breast 95.0% 90.8% 97.9% 93% 88% admissions on day of surgery 95.60 91.97 92.42 85% 80%% reported within 48Hours - quarterly 82%50% 49% 2 Wk. GP RefTo 1st OP for susp cancer 96.6% 96.7% 97.7% 93% 88% % patients discharged between 6 am and 11 am 9.71% 12.00% 8.00% 50% 30%2 Wk GP Ref To 1st OP for breast symptoms 95.0% 90.8% 98.8% 93% 88%Infection Control31 Day 2nd Or Subs Treatment - Surgery 100.0% 100.0% 100.0% 94% 89%Enhanced RecoveryMRSA Bloodstream Isolates 8 YTD7 31 Day 2nd Or Subs Treatment - Drug 100.0% 100.0% 95.5% 98% 93%% patients with an ERP code entered onto the nationaldatabase* 100% 100% nd 95% 95%C Diff Toxic Positive Stools 59 YTD59 44 31 Day DTT for all cancers 99.7% 98.5% 97.4% 96% 91% % planned colorectal having GDFT* 82% 86% nd 80% 80%At period end - number of days since lastreported MRSA 65 96 127 0 0 62 Day RTT From Cancer Screening* 89.7% 100.0% 88.9% 90% 85% % emergency abdominal patients having GDFT* 57% 74% nd 80% 80%At period end - number of days since lastreported Cdif 5 3 6 0 0 62 Days - treated from referral * 86.6% 91.8% 87.3% 86% 80% *one month in arrearsMRSA Elective Screening 86% 86% 87% 95% 86% 62 Day RTT From Hosp Specialist* 100.0% 86.4% 75.0% 85% 80%OutpatientsMRSA Emergency Screening 81% 81% 83% 95% 86% 62 Days Urgent RTT of all cancers* 85.1% 91.8% 89.6% 85% 80% FFU Ratio 2.08 2.17 2.17 2.16 2.2031 Day Subs Treatment - Radiotherapy 100.0% 100.0% 89.5% 94% 89% DNA First 9.70% 10.45% 9.90% 5.00% 5.50%Complaints * fully validated data provided one month in arrears OCT - DEC data reported DNA Follow-Up 10.91% 11.18% 11.64% 5.00% 5.50%number of complaints received 81 65 91 TBA TBAA&E% complaints responded to in line withagreement with patients 43.00% 48.00% 34.00% 80% 79% Four-Hour Maximum Wait In A&E 89.96% 83.29% 83.57% 95% 94%FinancePercentage of patients referred to speciality teamTotal number of complaints open 187 182 188 TBA TBA

EXECUTIVE SUMMARYTITLE:BOARD/GROUP/COMMITTEE:2012 Staff Survey Results Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:The 2012 staff survey has been conducted with a 39%response rate. A summary of the findings presented at theWorkforce Committee in February are attached. Theoutcome of the survey is benchmarked internally againstthe 2011 staff survey results and the 2012 national staffsurvey results. All areas of the staff survey improved orwhere maintained from the 2011 staff survey within theTrust. When the Trust results are benchmarked nationallythere continue to be areas of required improvement. Theproposed next steps are that the results from the staffsurvey will be triangulated with the patient survey results toidentify any themes or trends and action around theseareas and improvements will be incorporated into theTrusts OD Strategy.□ PEQ ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ CLINICAL GOVERNANCE …………..………….....……□ CHARITABLE FUNDS ………………………………...…X TRUST BOARD: 06 March 2013□ REMUNERATION ………………………………….…...□ OTHER ……………………………………………………2. DECISION REQUIRED: CATEGORY:X NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Dorothy HoseinDATE: 06/03/20133. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:4. DELIVERABLESImproved staff satisfaction in all areas, resulting in the Trust being a care provider and employer of choice.5. KEY PERFORMANCE INDICATORSInternally and Nationally benchmarked information regarding the Staff Survey Outcomes.AGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

Staff Survey 2012 Summary of resultsPresented at the Workforce Committee Meeting 18 February 2013For each of the 28 Key Findings acute trusts in England were ranked in order.The largest positive local changes since the 2011 Survey were in the following areas:• staff job satisfaction• % of staff experiencing discrimination at work in last 12 months• % of staff able to contribute towards improvements at work• support from immediate managers• staff motivation at workIt is noted that internally the Trust improved or maintained all outcomes on each keyfinding from the 2011 to 2012 staff surveys. Therefore there are no negative localchanges. However when compared nationally against acute Trusts the position of theTrust is:The Trust is in the best 20% of acute Trusts in the following:• staff feeling satisfied with the quality of work & patient care they are able to deliver• staff agreeing their role makes a difference to patients• staff receiving job-relevant training, learning or development in last 12 months• staff appraised in last 12 months• % of staff having well structured appraisals in last 12 months• % of staff reporting errors, near misses or incidents witnessed• in the last monthThe Trust is in the worst 20% of acute Trusts in the following:• work pressure• team working• % of staff experiencing physical violence from patients, relatives or the public inlast 12 monthsSummary of all key findings compared to acute Trusts:Green = positive findings where there has been a statistically significant positive changesince the 2011 survey compared nationally:• staff feeling satisfied with the quality of work and patient care they are able todeliver• having equality and diversity training in the last 12 months• experiencing discrimination in last 12 months• support from immediate managers• fairness and effectiveness of incident reporting procedures1

• staff recommending the Trust as a place to work or receive treatment• feeling satisfied with the quality of work and patient care they are able to deliver• agreeing role makes a difference to patients• reporting errors, near misses or incidents in last 12 months• staff motivation at workRed = negative findings where there has been a statistically significant change since the2011 survey compared nationally:• hand washing materials are always available• witnessing potentially harmful errors, near misses or incidents• experiencing physical violence from patients, relatives, public and staff• experiencing harassment, bullying or abuse from patients, relatives, public andstaff• good communication between senior management and staff• experiencing discrimination at work• work pressure• effective team working• % of staff reporting good communication between senior management and staffThe following shows top and bottom ranking of the Trust when compared to acuteTrusts:top 5 ranking scores• % of staff having well structuredappraisals in last 12 months• % of staff agreeing their role makes adifference to patients• % of staff appraised in the last 12months• % of staff receiving job relevant training,learning or development in the last 12months• % of staff feeling satisfied with thequality of work and patient care they areable to deliverbottom five ranking scores• % of staff able to contribute towardsimprovements at work• % of staff believing the Trust providesequal opportunities for careerprogression or promotion• % of staff recommending the Trust asa place to work or receive treatment• % of staff suffering work related stressin last 12 months• % of staff stating there is effectiveteam workingNext Steps:• Triangulate staff survey results with patient survey outcomes – identifying anytrends;• Incorporate feedback from the staff survey into the Organisational DevelopmentStrategy.Mark SmithHead of Workforce Transformation24 February 20132

SELF-CERTIFICATION RETURNSOrganisation Name:BHRUTMonitoring Period:December 2012NHS Trust Over-sight self certification templateReturns to XXX by the last working day of each

NHS Trust Governance Declarations : 2012/13 In-Year ReportingName of Organisation: BHRUTPeriod: December 2012Organisational risk ratingEach organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to anycontractual issues and compliance with CQC essential standards:Governance Risk Rating (RAG as per SOM guidance)Key Area for rating / comment by ProviderScore / RAG rating*RNormalised YTD Financial Risk Rating (Assign number as per SOM guidance) 1* Please type in R, AR, AG or G and assign a number for the FRRGovernance DeclarationsDeclaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation.Supporting detail is required where compliance cannot be confirmed.Please complete one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either handwritten or electronic, you are required to print your name.Governance declaration 1The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the BoardStatements.Signed by:Print Name:on behalf of the Trust BoardActing in capacity as:Signed by:Print Name:on behalf of the Trust BoardActing in capacity as:Governance declaration 2At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements ofthe Board Statements.Signed by : Print Name :Sir Peter Dixonon behalf of the Trust BoardActing in capacity as:ChairmanSigned by : Print Name :Averil Dongworthon behalf of the Trust BoardActing in capacity as:Chief ExecutiveIf Declaration 2 has been signed:For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explainbriefly what steps are being taken to resolve the issue. Please provide an appropriate level of detail.Target/Standard:The Issue :Action :Target/Standard:The Issue :Action :Target/Standard:The Issue :Action :Target/Standard:The Issue :Action :4. The trust will maintain a FRR ≥ 3 over the next 12 months.Trust is trading at a deficit.LTFM developed setting out plans to reduce deficit5. The trust shall at all times remain a going concern.Trust is trading at a deficit.LTFM developed setting out plans to reduce deficit11. Plans in place to ensure ongoing compliance with all existing targets.MRSA Target exceeded, A&E 4 Hour Access TargetAction plans agreed to address issues12. Achieved a minimum of Level 2 of the IG Toolkit.a number of areas rated as level 1 in 2012/13 assessmentAction plans in place for all requirements rated as level 1Target/Standard:The Issue :Action :

Board StatementsBHRUTDecember 2012For each statement, the Board is asked to confirm the following:For CLINICAL QUALITY, that:ResponseThe Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to theSOM's Oversight Regime (supported by Care Quality Commission information, its own information on serious incidents,1 patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place,Yeseffective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to itspatients.2The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care QualityCommission’s registration requirements.YesThe board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on3 Yesbehalf of the trust have met the relevant registration and revalidation requirements.For FINANCE, that:Response4 The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months. No5The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accountingstandards in force from time to time.NoFor GOVERNANCE, that:Response6 The board will ensure that the trust at all times has regard to the NHS Constitution.YesAll current key risks have been identified (raised either internally or by external audit and assessment bodies) and7 Yesaddressed – or there are appropriate action plans in place to address the issues – in a timely mannerThe board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,8 Yeslikelihood of occurrence and the plans for mitigation of these risks.The necessary planning, performance management and corporate and clinical risk management processes and9 mitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted by Yesthe board are implemented satisfactorily.An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance10 framework requirements that support the Statement pursuant to the most up to date guidance from HM TreasuryYes(www.hm-treasury.gov.uk).The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the11 application of thresholds) as set out in the Governance Risk Rating; and a commitment to comply with allNocommissioned targets going forward.The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance12 NoToolkit.The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests,13ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, orplans are in place to fill any vacancies, and that any elections to the shadow board of governors are held in accordanceYeswith the election rules.The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and14 skills to discharge their functions effectively, including setting strategy, monitoring and managing performance andYesrisks, and ensuring management capacity and capability.The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the15 Yesannual plan; and the management structure in place is adequate to deliver the annual plan.Signed on behalf of the Trust: Print name DateCEOAveril DongworthChairSir Peter Dixon

QUALITYBHRUTInformation to inform discussion meetingInsert Performance in MonthCriteriaUnit Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Board Action1 SHMI - latest data Score 97.5 97.5 97.5The latest SHMI data update has yet to be released. Workcontinues with the roll-out of CHKS into the trust with thecompany representative carrying out application training viaClinical Directorate Clinical Governance meetings andgeneral training sessions. Staff engagement is good.2Venous Thromboembolism (VTE)Screening% 90 91 91 94 94 93 94 94 95 96 95 933a Elective MRSA Screening % 67 81 78 78 78 74 78 79 74 86 86 86December saw the introduction of an “all in” approach toscreening with all patients admitted and undergoing aprocedure being screened.3b Non Elective MRSA Screening % 71 70 69 69 74 83 77 75 79 78 81 81To ensure emergency screening increases a daily report isbeing introduced that will list all emergency admissionswithin the last 48 hours with no screening entered onto thepathology Cyberlab system. The Infection Control andPrevention Team would use this daily list to target thosewards which are non - compliant and ensure the screeningsare completed.4 Single Sex Accommodation Breaches Number 17 21 30 30 21 10 12 19 13 13 0 05Open Serious Incidents RequiringInvestigation (SIRI)Number 274 274 270 216 105 91 68 46 35 34 32 326 "Never Events" occurring in month Number 0 0 0 0 0 0 0 0 0 0 1 17 CQC Conditions or Warning Notices Number 3 2 2 2 2 2 2 2 2 2 2 2Retained swab following surgery. Following the RCA anaction plan is in place to address the issues identified.Following the inspections in December the conditions wereremoved from maternity, proposed conditions on A&E beingagreed with CQC8Open Central Alert System (CAS)AlertsNumber 0 0 0 0 0 0 0 0 0 0 0 0The number of red areas have reduced from previousmonths. A plan has been put in place to ensure improvmentin performance for each of these areas.The red areas are9RED rated areas on your maternitydashboard?Number 6 7 5 8 10 9 7 5 5 12 8 5Caesarean section rateGrade 1 caesarean sections within 30 minutesMidwife VacanciesSicknessPostpartum haemorrhageFalls resulting in severe injury or10deathNumber 1 1 3 3 3 2 2 2 2 2 1 1To support implementation of the falls plan two senior fallsleads are being appointed in Jan 13Category 4 pressure ulcers have reduced compared to thesame reporting period last year, however in December 2012the trust reported a hospital acquired grade 4 pressureulcer. This is the first reported grade 4, hospital acquiredpressure ulcer, since February 2012. A root cause analysis isbeing undertaken and an action plan will be put in place forthe ward where the incident was reported. The action planwill be monitored by the Clinical Lead, Elderly Care.11 Grade 3 or 4 pressure ulcers Number 11 6 5 5 4 6 5 2 2 3 3 3The tissue viability team are increasing theirtraining/education commitments to help re-enforce to staffthe SKIN Pathway and the importance of being proactiverather than re-active in delivering this preventative care.Education/training is delivered via the mandatory andinduction programmes and on the student nurse passport.‘Drop in’ training sessions have been organised on a weeklybasis on both trust sites to allow clinical staff the flexibilityof attending additional educational sessions.100% compliance with WHO surgical12checklistY/N yes yes no yes yes yes no noThe WHO checklist was not being audited in maternitytheatres. This is now in place . Medical Director has agreed aplan with the directorate to rectify this performance.13 Formal complaints received Number 121 120 128 101 98 85 100 85 67 105 81 65Agency as a % of Employee Benefit14Expenditure% 5.3 6.5 4.7 5.3 4.8 4.65 4.56 6.2 5.5This has been agreed as an area to target in 13/14 with aplan to reduce by 50% as part of the CIP programme15 Sickness absence rate % 5.18 5.81 4.41 4.29 4.51 4 4.59 4.68 4.88 5.07 5.3 5.7Consultants which, at their last16 appraisal, had fully completed theirprevious years PDP%

FINANCIAL RISK RATINGBHRUTInsert the Score (1-5) Achieved for eachCriteria Per MonthRisk RatingsReportedPositionNormalisedPosition*Criteria Indicator Weight 5 4 3 2 1Year toDateForecastOutturnYear toDateForecastOutturnBoard ActionUnderlyingperformanceEBITDA margin % 25% 11 9 5 1

FINANCIAL RISK TRIGGERSBHRUTInsert "Yes" / "No" Assessment for the MonthHistoric DataCurrent DataCriteriaQtr toMar-12Qtr toJun-12Qtr toSep-12Oct-12 Nov-12 Dec-12Qtr toDec-12Board Action1Unplanned decrease in EBITDA margin in two consecutivequartersYes No No No No No No11/12 figures influenced by position against Plan where agreedControl total with SHA adjusted by £10m.2Quarterly self-certification by trust that the normalisedfinancial risk rating (FRR) may be less than 3 in the next12 monthsYes Yes Yes Yes Yes Yes YesDriven by deficit position both planned and actual3Working capital facility (WCF) agreement includes defaultclauseN/a N/a N/a N/a N/a N/a N/a4Debtors > 90 days past due account for more than 5% oftotal debtor balancesYes Yes Yes Yes No No NoTaken from AR ledger, after application of bad debt provision.Debtors > 90 days account for 10% of total debt;, but only 4%after provision. Overseas patients forms a particular risk.5Creditors > 90 days past due account for more than 5% oftotal creditor balancesYes Yes Yes Yes Yes Yes YesTaken from AP ledger, creditors over 90 days form 26% of totalcreditors. Heavily influenced by cash-flow consequences ofrunning a deficit, plus planning for PFI payments.6Two or more changes in Finance Director in a twelvemonth periodNo No No No No No No7Interim Finance Director in place over more than onequarter endNo No No No No No YesInterim Finance Director appointed until end of financial year asagreed with NHS London8 Quarter end cash balance

GOVERNANCE RISK RATINGSBHRUTInsert YES, NO or N/A (as appropriate)See 'Notes' for further detail of each of the below indicatorsArea Ref Indicator Sub SectionsEffectiveness1a1bData completeness: Community servicescomprising:Data completeness, community services:(may be introduced later)Referral to treatment information 50%Referral information 50%Treatment activity information 50%ThresholdWeightingQtr toMar-12Historic DataQtr toJun-12Qtr toSep-12Oct-12 Nov-12 Dec-12Patient identifier information 50% N/a N/a N/a N/a N/a N/a N/aPatients dying at home / carehome1.0 N/a N/a N/ N/a N/a N/ N/aCurrent DataQtr toDec-1250% N/a n/a N/a N/a N/a N/a N/a1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a N/aN/aN/aBoard ActionPatient Experience1c2a2b2c2d3aData completeness: outcomes for patientson CPAFrom point of referral to treatment inaggregate (RTT) – admittedFrom point of referral to treatment inaggregate (RTT) – non-admittedFrom point of referral to treatment inaggregate (RTT) – patients on anincomplete pathwayCertification against compliance withrequirements regarding access tohealthcare for people with a learningdisabilityAll cancers: 31-day wait for second orsubsequent treatment, comprising :50% 0.5 N/a N/a N/a N/a N/a N/a N/aMaximum time of 18 weeks 90% 1.0 Yes Yes Yes Yes Yes Yes YesMaximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes Yes Yes YesMaximum time of 18 weeks 92% 1.0 Yes Yes Yes Yes Yes Yes YesSurgery 94%Anti cancer drug treatments 98%Radiotherapy 94%N/A 0.5 No No No No Yes Yes Yes1.0YesYesYesYesYesYesYesThis indicator may deteriorate when work isundertaken to reduce the blacklog ofpatients on the waiting list waiting over 18This indicator may deteriorate when work isundertaken to reduce the backlog of patientson the waiting list waiting over 18 ww3b3cAll cancers: 62-day wait for first treatment:All Cancers: 31-day wait from diagnosis tofirst treatmentFrom urgent GP referral forsuspected cancerFrom NHS Cancer ScreeningService referral85%90%1.0YesYesYesYes Yes Yes96% 0.5 Yes Yes Yes Yes Yes Yes YesYes3dCancer: 2 week wait from referral to datefirst seen, comprising:all urgent referrals 93%for symptomatic breast patients(cancer not initially suspected)93%0.5 YesYesYesYesYesYesYesQuality3e3f3g3hA&E: From arrival toadmission/transfer/dischargeCare Programme Approach (CPA)patients, comprising:Minimising mental health delayed transfersof careAdmissions to inpatients services hadaccess to Crisis Resolution/HomeTreatment teamsMaximum waiting time of fourhoursReceiving follow-up contact within7 days of dischargeHaving formal reviewwithin 12 months95% 1.0 No No No No No No No Cross Economy Remedial Action Plan beingimplemented and being supported by winterpressure funding.95%95%1.0N/a N/a N/a N/a N/a N/a N/a≤7.5% 1.0 N/a N/a N/a N/a N/a N/a N/a95% 1.0 N/a N/a N/a N/a N/a N/a N/a

GOVERNANCE RISK RATINGSBHRUTInsert YES, NO or N/A (as appropriate)See 'Notes' for further detail of each of the below indicatorsArea Ref Indicator Sub SectionsSafety3i3j3kMeeting commitment to serve newpsychosis cases by early interventionteamsCategory A call – ambulance vehiclearrives within 19 minutesThresholdWeightingQtr toMar-12Historic DataQtr toJun-12Qtr toSep-12Current DataOct-12 Nov-12 Dec-12Qtr toDec-1295% 0.5 N/a N/a N/a N/a N/a N/a N/aRed 1 80% 0.5 N/a N/a N/a N/a N/a N/a N/aRed 2 75% 0.5 N/a N/a N/a N/a N/a N/a N/a95% 1.0 N/a n/a N/a N/a N/a N/a N/aIs the Trust below the de minimus 12 No No No No No No No4a Clostridium Difficile 1.0Is the Trust below the YTD ceiling 44 No No No No No No No4bCategory A call – emergency responsewithin 8 minutesMRSAIs the Trust below the de minimus 6 Yes Yes No No No No No1.0Is the Trust below the YTD ceiling 5 No No No No No No NoBoard ActionFollowing a review of the December casesthe main issue to concentrate on is patientswho have symptoms of diarrhoea onadmission having specimens sent in a timelymanner to pathology. To address thissituation ward base nurse and doctortraining is being undertaken by the infection,prevention and control teamIn order to reduce blood culturecontamination the following actions arebeing taken :Staff training in proper technique (Asepticnon-touch training). The bundling of the skinsite decontamination items with bloodculture sets. We are addressing this bypurchasing blood culture packs with theproper skin decontaminants already in thepacks. Junior Medical staff email cascadesystem for rapid communications from the ,Aflagging system for all inpatients colonisedwith MRSAACQC RegistrationNon-Compliance with CQC EssentialStandards resulting in a Major Impact onPatients0 2.0 Yes No No No No No NoBCNon-Compliance with CQC EssentialStandards resulting in Enforcement ActionNHS Litigation Authority – Failure tomaintain, or certify a minimum publishedCNST level of 1.0 or have in placeappropriate alternative arrangements0 4.0 Yes Yes Yes Yes Yes Yes Yes0 2.0 No No No No No No NoTOTAL 6.5 6.5 7.5 7.5 7.0 7.0 7.0RAG RATING : R R R R R R RGREEN = Score less than 1AMBER/GREEN = Score greater than or equal to 1, but less than 2AMBER / RED = Score greater than or equal to 2, but less than 4RED = Score greater than or equal to 4Following the inspections in December theconditions were removed from maternity,conditions on A&E being agreed with CQC

