1 TRUST BOARD MEETING Wednesday, 6 March 2013 at 1.00 pm ...
1 TRUST BOARD MEETING Wednesday, 6 March 2013 at 1.00 pm ...
1 TRUST BOARD MEETING Wednesday, 6 March 2013 at 1.00 pm ...
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<strong>TRUST</strong> <strong>BOARD</strong> <strong>MEETING</strong><strong>Wednesday</strong>, 6 <strong>March</strong> <strong>2013</strong> <strong>at</strong> <strong>1.00</strong> <strong>pm</strong>Board Room, Trust HeadquartersQueen’s HospitalA G E N D A1. Apologies for Absence2. Minutes of the meeting held on 9 January <strong>2013</strong> (Attachment A)3. M<strong>at</strong>ters Arising and Actions4. GOVERNANCE:4.1 Care Quality Commission Reports (M<strong>at</strong>ernity Services (Attachments B)and Emergency Department <strong>at</strong> Queen’s Hospital (DK)4.2 Emergency Care Risk Summit 7 February <strong>2013</strong> - 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 M<strong>at</strong>ernity Services Upd<strong>at</strong>e, including sign off of King George (Attachment F)Hospital M<strong>at</strong>ernity Services move to Queen’s Hospital (DH)5.4 Quality & P<strong>at</strong>ient Standards Performance Report – (Attachment G)January <strong>2013</strong> (NM/Executive Directors)5.5 Staff Survey 2012 (DH) (Attachment H)6. FINANCE, WORKFORCE AND ACTIVITY6.1 Single Oper<strong>at</strong>ing Model – December 2012 (NM) (Attachment I)6.2 Finance Report – Month 10 (January) 2012/13 (DG) (Attachment J)6.3 Workforce Key Performance Indic<strong>at</strong>ors – January <strong>2013</strong> (DH) (Attachment K)6.4 Barking, Havering & Redbridge University Hospitals NHS (Attachment L)Trust Revised Standing Orders (DK)7. COMMITTEE ESCALATION REPORTS7.1 Escal<strong>at</strong>ion Report from Quality & Safety Committee (CW) (Attachment M)7.2 Escal<strong>at</strong>ion Report from Trust Executive Committee (AD) (Attachment N)8. INFORMATIONM<strong>at</strong>ters 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 <strong>2013</strong>9. Any Other BusinessD<strong>at</strong>e of Next Meeting: The next public meeting will be held on <strong>Wednesday</strong>,1 May <strong>2013</strong> <strong>at</strong> <strong>1.00</strong> p.m. in the Board Room, Trust Headquarters, Queen’s Hospital10. Questions from the PublicTrust Board Agenda – 6 <strong>March</strong> <strong>2013</strong> 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 <strong>March</strong> <strong>2013</strong> 2
EXECUTIVE SUMMARYTITLE:Care Quality Commission Reports (M<strong>at</strong>ernity Services andEmergency Department) <strong>at</strong> Queens Hospital.<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:Following the CQC unannounced visit to both the M<strong>at</strong>ernityDepartment ( visits on 5 th and 6 th December 2012) and theEmergency Department (visits on 28 th and 289 th Novemberand the 5th December 2012).M<strong>at</strong>ernity DepartmentThe trust was found to be compliant with 3 outcomes: careand Welfare of People who use services; safety availabilityand suitability of equi<strong>pm</strong>ent; and staffing. Overall the CQCfelt th<strong>at</strong> there had been improvements in our m<strong>at</strong>ernityservices 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 culmin<strong>at</strong>ed in a RiskSummit on the 7 th February to discuss the Trust actionplan to improve the Emergency Care P<strong>at</strong>hway. 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 ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:The <strong>at</strong>tached 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 inform<strong>at</strong>ion.4. DELIVERABLES
5. KEY PERFORMANCE INDICATORSFailure to meet n<strong>at</strong>ional target on emergency tre<strong>at</strong>ment and care within 4hours.AGREED AT __Trust Board MeetingORREFERRED TO: __________________________DATE: ____<strong>2013</strong>_DATE: ____________________________REVIEW DATE (if applicable) ___________________________2
Inspection ReportWe are the regul<strong>at</strong>or: Our job is to check whether hospitals, care homes and careservices are meeting essential standards.Queen's HospitalRom Valley Way, Romford, RM7 0AG Tel: 01708435000D<strong>at</strong>e of Inspections: 06 December 201205 December 2012D<strong>at</strong>e of Public<strong>at</strong>ion: January<strong>2013</strong>We inspected the following standards to check th<strong>at</strong> action had been taken to meetthem. This is wh<strong>at</strong> we found:Care and welfare of people who use servicesSafety, availability and suitability of equi<strong>pm</strong>entStaffingMet this standardMet this standardMet this standard| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 1
Details about this loc<strong>at</strong>ionRegistered ProviderOverview of theserviceType of serviceRegul<strong>at</strong>ed activitiesBarking, Havering and Redbridge University Hospitals NHSTrustQueen's Hospitalis part of Barking, Havering and RedbridgeUniversity Hospitals NHS Trust which is loc<strong>at</strong>ed in Romfordand provides m<strong>at</strong>ernity services for women, includingwomen who have high risk pregnancies.Acute services with overnight bedsDiagnostic and screening proceduresFamily planningM<strong>at</strong>ernity and midwifery servicesSurgical proceduresTermin<strong>at</strong>ion of pregnanciesTre<strong>at</strong>ment of disease, disorder or injury| Inspection Report | Queen's Hospital | January <strong>2013</strong> 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 4Wh<strong>at</strong> people told us and wh<strong>at</strong> we found 4More inform<strong>at</strong>ion about the provider 5Our judgements for each standard inspected:Care and welfare of people who use services 6Safety, availability and suitability of equi<strong>pm</strong>ent 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 <strong>2013</strong> 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 equi<strong>pm</strong>ent• StaffingThis was an unannounced inspection.How we carried out this inspectionWe looked <strong>at</strong> the personal care or tre<strong>at</strong>ment 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 <strong>at</strong> each stage of their tre<strong>at</strong>mentand care. We talked with people who use the service, talked with carers and / or familymembers and talked with staff.Wh<strong>at</strong> people told us and wh<strong>at</strong> we foundSince our last inspection the m<strong>at</strong>ernity services <strong>at</strong> Queen's Hospital has made a range ofimprovements and the care of women has improved. Women we spoke with wereunanimous in saying th<strong>at</strong> 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 aw<strong>at</strong>er 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 <strong>at</strong> 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 tre<strong>at</strong>ment rooms in the anten<strong>at</strong>al andlabour wards to check th<strong>at</strong> equi<strong>pm</strong>ent was available, and th<strong>at</strong> maintenance records hadbeen kept up to d<strong>at</strong>e. Our inspection covered, cardiotocography monitors (CTGs - whichare used by staff to monitor the condition of the baby before it is born), infusion pumps,adult resuscit<strong>at</strong>ion equi<strong>pm</strong>ent and infant resuscitaries. We found th<strong>at</strong> the m<strong>at</strong>ernityservices had all the equi<strong>pm</strong>ent it needs and th<strong>at</strong> it is properly maintained.There was sufficient experienced midwifery and medical staff to ensure women receivedcare th<strong>at</strong> 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 <strong>2013</strong> www.cqc.org.uk 4
More inform<strong>at</strong>ion about the providerPlease see our website www.cqc.org.uk for more inform<strong>at</strong>ion, 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 <strong>at</strong> the back of this report which has definitions for words and phraseswe use in the report.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 5
Our judgements for each standard inspectedCare and welfare of people who use servicesMet this standardPeople should get safe and appropri<strong>at</strong>e care th<strong>at</strong> meets their needs and supportstheir rightsOur judgementThe provider was meeting this standard.People experienced care, tre<strong>at</strong>ment and support th<strong>at</strong> met their needs and protected theirrights.Reasons for our judgementThe m<strong>at</strong>ernity services <strong>at</strong> Queen's Hospital have made a range of improvements since ourlast inspection. We spoke to five women on the two postn<strong>at</strong>al wards and they wereunanimous in saying th<strong>at</strong> 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 aw<strong>at</strong>er 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 'M<strong>at</strong>ernity P<strong>at</strong>ient Experience Survey' form which is given to eachmother before they leave. We examined a random selection of 146 of these forms andalso the management inform<strong>at</strong>ion the Trust coll<strong>at</strong>es from them. We found from the surveyfor November 2012 th<strong>at</strong> 96% of women would recommend the m<strong>at</strong>ernity ward to friends orfamily if they needed similar care or tre<strong>at</strong>ment. 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 th<strong>at</strong>women 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 n<strong>at</strong>urally.Overall, we found care plans to be well documented with clear and appropri<strong>at</strong>e 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 theirexpect<strong>at</strong>ions 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 wh<strong>at</strong> happened when things went wrong, staff said th<strong>at</strong> they werereported and in serious cases an investig<strong>at</strong>ion would be undertaken. The Trust had adetailed process for investig<strong>at</strong>ing and learning from Serious Incidents th<strong>at</strong> occur.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 6
The m<strong>at</strong>ernity services <strong>at</strong> Queen's Hospital sets two key targets around triage; the first isth<strong>at</strong> all women in triage should be seen within 30 minutes 90% of the time. In the summerof 2011 our inspection noted th<strong>at</strong> 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 l<strong>at</strong>est figure for October 2012 showed performance <strong>at</strong>89%. From speaking to staff we found th<strong>at</strong> women needing immedi<strong>at</strong>e 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 <strong>at</strong> all".The second target set by the trust is th<strong>at</strong> 90% of women needing an obstetric assessmentwill receive one within one hour. Since our last inspection the Trust's performance hasimproved and the l<strong>at</strong>est figure for October 2012 showed performance <strong>at</strong> 98%.The m<strong>at</strong>ernity services <strong>at</strong> 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. Inform<strong>at</strong>ion shows th<strong>at</strong>performance 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 saidth<strong>at</strong> 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 th<strong>at</strong> the correct figure for October should have been 82%. The Trust might wish toensure th<strong>at</strong> all doctors are clear on how to record the different c<strong>at</strong>egories of caesareansections in p<strong>at</strong>ient notes.With regards to caesarean sections overall, Queen's has a r<strong>at</strong>e of around 25% whichcompares with a London average of 29%.Overall the m<strong>at</strong>ernity services <strong>at</strong> Queen's Hospital has improved its performance for mostindic<strong>at</strong>ors and women were positive about the care they had received. The staff we spoketo said th<strong>at</strong> 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 <strong>2013</strong> www.cqc.org.uk 7
Safety, availability and suitability of equi<strong>pm</strong>entMet this standardPeople should be safe from harm from unsafe or unsuitable equi<strong>pm</strong>entOur judgementThe provider was meeting this standard.People were protected from unsafe or unsuitable equi<strong>pm</strong>ent.Reasons for our judgementAs part of our inspection we looked in a number of tre<strong>at</strong>ment rooms in the anten<strong>at</strong>al andlabour wards to check th<strong>at</strong> equi<strong>pm</strong>ent was present, and th<strong>at</strong> maintenance records hadbeen kept up to d<strong>at</strong>e. Our inspection covered, CTGs, infusion pumps, adult resuscit<strong>at</strong>ionequi<strong>pm</strong>ent and infant resuscitaires.During our last inspection in April 2012 we found th<strong>at</strong> equi<strong>pm</strong>ent was not alwaysaccessible and was not always checked in line with the Trust and n<strong>at</strong>ional guidance. Inparticular, there was evidence th<strong>at</strong> CTGs had not always been checked and their various<strong>at</strong>tachments where not always easily available.We found th<strong>at</strong> all appropri<strong>at</strong>e equi<strong>pm</strong>ent was available. We noted th<strong>at</strong> all the equi<strong>pm</strong>entwas accompanied by maintenance records which showed equi<strong>pm</strong>ent had been checked <strong>at</strong>least daily in compliance with the joint st<strong>at</strong>ement by the Royal College of Anaesthetists,Royal College of Physicians, Intensive Care Society and Resuscit<strong>at</strong>ion Council UK st<strong>at</strong>esin chapter 9 which st<strong>at</strong>es, "Responsibility for checking resuscit<strong>at</strong>ion equi<strong>pm</strong>ent rests withthe department where the equi<strong>pm</strong>ent 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 th<strong>at</strong> they have enough time to check equi<strong>pm</strong>entand th<strong>at</strong> all equi<strong>pm</strong>ent is checked <strong>at</strong> least daily.Midwives and medical staff told us th<strong>at</strong> equi<strong>pm</strong>ent was always available and none of themwere aware of any incidents where equi<strong>pm</strong>ent was missing or not working properly.| Inspection Report | Queen's Hospital | January <strong>2013</strong> 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 th<strong>at</strong> m<strong>at</strong>ernity services <strong>at</strong> Queen'shospital were not meeting this essential standard. This was because women using them<strong>at</strong>ernity services did not consistently have their health and welfare needs met bysufficient numbers of appropri<strong>at</strong>ely 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 cannul<strong>at</strong>ion(inserting a tube) and suturing.Overall the M<strong>at</strong>ernity Unit <strong>at</strong> Queen's has a current complement of 321 midwives. Thisallows them to maintain a midwife to woman r<strong>at</strong>io of 1:29, which compares with a Londontarget of 1:30. The Trust's d<strong>at</strong>a shows th<strong>at</strong> it has been able to maintain a 1:1 r<strong>at</strong>io 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 th<strong>at</strong> the m<strong>at</strong>ernity management wereproactive in managing the workforce and when needed, they moved staff between wardsto m<strong>at</strong>ch demand.We spoke to staff who said th<strong>at</strong> 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 th<strong>at</strong> the vacancy r<strong>at</strong>e 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 m<strong>at</strong>ernity recruitment str<strong>at</strong>egy with management. The Trust is nowdeveloping a 'grow your own' approach where trainee midwives are encouraged to remain<strong>at</strong> Queen's. Most recently this approach has proved successful with every one of the lastgroup of 12 trainees deciding to stay on <strong>at</strong> 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 foundth<strong>at</strong> no staff had less than 12 months experience. On the labour ward for the same periodwe found th<strong>at</strong> for each shift of about 15 midwives the highest number with less than 12| Inspection Report | Queen's Hospital | January <strong>2013</strong> 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 th<strong>at</strong> they had a gre<strong>at</strong> deal of supportfrom their more experienced colleagues.Previous inspections had raised concerns th<strong>at</strong> not enough midwives were trained in,cannul<strong>at</strong>ion, 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 th<strong>at</strong> 86% ofstaff had received recent CTG training (an increase from 65% in January 2012); 64% aretrained in cannul<strong>at</strong>ion (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 m<strong>at</strong>ernity unit has an establishment of 20 Obstetric andGynaecology consultants, who provide 98 hours of cover on labour ward. The m<strong>at</strong>ernitydepartment has submitted a business case to increase this to 168 hours of cover byemploying an additional four consultants.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 10
About CQC inspectionsWe are the regul<strong>at</strong>or of health and social care in England.All providers of regul<strong>at</strong>ed 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 (Regul<strong>at</strong>edActivities) Regul<strong>at</strong>ions 2010 and the Care Quality Commission (Registr<strong>at</strong>ion) Regul<strong>at</strong>ions2009. We regul<strong>at</strong>e 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 <strong>at</strong> least once a year to judge whether or not the essentialstandards are being met. We carry out inspections of dentists and other services <strong>at</strong> 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 th<strong>at</strong> rel<strong>at</strong>e 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 <strong>at</strong> any time depending on the individual circumstances of theservice. Because of this we often check different standards <strong>at</strong> different times but wealways inspect <strong>at</strong> 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 reviewinform<strong>at</strong>ion we have g<strong>at</strong>hered 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 regul<strong>at</strong>ions,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 inform<strong>at</strong>ion we have about providers. Theinform<strong>at</strong>ion comes from the public, the provider, other organis<strong>at</strong>ions, and from careworkers.You can tell us about your experience of this provider on our website.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 11
How we define our judgementsThe following pages show our findings and regul<strong>at</strong>ory judgement for each essentialstandard or part of the standard th<strong>at</strong> we inspected. Our judgements are based on theongoing review and analysis of the inform<strong>at</strong>ion g<strong>at</strong>hered 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 th<strong>at</strong> the standard was being met in th<strong>at</strong> theprovider was compliant with the regul<strong>at</strong>ion. If we find th<strong>at</strong>standards were met, we take no regul<strong>at</strong>ory action but wemay make comments th<strong>at</strong> may be useful to the provider andto the public about minor improvements th<strong>at</strong> could be made.Action neededThis means th<strong>at</strong> the standard was not being met in th<strong>at</strong> theprovider was non-compliant with the regul<strong>at</strong>ion.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 implement<strong>at</strong>ion of action plans in thesereports and, if necessary, take further action.We may have identified a breach of a regul<strong>at</strong>ion 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 regul<strong>at</strong>ion 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 relevantregul<strong>at</strong>ions. 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 registr<strong>at</strong>ion or prosecutinga manager or provider. These enforcement powers are setout in law and mean th<strong>at</strong> we can take swift, targeted actionwhere services are failing people.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 12
How we define our judgements (continued)Where we find non-compliance with a regul<strong>at</strong>ion (or part of a regul<strong>at</strong>ion), we st<strong>at</strong>e whichpart of the regul<strong>at</strong>ion has been breached. We make a judgement about the level of impacton people who use the service (and others, if appropri<strong>at</strong>e to the regul<strong>at</strong>ion) from thebreach. This could be a minor, moder<strong>at</strong>e or major impact.Minor impact – people who use the service experienced poor care th<strong>at</strong> had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was notsignificant and the m<strong>at</strong>ter could be managed or resolved quickly.Moder<strong>at</strong>e impact – people who use the service experienced poor care th<strong>at</strong> had asignificant effect on their health, safety or welfare or there was a risk of this happening.The m<strong>at</strong>ter may need to be resolved quickly.Major impact – people who use the service experienced poor care th<strong>at</strong> had a seriouscurrent or long term impact on their health, safety and welfare, or there was a risk of thishappening. The m<strong>at</strong>ter needs to be resolved quicklyWe decide the most appropri<strong>at</strong>e action to take to ensure th<strong>at</strong> the necessary changes aremade. We always follow up to check whether action has been taken to meet thestandards.| Inspection Report | Queen's Hospital | January <strong>2013</strong> 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 (Regul<strong>at</strong>ed Activities) Regul<strong>at</strong>ions 2010 and theCare Quality Commission (Registr<strong>at</strong>ion) Regul<strong>at</strong>ions 2009. These regul<strong>at</strong>ions describe theessential standards of quality and safety th<strong>at</strong> 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 (Regul<strong>at</strong>ion 17)Consent to care and tre<strong>at</strong>ment - Outcome 2 (Regul<strong>at</strong>ion 18)Care and welfare of people who use services - Outcome 4 (Regul<strong>at</strong>ion 9)Meeting Nutritional Needs - Outcome 5 (Regul<strong>at</strong>ion 14)Cooper<strong>at</strong>ing with other providers - Outcome 6 (Regul<strong>at</strong>ion 24)Safeguarding people who use services from abuse - Outcome 7 (Regul<strong>at</strong>ion 11)Cleanliness and infection control - Outcome 8 (Regul<strong>at</strong>ion 12)Management of medicines - Outcome 9 (Regul<strong>at</strong>ion 13)Safety and suitability of premises - Outcome 10 (Regul<strong>at</strong>ion 15)Safety, availability and suitability of equi<strong>pm</strong>ent - Outcome 11 (Regul<strong>at</strong>ion 16)Requirements rel<strong>at</strong>ing to workers - Outcome 12 (Regul<strong>at</strong>ion 21)Staffing - Outcome 13 (Regul<strong>at</strong>ion 22)Supporting Staff - Outcome 14 (Regul<strong>at</strong>ion 23)Assessing and monitoring the quality of service provision - Outcome 16 (Regul<strong>at</strong>ion 10)Complaints - Outcome 17 (Regul<strong>at</strong>ion 19)Records - Outcome 21 (Regul<strong>at</strong>ion 20)Regul<strong>at</strong>ed activityThese are prescribed activities rel<strong>at</strong>ed to care and tre<strong>at</strong>ment th<strong>at</strong> require registr<strong>at</strong>ion withCQC. These are set out in legisl<strong>at</strong>ion, and reflect the services provided.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 14
Glossary of terms we use in this report (continued)(Registered) ProviderThere are several legal terms rel<strong>at</strong>ing to the providers of services. These includeregistered person, service provider and registered manager. The term 'provider' meansanyone with a legal responsibility for ensuring th<strong>at</strong> the requirements of the law are carriedout. On our website we often refer to providers as a 'service'.Regul<strong>at</strong>ionsWe regul<strong>at</strong>e against the Health and Social Care Act 2008 (Regul<strong>at</strong>ed Activities)Regul<strong>at</strong>ions 2010 and the Care Quality Commission (Registr<strong>at</strong>ion) Regul<strong>at</strong>ions 2009.Responsive inspectionThis is carried out <strong>at</strong> any time in rel<strong>at</strong>ion to identified concerns.Routine inspectionThis is planned and could occur <strong>at</strong> any time. We sometimes describe this as a scheduledinspection.Themed inspectionThis is targeted to look <strong>at</strong> specific standards, sectors or types of care.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 15
Contact usPhone: 03000 616161Email:enquiries@cqc.org.ukWrite to us<strong>at</strong>:Care Quality CommissionCityg<strong>at</strong>eGallowg<strong>at</strong>eNewcastle upon TyneNE1 4PAWebsite:www.cqc.org.ukCopyright Copyright © (2011) Care Quality Commission (CQC). This public<strong>at</strong>ion maybe reproduced in whole or in part, free of charge, in any form<strong>at</strong> or medium providedth<strong>at</strong> it is not used for commercial gain. This consent is subject to the m<strong>at</strong>erial beingreproduced accur<strong>at</strong>ely and on proviso th<strong>at</strong> it is not used in a derog<strong>at</strong>ory manner ormisleading context. The m<strong>at</strong>erial should be acknowledged as CQC copyright, with thetitle and d<strong>at</strong>e of public<strong>at</strong>ion of the document specified.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 16
Inspection ReportWe are the regul<strong>at</strong>or: Our job is to check whether hospitals, care homes and careservices are meeting essential standards.Queen's HospitalRom Valley Way, Romford, RM7 0AG Tel: 01708435000D<strong>at</strong>e of Inspections: 05 December 201229 November 201228 November 2012D<strong>at</strong>e of Public<strong>at</strong>ion: January<strong>2013</strong>We inspected the following standards to check th<strong>at</strong> action had been taken to meetthem. This is wh<strong>at</strong> we found:Care and welfare of people who use servicesStaffingRecordsAction neededAction neededAction needed| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 1
Details about this loc<strong>at</strong>ionRegistered ProviderOverview of theserviceType of serviceRegul<strong>at</strong>ed 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 popul<strong>at</strong>ion 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 planningM<strong>at</strong>ernity and midwifery servicesSurgical proceduresTermin<strong>at</strong>ion of pregnanciesTre<strong>at</strong>ment of disease, disorder or injury| Inspection Report | Queen's Hospital | January <strong>2013</strong> 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 4Wh<strong>at</strong> people told us and wh<strong>at</strong> we found 4Wh<strong>at</strong> we have told the provider to do 5More inform<strong>at</strong>ion about the provider 5Our judgements for each standard inspected:Care and welfare of people who use services 6Staffing 9Records 10Inform<strong>at</strong>ion 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 <strong>2013</strong> 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 <strong>at</strong> the personal care or tre<strong>at</strong>ment 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 <strong>at</strong>each stage of their tre<strong>at</strong>ment and care. We talked with people who use the service, talkedwith carers and / or family members and talked with staff.Wh<strong>at</strong> people told us and wh<strong>at</strong> we foundThe accident and emergency department (known as the Emergency Department) has notmet most of the n<strong>at</strong>ional quality indic<strong>at</strong>ors as a result of extensive delays in the care ofp<strong>at</strong>ients. Five percent of p<strong>at</strong>ients 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% ofp<strong>at</strong>ients who are being admitted to wards within four hours of their arrival.This has led to poor care for p<strong>at</strong>ients in the 'Majors' area where seriously ill p<strong>at</strong>ients arecared for. The 'Majors' environment is unsuitable for p<strong>at</strong>ients 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 th<strong>at</strong> many p<strong>at</strong>ients, 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, dehydr<strong>at</strong>ion, and an increase infalls.There are not enough consultant or junior doctors to provide medical care for the numberof people who <strong>at</strong>tend Queen's ED. In the 'Majors' area there are not enough nurses toprovide adequ<strong>at</strong>e care for p<strong>at</strong>ients.The Emergency Department Medical Unit (EDMU) had the names, d<strong>at</strong>es of birth anddiagnosis of p<strong>at</strong>ients on 'white boards' which were visible to both the public and otherp<strong>at</strong>ients.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 4