GOVERNANCE RISK RATINGSBHRUTSee 'Notes' for further detail of each of the below indicatorsArea Ref Indicator Sub SectionsThresholdWeightingQtr toMar-12Insert YES, NO or N/A (as appropriate)Historic DataQtr toJun-12Qtr toSep-12Current DataOct-12 Nov-12 Dec-12Qtr toDec-12Board ActionOverriding Rules - Nature and Duration of Override at SHA's DiscretionGreater than six cases in the year to date, and breachesi) Meeting the MRSA Objective the cumulative year-to-date trajectory for three successivequartersNo Yes Yes Yes Yes Yes Yes At the end ofDecember - 96 days since lastinfectionii)iii)Meeting the C-Diff ObjectiveRTT Waiting TimesGreater than 12 cases in the year to date, and either:Breaches the cumulative year-to-date trajectory for threesuccessive quartersReports important or signficant outbreaks of C.difficile, asdefined by the Health Protection Agency.Breaches:The admitted patients 18 weeks waiting time measure for athird successive quarterThe non-admitted patients 18 weeks waiting time measurefor a third successive quarterThe incomplete pathway 18 weeks waiting time measurefor a third successive quarterYes Yes YesFails to meet the A&E target twice in any two quarters overiv) A&E Clinical Quality Indicator a 12-month period and fails the indicator in a quarter during Yes Yes Yes Yes Yes Yes Yesthe subsequent nine-month period or the full year.NoNoNoYesNoYesNoYesNoYesNoas abovev) Cancer Wait TimesBreaches either:the 31-day cancer waiting time target for a third successivequarterthe 62-day cancer waiting time target for a third successivequarterNoNoNoNoNoNoNovi)Ambulance Response TimesBreaches:the category A 8-minute response time target for a thirdsuccessive quarterthe category A 19-minute response time target for a thirdsuccessive quarterN/aN/aN/aN/aN/aN/aN/aeither Red 1 or Red 2 targets for a third successive quarterFails to maintain the threshold for data completeness for:referral to treatment information for a third successivequarter;vii) Community Services data completeness service referral information for a third successive quarter, N/a N/aor;treatment activity information for a third successive quarterN/aN/aN/aN/aN/aviii) Any other Indicator weighted 1.0 Breaches the indicator for three successive quarters.No No No No No NoAdjusted Governance Risk Rating 6.5 6.5 7.5 7.5 7.0 7.0 7.0R R R R R R R

CONTRACTUAL DATABHRUTInformation to inform discussion meetingInsert "Yes" / "No" Assessment for the MonthCriteriaQtr toMar-12Historic DataQtr toJun-12Current DataQtr toSep-12 Oct-12 Nov-12 Dec-12 Qtr toDec-12Board Action1 Are the prior year contracts* closed? Yes Yes yes yes Yes Yes234Are all current year contracts* agreed andsigned?Has the Trust received income support outsideof the NHS standard contract e.g.transformational support?Are both the NHS Trust and commissionerfulfilling the terms of the contract?Yes Yes yes Yes Yes YesYes Yes yes Yes Yes YesNo No no Yes Yes YesCovered in sections on C Diff and A&E56Are there any disputes over the terms of thecontract?Might the dispute require third party interventionor arbitration?No No no No No NoNo No no No No Nono7 Are the parties already in arbitration? No Yes no No No No8 Have any performance notices been issued? No No no No No No9 Have any penalties been applied? No No no No No No*All contracts which represent more than 25% of the Trust's operating revenue.

TFA ProgressMar-13Select the Performance from the drop-down listTFA Milestone (All including those delivered)MilestoneDatePerformanceBoard Action1 AA - TFA governance agreed by Trust / Cluster / SHA Aug-12 Fully achieved in time2 AA - Trust Transformation Programme Plan developed Sep-12 Fully achieved but late3 AA - Transformation plan approved by Board Oct-12 Fully achieved but latePresented to Trust Board in NovemberTransformation plan developed for 2013/144 AA - All Trust Board and Executive Director positions filled Oct-12 Fully achieved in time5 AA - OD plan agreed with deliverables/milestones Dec-12 Fully achieved but lateTrust Board presentation in February with update on 4 workstreams.Vision, Values and Behaviours under review. Governance overview agreedat Trust Executive Committee6 AA - Quality Governance self assessment agreed by Trust Board Jan-13 Not fully achieved Assessment initiatied and expected to be completed in June 20137 AA - BGAF self assessment agreed by Trust Board Jan-13 Not fully achieved Assessment initiatied and expected to be completed in June 20138 AA - Formal review of Transformation Programme Jan-13 Fully achieved in time 2013/14 plan developed9 AA - Workforce strategy/education/training plan approved May-13 On track to deliver Head of HR taking the lead on this development10 AA - A&E target achieved at KGH Aug-12 Fully achieved in time KGH met 95% target in June 2012. This was sustained until December 201211 AA - A&E target achieved at Queen’s Oct-12 Not fully achievedCross Economy Remedial Action Plan being implemented including allocatedwinter pressure funding12 AA - Quality Improvement Strategy approved by Trust Board Jan-13 Not fully achievedDraft strategy will be completed at the end of February in preparation forreview at April 2013 Trust Board.13 AA - March 2012 CQC compliance actions addressed Dec-12 Fully achieved in timeThe strategic actions following the March 2012 report have now beenincorporporated as business as usual.14 AA - 12/13 monthly CIP plan re-profiled Sep-12 Fully achieved in time completed in August 201215 AA - Plan to deliver £23m Recurrent CIP by Mar 13 agreed by Trust Board Oct-12 Fully achieved in timePlan to deliver £23m recurrent savings agreed at Trust Board. Mitigatingaction in place to ensure delivery of recurrent savings.AA - Plan to deliver additional in year non recurrent CIP to deliver 12/1316control total agreed by Trust BoardOct-12Fully achieved in timePlan to deliver in-year non-recurrent CIP agreed at finance committee andTrust Board.17 AA - 2012/13 £23.2m CIP target delivered Oct-12 Not fully achieved Trust forecasting £18.0M at month 1018 AA - 2012/13 Plan deficit no greater than £39.7m Apr-13 On track to deliver19 AA - 5 year Trust productivity programme developed Sep-12 Fully achieved in timeBaseline LTFM with 5 yr productivity programme complete with report toTrust BoardAA - LTFM base case assumptions and options to bridge gap agreed by20commissionersOct-12Not fully achievedBaseline LTFM complete. Refresh to be completed following reciept ofdetailed QIPP plans.AA - SHA review 5 year Trust productivity programme and LTFM baseline21and options to bridge gapOct-12Fully achieved but lateBaseline LTFM complete. Refresh to be completed following reciept ofdetailed QIPP plans.22 AA - Clinical & Financial Viability Plan approved by Trust Board Dec-12Risk to delivery withintimescaleDraft LTFM agreed by Trust Board - requires update to take account of CCGQIPP23 AA - OBC (inc commissioner support) approved by Trust Board Feb-13Risk to delivery withintimescaleSCBU / Cardiac Cath OBC submitted to NHSL. Feedback received toprogress to combined OBC/FBC. /Sexual Health/ urgent care OBCs to becompleted by end of March. Confirmation required on Renal unit OBCprocess for approval. Remaining Emergency Department requirements tobe developed into OBC, timescale to be agreed. Approval process for allOBC/FBCs currently being confirmed by NTDA.24 AA - SHA approval of OBC at CIC Feb-13Risk to delivery withintimescaleAs above25 AA - FBC approved by Trust Board Date for FBC to be confirmed26 AA - SHA approval of FBC Date for FBC to be confirmed27 AA - BHR transition plan for closure KGH maternity (intrapartum care) Oct-12 Fully achieved in timeFinal gateway review completed. Recommendation being made to NELCBoard and BHRUT Board that deliveries cease at KGH week commencing 17March 201328 AA - BHR system readiness assurance gateway Feb-12 On track to deliver See above29 AA - BHR birth numbers < 8000 per annum (@660 pcm) Feb-13 On track to deliverCurrent performance indicates that deliveries are reducing as anticipatedand c8000 deliveries will occur in 2013/14.30 AA - KGH maternity closed Mar-13 On track to deliver See above31323334353637383940

NotesRef Indicator DetailsThe SHA will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing toThresholds achieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or notolerance against the target, e.g. those set between 99-100%.1a1b1cDataCompleteness:CommunityServicesData completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, toconsist of:- Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community;- Community treatment activity – referrals; and- Community treatment activity – care contact activity.While failure against any threshold will score 1.0, the overall impact will be capped at 1.0. Failure of the same measure for three quarters willresult in a red-rating.Numerator:all data in the denominator actually captured by the trust electronically (not solely CIDS-specified systems).Denominator:all activity data required by CIDS.DataThe inclusion of this data collection in addition to Monitor's indicators (until the Compliance Framework is changed) is in order for the SHA toCompleteness track the Trust's action plan to produce such data.CommunityServices (further This data excludes a weighting, and therefore does not currently impact on the Trust's governance risk rating.data):Mental HealthMDSPatient identity data completeness metrics (from MHMDS) to consist of:- NHS number;- Date of birth;- Postcode (normal residence);- Current gender;- Registered General Medical Practice organisation code; and- Commissioner organisation code.1dMental Health:CPANumerator:count of valid entries for each data item above.(For details of how data items are classified as VALID please refer to the data quality constructions available on the Information Centre’swebsite: www.ic.nhs.uk/services/mhmds/dq)Denominator:total number of entriesOutcomes for patients on Care Programme Approach:• Employment status:Numerator:the number of adults in the denominator whose employment status is known at the time of their most recent assessment, formal review or othermulti-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during thereference period. The reference period is the last 12 months working back from the end of the reported month.Denominator:the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during thereported month.• Accommodation status:Numerator:the number of adults in the denominator whose accommodation status (i.e. settled or non-settled accommodation) is known at the time of theirmost recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews werecarried out during the reference period. The reference period is the last 12 months working back from the end of the reported month.Denominator:the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during thereported month.• Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:Numerator:The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months.Denominator:The total number of adults who have received secondary mental health services and who were on the CPA during the reference period.2a-c2d3a3b3c3dRTTLearningDisabilities:Access tohealthcareCancer:31 day waitCancer:62 day waitCancerCancerPerformance is measured on an aggregate (rather than specialty) basis and trusts are required to meet the threshold on a monthly basis.Consequently, any failure in one month is considered to be a quarterly failure. Failure in any month of a quarter following two quarters’ failure ofthe same measure represents a third successive quarter failure and should be reported via the exception reporting process.Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any threshold will score 1.0, theoverall impact will be capped at 2.0. The measures apply to acute patients whether in an acute or community setting. Where a trust with existingacute facilities acquires a community hospital, performance will be assessed on a combined basis.The SHA will take account of breaches of the referral to treatment target in 2011/12 when considering consecutive failures of the referral totreatment target in 2012/13. For example, if a trust fails the 2011/12 admitted patients target at quarter 4 and the 2012/13 admitted patientstarget in quarters 1 and 2, it will be considered to have breached for three quarters in a row.Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH,2008):a) Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways ofcare are reasonably adjusted to meet the health needs of these patients?b) Does the trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:- treatment options;- complaints procedures; and- appointments?c) Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?d) Does the trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?e) Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers?f) Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings inroutine public reports?Note: trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan stage and in each month. Failure todo so will result in the application of the service performance score for this indicator.31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold represents a failure againstthe overall target. The target will not apply to trusts having five cases or less in a quarter. The SHA will not score trusts failing individual cancerthresholds but only reporting a single patient breach over the quarter.. Will apply to any community providers providing the specific cancertreatment pathways62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and other consultants.Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or less in aquarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply toany community providers providing the specific cancer treatment pathways.National guidance states that for patients referred from one provider to another, breaches of this target are automatically shared and treated on a50:50 basis. These breaches may be reallocated in full back to the referring organisation(s) provided the SHA receive evidence of writtenagreement to do so between the relevant providers (signed by both Chief Executives) in place at the time the trust makes its monthly declarationto the SHA.In the absence of any locally-agreed contractual arrangements, the SHA encourages trusts to work with other providers to reach a local systemwideagreement on the allocation of cancer target breaches to ensure that patients are treated in a timely manner. Once an agreement of thisnature has been reached, the SHA will consider applying the terms of the agreement to trusts party to the arrangement.Measured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter. The SHAwill not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any communityproviders providing the specific cancer treatment pathways.Measured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary careprofessional).Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases orfewer in a quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter.Will apply to any community providers providing the specific cancer treatment pathways.Specific guidance and documentation concerning cancer waiting targets can be found at:http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation

NotesRef Indicator Details3e A&EWaiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour waiting time indicator willapply to minor injury units/walk in centres.3f Mental 7-day follow up:Numerator:the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion)within seven days of discharge from psychiatric inpatient care.Denominator:the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care.All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up withinseven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team.Exemptions from both the numerator and the denominator of the indicator include:- patients who die within seven days of discharge;- where legal precedence has forced the removal of a patient from the country; or- patients discharged to another NHS psychiatric inpatient ward.For 12 month review (from Mental Health Minimum Data Set):Numerator:the number of adults in the denominator who have had at least one formal review in the last 12 months.Denominator:the total number of adults who have received secondary mental health services during the reporting period (month) who had spent at least 12months on CPA (by the end of the reporting period OR when their time on CPA ended).3gMental Health:DTOCFor full details of the changes to the CPA process, please see the implementation guidance Refocusing the Care Programme Approach on theD t t f H lth’ b itNumerator:the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of carewas delayed during the month. For example, one patient delayed for five days counts as five.Denominator:the total number of occupied bed days (consultant-led and non-consultant-led) during the month.3hMental Health: I/Pand CRHTDelayed transfers of care attributable to social care services are included.This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The following cases can be excluded:- planned admissions for psychiatric care from specialist units;- internal transfers of service users between wards in a trust and transfers from other trusts;- patients recalled on Community Treatment Orders; or- patients on leave under Section 17 of the Mental Health Act 1983.3i3j-kMental HealthAmbulanceCat AThe indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolutionteam if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted inadmission.For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on theDepartment of Health’s website. As set out in this guidance, the crisis resolution home treatment team should:a) provide a mobile 24 hour, seven days a week response to requests for assessments;b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires face-to-face contact unless it can bedemonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate, adeclaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;c) be notified of all pending Mental Health Act assessments;d) be assessing all these cases before admission happens; ande) be central to the decision making process in conjunction with the rest of the multidisciplinary team.Monthly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance,rounded down.For patients with immediately life-threatening conditions.The Operating Framework for 2012-13 requires all Ambulance Trusts to reach 75 per cent of urgent cases, Category A patients, within 8 minutes.From 1 June 2012, Category A cases will be split into Red 1 and Red 2 calls:• Red 1 calls are patients who are suffering cardiac arrest, are unconscious or who have stopped breathing.• Red 2 calls are serious cases, but are not ones where up to 60 additional seconds will affect a patient’s outcome, for example diabeticepisodes and fits.Ambulance Trusts will be required to improve their performance to show they can reach 80 per cent of Red 1 calls within 8 minutes by April 2013.4a4bC.DiffMRSAWill apply to any inpatient facility with a centrally set C. difficile objective. Where a trust with existing acute facilities acquires a communityhospital, the combined objective will be an aggregate of the two organisations’ separate objectives. Both avoidable and unavoidable cases of C.difficile will be taken into account for regulatory purposes.Where there is no objective (i.e. if a mental health trust without a C. difficile objective acquires a community provider without an allocated C.difficile objective) we will not apply a C. difficile score to the trust’s governance risk rating.Monitor’s annual de minimis limit for cases of C. difficile is set at 12. However, Monitor may consider scoring cases of

EXECUTIVE SUMMARYTITLE:Finance Report – Month Ten (January)2012/13BOARD/GROUP/COMMITTEE:Trust Board1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) andDATE:• The in month position showed a recorded surplusof £0.2m. Adjustments for previous monthsincome over performance, a larger thananticipated council tax refund and reduction indepreciation charges have helped improve theunderlying position which would have otherwiserecorded a £2.2m deficit without these benefits.• The year to date position at Month 10 shows acumulative deficit of £34.2m, representing a£0.4m adverse variance against budget for the tenmonths. The adverse variance is largely explaineda shortfall in the CIP delivery of £5.9m, andoverspending on pay and non-pay budgets of£7.1m partially offset by a favourable incomevariance of £11.4m generated by overperformanceand favourable movements in nonoperatingexpenditure of £1.2m, thus giving anoverall net adverse variance of £0.4m for thecumulative period.• The CIP position shows year to date delivery of£11.0m against a target for the period of £16.9m,a shortfall of £5.9m (compared with a shortfall of£4.9m in Month 9). The forecast CIP outturn forthe year is £18.0m, which is in line with theminimum required level of £18m and £2.0m belowthe desired target of £20m to support theachievement of the full year Trust control total of£39.7m. Of the £18.0m forecast outturn £1.0m ismade up of Amber and Red schemes, reflecting asignificant improvement in the risk profile.However, there remains a very real need for aconcentrated push on achieving the savings overthe remaining two months of 2012/13. The CIPperformance in delivering the Red and Amberschemes is being monitored through the weeklyTrust Accountability Meeting.• The cumulative income position is £11.4m aheadof plan at month 10 and is forecast to be £16.2mahead of the full year plan, a position which hasbeen agreed with the Commissioners.□ 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 achieve financialsecurity for the Trust, with reduced costs, improvedproductivity and collecting income due□ OTHER …………………….. (please specify)AUTHOR/PRESENTER:Alan Davies, Deputy Director of Finance / DavidGilburt, Director of FinanceDATE:• The year on year Trust performance is showing avery marked improvement with a £15.9mEBITDA positive development. Pay costsrepresent 68% of income this year compared71% last year, non-pay as a percentage ofincome is showing a 1% improvement on lastyear. The combination of continuing strong costcontrol, improving income generation and thedelivery of the CIP schemes should ensure thatthe Trust will meet its 2012/13 control total of£39.7m.• Cash management is also on target to deliver anEFL of £41.1m.1

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:The Trust Board is request to approve the report and note the actions to mitigate risk in achievingthe control total deficit of £39.7mAGREED AT ______________________MEETING, ORREFERRED TO: ______________________DATE: ____________________________DATE: ____________________________REVIEW DATE _________________________(if applicable)2

1. EXECUTIVE SUMMARYTrust I&E Summary (+ve variances = favourable, -ve = adverse)3

In Month and YTD PerformanceNon-pay expenditureIncomeThere was an over- performance of £3.3m in the month, with a year to date over-performance of£11.4m. The central income position shows an over- performance of £3.3m in the month, with ayear to date over-performance of £10m. The reported position assumes a forecast £19.6m overperformanceon the ONEL contract, with a FOT under-performance of £1.5m on the East ofEngland contract and £2.1m on other income, which includes £4.3m transitional support notagreedPay expenditureThe monthly payroll costs of £24.6m are slightly above budget by £95k. Cost over runs onNursing & Midwifery in Medicine (£123k) and Anaesthetics (£84k) are offset by savings inAdmin & Management across most areas £157k.The YTD position is £244.9m, giving a budget overspend of £247k. The main areas ofoverspend relate to Medical Staffing in Anaesthetics (£452k), Specialist Surgery (£383k) andRadiology (£524k), Nursing Staff costs in Medicine (£1,111k) being offset by savings inAdmin& Management of £968k across Corporate, Women’s and Children’s and EmergencyCare.The cost overruns in Medical Staffing are mainly attributable to the working of additionalsessions and the settlement of back pay claims in Anaesthetics, Specialist Surgery (ENT,Orthopaedics and Ophthalmology) along with high agency costs incurred for the covering of 5.96WTE vacancies in Radiology. Going forward management processes are being put into place toensure that all sessions as far as possible are done within normal hours and that vacancies aremanaged in such a manner so as to avoid high cost agency premiums, the in month costposition in Radiology is broadly in line with budget indicating that the remedial managementactions are taking effect.EBITDANon-pay expenditure exceeded budget by £0.6m in the month. The overrun predominatelyrelates to Clinical Supplies and Appliances in Anaesthetics (£148k) and the high usage ofDrugs in Specialist Medicine (£244k).The year to date non-pay over spend of £3.0m against budget is mainly attributable to Drugs inWomen’s and Children’s (£443k) relating to increased activity in NICU (being the use ofSurfactant), HIV drugs no longer being distributed through Homecare and in SpecialistMedicine (£697k) on cancer treatment drugs due to increased levels of cancer activity. Theprescribing process is being reviewed to ensure that it is being carried out in the most efficientand cost effective manner by reviewing each consultant’s level of prescribing with the Head ofPharmacy. Clinical Supplies and Appliances expenditure in Anaesthetics, relating toadditional sessions and prosthetics accounts for (£966k) of the overspend, driven by theadditional sessions being worked to address the eighteen week backlog. It is anticipated that inexcess of five hundred additional sessions will be carried out this financial year mainly beingperformed in orthopaedics. (£214k) is attributable to Medicine as a result of over-performancein endoscopy. Pathology and Radiology are responsible for (£516k) relating to the high usagein haematology and A&E of blood products and high cost devices such as coiling and stents. Areview of the blood product usage rates is being undertaken by Finance in conjunction withPathology.Earnings before Interest, Tax, Depreciation and Amortisation (EBITDA) were £3.1m positive inthe month and £0.4m negative YTD. The month position was primarily driven by increasedincome due to agreement of the final outturn position with ONEL commissioners. Expenditurelevels are above the level of the last two months (see graph attached). The YTD EBITDA of£0.39m negative is £1.16m adverse against plan but has improved by £14.4m compared withthe same period last year. The forecast is £1.5m positive, £11.6m better than last year’soutturn.The cumulative Nursing cost adverse variance in Medicine is made up of nursing skill mixpressures and additional specialling support (£550k), additional bed capacity supporting nonelectivedemand (£90k), endoscopy support in the delivery of 10% activity over-performance(£200k) and the upgrading of Sky A to a full acute medicine unit (£100K).Net deficitThe net deficit is £34.2m to date, which is £0.4m worse than plan. The forecast deficit is£39.7m, which is consistent with the required control total. Key assumptions are:ooPayment by ONEL commissioners of £19.6m over-performance (less £4.3mtransitional support)Delivery of £18m CIP as a minimum, with a target of £20m to mitigate against the riskon the red and amber schemes within the current forecast against the £23.1m plan.4

CIPCIP• Overall CIP delivery for Month 10 was £2.0m in month and £11.0m YTD. The forecast outturn is £18.0m, including £0.0m red and £1.2m amber-rated schemes. This represents anincrease of £0.7m from the November position, when the forecast was £17.3m, but when the value of red and amber schemes was £0.8m and £2.6m respectively.Financial risk rating (per Monitor criteria) KPIsRisk RatingsReportedPositionNormalisedPosition*Jan 13 Jan 13Act Score Bud ScoreInitial Planning Planned Outturn as a % of turnover -9.4% -9.4%Criteria Indicator Weight 5 4 3 2 1Year toDateForecastOutturnYear toDateForecastOutturnComments where targetnot achievedYtoD - operating performance Ytd Operating surplus/Forecast Income % -2.8% -2.6%YtoD - EBITDA Ytd EBITDA/Ytd Income % -0.1% 0.2%Forecast Op Performance Forecast (Surp) or Def/Forecast income % -9.4% -9.4%Forecast EBITDA : DH Risk score Forecast EBITDA/Forecast Income % 0.3% 0.4%UnderlyingperformanceAchievement ofplanFinancialefficiencyEBITDA margin % 25% 11 9 5 1

Trust I&E summary by Division/Directorate:• Central income over-performance is net of £5.9m YTD & £7.2m FOT income devolved to Business Units. The gross FOT over-performance is therefore £15.06m.• Surgical Services YTD overspending primarily driven by £1.0m CIP shortfall, Medical staffing £0.9m and Clinical supplies expenditure £0.9m.• Emergency/Medicine/Neuro/Therapies YTD overspending primarily related to staffing costs for Nursing in Acute Medicine £1.02m and Scientific Staff in Therapies of£0.24m.• Women/Children/Support YTD overspend is net of £246k sexual health income arrears and £152k funding for two band 8A posts in Midwifery. This is masking £269k,CIP short fall and £144k underperformance income allocation, primarily in Women.• Diagnostics & Specialist Medicine primarily related to Pathology consumables £0.1m, CIP shortfall £0.3m, Radiology Medical Staff 0.6m.• Corporate under-spending primarily from non-recurrent charitable funds contribution £0.5m and Estates £0.9m6

2. CLINICAL INCOMEKey points:• In line with guidance from the SHA, the Trust and Commissioners’ haveagreed a monthly profile plan based on Commissioners’ QIPP schemes; assuch the Budget has been re-profiled to reflect this change.• There was an over- performance of £3.3m in the month, with a year to dateover-performance of £10m. The reported position assumes a forecast £19.6mover- performance on the ONEL contract, with a FOT under-performance of£1.5m on the East of England contract and £2.1m on other income, whichincludes £4.3m transitional support not agreed.• The Month 10 income position includes an estimated average price on higherthan normal level of un-coded activity. Therefore some uncertainty existsaround the income forecast. The total un-coded activity in the position is circa2,000 attendances with a value of £2.2m.Business UnitPerformanceIn Month Year to date ForecastActual Var Actual Var Actual Var(7,716) 742 Medicine (74,375) 5,460 (88,847) 6,894(1,903) (22) Anaesthetics (18,464) (225) (22,066) (310)(2,031) 3 Children (19,842) (325) (23,687) (369)(2,452) 64 Emergency Care (23,777) (223) (28,416) (106)(2,361) (95) Neurosciences (22,873) (1,265) (27,340) (1,511)(881) (6) Pathology (8,294) 4 (9,896) (22)(776) 119 Radiology (7,378) 1,056 (8,823) 1,288(3,097) 276 Specialist Medicine (29,741) 2,863 (35,577) 3,440(3,876) 306 Specialist Surgery (36,850) 2,893 (43,987) 3,429(3,837) 99 Surgery (36,603) 651 (43,725) 855(4,315) (61) Women (43,150) 605 (51,555) 823(2,918) 1,854 Corp (8,637) (1,509) (13680) 1529(36,162) 3,278 Total (329,983) 9,988 (395,999) 15,940Devolved Income 5,925 (5,925) 7,241 (7,241)7• The Trust has agreed the final outturn position with ONEL commissioners andas such ten twelfths of this is reflected in the position. This explains £2m ofthe in-month favourable movement of £4.2m..• East of England Contract has seen an adverse in month movement due tolower than planned breast screening activity.• The activity table below compares current year YTD activity with the sameperiod last year. A&E activity has grown by 5% year on year, but this isprimarily due to the full-year effect of the Queen’s UCC, which was taken onby BHRUT in August 2011.• There is a growth of 4% in Day cases year on year as a result of theachievement of the 18 weeks targets, coupled with the Trust undertaking workthat went to the ISTC last year. The Trust is also seeing a large increase inendoscopic work as a result of the expansion of bowel screeningprogrammes.• Non Elective activity has declined by 3% year on year Trust wide. However,B&D and Havering CCGs activity continues to increase year on year and thisis putting considerable pressure on our finances as tariff is paid at 30%marginal rate. The reclassification of paediatric zero length of stay patients toa paediatric assessment unit is also responsible for a third of this reduction.• Prior months’ actual income came in at £171k less than accrued. The YTDposition has been adjusted for this movement.• The tables show the proportion of income over-performance that has beendevolved to Clinical Directorates both YTD (£5.9m) and FOT (£7.2m). Thishas increased by £2.7m, primarily due to the increase in elective income sincethe M6 forecast, related to additional activity to meet the 18 weeks target.• The forecast outturn position includes SHA approved funding for winterpressures of £2.8m. The trust has put in place specific work streams whichwill alleviate pressures in A&E. The funding is to pay for additionalexpenditure on staff and non-pay and will not result in additional activity

Income by PODIn Month Year to dateForecastActual Var Actual Var Actual Var(1,828) 117 AandE (17,735) 438 (21,194) 650(83) 2 Ambulatory Care (778) 24 (928) 27(192) (10) Breast Screening (1,804) (70) (2,152) (89)(199) (17) Challenge Trust Board (2,149) (17) (2,548) (52)(1,321) 943 CQUIN (5,666) 1,886 (6,799) 2,263(2,311) 31 Critical Care (22,658) 246 (27,053) 199(3,045) 166 Daycases (28,652) 1,901 (34,189) 2,203(1,004) 79 Devices & Drugs (9,911) 1,005 (11,918) 1,287(1,405) 57 Direct Access (13,217) 639 (15,771) 722(2,126) 16 Elective (20,000) 366 (23,864) 395(355) 0 HIV Contract (3,554) (0) (4,264) 0(36) (9) ISTC Contract (374) (76) (441) (99)(11,451) 525 Non Elective (111,446) 1,686 (133,199) 2,742(2,878) 182 OP First Attendances (27,077) 1,967 (32,309) 2,303(3,095) 259 OP Follow Ups (29,123) 2,700 (34,751) 3,175(570) 92 OP Procedures (5,366) 925 (6,403) 1,093(2,580) 1,107 Other (15,228) 496 (19,918) 3,840(302) 21 Patient Transport Services (3,015) 210 (3,618) 252(349) 4 Radiotherapy (3,399) 173 (4,064) 203308 188 Readmissions 4,584 377 5,502 451(506) 2 Regular Day Attenders (4,925) 217 (5,887) 254(130) (109) Road Traffic Accidents (2,033) (353) (2,431) (433)(33) (325) Transitional Funding 67 (3,650) (0) (4,300)(671) (42) XBD (6,525) (1,103) (7,799) (1,147)(36,162) 3,278 Total (329,983) 9,988 (395,999) 15,940Devolved Income 5,925 (5,925) 7,241 (7,241)ActivityPOD Group 2011-12 2012-13 Var % ChangeAandE 168,312 184,529 16,217 5%Ambulatory Care 2,620 2,637 17 0%Breast Screening 18,838 18,220 (618) -2%Critical Care 22,457 23,207 750 2%Daycases 34,929 38,091 3,162 4%Direct Access 4,036,219 4,050,785 14,566 0%Elective 6,472 6,604 132 1%Non Elective 65,808 62,394 (3,414) -3%OP First Attendan 144,227 148,370 4,143 1%OP Follow Ups 337,066 332,462 (4,604) -1%OP Procedures 26,799 32,051 5,252 9%Other 69,952 69,454 (498) 0%Radiotherapy 14,892 17,483 2,591 8%Regular Day Atten 11,750 12,206 456 2%XBD 33,422 24,705 (8,717) -15%Total 4,993,763 5,023,199 29,4368

Cluster PerformanceIn Month Year to date ForecastActual Var Actual Var Actual Var(31,586) 4,225 Outer North East London (277,762) 12,401 (335,853) 19,625(493) 3 Inner North East London (4,749) (69) (5,675) (96)(984) 35 London Specialist Commissioning (9,817) 331 (11,721) 338(3,163) (103) East Of England Specialist Commissioning (30,919) (1,117) (36,854) (1,505)(362) 21 Non Contract Activity (3,514) (15) (4,200) 2(67) 3 North Central London (648) 11 (774) 11493 (906) Trust (2,574) (1,555) (921) (2,434)(36,162) 3,278 (329,983) 9,988 (395,999) 15,940Devolved Income 5,925 (5,925) 7,241 (7,241)9

3. COST IMPROVEMENT PROGRAMMECommentaryThe forecast outturn as at Month 10 is £18.0m, which is a £700k increase from the Month 9 forecast position. In addition, there has been a continued improvement in the Red and Amberschemes being converted into Blue and Green schemes. Red schemes have reduced by £0.75m compared to last month, and now stand at zero. Amber schemes have similarly reduced byThe £1.6m. renOf the forecast outturn of £18.0m the Red and Amber schemes represent £1.153m (6.4%), with only eight weeks of the financial year remaining there needs to be a very strong focus placedupon the full achievement of the savings plans by the Trust. The management of the Amber schemes will be monitored through the weekly Trust Accountability Meeting.The current monthly CIP run rate is £1.1m. To achieve the desired annual target of £20m the run rate will need to be increased to £3.7m per month over the remainder of the year.The main movements in the forecast outturns are:Length of Stay - £327k reduction as anticipated ward closure for February being removedCorporate - £890k increase due to addition of other actions that can be taken at the year end (e.g. annual leave accrual.Medicines Management - £289k decrease due to removal of the VAT scheme10

• £7.0m to be delivered overremaining two months of the year.• Includes a number of schemeswhich are due to impact as part ofthe end of year processes, includingannual leave accrual (£0.7m),• Includes and other productivitygains (£0.7m)In Month (£) Year To Date (£) ForecastOutturnForecast Outturn ProfileRun RatesFull YearDirectorate Plan Actual Variance % Var Plan Actual Variance % Var % Var Blue Green Amber Red YTD YTG EffectAnaesthetics 321,134 93,313 (227,821) (71%) 1,458,979 449,461 (1,009,518) (69%) (68%) 519,046 155,757 - - 44,946 112,671 1,314,036Central 838,763 506,336 (332,427) (40%) 4,195,439 2,287,584 (1,907,855) (45%) (20%) 1,057,907 2,931,046 650,000 - 228,758 1,175,684 4,897,153Children 64,543 73,497 8,954 14% 605,844 642,587 36,743 6% 8% 797,026 - - - 64,259 77,220 889,414Corporate 183,488 218,540 35,052 19% 1,614,028 1,597,230 (16,797) (1%) 66% 1,595,272 1,688,860 97,500 - 159,723 892,201 1,995,604Emergency Care - 62,000 84,169 146,169 (236%) 751,066 526,776 (224,290) (30%) (37%) 689,983 4,500 - - 52,678 83,854 879,832Medicine 450,274 244,574 (205,700) (46%) 1,722,649 1,597,222 (125,427) (7%) (18%) 2,067,225 4,750 - - 159,722 237,376 2,784,002Neurosciences 91,107 47,096 (44,011) (48%) 507,549 447,645 (59,904) (12%) (20%) 541,845 5,250 - - 44,765 49,725 672,932Pathology 140,604 69,969 (70,635) (50%) 797,607 356,228 (441,379) (55%) (52%) 411,334 104,415 - - 35,623 79,760 1,021,465Radiology 122,158 67,335 (54,824) (45%) 670,700 328,351 (342,349) (51%) (49%) 393,100 61,799 6,311 - 32,835 66,429 717,981Specialist Medicine 294,758 220,904 (73,854) (25%) 1,433,702 1,034,858 (398,844) (28%) (15%) 851,607 456,397 400,000 - 103,486 336,573 2,038,909Specialist Surgery 84,314 64,788 (19,526) (23%) 702,219 573,439 (128,780) (18%) (19%) 702,416 4,000 - - 57,344 66,489 825,468Support Services 96,216 13,666 (82,550) (86%) 339,932 18,666 (321,266) (95%) (69%) 19,998 145,558 - - 1,867 73,445 198,000Surgery 107,845 77,676 (30,169) (28%) 625,083 461,668 (163,415) (26%) (25%) 617,025 8,707 - - 46,167 82,032 945,055Women 222,824 173,326 (49,498) (22%) 1,443,635 669,300 (774,336) (54%) (46%) 583,429 432,498 - - 66,930 173,314 1,404,708Totals 2,956,028 1,955,189 (1,000,839) (34%) 16,868,432 10,991,015 (5,877,417) (35%) (22%) 10,847,211 6,003,537 1,153,811 - 1,099,101 3,506,772 20,584,55811

4. BALANCE SHEETCurrent Previous Last(£m) Period Period Yr EndJan-13 Dec-12 Mar-12Non-current assets £357.6 £390.2 £387.5Current assetsInventories £5.0 £5.4 £5.8Trade and other receivables £49.1 £36.9 £35.6Cash and cash equivalents £13.2 £27.6 £4.2£67.3 £69.9 £45.6Current liabilitiesTrade and other payables (£81.6) (£83.3) (£46.3)PFI \ Borrowings (£6.5) (£6.4) (£6.0)Provisions (£1.9) (£2.1) (£1.8)Net current assets/(liabilities) (£22.7) (£21.9) (£8.4)Non-current liabilities:PFI \ Borrowings (£254.9) (£256.5) (£258.7)Trade and other payables (£4.7) (£4.9) (£4.9)Provisions (£3.6) (£3.7) (£3.2)Total assets employed £71.7 £103.3 £112.2Financed by taxpayers' equity:Public dividend capital £388.7 £388.7 £365.7Retained Earnings - P&L (£327.6) (£296.9) (£263.8)Retained Earnings - Donated Assets - - -Revaluation reserve £10.6 £11.5 £10.3Donated asset reserve £0.0 £0.0 -Total taxpayers' equity £71.7 £103.3 £112.2Current Prior LastKPIs Period Period Yr EndJan-13 Dec-12 Mar-12Average Debtors days 20 26 21Debtors >90 days (£'000s) £572 £894 £592Debtors >180 days (£'000s) £293 £269 £1,536Debtors >365 days (£'000s) £1,299 £1,442 £2,825Total Bad Debt Provision (£'000s) £1,602 £1,699 £1,926>365 days provided (£'000s) £1,029 £1,171 £1,293Average creditor days 25 30 58Current ratio 72% 73% 84%Better payment practice code performance:- Non-NHS- Volume - paid on time 3,841 4,416 2,773- Volume - % paid on time 90.97% 85.49% 27.96%- Value - paid on time (£'000s) £24,001 £9,022 £5,150- Value - % paid on time 95.44% 82.26% 35.85%- NHS- Volume - paid on time 259 50 316- Volume - % paid on time 86.05% 83.33% 34.39%- Value - paid on time (£'000s) £2,319 £523 £1,630- Value - % paid on time 88.95% 99.82% 30.52%Key points:• The overall balance sheet position showed a decreaseof £31.6m, which mainly related to £32.6m decrease onNon-current assets as a result of the revaluation of landand buildings by DTZ.• The cash position showed a decrease of £14.4m,compared with December. This was primarily due to thepayment of £14.0m PFI quarterly payment in January.Key points:• Debtors>90days (£000s) decreased by £322k in January, withdebtors >365 days reducing by another £143k• Better payment practice code performance has improvedsignificantly over the last two months, following the draw down ofPublic Dividend Capital in December.• Within Trade and other payables is £37m SLA invoicesraised in advance12

5. CAPITAL AND CASHFLOWSummary Cashflow - Year to date £000'sOperating Deficit (42,510)Interest Paid (24,461)PDC Dividend Paid (2,044)Interest received 559Impairments 29,459Transfers -Net I&E deficit (cash impact) (38,998)Depreciation and Amortisation 11,772Movements in working balances:Decrease in Inventories (6,208)Increase in Trade and Other Receivables (1,902)Increase in Trade and Other Payables 38,310Decrease in Provisions (2,139)- sub-total 835Capital expenditure (10,243)Revenue Rental Income 1,416Net cashflow before financing (7,992)Capital Element of Finance Leases and PFI (6,195)Loans repaid -Public Dividend Capital Received 23,000Net Increase/(Decrease) in Cash and CashEquivalents8,813Opening cash balance 4,343Closing cash balance 13,156Capital Programme Summary Original YTD Total Forecast ToPlan Spend Spend 31-03-13Internally Funded SchemesMedical Equipment 2,325 1,337 1,123IT - Hardware 1,230 993 1,361IT - Softw are 62 294 438Other Plant & Machinery 500 250 500Estates 3,625 1,597 3,031Revenue to Capital other 500sub-Total 7,742 4,471 6,953Externally Funded AssetsDigital Mammography 1,548 0 1,548Pathology 5,094 606 1,000SAN 714 989 942MLU 1,526 1,290 1,256SCBU 1,050 176 158Access Funded Assets 261 51 51PAS Replacement 10,000 0 600Improving Birthing Environments 0sub-Total 20,193 3,112 5,555Trust Variation Enquiries 2,966 2,818 3,334Total Trust - Funded 30,901 10,401 15,842Subject to External Approval & FundingCardiac Cath Lab 1,700 0CT Scanners 2,000 811 0A&E Reconfiguration 3,000 0sub-Total 6,700 811 0Total Capital Plan to Date 37,601 11,212 15,842Assets to be Considered via Charitable FundsDa Vinci Robot 2,400TRUS Biopsy Probe 0 8Rapid Arc 0 467 4672,400 467 475Grand Total 40,001 11,679 16,317Key points:• The cash position showed adecrease of £14.4m, compared withDecember. This was primarily dueto the payment of £14.0m PFIquarterly payment in January.• The increase in trade & otherpayables includes £37m PCTadvancesKey points:• Year to date capital expenditure is £11.7m, anincrease of £300k compared with December.• The forecast, based on Month 9, is £16.3m, withinthe CRL of £17.2m. The CPG is consideringadditional schemes to utilise the spare CRL13• A full Month 10 capital report, including revisedforecast, will be included separately on the agenda

EXECUTIVE SUMMARYTITLE:Workforce Committee Board ReportBOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:To inform the board of all workforce relatedactivity and strategy for the month of January2013.The information contained within the report hasbeen presented to and approved by theWorkforce Committee.The report adopts a revised format fromprevious months and on-going iterations of thereport will incorporate an improved content andpresentation following re commendations andfeedback received through the WorkforceCommittee.□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …………..………….....…… WORKFORCE ……18 th Feb 2013……………□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:Trust Board are asked to note the content of thereport□ NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Dorothy HoseinAGREED AT _____ _ MEETINGORREFERRED TO: __________________________DATE:DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