You can see our judgements on the front page of this report.Wh<strong>at</strong> we have told the provider to doWe have asked the provider to send us a report by 09 February <strong>2013</strong>, setting out theaction they will take to meet the standards. We will check to make sure th<strong>at</strong> this action istaken.Where we have identified a breach of a regul<strong>at</strong>ion 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 appropri<strong>at</strong>e). 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 inform<strong>at</strong>ion about the providerPlease see our website www.cqc.org.uk for more inform<strong>at</strong>ion, 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 <strong>at</strong> the back of this report which has definitions for words and phraseswe use in the report.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 5
Our judgements for each standard inspectedCare and welfare of people who use servicesAction neededPeople should get safe and appropri<strong>at</strong>e care th<strong>at</strong> meets their needs and supportstheir rightsOur judgementThe provider was not meeting this standard.People did not experience care, tre<strong>at</strong>ment and support th<strong>at</strong> met their needs and protectedtheir rights.We have judged th<strong>at</strong> 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) <strong>at</strong> Queen's Hospital because we had identifiedmajor concerns about the care and welfare of p<strong>at</strong>ients during a previous visit in <strong>March</strong>2012. We carried out this inspection to ensure they had made improvements, in rel<strong>at</strong>ion toconcerns identified about meeting waiting times and delays experienced by p<strong>at</strong>ients inreceiving care and the quality of the care they received.The ED monitors its performance times for dealing with all p<strong>at</strong>ients. For both p<strong>at</strong>ients whoare subsequently admitted and those who are not it aims to tre<strong>at</strong> 95 % of them within fourhours. For those p<strong>at</strong>ients who do not require admission, since September 2012 the EDhas been meeting this target. However, for those p<strong>at</strong>ients who need to be admitted the EDis not meeting the target and 5% of p<strong>at</strong>ients 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 p<strong>at</strong>ients, it now sees around 132,000 p<strong>at</strong>ients per year. Althoughother ED departments in London see more p<strong>at</strong>ients, 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 separ<strong>at</strong>e paedi<strong>at</strong>rics, resuscit<strong>at</strong>ion, rapid assessment andtre<strong>at</strong>ment (RAT), Majors, Emergency Medicine Decisions Unit (EDMU), where ED p<strong>at</strong>ientscan be accommod<strong>at</strong>ed for up to 24 hours to assess their condition, and minor injuries areawhich is co-loc<strong>at</strong>ed with the urgent care area.We reviewed inform<strong>at</strong>ion provided by the London Ambulance Service (LAS) for the periodMay to November 2012 rel<strong>at</strong>ing to Queen's Hospital. The report showed th<strong>at</strong> Queen's EDwas responsible for most of the ambulance diverts (when an ED has to close and non- lifethre<strong>at</strong>ening 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 <strong>2013</strong> 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 <strong>at</strong> a hospital, until both the clinical handover and thep<strong>at</strong>ient handover has taken place). For the three month period from January to <strong>March</strong>2012 there were 231 recorded "black breaches" <strong>at</strong> 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 p<strong>at</strong>ients 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 se<strong>at</strong>ing area with six se<strong>at</strong>s; it also includes the five RAT cubicles.Once the hospital has made a Decision to Admit (DTA), a p<strong>at</strong>ient 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 <strong>at</strong> 11am there were 22 p<strong>at</strong>ients in the 'Majors' area.For five of these it was noted th<strong>at</strong> a DTA had been made and six p<strong>at</strong>ients had been in theED since midnight. One of the p<strong>at</strong>ients had been in the ED since 5<strong>pm</strong> the previousevening. P<strong>at</strong>ients told us the only drinks they had been offered was th<strong>at</strong> morning with theirbreakfast which was toast. One of the female p<strong>at</strong>ients we spoke to said she was verythirsty and we could see th<strong>at</strong> her mouth was dry, there was no inform<strong>at</strong>ion on her p<strong>at</strong>ientrecords indic<strong>at</strong>ing th<strong>at</strong> she her been given a drink since her arrival 11 hours previously.On the second day of our inspection, <strong>at</strong> 1030am, there were 30 p<strong>at</strong>ients 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 p<strong>at</strong>ient's records and found th<strong>at</strong> 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 p<strong>at</strong>ients who had been in since midnight, fourwere still on a hospital trolley instead of a hospital bed. We spoke to four of the tenp<strong>at</strong>ients who had been there since before midnight, we found th<strong>at</strong> they had been givendrinks when needed. We noted th<strong>at</strong> 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 <strong>at</strong> 4<strong>pm</strong> and found there were 27 p<strong>at</strong>ients inthe 'Majors' area. Eleven of them had been <strong>at</strong> the hospital for more than four hours andnine had been there for more than six hours. The longest time a p<strong>at</strong>ient had been therewas 14 hours and 43 minutes. Staff told us th<strong>at</strong> nine of the p<strong>at</strong>ients were waiting to seemedical specialists from other parts of the hospital. All of the p<strong>at</strong>ients were lying on ahospital trolley. P<strong>at</strong>ients told us th<strong>at</strong> they had been offered w<strong>at</strong>er throughout their stay andsandwiches <strong>at</strong> lunchtime.Over the three days of our inspection we spoke to a number of staff in 'Majors', they toldus th<strong>at</strong> 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 th<strong>at</strong> we had visited <strong>at</strong> a particularly busy time but th<strong>at</strong> it was oftenvery busy and wh<strong>at</strong> we had found on our inspection was typical for the ED. They told usth<strong>at</strong> the problem was the hospital wards were not making beds available so they couldtransfer p<strong>at</strong>ients. In addition staff said th<strong>at</strong> there were excessive delays in specialistdoctors from other parts of the hospital <strong>at</strong>tending the ED to see p<strong>at</strong>ients. We examinedp<strong>at</strong>ient's medical notes and confirmed this to be the case; we found two examples wherep<strong>at</strong>ients had been waiting for more than seven hours to be seen by a specialist doctor.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 7
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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 th<strong>at</strong> 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 th<strong>at</strong> we were inspecting. Staff also told us th<strong>at</strong> the department wasusually very busy. We examined the staff rotas and observed the actual number of nurseson duty. We found th<strong>at</strong> there were always four nurses on duty in the 'Majors' area which,for the number of p<strong>at</strong>ients they had to look after, meant their r<strong>at</strong>io ranged from oneregistered nurse to 5.5 p<strong>at</strong>ients to one registered nurse for 7.5 p<strong>at</strong>ients. We were informedth<strong>at</strong> the baseline r<strong>at</strong>io for 'Majors' was a r<strong>at</strong>io of one registered nurse to six p<strong>at</strong>ients <strong>at</strong>night and one registered nurse to five p<strong>at</strong>ients 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 to10<strong>pm</strong> Monday to Friday and 6 hours (as a minimum) on S<strong>at</strong>urdays and Sundays, <strong>at</strong> eachsite. In addition there are two Paedi<strong>at</strong>ric 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 th<strong>at</strong> for the number of p<strong>at</strong>ients seen <strong>at</strong>the ED <strong>at</strong> 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 5<strong>pm</strong>but after 5<strong>pm</strong> there is often only one consultant available until 10<strong>pm</strong>. Staff told us th<strong>at</strong>consultants do not finish their shift <strong>at</strong> 10<strong>pm</strong> until they are happy it is 'safe' to do so. After10<strong>pm</strong> there is a consultant available on call. The ED <strong>at</strong> Queen's is under resourced forconsultants.Additionally consultants need to be supported by a multidisciplinary workforce th<strong>at</strong> 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 p<strong>at</strong>tern covering both KingGeorge and Queen's Hospitals. The rest of the vacancies are filled by locums. The ED <strong>at</strong>Queen's is under resourced for middle grade doctors.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 9
RecordsAction neededPeople's personal records, including medical records, should be accur<strong>at</strong>e andkept safe and confidentialOur judgementThe provider was not meeting this standard.Records are not being kept securelyWe have judged th<strong>at</strong> 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 p<strong>at</strong>ients from the EDcan be accommod<strong>at</strong>ed for up to 24 hours to assess their condition. The unit consists oftwo wards with four bays in each. We looked <strong>at</strong> the unit in detail and found th<strong>at</strong> it was fullwith eight p<strong>at</strong>ients. However, only one of them met the criteria for an EDMU p<strong>at</strong>ient, all theothers were overflow from the Medical Assessment Unit (MAU) which is a ward th<strong>at</strong> is notpart of the ED and can accommod<strong>at</strong>e up to 60 p<strong>at</strong>ients for stays for up to 48 hours beforep<strong>at</strong>ients are either discharged or transferred to a main ward.When we visited the EMDU, we found th<strong>at</strong> p<strong>at</strong>ients' notes were securely stored in alockable trolley. However, we found th<strong>at</strong> p<strong>at</strong>ient's names, d<strong>at</strong>es of birth and a summary oftheir diagnosis where written on large 'white boards' th<strong>at</strong> were fully visible to the public andother p<strong>at</strong>ients. We identified this issue to senior staff on the first day of our visit but foundthe same situ<strong>at</strong>ion when we returned on the second day.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 10
This section is primarily inform<strong>at</strong>ion for the providerAction we have told the provider to takeCompliance actionsThe table below shows the essential standards of quality and safety th<strong>at</strong> were not beingmet. The provider must send CQC a report th<strong>at</strong> says wh<strong>at</strong> action they are going to take tomeet these essential standards.Regul<strong>at</strong>ed activityTre<strong>at</strong>ment ofdisease, disorder orinjuryRegul<strong>at</strong>ionRegul<strong>at</strong>ion 20 HSCA 2008 (Regul<strong>at</strong>ed Activities) Regul<strong>at</strong>ions2010RecordsHow the regul<strong>at</strong>ion was not being met:To be advisedThis report is requested under regul<strong>at</strong>ion 10(3) of the Health and Social Care Act 2008(Regul<strong>at</strong>ed Activities) Regul<strong>at</strong>ions 2010.The provider's report should be sent to us by 09 February <strong>2013</strong>.CQC should be informed when compliance actions are complete.We will check to make sure th<strong>at</strong> action has been taken to meet the standards and willreport on our judgements.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 11
About CQC inspectionsWe are the regul<strong>at</strong>or of health and social care in England.All providers of regul<strong>at</strong>ed 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 (Regul<strong>at</strong>edActivities) Regul<strong>at</strong>ions 2010 and the Care Quality Commission (Registr<strong>at</strong>ion) Regul<strong>at</strong>ions2009. We regul<strong>at</strong>e 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 <strong>at</strong> least once a year to judge whether or not the essentialstandards are being met. We carry out inspections of dentists and other services <strong>at</strong> 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 th<strong>at</strong> rel<strong>at</strong>e 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 <strong>at</strong> any time depending on the individual circumstances of theservice. Because of this we often check different standards <strong>at</strong> different times but wealways inspect <strong>at</strong> 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 reviewinform<strong>at</strong>ion we have g<strong>at</strong>hered 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 regul<strong>at</strong>ions,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 inform<strong>at</strong>ion we have about providers. Theinform<strong>at</strong>ion comes from the public, the provider, other organis<strong>at</strong>ions, and from careworkers.You can tell us about your experience of this provider on our website.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 12
How we define our judgementsThe following pages show our findings and regul<strong>at</strong>ory judgement for each essentialstandard or part of the standard th<strong>at</strong> we inspected. Our judgements are based on theongoing review and analysis of the inform<strong>at</strong>ion g<strong>at</strong>hered 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 th<strong>at</strong> the standard was being met in th<strong>at</strong> theprovider was compliant with the regul<strong>at</strong>ion. If we find th<strong>at</strong>standards were met, we take no regul<strong>at</strong>ory action but wemay make comments th<strong>at</strong> may be useful to the provider andto the public about minor improvements th<strong>at</strong> could be made.Action neededThis means th<strong>at</strong> the standard was not being met in th<strong>at</strong> theprovider was non-compliant with the regul<strong>at</strong>ion.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 implement<strong>at</strong>ion of action plans in thesereports and, if necessary, take further action.We may have identified a breach of a regul<strong>at</strong>ion 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 regul<strong>at</strong>ion 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 relevantregul<strong>at</strong>ions. 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 registr<strong>at</strong>ion or prosecutinga manager or provider. These enforcement powers are setout in law and mean th<strong>at</strong> we can take swift, targeted actionwhere services are failing people.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 13
How we define our judgements (continued)Where we find non-compliance with a regul<strong>at</strong>ion (or part of a regul<strong>at</strong>ion), we st<strong>at</strong>e whichpart of the regul<strong>at</strong>ion has been breached. We make a judgement about the level of impacton people who use the service (and others, if appropri<strong>at</strong>e to the regul<strong>at</strong>ion) from thebreach. This could be a minor, moder<strong>at</strong>e or major impact.Minor impact – people who use the service experienced poor care th<strong>at</strong> had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was notsignificant and the m<strong>at</strong>ter could be managed or resolved quickly.Moder<strong>at</strong>e impact – people who use the service experienced poor care th<strong>at</strong> had asignificant effect on their health, safety or welfare or there was a risk of this happening.The m<strong>at</strong>ter may need to be resolved quickly.Major impact – people who use the service experienced poor care th<strong>at</strong> had a seriouscurrent or long term impact on their health, safety and welfare, or there was a risk of thishappening. The m<strong>at</strong>ter needs to be resolved quicklyWe decide the most appropri<strong>at</strong>e action to take to ensure th<strong>at</strong> the necessary changes aremade. We always follow up to check whether action has been taken to meet thestandards.| Inspection Report | Queen's Hospital | January <strong>2013</strong> 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 (Regul<strong>at</strong>ed Activities) Regul<strong>at</strong>ions 2010 and theCare Quality Commission (Registr<strong>at</strong>ion) Regul<strong>at</strong>ions 2009. These regul<strong>at</strong>ions describe theessential standards of quality and safety th<strong>at</strong> 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 (Regul<strong>at</strong>ion 17)Consent to care and tre<strong>at</strong>ment - Outcome 2 (Regul<strong>at</strong>ion 18)Care and welfare of people who use services - Outcome 4 (Regul<strong>at</strong>ion 9)Meeting Nutritional Needs - Outcome 5 (Regul<strong>at</strong>ion 14)Cooper<strong>at</strong>ing with other providers - Outcome 6 (Regul<strong>at</strong>ion 24)Safeguarding people who use services from abuse - Outcome 7 (Regul<strong>at</strong>ion 11)Cleanliness and infection control - Outcome 8 (Regul<strong>at</strong>ion 12)Management of medicines - Outcome 9 (Regul<strong>at</strong>ion 13)Safety and suitability of premises - Outcome 10 (Regul<strong>at</strong>ion 15)Safety, availability and suitability of equi<strong>pm</strong>ent - Outcome 11 (Regul<strong>at</strong>ion 16)Requirements rel<strong>at</strong>ing to workers - Outcome 12 (Regul<strong>at</strong>ion 21)Staffing - Outcome 13 (Regul<strong>at</strong>ion 22)Supporting Staff - Outcome 14 (Regul<strong>at</strong>ion 23)Assessing and monitoring the quality of service provision - Outcome 16 (Regul<strong>at</strong>ion 10)Complaints - Outcome 17 (Regul<strong>at</strong>ion 19)Records - Outcome 21 (Regul<strong>at</strong>ion 20)Regul<strong>at</strong>ed activityThese are prescribed activities rel<strong>at</strong>ed to care and tre<strong>at</strong>ment th<strong>at</strong> require registr<strong>at</strong>ion withCQC. These are set out in legisl<strong>at</strong>ion, and reflect the services provided.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 15
Glossary of terms we use in this report (continued)(Registered) ProviderThere are several legal terms rel<strong>at</strong>ing to the providers of services. These includeregistered person, service provider and registered manager. The term 'provider' meansanyone with a legal responsibility for ensuring th<strong>at</strong> the requirements of the law are carriedout. On our website we often refer to providers as a 'service'.Regul<strong>at</strong>ionsWe regul<strong>at</strong>e against the Health and Social Care Act 2008 (Regul<strong>at</strong>ed Activities)Regul<strong>at</strong>ions 2010 and the Care Quality Commission (Registr<strong>at</strong>ion) Regul<strong>at</strong>ions 2009.Responsive inspectionThis is carried out <strong>at</strong> any time in rel<strong>at</strong>ion to identified concerns.Routine inspectionThis is planned and could occur <strong>at</strong> any time. We sometimes describe this as a scheduledinspection.Themed inspectionThis is targeted to look <strong>at</strong> specific standards, sectors or types of care.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 16
Contact usPhone: 03000 616161Email:enquiries@cqc.org.ukWrite to us<strong>at</strong>:Care Quality CommissionCityg<strong>at</strong>eGallowg<strong>at</strong>eNewcastle upon TyneNE1 4PAWebsite:www.cqc.org.ukCopyright Copyright © (2011) Care Quality Commission (CQC). This public<strong>at</strong>ion maybe reproduced in whole or in part, free of charge, in any form<strong>at</strong> or medium providedth<strong>at</strong> it is not used for commercial gain. This consent is subject to the m<strong>at</strong>erial beingreproduced accur<strong>at</strong>ely and on proviso th<strong>at</strong> it is not used in a derog<strong>at</strong>ory manner ormisleading context. The m<strong>at</strong>erial should be acknowledged as CQC copyright, with thetitle and d<strong>at</strong>e of public<strong>at</strong>ion of the document specified.| Inspection Report | Queen's Hospital | January <strong>2013</strong> www.cqc.org.uk 17
EXECUTIVE SUMMARYTITLE:Emergency Care Risk Summit held 7 th February <strong>2013</strong><strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:The <strong>at</strong>tached letter is feedback from the NHS LondonMedical Director and the Care Quality Commission onthe Emergency care p<strong>at</strong>hway diagnostic andimprovement plan presented to the risk summit on the7 th February <strong>2013</strong>.□ TEC …X………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …X………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:The board are asked to note the comments receivedfrom NHS London, The commissioning Board(London), The N<strong>at</strong>ional Trust Develo<strong>pm</strong>ent Authorityand the Care Quality Commission. Currently these arebeing addressed through the Emergency CareP<strong>at</strong>hway 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 th<strong>at</strong> the Emergency Care p<strong>at</strong>hway plan addresses the further requirements th<strong>at</strong> 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 th<strong>at</strong> str<strong>at</strong>egic risks are being mitig<strong>at</strong>ed.5. KEY PERFORMANCE INDICATORSN<strong>at</strong>ional 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 <strong>2013</strong>Tel: 020 7932 3700Fax: 020 7932 3800Dear Averil,Emergency Care Risk Summit - 7 February <strong>2013</strong>Thank you for hosting last week’s risk summit, held to consider the emerging plans ofthe Trust to address significant shortfalls in the care of p<strong>at</strong>ients on the emergency carep<strong>at</strong>hway <strong>at</strong> 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 th<strong>at</strong> considered the proposed action plans were:NHS London / NHSCommissioning Board(London) (NHSCB(L)) /NHS Trust Develo<strong>pm</strong>entAuthority (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 Str<strong>at</strong>egy and ProviderDevelo<strong>pm</strong>ent, 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 <strong>at</strong> Chelsea &Westminster Hospital NHS FT and Chair in Acute Medicine <strong>at</strong>Imperial College Healthcare NHS TrustM<strong>at</strong>thew Trainer, Deputy Director of Oper<strong>at</strong>ions (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 p<strong>at</strong>ients and the steps th<strong>at</strong> have been taken to begin todevelop a set of actions in response to those challenges. At the same time, we agreedth<strong>at</strong> a cohesive health economy-wide set of actions was the right approach. It was clearth<strong>at</strong> all organis<strong>at</strong>ions understood th<strong>at</strong> they each had a responsibility to work together todeliver the changes necessary to improve p<strong>at</strong>ient care and emergency careLondon Str<strong>at</strong>egic Health AuthorityInterim Chair: Professor Mike SpyerChief Executive: Ruth Carnall CBE
performance. In addition, there was clear leadership demonstr<strong>at</strong>ed by the clinical body,which both Caroline and I were pleased to note represented a positive change in yourorganis<strong>at</strong>ion’s determin<strong>at</strong>ion and approach to transforming care.M<strong>at</strong>thew Trainer and CQC colleagues agreed with this view, commenting th<strong>at</strong> theysensed an improved sense of ownership of the issues and increased level of clinicalengagement. Also, M<strong>at</strong>thew confirmed th<strong>at</strong> the CQC would consider the Trust’sproposed actions when implementing the condition on the Trust’s registr<strong>at</strong>ion th<strong>at</strong> theCQC would be applying.The expert panel’s recommend<strong>at</strong>ions and observ<strong>at</strong>ions were:Although the Trust and its partner organis<strong>at</strong>ions outlined an extensive proposed actionplan, we felt it contained too wide a range of initi<strong>at</strong>ives - with too many th<strong>at</strong> were littlemore than aspir<strong>at</strong>ions <strong>at</strong> this stage - to drive improvement successfully. We noted theambitious recovery trajectory th<strong>at</strong> fe<strong>at</strong>ured in the plan which, although agreed betweenthe Trust and the three CCGs, risked not being met without prioritising actions in moredetail. We therefore suggested th<strong>at</strong> 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 th<strong>at</strong>, in the short term, actions were taken to secure rapidimprovements in p<strong>at</strong>ient experience th<strong>at</strong> could be sustained for the longer term. Thisneeded to be explicitly highlighted in the revised action plan.The Trust and its partner organis<strong>at</strong>ions should ensure th<strong>at</strong> the funding th<strong>at</strong> had beenmade available through the additional winter funding alloc<strong>at</strong>ion is deployed in a way th<strong>at</strong>maximises the short-term gain but also in a way th<strong>at</strong> 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 p<strong>at</strong>ient care, r<strong>at</strong>herthan 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 rel<strong>at</strong>ionship with UCL Partners and exploring thepotential for developing clinical rotas th<strong>at</strong> spanned the Trust and Barts Health NHSTrust. In addition, Caroline offered to support the Trust to develop transform<strong>at</strong>ionalnursing roles across the emergency care p<strong>at</strong>hway and helping to connect the Trust towider nursing networks th<strong>at</strong> would support the recruitment challenges.In view of some constraints in the physical layout of Queen’s Hospital and the need th<strong>at</strong>has been identified to reloc<strong>at</strong>e sexual health services and renal services to facilit<strong>at</strong>edepartmental reconfigur<strong>at</strong>ion, the Trust should ensure th<strong>at</strong> the plan for these moves areincluded in the action plan.Given the expert panel’s concern th<strong>at</strong> little evidence of Board-level engagement andscrutiny of the plan was presented, the Trust should strengthen its plan so th<strong>at</strong> there is
explicit reference to the governance and reporting framework in which the improvementprogramme would sit.Next stepsIt is vital th<strong>at</strong> the work undertaken so far to engage with the wider local health economycontinues <strong>at</strong> pace to inform the develo<strong>pm</strong>ent 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 agreedth<strong>at</strong> sets out clearly the contribution from the various organis<strong>at</strong>ions across the widerhealth economy. This plan should identify the actions th<strong>at</strong> 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 <strong>March</strong>. It would be helpful if you andyour team could present further progress in developing the plan, demonstr<strong>at</strong>ing th<strong>at</strong> youare addressing the actions agreed <strong>at</strong> the risk summit and the recommend<strong>at</strong>ions listedabove, <strong>at</strong> the next monthly escal<strong>at</strong>ion 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 <strong>at</strong> th<strong>at</strong> meeting to ensure agreement of theplan by 15 <strong>March</strong>. In addition, the TDA will require the performance metrics and planmilestones to be reflected in the Trust’s <strong>2013</strong>/14 oper<strong>at</strong>ing 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 p<strong>at</strong>ientexperience <strong>at</strong> 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 BurkeM<strong>at</strong>thew TrainerMargaret McGlynnRuth CarnellAlwen WilliamsSimon WeldonK<strong>at</strong>e SouthwellAlastair FinneyCaroline AlexanderPeter ColesVanessa Lodge