BHRUT - HR Workforce KPI Report for January 2013Diagnostics & Specialist Medicine and NeurosciencesEmergency & Acute MedSurgical ServicesWomen, Children & SupportServicesFunded Establishment (FTE)SIP (FTE)Vacancy Rate (FTE)Vacancy Factor (%)Starters (FTE)Leavers (FTE)Turnover (annualised %)TargetCorporateNeurosciencesPathologyRadiologySpecialistMedicineTherapiesAcute MedicineEmergencyCare618.8 231.7 288.7 291.9 409.2 175.5 1049.6 340.4 660.3 221.9 320.1 253.4 369.7 660.1 5891.3 5880.9 529.6 196.5 271.6 268.2 396.3 160.3 956.1 290.7 598.7 206.3 296.9 223.1 346.9 571.3 5312.5 5322.2 89.1 35.2 17.1 23.8 12.9 15.2 93.5 49.8 61.6 15.6 23.2 30.3 22.8 88.8 578.7 558.7 8% 14.4% 15.2% 5.9% 8.1% 3.1% 8.7% 8.9% 14.6% 9.3% 7.0% 7.2% 11.9% 6.2% 13.5% 9.8% 9.5% 3.4 1.0 1.0 1.0 7.4 1.0 9.0 3.6 5.9 2.0 0.4 2.0 0.0 7.0 44.8 14.6 1.0 2.0 2.0 1.0 3.0 1.0 10.6 3.4 2.9 1.5 0.8 3.0 2.8 4.0 38.9 51.4 11% 12.7% 13.2% 8.3% 5.8% 10.2% 13.4% 12.0% 26.9% 9.3% 12.0% 11.0% 13.5% 9.1% 15.8% 12.2% 12.3% AnaestheticsSpecialistSurgerySurgeryChildrenSupportServicesWomenOverall(reportingmonth)Overall(previousmonth)TrendStability (% leavers in month with lessthan 12 months service)Sickness Absence Long Term (%)25% 0.0% 0.0% 50.0% 0.0% 0.0% 0.0% 20.0% 25.0% 66.7% 0.0% 0.0% 0.0% 33.3% 66.7% 25.0% 20.7%2% 5.7% 0.5% 4.0% 3.4% 2.4% 1.6% 2.2% 1.6% 2.2% 2.9% 1.4% 2.5% 4.8% 1.2% 2.7% 3.6%Sickness Absence Short Term (%)Overall Sickness Absence (%)Bank/Agency Use (FTE)Bank/Agency Spend (£)Paybill Budget (£)% Paybill Budget spent on Bank& Agency staff (%)Number of SuspensionsAppraisals (%)Resus (%)2% 2.0% 1.8% 2.2% 2.0% 1.9% 2.0% 3.0% 2.8% 2.2% 1.7% 2.2% 2.2% 2.9% 2.0% 2.3% 2.1%4% 7.7% 2.3% 6.2% 5.3% 4.3% 3.6% 5.2% 4.4% 4.4% 4.7% 3.6% 4.7% 7.7% 3.2% 5.0% 5.7% BANK 19.5 33.8 4.6 22.7 7.6 2.93 121.0 22.7 60.0 8.1 20.0 26.3 18.9 51.7 419.8 388.3 AGCY 10.9 1.1 6.2 7.7 14.6 11.51 23.4 32.9 17.4 6.5 5.3 10.1 1.6 4.7 153.8 138.7 BANK 54,383 101,184 30,567 127,764 26,890 7,638 415,807 96,103 340,855 80,628 70,624 109,142 43,253 185,913 1,690,751 1,547,259 AGCY 62,107 6,874 23,217 95,242 118,625 68,607 196,023 346,063 112,241 64,934 42,672 67,955 4,224 28,543 1,237,327 1,066,974 3,051,728 990,380 1,130,509 1,321,926 1,635,578 619,746 4,038,563 1,692,366 2,782,529 1,147,728 1,382,478 1,175,463 859,285 2,643,390 24,471,668 24,506,830 BANK 11% 1.8% 10.2% 2.7% 9.7% 1.6% 1.2% 10.3% 5.7% 12.2% 7.0% 5.1% 9.3% 5.0% 7.0% 6.9% 6.3% AGCY 11% 2.0% 0.7% 2.1% 7.2% 7.3% 11.1% 4.9% 20.4% 4.0% 5.7% 3.1% 5.8% 0.5% 1.1% 5.1% 4.4% 1 1 0 1 0 0 2 0 2 0 1 1 1 2 12 11 80% 41.7% 84.8% 76.6% 74.6% 82.6% 68.2% 82.5% 50.9% 80.3% 73.5% 77.7% 80.3% 84.8% 69.8% 73.9% 71.1% 80% 58.0% 67.6% 89.5% 57.3% 78.8% 76.5% 71.5% 73.4% 76.3% 73.1% 66.4% 80.6% 73.1% 77.8% 72.7% 72.1% Data Sources:Funded Establishments & Paybill Budget data from Finance Dept.Bank & Agency Data from StaffBank systemsAll other data from Electronic Staff Records system (HR and Payroll database)

BHRUT - Trust Overall Staff Levels and Suporting NarrativeEstablishments v SIP & Vacancy RateDiagnostics & Specialist Medicine NarrativeThe vacancy rate for Therapies is 8.9%. A recruitment plan is in place to addressthis.Diagnostics & Spec Med ActionsPaybill Budget and IHB Spend (£)FTE Estab & SIP6000590058005700560055005400530052005100500028,000,00026,000,00024,000,00022,000,00020,000,00018,000,00016,000,00014,000,00012,000,00010,000,0008,000,0006,000,0004,000,0002,000,000-MonthEstablishmentsStaff in PostVacancy Rate (Estab minus SIP)Paybill Budget v IHB Spend & Bookings700.00600.00500.00400.00300.00200.00100.000.008007006005004003002001000Vacancy (fte)IHB Bookings (FTE)The percentage of paybill spend for bank and agency remains high in radiology dueto ongoing agency usage for Ultrasonographers where maternity leave andvacancies have been difficult to recruit to. Interviews scheduled for 26th Februarywill address this. In addition MRI activity between 8pm and 12 am has increasedagency usage. The 11% paybill spend within Therapies will be addressed throughthe recruitment plan anticipated to conclude in MayEmergency, Gen Med & Neuro NarrativePaybill on Bank & Agency staff reflects the continued reliance on temporary staff.The highest proportion of this spend is attributable to the M&D agency staff andreflects the current vacancy factor within the BU.There is an increase in the retention of staff in the business units with less staffleaving in Acute Medicine which has a stability rate of 20% down from 45% inprevious month however the vacancy rates remain high in the Business UnitSurgical Services NarrativeHigher than average vacancy factor in Anaestics is due to hard to fill medical anddental posts.Total Bank and agency spend stands at 16.2% this month. As reported in Decembertemporary staffing usage with the Anaesthetics is proportionate to the volume ofactivity and vacancy factor. This additional activity although income generating hashad a large impact on medical and nursing costs. Within ITU as well the highvolumes of patients has resulted in higher staffing costs.Women, Children & Support Services NarrativeThe Women's BU currently has a higher than average vacancy factor of 13.5% withthe highest proportion of vacancies relating to midwives. This is however expectedto reduce by 11 fte's following the disestablishment of recently TUPE'd posts andthe division are expected to carry a higher than normal vacancy rate whilst a longterm workforce plan is established to reflect the reducing volume of activity.The higher than expected turnover rate in Women's is also driven by the TUPEtransfer of a number of community midwives to Bart's Health.Emergency, Gen Med & Neuro ActionsAn investigation into turnover in theEmergency dept. is ongoing as this isacknowledged to be the highest in the Trustat 26.9%. The recruitment difficulties, highsickness and dependence on temporary staffis likely to drive high turnover and the currentworkforce planning exercise aims to identifylong term solutions to these problems. This isalso being addressed through ongoingrecruitment activity and sicknessmanagement.There is ongoing recruitment drive to fillvacancies in the Emergency department witha current recruitment activity for 19 Doctorsand 3 N&M staff of different grades. Thecurrent recruitment activity in Acute MedicineBU is for 22 doctors (various grades) and 44N&M staff mostly band 5 nurses. Therecruitment plan will help to achieveimprovement in the business unit through asignificant reduction in the use of bank andAgency spendSurgical Services ActionsActive recruitment drive for doctors andqualified nurses in Anaesthetics is to beundertaken. Review of new ways to attractthese staff groups.Women, Children & Support actionsMonthIHB Spend (£) Paybill Budget (£) IHB Bookings

BHRUT - Trust Overall Sickness Absence and Temporary StaffDiagnostics & Specialist Medicine NarrativeDiagnostics & Spec Med ActionsPercentage7.06.05.04.03.02.01.0BHRUT Overall Long Term, Short Term and Overall Sickness AbsenceRateLong term sickness for Pathology has reduced from 6.3% to 4%. This is mainly due tothe fact a number of records of open ended sickness were closed. Greater focusneeds to be made to the prompt closing of staff records to ensure over reporting doesnot continue to occur in the future.Within Pathology actions are planned to reduce long term sickness, to include moving3 staff to the formal stage of the procedure and exploring the possibility for ill healthretirement for a further staff member.Long term sickness for Specialist Medicine has reduced from 3.7% to 2.4%. A numberof records were incorrectly reported, which have now been rectified. One member ofstaff is due to return from LT sickness on 18/2/2012 and another is due to move to theformal stage of the policy.Continued review of open ended sicknessrecording and over reporting to be highlightedto relevant managers.There are approximately 10 staff on LTsickness across the directorate whorequirement management under the first(informal) stage of the LT sickness procedure.In line with the release of the revised SicknessAbsence Policy, for a review of staff with highlevels of short term sickness to be conductedacross the Directorate and action plans to bedevelopedLong term sickness for Radiology has reduced from 3.9% to 3.4%. A phased RTW Emergency, Gen Med & Neuro Actionsprogramme is in the process of been arranged for one member of staff and two casesare formally being managed through the policy. One case is due to be considered at a 17 long Term absence cases identified andformal meeting on 6 March.currently being managed under the informalprocess with a number of them due toEmergency, Gen Med & Neuro Narrativeprogress to the formal stage.0.0MonthSickness in this area has been reviewed with the General Managers. On-going noncompliance in closing episodes has resulted in artificially high levels of long termabsence. This is being been rectified and a number of long term confirmedabsentees are being managed under the sickness absence policy.Action plan in place to ensure compliance inreporting through line manager responsibilityfor accurate reporting and management in linewith the sickness absence policy.Percentage82.00%80.00%78.00%76.00%74.00%72.00%70.00%68.00%Long Term Short Term OverallBHRUT Overall Appraisal Compliance RatesSurgical Services NarrativeThere were no sickness absence hotspots reported in January 2013. There was a0.6% reduction in LT sickness between December and January but a correspondingincrease by the same amount for ST sickness. Action plans have been put in place totarget and ensure that significant sickness absences are recorded accurately andreported in a timely manner.Women, Children & Support NarrativeLong term sickness rates in Support Services has reduced from 7.8 % to 4.8%however this is still not an accurate reflection of the number of staff on long term sickand this increased rate reflects continuing issues surrounding reporting compliance.The on-going implementation of eRostering in this area will improve transparency andreporting compliance but remedial action continues to improve the reporting ofsickness in this area and this is apparent in the overall reduction of sickness forSupport Services from 9.4% to 7.7%. There does however remain a large number oflong term sickness cases in Women's BU and action is being taken locally to managethese cases with support from Occupational HealthOngoing review of short term sicknessSurgical Services ActionsAction plans have been put in place to targetand ensure that significant sickness absencesare accurately and reported in a timelymanner.Other HR interventions include a sicknessabsence training workshop on 1.3.13 for Band7s in HDU/ITU who have new responsibility forsickness absence management. (2) Sicknessabsence policy update training workshopsplanned for Trust managers to begin on 27February 13.Women, Children & Support Actons66.00%64.00%Action to be taken locally to manage long termsickness absentees with support fromOccupational Health.62.00%Month

BHRUT - Corporate UpdateSickness AbsenceThe theme consistent throughout has been the non closure of episodes of sickness absence in a timely manner for accurate sickness and absence reporting. Areas using E-Rostering do not demostrate the same levels ofnon compliance as those areas that remain on weekly absence returns.The roll out program for e-rostering to incorpate all employees will go some way to resolve this ongoing issue. In the meantime, the HR department will monitor line managers adherance to instruction with regard to promptsubmission of weekly absence returns.Supporting the ongoing management of sickenss absence is a fully revised policy and process which launches on 25th Feb 2013.Key changes within the policy include:- Revised Bradford score trigger- Reduction in montioring periods- Reduction in paid phased return to work entiltement- Clarified and simplified management processImplementation of the policy is underway with a comprehensive communications strategy (agreed by Workforce Committee) supplemented by a number of training sessions for managers.AppraisalsAppraisal rates have increased steadily over the last quarter with a further increase of nearly 3% in December. The current appraisal compliance rate across the Trust is 73.88%.Performance across the directorates is generally improved with all business units seeing some increase, albeit small, contributing to the overall percentage increase. January 2013 figures for the Clinical Directorates are:Diagnostic & Specialist medicine 78.35%Emergency & General Medicine 75.56%Surgical Services 78.35%Women, Children & Support Services 76.82%Corporate Directorate 41.65%Corporate areas have increased from 40.66% in December to 41.65% in January however, corporate still remain very much below target. There is no one area within the corporate directorate that can be identified as a specificoutlier. There are many single post holders within Corporate who, due to management restructures, are waiting on new objectives to be set and an appraisal done by their new line manager. On review of the corporate areas,there are planned dates in place for outstanding appraisalsAn appraisal lead has not yet been identified in each Directorate but will be in advance of the update and re-launch of the trust’s appraisal policy originally planned for February although now to be included in the OD strategyplan.All Corporate Leads will be sent a list of their staff with the reminder for appraisal to be completed.Auto EnrolmentThe rules for work based pensions have changed and with effect from the 1st April 2013 the Trust is required to have in place an alternative pension provision available for staff ineligible to join the NHS Superannuationpension scheme. Agreement has been obtained through TEC to engage NEST as the supporting scheme as this offers maximum flexibility for the Trust and is also the most cost effective.The forecast cost of Auto enrolmentvia NEST scheme for previously ineligible staff estimated at £1700 per month. There is also a potential for increased expenditure under NHS pension scheme for “opt in” of current “opted out” staff which carries a maximumpotential exposure of £250k per month. Although the risk is unquanitifiable at present as there is no benchmark data from other NHS Trsuts to suggest the likely increase in NHSPS uptake.Although this remains an unquantifiable risk there is a strong likelihood that the circumstances prompting staff to opt out prior to auto enrolment will remain unchanged after the 1st April and therefore it may be assumed that alarge proportion of employees are likely to re-opt out lessening the financial impact.Communication to all staff and stakeholders will commence throughout March with the first pension contributions deducted under autoenrolement from April pay period.

BHRUT - Education UpdateReporting Period - Compliance RateCourse Name Frequency 28-Feb-11 30-Jun-11 30-Sep-11 31-Dec-11 31-Mar-12 30-Jun-12 30-Sep-12 31-Dec-12Conflict Resolution 3 yearly 11.61% 12.91%Equality, Diversity & Human Rights 3 yearly 55.92% 54.42%Fire Training Annual 39.49% 36.33% 28.63% 33.57% 21.63% 35.10% 45.46% 45.58%Health & Safety Annual 41.31% 47.65%Infection Control Annual 41.61% 49.16%Information Governance Annual 36.22% 36.92% 37.98% 17.43% 21.45% 21.35% 28.23% 31.50%Manual Handling (Loads) 2 yearly 18.76% 20.37% 22.77% 33.00% 39.54% 33.53% 38.28% 52.37%Manual Handling (People - Refresher) 2 yearly 63.50% 68.83% 69.22% 85.12% 73.84% 76.19% 71.16% 73.89%Manual Handling (People + Loads) Once 46.60% 41.62% 40.90% 40.55% 40.77% 65.95% 63.80% 65.08%Resuscitation Annual 89.72% 78.42% 69.04% 72.15% 78.61% 77.89% 75.09% 72.11%Safeguarding Adults 3 Yearly 65.84% 68.09%Safeguarding Children Level 1 3 yearly 62.61% 70.50% 56.61% 67.79% 69.72% 71.15% 71.12% 73.27%Safeguarding Children Level 2 3 yearly 26.87% 37.50% 10.76% 53.25% 58.29% 30.08% 42.93% 50.14%Safeguarding Children Level 3 3 Yearly 54.49% 50.97% 34.78% 67.68% 80.82% 72.14% 71.29% 73.20%Percentage Compliant80.00%78.00%76.00%74.00%72.00%70.00%68.00%Resus Compliance RatesMonthEducation & Learning NarrativeTraining release and therefore compliance continues to be a challenge; this has consequences for external accreditationand internal governance.Uptake remains consistent, with significant improvements in Manual Handling of Loads.Further improvements are anticipated with regard to Safeguarding Children Level 2 as more staff attends the mandatoryprogrammes.Conflict resolution refresher training has been commencedUptake on advertised resuscitation training sessions to date remains good. Non-attendance rates are being monitoredclosely & absences continue to be escalated to the appropriate managers.WIREDThe Trust is in the process of purchasing WIRED (Workforce Information Reporting Engine Database). WIRED is a webbasedtool that will enable us to export data from ESR to quickly produce a wide range of high quality compliance reports.Individuals will be able to view and manage their own statutory and mandatory training compliance. WIRED reports willbe instantly available to all managers via the Intranet.Because of the amount of resource required to implement this tool, it will be a phased implementation and we will befocusing on high profile statutory/mandatory compliance data first, i.e. Resus, Safeguarding and Manual Handling. Allother statutory and mandatory compliance reports will follow as soon as practicable.

EXECUTIVE SUMMARYTITLE:Trust Standing OrdersBOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:The Standing Orders are an important aspect ofthe Governance of BHRUT and set out thecomposition and responsibilities of the Board ofDirectors and the code of conduct to which itshould comply. They also set out how Boardbusiness should be conducted and contain theTrust’s rules in relation to Board responsibilities.A number of decisions in relation to theoperation and management of the Trust arereserved for the Board of Directors (the Board),and Standing Orders set out what these are. Itis therefore important that all staff should atleast be aware of the content of StandingOrders and indeed the Trust’s StandingFinancial Instructions, to ensure they do notbreach these important documents.□ TEC ………X……..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ……X…….……..….□ QUALITY & SAFETY …………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:To approve the Standing Orders/ delegation ofpowers.□ NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Donna KinnairDATE: 6 th March 20133. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:None4. DELIVERABLESGood Governance5. KEY PERFORMANCE INDICATORSTo be AGREED AT _____Trust___Board______________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

BARKING, HAVERING AND REDBRIDGE UNIVERSITYHOSPITALS NHS TRUSTSTANDING ORDERSThis document can be made available in other formats and languages upon request.Please contact the PALS office on 01708 435 454.CONTENTS1. Interpretation and definitions for standing orders and standing financial instructions2. Standing Orders3. The board: Composition of membership, tenure and role of members4. Meetings of the board5. Appointments of committees and subcommittees6. Arrangements for the exercise of board functions by delegation7. Overlap with other trust policy statements / procedures, regulations and the standingfinancial instructions8. Duties and obligations of the board and senior managers under these standing orders9. Custody of seal, sealing of documents and signature of documents.Document description: Trust Standing Orders Version: 1.1Ratified by:Date:Reviewed by:Date:Approved by:Date:Name & Title of originator/author: Donna Kinnair, Director of GovernanceResponsible committee/individual: Trust BoardDate issued: November 2012 Review Date: April 2013Target audience: All audiencesRelated documents:Approvals: Audit Committee Meeting on 14 February 2013

Document StatusThis is a controlled document. Whilst this document may be printed, the electronic version postedon the intranet (a scanned in copy of the signed document) is the controlled copy. Any printedversions of the document are not controlled.1

1. Interpretation and definitions for standing Orders and Standingfinancial instructions1.1 Save as otherwise permitted by law, at any meeting the Chair of the Trustshall be the final authority on the interpretation of Standing Orders (onwhich they should be advised by the Chief Executive or Secretary to theBoard).1.2 Unless a contrary intention is evident or the context so requires, words andexpressions contained in these standing orders shall have the samemeaning as set out in the NHS Act 2006 and the HSCA2012 (as suchterms described below) or in any secondary legislation made under theNHS Act 2006 and the HSCA 2012 and the following defined terms shallhave the specific meaning given to them below.“Accountable Officer”Board”BudgetBudget HolderChairChief ExecutiveQuality and SafetyCommitteeCommitteeCommittee membersChief Financial OfficerFunds Held on TrustMeans the person responsible and accountable forresources within the control of the Board, in accordancewith HM Treasury guidance managing public moneyMay 2012. Under paragraph 15 0r schedule A1 of theNHS Act 2006 the Accounting Officer is the ChiefExecutive;Means the Chair , non-executive and voting executiveMembers of NHS BHRUT collectively as a body;Means a resource, expressed in financial terms,proposed by the Board for the purpose of carrying out,for a specific period, any or all of the functions ofBHRUT NHS Trust.Means the individual with delegated authority tomanage finances (income and expenditure) for aspecific area of the organisation.is the person appointed by the Secretary of State forHealth under paragraph2(1) 0f Schedule A1 of the NHSAct 2006, to lead the Board and to ensure that itsuccessfully discharges its overall responsibility for theTrust as a whole. The expression “the Chair of theTrust” shall be deemed to include the Vice-Chair of theTrust if the Chair is absent from the meeting or isotherwise unavailableMeans the Chief executive of BHRUT NHS Trustpursuant to paragraph 3 of schedule A12 of NHS Act2006: Chief officer of the Trust.Means a committee whose functions are concernedwith the arrangements for the purposes of monitoringand improving the quality of healthcare for whichBHRUT has responsibilityMeans a subcommittee created and appointed by theboardMeans a person formally appointed by the board to siton or to chair specific committeesMeans the Director of Finance of BHRUT NHS TrustShall mean those funds the board holds on the date ofincorporation, receives on distribution by statutory2

MemberMotionNominated OfficeNon-Executive OfficerExecutive MemberSecretarySecretary of StateSFIsSOsVice Chairinstrument or chooses subsequently to accept underpowers derived under section 13Y and paragraph 11,schedule A1 of the NHS Act 2006. Such funds may ormay not include charitable funds.Means officer or non-officer member of the Board asthe context permits. Member in relation to the Boarddoes not include its Chair.Means a formal proposition to be discussed and votedon during the course of a meeting of the board;Means an officer charged with the responsibility ofdischarging specific tasks within SO’s SFI’s;Means a member of the board who is appointed underparagraph 2(1)(a) and (b) of Schedule A1 of NHS Act2006;Means a member of the board who is appointed underparagraph 3 of schedule A1 of the NHS Act 2006;Means a person appointed by the board to provideadvice on governance issues to the board and thechair, and to monitor the board’s compliance with thelaw, standing orders and standing financial instructionsand guidance issued by the secretary of state;Means the UK cabinet minister responsible for theDepartment of Health and any other body that he hasdelegated power to.Means Standing Financial Instructions;Means Standing OrdersMeans the non- executive Member appointed by theBoard to take on the Chair’s duties if the chair is absentfor any reason.3

2. STANDING ORDERS2.1 Statutory Framework2.1.1 Barking, Havering and Redbridge University NHS Trustis a statutory body established under section 1H of theNHS Act 2006.2.1.2 The principal place of business is Queen’s Hospital RomValley Way, Romford RM&0AG2.1.3 NHS Trusts are governed by the NHS Act 2006, theHSCA 2012 and by Secondary legislation made underthese Acts2.1.4 The functions of the Trust are conferred by the NHS Act2006 and HSCA 20122.1.5 As a statutory body, the Trust has specified powers tocontract in its own name and to act as a corporatetrustee. In the latter role it is accountable to the CharityCommission for those funds deemed to be charitable aswell as to the Secretary of State for Health. Undersection 11 of the NHS Act 2006, the board has powers toenter into certain contracts for specified purposes.2.1.6 Under Section 13V of the NHS Act 2006, the board hasthe ability to establish and maintain pooled funds withlocal authorities’ voluntary organisations and otherbodies.2.1.7 The Code of Practice on Openness in the NHS sets outthe requirements for public access to information on theNHS.2.1.8 Joint Finance ArrangementsThe Board may confirm contracts to purchase from avoluntary organisation or a local authority using itspowers under Section 28A of the NHS Act 1977. TheBoard may confirm contracts to transfer money from theNHS to the voluntary sector or the health relatedfunctions of local authorities where such a transfer is tofund services to improve the health of the localpopulation more effectively than equivalent expenditureon NHS services, using its powers under Section 28A ofthe NHS Act 1977, as amended by section 29 of theHealth Act 1999.See overlap with Standing Financial Instruction No. 21.3.4