EXECUTIVE SUMMARYTITLE:M<strong>at</strong>ernity Services Upd<strong>at</strong>e, including sign off of KingGeorge Hospital M<strong>at</strong>ernity Services move to Queen’sHospital<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:A Upd<strong>at</strong>e on current st<strong>at</strong>us and progress pertaining tothe reconfigur<strong>at</strong>ion of M<strong>at</strong>ernity Services from KingGeorge Hospital to Queens’ Hospital□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY: TO NOTETo Note progress and actions to d<strong>at</strong>e.□ 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 <strong>2013</strong>4. DELIVERABLESAction Plan to be fully implemented5. KEY PERFORMANCE INDICATORSM<strong>at</strong>ernity ActivityAGREED AT ______________________ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________Trust Board Upd<strong>at</strong>e M<strong>at</strong>ernity Reconfigur<strong>at</strong>ion 1Feb 2012
RECONFIGURATION OF MATERNITY SERVICES1. SummaryFollowing a meeting held on 6 th February <strong>2013</strong>, the NHS London team chaired byDr Andy Mitchell, Medical Director agreed th<strong>at</strong> NHS London would be writing to theSecretary of St<strong>at</strong>e for Health st<strong>at</strong>ing th<strong>at</strong>:• NHS London were s<strong>at</strong>isfied th<strong>at</strong> the IRP recommend<strong>at</strong>ions had been met• The standards of care <strong>at</strong> 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 organis<strong>at</strong>ions• NELC g<strong>at</strong>eway review reports undertaken <strong>at</strong> BHRUT, Barts Health andHomerton• Advice from neon<strong>at</strong>al commissioning lead (NCB) th<strong>at</strong> it is s<strong>at</strong>isfied with thearrangements• A positive CQC report on M<strong>at</strong>ernity Services <strong>at</strong> Queen’s Hospital followingan unannounced visit• Achievement of Level 1 NHS Litig<strong>at</strong>ion 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 <strong>2013</strong> has received muchpraise for the levels of care it provides to women. To d<strong>at</strong>e the target trajectory setby commissioners has been met with 30 deliveries in January and 32 in February tod<strong>at</strong>e.The QBC comprises 8 Delivery rooms and 6 Post-N<strong>at</strong>al beds Birthing Pools are wellused and this has meant few transfers of care to the main labour ward. It shouldalso be noted th<strong>at</strong> there are high level of breast feeding initi<strong>at</strong>ion, which can bedirectly linked to the <strong>at</strong>mosphere, levels of care and environment experienced bywomen choosing the QBC for delivery.The Board is asked to note th<strong>at</strong> the service is planning to close to births onTuesday 19 th <strong>March</strong>, with a final closure to deliveries <strong>at</strong> King George Hospitalon 20 th <strong>March</strong> <strong>2013</strong>.The Board is asked to note th<strong>at</strong> the provision of Anten<strong>at</strong>al clinics remainsunchanged. This is subject to the NELC Board decision on 7 th <strong>March</strong>.2
EXECUTIVE SUMMARYTITLE:<strong>BOARD</strong>/GROUP/COMMITTEE:Quality and P<strong>at</strong>ient Standards PerformanceReport – January <strong>2013</strong>Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:The Quality and P<strong>at</strong>ient Standards Performance Reportprovides an analysis of performance against trust-wideand n<strong>at</strong>ional targets for the following domains:• P<strong>at</strong>ient Safety and Quality• Performance• Workforce• Productivity• FinanceA number of additional indic<strong>at</strong>ors have been includedfollowing a review of the Dashboard by the P<strong>at</strong>ient Safetyand QualityCommitteeThe following areas where monthly performance is of concerndiscussed within the report• MRSA blood stream isol<strong>at</strong>es (previously MRSA)• Clostridium difficile toxin-positive stools(previously Clostridium Difficile)• MRSA Screening – elective and emergency• Complaints• Dementia assessments• %P<strong>at</strong>ients 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 Inform<strong>at</strong>ionPRESENTER: Neill Moloney, Director of DeliveryDATE: Feb <strong>2013</strong>3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:Not applicable.4. DELIVERABLESThe delivery of the Trust wide objectives.5. KEY PERFORMANCE INDICATORSPlease see <strong>at</strong>tached Trust Performance Dashboard.AGREED AT ______________________ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________2
1. IntroductionPerformance ReportJanuary <strong>2013</strong>Performance Indic<strong>at</strong>ors - Exception ReportThis report provides the Board with an overview of mitig<strong>at</strong>ing actions identified by the BusinessUnits to improve performance such th<strong>at</strong> it brings it back into line with target. Finance and HumanResources performance are subject to separ<strong>at</strong>e reports to the Trust Board.2. P<strong>at</strong>ient Safety and QualityMRSA blood stream isol<strong>at</strong>es (previously MRSA bacteraemia) - At the end of January <strong>2013</strong>there has been 127 days since the last MRSA blood stream isol<strong>at</strong>e.The following actions are being undertaken to reduce MRSA blood stream isol<strong>at</strong>es:• An MRSA eradic<strong>at</strong>ion protocol prescription sticker has been ordered and awaitingdelivery.• Pre-printed blood culture bags due for delivery 18th February <strong>2013</strong>• Infection Prevention & Control p<strong>at</strong>hway now embedded into Trust and will be audited in<strong>March</strong> <strong>2013</strong>• ANTT will be reviewed regarding the trusts current st<strong>at</strong>us and progress and localownership.Clostridium difficile toxin-positive stools (previously clostridium difficile infection) - At theend of January 59 C. difficile positive p<strong>at</strong>ients had been reported, an increase of 5 on theprevious month.The following actions are being taken:• Hot spots to be targeted - Educ<strong>at</strong>ion commenced on these areas jointly with pharmacy.• C.difficile ward rounds continue with input from antibiotic pharmacist.P<strong>at</strong>hology willundertake an audit ofthe forms in Microbiology to ascertain wh<strong>at</strong>inform<strong>at</strong>ion is missing and which areas thisaffects.MRSA Screening There is no improvement in MRSAemergency screening (82.1 %) or elective screening (85.1%)for January <strong>2013</strong>. Screens th<strong>at</strong> have inadequ<strong>at</strong>e or incorrectinform<strong>at</strong>ion do not get processed and there have also beenincidences of screensnot arriving <strong>at</strong> thelabor<strong>at</strong>ory.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 Director<strong>at</strong>e response r<strong>at</strong>es. During January<strong>2013</strong>, the Complaints Team have undertaken focussed work to ensure th<strong>at</strong> complainants are keptupd<strong>at</strong>ed with response due d<strong>at</strong>es and to ensure th<strong>at</strong> 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 ensureth<strong>at</strong> all complaints are being progressed and it is expected th<strong>at</strong> the reduction in responsepercentages in January <strong>2013</strong> will not be repe<strong>at</strong>ed.Dementia assessments – Achievement of metric 3 continues however metrics 1 and 2 havedeterior<strong>at</strong>ed. Daily ward d<strong>at</strong>a is now available and sent to M<strong>at</strong>rons enabling wards th<strong>at</strong> requirefurther support to be focussed on. However the resource to support this initi<strong>at</strong>ive 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.% P<strong>at</strong>ients Risk Free92.34%92.05% 92.04% 91.81%90.92%90.92%89.67% 89.76% 89.62% 89.40%% p<strong>at</strong>ients 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 th<strong>at</strong> 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 p<strong>at</strong>ient’s th<strong>at</strong> have sustained severe harm as a result of the fall.Unfortun<strong>at</strong>ely, in January <strong>2013</strong> to d<strong>at</strong>e, six p<strong>at</strong>ients have fallen and sustained severe harm.During January the Serious Incident (SI) process for falls has been reviewed and a new SItempl<strong>at</strong>e circul<strong>at</strong>ed, training given and currently in use following consult<strong>at</strong>ion with NHS London.Review of the Falls P<strong>at</strong>hway is planned by the Falls Prevention Group to make it simpler tocomplete and address concerns identified from SI reporting with regard to medic<strong>at</strong>ion review andcompliance with completion of the document<strong>at</strong>ion. The Falls Prevention Group aim to provide fallprevention str<strong>at</strong>egies for ward staff i.e. is equi<strong>pm</strong>ent within reach of the p<strong>at</strong>ient, is the p<strong>at</strong>ient’sfootwear suitable and the actions staff should take post fall.Re-admissions: elective
Re-admissions: non-elective
3. PerformanceReferral to tre<strong>at</strong>ment (RTT), delivery in all specialties – the Trust continues to deliver theoverall trust target on the RTT admitted p<strong>at</strong>hway. Inform<strong>at</strong>ion has been shared withcommissioners and the N<strong>at</strong>ional Trust Develo<strong>pm</strong>ent Agency on how speciality level targets couldbe met. However the consequence of reducing the backlog in 18 weeks will be th<strong>at</strong> the in monthadmitted p<strong>at</strong>ients performance will deterior<strong>at</strong>e.Cancer targets –• 62 Day RTT from Cancer Screening – the d<strong>at</strong>a is currently still being valid<strong>at</strong>ed and our finalperformance will be known <strong>at</strong> the beginning of <strong>March</strong>. The reason for the under performanceis the small number of tre<strong>at</strong>ments; there are currently 13.5 tre<strong>at</strong>ments with 1.5 breaches. Thehalf breach was due to a p<strong>at</strong>ient requesting a referral to the Royal Marsden <strong>at</strong> the end of herp<strong>at</strong>hway and the other p<strong>at</strong>ient was a breach due to a delay in obtaining her stereotactic biopsystains and results.• 62 Day RTT From Hosp Specialist – the d<strong>at</strong>a currently still being valid<strong>at</strong>ed and our finalperformance will be known <strong>at</strong> the beginning of <strong>March</strong>. The poor performance this month is theresult of p<strong>at</strong>ient choice, the p<strong>at</strong>ient requesting a slow p<strong>at</strong>hway for personal reasons• 31 Day Subs Tre<strong>at</strong>ment – Radiotherapy - the d<strong>at</strong>a is currently still being valid<strong>at</strong>ed and ourfinal performance will be known <strong>at</strong> the beginning of <strong>March</strong>. The current underperformance isdue to the small number of tre<strong>at</strong>ments th<strong>at</strong> have been uploaded so far. A small delay hasoccurred in the recording of these p<strong>at</strong>ients on the cancer system and additional support hasbeen organised to resolve this as a m<strong>at</strong>ter of urgency. As we have until the close of Q3 toupload the d<strong>at</strong>a 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 <strong>2013</strong> with aperformance of 83.57%. There has been a significant pressure on bed flow throughout January<strong>2013</strong>.Actions being taken to improve performance and monitored with the Chief Oper<strong>at</strong>ing Officer are:• Opening of a new Surgical Assessment Unit from 4th February <strong>2013</strong>• Opening of a new GP unit based on the Medical Assessment Unit form 11th February<strong>2013</strong>• Increased provision of rehabilit<strong>at</strong>ion 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 altern<strong>at</strong>ive p<strong>at</strong>hways of care to preventinappropri<strong>at</strong>e <strong>at</strong>tendances <strong>at</strong> the Emergency Department (ED).• Implement<strong>at</strong>ion of competency based streaming, including GP streaming to ensure thep<strong>at</strong>ients are signposted to the most appropri<strong>at</strong>e organis<strong>at</strong>ion / area for their presentingcondition this includes redirection back to their own GP and or community supportorganis<strong>at</strong>ion including Walk-in-centres and pharmacies.% of p<strong>at</strong>ients referred to speciality team
10.24% were seen by the specialty team following referral within 30 minutes <strong>at</strong> the QH site.Inform<strong>at</strong>ion 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 <strong>2013</strong>. The underlying cause of the black breaches was a lack ofcapacity in offloading the ambulances. All 10 black breaches occurred on the 28th January <strong>2013</strong>.On the 28th January <strong>2013</strong> there were a total of 427 <strong>at</strong>tendances to the ED with 135 ambulanceconveyances to QH ED, equ<strong>at</strong>ing to 31.06% of total <strong>at</strong>tendances being conveyed by ambulance.There were 2 peaks of 11 and 10 <strong>at</strong> ambulance arrivals per hour in the evening. P<strong>at</strong>ients areconstantly monitored on an individual p<strong>at</strong>ient basis by a clinician to assess the p<strong>at</strong>ient’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 p<strong>at</strong>ients are tre<strong>at</strong>ed in theappropri<strong>at</strong>e 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 th<strong>at</strong> ambulanceassessment and handover can take place effectively and efficiently.Page 5 of 8
4. WorkforceAppraisals (rolling 12mnts) – Appraisal r<strong>at</strong>es have increased steadily over the last quarter witha further increase of nearly 3% in December. The current appraisal compliance r<strong>at</strong>e across theTrust is 73.88%. Performance across the director<strong>at</strong>es is generally improved with all business unitsseeing some increase, albeit small, contributing to the overall percentage increase. January <strong>2013</strong>figures for the Clinical Director<strong>at</strong>es are:Diagnostic & Specialist medicine 78.35%Emergency & General Medicine 75.56%Surgical Services 78.35%Women, Children & Support Services 76.82%Corpor<strong>at</strong>e Director<strong>at</strong>e 41.65%Corpor<strong>at</strong>e areas have increased from 40.66% in December to 41.65% in January however,corpor<strong>at</strong>e still remain very much below target. There is no one area within the corpor<strong>at</strong>edirector<strong>at</strong>e th<strong>at</strong> can be identified as a specific outlier. There are many single post holders withinCorpor<strong>at</strong>e 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 corpor<strong>at</strong>e areas, there are plannedd<strong>at</strong>es in place for outstanding appraisalsAn appraisal lead has not yet been identified in each Director<strong>at</strong>e but will be in advance of theupd<strong>at</strong>e and re-launch of the trust’s appraisal policy originally planned for February, although nowto be included in the organis<strong>at</strong>ional develo<strong>pm</strong>ent str<strong>at</strong>egy plan.All Corpor<strong>at</strong>e Leads will be sent a list of their staff with the reminder for appraisal to be completed.Basic life support training (BLS) - Resuscit<strong>at</strong>ion training compliance for the period stands <strong>at</strong>72.68%. This shows a slight increase in compliance of 0.57% from last month’s report. This hasincreased the projected overall compliance r<strong>at</strong>e for the end of <strong>March</strong> <strong>2013</strong> to 76.67%, an increaseof 2.82% on last months report, based on bookings already made.Uptake on advertised resuscit<strong>at</strong>ion training sessions to d<strong>at</strong>e remains good. Non-<strong>at</strong>tendance r<strong>at</strong>esare being monitored closely and absences continue to be escal<strong>at</strong>ed to the appropri<strong>at</strong>e managers.Monthly compliance reports continue to be sent to the business units to highlight those staff th<strong>at</strong>still need to book onto training, outlining actual and projected compliance r<strong>at</strong>esPage 6 of 8
5. ProductivityLength of stay (LoS)January LOS deterior<strong>at</strong>ed for non elective p<strong>at</strong>ients reflected by poor p<strong>at</strong>ient flow and impact onED target. Lack of community rehabilit<strong>at</strong>ion beds was a problem post Christmas, this wasmanaged by our partners and additional beds opening.January saw eight p<strong>at</strong>ients discharged with a LOS of longer than 100 days, with one p<strong>at</strong>ienthaving a LOS over over one year. If this p<strong>at</strong>ient was removed from the cacul<strong>at</strong>ion the LOS wouldbe 5.06. this compares to two p<strong>at</strong>ients with a length of stay over 100 days discharged inDecember and in November four p<strong>at</strong>ients.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 alloc<strong>at</strong>ed to enable the backfill of senior sisters to enable them tofocus on discharge planning and standards of care. Unfortun<strong>at</strong>ely few of these shifts are beingfilled. High sickness r<strong>at</strong>es on the ward is also impacting on the discharge planning process.The community tre<strong>at</strong>ment team programme commenced on January 14th concentr<strong>at</strong>ing on fallsand COPD. In addition an enhanced consultant MAU rota commenced increasing the consultantpresence supporting the oncall team in A&E.% P<strong>at</strong>ients 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 p<strong>at</strong>ients – A further improvedfigure this month is due to continuous communic<strong>at</strong>ion and raised awareness throughout thedepartment to use the GDFT for all emergency abdominal p<strong>at</strong>ients. The Clinical Lead for the<strong>at</strong>reswill continue to contact all consultants and junior grade doctors who have not used the devicesduring their procedures when appropri<strong>at</strong>e to challenge their practice.The use of GDFT has been raised <strong>at</strong> a recent Clinical Governance meeting and discussedextensively in medical meetings. The Enhanced Recovery Program (ERP) nurses have <strong>at</strong>tendedthe<strong>at</strong>res during November to educ<strong>at</strong>e staff in the use of GDFT and improve general awareness ofthe ERP program.First to follow-up r<strong>at</strong>io (FFR) - This remains <strong>at</strong> the same level as December. The activity inJanuary for new p<strong>at</strong>ients 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 <strong>at</strong>tend (DNA) r<strong>at</strong>es for first and follow-up appointments – The Trust DNA r<strong>at</strong>e for First<strong>at</strong>tendances has shown a small improvement from 10.45% to 9.9%. Follow Up DNA r<strong>at</strong>es are still<strong>at</strong> previous levels against a target of 5%.Progress against current initi<strong>at</strong>ives to improve DNA performance:• Review of text alerts set up for specific clinic codes are being valid<strong>at</strong>ed by PAS andOutp<strong>at</strong>ients Appointment Team. This will be completed in mid <strong>March</strong>. This will help toincrease the number of text messages sent to p<strong>at</strong>ients. Review completed last monthshowed th<strong>at</strong> 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 % untre<strong>at</strong>ed 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 p<strong>at</strong>ients 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 p<strong>at</strong>ients 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 3.92M<strong>at</strong>ernal De<strong>at</strong>h R<strong>at</strong>e 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 r<strong>at</strong>e - 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% % p<strong>at</strong>ients 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 Tre<strong>at</strong>ment - Surgery 100.0% 100.0% 100.0% 94% 89%Enhanced RecoveryMRSA Bloodstream Isol<strong>at</strong>es 8 YTD7 31 Day 2nd Or Subs Tre<strong>at</strong>ment - Drug 100.0% 100.0% 95.5% 98% 93%% p<strong>at</strong>ients with an ERP code entered onto the n<strong>at</strong>ionald<strong>at</strong>abase* 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 p<strong>at</strong>ients having GDFT* 57% 74% nd 80% 80%At period end - number of days since lastreported Cdif 5 3 6 0 0 62 Days - tre<strong>at</strong>ed 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%Outp<strong>at</strong>ientsMRSA Emergency Screening 81% 81% 83% 95% 86% 62 Days Urgent RTT of all cancers* 85.1% 91.8% 89.6% 85% 80% FFU R<strong>at</strong>io 2.08 2.17 2.17 2.16 2.2031 Day Subs Tre<strong>at</strong>ment - Radiotherapy 100.0% 100.0% 89.5% 94% 89% DNA First 9.70% 10.45% 9.90% 5.00% 5.50%Complaints * fully valid<strong>at</strong>ed d<strong>at</strong>a provided one month in arrears OCT - DEC d<strong>at</strong>a 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 p<strong>at</strong>ients 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 p<strong>at</strong>ients referred to speciality teamTotal number of complaints open 187 182 188 TBA TBA
EXECUTIVE SUMMARYTITLE:<strong>BOARD</strong>/GROUP/COMMITTEE:2012 Staff Survey Results Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:The 2012 staff survey has been conducted with a 39%response r<strong>at</strong>e. A summary of the findings presented <strong>at</strong> theWorkforce Committee in February are <strong>at</strong>tached. Theoutcome of the survey is benchmarked internally againstthe 2011 staff survey results and the 2012 n<strong>at</strong>ional staffsurvey results. All areas of the staff survey improved orwhere maintained from the 2011 staff survey within theTrust. When the Trust results are benchmarked n<strong>at</strong>ionallythere continue to be areas of required improvement. Theproposed next steps are th<strong>at</strong> the results from the staffsurvey will be triangul<strong>at</strong>ed with the p<strong>at</strong>ient survey results toidentify any themes or trends and action around theseareas and improvements will be incorpor<strong>at</strong>ed into theTrusts OD Str<strong>at</strong>egy.□ PEQ ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ CLINICAL GOVERNANCE …………..………….....……□ CHARITABLE FUNDS ………………………………...…X <strong>TRUST</strong> <strong>BOARD</strong>: 06 <strong>March</strong> <strong>2013</strong>□ 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/<strong>2013</strong>3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:4. DELIVERABLESImproved staff s<strong>at</strong>isfaction in all areas, resulting in the Trust being a care provider and employer of choice.5. KEY PERFORMANCE INDICATORSInternally and N<strong>at</strong>ionally benchmarked inform<strong>at</strong>ion regarding the Staff Survey Outcomes.AGREED AT ______________________ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________
Staff Survey 2012 Summary of resultsPresented <strong>at</strong> the Workforce Committee Meeting 18 February <strong>2013</strong>For 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 s<strong>at</strong>isfaction• % of staff experiencing discrimin<strong>at</strong>ion <strong>at</strong> work in last 12 months• % of staff able to contribute towards improvements <strong>at</strong> work• support from immedi<strong>at</strong>e managers• staff motiv<strong>at</strong>ion <strong>at</strong> workIt is noted th<strong>at</strong> internally the Trust improved or maintained all outcomes on each keyfinding from the 2011 to 2012 staff surveys. Therefore there are no neg<strong>at</strong>ive localchanges. However when compared n<strong>at</strong>ionally against acute Trusts the position of theTrust is:The Trust is in the best 20% of acute Trusts in the following:• staff feeling s<strong>at</strong>isfied with the quality of work & p<strong>at</strong>ient care they are able to deliver• staff agreeing their role makes a difference to p<strong>at</strong>ients• staff receiving job-relevant training, learning or develo<strong>pm</strong>ent 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 p<strong>at</strong>ients, rel<strong>at</strong>ives or the public inlast 12 monthsSummary of all key findings compared to acute Trusts:Green = positive findings where there has been a st<strong>at</strong>istically significant positive changesince the 2011 survey compared n<strong>at</strong>ionally:• staff feeling s<strong>at</strong>isfied with the quality of work and p<strong>at</strong>ient care they are able todeliver• having equality and diversity training in the last 12 months• experiencing discrimin<strong>at</strong>ion in last 12 months• support from immedi<strong>at</strong>e managers• fairness and effectiveness of incident reporting procedures1
• staff recommending the Trust as a place to work or receive tre<strong>at</strong>ment• feeling s<strong>at</strong>isfied with the quality of work and p<strong>at</strong>ient care they are able to deliver• agreeing role makes a difference to p<strong>at</strong>ients• reporting errors, near misses or incidents in last 12 months• staff motiv<strong>at</strong>ion <strong>at</strong> workRed = neg<strong>at</strong>ive findings where there has been a st<strong>at</strong>istically significant change since the2011 survey compared n<strong>at</strong>ionally:• hand washing m<strong>at</strong>erials are always available• witnessing potentially harmful errors, near misses or incidents• experiencing physical violence from p<strong>at</strong>ients, rel<strong>at</strong>ives, public and staff• experiencing harassment, bullying or abuse from p<strong>at</strong>ients, rel<strong>at</strong>ives, public andstaff• good communic<strong>at</strong>ion between senior management and staff• experiencing discrimin<strong>at</strong>ion <strong>at</strong> work• work pressure• effective team working• % of staff reporting good communic<strong>at</strong>ion 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 p<strong>at</strong>ients• % of staff appraised in the last 12months• % of staff receiving job relevant training,learning or develo<strong>pm</strong>ent in the last 12months• % of staff feeling s<strong>at</strong>isfied with thequality of work and p<strong>at</strong>ient care they areable to deliverbottom five ranking scores• % of staff able to contribute towardsimprovements <strong>at</strong> work• % of staff believing the Trust providesequal opportunities for careerprogression or promotion• % of staff recommending the Trust asa place to work or receive tre<strong>at</strong>ment• % of staff suffering work rel<strong>at</strong>ed stressin last 12 months• % of staff st<strong>at</strong>ing there is effectiveteam workingNext Steps:• Triangul<strong>at</strong>e staff survey results with p<strong>at</strong>ient survey outcomes – identifying anytrends;• Incorpor<strong>at</strong>e feedback from the staff survey into the Organis<strong>at</strong>ional Develo<strong>pm</strong>entStr<strong>at</strong>egy.Mark SmithHead of Workforce Transform<strong>at</strong>ion24 February <strong>2013</strong>2
SELF-CERTIFICATION RETURNSOrganis<strong>at</strong>ion Name:BHRUTMonitoring Period:December 2012NHS Trust Over-sight self certific<strong>at</strong>ion templ<strong>at</strong>eReturns to XXX by the last working day of each
NHS Trust Governance Declar<strong>at</strong>ions : 2012/13 In-Year ReportingName of Organis<strong>at</strong>ion: BHRUTPeriod: December 2012Organis<strong>at</strong>ional risk r<strong>at</strong>ingEach organis<strong>at</strong>ion is required to calcul<strong>at</strong>e their risk score and RAG r<strong>at</strong>e their current performance, in addition to providing comment with regard to anycontractual issues and compliance with CQC essential standards:Governance Risk R<strong>at</strong>ing (RAG as per SOM guidance)Key Area for r<strong>at</strong>ing / comment by ProviderScore / RAG r<strong>at</strong>ing*RNormalised YTD Financial Risk R<strong>at</strong>ing (Assign number as per SOM guidance) 1* Please type in R, AR, AG or G and assign a number for the FRRGovernance Declar<strong>at</strong>ionsDeclar<strong>at</strong>ion 1 or declar<strong>at</strong>ion 2 reflects whether the Board believes the Trust is currently performing <strong>at</strong> a level comp<strong>at</strong>ible with FT authoris<strong>at</strong>ion.Supporting detail is required where compliance cannot be confirmed.Please complete one of the two declar<strong>at</strong>ions below. If you sign declar<strong>at</strong>ion 2, provide supporting detail using the form below. Sign<strong>at</strong>ure may be either handwritten or electronic, you are required to print your name.Governance declar<strong>at</strong>ion 1The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the BoardSt<strong>at</strong>ements.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 declar<strong>at</strong>ion 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 St<strong>at</strong>ements.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 Declar<strong>at</strong>ion 2 has been signed:For each target/standard, where the board is declaring insufficient assurance please st<strong>at</strong>e the reason for being unable to sign the declar<strong>at</strong>ion, and explainbriefly wh<strong>at</strong> steps are being taken to resolve the issue. Please provide an appropri<strong>at</strong>e 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 <strong>at</strong> a deficit.LTFM developed setting out plans to reduce deficit5. The trust shall <strong>at</strong> all times remain a going concern.Trust is trading <strong>at</strong> 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 r<strong>at</strong>ed as level 1 in 2012/13 assessmentAction plans in place for all requirements r<strong>at</strong>ed as level 1Target/Standard:The Issue :Action :
Board St<strong>at</strong>ementsBHRUTDecember 2012For each st<strong>at</strong>ement, the Board is asked to confirm the following:For CLINICAL QUALITY, th<strong>at</strong>:ResponseThe Board is s<strong>at</strong>isfied th<strong>at</strong>, 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 inform<strong>at</strong>ion, its own inform<strong>at</strong>ion on serious incidents,1 p<strong>at</strong>terns 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 itsp<strong>at</strong>ients.2The board is s<strong>at</strong>isfied th<strong>at</strong> plans in place are sufficient to ensure ongoing compliance with the Care QualityCommission’s registr<strong>at</strong>ion requirements.YesThe board is s<strong>at</strong>isfied th<strong>at</strong> processes and procedures are in place to ensure all medical practitioners providing care on3 Yesbehalf of the trust have met the relevant registr<strong>at</strong>ion and revalid<strong>at</strong>ion requirements.For FINANCE, th<strong>at</strong>:Response4 The board anticip<strong>at</strong>es th<strong>at</strong> the trust will continue to maintain a financial risk r<strong>at</strong>ing of <strong>at</strong> least 3 over the next 12 months. No5The board is s<strong>at</strong>isfied th<strong>at</strong> the trust shall <strong>at</strong> all times remain a going concern, as defined by relevant accountingstandards in force from time to time.NoFor GOVERNANCE, th<strong>at</strong>:Response6 The board will ensure th<strong>at</strong> the trust <strong>at</strong> 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 appropri<strong>at</strong>e action plans in place to address the issues – in a timely mannerThe board has considered all likely future risks and has reviewed appropri<strong>at</strong>e evidence regarding the level of severity,8 Yeslikelihood of occurrence and the plans for mitig<strong>at</strong>ion of these risks.The necessary planning, performance management and corpor<strong>at</strong>e and clinical risk management processes and9 mitig<strong>at</strong>ion plans are in place to deliver the annual plan, including th<strong>at</strong> all audit committee recommend<strong>at</strong>ions accepted by Yesthe board are implemented s<strong>at</strong>isfactorily.An Annual Governance St<strong>at</strong>ement is in place, and the trust is compliant with the risk management and assurance10 framework requirements th<strong>at</strong> support the St<strong>at</strong>ement pursuant to the most up to d<strong>at</strong>e guidance from HM TreasuryYes(www.hm-treasury.gov.uk).The board is s<strong>at</strong>isfied th<strong>at</strong> plans in place are sufficient to ensure ongoing compliance with all existing targets (after the11 applic<strong>at</strong>ion of thresholds) as set out in the Governance Risk R<strong>at</strong>ing; 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 Inform<strong>at</strong>ion Governance12 NoToolkit.The board will ensure th<strong>at</strong> the trust will <strong>at</strong> all times oper<strong>at</strong>e effectively. This includes maintaining its register of interests,13ensuring th<strong>at</strong> there are no m<strong>at</strong>erial conflicts of interest in the board of directors; and th<strong>at</strong> all board positions are filled, orplans are in place to fill any vacancies, and th<strong>at</strong> any elections to the shadow board of governors are held in accordanceYeswith the election rules.The board is s<strong>at</strong>isfied th<strong>at</strong> all executive and non-executive directors have the appropri<strong>at</strong>e qualific<strong>at</strong>ions, experience and14 skills to discharge their functions effectively, including setting str<strong>at</strong>egy, monitoring and managing performance andYesrisks, and ensuring management capacity and capability.The board is s<strong>at</strong>isfied th<strong>at</strong>: the management team has the capacity, capability and experience necessary to deliver the15 Yesannual plan; and the management structure in place is adequ<strong>at</strong>e to deliver the annual plan.Signed on behalf of the Trust: Print name D<strong>at</strong>eCEOAveril DongworthChairSir Peter Dixon
QUALITYBHRUTInform<strong>at</strong>ion 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 - l<strong>at</strong>est d<strong>at</strong>a Score 97.5 97.5 97.5The l<strong>at</strong>est SHMI d<strong>at</strong>a upd<strong>at</strong>e has yet to be released. Workcontinues with the roll-out of CHKS into the trust with thecompany represent<strong>at</strong>ive carrying out applic<strong>at</strong>ion training viaClinical Director<strong>at</strong>e 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 p<strong>at</strong>ients 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 th<strong>at</strong> will list all emergency admissionswithin the last 48 hours with no screening entered onto thep<strong>at</strong>hology 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 Accommod<strong>at</strong>ion Breaches Number 17 21 30 30 21 10 12 19 13 13 0 05Open Serious Incidents RequiringInvestig<strong>at</strong>ion (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 m<strong>at</strong>ernity, 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 r<strong>at</strong>ed areas on your m<strong>at</strong>ernitydashboard?Number 6 7 5 8 10 9 7 5 5 12 8 5Caesarean section r<strong>at</strong>eGrade 1 caesarean sections within 30 minutesMidwife VacanciesSicknessPostpartum haemorrhageFalls resulting in severe injury or10de<strong>at</strong>hNumber 1 1 3 3 3 2 2 2 2 2 1 1To support implement<strong>at</strong>ion of the falls plan two senior fallsleads are being appointed in Jan 13C<strong>at</strong>egory 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/educ<strong>at</strong>ion commitments to help re-enforce to staffthe SKIN P<strong>at</strong>hway and the importance of being proactiver<strong>at</strong>her than re-active in delivering this prevent<strong>at</strong>ive care.Educ<strong>at</strong>ion/training is delivered via the mand<strong>at</strong>ory 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 <strong>at</strong>tending additional educ<strong>at</strong>ional sessions.100% compliance with WHO surgical12checklistY/N yes yes no yes yes yes no noThe WHO checklist was not being audited in m<strong>at</strong>ernitythe<strong>at</strong>res. This is now in place . Medical Director has agreed aplan with the director<strong>at</strong>e 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 r<strong>at</strong>e % 5.18 5.81 4.41 4.29 4.51 4 4.59 4.68 4.88 5.07 5.3 5.7Consultants which, <strong>at</strong> their last16 appraisal, had fully completed theirprevious years PDP%
FINANCIAL RISK RATINGBHRUTInsert the Score (1-5) Achieved for eachCriteria Per MonthRisk R<strong>at</strong>ingsReportedPositionNormalisedPosition*Criteria Indic<strong>at</strong>or Weight 5 4 3 2 1Year toD<strong>at</strong>eForecastOutturnYear toD<strong>at</strong>eForecastOutturnBoard ActionUnderlyingperformanceEBITDA margin % 25% 11 9 5 1
FINANCIAL RISK TRIGGERSBHRUTInsert "Yes" / "No" Assessment for the MonthHistoric D<strong>at</strong>aCurrent D<strong>at</strong>aCriteriaQtr 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-certific<strong>at</strong>ion by trust th<strong>at</strong> the normalisedfinancial risk r<strong>at</strong>ing (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 applic<strong>at</strong>ion of bad debt provision.Debtors > 90 days account for 10% of total debt;, but only 4%after provision. Overseas p<strong>at</strong>ients 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 appropri<strong>at</strong>e)See 'Notes' for further detail of each of the below indic<strong>at</strong>orsArea Ref Indic<strong>at</strong>or Sub SectionsEffectiveness1a1bD<strong>at</strong>a completeness: Community servicescomprising:D<strong>at</strong>a completeness, community services:(may be introduced l<strong>at</strong>er)Referral to tre<strong>at</strong>ment inform<strong>at</strong>ion 50%Referral inform<strong>at</strong>ion 50%Tre<strong>at</strong>ment activity inform<strong>at</strong>ion 50%ThresholdWeightingQtr toMar-12Historic D<strong>at</strong>aQtr toJun-12Qtr toSep-12Oct-12 Nov-12 Dec-12P<strong>at</strong>ient identifier inform<strong>at</strong>ion 50% N/a N/a N/a N/a N/a N/a N/aP<strong>at</strong>ients dying <strong>at</strong> home / carehome1.0 N/a N/a N/ N/a N/a N/ N/aCurrent D<strong>at</strong>aQtr toDec-1250% N/a n/a N/a N/a N/a N/a N/a1c D<strong>at</strong>a completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a N/aN/aN/aBoard ActionP<strong>at</strong>ient Experience1c2a2b2c2d3aD<strong>at</strong>a completeness: outcomes for p<strong>at</strong>ientson CPAFrom point of referral to tre<strong>at</strong>ment inaggreg<strong>at</strong>e (RTT) – admittedFrom point of referral to tre<strong>at</strong>ment inaggreg<strong>at</strong>e (RTT) – non-admittedFrom point of referral to tre<strong>at</strong>ment inaggreg<strong>at</strong>e (RTT) – p<strong>at</strong>ients on anincomplete p<strong>at</strong>hwayCertific<strong>at</strong>ion against compliance withrequirements regarding access tohealthcare for people with a learningdisabilityAll cancers: 31-day wait for second orsubsequent tre<strong>at</strong>ment, 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 tre<strong>at</strong>ments 98%Radiotherapy 94%N/A 0.5 No No No No Yes Yes Yes1.0YesYesYesYesYesYesYesThis indic<strong>at</strong>or may deterior<strong>at</strong>e when work isundertaken to reduce the blacklog ofp<strong>at</strong>ients on the waiting list waiting over 18This indic<strong>at</strong>or may deterior<strong>at</strong>e when work isundertaken to reduce the backlog of p<strong>at</strong>ientson the waiting list waiting over 18 ww3b3cAll cancers: 62-day wait for first tre<strong>at</strong>ment:All Cancers: 31-day wait from diagnosis tofirst tre<strong>at</strong>mentFrom 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 d<strong>at</strong>efirst seen, comprising:all urgent referrals 93%for symptom<strong>at</strong>ic breast p<strong>at</strong>ients(cancer not initially suspected)93%0.5 YesYesYesYesYesYesYesQuality3e3f3g3hA&E: From arrival toadmission/transfer/dischargeCare Programme Approach (CPA)p<strong>at</strong>ients, comprising:Minimising mental health delayed transfersof careAdmissions to inp<strong>at</strong>ients services hadaccess to Crisis Resolution/HomeTre<strong>at</strong>ment 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 appropri<strong>at</strong>e)See 'Notes' for further detail of each of the below indic<strong>at</strong>orsArea Ref Indic<strong>at</strong>or Sub SectionsSafety3i3j3kMeeting commitment to serve newpsychosis cases by early interventionteamsC<strong>at</strong>egory A call – ambulance vehiclearrives within 19 minutesThresholdWeightingQtr toMar-12Historic D<strong>at</strong>aQtr toJun-12Qtr toSep-12Current D<strong>at</strong>aOct-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 No4bC<strong>at</strong>egory 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 concentr<strong>at</strong>e on is p<strong>at</strong>ientswho have symptoms of diarrhoea onadmission having specimens sent in a timelymanner to p<strong>at</strong>hology. To address thissitu<strong>at</strong>ion ward base nurse and doctortraining is being undertaken by the infection,prevention and control teamIn order to reduce blood culturecontamin<strong>at</strong>ion the following actions arebeing taken :Staff training in proper technique (Asepticnon-touch training). The bundling of the skinsite decontamin<strong>at</strong>ion 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 communic<strong>at</strong>ions from the ,Aflagging system for all inp<strong>at</strong>ients colonisedwith MRSAACQC Registr<strong>at</strong>ionNon-Compliance with CQC EssentialStandards resulting in a Major Impact onP<strong>at</strong>ients0 2.0 Yes No No No No No NoBCNon-Compliance with CQC EssentialStandards resulting in Enforcement ActionNHS Litig<strong>at</strong>ion Authority – Failure tomaintain, or certify a minimum publishedCNST level of 1.0 or have in placeappropri<strong>at</strong>e altern<strong>at</strong>ive 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 gre<strong>at</strong>er than or equal to 1, but less than 2AMBER / RED = Score gre<strong>at</strong>er than or equal to 2, but less than 4RED = Score gre<strong>at</strong>er than or equal to 4Following the inspections in December theconditions were removed from m<strong>at</strong>ernity,conditions on A&E being agreed with CQC
GOVERNANCE RISK RATINGSBHRUTSee 'Notes' for further detail of each of the below indic<strong>at</strong>orsArea Ref Indic<strong>at</strong>or Sub SectionsThresholdWeightingQtr toMar-12Insert YES, NO or N/A (as appropri<strong>at</strong>e)Historic D<strong>at</strong>aQtr toJun-12Qtr toSep-12Current D<strong>at</strong>aOct-12 Nov-12 Dec-12Qtr toDec-12Board ActionOverriding Rules - N<strong>at</strong>ure and Dur<strong>at</strong>ion of Override <strong>at</strong> SHA's DiscretionGre<strong>at</strong>er than six cases in the year to d<strong>at</strong>e, and breachesi) Meeting the MRSA Objective the cumul<strong>at</strong>ive year-to-d<strong>at</strong>e 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 TimesGre<strong>at</strong>er than 12 cases in the year to d<strong>at</strong>e, and either:Breaches the cumul<strong>at</strong>ive year-to-d<strong>at</strong>e trajectory for threesuccessive quartersReports important or signficant outbreaks of C.difficile, asdefined by the Health Protection Agency.Breaches:The admitted p<strong>at</strong>ients 18 weeks waiting time measure for <strong>at</strong>hird successive quarterThe non-admitted p<strong>at</strong>ients 18 weeks waiting time measurefor a third successive quarterThe incomplete p<strong>at</strong>hway 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 Indic<strong>at</strong>or a 12-month period and fails the indic<strong>at</strong>or 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 c<strong>at</strong>egory A 8-minute response time target for a thirdsuccessive quarterthe c<strong>at</strong>egory 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 d<strong>at</strong>a completeness for:referral to tre<strong>at</strong>ment inform<strong>at</strong>ion for a third successivequarter;vii) Community Services d<strong>at</strong>a completeness service referral inform<strong>at</strong>ion for a third successive quarter, N/a N/aor;tre<strong>at</strong>ment activity inform<strong>at</strong>ion for a third successive quarterN/aN/aN/aN/aN/aviii) Any other Indic<strong>at</strong>or weighted 1.0 Breaches the indic<strong>at</strong>or for three successive quarters.No No No No No NoAdjusted Governance Risk R<strong>at</strong>ing 6.5 6.5 7.5 7.5 7.0 7.0 7.0R R R R R R R
CONTRACTUAL DATABHRUTInform<strong>at</strong>ion to inform discussion meetingInsert "Yes" / "No" Assessment for the MonthCriteriaQtr toMar-12Historic D<strong>at</strong>aQtr toJun-12Current D<strong>at</strong>aQtr 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.transform<strong>at</strong>ional 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 arbitr<strong>at</strong>ion?No No no No No NoNo No no No No Nono7 Are the parties already in arbitr<strong>at</strong>ion? 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 oper<strong>at</strong>ing revenue.
TFA ProgressMar-13Select the Performance from the drop-down listTFA Milestone (All including those delivered)MilestoneD<strong>at</strong>ePerformanceBoard Action1 AA - TFA governance agreed by Trust / Cluster / SHA Aug-12 Fully achieved in time2 AA - Trust Transform<strong>at</strong>ion Programme Plan developed Sep-12 Fully achieved but l<strong>at</strong>e3 AA - Transform<strong>at</strong>ion plan approved by Board Oct-12 Fully achieved but l<strong>at</strong>ePresented to Trust Board in NovemberTransform<strong>at</strong>ion plan developed for <strong>2013</strong>/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 l<strong>at</strong>eTrust Board present<strong>at</strong>ion in February with upd<strong>at</strong>e on 4 workstreams.Vision, Values and Behaviours under review. Governance overview agreed<strong>at</strong> Trust Executive Committee6 AA - Quality Governance self assessment agreed by Trust Board Jan-13 Not fully achieved Assessment initi<strong>at</strong>ied and expected to be completed in June <strong>2013</strong>7 AA - BGAF self assessment agreed by Trust Board Jan-13 Not fully achieved Assessment initi<strong>at</strong>ied and expected to be completed in June <strong>2013</strong>8 AA - Formal review of Transform<strong>at</strong>ion Programme Jan-13 Fully achieved in time <strong>2013</strong>/14 plan developed9 AA - Workforce str<strong>at</strong>egy/educ<strong>at</strong>ion/training plan approved May-13 On track to deliver Head of HR taking the lead on this develo<strong>pm</strong>ent10 AA - A&E target achieved <strong>at</strong> 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 <strong>at</strong> Queen’s Oct-12 Not fully achievedCross Economy Remedial Action Plan being implemented including alloc<strong>at</strong>edwinter pressure funding12 AA - Quality Improvement Str<strong>at</strong>egy approved by Trust Board Jan-13 Not fully achievedDraft str<strong>at</strong>egy will be completed <strong>at</strong> the end of February in prepar<strong>at</strong>ion forreview <strong>at</strong> April <strong>2013</strong> Trust Board.13 AA - <strong>March</strong> 2012 CQC compliance actions addressed Dec-12 Fully achieved in timeThe str<strong>at</strong>egic actions following the <strong>March</strong> 2012 report have now beenincorporpor<strong>at</strong>ed 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 <strong>at</strong> Trust Board. Mitig<strong>at</strong>ingaction 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 <strong>at</strong> finance committee andTrust Board.17 AA - 2012/13 £23.2m CIP target delivered Oct-12 Not fully achieved Trust forecasting £18.0M <strong>at</strong> month 1018 AA - 2012/13 Plan deficit no gre<strong>at</strong>er 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 l<strong>at</strong>eBaseline 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 upd<strong>at</strong>e to take account of CCGQIPP23 AA - OBC (inc commissioner support) approved by Trust Board Feb-13Risk to delivery withintimescaleSCBU / Cardiac C<strong>at</strong>h OBC submitted to NHSL. Feedback received toprogress to combined OBC/FBC. /Sexual Health/ urgent care OBCs to becompleted by end of <strong>March</strong>. Confirm<strong>at</strong>ion 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 <strong>at</strong> CIC Feb-13Risk to delivery withintimescaleAs above25 AA - FBC approved by Trust Board D<strong>at</strong>e for FBC to be confirmed26 AA - SHA approval of FBC D<strong>at</strong>e for FBC to be confirmed27 AA - BHR transition plan for closure KGH m<strong>at</strong>ernity (intrapartum care) Oct-12 Fully achieved in timeFinal g<strong>at</strong>eway review completed. Recommend<strong>at</strong>ion being made to NELCBoard and BHRUT Board th<strong>at</strong> deliveries cease <strong>at</strong> KGH week commencing 17<strong>March</strong> <strong>2013</strong>28 AA - BHR system readiness assurance g<strong>at</strong>eway Feb-12 On track to deliver See above29 AA - BHR birth numbers < 8000 per annum (@660 pcm) Feb-13 On track to deliverCurrent performance indic<strong>at</strong>es th<strong>at</strong> deliveries are reducing as anticip<strong>at</strong>edand c8000 deliveries will occur in <strong>2013</strong>/14.30 AA - KGH m<strong>at</strong>ernity closed Mar-13 On track to deliver See above31323334353637383940
NotesRef Indic<strong>at</strong>or 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 th<strong>at</strong> have little or notolerance against the target, e.g. those set between 99-100%.1a1b1cD<strong>at</strong>aCompleteness:CommunityServicesD<strong>at</strong>a completeness levels for trusts commissioned to provide community services, using Community Inform<strong>at</strong>ion D<strong>at</strong>a Set (CIDS) definitions, toconsist of:- Referral to tre<strong>at</strong>ment times – consultant-led tre<strong>at</strong>ment in hospitals and Allied Healthcare Professional-led tre<strong>at</strong>ments in the community;- Community tre<strong>at</strong>ment activity – referrals; and- Community tre<strong>at</strong>ment activity – care contact activity.While failure against any threshold will score 1.0, the overall impact will be capped <strong>at</strong> 1.0. Failure of the same measure for three quarters willresult in a red-r<strong>at</strong>ing.Numer<strong>at</strong>or:all d<strong>at</strong>a in the denomin<strong>at</strong>or actually captured by the trust electronically (not solely CIDS-specified systems).Denomin<strong>at</strong>or:all activity d<strong>at</strong>a required by CIDS.D<strong>at</strong>aThe inclusion of this d<strong>at</strong>a collection in addition to Monitor's indic<strong>at</strong>ors (until the Compliance Framework is changed) is in order for the SHA toCompleteness track the Trust's action plan to produce such d<strong>at</strong>a.CommunityServices (further This d<strong>at</strong>a excludes a weighting, and therefore does not currently impact on the Trust's governance risk r<strong>at</strong>ing.d<strong>at</strong>a):Mental HealthMDSP<strong>at</strong>ient identity d<strong>at</strong>a completeness metrics (from MHMDS) to consist of:- NHS number;- D<strong>at</strong>e of birth;- Postcode (normal residence);- Current gender;- Registered General Medical Practice organis<strong>at</strong>ion code; and- Commissioner organis<strong>at</strong>ion code.1dMental Health:CPANumer<strong>at</strong>or:count of valid entries for each d<strong>at</strong>a item above.(For details of how d<strong>at</strong>a items are classified as VALID please refer to the d<strong>at</strong>a quality constructions available on the Inform<strong>at</strong>ion Centre’swebsite: www.ic.nhs.uk/services/mhmds/dq)Denomin<strong>at</strong>or:total number of entriesOutcomes for p<strong>at</strong>ients on Care Programme Approach:• Employment st<strong>at</strong>us:Numer<strong>at</strong>or:the number of adults in the denomin<strong>at</strong>or whose employment st<strong>at</strong>us is known <strong>at</strong> 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.Denomin<strong>at</strong>or:the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA <strong>at</strong> any point during thereported month.• Accommod<strong>at</strong>ion st<strong>at</strong>us:Numer<strong>at</strong>or:the number of adults in the denomin<strong>at</strong>or whose accommod<strong>at</strong>ion st<strong>at</strong>us (i.e. settled or non-settled accommod<strong>at</strong>ion) is known <strong>at</strong> 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.Denomin<strong>at</strong>or:the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA <strong>at</strong> any point during thereported month.• Having a Health of the N<strong>at</strong>ion Outcome Scales (HoNOS) assessment in the past 12 months:Numer<strong>at</strong>or:The number of adults in the denomin<strong>at</strong>or who have had <strong>at</strong> least one HoNOS assessment in the past 12 months.Denomin<strong>at</strong>or: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 aggreg<strong>at</strong>e (r<strong>at</strong>her 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 p<strong>at</strong>hways provided. While failure against any threshold will score 1.0, theoverall impact will be capped <strong>at</strong> 2.0. The measures apply to acute p<strong>at</strong>ients 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 tre<strong>at</strong>ment target in 2011/12 when considering consecutive failures of the referral totre<strong>at</strong>ment target in 2012/13. For example, if a trust fails the 2011/12 admitted p<strong>at</strong>ients target <strong>at</strong> quarter 4 and the 2012/13 admitted p<strong>at</strong>ientstarget 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 recommend<strong>at</strong>ions set out in Healthcare for All (DH,2008):a) Does the trust have a mechanism in place to identify and flag p<strong>at</strong>ients with learning disabilities and protocols th<strong>at</strong> ensure th<strong>at</strong> p<strong>at</strong>hways ofcare are reasonably adjusted to meet the health needs of these p<strong>at</strong>ients?b) Does the trust provide readily available and comprehensible inform<strong>at</strong>ion to p<strong>at</strong>ients with learning disabilities about the following criteria:- tre<strong>at</strong>ment options;- complaints procedures; and- appointments?c) Does the trust have protocols in place to provide suitable support for family carers who support p<strong>at</strong>ients with learning disabilities?d) Does the trust have protocols in place to routinely include training on providing healthcare to p<strong>at</strong>ients with learning disabilities for all staff?e) Does the trust have protocols in place to encourage represent<strong>at</strong>ion of people with learning disabilities and their family carers?f) Does the trust have protocols in place to regularly audit its practices for p<strong>at</strong>ients with learning disabilities and to demonstr<strong>at</strong>e the findings inroutine public reports?Note: trust boards are required to certify th<strong>at</strong> their trusts meet requirements a) to f) above <strong>at</strong> the annual plan stage and in each month. Failure todo so will result in the applic<strong>at</strong>ion of the service performance score for this indic<strong>at</strong>or.31-day wait: measured from cancer tre<strong>at</strong>ment period start d<strong>at</strong>e to tre<strong>at</strong>ment start d<strong>at</strong>e. 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 p<strong>at</strong>ient breach over the quarter.. Will apply to any community providers providing the specific cancertre<strong>at</strong>ment p<strong>at</strong>hways62-day wait: measured from day of receipt of referral to tre<strong>at</strong>ment start d<strong>at</strong>e. 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 p<strong>at</strong>ient breach over the quarter. Will apply toany community providers providing the specific cancer tre<strong>at</strong>ment p<strong>at</strong>hways.N<strong>at</strong>ional guidance st<strong>at</strong>es th<strong>at</strong> for p<strong>at</strong>ients referred from one provider to another, breaches of this target are autom<strong>at</strong>ically shared and tre<strong>at</strong>ed on a50:50 basis. These breaches may be realloc<strong>at</strong>ed in full back to the referring organis<strong>at</strong>ion(s) provided the SHA receive evidence of writtenagreement to do so between the relevant providers (signed by both Chief Executives) in place <strong>at</strong> the time the trust makes its monthly declar<strong>at</strong>ionto 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 alloc<strong>at</strong>ion of cancer target breaches to ensure th<strong>at</strong> p<strong>at</strong>ients are tre<strong>at</strong>ed in a timely manner. Once an agreement of thisn<strong>at</strong>ure has been reached, the SHA will consider applying the terms of the agreement to trusts party to the arrangement.Measured from decision to tre<strong>at</strong> to first definitive tre<strong>at</strong>ment. 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 p<strong>at</strong>ient breach over the quarter. Will apply to any communityproviders providing the specific cancer tre<strong>at</strong>ment p<strong>at</strong>hways.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 p<strong>at</strong>ient breach over the quarter.Will apply to any community providers providing the specific cancer tre<strong>at</strong>ment p<strong>at</strong>hways.Specific guidance and document<strong>at</strong>ion concerning cancer waiting targets can be found <strong>at</strong>:http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/document<strong>at</strong>ion