2.2 Delegation of PowersThe Trust has powers to delegate and make arrangements for delegation.The Standing Orders set out the detail of these arrangements. Underthe Standing Order relating to the Arrangements for the Exercise ofFunctions (SO 6) the Trust is given powers to "make arrangements forthe exercise, on behalf of the Trust of any of their functions by acommittee, sub-committee or joint committee appointed by virtue ofStanding Order 6.4 or by an officer of the Trust, in each case subject tosuch restrictions and conditions as the Trust thinks fit or as theSecretary of State may direct". Delegated Powers are covered inAnnexe 1 This document has effect as if incorporated into the StandingOrders. Delegated Powers are covered in a separate document entitled– ‘Schedule of Matters reserved to the Board and Scheme ofDelegation’ and have effect as if incorporated into the Standing Ordersand Standing Financial Instructions.2.3 Failure to Comply with SOs2.3.1 Failure to comply with SOs is a disciplinary matter that may result indismissal.3. THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENUREAND ROLE OF MEMBERS3.1 Composition of the Membership of the Trust Board3.1.1 In accordance with the Membership, Procedure and AdministrationArrangements regulations the composition of the Board shall be:1 . The Chair of the Trust (Appointed by the NHS AppointmentsCommission);2 . Up to 5 non-officer members (appointed by the NHSAppointments Commission);3 . Up to 5 officer members (but not exceeding the number ofnon-officer members) including:• the Chief Executive;• The Director of FinanceTrust shall have not more than 11 and not less than 8 members(unless otherwise determined by the Secretary of State forHealth and set out in the Trust’s Establishment Order or suchother communication from the Secretary of State).5

3.2 Appointment of Chair and Members of the Trust3.2.1 Appointment of the Chair and Members of the Trust - Paragraph 3 ofthe NHS Act 2006 schedule 4 parts 1, provides that the Chair isappointed by the Secretary of State, as are the other non-executivemembers. This is executed through the NHS National TrustDevelopment Authority.3.3 Terms of Office of the Chair and Members3.3.1 The terms of office of the Chair and members and for the termination orsuspension of office of the Chair and members are contained inSections 2 to 4 of the Membership, Procedure and AdministrationArrangements and Administration Regulations.3.4 Appointment and Powers of Vice-Chair3.4.1 Subject to Standing Order 3.4 (2) below, the Chair and members of theTrust may appoint one of their numbers, who is not also an officermember, to be Vice-Chair, for such period, not exceeding theremainder of his term as a member of the Trust, as they may specify onappointing him.3.4.2 Any member so appointed may at any time resign from the office ofVice-Chair by giving notice in writing to the Chair. The Chair andmembers may thereupon appoint another member as Vice-Chair inaccordance with the provisions of Standing Order 3.4.1.3.4.3 3.4 1 above.3.4.4 Where the Chair of the Trust has died or has ceased to hold office, orwhere they have been unable to perform their duties as Chair owing toillness or any other cause, the Vice-Chair shall act as Chair until a newChair is appointed or the existing Chair resumes their duties, as thecase may be; and references to the Chair in these Standing Ordersshall, so long as there is no Chair able to perform those duties, betaken to include references to the Vice-Chair.3.5 Joint MembersWhere more than one person is appointed jointly to a post mentioned inregulation 2(4)(a) of the Membership, Procedure and AdministrationArrangements Regulations those persons shall count for the purpose ofStanding Order 2.1 as one person.Where the office of a member of the Board is shared jointly by morethan one person:6

(a)(b)(c)(d)either or both of those persons may attend or take part inmeetings of the Board;if both are present at a meeting they should cast one voteif they agree;in the case of disagreements no vote should be cast;the presence of either or both of those persons shouldcount as the presence of one person for the purposes ofStanding Order 3.1.1 Quorum.3.6 Role of MembersThe Board will function as a corporate decision-making body, Officerand Non-Officer Members will be full and equal members. Their role asmembers of the Board of Directors will be to consider the key strategicand managerial issues facing the Trust in carrying out its statutory andother functions.(i) Executive MembersExecutive Members shall exercise their authority within the terms ofthese Standing Orders and Standing Financial Instructions and theScheme of Delegation.(ii) Chief ExecutiveThe Chief Executive shall be responsible for the overall performance ofthe executive functions of the Trust. He/she is the AccountableOfficer for the Trust and shall be responsible for ensuring thedischarge of obligations under Financial Directions and in line with therequirements of the Accountable Officer Memorandum for Trust ChiefExecutives.(iii) Director of FinanceThe Director of Finance shall be responsible for the provision offinancial advice to the Trust and to its members and for the supervisionof financial control and accounting systems. He/she shall beresponsible along with the Chief Executive for ensuring the dischargeof obligations under relevant Financial Directions.(iv) Non-Executive MembersThe Non-Executive Members shall not be granted nor shall they seekto exercise any individual executive powers on behalf of the Trust.They may however, exercise collective authority when acting asmembers of or when chairing a committee of the Trust which hasdelegated powers.(v) ChairThe Chair shall be responsible for the operation of the Board and chairall Board meetings when present. The Chair has certain delegated7

executive powers. The Chair must comply with the terms ofappointment and with these Standing Orders.The Chair shall liaise with the NHS National Trust DevelopmentAuthority over the appointment of Non-Executive Directors and onceappointed shall take responsibility either directly or indirectly for theirinduction, their portfolios of interests and assignments, and theirperformance.The Chair shall work in close harmony with the Chief Executive andshall ensure that key and appropriate issues are discussed by theBoard in a timely manner with all the necessary information and advicebeing made available to the Board to inform the debate and ultimateresolutions.3.7 Corporate role of the Board(a)(b)All business shall be conducted in the name of the Trust.All funds received in trust shall be held in the name of the Trust ascorporate trustee.(c) The powers of the Trust established under statute shall beexercised by the Board meeting in public session except asotherwise provided for in Standing Order No. 3.(d) The Board shall define and regularly review the functions itexercises on behalf of the Secretary of State.3.8 Schedule of Matters reserved to the Board and Scheme ofDelegation3.8.1 The Board has resolved that certain powers and decisions may only beexercised by the Board in formal session. These powers and decisionsare set out in the ‘Schedule of Matters Reserved to the Board’ and shallhave effect as if incorporated into the Standing Orders. Those powerswhich it has delegated to officers and other bodies are contained in theScheme of Delegation.3.9 Lead Roles for Board MembersThe Chair will ensure that the designation of Lead roles orappointments of Board members as required by the Department ofHealth or as set out in any statutory or other guidance will be made inaccordance with that guidance or statutory requirement (e.g. appointinga Lead Board Member with responsibilities for Infection Control or ChildProtection Services etc.).4. MEETINGS OF THE TRUST8

4.1 Calling meetings(1) Ordinary meetings of the Board shall be held at regular intervalsat such times and places as the Board may determine.(2) Meetings of the Board may be called by the Secretary, or by theChair or by one third or more members of the Board who mayrequisition a meeting in writing specifying the business to becarried out. The secretary shall send by appropriate means awritten notice of the dates, times and location of meetings to allmembers as soon as possible after the receipt of such a request.Other emergency meetings of the members may be called,subject to SO4.5 below. If the Chair refuses, or fails, to call ameeting within seven days of a requisition being presented, themembers signing the requisition may forthwith call a meeting.(3) In special circumstances, where there is an urgent need to call ameeting, the Secretary or the chair may decide that such ameeting shall be called in less than 14 days notice and in suchcircumstances as much notice as possible shall be given of themeeting to each of the Members.(4) Subject to SO 4.5 below, lack of the service of notice on anymember shall not affect the validity of a meeting.(5) Failure to serve notice specifying the business on more than twoMembers will invalidate the meeting. A notice will have beenpresumed to have been served at the time when the notice willhave been ordinarily delivered in the ordinary course of post orwhere the notice is sent by email, at the time at which the emailwas sent.4.2 Notice of Meetings and the Business to be transacted(1) Before each meeting of the Board a written notice specifying thebusiness proposed to be transacted shall be delivered to everymember, or sent by post to the usual place of residence of eachmember, so as to be available to members at least three cleardays before the meeting. The notice shall be signed by the Chairor by an officer authorised by the Chair to sign on their behalf.Want of service of such a notice on any member shall not affectthe validity of a meeting.(2) In the case of a meeting called by members in default of the Chaircalling the meeting, the notice shall be signed by those members.(3) No business shall be transacted at the meeting other than thatspecified on the agenda, or emergency motions allowed underStanding Order 3.6.9

(4) A member desiring a matter to be included on an agenda shallmake his/her request in writing to the Chair at least [15] clear daysbefore the meeting. The request should state whether the item ofbusiness is proposed to be transacted in the presence of thepublic and should include appropriate supporting information.Requests made less than [15] days before a meeting may beincluded on the agenda at the discretion of the Chair.(5) Before each meeting of the Board, a public notice of the time andplace of the meeting, and the public part of the agenda, shall bedisplayed at the Trust’s principal offices at least three clear daysbefore the meeting.4.3 Agenda and Supporting PapersBefore each meeting of the Board an agenda of the meeting specifyingthe business proposed to be transacted at it and any supporting papersshall be delivered to each Member so as to be available to him at leastthree clear days before meetings.The board may determine that certain matters shall appear on everyagenda for a meeting of the Board and shall be addressed prior to anyother business being conducted. (Such matters may be identified withinthe SOs or following subsequent resolution shall be listed on anappendix of the SOs.)A member desiring a matter to be included on an agenda shall makehis or her request in writing to the Chair at least 10 clear days beforethe meeting. Requests made with less 10 days prior to a meeting maybe included into the agenda at the discretion of the Chair.4.4 Notice of Motion(1) Subject to the provision of Standing Orders 4.6 ‘Motions:Procedure at and during a meeting’ and 4.7 ‘Motions to rescind aresolution’, a member of the Board wishing to move a motion shallsend a written notice to the Chief Executive who will ensure that itis brought to the immediate attention of the Chair.(2) The notice shall be delivered at least [l5] clear days before themeeting. The Chief Executive shall include in the agenda for themeeting all notices so received that are in order and permissibleunder governing regulations. This Standing Order shall notprevent any motion being withdrawn or moved without notice onany business mentioned on the agenda for the meeting.4.5 Emergency MotionsSubject to the agreement of the Chair, and subject also to the provisionof Standing Order 4.6 ‘Motions: Procedure at and during a meeting’, a10

member of the Board may give written notice of an emergency motionafter the issue of the notice of meeting and agenda, up to one hourbefore the time fixed for the meeting. The notice shall state the groundsof urgency. If in order, it shall be declared to the Trust Board at thecommencement of the business of the meeting as an additional itemincluded in the agenda. The Chair's decision to include the item shallbe final.4.6 Motions: Procedure at and during a meetingi) Who may propose?A motion may be proposed by the Chair of the meeting or any memberpresent. It must also be seconded by another member.ii) Contents of motionsThe Chair may exclude from the debate at their discretion any suchmotion of which notice was not given on the notice summoning themeeting other than a motion relating to:- the reception of a report;- consideration of any item of business before the Trust Board;- the accuracy of minutes;- that the Board proceed to next business;- that the Board adjourn;- that the question be now put.iii) Amendments to motionsA motion for amendment shall not be discussed unless it has beenproposed and seconded.Amendments to motions shall be moved relevant to the motion, andshall not have the effect of negating the motion before the Board.If there are a number of amendments, they shall be considered one ata time. When a motion has been amended, the amended motion shallbecome the substantive motion before the meeting, upon which anyfurther amendment may be moved.iv) Rights of reply to motionsa) AmendmentsThe mover of an amendment may reply to the debate on theiramendment immediately prior to the mover of the originalmotion, who shall have the right of reply at the close of debateon the amendment, but may not otherwise speak on it.b) Substantive/original motionThe member who proposed the substantive motion shall have aright of reply at the close of any debate on the motion.11

v) Withdrawing a motionA motion, or an amendment to a motion, may be withdrawn.vi) Motions once under debateWhen a motion is under debate, no motion may be moved other than:- an amendment to the motion;- the adjournment of the discussion, or the meeting;- that the meeting proceed to the next business;- that the question should be now put;- the appointment of an 'ad hoc' committee to deal with a specifictem of business;- that a member/director be not further heard;- a motion under Section l (2) or Section l (8) of the Public Bodies(Admissions to Meetings) Act l960 resolving to exclude thepublic, including the press (see Standing Order 4.16).In those cases where the motion is either that the meeting proceeds tothe ‘next business’ or ‘that the question be now put’ in the interests ofobjectivity these should only be put forward by a member of the Boardwho has not taken part in the debate and who is eligible to vote.If a motion to proceed to the next business or that the question be nowput, is carried, the Chair should give the mover of the substantivemotion under debate a right of reply, if not already exercised. Thematter should then be put to the vote.4.7 Motion to Rescind a Resolution(1) Notice of motion to rescind any resolution (or the generalsubstance of any resolution) which has been passed within thepreceding six calendar months shall bear the signature of themember who gives it and also the signature of three othermembers, and before considering any such motion of whichnotice shall have been given, the Trust Board may refer thematter to any appropriate Committee or the Chief Executive forrecommendation.(2) When any such motion has been dealt with by the Trust Board itshall not be competent for any director/member other than theChair to propose a motion to the same effect within six months.This Standing Order shall not apply to motions moved inpursuance of a report or recommendations of a Committee or theChief Executive.4.8 Chair of meeting12

(1) At any meeting of the Trust Board the Chair, if present, shallpreside. If the Chair is absent from the meeting, the Vice-Chair (ifthe Board has appointed one), if present, shall preside.(2) If the Chair and Vice-Chair are absent, such member (who is notalso an Officer Member of the Trust) as the members presentshall choose shall preside.4.9 Chair's rulingThe decision of the Chair of the meeting on questions of order,relevancy and regularity (including procedure on handling motions) andtheir interpretation of the Standing Orders and Standing FinancialInstructions, at the meeting, shall be final.4.10 Quorum(i)(ii)No business shall be transacted at a meeting unless at least onethirdof the whole number of the Chair and members (including atleast one member who is als o an Officer Member of the Trust andone member who is not) is present.An Officer in attendance for an Executive Director (Officer Member)but without formal acting up status may not count towards thequorum.(iii) If the Chair or Member has been disqualified from participating inthe discussion on any matter and/or from voting on any resolutionby reason of a declaration of a conflict of interest (see SO No.7)that person shall no longer count towards the quorum. If a quorumis then not available for the discussion and/or the passing of aresolution on any matter, that matter may not be discussed furtheror voted upon at that meeting. Such a position shall be recorded inthe minutes of the meeting. The meeting must then proceed to thenext business.4.11 Voting(i)(ii)Save as provided in Standing Orders 4.12 Suspension ofStanding Orders and 4.13 - Variation and Amendment of StandingOrders, every question put to a vote at a meeting shall bedetermined by a majority of the votes of members present andvoting on the question. In the case of an equal vote, the personpresiding (i.e.: the Chair of the meeting shall have a second, andcasting vote.At the discretion of the Chair all questions put to the vote shall bedetermined by oral expression or by a show of hands, unless theChair directs otherwise, or it is proposed, seconded and carriedthat a vote be taken by paper ballot.13

(iii) If at least one third of the members present so request, the votingon any question may be recorded so as to show how eachmember present voted or did not vote (except when conducted bypaper ballot).(iv) If a member so requests, their vote shall be recorded by name.(v) In no circumstances may an absent member vote by proxy.Absence is defined as being absent at the time of the vote.(vi) A manager who has been formally appointed to act up for anOfficer Member during a period of incapacity or temporarily to fillan Executive Director vacancy shall be entitled to exercise thevoting rights of the Officer Member.(vii) A manager attending the Trust Board meeting to represent anOfficer Member during a period of incapacity or temporaryabsence without formal acting up status may not exercise thevoting rights of the Officer Member. An Officer’s status whenattending a meeting shall be recorded in the minutes.(viii) An Officer’s status when attending a meeting shall be recorded inthe minutes(ix) For the voting rules relating to joint members see Standing Order3.5 (If both officers hold a voting right there will be one vote)4.12 Suspension of Standing Orders(i)(ii)Except where this would contravene any statutory provision or anydirection made by the Secretary of State or the rules relating tothe Quorum (SO 4.10), any one or more of the Standing Ordersmay be suspended at any meeting, provided that at least twothirdsof the whole number of the members of the Board arepresent (including at least one member who is an Officer Memberof the Trust and one member who is not) and that at least twothirdsof those members present signify their agreement to suchsuspension. The reason for the suspension shall be recorded inthe Trust Board's minutes.A separate record of matters discussed during the suspension ofStanding Orders shall be made and shall be available to the Chairand members of the Trust.(iii) No formal business may be transacted while Standing Orders aresuspended.(iv) The Audit Committee shall review every decision to suspendStanding Orders.14

4.13 Variation and amendment of Standing OrdersThese Standing Orders shall not be varied except in the followingcircumstances:- upon a notice of motion under Standing Order 4.6- upon a recommendation of the Chair or Chief Executive includedon the agenda for the meeting;- that two thirds of the Board members are present at the meetingwhere the variation or amendment is being discussed, and thatat least half of the Trust’s Non-Officer members vote in favour ofthe amendment;- providing that any variation or amendment does not contravenea statutory provision or direction made by the Secretary of State.A separate record of matters discussed during the suspension of SOsshall be made and shall be available to the Chair and Members of theBoard.No formal business may be transacted while SOs are suspended.The Audit Committee shall review every decision to suspend SOs.4.14 Record of AttendanceThe names of the Chair and Directors/members present at themeeting shall be recorded.4.15 MinutesThe minutes of the proceedings of a meeting shall be drawn up andsubmitted for agreement at the next ensuing meeting where theyshall be signed by the person presiding at it.No discussion shall take place upon the minutes except upon theiraccuracy or where the Chair considers discussion appropriate.4.16 Admission of public and the press(i)Admission and exclusion on grounds of confidentiality ofbusiness to be transactedThe public and representatives of the press may attend allmeetings of the Trust, but shall be required to withdraw upon theTrust Board as follows:- 'that representatives of the press, and other members of thepublic, be excluded from the remainder of this meetinghaving regard to the confidential nature of the business to be15

transacted, publicity on which would be prejudicial to thepublic interest', Section 1 (2), Public Bodies (Admission toMeetings) Act l960- Guidance should be sought from the NHS Trust’s Freedomof Information Lead to ensure correct procedure is followedon matters to be included in the exclusion.(ii)General disturbancesThe Chair (or Vice-Chair if one has been appointed) or theperson presiding over the meeting shall give such directions ashe thinks fit with regard to the arrangements for meetings andaccommodation of the public and representatives of the presssuch as to ensure that the Trust’s business shall be conductedwithout interruption and disruption and, without prejudice to thepower to exclude on grounds of the confidential nature of thebusiness to be transacted, the public will be required to withdrawupon the Trust Board resolving as follows:- `That in the interests of public order the meeting adjourn for(the period to be specified) to enable the Trust Board tocomplete its business without the presence of the public'.Section 1(8) Public Bodies (Admissions to Meetings) Actl960.(iii) Business proposed to be transacted when the press andpublic have been excluded from a meetingMatters to be dealt with by the Trust Board following theexclusion of representatives of the press, and other members ofthe public, as provided in (i) and (ii) above, shall be confidentialto the members of the Board.Members and Officers or any employee of the Trust inattendance shall not reveal or disclose the contents of papersmarked 'In Confidence' or minutes headed 'Items Taken inPrivate' outside of the Trust, without the express permission ofthe Trust. This prohibition shall apply equally to the content ofany discussion during the Board meeting which may take placeon such reports or papers.(iv) Use of Mechanical or Electrical Equipment for Recording orTransmission of MeetingsNothing in these Standing Orders shall be construed aspermitting the introduction by the public, or pressrepresentatives, of recording, transmitting, video or similarapparatus into meetings of the Trust or Committee thereof.Such permission shall be granted only upon resolution of theTrust.16

4.17 Observers at Trust meetingsThe Trust will decide what arrangements and terms and conditions itfeels are appropriate to offer in extending an invitation to observers toattend and address any of the Trust Board's meetings and maychange, alter or vary these terms and conditions as it deems fit.5. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES5.1 Appointment of CommitteesSubject to such directions as may be given by the Secretary of Statefor Health, the Trust Board may appoint committees of the Trust.The Trust shall determine the membership and terms of reference ofcommittees and sub-committees and shall if it requires to, receive andconsider reports of such committees.5.2 Joint Committees(i)(ii)Joint committees may be appointed by the Trust by joiningtogether with one or more other Strategic Health Authorities, orother Trusts consisting of, wholly or partly of the Chair andmembers of the Trust or other health service bodies, or wholly ofpersons who are not members of the Trust or other healthbodies in question.Any committee or joint committee appointed under this StandingOrder may, subject to such directions as may be given by theSecretary of State or the Trust or other health bodies inquestion, appoint sub-committees consisting wholly or partly ofmembers of the committees or joint committee (whether or notthey are members of the Trust or health bodies in question) orwholly of persons who are not members of the Trust or healthbodies in question or the committee of the Trust or health bodiesin question.5.3 Applicability of Standing Orders and Standing FinancialInstructions to CommitteesThe Standing Orders and Standing Financial Instructions of the Trust,as far as they are applicable, shall as appropriate apply to meetingsand any committees established by the Trust. In which case the term“Chair” is to be read as a reference to the Chair of other committee asthe context permits, and the term “member” is to be read as areference to a member of other committee also as the contextpermits. (There is no requirement to hold meetings of committeesestablished by the Trust in public.)5.4 Terms of Reference17