NotesRef Indic<strong>at</strong>or Details3e A&EWaiting time is assessed on a site basis: no activity from off-site partner organis<strong>at</strong>ions should be included. The 4-hour waiting time indic<strong>at</strong>or willapply to minor injury units/walk in centres.3f Mental 7-day follow up:Numer<strong>at</strong>or: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 psychi<strong>at</strong>ric inp<strong>at</strong>ient care.Denomin<strong>at</strong>or:the total number of people under adult mental illness specialties on CPA who were discharged from psychi<strong>at</strong>ric inp<strong>at</strong>ient care.All p<strong>at</strong>ients discharged to their place of residence, care home, residential accommod<strong>at</strong>ion, or to non-psychi<strong>at</strong>ric care must be followed up withinseven days of discharge. Where a p<strong>at</strong>ient has been transferred to prison, contact should be made via the prison in-reach team.Exemptions from both the numer<strong>at</strong>or and the denomin<strong>at</strong>or of the indic<strong>at</strong>or include:- p<strong>at</strong>ients who die within seven days of discharge;- where legal precedence has forced the removal of a p<strong>at</strong>ient from the country; or- p<strong>at</strong>ients discharged to another NHS psychi<strong>at</strong>ric inp<strong>at</strong>ient ward.For 12 month review (from Mental Health Minimum D<strong>at</strong>a Set):Numer<strong>at</strong>or:the number of adults in the denomin<strong>at</strong>or who have had <strong>at</strong> least one formal review in the last 12 months.Denomin<strong>at</strong>or:the total number of adults who have received secondary mental health services during the reporting period (month) who had spent <strong>at</strong> 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 implement<strong>at</strong>ion guidance Refocusing the Care Programme Approach on theD t t f H lth’ b itNumer<strong>at</strong>or:the number of non-acute p<strong>at</strong>ients (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 p<strong>at</strong>ient delayed for five days counts as five.Denomin<strong>at</strong>or:the total number of occupied bed days (consultant-led and non-consultant-led) during the month.3hMental Health: I/Pand CRHTDelayed transfers of care <strong>at</strong>tributable to social care services are included.This indic<strong>at</strong>or applies only to admissions to the found<strong>at</strong>ion trust’s mental health psychi<strong>at</strong>ric inp<strong>at</strong>ient care. The following cases can be excluded:- planned admissions for psychi<strong>at</strong>ric care from specialist units;- internal transfers of service users between wards in a trust and transfers from other trusts;- p<strong>at</strong>ients recalled on Community Tre<strong>at</strong>ment Orders; or- p<strong>at</strong>ients on leave under Section 17 of the Mental Health Act 1983.3i3j-kMental HealthAmbulanceC<strong>at</strong> AThe indic<strong>at</strong>or applies to users of working age (16-65) only, unless otherwise contracted. An admission has been g<strong>at</strong>e-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 fe<strong>at</strong>ures of g<strong>at</strong>e-keeping, please see Guidance St<strong>at</strong>ement on Fidelity and Best Practice for Crisis Services on theDepartment of Health’s website. As set out in this guidance, the crisis resolution home tre<strong>at</strong>ment 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 bedemonstr<strong>at</strong>ed th<strong>at</strong> face-to-face contact was not appropri<strong>at</strong>e or possible. For each case where face-to-face contact is deemed inappropri<strong>at</strong>e, adeclar<strong>at</strong>ion th<strong>at</strong> the face-to-face contact was not the most appropri<strong>at</strong>e 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 p<strong>at</strong>ients with immedi<strong>at</strong>ely life-thre<strong>at</strong>ening conditions.The Oper<strong>at</strong>ing Framework for 2012-13 requires all Ambulance Trusts to reach 75 per cent of urgent cases, C<strong>at</strong>egory A p<strong>at</strong>ients, within 8 minutes.From 1 June 2012, C<strong>at</strong>egory A cases will be split into Red 1 and Red 2 calls:• Red 1 calls are p<strong>at</strong>ients who are suffering cardiac arrest, are unconscious or who have stopped bre<strong>at</strong>hing.• Red 2 calls are serious cases, but are not ones where up to 60 additional seconds will affect a p<strong>at</strong>ient’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 <strong>2013</strong>.4a4bC.DiffMRSAWill apply to any inp<strong>at</strong>ient facility with a centrally set C. difficile objective. Where a trust with existing acute facilities acquires a communityhospital, the combined objective will be an aggreg<strong>at</strong>e of the two organis<strong>at</strong>ions’ separ<strong>at</strong>e objectives. Both avoidable and unavoidable cases of C.difficile will be taken into account for regul<strong>at</strong>ory purposes.Where there is no objective (i.e. if a mental health trust without a C. difficile objective acquires a community provider without an alloc<strong>at</strong>ed C.difficile objective) we will not apply a C. difficile score to the trust’s governance risk r<strong>at</strong>ing.Monitor’s annual de minimis limit for cases of C. difficile is set <strong>at</strong> 12. However, Monitor may consider scoring cases of
EXECUTIVE SUMMARYTITLE:Finance Report – Month Ten (January)2012/13<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. KEY ISSUES: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) andDATE:• The in month position showed a recorded surplusof £0.2m. Adjustments for previous monthsincome over performance, a larger thananticip<strong>at</strong>ed council tax refund and reduction indepreci<strong>at</strong>ion charges have helped improve theunderlying position which would have otherwiserecorded a £2.2m deficit without these benefits.• The year to d<strong>at</strong>e position <strong>at</strong> Month 10 shows acumul<strong>at</strong>ive 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 gener<strong>at</strong>ed by overperformanceand favourable movements in nonoper<strong>at</strong>ingexpenditure of £1.2m, thus giving anoverall net adverse variance of £0.4m for thecumul<strong>at</strong>ive period.• The CIP position shows year to d<strong>at</strong>e 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 aconcentr<strong>at</strong>ed 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 cumul<strong>at</strong>ive income position is £11.4m aheadof plan <strong>at</strong> 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 ……………………….<strong>TRUST</strong> <strong>BOARD</strong> ………………………………□ 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 develo<strong>pm</strong>ent. Pay costsrepresent 68% of income this year compared71% last year, non-pay as a percentage ofincome is showing a 1% improvement on lastyear. The combin<strong>at</strong>ion of continuing strong costcontrol, improving income gener<strong>at</strong>ion and thedelivery of the CIP schemes should ensure th<strong>at</strong>the 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 mitig<strong>at</strong>e risk in achievingthe control total deficit of £39.7mAGREED AT ______________________<strong>MEETING</strong>, 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 d<strong>at</strong>e over-performance of£11.4m. The central income position shows an over- performance of £3.3m in the month, with ayear to d<strong>at</strong>e 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 rel<strong>at</strong>e 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 Corpor<strong>at</strong>e, Women’s and Children’s and EmergencyCare.The cost overruns in Medical Staffing are mainly <strong>at</strong>tributable 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 th<strong>at</strong> all sessions as far as possible are done within normal hours and th<strong>at</strong> 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 indic<strong>at</strong>ing th<strong>at</strong> the remedial managementactions are taking effect.EBITDANon-pay expenditure exceeded budget by £0.6m in the month. The overrun predomin<strong>at</strong>elyrel<strong>at</strong>es to Clinical Supplies and Appliances in Anaesthetics (£148k) and the high usage ofDrugs in Specialist Medicine (£244k).The year to d<strong>at</strong>e non-pay over spend of £3.0m against budget is mainly <strong>at</strong>tributable to Drugs inWomen’s and Children’s (£443k) rel<strong>at</strong>ing to increased activity in NICU (being the use ofSurfactant), HIV drugs no longer being distributed through Homecare and in SpecialistMedicine (£697k) on cancer tre<strong>at</strong>ment drugs due to increased levels of cancer activity. Theprescribing process is being reviewed to ensure th<strong>at</strong> 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, rel<strong>at</strong>ing toadditional sessions and prosthetics accounts for (£966k) of the overspend, driven by theadditional sessions being worked to address the eighteen week backlog. It is anticip<strong>at</strong>ed th<strong>at</strong> inexcess of five hundred additional sessions will be carried out this financial year mainly beingperformed in orthopaedics. (£214k) is <strong>at</strong>tributable to Medicine as a result of over-performancein endoscopy. P<strong>at</strong>hology and Radiology are responsible for (£516k) rel<strong>at</strong>ing to the high usagein haem<strong>at</strong>ology and A&E of blood products and high cost devices such as coiling and stents. Areview of the blood product usage r<strong>at</strong>es is being undertaken by Finance in conjunction withP<strong>at</strong>hology.Earnings before Interest, Tax, Depreci<strong>at</strong>ion and Amortis<strong>at</strong>ion (EBITDA) were £3.1m positive inthe month and £0.4m neg<strong>at</strong>ive 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 <strong>at</strong>tached). The YTD EBITDA of£0.39m neg<strong>at</strong>ive 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 cumul<strong>at</strong>ive 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 d<strong>at</strong>e, 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 mitig<strong>at</strong>e 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-r<strong>at</strong>ed 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 r<strong>at</strong>ing (per Monitor criteria) KPIsRisk R<strong>at</strong>ingsReportedPositionNormalisedPosition*Jan 13 Jan 13Act Score Bud ScoreInitial Planning Planned Outturn as a % of turnover -9.4% -9.4%Criteria Indic<strong>at</strong>or Weight 5 4 3 2 1Year toD<strong>at</strong>eForecastOutturnYear toD<strong>at</strong>eForecastOutturnComments where targetnot achievedYtoD - oper<strong>at</strong>ing performance Ytd Oper<strong>at</strong>ing 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/Director<strong>at</strong>e:• 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 rel<strong>at</strong>ed 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 alloc<strong>at</strong>ion, primarily in Women.• Diagnostics & Specialist Medicine primarily rel<strong>at</strong>ed to P<strong>at</strong>hology consumables £0.1m, CIP shortfall £0.3m, Radiology Medical Staff 0.6m.• Corpor<strong>at</strong>e under-spending primarily from non-recurrent charitable funds contribution £0.5m and Est<strong>at</strong>es £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 d<strong>at</strong>eover-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 estim<strong>at</strong>ed 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 <strong>at</strong>tendances with a value of £2.2m.Business UnitPerformanceIn Month Year to d<strong>at</strong>e 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) P<strong>at</strong>hology (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 workth<strong>at</strong> 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 <strong>at</strong> 30%marginal r<strong>at</strong>e. The reclassific<strong>at</strong>ion of paedi<strong>at</strong>ric zero length of stay p<strong>at</strong>ients toa paedi<strong>at</strong>ric assessment unit is also responsible for a third of this reduction.• Prior months’ actual income came in <strong>at</strong> £171k less than accrued. The YTDposition has been adjusted for this movement.• The tables show the proportion of income over-performance th<strong>at</strong> has beendevolved to Clinical Director<strong>at</strong>es both YTD (£5.9m) and FOT (£7.2m). Thishas increased by £2.7m, primarily due to the increase in elective income sincethe M6 forecast, rel<strong>at</strong>ed 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 allevi<strong>at</strong>e 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 d<strong>at</strong>eForecastActual Var Actual Var Actual Var(1,828) 117 AandE (17,735) 438 (21,194) 650(83) 2 Ambul<strong>at</strong>ory 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 P<strong>at</strong>ient 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%Ambul<strong>at</strong>ory 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 d<strong>at</strong>e 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 <strong>at</strong> 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 <strong>at</strong> 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 r<strong>at</strong>e is £1.1m. To achieve the desired annual target of £20m the run r<strong>at</strong>e 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 anticip<strong>at</strong>ed ward closure for February being removedCorpor<strong>at</strong>e - £890k increase due to addition of other actions th<strong>at</strong> can be taken <strong>at</strong> 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 D<strong>at</strong>e (£) ForecastOutturnForecast Outturn ProfileRun R<strong>at</strong>esFull YearDirector<strong>at</strong>e 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 77,220 889,414Corpor<strong>at</strong>e 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 49,725 672,932P<strong>at</strong>hology 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 - Don<strong>at</strong>ed Assets - - -Revalu<strong>at</strong>ion reserve £10.6 £11.5 £10.3Don<strong>at</strong>ed 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 r<strong>at</strong>io 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 rel<strong>at</strong>ed to £32.6m decrease onNon-current assets as a result of the revalu<strong>at</strong>ion 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 d<strong>at</strong>e £000'sOper<strong>at</strong>ing 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)Depreci<strong>at</strong>ion and Amortis<strong>at</strong>ion 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 Equi<strong>pm</strong>ent 2,325 1,337 1,123IT - Hardware 1,230 993 1,361IT - Softw are 62 294 438Other Plant & Machinery 500 250 500Est<strong>at</strong>es 3,625 1,597 3,031Revenue to Capital other 500sub-Total 7,742 4,471 6,953Externally Funded AssetsDigital Mammography 1,548 0 1,548P<strong>at</strong>hology 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 Vari<strong>at</strong>ion Enquiries 2,966 2,818 3,334Total Trust - Funded 30,901 10,401 15,842Subject to External Approval & FundingCardiac C<strong>at</strong>h Lab 1,700 0CT Scanners 2,000 811 0A&E Reconfigur<strong>at</strong>ion 3,000 0sub-Total 6,700 811 0Total Capital Plan to D<strong>at</strong>e 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 d<strong>at</strong>e 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 separ<strong>at</strong>ely on the agenda
EXECUTIVE SUMMARYTITLE:Workforce Committee Board Report<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:To inform the board of all workforce rel<strong>at</strong>edactivity and str<strong>at</strong>egy for the month of January<strong>2013</strong>.The inform<strong>at</strong>ion contained within the report hasbeen presented to and approved by theWorkforce Committee.The report adopts a revised form<strong>at</strong> fromprevious months and on-going iter<strong>at</strong>ions of thereport will incorpor<strong>at</strong>e an improved content andpresent<strong>at</strong>ion following re commend<strong>at</strong>ions andfeedback received through the WorkforceCommittee.□ TEC ……………..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …………..………….....…… WORKFORCE ……18 th Feb <strong>2013</strong>……………□ CHARITABLE FUNDS ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….………….□ 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 _____ _ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE:DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________
BHRUT - HR Workforce KPI Report for January <strong>2013</strong>Diagnostics & Specialist Medicine and NeurosciencesEmergency & Acute MedSurgical ServicesWomen, Children & SupportServicesFunded Establishment (FTE)SIP (FTE)Vacancy R<strong>at</strong>e (FTE)Vacancy Factor (%)Starters (FTE)Leavers (FTE)Turnover (annualised %)TargetCorpor<strong>at</strong>eNeurosciencesP<strong>at</strong>hologyRadiologySpecialistMedicineTherapiesAcute 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% D<strong>at</strong>a Sources:Funded Establishments & Paybill Budget d<strong>at</strong>a from Finance Dept.Bank & Agency D<strong>at</strong>a from StaffBank systemsAll other d<strong>at</strong>a from Electronic Staff Records system (HR and Payroll d<strong>at</strong>abase)
BHRUT - Trust Overall Staff Levels and Suporting Narr<strong>at</strong>iveEstablishments v SIP & Vacancy R<strong>at</strong>eDiagnostics & Specialist Medicine Narr<strong>at</strong>iveThe vacancy r<strong>at</strong>e 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 R<strong>at</strong>e (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 m<strong>at</strong>ernity leave andvacancies have been difficult to recruit to. Interviews scheduled for 26th Februarywill address this. In addition MRI activity between 8<strong>pm</strong> and 12 am has increasedagency usage. The 11% paybill spend within Therapies will be addressed throughthe recruitment plan anticip<strong>at</strong>ed to conclude in MayEmergency, Gen Med & Neuro Narr<strong>at</strong>ivePaybill on Bank & Agency staff reflects the continued reliance on temporary staff.The highest proportion of this spend is <strong>at</strong>tributable 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 r<strong>at</strong>e of 20% down from 45% inprevious month however the vacancy r<strong>at</strong>es remain high in the Business UnitSurgical Services Narr<strong>at</strong>iveHigher than average vacancy factor in Anaestics is due to hard to fill medical anddental posts.Total Bank and agency spend stands <strong>at</strong> 16.2% this month. As reported in Decembertemporary staffing usage with the Anaesthetics is proportion<strong>at</strong>e to the volume ofactivity and vacancy factor. This additional activity although income gener<strong>at</strong>ing hashad a large impact on medical and nursing costs. Within ITU as well the highvolumes of p<strong>at</strong>ients has resulted in higher staffing costs.Women, Children & Support Services Narr<strong>at</strong>iveThe Women's BU currently has a higher than average vacancy factor of 13.5% withthe highest proportion of vacancies rel<strong>at</strong>ing 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 r<strong>at</strong>e whilst a longterm workforce plan is established to reflect the reducing volume of activity.The higher than expected turnover r<strong>at</strong>e in Women's is also driven by the TUPEtransfer of a number of community midwives to Bart's Health.Emergency, Gen Med & Neuro ActionsAn investig<strong>at</strong>ion into turnover in theEmergency dept. is ongoing as this isacknowledged to be the highest in the Trust<strong>at</strong> 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 <strong>at</strong>tractthese staff groups.Women, Children & Support actionsMonthIHB Spend (£) Paybill Budget (£) IHB Bookings
BHRUT - Trust Overall Sickness Absence and Temporary StaffDiagnostics & Specialist Medicine Narr<strong>at</strong>iveDiagnostics & Spec Med ActionsPercentage7.06.05.04.03.02.01.0BHRUT Overall Long Term, Short Term and Overall Sickness AbsenceR<strong>at</strong>eLong term sickness for P<strong>at</strong>hology has reduced from 6.3% to 4%. This is mainly due tothe fact a number of records of open ended sickness were closed. Gre<strong>at</strong>er focusneeds to be made to the prompt closing of staff records to ensure over reporting doesnot continue to occur in the future.Within P<strong>at</strong>hology 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 approxim<strong>at</strong>ely 10 staff on LTsickness across the director<strong>at</strong>e 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 Director<strong>at</strong>e 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 <strong>at</strong> a 17 long Term absence cases identified andformal meeting on 6 <strong>March</strong>.currently being managed under the informalprocess with a number of them due toEmergency, Gen Med & Neuro Narr<strong>at</strong>iveprogress 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 accur<strong>at</strong>e 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 R<strong>at</strong>esSurgical Services Narr<strong>at</strong>iveThere were no sickness absence hotspots reported in January <strong>2013</strong>. 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 th<strong>at</strong> significant sickness absences are recorded accur<strong>at</strong>ely andreported in a timely manner.Women, Children & Support Narr<strong>at</strong>iveLong term sickness r<strong>at</strong>es in Support Services has reduced from 7.8 % to 4.8%however this is still not an accur<strong>at</strong>e reflection of the number of staff on long term sickand this increased r<strong>at</strong>e reflects continuing issues surrounding reporting compliance.The on-going implement<strong>at</strong>ion 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 Occup<strong>at</strong>ional HealthOngoing review of short term sicknessSurgical Services ActionsAction plans have been put in place to targetand ensure th<strong>at</strong> significant sickness absencesare accur<strong>at</strong>ely 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 upd<strong>at</strong>e 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 fromOccup<strong>at</strong>ional Health.62.00%Month
BHRUT - Corpor<strong>at</strong>e Upd<strong>at</strong>eSickness AbsenceThe theme consistent throughout has been the non closure of episodes of sickness absence in a timely manner for accur<strong>at</strong>e sickness and absence reporting. Areas using E-Rostering do not demostr<strong>at</strong>e the same levels ofnon compliance as those areas th<strong>at</strong> remain on weekly absence returns.The roll out program for e-rostering to incorp<strong>at</strong>e 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 <strong>2013</strong>.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 processImplement<strong>at</strong>ion of the policy is underway with a comprehensive communic<strong>at</strong>ions str<strong>at</strong>egy (agreed by Workforce Committee) supplemented by a number of training sessions for managers.AppraisalsAppraisal r<strong>at</strong>es have increased steadily over the last quarter with a further increase of nearly 3% in December. The current appraisal compliance r<strong>at</strong>e across the Trust is 73.88%.Performance across the director<strong>at</strong>es is generally improved with all business units seeing some increase, albeit small, contributing to the overall percentage increase. January <strong>2013</strong> figures for the Clinical Director<strong>at</strong>es are:Diagnostic & Specialist medicine 78.35%Emergency & General Medicine 75.56%Surgical Services 78.35%Women, Children & Support Services 76.82%Corpor<strong>at</strong>e Director<strong>at</strong>e 41.65%Corpor<strong>at</strong>e areas have increased from 40.66% in December to 41.65% in January however, corpor<strong>at</strong>e still remain very much below target. There is no one area within the corpor<strong>at</strong>e director<strong>at</strong>e th<strong>at</strong> can be identified as a specificoutlier. There are many single post holders within Corpor<strong>at</strong>e 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 corpor<strong>at</strong>e areas,there are planned d<strong>at</strong>es in place for outstanding appraisalsAn appraisal lead has not yet been identified in each Director<strong>at</strong>e but will be in advance of the upd<strong>at</strong>e and re-launch of the trust’s appraisal policy originally planned for February although now to be included in the OD str<strong>at</strong>egyplan.All Corpor<strong>at</strong>e 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 <strong>2013</strong> the Trust is required to have in place an altern<strong>at</strong>ive pension provision available for staff ineligible to join the NHS Superannu<strong>at</strong>ionpension 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 estim<strong>at</strong>ed <strong>at</strong> £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 <strong>at</strong> present as there is no benchmark d<strong>at</strong>a from other NHS Trsuts to suggest the likely increase in NHSPS uptake.Although this remains an unquantifiable risk there is a strong likelihood th<strong>at</strong> the circumstances prompting staff to opt out prior to auto enrolment will remain unchanged after the 1st April and therefore it may be assumed th<strong>at</strong> alarge proportion of employees are likely to re-opt out lessening the financial impact.Communic<strong>at</strong>ion to all staff and stakeholders will commence throughout <strong>March</strong> with the first pension contributions deducted under autoenrolement from April pay period.
BHRUT - Educ<strong>at</strong>ion Upd<strong>at</strong>eReporting Period - Compliance R<strong>at</strong>eCourse 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%Inform<strong>at</strong>ion 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%Resuscit<strong>at</strong>ion 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 R<strong>at</strong>esMonthEduc<strong>at</strong>ion & Learning Narr<strong>at</strong>iveTraining release and therefore compliance continues to be a challenge; this has consequences for external accredit<strong>at</strong>ionand internal governance.Uptake remains consistent, with significant improvements in Manual Handling of Loads.Further improvements are anticip<strong>at</strong>ed with regard to Safeguarding Children Level 2 as more staff <strong>at</strong>tends the mand<strong>at</strong>oryprogrammes.Conflict resolution refresher training has been commencedUptake on advertised resuscit<strong>at</strong>ion training sessions to d<strong>at</strong>e remains good. Non-<strong>at</strong>tendance r<strong>at</strong>es are being monitoredclosely & absences continue to be escal<strong>at</strong>ed to the appropri<strong>at</strong>e managers.WIREDThe Trust is in the process of purchasing WIRED (Workforce Inform<strong>at</strong>ion Reporting Engine D<strong>at</strong>abase). WIRED is a webbasedtool th<strong>at</strong> will enable us to export d<strong>at</strong>a from ESR to quickly produce a wide range of high quality compliance reports.Individuals will be able to view and manage their own st<strong>at</strong>utory and mand<strong>at</strong>ory 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 implement<strong>at</strong>ion and we will befocusing on high profile st<strong>at</strong>utory/mand<strong>at</strong>ory compliance d<strong>at</strong>a first, i.e. Resus, Safeguarding and Manual Handling. Allother st<strong>at</strong>utory and mand<strong>at</strong>ory compliance reports will follow as soon as practicable.
EXECUTIVE SUMMARYTITLE:Trust Standing Orders<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/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 rel<strong>at</strong>ion to Board responsibilities.A number of decisions in rel<strong>at</strong>ion to theoper<strong>at</strong>ion and management of the Trust arereserved for the Board of Directors (the Board),and Standing Orders set out wh<strong>at</strong> these are. Itis therefore important th<strong>at</strong> all staff should <strong>at</strong>least 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 ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:To approve the Standing Orders/ deleg<strong>at</strong>ion 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 <strong>March</strong> <strong>2013</strong>3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:None4. DELIVERABLESGood Governance5. KEY PERFORMANCE INDICATORSTo be AGREED AT _____Trust___Board______________ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________
BARKING, HAVERING AND REDBRIDGE UNIVERSITYHOSPITALS NHS <strong>TRUST</strong>STANDING ORDERSThis document can be made available in other form<strong>at</strong>s and languages upon request.Please contact the PALS office on 01708 435 454.CONTENTS1. Interpret<strong>at</strong>ion 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 deleg<strong>at</strong>ion7. Overlap with other trust policy st<strong>at</strong>ements / procedures, regul<strong>at</strong>ions and the standingfinancial instructions8. Duties and oblig<strong>at</strong>ions of the board and senior managers under these standing orders9. Custody of seal, sealing of documents and sign<strong>at</strong>ure of documents.Document description: Trust Standing Orders Version: 1.1R<strong>at</strong>ified by:D<strong>at</strong>e:Reviewed by:D<strong>at</strong>e:Approved by:D<strong>at</strong>e:Name & Title of origin<strong>at</strong>or/author: Donna Kinnair, Director of GovernanceResponsible committee/individual: Trust BoardD<strong>at</strong>e issued: November 2012 Review D<strong>at</strong>e: April <strong>2013</strong>Target audience: All audiencesRel<strong>at</strong>ed documents:Approvals: Audit Committee Meeting on 14 February <strong>2013</strong>
Document St<strong>at</strong>usThis 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. Interpret<strong>at</strong>ion and definitions for standing Orders and Standingfinancial instructions1.1 Save as otherwise permitted by law, <strong>at</strong> any meeting the Chair of the Trustshall be the final authority on the interpret<strong>at</strong>ion 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 legisl<strong>at</strong>ion 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 deleg<strong>at</strong>ed authority tomanage finances (income and expenditure) for aspecific area of the organis<strong>at</strong>ion.is the person appointed by the Secretary of St<strong>at</strong>e forHealth under paragraph2(1) 0f Schedule A1 of the NHSAct 2006, to lead the Board and to ensure th<strong>at</strong> 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 cre<strong>at</strong>ed 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 d<strong>at</strong>e ofincorpor<strong>at</strong>ion, receives on distribution by st<strong>at</strong>utory2
MemberMotionNomin<strong>at</strong>ed OfficeNon-Executive OfficerExecutive MemberSecretarySecretary of St<strong>at</strong>eSFIsSOsVice 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 rel<strong>at</strong>ion 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 st<strong>at</strong>e;Means the UK cabinet minister responsible for theDepartment of Health and any other body th<strong>at</strong> he hasdeleg<strong>at</strong>ed 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 St<strong>at</strong>utory Framework2.1.1 Barking, Havering and Redbridge University NHS Trustis a st<strong>at</strong>utory 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 legisl<strong>at</strong>ion made underthese Acts2.1.4 The functions of the Trust are conferred by the NHS Act2006 and HSCA 20122.1.5 As a st<strong>at</strong>utory body, the Trust has specified powers tocontract in its own name and to act as a corpor<strong>at</strong>etrustee. In the l<strong>at</strong>ter role it is accountable to the CharityCommission for those funds deemed to be charitable aswell as to the Secretary of St<strong>at</strong>e 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 organis<strong>at</strong>ions and otherbodies.2.1.7 The Code of Practice on Openness in the NHS sets outthe requirements for public access to inform<strong>at</strong>ion on theNHS.2.1.8 Joint Finance ArrangementsThe Board may confirm contracts to purchase from avoluntary organis<strong>at</strong>ion 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 rel<strong>at</strong>edfunctions of local authorities where such a transfer is tofund services to improve the health of the localpopul<strong>at</strong>ion 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 Deleg<strong>at</strong>ion of PowersThe Trust has powers to deleg<strong>at</strong>e and make arrangements for deleg<strong>at</strong>ion.The Standing Orders set out the detail of these arrangements. Underthe Standing Order rel<strong>at</strong>ing 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 St<strong>at</strong>e may direct". Deleg<strong>at</strong>ed Powers are covered inAnnexe 1 This document has effect as if incorpor<strong>at</strong>ed into the StandingOrders. Deleg<strong>at</strong>ed Powers are covered in a separ<strong>at</strong>e document entitled– ‘Schedule of M<strong>at</strong>ters reserved to the Board and Scheme ofDeleg<strong>at</strong>ion’ and have effect as if incorpor<strong>at</strong>ed into the Standing Ordersand Standing Financial Instructions.2.3 Failure to Comply with SOs2.3.1 Failure to comply with SOs is a disciplinary m<strong>at</strong>ter th<strong>at</strong> may result indismissal.3. THE <strong>TRUST</strong> <strong>BOARD</strong>: 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 Administr<strong>at</strong>ionArrangements regul<strong>at</strong>ions 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 St<strong>at</strong>e forHealth and set out in the Trust’s Establishment Order or suchother communic<strong>at</strong>ion from the Secretary of St<strong>at</strong>e).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 th<strong>at</strong> the Chair isappointed by the Secretary of St<strong>at</strong>e, as are the other non-executivemembers. This is executed through the NHS N<strong>at</strong>ional TrustDevelo<strong>pm</strong>ent 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 termin<strong>at</strong>ion orsuspension of office of the Chair and members are contained inSections 2 to 4 of the Membership, Procedure and Administr<strong>at</strong>ionArrangements and Administr<strong>at</strong>ion Regul<strong>at</strong>ions.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 <strong>at</strong> 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 inregul<strong>at</strong>ion 2(4)(a) of the Membership, Procedure and Administr<strong>at</strong>ionArrangements Regul<strong>at</strong>ions 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 <strong>at</strong>tend or take part inmeetings of the Board;if both are present <strong>at</strong> 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 corpor<strong>at</strong>e 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 str<strong>at</strong>egicand managerial issues facing the Trust in carrying out its st<strong>at</strong>utory andother functions.(i) Executive MembersExecutive Members shall exercise their authority within the terms ofthese Standing Orders and Standing Financial Instructions and theScheme of Deleg<strong>at</strong>ion.(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 oblig<strong>at</strong>ions 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 oblig<strong>at</strong>ions 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 hasdeleg<strong>at</strong>ed powers.(v) ChairThe Chair shall be responsible for the oper<strong>at</strong>ion of the Board and chairall Board meetings when present. The Chair has certain deleg<strong>at</strong>ed7
executive powers. The Chair must comply with the terms ofappointment and with these Standing Orders.The Chair shall liaise with the NHS N<strong>at</strong>ional Trust Develo<strong>pm</strong>entAuthority 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 th<strong>at</strong> key and appropri<strong>at</strong>e issues are discussed by theBoard in a timely manner with all the necessary inform<strong>at</strong>ion and advicebeing made available to the Board to inform the deb<strong>at</strong>e and ultim<strong>at</strong>eresolutions.3.7 Corpor<strong>at</strong>e 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 ascorpor<strong>at</strong>e trustee.(c) The powers of the Trust established under st<strong>at</strong>ute 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 St<strong>at</strong>e.3.8 Schedule of M<strong>at</strong>ters reserved to the Board and Scheme ofDeleg<strong>at</strong>ion3.8.1 The Board has resolved th<strong>at</strong> certain powers and decisions may only beexercised by the Board in formal session. These powers and decisionsare set out in the ‘Schedule of M<strong>at</strong>ters Reserved to the Board’ and shallhave effect as if incorpor<strong>at</strong>ed into the Standing Orders. Those powerswhich it has deleg<strong>at</strong>ed to officers and other bodies are contained in theScheme of Deleg<strong>at</strong>ion.3.9 Lead Roles for Board MembersThe Chair will ensure th<strong>at</strong> the design<strong>at</strong>ion of Lead roles orappointments of Board members as required by the Department ofHealth or as set out in any st<strong>at</strong>utory or other guidance will be made inaccordance with th<strong>at</strong> guidance or st<strong>at</strong>utory requirement (e.g. appointinga Lead Board Member with responsibilities for Infection Control or ChildProtection Services etc.).4. <strong>MEETING</strong>S OF THE <strong>TRUST</strong>8
4.1 Calling meetings(1) Ordinary meetings of the Board shall be held <strong>at</strong> regular intervals<strong>at</strong> 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 appropri<strong>at</strong>e means awritten notice of the d<strong>at</strong>es, times and loc<strong>at</strong>ion 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 th<strong>at</strong> 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 invalid<strong>at</strong>e the meeting. A notice will have beenpresumed to have been served <strong>at</strong> the time when the notice willhave been ordinarily delivered in the ordinary course of post orwhere the notice is sent by email, <strong>at</strong> the time <strong>at</strong> 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 <strong>at</strong> 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 <strong>at</strong> the meeting other than th<strong>at</strong>specified on the agenda, or emergency motions allowed underStanding Order 3.6.9
(4) A member desiring a m<strong>at</strong>ter to be included on an agenda shallmake his/her request in writing to the Chair <strong>at</strong> least [15] clear daysbefore the meeting. The request should st<strong>at</strong>e whether the item ofbusiness is proposed to be transacted in the presence of thepublic and should include appropri<strong>at</strong>e supporting inform<strong>at</strong>ion.Requests made less than [15] days before a meeting may beincluded on the agenda <strong>at</strong> 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 <strong>at</strong> the Trust’s principal offices <strong>at</strong> 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 <strong>at</strong> it and any supporting papersshall be delivered to each Member so as to be available to him <strong>at</strong> leastthree clear days before meetings.The board may determine th<strong>at</strong> certain m<strong>at</strong>ters shall appear on everyagenda for a meeting of the Board and shall be addressed prior to anyother business being conducted. (Such m<strong>at</strong>ters may be identified withinthe SOs or following subsequent resolution shall be listed on anappendix of the SOs.)A member desiring a m<strong>at</strong>ter to be included on an agenda shall makehis or her request in writing to the Chair <strong>at</strong> least 10 clear days beforethe meeting. Requests made with less 10 days prior to a meeting maybe included into the agenda <strong>at</strong> the discretion of the Chair.4.4 Notice of Motion(1) Subject to the provision of Standing Orders 4.6 ‘Motions:Procedure <strong>at</strong> 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 th<strong>at</strong> itis brought to the immedi<strong>at</strong>e <strong>at</strong>tention of the Chair.(2) The notice shall be delivered <strong>at</strong> least [l5] clear days before themeeting. The Chief Executive shall include in the agenda for themeeting all notices so received th<strong>at</strong> are in order and permissibleunder governing regul<strong>at</strong>ions. 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 <strong>at</strong> 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 st<strong>at</strong>e the groundsof urgency. If in order, it shall be declared to the Trust Board <strong>at</strong> 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 <strong>at</strong> 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 deb<strong>at</strong>e <strong>at</strong> their discretion any suchmotion of which notice was not given on the notice summoning themeeting other than a motion rel<strong>at</strong>ing to:- the reception of a report;- consider<strong>at</strong>ion of any item of business before the Trust Board;- the accuracy of minutes;- th<strong>at</strong> the Board proceed to next business;- th<strong>at</strong> the Board adjourn;- th<strong>at</strong> 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 neg<strong>at</strong>ing the motion before the Board.If there are a number of amendments, they shall be considered one <strong>at</strong>a 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 deb<strong>at</strong>e on theiramendment immedi<strong>at</strong>ely prior to the mover of the originalmotion, who shall have the right of reply <strong>at</strong> the close of deb<strong>at</strong>eon the amendment, but may not otherwise speak on it.b) Substantive/original motionThe member who proposed the substantive motion shall have aright of reply <strong>at</strong> the close of any deb<strong>at</strong>e on the motion.11
v) Withdrawing a motionA motion, or an amendment to a motion, may be withdrawn.vi) Motions once under deb<strong>at</strong>eWhen a motion is under deb<strong>at</strong>e, no motion may be moved other than:- an amendment to the motion;- the adjournment of the discussion, or the meeting;- th<strong>at</strong> the meeting proceed to the next business;- th<strong>at</strong> the question should be now put;- the appointment of an 'ad hoc' committee to deal with a specifictem of business;- th<strong>at</strong> 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 th<strong>at</strong> the meeting proceeds tothe ‘next business’ or ‘th<strong>at</strong> 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 deb<strong>at</strong>e and who is eligible to vote.If a motion to proceed to the next business or th<strong>at</strong> the question be nowput, is carried, the Chair should give the mover of the substantivemotion under deb<strong>at</strong>e a right of reply, if not already exercised. Them<strong>at</strong>ter 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 sign<strong>at</strong>ure of themember who gives it and also the sign<strong>at</strong>ure of three othermembers, and before considering any such motion of whichnotice shall have been given, the Trust Board may refer them<strong>at</strong>ter to any appropri<strong>at</strong>e Committee or the Chief Executive forrecommend<strong>at</strong>ion.(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 recommend<strong>at</strong>ions 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 interpret<strong>at</strong>ion of the Standing Orders and Standing FinancialInstructions, <strong>at</strong> the meeting, shall be final.4.10 Quorum(i)(ii)No business shall be transacted <strong>at</strong> a meeting unless <strong>at</strong> least onethirdof the whole number of the Chair and members (including <strong>at</strong>least one member who is als o an Officer Member of the Trust andone member who is not) is present.An Officer in <strong>at</strong>tendance for an Executive Director (Officer Member)but without formal acting up st<strong>at</strong>us may not count towards thequorum.(iii) If the Chair or Member has been disqualified from particip<strong>at</strong>ing inthe discussion on any m<strong>at</strong>ter and/or from voting on any resolutionby reason of a declar<strong>at</strong>ion of a conflict of interest (see SO No.7)th<strong>at</strong> 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 m<strong>at</strong>ter, th<strong>at</strong> m<strong>at</strong>ter may not be discussed furtheror voted upon <strong>at</strong> th<strong>at</strong> 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 - Vari<strong>at</strong>ion and Amendment of StandingOrders, every question put to a vote <strong>at</strong> 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 carriedth<strong>at</strong> a vote be taken by paper ballot.13
(iii) If <strong>at</strong> 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 <strong>at</strong> 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 <strong>at</strong>tending the Trust Board meeting to represent anOfficer Member during a period of incapacity or temporaryabsence without formal acting up st<strong>at</strong>us may not exercise thevoting rights of the Officer Member. An Officer’s st<strong>at</strong>us when<strong>at</strong>tending a meeting shall be recorded in the minutes.(viii) An Officer’s st<strong>at</strong>us when <strong>at</strong>tending a meeting shall be recorded inthe minutes(ix) For the voting rules rel<strong>at</strong>ing 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 st<strong>at</strong>utory provision or anydirection made by the Secretary of St<strong>at</strong>e or the rules rel<strong>at</strong>ing tothe Quorum (SO 4.10), any one or more of the Standing Ordersmay be suspended <strong>at</strong> any meeting, provided th<strong>at</strong> <strong>at</strong> least twothirdsof the whole number of the members of the Board arepresent (including <strong>at</strong> least one member who is an Officer Memberof the Trust and one member who is not) and th<strong>at</strong> <strong>at</strong> least twothirdsof those members present signify their agreement to suchsuspension. The reason for the suspension shall be recorded inthe Trust Board's minutes.A separ<strong>at</strong>e record of m<strong>at</strong>ters 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 Vari<strong>at</strong>ion 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 recommend<strong>at</strong>ion of the Chair or Chief Executive includedon the agenda for the meeting;- th<strong>at</strong> two thirds of the Board members are present <strong>at</strong> the meetingwhere the vari<strong>at</strong>ion or amendment is being discussed, and th<strong>at</strong><strong>at</strong> least half of the Trust’s Non-Officer members vote in favour ofthe amendment;- providing th<strong>at</strong> any vari<strong>at</strong>ion or amendment does not contravenea st<strong>at</strong>utory provision or direction made by the Secretary of St<strong>at</strong>e.A separ<strong>at</strong>e record of m<strong>at</strong>ters 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 <strong>at</strong> themeeting shall be recorded.4.15 MinutesThe minutes of the proceedings of a meeting shall be drawn up andsubmitted for agreement <strong>at</strong> the next ensuing meeting where theyshall be signed by the person presiding <strong>at</strong> it.No discussion shall take place upon the minutes except upon theiraccuracy or where the Chair considers discussion appropri<strong>at</strong>e.4.16 Admission of public and the press(i)Admission and exclusion on grounds of confidentiality ofbusiness to be transactedThe public and represent<strong>at</strong>ives of the press may <strong>at</strong>tend allmeetings of the Trust, but shall be required to withdraw upon theTrust Board as follows:- 'th<strong>at</strong> represent<strong>at</strong>ives of the press, and other members of thepublic, be excluded from the remainder of this meetinghaving regard to the confidential n<strong>at</strong>ure 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 Inform<strong>at</strong>ion Lead to ensure correct procedure is followedon m<strong>at</strong>ters 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 andaccommod<strong>at</strong>ion of the public and represent<strong>at</strong>ives of the presssuch as to ensure th<strong>at</strong> the Trust’s business shall be conductedwithout interruption and disruption and, without prejudice to thepower to exclude on grounds of the confidential n<strong>at</strong>ure of thebusiness to be transacted, the public will be required to withdrawupon the Trust Board resolving as follows:- `Th<strong>at</strong> 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 meetingM<strong>at</strong>ters to be dealt with by the Trust Board following theexclusion of represent<strong>at</strong>ives 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 in<strong>at</strong>tendance shall not reveal or disclose the contents of papersmarked 'In Confidence' or minutes headed 'Items Taken inPriv<strong>at</strong>e' 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 Equi<strong>pm</strong>ent for Recording orTransmission of MeetingsNothing in these Standing Orders shall be construed aspermitting the introduction by the public, or pressrepresent<strong>at</strong>ives, of recording, transmitting, video or similarappar<strong>at</strong>us into meetings of the Trust or Committee thereof.Such permission shall be granted only upon resolution of theTrust.16
4.17 Observers <strong>at</strong> Trust meetingsThe Trust will decide wh<strong>at</strong> arrangements and terms and conditions itfeels are appropri<strong>at</strong>e to offer in extending an invit<strong>at</strong>ion to observers to<strong>at</strong>tend 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 St<strong>at</strong>efor 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 Str<strong>at</strong>egic 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 St<strong>at</strong>e 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 appropri<strong>at</strong>e 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 anylegisl<strong>at</strong>ion and regul<strong>at</strong>ion or direction issued by the Secretary of St<strong>at</strong>e.Such terms of reference shall have effect as if incorpor<strong>at</strong>ed into theStanding Orders.5.5 Deleg<strong>at</strong>ion of powers by Committees to Sub-CommitteesWhere committees are authorised to establish sub-committees theymay not deleg<strong>at</strong>e 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, andregul<strong>at</strong>ions permit, th<strong>at</strong> 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 St<strong>at</strong>e. The Board shall define the powers of suchappointees and shall agree allowances, including reimbursement forloss of earnings, and/or expenses in accordance where appropri<strong>at</strong>ewith n<strong>at</strong>ional guidance.5.7 Appointments for St<strong>at</strong>utory functionsWhere the Board is required to appoint persons to a committee and/orto undertake st<strong>at</strong>utory functions as required by the Secretary of St<strong>at</strong>e,and where such appointments are to oper<strong>at</strong>e independently of theBoard such appointment shall be made in accordance with theregul<strong>at</strong>ions and directions made by the Secretary of St<strong>at</strong>e.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 theorganiz<strong>at</strong>ion. The Audit Committee must recognise the pivotal rolethe Board Assurance Framework should play in managing theorganis<strong>at</strong>ion’s str<strong>at</strong>egic objectives. The Audit Committee will maintaina system<strong>at</strong>ic approach th<strong>at</strong> considers and measures the potentialimpact of proposed cost reductions on the quality of healthcare. Itdelivers to its financial governance oblig<strong>at</strong>ions and compliance with18
elevant legisl<strong>at</strong>ion 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 Remuner<strong>at</strong>ion and Terms of Service CommitteeA remuner<strong>at</strong>ion and Terms of Service committee will be establishedand be comprised exclusively of <strong>at</strong> least three Non-ExecutiveDirectors, who are independent of management.The primary purpose of the Committee will be to advise the TrustBoard about appropri<strong>at</strong>e remuner<strong>at</strong>ion and terms of service for theChief Executive and other Executive Directors including:(i)(ii)(iii)all aspects of salary (including any performance-rel<strong>at</strong>edelements/bonuses);provisions for other benefits, including pensions and cars;arrangements for termin<strong>at</strong>ion of employment and othercontractual terms.5.8.3 Trust and Charitable Funds CommitteeIn line with its role as a corpor<strong>at</strong>e 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 st<strong>at</strong>utory 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 th<strong>at</strong> processes and protocolsare developed to ensure th<strong>at</strong> the Trust delivers its legal andoper<strong>at</strong>ional responsibilities in providing a high standard of clinical care.In line with the code of conducts’ th<strong>at</strong> govern clinical and managerialstaff all staff will cooper<strong>at</strong>e with the requests of this committee.5.8.5 Finance CommitteeThe primary purpose is to consider the trusts financial str<strong>at</strong>egy 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, innov<strong>at</strong>ion 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 organiz<strong>at</strong>ion. Ensuring th<strong>at</strong> the services areplanned for and delivered by a skilled and educ<strong>at</strong>ed 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 <strong>TRUST</strong> FUNCTIONSBY DELEGATION6.1 Deleg<strong>at</strong>ion of Functions to Committees, Officers or other bodies6.1.1 Subject to such directions as may be given by the Secretary of St<strong>at</strong>e,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 regul<strong>at</strong>ionsto provide for the functions of Trust’s to be carried out by third parties.In accordance with The Trusts (Membership, Procedure andAdministr<strong>at</strong>ion Arrangements) Regul<strong>at</strong>ions 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,Str<strong>at</strong>egic Health Authorities or PCTs;(iii) by arrangement with the appropri<strong>at</strong>e Trust or PCT, by a jointcommittee or joint sub-committee of the Trust and one or more otherhealth service bodies;(iv) in rel<strong>at</strong>ion to arrangements made under S63(1) of the HealthServices and Public Health Act 1968, jointly with one or moreStr<strong>at</strong>egic Health Authorities, SHAs, NHS Trusts or PCT.6.1.3 Where a function is deleg<strong>at</strong>ed by these Regul<strong>at</strong>ions to another Trust,then th<strong>at</strong> Trust or health service body exercises the function in itsown right; the receiving Trust has responsibility to ensure th<strong>at</strong> theproper deleg<strong>at</strong>ion of the function is in place. In other situ<strong>at</strong>ions, i.e.20
deleg<strong>at</strong>ion to committees, sub-committees or officers, the Trustdeleg<strong>at</strong>ing 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 <strong>at</strong> 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 formalr<strong>at</strong>ific<strong>at</strong>ion.6.3 Deleg<strong>at</strong>ion to Committees6.3.1 The Board shall agree from time to time to the deleg<strong>at</strong>ion 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 St<strong>at</strong>e. 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 shalloper<strong>at</strong>e as a committee and may only exercise such powers as mayhave been deleg<strong>at</strong>ed to it by the Trust in public session.6.4 Deleg<strong>at</strong>ion to Officers6.4.1 Those functions of the Trust which have not been retained asreserved by the Board or deleg<strong>at</strong>ed 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 nomin<strong>at</strong>e 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 Deleg<strong>at</strong>ion identifyinghis/her proposals which shall be considered and approved by theBoard. The Chief Executive may periodically propose amendment tothe Scheme of Deleg<strong>at</strong>ion which shall be considered and approvedby the Board.6.4.3 Nothing in the Scheme of Deleg<strong>at</strong>ion shall impair the discharge of thedirect accountability to the Board of the Director of Finance to provideinform<strong>at</strong>ion and advise the Board in accordance with st<strong>at</strong>utory orDepartment of Health requirements. Outside these st<strong>at</strong>utoryrequirements the roles of the Director of Finance shall be accountableto the Chief Executive for oper<strong>at</strong>ional m<strong>at</strong>ters.21