Each such committee shall have such terms of reference and powersand be subject to such conditions (as to reporting back to the Board),as the Board shall decide and shall be in accordance with anylegislation and regulation or direction issued by the Secretary of State.Such terms of reference shall have effect as if incorporated into theStanding Orders.5.5 Delegation of powers by Committees to Sub-CommitteesWhere committees are authorised to establish sub-committees theymay not delegate executive powers to the sub-committee unlessexpressly authorised by the Trust Board.5.6 Approval of Appointments to CommitteesThe Board shall approve the appointments to each of the committeeswhich it has formally constituted. Where the Board determines, andregulations permit, that persons, who are neither members norofficers, shall be appointed to a committee the terms of suchappointment shall be within the powers of the Board as defined by theSecretary of State. The Board shall define the powers of suchappointees and shall agree allowances, including reimbursement forloss of earnings, and/or expenses in accordance where appropriatewith national guidance.5.7 Appointments for Statutory functionsWhere the Board is required to appoint persons to a committee and/orto undertake statutory functions as required by the Secretary of State,and where such appointments are to operate independently of theBoard such appointment shall be made in accordance with theregulations and directions made by the Secretary of State.5.8 Committees established by the Trust BoardThe sub-committees established by the Board are:5.8.1 Audit CommitteeAn audit Committee is established and constituted to provide theBoard with independent and objective advice. The Audit Committeemust have a broad remit to take a comprehensive view ofgovernance, risk management and internal control across theorganization. The Audit Committee must recognise the pivotal rolethe Board Assurance Framework should play in managing theorganisation’s strategic objectives. The Audit Committee will maintaina systematic approach that considers and measures the potentialimpact of proposed cost reductions on the quality of healthcare. Itdelivers to its financial governance obligations and compliance with18

elevant legislation and guidance, including HM treasury’s guidanceon Managing Public Money May 2012. The Terms of Reference willbe approved by the Trust Board and reviewed on a periodic basis.A minimum of three non-executive directors be appointed, unless theBoard decides otherwise, of which one must have significant, recentand relevant financial experience.5.8.2 Remuneration and Terms of Service CommitteeA remuneration and Terms of Service committee will be establishedand be comprised exclusively of at least three Non-ExecutiveDirectors, who are independent of management.The primary purpose of the Committee will be to advise the TrustBoard about appropriate remuneration and terms of service for theChief Executive and other Executive Directors including:(i)(ii)(iii)all aspects of salary (including any performance-relatedelements/bonuses);provisions for other benefits, including pensions and cars;arrangements for termination of employment and othercontractual terms.5.8.3 Trust and Charitable Funds CommitteeIn line with its role as a corporate trustee for any funds held in trust,either as charitable or non charitable funds, the Trust Board willestablish a Trust and Charitable Funds Committee to administer thosefunds in accordance with any statutory or other legal requirements orbest practice required by the Charities Commission.The provisions of this Standing Order must be read in conjunctionwith Standing Financial Instructions.l instructions.5.8.4 Quality and Safety CommitteeThe primary purpose of the quality and safety committee will overseeall aspects of clinical care and ensure that processes and protocolsare developed to ensure that the Trust delivers its legal andoperational responsibilities in providing a high standard of clinical care.In line with the code of conducts’ that govern clinical and managerialstaff all staff will cooperate with the requests of this committee.5.8.5 Finance CommitteeThe primary purpose is to consider the trusts financial strategy interms of revenue and capital. Provide the board with assurance andconduct a board level review of financial policy planning andperformance of the Trust. The committee will manage the financial19

aspects of cost improvement, Quality Improvement, innovation andproductivity. Reviewing and monitoring all major business cases orrevenue costs in excess of £1m.5.8.6 Workforce CommitteeThis committee is responsible for reviewing and planning for theworkforce needs of the organization. Ensuring that the services areplanned for and delivered by a skilled and educated workforce.5.8.7 Other Committees5.8.8 The Board may also establish such other committees as required todischarge the Trust's responsibilities6. ARRANGEMENTS FOR THE EXERCISE OF TRUST FUNCTIONSBY DELEGATION6.1 Delegation of Functions to Committees, Officers or other bodies6.1.1 Subject to such directions as may be given by the Secretary of State,the Board may make arrangements for the exercise, on behalf of theBoard, of any of its functions by a committee, sub-committeeappointed by virtue of Standing Order 6.3, or by an officer of theTrust, or by another body as defined in Standing Order 6.1.2 below, ineach case subject to such restrictions and conditions as the Trustthinks fit.6.1.2 Schedule 4 part 2 Section 18 the NHS Act 2006 allows for regulationsto provide for the functions of Trust’s to be carried out by third parties.In accordance with The Trusts (Membership, Procedure andAdministration Arrangements) Regulations 2000 the functions of theTrust may also be carried out in the following ways:(i)by another Trust;(ii) jointly with any one or more of the following: NHS trusts,Strategic Health Authorities or PCTs;(iii) by arrangement with the appropriate Trust or PCT, by a jointcommittee or joint sub-committee of the Trust and one or more otherhealth service bodies;(iv) in relation to arrangements made under S63(1) of the HealthServices and Public Health Act 1968, jointly with one or moreStrategic Health Authorities, SHAs, NHS Trusts or PCT.6.1.3 Where a function is delegated by these Regulations to another Trust,then that Trust or health service body exercises the function in itsown right; the receiving Trust has responsibility to ensure that theproper delegation of the function is in place. In other situations, i.e.20

delegation to committees, sub-committees or officers, the Trustdelegating the function retains full responsibility.6.2 Emergency Powers and urgent decisionsThe powers which the Board has reserved to itself within theseStanding Orders (see Standing Order 4.5) may in emergency or foran urgent decision be exercised by the Chief Executive and the Chairafter having consulted at least two non-officer members. The exerciseof such powers by the Chief Executive and Chair shall be reported tothe next formal meeting of the Trust Board in public session for formalratification.6.3 Delegation to Committees6.3.1 The Board shall agree from time to time to the delegation of executivepowers to be exercised by other committees, or sub-committees, orjoint-committees, which it has formally constituted in accordance withdirections issued by the Secretary of State. The constitution andterms of reference of these committees, or sub-committees, or jointcommittees, and their specific executive powers shall be approved bythe Board in respect of its sub-committees.6.3.2 When the Board is not meeting as the Trust in public session it shalloperate as a committee and may only exercise such powers as mayhave been delegated to it by the Trust in public session.6.4 Delegation to Officers6.4.1 Those functions of the Trust which have not been retained asreserved by the Board or delegated to other committee or subcommitteeor joint-committee shall be exercised on behalf of the Trustby the Chief Executive. The Chief Executive shall determine whichfunctions he/she will perform personally and shall nominate officers toundertake the remaining functions for which he/she will still retainaccountability to the Trust.6.4.2 The Chief Executive shall prepare a Scheme of Delegation identifyinghis/her proposals which shall be considered and approved by theBoard. The Chief Executive may periodically propose amendment tothe Scheme of Delegation which shall be considered and approvedby the Board.6.4.3 Nothing in the Scheme of Delegation shall impair the discharge of thedirect accountability to the Board of the Director of Finance to provideinformation and advise the Board in accordance with statutory orDepartment of Health requirements. Outside these statutoryrequirements the roles of the Director of Finance shall be accountableto the Chief Executive for operational matters.21

6.5 Schedule of Matters Reserved to the Trust and Scheme ofDelegation of powers6.5.1 The arrangements made by the Board as set out in the "Schedule ofMatters Reserved to the Board” and “Scheme of Delegation” ofpowers shall have effect as if incorporated in these Standing Orders.6.6 Duty to report non-compliance with Standing Orders andStanding Financial InstructionsIf for any reason these Standing Orders are not complied with, fulldetails of the non-compliance and any justification for non-complianceand the circumstances around the non-compliance, shall be reportedto the next formal meeting of the Board for action or ratification. Allmembers of the Trust Board and staff have a duty to disclose anynon-compliance with these Standing Orders to the Chief Executive assoon as possible.7. OVERLAP WITH OTHER TRUST POLICYSTATEMENTS/PROCEDURES, REGULATIONS AND THESTANDING FINANCIAL INSTRUCTIONS7.1 Policy statements: general principlesThe Trust Board will from time to time agree and approve Policystatements/ procedures which will apply to all or specific groups ofstaff employed by Barking Havering and Redbridge universityHospital NHS Trust. The decisions to approve such policies andprocedures will be recorded in an appropriate Trust Board minute andwill be deemed where appropriate to be an integral part of the Trust'sStanding Orders and Standing Financial Instructions.7.2 Specific Policy statementsNotwithstanding the application of SO 6.0 above, these StandingOrders and Standing Financial Instructions must be read inconjunction with the following Policy statements:- the Standards of Business Conduct and Conflicts of InterestPolicy for Barking, Havering and Redbridge University HospitalsNHS Trust staff;- the staff Disciplinary and Appeals Procedures adopted by theTrust both of which shall have effect as if incorporated in theseStanding Orders.7.3 Standing Financial Instructions22

Standing Financial Instructions adopted by the Trust Board inaccordance with the Financial Regulations shall have effect as ifincorporated in these Standing Orders.7.4 Specific guidanceNotwithstanding the application of SO 6.1 above, these StandingOrders and Standing Financial Instructions must be read inconjunction All applicable law and guidance issued by the Secretaryof State for Health:8. DUTIES AND OBLIGATIONS OF BOARD MEMBERS/DIRECTORSAND SENIOR MANAGERS UNDER THESE STANDING ORDERS8.1 Declaration of Interests8.1.1 Requirements for Declaring Interests and applicability to BoardMembersi) Trust Board Members shall to declare interests which are relevantand material to the NHS Trust Board of which they are a member.All existing Board members should declare such interests. AnyBoard members appointed subsequently should do so onappointment.8.1.2 Interests which are relevant and material(i)Interests which should be regarded as "relevant and material" are:a) Directorships, including Non-ExecutiveDirectorships held in private companies or PLCs(with the exception of those of dormant companies);b) Ownership or part-ownership of private companies,businesses or consultancies likely or possiblyseeking to do business with the NHS;c) Majority or controlling share holdings inorganisations likely or possibly seeking to dobusiness with the NHS;d) A position of Authority in a charity or voluntaryorganisation in the field of health and social care;e) Any connection with a voluntary or otherorganisation contracting for NHS services;f) Research funding/grants that may be received byan individuals or their department;g) Interests in pooled funds that are under separatemanagement.23

(ii) Any member of the Trust Board who comes to know that theTrust has entered into or proposes to enter into a contract inwhich he/she or any person connected with him/her (as definedin Standing Order 7.3 below and elsewhere) has any pecuniaryinterest, direct or indirect, the Board member shall declarehis/her interest by giving notice in writing of such fact to theTrust as soon as practicable.8.1.3 Advice on InterestsIf Board members have any doubt about the relevance of aninterest, this should be discussed with the Chair of the Trust orwith the Trust’s Company Secretary.Financial Reporting Standard No 8 (issued by the AccountingStandards Board) specifies that influence rather than the immediacyof the relationship is more important in assessing the relevance of aninterest. The interests of partners in professional partnershipsincluding general practitioners should also be considered.8.1.4 Recording of Interests in Trust Board minutesAt the time Board members' interests are declared, they should berecorded in the Trust Board minutes.Any changes in interests should be declared at the next Trust Boardmeeting following the change occurring and recorded in the minutesof that meeting.8.1.5 Publication of declared interests in Annual ReportBoard members' directorships of companies likely or possibly seekingto do business with the NHS should be published in the Trust'sannual report. The information should be kept up to date for inclusionin succeeding annual reports.8.1.6 Conflicts of interest which arise during the course of a meetingDuring the course of a Trust Board meeting, if a conflict of interest isestablished, the Board member concerned should withdraw from themeeting and play no part in the relevant discussion or decision. (Seeoverlap with SO 7.3)8.2 Register of Interests8.2.1 The Chief Executive will ensure that a Register of Interests isestablished to record formally declarations of interests of Board orCommittee members. In particular the Register will include details of alldirectorships and other relevant and material interests (as defined in24

SO 7.1.2) which have been declared by both executive and nonexecutiveTrust Board members.8.2.2. These details will be kept up to date by means of a six monthly Reviewof the Register in which any changes to interests declared during thepreceding twelve months will be incorporated.8.2.3 The Register will be available to the public and the Chief Executive willtake reasonable steps to bring the existence of the Register to theattention of local residents and to publicise arrangements for viewing it.8.3 Exclusion of Chair and Members in proceedings on account ofpecuniary interest8.3.1 Definition of terms used in interpreting ‘Pecuniary’ interestFor the sake of clarity, the following definition of terms is to be used ininterpreting this Standing Order:(i) "spouse" shall include any person who lives with another personin the same household (and any pecuniary interest of onespouse shall, if known to the other spouse, be deemed to bean interest of that other spouse);(ii) “Person connected with a member” shall include a spouse (asdefined above ) and any other person with whom the memberhas a personal or professional relationship, including but notlimited to a family member, friend or acquaintance(ii)"contract" shall include any proposed contract or other course ofdealing.(iii) “Pecuniary interest”Subject to the exceptions set out in this Standing Order, aperson shall be treated as having an indirect pecuniary interestin a contract if:-a) he/she, or a nominee of his/her, is a member of acompany or other body (not being a public body), withwhich the contract is made, or to be made or which has adirect pecuniary interest in the same, orb) he/she is a partner, associate or employee of any personwith whom the contract is made or to be made or who hasa direct pecuniary interest in the same.iv)Exception to Pecuniary interests25

A person shall not be regarded as having a pecuniary interest inany contract if:-a) neither he/she or any person connected with him/her hasany beneficial interest in the securities of a company ofwhich he/she or such person appears as a member, orb) any interest that he/she or any person connected withhim/her may have in the contract is so remote orinsignificant that it cannot reasonably be regarded aslikely to influence him/her in relation to considering orvoting on that contract, orc) those securities of any company in which he/she (or anyperson connected with him/her) has a beneficial interestdo not exceed £5,000 in nominal value or one per cent ofthe total issued share capital of the company or of therelevant class of such capital, whichever is the less.Provided however, that where paragraph (c) above applies theperson shall nevertheless be obliged to disclose/declare theirinterest in accordance with Standing Order 88.3.2 Exclusion in proceedings of the Trust Board(i)Subject to the following provisions of this Standing Order, if theChair or a member of the Trust Board has any pecuniaryinterest, direct or indirect, in any contract, proposed contract orother matter and is present at a meeting of the Trust Board atwhich the contract or other matter is the subject of consideration,they shall at the meeting and as soon as practicable after itscommencement disclose the fact and shall not take part in theconsideration or discussion of the contract or other matter orvote on any question with respect to it.(ii) The Secretary of State may, subject to such conditions ashe/she may think fit to impose, remove any disability imposed bythis Standing Order in any case in which it appears to him/her inthe interests of the National Health Service that the disabilityshould be removed.(iii) The Trust Board may exclude the Chair or a member of theBoard from a meeting of the Board while any contract, proposedcontract or other matter in which he/she has a pecuniary interestis under consideration.(iv) Any remuneration, compensation or allowance payable to theChair or a Member by virtue of paragraph 11 of Schedule 5A tothe National Health Service Act 1977 (pay and allowances) shall26

not be treated as a pecuniary interest for the purpose of thisStanding Order.(v) This Standing Order applies to a committee or sub-committeeand to a joint committee or sub-committee as it applies to theTrust and applies to a member of any such committee or subcommittee(whether or not he/she is also a member of the Trust)as it applies to a member of the Trust.8.4.2 Standards of business conductAll board member should comply with the boards standards ofbusiness conduct, the conflicts of interest policy and Staffdisciplinary and appeals procedure.8.4.3 Interest of Officers in Contractsi) Any officer or employee of the Trust who comes to know that theTrust has entered into or proposes to enter into a contract inwhich he/she or any person connected with him/her (as definedin SO 8.1) has any pecuniary interest, direct or indirect, theOfficer shall declare their interest by giving notice in writing ofsuch fact to the Chief Executive or Trust’s Company Secretaryas soon as practicable.ii)iii)An Officer/ Member should also declare to the Chief Executiveany other employment or business or other relationship ofhis/her, or of a cohabiting spouse, that conflicts, or mightreasonably be predicted could conflict with the interests of theTrust.The Trust will require interests, employment or relationships sodeclared to be entered in a register of interests of staff.8.4.4 Canvassing of and Recommendations by Members in Relation toAppointmentsi) Canvassing of members of the Trust or of any Committee of theTrust directly or indirectly for any appointment under the Trustshall disqualify the candidate for such appointment. Thecontents of this paragraph of the Standing Order shall beincluded in application forms or otherwise brought to theattention of candidates.ii)Members of the Trust shall not solicit for any person anyappointment under the Trust or recommend any person for suchappointment; but this paragraph of this Standing Order shall notpreclude a member from giving written testimonial of acandidate’s ability, experience or character for submission to theTrust.27

8.4.5 Relatives of Members or Officersi) Candidates for any staff appointment under the Trust shall,when making an application, disclose in writing to the Trustwhether they are related to any member or the holder of anyoffice under the Trust. Failure to disclose such a relationshipshall disqualify a candidate and, if appointed, render him liableto instant dismissal.ii)The Chair and every member and officer of the Trust shalldisclose to the Trust Board any relationship between himself anda candidate of whose candidature that member or officer isaware. It shall be the duty of the Chief Executive to report to theTrust Board any such disclosure made.iii) On appointment, members (and prior to acceptance of anappointment in the case of Executive Directors) should discloseto the Trust whether they are related to any other member orholder of any office under the Trust.iii)Where the relationship to a member of the Trust is disclosed, theStanding Order headed ‘Disability of Chair and members inproceedings on account of pecuniary interest’ (SO 8.3.2) shallapply.28

9. CUSTODY OF SEAL, SEALING OF DOCUMENTS ANDSIGNATURE OF DOCUMENTS9.1 Custody of SealThe common seal of the Trust shall be kept by the Chief Executive ora nominated Manager by him/her in a secure place.9.2 Sealing of DocumentsWhere it is necessary that a document shall be sealed, the seal shallbe affixed in the presence of a Trust Director and a Non-ExecutiveDirector (not from the originating department), and shall be attestedby them.9.3 Register of SealingThe Chief Executive shall keep a register in which he/she, or anothermanager of the Authority authorised by him/her, shall enter a recordof the sealing of every document.9.4 Signature of documentsWhere any document will be a necessary step in legal proceedingson behalf of the Trust, it shall, unless any enactment otherwiserequires or authorises, be signed by a Director of the Trust and aNon-Executive Director.In land transactions, the signing of certain supporting documents willbe delegated to Managers and set out clearly in the Scheme ofDelegation but will not include the main or principal documentseffecting the transfer (e.g. sale/purchase agreement, lease, contractsfor construction works and main warranty agreements or anydocument which is required to be executed as a deed).29

SCHEME OF DELEGATION STANDING ORDERSSO REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED1.1 Chair Final authority in interpretation of Standing Orders (SOs).3.4 Board Appointment of Vice Chair4.2 Chair Call meetings.3.6 Chair Chair all Board meetings and associated responsibilities.4.9 Chair Give final ruling in questions of order, relevancy and regularity of meetings.4.11 Chair Having a second or casting vote4.12 Board Suspension of Standing Orders4.12 Audit Committee Audit Committee to review every decision to suspend Standing Orders (power tosuspend Standing Orders is reserved to the Board)4.13 Board Variation or amendment of Standing Orders6.1, 6.2 Board Formal delegation of powers to sub committees or joint committees and approval of theirconstitution and terms of reference. (Constitution and terms of reference of subcommittees may be approved by the Chief Executive.)6 Chair & ChiefExecutiveThe powers which the Board has retained to itself within these Standing Orders may inemergency be exercised by the Chair and Chief Executive after having consulted atleast two Non-Executive members.6.5 Chief Executive The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposalsthat shall be considered and approved by the Board, subject to any amendment agreedduring the discussion.6.6 All Disclosure of non-compliance with Standing Orders to the Chief Executive as soon aspossible.8 the Board Declare relevant and material interests.8.1 Chief Executive Maintain Register(s) of Interests.8.4.3 All staff Comply with guidance contained in8.4.3 (ii) All Disclose relationship between self and candidate for staff appointment. (CE to report the30

SO REF DELEGATED TO AUTHORITIES/DUTIES DELEGATEDdisclosure to the Board.)9.1/9.3 Chief Executive Keep seal in safe place and maintain a register of sealing.9.4 ChiefExecutive/Executive DirectorApprove and sign all documents which will be necessary in legal proceedings.* Nominated officers and the areas for which they are responsible should be incorporated into the Trust’s Scheme of Delegationdocument.31

EXECUTIVE SUMMARYTITLE:Quality & Safety Committee Escalation Report – Part IBOARD/GROUP/COMMITTEE:Trust Board – Part I1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:The Quality & Safety Committee wishes to keep the TrustBoard advised that following the recent Risk ManagementStandards Level 1 review the Trust successfully achieved50 out of 50.The Level 1 review aims to ensure Trust policy documentsand key processes for risk management are meeting theprescribe standards laid down by the NHS LitigationAuthority.□ TEC ……………..….. □ STRATEGY……….….……□ FINANCE ……..……… □ AUDIT ………….………….x QUALITY & SAFETY …………..…12.2.13....……….…□ WORKFORCE ………………………………………….…□ CHARITABLE FUNDS ………………………………...…□ TRUST BOARD ……………………………….……….….2. DECISION REQUIRED: CATEGORY:□ REMUNERATION ………………………………….….....□ OTHER …………………………..……. (please specify)The Trust Board is asked to note the successful RMSassessment result.□ NATIONAL TARGET□ CQC REGISTRATION□ RMS□ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERSX CORPORATE OBJECTIVE …Achieving RMS Level 1□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Caroline Wright, Chair ofQuality & Safety CommitteeDATE: 14.2.133. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:The Trust will retain the 10% discount on its Clinical Negligence Scheme for Trusts premium paid to the NHS LitigationAuthority.4. DELIVERABLESA raft of key risk management policies that meet the Risk Management Standards laid down under the ClinicalNegligence Scheme for Trusts.5. KEY PERFORMANCE INDICATORSKey performance indicators for each of the relevant policies is clearly laid out in a monitoring matrix which is aimed atfacilitating the collection of Level 2 data for subsequent accreditation.AGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