6.5 Schedule of M<strong>at</strong>ters Reserved to the Trust and Scheme ofDeleg<strong>at</strong>ion of powers6.5.1 The arrangements made by the Board as set out in the "Schedule ofM<strong>at</strong>ters Reserved to the Board” and “Scheme of Deleg<strong>at</strong>ion” ofpowers shall have effect as if incorpor<strong>at</strong>ed 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 justific<strong>at</strong>ion for non-complianceand the circumstances around the non-compliance, shall be reportedto the next formal meeting of the Board for action or r<strong>at</strong>ific<strong>at</strong>ion. 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 <strong>TRUST</strong> POLICYSTATEMENTS/PROCEDURES, REGULATIONS AND THESTANDING FINANCIAL INSTRUCTIONS7.1 Policy st<strong>at</strong>ements: general principlesThe Trust Board will from time to time agree and approve Policyst<strong>at</strong>ements/ 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 appropri<strong>at</strong>e Trust Board minute andwill be deemed where appropri<strong>at</strong>e to be an integral part of the Trust'sStanding Orders and Standing Financial Instructions.7.2 Specific Policy st<strong>at</strong>ementsNotwithstanding the applic<strong>at</strong>ion of SO 6.0 above, these StandingOrders and Standing Financial Instructions must be read inconjunction with the following Policy st<strong>at</strong>ements:- 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 incorpor<strong>at</strong>ed in theseStanding Orders.7.3 Standing Financial Instructions22
Standing Financial Instructions adopted by the Trust Board inaccordance with the Financial Regul<strong>at</strong>ions shall have effect as ifincorpor<strong>at</strong>ed in these Standing Orders.7.4 Specific guidanceNotwithstanding the applic<strong>at</strong>ion of SO 6.1 above, these StandingOrders and Standing Financial Instructions must be read inconjunction All applicable law and guidance issued by the Secretaryof St<strong>at</strong>e for Health:8. DUTIES AND OBLIGATIONS OF <strong>BOARD</strong> MEMBERS/DIRECTORSAND SENIOR MANAGERS UNDER THESE STANDING ORDERS8.1 Declar<strong>at</strong>ion of Interests8.1.1 Requirements for Declaring Interests and applicability to BoardMembersi) Trust Board Members shall to declare interests which are relevantand m<strong>at</strong>erial 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 m<strong>at</strong>erial(i)Interests which should be regarded as "relevant and m<strong>at</strong>erial" are:a) Directorships, including Non-ExecutiveDirectorships held in priv<strong>at</strong>e companies or PLCs(with the exception of those of dormant companies);b) Ownership or part-ownership of priv<strong>at</strong>e companies,businesses or consultancies likely or possiblyseeking to do business with the NHS;c) Majority or controlling share holdings inorganis<strong>at</strong>ions likely or possibly seeking to dobusiness with the NHS;d) A position of Authority in a charity or voluntaryorganis<strong>at</strong>ion in the field of health and social care;e) Any connection with a voluntary or otherorganis<strong>at</strong>ion contracting for NHS services;f) Research funding/grants th<strong>at</strong> may be received byan individuals or their department;g) Interests in pooled funds th<strong>at</strong> are under separ<strong>at</strong>emanagement.23
(ii) Any member of the Trust Board who comes to know th<strong>at</strong> 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 th<strong>at</strong> influence r<strong>at</strong>her than the immediacyof the rel<strong>at</strong>ionship 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 <strong>at</strong> the next Trust Boardmeeting following the change occurring and recorded in the minutesof th<strong>at</strong> meeting.8.1.5 Public<strong>at</strong>ion 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 inform<strong>at</strong>ion should be kept up to d<strong>at</strong>e 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 th<strong>at</strong> a Register of Interests isestablished to record formally declar<strong>at</strong>ions of interests of Board orCommittee members. In particular the Register will include details of alldirectorships and other relevant and m<strong>at</strong>erial 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 d<strong>at</strong>e by means of a six monthly Reviewof the Register in which any changes to interests declared during thepreceding twelve months will be incorpor<strong>at</strong>ed.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 the<strong>at</strong>tention 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 th<strong>at</strong> 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 rel<strong>at</strong>ionship, 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 tre<strong>at</strong>ed 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, associ<strong>at</strong>e 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 th<strong>at</strong> he/she or any person connected withhim/her may have in the contract is so remote orinsignificant th<strong>at</strong> it cannot reasonably be regarded aslikely to influence him/her in rel<strong>at</strong>ion to considering orvoting on th<strong>at</strong> 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, th<strong>at</strong> 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 m<strong>at</strong>ter and is present <strong>at</strong> a meeting of the Trust Board <strong>at</strong>which the contract or other m<strong>at</strong>ter is the subject of consider<strong>at</strong>ion,they shall <strong>at</strong> the meeting and as soon as practicable after itscommencement disclose the fact and shall not take part in theconsider<strong>at</strong>ion or discussion of the contract or other m<strong>at</strong>ter orvote on any question with respect to it.(ii) The Secretary of St<strong>at</strong>e 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 N<strong>at</strong>ional Health Service th<strong>at</strong> 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 m<strong>at</strong>ter in which he/she has a pecuniary interestis under consider<strong>at</strong>ion.(iv) Any remuner<strong>at</strong>ion, compens<strong>at</strong>ion or allowance payable to theChair or a Member by virtue of paragraph 11 of Schedule 5A tothe N<strong>at</strong>ional Health Service Act 1977 (pay and allowances) shall26
not be tre<strong>at</strong>ed 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 th<strong>at</strong> 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 rel<strong>at</strong>ionship ofhis/her, or of a cohabiting spouse, th<strong>at</strong> conflicts, or mightreasonably be predicted could conflict with the interests of theTrust.The Trust will require interests, employment or rel<strong>at</strong>ionships sodeclared to be entered in a register of interests of staff.8.4.4 Canvassing of and Recommend<strong>at</strong>ions by Members in Rel<strong>at</strong>ion toAppointmentsi) Canvassing of members of the Trust or of any Committee of theTrust directly or indirectly for any appointment under the Trustshall disqualify the candid<strong>at</strong>e for such appointment. Thecontents of this paragraph of the Standing Order shall beincluded in applic<strong>at</strong>ion forms or otherwise brought to the<strong>at</strong>tention of candid<strong>at</strong>es.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 acandid<strong>at</strong>e’s ability, experience or character for submission to theTrust.27
8.4.5 Rel<strong>at</strong>ives of Members or Officersi) Candid<strong>at</strong>es for any staff appointment under the Trust shall,when making an applic<strong>at</strong>ion, disclose in writing to the Trustwhether they are rel<strong>at</strong>ed to any member or the holder of anyoffice under the Trust. Failure to disclose such a rel<strong>at</strong>ionshipshall disqualify a candid<strong>at</strong>e 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 rel<strong>at</strong>ionship between himself anda candid<strong>at</strong>e of whose candid<strong>at</strong>ure th<strong>at</strong> 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 rel<strong>at</strong>ed to any other member orholder of any office under the Trust.iii)Where the rel<strong>at</strong>ionship 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 nomin<strong>at</strong>ed Manager by him/her in a secure place.9.2 Sealing of DocumentsWhere it is necessary th<strong>at</strong> a document shall be sealed, the seal shallbe affixed in the presence of a Trust Director and a Non-ExecutiveDirector (not from the origin<strong>at</strong>ing department), and shall be <strong>at</strong>testedby 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 Sign<strong>at</strong>ure 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 deleg<strong>at</strong>ed to Managers and set out clearly in the Scheme ofDeleg<strong>at</strong>ion 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 interpret<strong>at</strong>ion of Standing Orders (SOs).3.4 Board Appointment of Vice Chair4.2 Chair Call meetings.3.6 Chair Chair all Board meetings and associ<strong>at</strong>ed 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 Vari<strong>at</strong>ion or amendment of Standing Orders6.1, 6.2 Board Formal deleg<strong>at</strong>ion 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 <strong>at</strong>least two Non-Executive members.6.5 Chief Executive The Chief Executive shall prepare a Scheme of Deleg<strong>at</strong>ion identifying his/her proposalsth<strong>at</strong> 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 m<strong>at</strong>erial 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 rel<strong>at</strong>ionship between self and candid<strong>at</strong>e 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.* Nomin<strong>at</strong>ed officers and the areas for which they are responsible should be incorpor<strong>at</strong>ed into the Trust’s Scheme of Deleg<strong>at</strong>iondocument.31
EXECUTIVE SUMMARYTITLE:Quality & Safety Committee Escal<strong>at</strong>ion Report – Part I<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board – Part I1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:The Quality & Safety Committee wishes to keep the TrustBoard advised th<strong>at</strong> 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 Litig<strong>at</strong>ionAuthority.□ TEC ……………..….. □ STRATEGY……….….……□ FINANCE ……..……… □ AUDIT ………….………….x QUALITY & SAFETY …………..…12.2.13....……….…□ WORKFORCE ………………………………………….…□ CHARITABLE FUNDS ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….……….….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 Litig<strong>at</strong>ionAuthority.4. DELIVERABLESA raft of key risk management policies th<strong>at</strong> meet the Risk Management Standards laid down under the ClinicalNegligence Scheme for Trusts.5. KEY PERFORMANCE INDICATORSKey performance indic<strong>at</strong>ors for each of the relevant policies is clearly laid out in a monitoring m<strong>at</strong>rix which is aimed <strong>at</strong>facilit<strong>at</strong>ing the collection of Level 2 d<strong>at</strong>a for subsequent accredit<strong>at</strong>ion.AGREED AT ______________________ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________
EXECUTIVE SUMMARYTITLE:Escal<strong>at</strong>ion Report from the Trust ExecutiveCommittee<strong>BOARD</strong>/GROUP/COMMITTEE:Trust Board1. PURPOSE: REVIEWED BY (<strong>BOARD</strong>/COMMITTEE) and DATE:A summary of issues discussed <strong>at</strong> the February<strong>2013</strong> and December 2012 Trust Executivemeetings.□ TEC ……..….. □ STRATEGY……….….…….□ FINANCE ……..……… □ AUDIT ………….……..….□ QUALITY & SAFETY …………..………….....……□ WORKFORCE□ CHARITABLE FUNDS ………………………………...…□ <strong>TRUST</strong> <strong>BOARD</strong> ……………………………….………….□ REMUNERATION ………………………………….…...□ OTHER …………………………..……. (please specify)2. DECISION REQUIRED: CATEGORY:For inform<strong>at</strong>ion□ NATIONAL TARGET □ CNST□ CQC REGISTRATION □ HEALTH & SAFETY□ ASSURANCE FRAMEWORK□ CQUIN/TARGET FROM COMMISSIONERS□ CORPORATE OBJECTIVE ……………………………....□ OTHER …………………….. (please specify)AUTHOR/PRESENTER: Averil DongworthDATE: 24 February <strong>2013</strong>3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:n/a4. DELIVERABLES5. KEY PERFORMANCE INDICATORSAGREED AT ______________________ <strong>MEETING</strong>ORREFERRED TO: __________________________DATE: ____________________________DATE: ____________________________REVIEW DATE (if applicable) ___________________________
Trust Executive Board Report to the Board of Directors 6 <strong>March</strong> <strong>2013</strong>CQC Report on Emergency Department and m<strong>at</strong>ernity services.Board members will need to be aware th<strong>at</strong> the CQC reports for the emergency department andm<strong>at</strong>ernity 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 p<strong>at</strong>hway 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 p<strong>at</strong>hway. Ambul<strong>at</strong>ory 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 alloc<strong>at</strong>ions. These plans were used as the basis for improvements for the Risk Summitwhich took place on the 7 th February <strong>2013</strong>. Further work to improve the plan to incorpor<strong>at</strong>e thefeedback from NHS London the N<strong>at</strong>ional Commissioning Board London, The N<strong>at</strong>ional TrustDevelo<strong>pm</strong>ent authority and the Care Quality Commission is underway.It was proposed th<strong>at</strong> the Trust look <strong>at</strong> buying in some clinical support from organis<strong>at</strong>ions currentlydelivering the 4-hour target, in order to support the ED and the Acute Medicine p<strong>at</strong>hway. 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 d<strong>at</strong>es.The TEC received a present<strong>at</strong>ion from QFI, an analysis of the current functioning of the MedicalAssessment Unit (MAU). This highlighted th<strong>at</strong> it currently functions more of an admissions unit, andth<strong>at</strong> two thirds of the Trust’s p<strong>at</strong>ients are currently admitted directly to the wards. It was suggestedth<strong>at</strong> the lack of an effective assessment unit potentially contributes to increasing lengths of stay,with many of the p<strong>at</strong>ients directly admitted leaving the hospital within 48 hours. With beds taken upby p<strong>at</strong>ients directly admitted to the wards, it became hard to admit MAU p<strong>at</strong>ients when appropri<strong>at</strong>e,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 th<strong>at</strong> it could deliver more effectively by the end of<strong>March</strong>. This would include reviewing rotas and staffing requirements.The progress and improvement in M<strong>at</strong>ernity 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’); investig<strong>at</strong>ions for all three wereunderwayFinance ReportMembers were briefed on the current financial position. Members noted th<strong>at</strong> discussions had beenheld <strong>at</strong> the recent Transform<strong>at</strong>ion 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 <strong>at</strong> the moment was missingthe CIP and also mitig<strong>at</strong>ing the ‘red’ r<strong>at</strong>ed schemes. Everyone fully understood the challenge stillahead. A £30k Challenge was being launched today to engage Director<strong>at</strong>e teams in addressingthe financial gapIt was noted th<strong>at</strong> 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.D<strong>at</strong>a was reviewed and it was noted th<strong>at</strong> the In House Bank fill r<strong>at</strong>e was declining, and the reasonsfor this would be investig<strong>at</strong>ed. The revised sickness policy and new prob<strong>at</strong>ionary policy to beintroduced were noted.Performance Report.This was reviewed in some detail. Members noted th<strong>at</strong> the C diff r<strong>at</strong>e was not ab<strong>at</strong>ing, and th<strong>at</strong>actions needed to be stepped up, including reducing lax<strong>at</strong>ive use, screening on admission andstrengthening the antibiotic policy and its enforcement. The 18 week referral to tre<strong>at</strong>ment time wasdiscussed and the issue of the clinical responsibility for those p<strong>at</strong>ients waiting.Organis<strong>at</strong>ional Develo<strong>pm</strong>ent.£1.5m has been alloc<strong>at</strong>ed by NHS London for this work, and the Trust has secured the support ofSimon Mac Rory to assist with delivering this project. A mission st<strong>at</strong>ement, 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 th<strong>at</strong> it was essential the clinical director<strong>at</strong>es briefed the corpor<strong>at</strong>e director<strong>at</strong>e thoroughly onthe support they required, so this could be factored into the corpor<strong>at</strong>e 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 N<strong>at</strong>ional Employment Savings Trust scheme for those staffineligible to join the NHS Pensions Scheme was approved.Staff survey.It was noted th<strong>at</strong> 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 templ<strong>at</strong>e contract for external contractors was approved.Acute Quality Care Standards.Following an assessment of Queen’s in September 2012, d<strong>at</strong>a was to be published on ourcompliance with acute quality standards, and also standards in m<strong>at</strong>ernity care. The full d<strong>at</strong>a set isexpected to appear on 28 February.Board Assurance Framework:This was discussed and reviewed. Work was underway on str<strong>at</strong>egic risk sot ensure th<strong>at</strong> they wereall assessed and formed part of the Director<strong>at</strong>es’ Business Planning for next year. All memberswere asked to review the ‘CQC’s Essential Standards of Quality & Safety’ paper. It was agreedth<strong>at</strong> Emergency Care needed to be r<strong>at</strong>ed 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 th<strong>at</strong>BHRUT continued to develop a fully functional CRC and the proposal set out an enhanced
structure th<strong>at</strong> would ensure they were ‘fit for purpose’ to maximise research and revenue potentialand bring everyone into one management area. The loc<strong>at</strong>ion of the CRC still required furtherwork, but it was agreed this would be considered as part of business planning, and under onemanagement area.Quality & P<strong>at</strong>ient 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 p<strong>at</strong>ients. 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 notedth<strong>at</strong> the Trust was performing well on cancer staging d<strong>at</strong>a, the second best in London. P<strong>at</strong>ientExperience continued to be r<strong>at</strong>ed as ‘red’ and it was agreed th<strong>at</strong> it was important for staff to ensureth<strong>at</strong> all surveys were completed, as this inform<strong>at</strong>ion 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 th<strong>at</strong> the results from the Survey indic<strong>at</strong>ed th<strong>at</strong> BHRUT was severelyunderperforming in comparison to our peers, the worst in London and practically the worst in thecountry. Poor communic<strong>at</strong>ion between staff and p<strong>at</strong>ients was highlighted as a significant issue andthe culture of the organis<strong>at</strong>ion with staff saying ‘no’, r<strong>at</strong>her than saying ‘yes’, with some staff turningdown requests to review p<strong>at</strong>ients or support colleagues.This has been incorpor<strong>at</strong>ed in theEmergency Department ‘s emergency care p<strong>at</strong>hway improvement plan.Averil DongworthChief Executive4
1REPORT TO:REPORT FROM:Trust BoardChairmanDATE: 20 February <strong>2013</strong>SUBJECT:CHAIRMAN’S REPORTFOR:Inform<strong>at</strong>ion______________________________________________________________The Francis Enquiry:It will be hard for anyone not to have seen the details of the appalling care sufferedby many p<strong>at</strong>ients <strong>at</strong> Mid Staffordshire hospital, as described in the recent report.For us, it would seem to me th<strong>at</strong> there are two important issues. The first is th<strong>at</strong> weshould be absolutely clear th<strong>at</strong> we either have taken, or will very shortly be taking, allreasonable steps to ensure th<strong>at</strong> this systemic failure could not happen in ourhospitals. We must then demonstr<strong>at</strong>e this to our p<strong>at</strong>ients and the communities whorely on us. The second issue is th<strong>at</strong> should re-double our efforts to ensure th<strong>at</strong> weput p<strong>at</strong>ients <strong>at</strong> the heart of everything we do.While many of the 290 recommend<strong>at</strong>ions in the report require legisl<strong>at</strong>ion, 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 th<strong>at</strong> we are trying to do,but they bear repetition and emphasis.The report describes the important aspects of delivering an organis<strong>at</strong>ional 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;• Inform<strong>at</strong>ion accessible and useable by all, allowing effective comparison ofperformance by individuals, services and organis<strong>at</strong>ion.Chairman’s Report – <strong>March</strong> <strong>2013</strong>
2It also makes the point th<strong>at</strong> achieving this high performing culture does not requireradical re-organis<strong>at</strong>ion.In discussing the obstacles to the achievement of the sort of culture which putsp<strong>at</strong>ients <strong>at</strong> 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 consider<strong>at</strong>ion for p<strong>at</strong>ients;• 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 p<strong>at</strong>ient first in everything th<strong>at</strong> is done.I endorse this totally.I believe th<strong>at</strong> all of this is consistent with wh<strong>at</strong> we are trying to achieve <strong>at</strong> 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 p<strong>at</strong>ients and our communities have every right to seek re-assurance from us th<strong>at</strong>we 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 th<strong>at</strong> re-assurance is by being open to theviews of our p<strong>at</strong>ients and demonstr<strong>at</strong>ing th<strong>at</strong> we have an open and learning culture.It would be foolish to promise th<strong>at</strong> we will get everything right, but it is crucial th<strong>at</strong> welearn from errors and do all we can not to repe<strong>at</strong> them, and to apologise when we doslip up.I am asking the Executive Team to see if there is more th<strong>at</strong> we can learn from theFrancis report and report back to the Trust Board in one month’s time. Wh<strong>at</strong> I amdetermined to insist on is th<strong>at</strong> the care we provide to all our p<strong>at</strong>ients is care th<strong>at</strong> wecan be proud of and which everyone of us would want for ourselves.Peter Dixon25 February <strong>2013</strong>Chairman’s Report – <strong>March</strong> <strong>2013</strong>
1REPORT TO:REPORT FROM:Trust BoardChief ExecutiveDATE: 20 February <strong>2013</strong>SUBJECT:CHIEF EXECUTIVE’S REPORTFOR:Inform<strong>at</strong>ion______________________________________________________________1. INTRODUCTIONThis report contains a summary of:• Actions taken under emergency powers• Executive decisions• N<strong>at</strong>ional 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 P<strong>at</strong>ients <strong>2013</strong>/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, gre<strong>at</strong>er transparency and choice for p<strong>at</strong>ients, more p<strong>at</strong>ient particip<strong>at</strong>ion,better d<strong>at</strong>a to support the drive to improve services, and higher standards andsafer care.For further inform<strong>at</strong>ion go to:http://www.commissioningboard.nhs.uk/2012/12/17/everyonecounts/Chief Executive’s Report – <strong>March</strong> <strong>2013</strong>
2P<strong>at</strong>hology Quality Assurance Review Launched:A review of quality assurance arrangements for NHS P<strong>at</strong>hology Services hasbeen announced, to be led by Dr Ian Barnes, the N<strong>at</strong>ional Clinical Director forP<strong>at</strong>hology. It will scrutinise NHS arrangements for the oversight andsafeguards of labor<strong>at</strong>ory testing. Serious incidents are rare, but concerns wereraised <strong>at</strong> Sherwood Forest NHS Found<strong>at</strong>ion Trust in October about P<strong>at</strong>hologyTesting of breast cancers, used to choose the best tre<strong>at</strong>ment for each p<strong>at</strong>ient,where the care of a small number of women was disadvantaged.The review, expected to report <strong>at</strong> the end of <strong>2013</strong>, will bring together experts inthe field to explore how quality assurance systems can be strengthened and howorganis<strong>at</strong>ions can be more confident about the monitoring of the quality of carethey offer the public.For further inform<strong>at</strong>ion go to: http://mediacentre.dh.gov.uk/2012/12/18/p<strong>at</strong>hologyquality-assurance-review-launched/NHS funding transfer to Local Authorities <strong>2013</strong>/14:The Department of Health has published details of the transfer of £859m in<strong>2013</strong>/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 alloc<strong>at</strong>iondue 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 –Inform<strong>at</strong>ion System’ and will enable medical staff in Emergency Departments orUrgent Care Centres to see if the children they tre<strong>at</strong> are subject to a childprotection plan, or are being looked after by the Local Authority, or havefrequently <strong>at</strong>tended their units.They will be able to use this inform<strong>at</strong>ion as part of their overall clinicalassessment, along with d<strong>at</strong>a about where and when children have previouslybeen receiving urgent tre<strong>at</strong>ment. This will help them build up a better picture ofwh<strong>at</strong> 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 inform<strong>at</strong>ion 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 <strong>2013</strong>, 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 Alloc<strong>at</strong>ion (ACRA) – funding is specifically targeted for the first time<strong>at</strong> those areas with the worst health outcomes.Chief Executive’s Report – <strong>March</strong> <strong>2013</strong>
3In <strong>2013</strong>/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 inform<strong>at</strong>ion go to: http://www.dh.gov.uk/health/<strong>2013</strong>/01/public-healthbudgets/Government investment to boost health research:New funding for health research will benefit millions of p<strong>at</strong>ients and tackle someof the country’s biggest health problems over the next five years.The £120 million N<strong>at</strong>ional Institute for Health Research (NIHR) scheme willsupport up to 12 projects and is part of the Government’s commitment to put theUK <strong>at</strong> the forefront of health research. Previous funding has led to thedevelo<strong>pm</strong>ent of innov<strong>at</strong>ive health solutions, such as a new blood clotting drugth<strong>at</strong> reduces the risk of de<strong>at</strong>h in p<strong>at</strong>ients by 30 percent, and improved follow upcare for stroke survivors using a targeted questionnaire.For further inform<strong>at</strong>ion go to:http://mediacentre.dh.gov.uk/<strong>2013</strong>/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 p<strong>at</strong>ients of digital technology and onlinerecords.A PriceW<strong>at</strong>erhouseCoopers study reviewing better use of inform<strong>at</strong>ion andtechnology found th<strong>at</strong> measures such as increased use of text messages forneg<strong>at</strong>ive test results, electronic prescribing and electronic health records couldimprove care, allow health professionals to spend more time with p<strong>at</strong>ients andsave billions. A N<strong>at</strong>ional Mobile Health Worker report just published was a pilotstudy on introducing laptops <strong>at</strong> 11 NHS sites.The NHS should become paperless by 2018 to improve services and help meetthe challenges of an ageing popul<strong>at</strong>ion, Jeremy Hunt said. P<strong>at</strong>ients should havecomp<strong>at</strong>ible digital records so their health inform<strong>at</strong>ion could follow them aroundthe health and social care system. This would mean th<strong>at</strong> in the vast majority ofcases, whether a p<strong>at</strong>ient needed a GP, hospital or a care home, theprofessionals involved in their care could see their history <strong>at</strong> the touch of a buttonand share crucial inform<strong>at</strong>ion.For further inform<strong>at</strong>ion go to: http://www.dh.gov.uk/health./<strong>2013</strong>/01/paperless/Baroness Neuberger to lead review of Liverpool Care P<strong>at</strong>hway:The review examining how the Liverpool Care P<strong>at</strong>hway (LCP) is being used inpractice is to be chaired by crossbench peer Baroness Julia Neuberger. L<strong>at</strong>elast 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 represent<strong>at</strong>ives of p<strong>at</strong>ients and theirfamilies.Julia Neuberger, who is Senior Rabbi <strong>at</strong> 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 p<strong>at</strong>ients, families, and healthprofessionals, hospital complaints, local payments made to hospitals in respectof the LCP and the liter<strong>at</strong>ure about its benefits and limit<strong>at</strong>ions.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 – <strong>March</strong> <strong>2013</strong>