EXECUTIVE SUMMARYTITLE:Escalation Report from the Trust ExecutiveCommitteeBOARD/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:A summary of issues discussed at the February2013 and December 2012 Trust Executivemeetings.□ 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)AUTHOR/PRESENTER: Averil DongworthDATE: 24 February 20133. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:n/a4. DELIVERABLES5. KEY PERFORMANCE INDICATORSAGREED AT ______________________ MEETINGORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________

Trust Executive Board Report to the Board of Directors 6 March 2013CQC Report on Emergency Department and maternity services.Board members will need to be aware that the CQC reports for the emergency department andmaternity services were reviewed with the TEC committee and the diagnostics and action plan foremergency department were discussed enabling the whole hospital including support services toinput into the diagnostic and emergency care pathway improvement plan.The principles for improved working were defined by the medical director needed changes to UCC/ED and MAU and medical rotas were explored with clinical directors. Further plans included arange of ward moves between Queen’s and King George, to ensure the most effective use ofspecialist staff across both sites and availability for the emergency care pathway. Ambulatory careimprovements, additional GPs in the RATing area and redirects to the UCC were also planned.Further session between managers and clinical directors devised plans to use the winter pressuresfunding allocations. These plans were used as the basis for improvements for the Risk Summitwhich took place on the 7 th February 2013. Further work to improve the plan to incorporate thefeedback from NHS London the National Commissioning Board London, The National TrustDevelopment authority and the Care Quality Commission is underway.It was proposed that the Trust look at buying in some clinical support from organisations currentlydelivering the 4-hour target, in order to support the ED and the Acute Medicine pathway. The Trusthad to manage the flows, ambulances arriving, use KGH more pro-actively and meet the deadlineson the 4-hour Access Improvement Plan, with everyone working to achieve the deadline dates.The TEC received a presentation from QFI, an analysis of the current functioning of the MedicalAssessment Unit (MAU). This highlighted that it currently functions more of an admissions unit, andthat two thirds of the Trust’s patients are currently admitted directly to the wards. It was suggestedthat the lack of an effective assessment unit potentially contributes to increasing lengths of stay,with many of the patients directly admitted leaving the hospital within 48 hours. With beds taken upby patients directly admitted to the wards, it became hard to admit MAU patients when appropriate,resulting in blockages in MAU, causing blockages and delays in the ED. The MAU would need tobe twice its current size or have a much reduced length of stay to function as it does currently. Arange of solutions across the Trust were examined, including making use of assessment spaces inother departments, including care of the elderly. It was agreed to focus in the short term onincreasing the functional capacity of the MAU so that it could deliver more effectively by the end ofMarch. This would include reviewing rotas and staffing requirements.The progress and improvement in Maternity Services from the CQC report was noted, alongsidethe opening of the Birth centre. The members noted the reduction in deliveries (720 compared to790 in October). The Trust had also seen a reduction in the number of bookings and C-sections.Three SIs had been reported (one being a ‘Never Event’); investigations for all three wereunderwayFinance ReportMembers were briefed on the current financial position. Members noted that discussions had beenheld at the recent Transformation Board meeting around bringing forward other opportunities intothis financial year. All members were asked to consider the areas where further bank and agencyreductions could be made for the remainder of the year. The key risk at the moment was missingthe CIP and also mitigating the ‘red’ rated schemes. Everyone fully understood the challenge stillahead. A £30k Challenge was being launched today to engage Directorate teams in addressingthe financial gapIt was noted that the Trust had made a small surplus in January, due to non-recurrent income, andthis was a very positive step. Members were asked to ensure delivery of the remaining CIPs, whichwould enable us to deliver the control total.2

Workforce Report.Data was reviewed and it was noted that the In House Bank fill rate was declining, and the reasonsfor this would be investigated. The revised sickness policy and new probationary policy to beintroduced were noted.Performance Report.This was reviewed in some detail. Members noted that the C diff rate was not abating, and thatactions needed to be stepped up, including reducing laxative use, screening on admission andstrengthening the antibiotic policy and its enforcement. The 18 week referral to treatment time wasdiscussed and the issue of the clinical responsibility for those patients waiting.Organisational Development.£1.5m has been allocated by NHS London for this work, and the Trust has secured the support ofSimon Mac Rory to assist with delivering this project. A mission statement, values and set ofbehaviours has been drafted with the Board.Business plans.Feedback was identified on the cost pressures the clinical directors had identified. It was alsonoted that it was essential the clinical directorates briefed the corporate directorate thoroughly onthe support they required, so this could be factored into the corporate business plans.Pensions auto-enrolment of staff.The Government has introduced changes requiring auto-enrolment of all staff in a pensionscheme. This will cover staff who have previously opted out and those who work on the In HouseBank. A proposal to approve the National Employment Savings Trust scheme for those staffineligible to join the NHS Pensions Scheme was approved.Staff survey.It was noted that improvements had been made in the 2012 survey, which will be published on 28 thFebruary, although the Trust still has one of the lowest levels of recommending care to friends andfamily.Service Level Agreement for external contractors.A proposed standard template contract for external contractors was approved.Acute Quality Care Standards.Following an assessment of Queen’s in September 2012, data was to be published on ourcompliance with acute quality standards, and also standards in maternity care. The full data set isexpected to appear on 28 February.Board Assurance Framework:This was discussed and reviewed. Work was underway on strategic risk sot ensure that they wereall assessed and formed part of the Directorates’ Business Planning for next year. All memberswere asked to review the ‘CQC’s Essential Standards of Quality & Safety’ paper. It was agreedthat Emergency Care needed to be rated high on the BAF, bearing in mind the recent CQC visit tothe Department.Proposal to Restructure the Clinical Research Centre:A proposal was presented on restructuring the Clinical Research Centre (CRC), as they werespread geographically in many clinical and non-clinical areas in Queen’s. It was important thatBHRUT continued to develop a fully functional CRC and the proposal set out an enhanced

structure that would ensure they were ‘fit for purpose’ to maximise research and revenue potentialand bring everyone into one management area. The location of the CRC still required furtherwork, but it was agreed this would be considered as part of business planning, and under onemanagement area.Quality & Patient Standards Performance Report – November 2012:MRSA screening was improving, but still not on target (should be 100%). Members discussed theissues preventing the Trust from achieving 100% and how to address them.Complaints performance was poor, with only 43% of complaints being responded to in line withagreement with patients. There were still 187 complaints open and 26 were over 90 days old. Thecommittee asked the CD’s to work with the Director of nursing to improve complaints. It was notedthat the Trust was performing well on cancer staging data, the second best in London. PatientExperience continued to be rated as ‘red’ and it was agreed that it was important for staff to ensurethat all surveys were completed, as this information was very valuable in pushing forward theimprovements required. Sickness absence remained in the ‘red’, the recent action agreed onreporting sickness will be monitored for improvement.CQC Accident and Emergency Department Survey 2012:The members noted that the results from the Survey indicated that BHRUT was severelyunderperforming in comparison to our peers, the worst in London and practically the worst in thecountry. Poor communication between staff and patients was highlighted as a significant issue andthe culture of the organisation with staff saying ‘no’, rather than saying ‘yes’, with some staff turningdown requests to review patients or support colleagues.This has been incorporated in theEmergency Department ‘s emergency care pathway improvement plan.Averil DongworthChief Executive4

1REPORT TO:REPORT FROM:Trust BoardChairmanDATE: 20 February 2013SUBJECT:CHAIRMAN’S REPORTFOR:Information______________________________________________________________The Francis Enquiry:It will be hard for anyone not to have seen the details of the appalling care sufferedby many patients at Mid Staffordshire hospital, as described in the recent report.For us, it would seem to me that there are two important issues. The first is that weshould be absolutely clear that we either have taken, or will very shortly be taking, allreasonable steps to ensure that this systemic failure could not happen in ourhospitals. We must then demonstrate this to our patients and the communities whorely on us. The second issue is that should re-double our efforts to ensure that weput patients at the heart of everything we do.While many of the 290 recommendations in the report require legislation, or otherchanges which are outside our control, there are two sections in the report which Iwould like to highlight. I believe they are consistent with all that we are trying to do,but they bear repetition and emphasis.The report describes the important aspects of delivering an organisational culturewhich delivers high quality care with kindness and skill and lists them as follows:-• Emphasis on and commitment to common values throughout the system byall within it;• Readily accessible fundamental standards and means of compliance;• No tolerance of non-compliance and the rigorous policing of fundamentalstandards;• Openness, transparency and candour in all the system’s business;• Strong leadership in nursing and other professional values;• Strong support for leadership roles;• A level playing field for accountability;• Information accessible and useable by all, allowing effective comparison ofperformance by individuals, services and organisation.Chairman’s Report – March 2013

2It also makes the point that achieving this high performing culture does not requireradical re-organisation.In discussing the obstacles to the achievement of the sort of culture which putspatients at the centre and insists on nothing but the best, the report also outlines thesort of behaviours which prevent this happening:-• A lack of openness to criticism;• A lack of consideration for patients;• Defensiveness;• Looking inwards not outwards;• Secrecy;• Misplaced assumptions about the judgments and actions of others;• An acceptance of poor standards;• A failure to put the patient first in everything that is done.I endorse this totally.I believe that all of this is consistent with what we are trying to achieve at both KingGeorge’s and Queen’s and the changes we have made over the past two years.There is still further to go and more to learn.Our patients and our communities have every right to seek re-assurance from us thatwe are learning from the lessons of Mid Staffs and from the things which we have notgot right in the past. The way we can offer that re-assurance is by being open to theviews of our patients and demonstrating that we have an open and learning culture.It would be foolish to promise that we will get everything right, but it is crucial that welearn from errors and do all we can not to repeat them, and to apologise when we doslip up.I am asking the Executive Team to see if there is more that we can learn from theFrancis report and report back to the Trust Board in one month’s time. What I amdetermined to insist on is that the care we provide to all our patients is care that wecan be proud of and which everyone of us would want for ourselves.Peter Dixon25 February 2013Chairman’s Report – March 2013

1REPORT TO:REPORT FROM:Trust BoardChief ExecutiveDATE: 20 February 2013SUBJECT:CHIEF EXECUTIVE’S REPORTFOR:Information______________________________________________________________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 Chairman, or Chief Executive acting underemergency powers.4. EXECUTIVE DECISIONSThe Trust Executive Committee has been meeting on a monthly basis and havereviewed and inputted into several reports prior to their submission to the TrustBoard, such as the Emergency Care Report/4-Hour Access Improvement Plan,Staff Survey 2012, Acute Quality Standards and the CQC Accident andEmergency Department Survey 2012.5. NATIONAL ISSUES/NEWS:NHS Commissioning Board sets out planning guidance for first year:The NHS Commissioning Board has published its planning guidance for NHSCommissioners, called ‘Everyone Counts: Planning for Patients 2013/14’. Theguidance covers a set of outcomes against which to measure improvements. Itoutlines five offers, - more toward seven-day a week working for routine NHSservices, greater transparency and choice for patients, more patient participation,better data to support the drive to improve services, and higher standards andsafer care.For further information go to:http://www.commissioningboard.nhs.uk/2012/12/17/everyonecounts/Chief Executive’s Report – March 2013

2Pathology Quality Assurance Review Launched:A review of quality assurance arrangements for NHS Pathology Services hasbeen announced, to be led by Dr Ian Barnes, the National Clinical Director forPathology. It will scrutinise NHS arrangements for the oversight andsafeguards of laboratory testing. Serious incidents are rare, but concerns wereraised at Sherwood Forest NHS Foundation Trust in October about PathologyTesting of breast cancers, used to choose the best treatment for each patient,where the care of a small number of women was disadvantaged.The review, expected to report at the end of 2013, will bring together experts inthe field to explore how quality assurance systems can be strengthened and howorganisations can be more confident about the monitoring of the quality of carethey offer the public.For further information go to: http://mediacentre.dh.gov.uk/2012/12/18/pathologyquality-assurance-review-launched/NHS funding transfer to Local Authorities 2013/14:The Department of Health has published details of the transfer of £859m in2013/14 from the NHS to Local Authorities. The funding must support adultsocial care services in each Authority, which also has a health benefit. Theletter from Shaun Gallagher, Director General, Social Care, Local Governmentand Care partnerships, describes conditions of the transfer and the allocationdue to each Local Authority.Link: http://www.dh.gov.uk/health/2012/12/transfer-funding-nhs/New child abuse alert system for hospitals:Hospitals will have a new system to help Doctors and Nurses spot childrensuffering from abuse and neglect. It will be known as the ‘Child Protection –Information System’ and will enable medical staff in Emergency Departments orUrgent Care Centres to see if the children they treat are subject to a childprotection plan, or are being looked after by the Local Authority, or havefrequently attended their units.They will be able to use this information as part of their overall clinicalassessment, along with data about where and when children have previouslybeen receiving urgent treatment. This will help them build up a better picture ofwhat is happening in the child’s life so they can alert Social Services if they thinksomething might be wrong. Work on the system began this year and it will startto be introduced to NHS Hospitals in 2015.For further information go to: http://www.dh.gov.uk/health/2012/12/abuse-alertsystem/£5.45 billion budget for Local Public Health Services:A £5.45 billion two-year ring-fenced Public Health budget for Local Authoritieshas been announced by the Department of Health. From April 2013, when LocalAuthorities take the lead for improving the health of their local communities,Public Health budgets will be protected for the first time. This will help drivelocal efforts to improve health and wellbeing by tackling the wide determinants ofpoor health.Building on advice from an independent expert group – the Advisory Committeeon Resource Allocation (ACRA) – funding is specifically targeted for the first timeat those areas with the worst health outcomes.Chief Executive’s Report – March 2013

3In 2013/14, the total budget for local Public Health services will be just under£2.7 billion. In 2014/15, the budget will be just under £2.8 billion. Every LocalAuthority will receive a real terms increase in funding.For further information go to: http://www.dh.gov.uk/health/2013/01/public-healthbudgets/Government investment to boost health research:New funding for health research will benefit millions of patients and tackle someof the country’s biggest health problems over the next five years.The £120 million National Institute for Health Research (NIHR) scheme willsupport up to 12 projects and is part of the Government’s commitment to put theUK at the forefront of health research. Previous funding has led to thedevelopment of innovative health solutions, such as a new blood clotting drugthat reduces the risk of death in patients by 30 percent, and improved follow upcare for stroke survivors using a targeted questionnaire.For further information go to:http://mediacentre.dh.gov.uk/2013/01/09/government-invests-120-million-toboost-health-research/Benefits of digital technology highlighted:Two new reports and a speech by Health Secretary Jeremy Hunt haveemphasised the potential benefits to patients of digital technology and onlinerecords.A PriceWaterhouseCoopers study reviewing better use of information andtechnology found that measures such as increased use of text messages fornegative test results, electronic prescribing and electronic health records couldimprove care, allow health professionals to spend more time with patients andsave billions. A National Mobile Health Worker report just published was a pilotstudy on introducing laptops at 11 NHS sites.The NHS should become paperless by 2018 to improve services and help meetthe challenges of an ageing population, Jeremy Hunt said. Patients should havecompatible digital records so their health information could follow them aroundthe health and social care system. This would mean that in the vast majority ofcases, whether a patient needed a GP, hospital or a care home, theprofessionals involved in their care could see their history at the touch of a buttonand share crucial information.For further information go to: http://www.dh.gov.uk/health./2013/01/paperless/Baroness Neuberger to lead review of Liverpool Care Pathway:The review examining how the Liverpool Care Pathway (LCP) is being used inpractice is to be chaired by crossbench peer Baroness Julia Neuberger. Latelast year, Care and Support Minister Norman Lamb committed to appoint anindependent chair for the review, following a roundtable on the LCP with a widerange of experts in end of life care, and representatives of patients and theirfamilies.Julia Neuberger, who is Senior Rabbi at the West London synagogue and formerChief Executive of the King’s Fund, will examine various elements of the LCP,including the experience and opinions of patients, families, and healthprofessionals, hospital complaints, local payments made to hospitals in respectof the LCP and the literature about its benefits and limitations.The Minister said everyone wanted their loved ones’ final hours to be as pain freeand dignified as possible and experts agreed the LCP, if applied properly, couldChief Executive’s Report – March 2013

4play a vital role to achieve this. But there had been too many cases wherepatients or their families were ignored, or not properly involved in decisions, andthis was unacceptable.For further information go to:http://mediacentre/dh.gov.uk/2013/01/15/independent-review-of-liverpool-carepathway-to-be-chaired-by-baroness-neuberger/100 Hospitals to take part in £25m Maternity Unit Makeover:More than 100 hospitals across England will share a £25 million fund to improveand upgrade their maternity units.Several older maternity hospitals will be refurbished, such as the 1970’s unit atAiredale NHS Foundation Trust and one at Musgrove Park Hospital in Tauntonand Somerset NHS Foundation Trust, which dates back as far as the 1940’s.There will also be funding for a large number of simple measures that improveboth choice for women and their experience of maternity care.Improvements include approximately 40 new birthing pools that can help makelabour less stressful and painful, eight new midwife-led units that are morerelaxing places to give birth, and more en suite facilities in over 40 maternityunits, providing more dignity and privacy for women. Equipment such as bedsand family rooms will be installed in almost 50 units, allowing dads and familiesto stay overnight and support women while in labour, or if their baby needsneonatal care.For further information, go to: http://mediacentre.dh.gov.uk/2013/01/24/100-hospitals-to-take-part-in-25-million-maternity-unit-makeover/South London Healthcare NHS Trust to be dissolved by 1 October 2013:The most financially challenged NHS Trust in England is to be dissolved byOctober 2013 to address the risk it carries for ongoing patient care and thepressure it is placing on other parts of the NHS, Health Secretary JeremyHunt has announced.Previous attempts to solve the financial problems at South London HealthcareNHS Trust have failed. Currently, the Trust is losing more than £1 millionevery week and by the end of this year, is expected to have an accumulateddebt of more than £200 million – money that is being taken away frompatients elsewhere.On the advice of NHS Medical Director Professor Bruce Keogh, Mr Hunt alsoannounced he has decided it is in the best interests of patients that LewishamHospital should retain it’s A&E Department.For further information, go to: http://mediacentre/dh.gov.uk/2013/01/31/southlondon-healthcare-nhs-trust-to-be-dissolved-by-1-october-2013NHS Change Day 13 March 2013:This is one day of individual creativity by NHS staff and their supporters,pledging to do one simple thing to change the way they work and the carethey give. It is a grassroots initiative devised and led by the next generationof young and emergent clinical and managerial leaders from primary andsecondary care across the NHS.Link: www.changemodel.nhs.uk/changedayChief Executive’s Report – March 2013

5Whistleblowing: bridging the gap:Many people know about whistleblowing procedures, but some do not feelsafe using them. ‘Bridging the Gap’ is a campaign launched by theGovernment-funded whilsteblowing helpline to encourage a culture where allindividuals feel safe to raise concerns and where managers are equipped torespond. Free posters and fliers are available on the weblink.Link: http://wbhelpline.org.uk/about-us/campaigns/Sickness absence savings calculator:NHS Employers has recently launched an interactive sickness absencesavings calculator. It has been produced as part of a new web sectionfocused on implementing health and wellbeing. This offers support andguidance on areas including engaging the Board, building and evidencing thebusiness case, developing manager competence and designing anddelivering a strategy.Link:http://www.nhsemployers.org/HealthyWorkplaces/implementingHWB/Pages/SicknessAbsenceSavingsCalculator.aspxNHS Leaders encouraged to hold listening events following Mid StaffsReport:Health Secretary Jeremy Hunt and NHS Chief Executive Sir David Nicholsonhave asked NHS Leaders around the Country to hold staff listening eventsfollowing the publication of Robert Francis’s report of the Public Inquiry intoMid Staffordshire NHS Foundation Trust. The listening events will help theNHS discuss and learn from the report. The events will provide insights inhelping to achieve a safer, more open, and compassionate NHS.For further information, go to: http://www.dh.gov.uk/health/2013/02/dhresponds-midstaffs/Landmark reform to help people with care and support costs:Jeremy Hunt, Secretary of State for Health, has announced a series ofreforms that will provide greater financial support for the elderly, those withdisabilities and long-term conditions in paying for their care costs.For further information, go to:http://caringforourfuture.dh.gov.uk/2013/02/11/funding-how/Local Authorities – Health and Wellbeing Boards and Health ScrutinyRegulations:The Local Authority (Public Health, Health and Wellbeing Boards and HealthScrutiny) Regulations 2013 have now been published. These Regulationsare intended to help Local Authorities finalise preparations for Health andWellbeing Boards and Health Scrutiny arrangements.For further information, go to: http://healthandcare.dh.gov.uk/hwbs-healthscrutiny-regulations-2013/NHS Friends and Family Test:The Department of Health has published guidance for providers of NHS fundedservices on calculating and publishing the NHS Friends and Family Test results.Link: http://www.dh.gov.uk/health/2013/02/nhs-fft-guidance/Chief Executive’s Report – March 2013

6New national pledge to improve children’s health and reduce child deaths:A new pledge about making improvements to the health of children and youngpeople has been launched. The pledge is part of the Government’s response tothe Children and Young People’s Health Outcomes Forum. Dr Daniel PoulterMP, Parliamentary Under Secretary of State for Health was first to sign thepledge, at an event at the Evelina Children’s Hospital – part of Guy’s and StThomas NHS Foundation Trust.For further information, go to: http://www.dh.gov.uk/health/2013/02/nationalpledge-cyp/Patient Led Assessments of the Care Environment (PLACE):Jane Cummings, Chief Nursing Officer, sets out the arrangements for the newsystem for assessing the quality of the hospital environment, which replacesPatient Environment Action Team (PEAT) inspections from April 2013. PLACEassessments will apply to all hospitals delivering NHS-funded care, including daytreatment centres and hospices. NHS Chief Executives will ensure theirhospitals are ready to engage with the PLACE process when it goes live in April2013.For further information, go to:http://www.commissioningboard.nhs.uk/2013/02/19/place/Monitor’s new Provider Licence Published:Monitor’s new Provider Licence has now been finalised and published. It will usethis tool to regulate providers of NHS Services. Monitor has agreed withMinisters they will licence Foundation Trusts from April 2013 and other eligibleNHS providers from April 2014.Link: http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/ourpublications/monitors-new-role/the-new-nhs-provider-licenceChief Executive’s Report – March 2013

Approved at QSC12.2.13QUALITY & SAFETY COMMITTEEPART I - OPENMinutes of the meeting held on Tuesday 22 nd January 2013 at 14.00 hrs in Board Rooms1&2, Trust Headquarters, Queen’s Hospital, Romford.Present: Caroline Wright, Non Executive Director (Chair) – CWDr Maureen Dalziel, Non Executive Director – MDProf. Anthony Warrens, Non Executive Director – AWDr Mike Gill, Medical Director - MGDr Magda Smith, Associate Medical Director, Governance - MSFlo Panel-Coates, Director of Nursing – FPCDr Jane Stevens, Clinical Director, Specialist Medicine – JSDr Geraldine Soosay, Clinical Director, Pathology – GSoDr Remi Odejinmi, Clinical Director, Anaesthetics - ROMr Gabriel Sayer, Clinical Director, Specialist Surgery –GSDr Zoltan Nagy, Clinical Director, Radiology – ZNProf. Donna Kinnair, Director of Governance & Special Projects – DKPam Strange, Clinical Governance Director - PSPortia Omo-Bare, Chief Pharmacist – POBGary Etheridge, Deputy Director of Nursing – GECris Robinson, Accreditation Manager / Committee Coordinator – CRRachael Brady, Quality & Clinical Governance Manager, NELC - RBDeputies: Dr Ajith James, Consultant Nephrologist – AJ (for Dr Andrew Deaner)Dr Cath Pearce, Emergency Department Consultant - CP (for Dr Derek Hicks)Miss Caolin MacLaverty, Consultant Obstetrician - CMacL (for Mr Dele Olorunshola)Mr Joseph Huang, Consultant Surgeon - JH (for Mr Dip Mukherjee)In Attendance: Sir Peter Dixon, Chairman - PDApologiesApologies were received from:Averil Dongworth, Chief Executive – ADMr Stephen Burgess, Director of Clinical Strategy – SBMr Dele Olorunshola, Clinical Director, Women’s Service – DODr Ambalika Das, Clinical Director, Children’s Service – ADaDr Andrew Deaner, Clinical Director, Acute Medicine – ADeMr Dip Mukherjee, Clinical Director, Surgery – DMMr Jonathan Pollock, Clinical Director, Neurosciences – JPDerek Hicks, Clinical Director – Emergency CareImogen Shillito, Director of Communications – ISAlison Crombie, Director of Education - ACJohn Alcolado, Associate Medical Director, Academia – JAElaine Clark, IPEG Chair - ECActionQSC draft minutes – January 2013 1

007/2013 Minutes of the Meeting held on the 11 th December 2012The minutes from the previous meeting were agreed as a true record.008/2013 Matters ArisingAction Log158/2012 - Energise for Excellence reports have been removed from therolling programme.159/2012 - MG advised that the proposed SHMI mortality target of 70 wastoo ambitions and will be revised to 90 for delivery in the next 12-18 months.160/2012 - PS reported that Dr Davy Yeung is currently reviewing thenational guidance in relation to the clinical trials database. An updatewould be provided to the February meeting once the review wascompleted.The target of 85% for resuscitation training was agreed and the nextEducation Board meeting will debate whether specific groups of staffneed to achieve higher than the set target. An update would be providedto the next meeting.The resuscitation data requested would be provided in the Februaryiteration of the Quality Dashboard.PS advised the discussions relating to nurse training for blood transfusion wasongoing. FPC stated that the issue relates to the sign off staff competenciesand she was working closely with GSo to resolve the issue which has beengenerated by the loss of transfusion nurses. FPC confirmed that whilst therisks have been mitigated GE has been asked to carry out a baselineassessment to identify which staff are outstanding. An update wasrequested for the February meeting.The expected update on NPSA insulin syringe guidance has been added tothe Rolling Programme by CR.161/2012 - The discussions concerning the Radiology quality dashboard tookplace and MG confirmed that he had had discussions with the PerformanceTeam. He asked members to consider the relevance of the various KPIs whenit is discussed later in the agenda; this with a view to removing those wheredata is not available.162/2012 - GS advised that the planned meeting to discuss NICE guidancewith RB had not taken place and was being rescheduled.165/2012 - MG provided an update on progress with improving theEmergency Department performance in the absence of the Clinical Director.He reported that a step-wise transformation plan is being implemented andClinical Directors have been fully involved in order to facilitate 7 day a weeksupport for the Emergency Department pathway. The pathway includes setparameters to monitor patient experience and quality standards which arediscussed with the Commissioners. There is a CQC Summit on theEmergency Department on the 7 th February but he expected the pathway to befunctioning by mid-February. A slight improvement in performance last weekwas noted.169/2012 - The Clinical Directors have been asked to provide a responseto MG on compliance with historic NICE guidance. A report oncompliance levels will be brought to the April Quality & SafetyCommittee meeting.ActionPSACMGFPCMGQSC draft minutes – January 2013 2

Rolling ProgrammeThe rolling programme was noted.009/2013 Patient Experience SurveyPATIENT EXPERIENCE(Not covered at December meeting)GE presented the above survey commenting that the news was positive. Heexplained the staff preference was for paper surveys rather than electronicand 1400 ‘Family and Friends’ surveys had been completed in Decemberalthough the intended start date is the 1 st April. Trust data on ‘family andfriends’ has been submitted to NELC who noted the positive progress. Theintention is now to focus on areas where the survey is not compliant and, at arecent performance review meeting senior sisters were invited to discuss thetopic.FPC advised that the process has not yet been introduced in Majors, MAU orA&E and work is ongoing with them to ensure their patients have theopportunity to comment on their experience. Once there are better IT systemsin place, currently being discussed with Steve Huddlestone, Chief Informationofficer, the frequency of feedback reports will be agreed. GE added that someof the softer issues from the surveys are being shared monthly with thenursing staff.AW suggested the inclusion of a narrative on actions taken to address issuesraised would be beneficial and FPC explained that they are considering alocalised ‘you said, we did’ process for providing feedback. A request wasalso made by AW for the inclusion of percentages.Members were advised by FPC that the questions asked via the surveys areextracted from the national survey to enable more frequent monitoring onperformance in those areas.PD suggested additional information could be gathered through theintroduction of ‘mystery shoppers’ and DK said that this suggestion wasincluded for discussion as part of the NHS Change Day review on the 13 thMarch. The Chairman of the Trust volunteered to provide information ona conference being run soon by KPMG that he felt would be useful forsomeone to attend.Further suggestions for improving the usefulness of the report were putforward by CW who felt the Trust’s ranking against other Trusts could beincluded, and she thought an element of competition between wardswould be positive; it was agreed this would be explored with theCommunications Team. In addition, CW felt the report could be ‘cut’differently to pull out key themes.GE concluded by stating the Trust was currently doing well against others inthe Cluster. However, MG cautioned that 1 in 10 patients, based on theinformation provided so far, would not recommend the hospital to their friendsand family and we therefore need to make their experiences better byproviding consistently good patient care to all our patients.010/2013 Quality Account 2011/12The above report was summarised by PS for members, she explainedthat the Directorates have been asked for their priority areas for 2013/14and these would be brought to the February meeting.ActionPDGEPSQSC draft minutes – January 2013 3

FPC suggested the review of last year’s priorities needed a furthercolumn to indicate its RAG rating as this would describe the deviationfrom expectations. The timetable was felt to be lagging behind by PD andCW agreed as the timescales did not work well with the Trust Board meetings.PS explained that the performance data is not ready until late April or earlyMay and this affects the production schedule.It was suggested that our Stakeholders and Commissioners could bewritten to now to ask for 3 priority areas they believe the Trust should betackling which could be reviewed jointly with the information providedby the Directorates and then prioritised. This was agreed. Other areasfrom which topics for improvement could be sourced included the staff survey,the Risk Register, care issues, dementia and national audits that are requiredto be included by the Quality Account Regulations. An update on priorities forimprovement to be submitted to the February meeting.PS was asked to ensure that the final version of the Directorate update on lastyear’s priorities included updates against the specifics of the original objectivee.g. by the inclusion of clear data or benchmarking against other Trusts’ datato demonstrate improvement.011/2013 Safeguarding Adults Qtr.2 ReportThe key points of the Safeguarding Adults report were included on page 3 anddemonstrates that at Level 1 93% of relevant staff have attended their trainingand 90% at Level 2. GE explained that Level 3 training has becomemandatory for the Trust this year so a trajectory is being set by theSafeguarding Adults Board to ensure those areas where the biggest differencecan be achieved are targeted first. The Level 3 training will be provided partlyin-house with some provided externally.In response to a question by CW members were advised by FPC that infuture reports the format will be different to show the number of staffrequired to be trained for each level, the target percentage, and theactual percentage of staff trained.The report was noted.012/2013 Learning Disabilities Progress ReportFPC explained that due to timing issues, this report had already beensubmitted to the Trust Board and shared with IPEG. It was thereforesubmitted for noting but she was happy to answer any questions.MS questioned whether there was a rigorous process for adolescents withlearning disabilities moving from paediatric care to adult service as often, inher experience, the parents of such adolescents feel they have been‘dropped’. She stressed the importance of ensuring their transition wasrigorously managed. FPC felt it would be appropriate to seek a reply from theSafeguarding Board on this question although she was aware those decisionswere clinical and based on individual assessments she would seekclarification. Members requested an update on the report’s Appendix 2for the March meeting once those discussions had taken place.MG was also concerned that the processes were rigorous enough to ensuresuch patients received the best treatment even if it was the middle of the night.FPC advised that patients with learning disabilities are flagged on the PAS andSafeguard systems and the effectiveness of this is currently being tested forknown people via an audit.ActionPSPSFPC /GEFPCQSC draft minutes – January 2013 4

013/2013 Accident & Emergency Survey (2012)Members were advised that the report included in the papers did not providesufficient information especially on the Trust’s position against its peer group.FPC suggested the report be revisited when the ‘second cut’ data wasavailable, proposing that it be re-presented in another format when the fullstory was known. Unfortunately, the copy made available to the Trust Boardand Non Executive Directors was also bereft of the more detailed information.AW suggested the RAG rating was also updated for the next iteration.The fact that the report was available via the CQC website was raised by CWand this was expanded upon by MG who pointed out that the CQC will usevarious sources of information, including this document, to triangulate theirown data on our performance in the Emergency Department. FPC agreedthat the current ‘flagging’ systems did not appear to be working and shewould be working to rectify this and would work closely with theCommunication Director to ensure there was a rigorous response readyfor release once the CQC A&E report was made public.Members agreed that the report should be brought back in a revisedformat for the February meeting when it would be co-presented with theClinical Director for Emergency Medicine.An extended discussion then ensued, initiated by PD, on how assurance canbe provided that staff want to fix the problems that have been identified. Hisview was that staff feel they are expected to fail and are tolerant of failure. JSfelt strongly that the turnaround example set by maternity demonstrates thatonce processes are fit for purpose, staff attitudes improve. She felt that itclearly demonstrated that an ineffective working environment clearly affectsstaff attitudes and behaviour but that these can be transformed. The issueswere in her view clearly system generated. This view was also held by FPC,however she also felt that ensuring there was clarity around roles,responsibilities and expectations went a long way to improving the system sothat everyone knew what they had to do and how to escalate concerns. JScomments were also echoed by GS who added that the importance ofrecruitment and retention was a considerable contributory factor to theeffective running of any system if existing staff are not to be over-burdened.JH, deputising for Mr Mukherjee, felt the poor competency levels of somelocum staff in the department also adversely affected the running of thedepartment. He stated variable competency levels were clearly evident and itwas not possible for the Consultants to supervise them all of the time due toother commitments. It was noted that on the whole, staff felt able to flagcompetency issues to their line managers. MG reminded those present thatthe locum process requires a form to be completed about theircompetence and this needs to be completed honestly. It was agreed MGwould send out a message to the Consultant body reminding them ofthis requirement.Members debated alternative recruitment scenarios and those clinicianspresent were asked to ensure they considered asking good locums to take ontemporary contracts and consider whether doctors with other generalised skillscould be enticed into the Emergency Department. GB, RO and JS allresponded stressing all such avenues have been, and continue to be,explored to fill vacancies.FPC again stressed the need for local data in order to provide a coherentpatient experience story although other data, such as complaints, should beused to supplement the local data. The members were in total agreementthat the Trust has to improve and will not accept a reduced standard of careActionFPC /DHFPC /DHMGQSC draft minutes – January 2013 5

for patients in the Emergency Department.014/2013 Patient Experience Report – Qtr.2The quarterly report was presented and GE highlighted that 41-45% of allcomplaints are generated by patient concerns with the Trust’s appointmentsystem. A Task and Finish Group was suggested by FPC to review theissues and MS recommended that a discussion outside the meeting wasarranged as there was likely to be some duplication with the OutpatientWork stream. The Patient Experience Committee will focus on Outpatientissues at their next meeting.The report was noted.STRATEGY015/2013 Quality & Safety Committee Terms of Reference.Further to the discussion in Part II of the meeting, it was agreed that theTerms of Reference for the Quality & Safety Committee would beconsidered by key staff together with the Terms of Reference for theSerious Incident Review Panel and would be brought to the Marchmeeting for discussion.016/2013 Items for Escalation from Feeder CommitteesThere were no items requiring escalation from the feeder committees as themajority had not met since the last report to the Quality & Safety Committee inDecember.017/2013 Quality DashboardThe November quality data was incorporated into a revised dashboard, whichMG explained was still work in progress. He asked members for their viewson the ‘black’ areas. This needs to be considered outside of themeeting.FPC said that the complaints data was now available and would be included inthe next iteration.A request from MD for inclusion of compliance with the WHO checklistwas made and would be considered by MG, she suggested this could bebroken down in two ways 1) excluding maternity and 2) excluding maintheatres.The inclusion of the Radiology dashboard was noted, but it was agreed itshould replicate the format of the other Directorates. This was agreed byZN for the next iteration.Suggestions for further improvements were put forward including identifyingkey themes in the executive summary such as MRSA screening, which couldbe sourced from Dr Ian Hosein, Director of Infection Prevention & Control, orcomplaint themes. There was a short debate about whose responsibilityMRSA screening was for emergency patients.It was agreed the next iteration of the dashboard for the February meetingwould take on board the various comments and suggestions and wouldinclude medication incidents, full complaint data, all data in the same formatand comprehensive narratives to be provided by the Clinical Directorsagainst any ‘red’ indicators. The narrative must provide sufficient detail toassure the Committee that mitigating actions have been taken and examplesshould be provided.ActionFPC /MSCWPSMG / PSMGZNMG / AllClinicalDirectorsQSC draft minutes – January 2013 6

018/2013 Quality StrategyMG explained that he was working closely with DK to develop the QualityStrategy and the current draft was being added to with information supplied byFPC. SB will be scrutinising the Strategy and it will be brought to theFebruary meeting.019/2013 Savile Allegations ReviewPATIENT SAFETYIt was noted that this report has already been to the Trust Board and wassubmitted to the Committee for noting, FPC would take questions. The reporthad also been reviewed by the Safeguarding Committee and members wereadvised that investigations have shown there were no visits by Jimmy Savileto this Trust or its predecessor Trusts. The report was noted.020/2013 Care Quality Commission UpdateThe final checks on accuracy with the CQC Emergency Department reportwere being concluded and once approved by the Chief Executive would besubmitted. The report would form a large part of the discussions at theforthcoming CQC Summit on the 7 th February. Also included in the updatereport was information about a process for facilitating each department, notjust Maternity and the Emergency Department, to self-assess themselvesagainst the essential standards, the results of these self-assessments willbe brought to the Committee on completion. In relation to the CQCoverview sheet DK confirmed she was the Executive Lead for MedicinesManagement and FPC agreed she was the Executive Lead for Nutrition.Also included in the report was the deferred mental health registration item. Itwas confirmed that the Trust was not currently registered for detention underthe Mental Health Act and the service level agreement with North East LondonFoundation Trust needed to be scrutinised to ensure it covered all Registrationunder the Mental Health Act requirements on behalf of the Trust as this wouldnegate the need to be separately registered.PS confirmed that she and the Chief Executive had had conversations with theCQC Compliance Manager on this topic and the current actions were in linewith those discussions, but the CQC Compliance manager considered that theTrust should Register.It was agreed MG would progress the SLA review as quickly as possibleand DK would check out the Trust’s holding powers.A mental health registration progress report was requested for the nextmeeting.021/2013 Risk Management Standards (RMS)A status report on progress with the preparations for the Level 1 RMSassessment in February was provided by PS. She explained that the PolicyRatification Committee had done a huge amount of work on the RMS policiesrequired for review, but also on a large number of other Trust policydocuments. However, she advised that whilst 49 areas had been internallyassessed as compliant, there remained one area that the Trust would not becompliant with and that was because the GMC had some outstandingconcerns about ‘supervision of trainees’. The assessors make their decisionon compliance from information directly available from the GMC and which wehave been advised will not be resolved before the visit.PD suggested that information should be provided to the MarchCommittee on the plans to achieve Level 2 with clear timescales andActionMGDKMG/DKMGQSC draft minutes – January 2013 7

information on any obstacles to achievement. PS agreed to bring thisforward after the Level 1 visit and once their report had been received asthis would provide clarity on any areas of weakness. PD suggested theLevel 1 assessment could be included in the Quality Account.ActionPS022/2013 Any Other BusinessNo other business was raised.023/2013 Summary of Issues for Escalation to Trust BoardThere were no issues requiring escalation to the Trust Board.024/2013 Date of Next MeetingThe next scheduled meeting will be held in Board Rooms 1&2 at 14.00 hourson the 12 th February 2012.QSC draft minutes – January 2013 8

ACTION LOG – PART I22 nd January 2013008/2013 MATTERS ARISINGUpdate with Dr Davy Yeung’s review of a clinical database to record patientstaking part in clinical trials to be brought to the next meeting.Feedback from the Education Board on any specific staff groups needing toachieve higher than 85% for resuscitation training.Resuscitation data to be included in the next Quality Dashboard.Update on nurse training for blood transfusion competencies to the Februarymeeting.Report on compliance with historic NICE guidance by each Directorate to bebrought to the April meeting.009/2013 PATIENT EXPERIENCE SURVEYInformation on KPMG Conference that refers to ‘mystery shopper’ to becirculated to members by Trust Chairman.Consideration to be given to pulling out key themes from the survey for a futuremeeting – no date specified.010/2013 QUALITY ACCOUNTRAG rating column to be adding to the 2012/13 priorities for improvement.Clinical Directors to provide clear update on original intended actions and RAGrate progress with the improvements in the last Quality Account. Updatesrequired for the February meetingAn update on Trust priorities for improvement, taking on board Committeecomments, to be brought to the February meeting.Stakeholders and Commissioners to be asked for 3 priority areas for 2013/14improvement.011/2013 SAFEGUARDING ADULTS QTR.2 REPORTFuture report format to be as defined at January meeting.012/2013 LEARNING DISABILITIESAn update on the report’s Appendix 2 to be brought to the March meeting oncediscussions held with the Safeguarding Board.013/2013 A&E SURVEYRevised version of the report to be brought to the February meeting and copresentedwith the Clinical Director of Emergency Department.Work with Communications Team to ensure rigorous response ready forrelease of CQC reportReminder for honest completion of Locum Competency Forms to be sent toConsultant body.014/2013 PATIENT EXPERIENCE REPORTTask and Finish Group to discussed complaints, meeting to take place outsideQSC.ResponsibilityPSACMGFPCMGPDGECRAll ClinicalDirectorsPSPSFPC / GEFPCFPC / DHFPC / DHMGFPC / MSQSC draft minutes – January 2013 9

015/2013 QSC TERMS OF REFERENCEDiscussion of QSC and SI Review Panel Terms of Reference by key staff andrevision brought back to March Quality & Safety Committee meeting.CW to ask Sue Williams to make arrangements for the above requestedmeeting within the next month.017/2013 QUALITY DASHBOARDExisting black areas to be reviewed to determine which can be deleted due tonon-relevance / non-availability of data.Inclusion of WHO checklist compliance in dashboard to be considered.Revise Radiology dashboard into correct format for next meetingComprehensive narrative to be included against all ‘red’ KPIs by each ClinicalDirector.018/2013 QUALITY STRATEGYQuality Strategy to be brought to the February meeting.020/2013 CQCSelf-assessment timeframes to be defined to enable inclusion in QSC rollingprogramme.Mental health holding powers to be investigated urgentlyMental health SLA to be urgently reviewedUpdate on Registration with the Mental Health Act required for Februarymeeting.021/2013 RISK MANAGEMENT STANDARDSPlan for achieving Level 2 to be brought to the March Quality & SafetyCommittee meeting.PSCWMG / PSMGZNMG / All ClinicalDirectorsMGDKDKMGMG / DKPSQSC draft minutes – January 2013 10