4play a vital role to achieve this. But there had been too many cases wherep<strong>at</strong>ients or their families were ignored, or not properly involved in decisions, andthis was unacceptable.For further inform<strong>at</strong>ion go to:http://mediacentre/dh.gov.uk/<strong>2013</strong>/01/15/independent-review-of-liverpool-carep<strong>at</strong>hway-to-be-chaired-by-baroness-neuberger/100 Hospitals to take part in £25m M<strong>at</strong>ernity Unit Makeover:More than 100 hospitals across England will share a £25 million fund to improveand upgrade their m<strong>at</strong>ernity units.Several older m<strong>at</strong>ernity hospitals will be refurbished, such as the 1970’s unit <strong>at</strong>Airedale NHS Found<strong>at</strong>ion Trust and one <strong>at</strong> Musgrove Park Hospital in Tauntonand Somerset NHS Found<strong>at</strong>ion Trust, which d<strong>at</strong>es back as far as the 1940’s.There will also be funding for a large number of simple measures th<strong>at</strong> improveboth choice for women and their experience of m<strong>at</strong>ernity care.Improvements include approxim<strong>at</strong>ely 40 new birthing pools th<strong>at</strong> can help makelabour less stressful and painful, eight new midwife-led units th<strong>at</strong> are morerelaxing places to give birth, and more en suite facilities in over 40 m<strong>at</strong>ernityunits, providing more dignity and privacy for women. Equi<strong>pm</strong>ent 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 needsneon<strong>at</strong>al care.For further inform<strong>at</strong>ion, go to: http://mediacentre.dh.gov.uk/<strong>2013</strong>/01/24/100-hospitals-to-take-part-in-25-million-m<strong>at</strong>ernity-unit-makeover/South London Healthcare NHS Trust to be dissolved by 1 October <strong>2013</strong>:The most financially challenged NHS Trust in England is to be dissolved byOctober <strong>2013</strong> to address the risk it carries for ongoing p<strong>at</strong>ient care and thepressure it is placing on other parts of the NHS, Health Secretary JeremyHunt has announced.Previous <strong>at</strong>tempts to solve the financial problems <strong>at</strong> 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 accumul<strong>at</strong>eddebt of more than £200 million – money th<strong>at</strong> is being taken away fromp<strong>at</strong>ients elsewhere.On the advice of NHS Medical Director Professor Bruce Keogh, Mr Hunt alsoannounced he has decided it is in the best interests of p<strong>at</strong>ients th<strong>at</strong> LewishamHospital should retain it’s A&E Department.For further inform<strong>at</strong>ion, go to: http://mediacentre/dh.gov.uk/<strong>2013</strong>/01/31/southlondon-healthcare-nhs-trust-to-be-dissolved-by-1-october-<strong>2013</strong>NHS Change Day 13 <strong>March</strong> <strong>2013</strong>:This is one day of individual cre<strong>at</strong>ivity 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 initi<strong>at</strong>ive devised and led by the next gener<strong>at</strong>ionof young and emergent clinical and managerial leaders from primary andsecondary care across the NHS.Link: www.changemodel.nhs.uk/changedayChief Executive’s Report – <strong>March</strong> <strong>2013</strong>
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 calcul<strong>at</strong>or:NHS Employers has recently launched an interactive sickness absencesavings calcul<strong>at</strong>or. 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 str<strong>at</strong>egy.Link:http://www.nhsemployers.org/HealthyWorkplaces/implementingHWB/Pages/SicknessAbsenceSavingsCalcul<strong>at</strong>or.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 public<strong>at</strong>ion of Robert Francis’s report of the Public Inquiry intoMid Staffordshire NHS Found<strong>at</strong>ion 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 compassion<strong>at</strong>e NHS.For further inform<strong>at</strong>ion, go to: http://www.dh.gov.uk/health/<strong>2013</strong>/02/dhresponds-midstaffs/Landmark reform to help people with care and support costs:Jeremy Hunt, Secretary of St<strong>at</strong>e for Health, has announced a series ofreforms th<strong>at</strong> will provide gre<strong>at</strong>er financial support for the elderly, those withdisabilities and long-term conditions in paying for their care costs.For further inform<strong>at</strong>ion, go to:http://caringforourfuture.dh.gov.uk/<strong>2013</strong>/02/11/funding-how/Local Authorities – Health and Wellbeing Boards and Health ScrutinyRegul<strong>at</strong>ions:The Local Authority (Public Health, Health and Wellbeing Boards and HealthScrutiny) Regul<strong>at</strong>ions <strong>2013</strong> have now been published. These Regul<strong>at</strong>ionsare intended to help Local Authorities finalise prepar<strong>at</strong>ions for Health andWellbeing Boards and Health Scrutiny arrangements.For further inform<strong>at</strong>ion, go to: http://healthandcare.dh.gov.uk/hwbs-healthscrutiny-regul<strong>at</strong>ions-<strong>2013</strong>/NHS Friends and Family Test:The Department of Health has published guidance for providers of NHS fundedservices on calcul<strong>at</strong>ing and publishing the NHS Friends and Family Test results.Link: http://www.dh.gov.uk/health/<strong>2013</strong>/02/nhs-fft-guidance/Chief Executive’s Report – <strong>March</strong> <strong>2013</strong>
6New n<strong>at</strong>ional pledge to improve children’s health and reduce child de<strong>at</strong>hs: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 St<strong>at</strong>e for Health was first to sign thepledge, <strong>at</strong> an event <strong>at</strong> the Evelina Children’s Hospital – part of Guy’s and StThomas NHS Found<strong>at</strong>ion Trust.For further inform<strong>at</strong>ion, go to: http://www.dh.gov.uk/health/<strong>2013</strong>/02/n<strong>at</strong>ionalpledge-cyp/P<strong>at</strong>ient 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 replacesP<strong>at</strong>ient Environment Action Team (PEAT) inspections from April <strong>2013</strong>. PLACEassessments will apply to all hospitals delivering NHS-funded care, including daytre<strong>at</strong>ment centres and hospices. NHS Chief Executives will ensure theirhospitals are ready to engage with the PLACE process when it goes live in April<strong>2013</strong>.For further inform<strong>at</strong>ion, go to:http://www.commissioningboard.nhs.uk/<strong>2013</strong>/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 regul<strong>at</strong>e providers of NHS Services. Monitor has agreed withMinisters they will licence Found<strong>at</strong>ion Trusts from April <strong>2013</strong> and other eligibleNHS providers from April 2014.Link: http://www.monitor-nhsft.gov.uk/home/news-events-and-public<strong>at</strong>ions/ourpublic<strong>at</strong>ions/monitors-new-role/the-new-nhs-provider-licenceChief Executive’s Report – <strong>March</strong> <strong>2013</strong>
Approved <strong>at</strong> QSC12.2.13QUALITY & SAFETY COMMITTEEPART I - OPENMinutes of the meeting held on Tuesday 22 nd January <strong>2013</strong> <strong>at</strong> 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, Associ<strong>at</strong>e Medical Director, Governance - MSFlo Panel-Co<strong>at</strong>es, Director of Nursing – FPCDr Jane Stevens, Clinical Director, Specialist Medicine – JSDr Geraldine Soosay, Clinical Director, P<strong>at</strong>hology – 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, Accredit<strong>at</strong>ion Manager / Committee Coordin<strong>at</strong>or – CRRachael Brady, Quality & Clinical Governance Manager, NELC - RBDeputies: Dr Ajith James, Consultant Nephrologist – AJ (for Dr Andrew Deaner)Dr C<strong>at</strong>h 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 Str<strong>at</strong>egy – 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 Jon<strong>at</strong>han Pollock, Clinical Director, Neurosciences – JPDerek Hicks, Clinical Director – Emergency CareImogen Shillito, Director of Communic<strong>at</strong>ions – ISAlison Crombie, Director of Educ<strong>at</strong>ion - ACJohn Alcolado, Associ<strong>at</strong>e Medical Director, Academia – JAElaine Clark, IPEG Chair - ECActionQSC draft minutes – January <strong>2013</strong> 1
007/<strong>2013</strong> Minutes of the Meeting held on the 11 th December 2012The minutes from the previous meeting were agreed as a true record.008/<strong>2013</strong> M<strong>at</strong>ters ArisingAction Log158/2012 - Energise for Excellence reports have been removed from therolling programme.159/2012 - MG advised th<strong>at</strong> 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 th<strong>at</strong> Dr Davy Yeung is currently reviewing then<strong>at</strong>ional guidance in rel<strong>at</strong>ion to the clinical trials d<strong>at</strong>abase. An upd<strong>at</strong>ewould be provided to the February meeting once the review wascompleted.The target of 85% for resuscit<strong>at</strong>ion training was agreed and the nextEduc<strong>at</strong>ion Board meeting will deb<strong>at</strong>e whether specific groups of staffneed to achieve higher than the set target. An upd<strong>at</strong>e would be providedto the next meeting.The resuscit<strong>at</strong>ion d<strong>at</strong>a requested would be provided in the Februaryiter<strong>at</strong>ion of the Quality Dashboard.PS advised the discussions rel<strong>at</strong>ing to nurse training for blood transfusion wasongoing. FPC st<strong>at</strong>ed th<strong>at</strong> the issue rel<strong>at</strong>es to the sign off staff competenciesand she was working closely with GSo to resolve the issue which has beengener<strong>at</strong>ed by the loss of transfusion nurses. FPC confirmed th<strong>at</strong> whilst therisks have been mitig<strong>at</strong>ed GE has been asked to carry out a baselineassessment to identify which staff are outstanding. An upd<strong>at</strong>e wasrequested for the February meeting.The expected upd<strong>at</strong>e 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 th<strong>at</strong> he had had discussions with the PerformanceTeam. He asked members to consider the relevance of the various KPIs whenit is discussed l<strong>at</strong>er in the agenda; this with a view to removing those whered<strong>at</strong>a is not available.162/2012 - GS advised th<strong>at</strong> the planned meeting to discuss NICE guidancewith RB had not taken place and was being rescheduled.165/2012 - MG provided an upd<strong>at</strong>e on progress with improving theEmergency Department performance in the absence of the Clinical Director.He reported th<strong>at</strong> a step-wise transform<strong>at</strong>ion plan is being implemented andClinical Directors have been fully involved in order to facilit<strong>at</strong>e 7 day a weeksupport for the Emergency Department p<strong>at</strong>hway. The p<strong>at</strong>hway includes setparameters to monitor p<strong>at</strong>ient 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 p<strong>at</strong>hway 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 <strong>2013</strong> 2
Rolling ProgrammeThe rolling programme was noted.009/<strong>2013</strong> P<strong>at</strong>ient Experience SurveyPATIENT EXPERIENCE(Not covered <strong>at</strong> December meeting)GE presented the above survey commenting th<strong>at</strong> the news was positive. Heexplained the staff preference was for paper surveys r<strong>at</strong>her than electronicand 1400 ‘Family and Friends’ surveys had been completed in Decemberalthough the intended start d<strong>at</strong>e is the 1 st April. Trust d<strong>at</strong>a 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, <strong>at</strong> arecent performance review meeting senior sisters were invited to discuss thetopic.FPC advised th<strong>at</strong> the process has not yet been introduced in Majors, MAU orA&E and work is ongoing with them to ensure their p<strong>at</strong>ients have theopportunity to comment on their experience. Once there are better IT systemsin place, currently being discussed with Steve Huddlestone, Chief Inform<strong>at</strong>ionofficer, the frequency of feedback reports will be agreed. GE added th<strong>at</strong> someof the softer issues from the surveys are being shared monthly with thenursing staff.AW suggested the inclusion of a narr<strong>at</strong>ive on actions taken to address issuesraised would be beneficial and FPC explained th<strong>at</strong> 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 th<strong>at</strong> the questions asked via the surveys areextracted from the n<strong>at</strong>ional survey to enable more frequent monitoring onperformance in those areas.PD suggested additional inform<strong>at</strong>ion could be g<strong>at</strong>hered through theintroduction of ‘mystery shoppers’ and DK said th<strong>at</strong> this suggestion wasincluded for discussion as part of the NHS Change Day review on the 13 th<strong>March</strong>. The Chairman of the Trust volunteered to provide inform<strong>at</strong>ion ona conference being run soon by KPMG th<strong>at</strong> he felt would be useful forsomeone to <strong>at</strong>tend.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 theCommunic<strong>at</strong>ions Team. In addition, CW felt the report could be ‘cut’differently to pull out key themes.GE concluded by st<strong>at</strong>ing the Trust was currently doing well against others inthe Cluster. However, MG cautioned th<strong>at</strong> 1 in 10 p<strong>at</strong>ients, based on theinform<strong>at</strong>ion provided so far, would not recommend the hospital to their friendsand family and we therefore need to make their experiences better byproviding consistently good p<strong>at</strong>ient care to all our p<strong>at</strong>ients.010/<strong>2013</strong> Quality Account 2011/12The above report was summarised by PS for members, she explainedth<strong>at</strong> the Director<strong>at</strong>es have been asked for their priority areas for <strong>2013</strong>/14and these would be brought to the February meeting.ActionPDGEPSQSC draft minutes – January <strong>2013</strong> 3
FPC suggested the review of last year’s priorities needed a furthercolumn to indic<strong>at</strong>e its RAG r<strong>at</strong>ing as this would describe the devi<strong>at</strong>ionfrom expect<strong>at</strong>ions. 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 th<strong>at</strong> the performance d<strong>at</strong>a is not ready until l<strong>at</strong>e April or earlyMay and this affects the production schedule.It was suggested th<strong>at</strong> 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 inform<strong>at</strong>ion providedby the Director<strong>at</strong>es 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 n<strong>at</strong>ional audits th<strong>at</strong> are requiredto be included by the Quality Account Regul<strong>at</strong>ions. An upd<strong>at</strong>e on priorities forimprovement to be submitted to the February meeting.PS was asked to ensure th<strong>at</strong> the final version of the Director<strong>at</strong>e upd<strong>at</strong>e on lastyear’s priorities included upd<strong>at</strong>es against the specifics of the original objectivee.g. by the inclusion of clear d<strong>at</strong>a or benchmarking against other Trusts’ d<strong>at</strong><strong>at</strong>o demonstr<strong>at</strong>e improvement.011/<strong>2013</strong> Safeguarding Adults Qtr.2 ReportThe key points of the Safeguarding Adults report were included on page 3 anddemonstr<strong>at</strong>es th<strong>at</strong> <strong>at</strong> Level 1 93% of relevant staff have <strong>at</strong>tended their trainingand 90% <strong>at</strong> Level 2. GE explained th<strong>at</strong> Level 3 training has becomemand<strong>at</strong>ory 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 th<strong>at</strong> infuture reports the form<strong>at</strong> 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/<strong>2013</strong> Learning Disabilities Progress ReportFPC explained th<strong>at</strong> 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 paedi<strong>at</strong>ric 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 appropri<strong>at</strong>e to seek a reply from theSafeguarding Board on this question although she was aware those decisionswere clinical and based on individual assessments she would seekclarific<strong>at</strong>ion. Members requested an upd<strong>at</strong>e on the report’s Appendix 2for the <strong>March</strong> meeting once those discussions had taken place.MG was also concerned th<strong>at</strong> the processes were rigorous enough to ensuresuch p<strong>at</strong>ients received the best tre<strong>at</strong>ment even if it was the middle of the night.FPC advised th<strong>at</strong> p<strong>at</strong>ients 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 <strong>2013</strong> 4
013/<strong>2013</strong> Accident & Emergency Survey (2012)Members were advised th<strong>at</strong> the report included in the papers did not providesufficient inform<strong>at</strong>ion especially on the Trust’s position against its peer group.FPC suggested the report be revisited when the ‘second cut’ d<strong>at</strong>a wasavailable, proposing th<strong>at</strong> it be re-presented in another form<strong>at</strong> when the fullstory was known. Unfortun<strong>at</strong>ely, the copy made available to the Trust Boardand Non Executive Directors was also bereft of the more detailed inform<strong>at</strong>ion.AW suggested the RAG r<strong>at</strong>ing was also upd<strong>at</strong>ed for the next iter<strong>at</strong>ion.The fact th<strong>at</strong> the report was available via the CQC website was raised by CWand this was expanded upon by MG who pointed out th<strong>at</strong> the CQC will usevarious sources of inform<strong>at</strong>ion, including this document, to triangul<strong>at</strong>e theirown d<strong>at</strong>a on our performance in the Emergency Department. FPC agreedth<strong>at</strong> the current ‘flagging’ systems did not appear to be working and shewould be working to rectify this and would work closely with theCommunic<strong>at</strong>ion Director to ensure there was a rigorous response readyfor release once the CQC A&E report was made public.Members agreed th<strong>at</strong> the report should be brought back in a revisedform<strong>at</strong> for the February meeting when it would be co-presented with theClinical Director for Emergency Medicine.An extended discussion then ensued, initi<strong>at</strong>ed by PD, on how assurance canbe provided th<strong>at</strong> staff want to fix the problems th<strong>at</strong> have been identified. Hisview was th<strong>at</strong> staff feel they are expected to fail and are tolerant of failure. JSfelt strongly th<strong>at</strong> the turnaround example set by m<strong>at</strong>ernity demonstr<strong>at</strong>es th<strong>at</strong>once processes are fit for purpose, staff <strong>at</strong>titudes improve. She felt th<strong>at</strong> itclearly demonstr<strong>at</strong>ed th<strong>at</strong> an ineffective working environment clearly affectsstaff <strong>at</strong>titudes and behaviour but th<strong>at</strong> these can be transformed. The issueswere in her view clearly system gener<strong>at</strong>ed. This view was also held by FPC,however she also felt th<strong>at</strong> ensuring there was clarity around roles,responsibilities and expect<strong>at</strong>ions went a long way to improving the system soth<strong>at</strong> everyone knew wh<strong>at</strong> they had to do and how to escal<strong>at</strong>e concerns. JScomments were also echoed by GS who added th<strong>at</strong> 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 st<strong>at</strong>ed 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 th<strong>at</strong> on the whole, staff felt able to flagcompetency issues to their line managers. MG reminded those present th<strong>at</strong>the 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 deb<strong>at</strong>ed altern<strong>at</strong>ive 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 d<strong>at</strong>a in order to provide a coherentp<strong>at</strong>ient experience story although other d<strong>at</strong>a, such as complaints, should beused to supplement the local d<strong>at</strong>a. The members were in total agreementth<strong>at</strong> the Trust has to improve and will not accept a reduced standard of careActionFPC /DHFPC /DHMGQSC draft minutes – January <strong>2013</strong> 5
for p<strong>at</strong>ients in the Emergency Department.014/<strong>2013</strong> P<strong>at</strong>ient Experience Report – Qtr.2The quarterly report was presented and GE highlighted th<strong>at</strong> 41-45% of allcomplaints are gener<strong>at</strong>ed by p<strong>at</strong>ient concerns with the Trust’s appointmentsystem. A Task and Finish Group was suggested by FPC to review theissues and MS recommended th<strong>at</strong> a discussion outside the meeting wasarranged as there was likely to be some duplic<strong>at</strong>ion with the Outp<strong>at</strong>ientWork stream. The P<strong>at</strong>ient Experience Committee will focus on Outp<strong>at</strong>ientissues <strong>at</strong> their next meeting.The report was noted.STRATEGY015/<strong>2013</strong> Quality & Safety Committee Terms of Reference.Further to the discussion in Part II of the meeting, it was agreed th<strong>at</strong> 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 <strong>March</strong>meeting for discussion.016/<strong>2013</strong> Items for Escal<strong>at</strong>ion from Feeder CommitteesThere were no items requiring escal<strong>at</strong>ion from the feeder committees as themajority had not met since the last report to the Quality & Safety Committee inDecember.017/<strong>2013</strong> Quality DashboardThe November quality d<strong>at</strong>a was incorpor<strong>at</strong>ed 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 th<strong>at</strong> the complaints d<strong>at</strong>a was now available and would be included inthe next iter<strong>at</strong>ion.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 m<strong>at</strong>ernity and 2) excluding mainthe<strong>at</strong>res.The inclusion of the Radiology dashboard was noted, but it was agreed itshould replic<strong>at</strong>e the form<strong>at</strong> of the other Director<strong>at</strong>es. This was agreed byZN for the next iter<strong>at</strong>ion.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 deb<strong>at</strong>e about whose responsibilityMRSA screening was for emergency p<strong>at</strong>ients.It was agreed the next iter<strong>at</strong>ion of the dashboard for the February meetingwould take on board the various comments and suggestions and wouldinclude medic<strong>at</strong>ion incidents, full complaint d<strong>at</strong>a, all d<strong>at</strong>a in the same form<strong>at</strong>and comprehensive narr<strong>at</strong>ives to be provided by the Clinical Directorsagainst any ‘red’ indic<strong>at</strong>ors. The narr<strong>at</strong>ive must provide sufficient detail toassure the Committee th<strong>at</strong> mitig<strong>at</strong>ing actions have been taken and examplesshould be provided.ActionFPC /MSCWPSMG / PSMGZNMG / AllClinicalDirectorsQSC draft minutes – January <strong>2013</strong> 6
018/<strong>2013</strong> Quality Str<strong>at</strong>egyMG explained th<strong>at</strong> he was working closely with DK to develop the QualityStr<strong>at</strong>egy and the current draft was being added to with inform<strong>at</strong>ion supplied byFPC. SB will be scrutinising the Str<strong>at</strong>egy and it will be brought to theFebruary meeting.019/<strong>2013</strong> Savile Alleg<strong>at</strong>ions ReviewPATIENT SAFETYIt was noted th<strong>at</strong> 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 th<strong>at</strong> investig<strong>at</strong>ions have shown there were no visits by Jimmy Savileto this Trust or its predecessor Trusts. The report was noted.020/<strong>2013</strong> Care Quality Commission Upd<strong>at</strong>eThe 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 <strong>at</strong> theforthcoming CQC Summit on the 7 th February. Also included in the upd<strong>at</strong>ereport was inform<strong>at</strong>ion about a process for facilit<strong>at</strong>ing each department, notjust M<strong>at</strong>ernity 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 rel<strong>at</strong>ion 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 registr<strong>at</strong>ion item. Itwas confirmed th<strong>at</strong> the Trust was not currently registered for detention underthe Mental Health Act and the service level agreement with North East LondonFound<strong>at</strong>ion Trust needed to be scrutinised to ensure it covered all Registr<strong>at</strong>ionunder the Mental Health Act requirements on behalf of the Trust as this wouldneg<strong>at</strong>e the need to be separ<strong>at</strong>ely registered.PS confirmed th<strong>at</strong> she and the Chief Executive had had convers<strong>at</strong>ions with theCQC Compliance Manager on this topic and the current actions were in linewith those discussions, but the CQC Compliance manager considered th<strong>at</strong> 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 registr<strong>at</strong>ion progress report was requested for the nextmeeting.021/<strong>2013</strong> Risk Management Standards (RMS)A st<strong>at</strong>us report on progress with the prepar<strong>at</strong>ions for the Level 1 RMSassessment in February was provided by PS. She explained th<strong>at</strong> the PolicyR<strong>at</strong>ific<strong>at</strong>ion 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 th<strong>at</strong> whilst 49 areas had been internallyassessed as compliant, there remained one area th<strong>at</strong> the Trust would not becompliant with and th<strong>at</strong> was because the GMC had some outstandingconcerns about ‘supervision of trainees’. The assessors make their decisionon compliance from inform<strong>at</strong>ion directly available from the GMC and which wehave been advised will not be resolved before the visit.PD suggested th<strong>at</strong> inform<strong>at</strong>ion should be provided to the <strong>March</strong>Committee on the plans to achieve Level 2 with clear timescales andActionMGDKMG/DKMGQSC draft minutes – January <strong>2013</strong> 7
inform<strong>at</strong>ion 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/<strong>2013</strong> Any Other BusinessNo other business was raised.023/<strong>2013</strong> Summary of Issues for Escal<strong>at</strong>ion to Trust BoardThere were no issues requiring escal<strong>at</strong>ion to the Trust Board.024/<strong>2013</strong> D<strong>at</strong>e of Next MeetingThe next scheduled meeting will be held in Board Rooms 1&2 <strong>at</strong> 14.00 hourson the 12 th February 2012.QSC draft minutes – January <strong>2013</strong> 8
ACTION LOG – PART I22 nd January <strong>2013</strong>008/<strong>2013</strong> MATTERS ARISINGUpd<strong>at</strong>e with Dr Davy Yeung’s review of a clinical d<strong>at</strong>abase to record p<strong>at</strong>ientstaking part in clinical trials to be brought to the next meeting.Feedback from the Educ<strong>at</strong>ion Board on any specific staff groups needing toachieve higher than 85% for resuscit<strong>at</strong>ion training.Resuscit<strong>at</strong>ion d<strong>at</strong>a to be included in the next Quality Dashboard.Upd<strong>at</strong>e on nurse training for blood transfusion competencies to the Februarymeeting.Report on compliance with historic NICE guidance by each Director<strong>at</strong>e to bebrought to the April meeting.009/<strong>2013</strong> PATIENT EXPERIENCE SURVEYInform<strong>at</strong>ion on KPMG Conference th<strong>at</strong> refers to ‘mystery shopper’ to becircul<strong>at</strong>ed to members by Trust Chairman.Consider<strong>at</strong>ion to be given to pulling out key themes from the survey for a futuremeeting – no d<strong>at</strong>e specified.010/<strong>2013</strong> QUALITY ACCOUNTRAG r<strong>at</strong>ing column to be adding to the 2012/13 priorities for improvement.Clinical Directors to provide clear upd<strong>at</strong>e on original intended actions and RAGr<strong>at</strong>e progress with the improvements in the last Quality Account. Upd<strong>at</strong>esrequired for the February meetingAn upd<strong>at</strong>e 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 <strong>2013</strong>/14improvement.011/<strong>2013</strong> SAFEGUARDING ADULTS QTR.2 REPORTFuture report form<strong>at</strong> to be as defined <strong>at</strong> January meeting.012/<strong>2013</strong> LEARNING DISABILITIESAn upd<strong>at</strong>e on the report’s Appendix 2 to be brought to the <strong>March</strong> meeting oncediscussions held with the Safeguarding Board.013/<strong>2013</strong> A&E SURVEYRevised version of the report to be brought to the February meeting and copresentedwith the Clinical Director of Emergency Department.Work with Communic<strong>at</strong>ions Team to ensure rigorous response ready forrelease of CQC reportReminder for honest completion of Locum Competency Forms to be sent toConsultant body.014/<strong>2013</strong> PATIENT EXPERIENCE REPORTTask and Finish Group to discussed complaints, meeting to take place outsideQSC.ResponsibilityPSACMGFPCMGPDGECRAll ClinicalDirectorsPSPSFPC / GEFPCFPC / DHFPC / DHMGFPC / MSQSC draft minutes – January <strong>2013</strong> 9
015/<strong>2013</strong> QSC TERMS OF REFERENCEDiscussion of QSC and SI Review Panel Terms of Reference by key staff andrevision brought back to <strong>March</strong> Quality & Safety Committee meeting.CW to ask Sue Williams to make arrangements for the above requestedmeeting within the next month.017/<strong>2013</strong> QUALITY DASH<strong>BOARD</strong>Existing black areas to be reviewed to determine which can be deleted due tonon-relevance / non-availability of d<strong>at</strong>a.Inclusion of WHO checklist compliance in dashboard to be considered.Revise Radiology dashboard into correct form<strong>at</strong> for next meetingComprehensive narr<strong>at</strong>ive to be included against all ‘red’ KPIs by each ClinicalDirector.018/<strong>2013</strong> QUALITY STRATEGYQuality Str<strong>at</strong>egy to be brought to the February meeting.020/<strong>2013</strong> CQCSelf-assessment timeframes to be defined to enable inclusion in QSC rollingprogramme.Mental health holding powers to be investig<strong>at</strong>ed urgentlyMental health SLA to be urgently reviewedUpd<strong>at</strong>e on Registr<strong>at</strong>ion with the Mental Health Act required for Februarymeeting.021/<strong>2013</strong> RISK MANAGEMENT STANDARDSPlan for achieving Level 2 to be brought to the <strong>March</strong> Quality & SafetyCommittee meeting.PSCWMG / PSMGZNMG / All ClinicalDirectorsMGDKDKMGMG / DKPSQSC draft minutes – January <strong>2013</strong> 10